[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]
VET CENTERS
=======================================================================
HEARING
before the
SUBCOMMITTEE ON HEALTH
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED TENTH CONGRESS
FIRST SESSION
__________
JULY 19, 2007
__________
Serial No. 110-37
__________
Printed for the use of the Committee on Veterans' Affairs
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37-473 PDF WASHINGTON DC: 2008
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COMMITTEE ON VETERANS' AFFAIRS
BOB FILNER, California, Chairman
CORRINE BROWN, Florida STEVE BUYER, Indiana, Ranking
VIC SNYDER, Arkansas CLIFF STEARNS, Florida
MICHAEL H. MICHAUD, Maine JERRY MORAN, Kansas
STEPHANIE HERSETH SANDLIN, South RICHARD H. BAKER, Louisiana
Dakota HENRY E. BROWN, Jr., South
HARRY E. MITCHELL, Arizona Carolina
JOHN J. HALL, New York JEFF MILLER, Florida
PHIL HARE, Illinois JOHN BOOZMAN, Arkansas
MICHAEL F. DOYLE, Pennsylvania GINNY BROWN-WAITE, Florida
SHELLEY BERKLEY, Nevada MICHAEL R. TURNER, Ohio
JOHN T. SALAZAR, Colorado BRIAN P. BILBRAY, California
CIRO D. RODRIGUEZ, Texas DOUG LAMBORN, Colorado
JOE DONNELLY, Indiana GUS M. BILIRAKIS, Florida
JERRY McNERNEY, California VERN BUCHANAN, Florida
ZACHARY T. SPACE, Ohio
TIMOTHY J. WALZ, Minnesota
Malcom A. Shorter, Staff Director
______
SUBCOMMITTEE ON HEALTH
MICHAEL H. MICHAUD, Maine, Chairman
CORRINE BROWN, Florida JEFF MILLER, Florida, Ranking
VIC SNYDER, Arkansas CLIFF STEARNS, Florida
PHIL HARE, Illinois JERRY MORAN, Kansas
MICHAEL F. DOYLE, Pennsylvania RICHARD H. BAKER, Louisiana
SHELLEY BERKLEY, Nevada HENRY E. BROWN, Jr., South
JOHN T. SALAZAR, Colorado Carolina
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
official version. Because electronic submissions are used to prepare
both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
__________
July 19, 2007
Page
Vet Centers...................................................... 1
OPENING STATEMENTS
Chairman Michael H. Michaud...................................... 1
Prepared statement of Chairman Michaud....................... 27
Hon. Phil Hare................................................... 2
WITNESSES
U.S. Department of Veterans Affairs, Alfonso R. Batres, Ph.D.,
M.S.S.W., Chief Readjustment Counseling Officer, Veterans
Health Administration.......................................... 18
Prepared statement of Dr. Batres............................. 40
______
American Legion, Shannon Middleton, Deputy Director for Health,
Veterans Affairs and Rehabilitation Commission................. 7
Prepared statement of Ms. Middleton.......................... 30
Depression and Bipolar Support Alliance, Sue Bergeson, President. 3
Prepared statement of Ms. Bergeson........................... 27
Disabled American Veterans, Adrian M. Atizado, Assistant National
Legislative Director........................................... 9
Prepared statement of Mr. Atizado............................ 32
Veterans of Foreign Wars of the United States, Dennis M.
Cullinan, Director, National Legislative Service............... 10
Prepared statement of Mr. Cullinan........................... 35
Vietnam Veterans of America, Susan C. Edgerton, Senior Health
Care Consultant................................................ 12
Prepared statement of Ms. Edgerton........................... 37
SUBMISSIONS FOR THE RECORD
Miller, Hon. Jeff, Ranking Republican Member, and a
Representative in Congress from the State of Florida, statement 42
MATERIAL SUBMITTED FOR THE RECORD
Post-Hearing Questions and Responses for the Record:
Hon. Michael H. Michaud, Chairman, Subcommittee on Health,
Committee on Veterans' Affairs, to Sue Bergeson, President,
Depression and Bipolar Support Alliance, letter dated
August 2, 2007............................................. 42
Hon. Michael H. Michaud, Chairman, Subcommittee on Health,
Committee on Veterans' Affairs, to Shannon Middleton,
Deputy Director for Health, Veterans Affairs and
Rehabilitation Commission, American Legion, letter dated
August 2, 2007 (Questions for July 12 and July 19, 2007,
hearings).................................................. 44
Hon. Michael H. Michaud, Chairman, Subcommittee on Health,
Committee on Veterans' Affairs, to Shannon Middleton,
Deputy Director for Health, Veterans Affairs and
Rehabilitation Commission, American Legion, letter dated
August 2, 2007............................................. 45
Hon. Michael H. Michaud, Chairman, Subcommittee on Health,
Committee on Veterans' Affairs, to Adrian M. Atizado,
Assistant National Legislative Director, Disabled American
Veterans, letter dated August 2, 2007...................... 47
Hon. Michael H. Michaud, Chairman, Subcommittee on Health,
Committee on Veterans' Affairs, to Dennis M. Cullinan,
Director, National Legislative Service, letter dated August
2, 2007.................................................... 49
Hon. Michael H. Michaud, Chairman, Subcommittee on Health,
Committee on Veterans' Affairs, to Susan Edgerton, Senior
Health Care Consultant, Vietnam Veterans of America, letter
dated August 2, 2007....................................... 50
Hon. Michael H. Michaud, Chairman, Subcommittee on Health,
Committee on Veterans' Affairs, to Alfonso Batres, Ph.D.,
M.S.S.W., Chief Readjustment Counseling Officer, Veterans
Health Administration, U.S. Department of Veterans Affairs,
letter dated August 2, 2007................................ 52
VET CENTERS
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THURSDAY, JULY 19, 2007
U.S. House of Representatives,
Subcommittee on Health,
Committee on Veterans' Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 2:08 p.m., in
Room 334, Cannon House Office Building, Hon. Michael Michaud
[Chairman of the Subcommittee] presiding.
Present: Representatives Michaud, Hare, Snyder.
OPENING STATEMENT OF CHAIRMAN MICHAUD
Mr. Michaud. The Subcommittee will come to order. I would
like to thank everyone for coming today. Mr. Miller will be
joining us. He is at another meeting that he can't get out of,
but he will be here as soon as he can. I would like to thank
Mr. Hare for coming.
Before we begin, I would ask unanimous consent that all
written statements be made part of the record. Without
objection, so ordered. I also ask unanimous consent that all
Members be allowed five legislative days to revise and extend
their remarks. Without objection, so ordered.
Today we are here to discuss Vet Centers, the benefits that
they have provided to our current population of veterans and
the important and growing role they are playing helping out
veterans from Afghanistan and Iraq. The Vet Centers program was
established in 1979 to help Vietnam era veterans with
readjustment challenges. Vet Centers provide an alternative
environment outside the regular VA system for a broad range of
counseling, outreach and referral services.
Most importantly, Vet Centers provide an environment in
which veterans can speak openly to veterans about their
experiences. Vet Centers have been a success, and now they have
a new mission. In 2003, then-Secretary Principi extended Vet
Centers eligibility to Operation Enduring Freedom (OEF)/
Operation Iraqi Freedom (OIF) and Global War on Terror (GWOT)
veterans, as well as bereavement counseling to survivors of
military personnel who died while on active duty to include
Federal active Guard and Reservists.
Not surprisingly, the workload at Vet Centers continues to
increase. This trend will likely continue as OEF/OIF veterans
deal with everything from mild readjustment issues to serious
mental health challenges. VA currently has 2,009 Vet Centers
located throughout the United States, Guam, Puerto Rico and the
U.S. Virgin Islands. There are five Vet Centers in the State of
Maine as well.
The U.S. Department of Veterans Affairs (VA) has scheduled
23 new Vet Centers to be opened in the next 2 years. There has
been an effort to hire GWOT veterans to serve as peer-to-peer
counselors. The purpose of this hearing is to determine how Vet
Centers can continue to fulfill their unique and critical role
within the VA continuum of care.
Each generation of veterans has its own unique needs. It is
important that Vet Centers are prepared to meet the needs of
our new veterans, while continuing to care for veterans from
previous conflicts.
I look forward to hearing our witnesses here today on how
we can maintain and improve services provided by Vet Centers,
if we have appropriate facilities and staffing, what role can
and should other resources within our communities play to help
veterans and improve care, and most importantly, what should we
do to strengthen invaluable peer-to-peer counseling available
through Vet Centers.
And now I would like to recognize Congressman Hare for any
opening statement that he might have.
[The prepared statement of Chairman Michaud appears on pg.
1.]
OPENING STATEMENT OF HON. PHIL HARE
Mr. Hare. Thank you, Mr. Chairman. Thank you all for coming
today. And thank you for holding the hearing.
I am fortunate to have three outpatient Vet Centers in my
district and one just directly across the river in Davenport,
Iowa. The clinic in Moline actually is about a block and a half
from my district office in Moline. And I have to tell you, the
work that is done at the clinic and the support services and
the people that work at those clinics do a wonderful job and,
and I am a stronger supporter of these Vet Centers. And if
anything, I would like to see us expand.
I know today we are going to talk about what we can do to,
to hopefully get more and, and what we can do better at these
Vet Centers. But I just want to commend the people who work at
these facilities and I want to say that from my perspective,
Mr. Chairman, I think we should do whatever we can do to expand
the programs at these Vet Centers and ensure that we keep the
ones that we have and expand and get more Vet Centers to help
our returning veterans.
I think the problem is going to be made worse when we get a
lot of our vets coming back from Afghanistan and Iraq and I
think we have a--I said many times, I believe an obligation to
provide the services that we need for our returning veterans
from any conflict and from any branch of service.
So I am just honored to be here with you this afternoon and
I look forward to the testimony. And again, thank you very
much, Mr. Chairman, for calling the hearing.
Mr. Michaud. Thank you, Mr. Hare, and thank you for your
support of veterans' issues. For those of you who don't know,
Congressman Hare actually used to work for a gentleman that I
have a great deal of respect for who served on this Committee
for many years, former Congressman Lane Evans. And I really
appreciate your picking up the mantle from where Congressman
Evans had left off.
On the first panel, I would like to welcome Sue Bergeson
who is President of the Depression and Bipolar Support
Alliance. Thank you for coming here this afternoon. I look
forward to hearing your testimony.
STATEMENT OF SUE BERGESON, PRESIDENT, DEPRESSION AND BIPOLAR
SUPPORT ALLIANCE
Ms. Bergeson. Thank you. Chairman Michaud and Members of
the Committee, on behalf of the Depression and Bipolar Support
Alliance (DBSA), thank you for the opportunity to testify today
about the types of mental health services offered to our
veterans through Veterans Centers. DBSA further thanks you for
your efforts in focusing the Nation's attention on the plight
of the men and women of our military forces who are returning
from combat with their mental health devastated.
DBSA is the Nation's largest peer-run mental health
organization, with more than 1,000 State and local chapters in
all 50 States. Over 5 million people ask us for help each year.
By peer-directed, we mean that our organization is led by staff
and volunteers living with mental illnesses, people like me,
people who have experienced the debilitating effects of mental
illness first-hand. Our organization focuses on the power of
peer support as a key component in our recovery.
DBSA regularly partners with the VA on peer support
training for veterans, both nationally and at local facilities.
Additionally, DBSA has long been represented on the Consumer
Liaisons Council to the VA Committee on the Care of Veterans
with Serious Mental Illnesses.
The mental health difficulties of today's returning vets
are well-documented. Despite the valiant efforts of the many
really dedicated VA service providers, current capacity cannot
meet new demand. Long waits for treatment, often with tragic
consequences, result from an already overloaded system that
cannot reach all who are in need.
In 2006, a Committee of experts declared that the VA cannot
meet the ongoing needs of veterans of past deployments while
also reaching out to new combat veterans by employing older
models of care. We have a new job and we need to do it in new
and fresh ways.
Chairman Michaud, today we have the greatest resource to
help combat this grim picture right at our fingertips, and that
resource is our veterans themselves. Let me illustrate the
value of veteran peer support services through the example of a
resident of the Chairman's home State of Maine. As you know,
Mr. Chairman, Jack Berman is a resident of South Portland,
Maine. He is a disabled veteran who has served as Vice
President to the Maine Military Coalition and is President of
the Military Officers Association of America.
Mr. Berman is a man of many talents, in spite of the
adversity he has faced in his life. An entrepreneur, a
rehabilitation counselor, a highway planning engineer for the
New York Port Authority, these are just a few of Jack's
accomplishments.
Seventy-nine-year-old Jack Berman was appointed First
Lieutenant during the Korean war and fought on the frontlines.
He was awarded five medals, including three bronze stars. Yet
while in training, he was hospitalized and diagnosed with
bipolar disorder with episodes of severe depression. As an
individual living with a mental illness, how did Mr. Berman
survive and excel in so many areas? The answer was connecting
him with individuals just like himself.
As Mr. Berman tells us, veterans are not often inclined to
share their stories about the terrible experiences of war with
those who may not be able to understand them. He told DBSA,
``These guys are willing to get their medications from a
psychiatrist, but they don't want to talk to them. They want to
talk to others just like them.''
That is why Mr. Berman believes that peer-to-peer support
is the ideal solution for our country's veterans. ``When a
soldier can openly share his feelings with another soldier
living with a mental illness, something magical happens,'' Mr.
Berman says. ``Talking to my peers was the factor in my
recovery.''
A proven method to harness the power of peer support and
overcome the significant barriers to successful treatment is
the Certified Peer Specialist. These individuals are trained to
help their peers deal successfully with challenges and move
forward with their lives. Peer Specialist outreach in the
community, especially in rural or remote areas and through
veterans centers makes services more accessible than
traditional means alone. And this new role provides
opportunities for meaningful work and financial independence
for veterans with mental illness who otherwise may have
difficulty finding employment.
Peer Specialist services are also significantly cost-
effective and have been shown to cost up to five times less
than older models of care, with improved clinical outcomes. The
VA has already identified these services as a priority in its
Mental Health Strategic Plan and has provided very limited
funding for implementation at local VA facilities. DBSA is
proud to have assisted in many of these efforts.
However, barriers to VA implementation of Peer Specialists
remain. There is a critical need for a large scale, coordinated
national effort that sets the gold standard for VA Peer
Specialist training and delivery of services.
Therefore, we urge the Committee to encourage the VA Office
of Mental Health Services to do the following three things.
One, identify and allocate a significant increase in funding
for a national veterans mental health peer training and
employment initiative. Two, establish and fund a VA Technical
Assistance Center for Peer Support Services, partnering with an
established national organization with demonstrated experience
in peer support training. Three, create and pilot national
veteran Peer Support Technician training and certification
projects in multiple locations throughout the country.
These actions are just a small part of what we can do to
provide our veterans with the necessary tools to fight this new
battle on their return home.
DBSA stands ready to assist the Committee in its efforts. I
thank you for this opportunity to offer our input. Happy to
answer any questions.
[The prepared statement of Ms. Bergeson on pg. 27.]
Mr. Michaud. Thank you very much for that enlightening
testimony. I have just a couple of quick questions. You stated
that the greatest resource to help veterans suffering with
mental illness is veterans themselves in peer-to-peer support.
In your opinion, do you feel that the VA system nationwide is
not utilizing enough peer-to-peer support counselors?
Ms. Bergeson. Well, our experience working with VA Veterans
Integrated Service Networks (VISNs) across the country is that
they really embrace this. It is part of the strategic plan. It
is welcomed with open arms. And it has been shown to be very
successful with limited funding. We know that this works. The
data shows it works. It makes sense to extend this. And we
believe there is a great deal of openness to extend this.
But this is in the face of increased demand on the VA as
vets return home. So we are really urging an increase of
resources be made available to the VA to enhance these
services.
Mr. Michaud. You also had mentioned that 35 percent of the
OEF/OIF veterans treated by the VA have been diagnosed with
mental disorders and that the VA does not have the capacity to
care for them. Is that true for Vet Centers as well, or do you
separate the Vet Centers out? Do Vet Centers have the capacity
to deal with the need out there?
Ms. Bergeson. Well, the reality is that the VA and the Vet
Centers do a phenomenal job. But we are looking at this
tremendous surge of additional people. And no matter how
wonderfully talented the VA leadership that I have come in
contact is, you can only extend these resources so far. So I
believe that in light of increased demand on services, we need
to be looking at increased resource allocation.
Mr. Michaud. Thank you. Congressman Hare.
Mr. Hare. Thank you very much. I only have one question for
you Ms. Bergeson. You stated that even though the screening of
returning veterans for symptoms of mental illness is now more
widespread, that this screening does not identify many of the
affected individuals. I was wondering why you believe this is
the case and how the Vet Centers can improve the screening to
catch the veterans currently falling through the cracks?
Ms. Bergeson. I think that there are still stigmas
surrounding these illnesses and the difficulty with illnesses
such as depression, bipolar disorder or post traumatic stress
disorder (PTSD) is that many of the symptoms mimic or mirror
normal life. Are you a little sad today? Were you unable to
sleep? So it is difficult to people--for people to raise their
hand and say this is a problem for me.
And I think that the VA centers can do a really excellent
job in educating people and also highlighting peers who have
raised their hand, who are successful, who are great examples
of how this works. And I think that is a unique capability that
the Vet Centers have to do that and encourage more people to go
in and seek treatment.
Mr. Hare. I think you touched on this, but maybe just for
my purposes of jotting a couple more notes down, what kind of
investments do you think are needed to the Vet Centers to make
sure they are fully equipped to deal with the growing veterans
population?
One of my big concerns, as you mentioned, is the number of
veterans that we are going to be trying to help. And I am
wondering how do we get prepared for that? It is going to be
coming sooner, I believe, hopefully. But what do we need to do
to make these Vet Centers better and to be able to absorb the
number of vets that are coming in so that they are taken care
of in a timely fashion?
Ms. Bergeson. I guess that is one of the reasons I think of
peer-to-peer counselors, vet-to-vet counseling. Think of them
as an AA model where you have a mentor or a coach. When you can
hire vets who have gone through it and gone through and been
successful and give them really specific tools, not to be
therapists, not to be mini-psychiatrists, but to be peers to
help vets move forward, then you can deploy a larger workforce
that is overseen by clinical staff that can really do the kind
of things that vets need to move forward into wellness.
And it is a very economically advantageous way to work and
it has the benefit of employment for these vets as well.
Mr. Hare. Mm-hmm.
Ms. Bergeson. I think it is a very exciting model. We have
seen it work in States across the country and in different
VISNs as well.
Mr. Hare. Thank you very much. I yield back, Mr. Chairman.
Mr. Michaud. Thank you. We also will be submitting
additional questions. So thank you very much once again for
coming. I really appreciate it.
Ms. Bergeson. Thank you.
Mr. Michaud. Thank you. I would like to ask the second
panel to come forward. We welcome Shannon Middleton, Deputy
Director for Health for the American Legion, Adrian Atizado,
Assistant National Legislative Director for the Disabled
American Veterans (DAV). As you can see, I have improved on the
pronunciation of your name. And Dennis Cullinan who is the
Director of the National Legislative Service for Veterans of
Foreign Wars (VFW). And a special welcome back to Susan
Edgerton who is the Senior Health Care Counselor for the
Vietnam Veterans of America (VVA) and was a former staffer of
the Veterans' Affairs Committee.
So I want to thank all you for coming forward today and
look forward to hearing your testimony and we will start with
Ms. Middleton and, and work down. Thank you.
STATEMENTS OF SHANNON MIDDLETON, DEPUTY DIRECTOR FOR HEALTH,
VETERANS AFFAIRS AND REHABILITATION COMMISSION, AMERICAN
LEGION; ADRIAN M. ATIZADO, ASSISTANT NATIONAL LEGISLATIVE
DIRECTOR, DISABLED AMERICAN VETERANS; DENNIS M. CULLINAN,
DIRECTOR, NATIONAL LEGISLATIVE SERVICE, VETERANS OF FOREIGN
WARS OF THE UNITED STATES; AND SUSAN C. EDGERTON, SENIOR HEALTH
CARE CONSULTANT, VIETNAM VETERANS OF AMERICA
STATEMENT OF SHANNON MIDDLETON
Ms. Middleton. Thank you. Mr. Chairman and Members of the
Subcommittee, thank you for this opportunity to present the
American Legion's views on the current and future services
provided by Vet Centers.
Vet Centers provide a necessary service and are an
important resource for combat veterans experiencing
readjustment issues. The American Legion is proud to have been
involved in the Vet Center Program since its inception in
1979--excuse me. During the developmental phase, some of the
Vet Centers operated out of American Legion Posts, while
searching for permanent storefront locations.
Although we got off to a somewhat rocky start, the
readjustment counseling program became a safe haven for
thousands of Vietnam veterans suffering from PTSD, family
problems and other readjustment issues. As the program has
expanded, combat veterans of subsequent wars and their family
members have been able to avail themselves of the services
available through the readjustment counseling program.
OEF and OIF veterans are now positively benefiting from Vet
Centers and their outreach activities in increasing numbers. We
have stated on many occasions that we receive fewer complaints
and more positive comments on the Vet Center Program than any
other program administered by the VA.
This year, the American Legion's annual System Worth Saving
Report will focus on select Vet Centers as well as select
polytrauma centers. The System Worth Saving Task Force members
and National Field Service staff visited 46 Vet Centers that
were located near demobilization sites across the country.
Since many of the returning servicemembers would most
likely reside near the site of demobilization, the Vet Centers
selected had particular significance. In an effort to ascertain
the effects of OIF on utilization of services and available
services, Task Force and National Field Service staff solicited
information on enrollment, fiscal and staffing issues for
fiscal year 2003, the year OIF began, and fiscal year 2006. It
also included challenges faced by Vet Centers as identified by
staff and management.
In general, we found that the Vet Centers visited had
extensive outreach plans to reach the many counties within
their respective regions. Most had at least one position for a
Global War on Terror Technician, or a GWOT Technician. Most
participate in National Guard and Reserve demobilization
activities to include providing available at post-deployment
health reassessment activities and conducting briefings at Vet
Center services--about Vet Center services.
Many Vet Centers have community partnerships and
participate in their local college work study programs,
allowing OIF veterans who are enrolled in college to assist
with administrative tasks at the Vet Centers.
The Vet Centers all work with veteran service organizations
to provide assistance for veterans in filing claims. Some Vet
Centers even reserve space for service officers to make weekly
visits. They all illustrate productive referral systems between
the Vet Centers and the local medical centers.
Some Vet Centers have tailored their programs to
accommodate veterans and families that speak languages other
than English as a first language, or those who practice other
customs. Some Vet Centers indicate that they need to enhance
their services to accommodate culture differences and to target
rural, women and minority veterans.
In general, the veterans--sorry. In general, the Vet
Centers visited by the American Legion had the same staff
composition, usually a four-person team to include a team
leader, office manager, social workers and a psychologist or a
mental health counselor.
However, a few indicated that limited staffing was an
overall challenge, giving an anticipated influx of returning
OIF/OEF veterans in the catchment area. Some Vet Centers shared
GWOT Technicians and sexual trauma counselors with other Vet
Centers, or had part-time staff members.
Some Vet Centers had vacancies because the GWOT Technician,
as well as other key staff members, had been or would be soon
deployed again to serve in Iraq or Afghanistan.
A few indicated the need for a family therapist or a sexual
trauma counselor. Some of the vacancies have been funded but
not filled as management was seeking qualified individuals to
hire. Yet, other Vet Centers indicated that they just needed
staff augmentation to handle existing and anticipated
workloads.
The American Legion believes that all Vet Centers need to
be fully staffed to ensure that combat veterans seeking care
for adjustment--readjustment are afforded the same standard of
quality care, no matter which Vet Center they utilize. This
includes cross-training staff to speak other languages when
necessary, or hiring qualified bilingual staff, and training
staff to learn different mental health specialties.
The most important aspect of the Vet Center is that it
provides timely accessibility. Since Vet Centers are community-
based and veterans are assessed within minutes of their
arrival, eligible veterans are not subjected to long times to
be seem for--I am sorry--long wait times for disability claims
decisions to determine eligibility for enrollment, or long wait
times for available appointments. The Vet Center can provide
immediate attention to the veteran, either directly or through
contract are when necessary.
Combat veterans facing readjustment issues require
immediate access to mental health assessment and counseling.
Vet Centers make this possible. Making more communities aware
of Vet Center services will likely improve the quality of life
for many families.
Again, thank you, Mr. Chairman, for giving the American
Legion this opportunity to present its views on such an
important issue and we look forward to working with the
Committee to address the needs of all veterans.
[The prepared statement of Ms. Middleton on pg. 30.]
Mr. Michaud. Thank you. Mr. Atizado.
STATEMENT OF ADRIAN M. ATIZADO
Mr. Atizado. Mr. Chairman, Members of the Subcommittee, on
behalf of the 1.3 million members of the Disabled American
Veterans, I do thank you for the opportunity to testify that
this important hearing to examine VA's readjustment counseling
service.
Mr. Chairman, Vietnam veterans were called to service
mostly by involuntary conscription in a very unpopular and
politically charged war. They came home with medical, personal
and psychological burdens that the U.S. Government and the VA
minimized and largely ignored for years. In fact, Honorable Max
Cleland himself, a Vietnam veteran, and who at the time was
serving as VA's administrator, brought the healthcare needs of
Vietnam veterans before the House and Senate Veterans' Affairs
Committees, as well as the Administration.
In response, VA's readjustment counseling service was
established, as you had mentioned, in 1979, for which members,
our own members in DAV, as well as other disabled veterans,
have regained not only their health, but their lives by virtue
of the Vet Center Program.
Today, while Vet Centers have grown and matured over the
years into highly skilled and specialized psychological and
counseling centers, the DAV is concerned that demand is, in
fact, exceeding capacity. We note that VA's own estimate for
the number of OIF/OEF veterans who will seek VA care in fiscal
year 2007 had been exceeded back in April. Moreover, VA's
budget request for fiscal year 2008, for its readjustment
counseling service reflects a downward trend in obligated
spending and workload at a time when actual workload capacity
and program policies are expanding.
Providing over 6,500 bereavement counseling visits and
outreach efforts averaging more than 13,000 contacts each
month, this has increased this program's workload for OIF/OEF
veterans from less than 20,000 visits in fiscal year 2004 to
well over 200,000 in fiscal year 2006. The DAV is concerned
that the resources being provided to the Vet Center Program is
not commensurate with its expanding workload and
responsibilities even with the success of this program, which
makes--I am sorry--which provides over one million counseling
visits annually and makes an annual average of 200,000
referrals to the Veterans Health Administration for additional
medical care.
Mr. Chairman, this program, in part, contributes to the
ready access to VA care that OIF/OEF veterans enjoy today, as
well as their high rates of healthcare utilization.
Accordingly, when VA announced its intention to establish 23
additional Vet Centers bringing its total to capacity to 232,
we question why the bulk of these Vet Centers--we question why
the bulk of these Vet Centers openings are being delayed.
Also, as the Subcommittee is aware, a Committee staff
report issued in October of 2006 on the capacity of Vet
Centers, as well as other newspaper reports, clearly show that
VA staffing should be increased in existing centers to ensure
that all veterans, all veterans who help--who need help at Vet
Centers can gain that access to these important services.
Mr. Chairman, as I indicated earlier, the Vet Centers were
established because Vietnam veterans saw little about the old
VA of 35 years ago that appealed to them. The Independent
Budget for fiscal year 2008 recommends and urges VA and the
U.S. Department of Defense (DoD) to adopt their programs to
meet the needs of our newest combat veterans rather than
require these veterans to adapt their needs to the programs
being offered today.
From our contacts today with veterans of both Iraq and
Afghanistan wars, we are learning that today's VA, including
its readjustment counseling service, may not generally be
perceived as an organization that is tailoring its program to
meet the emerging needs of our newest combat veterans. We urge
this Subcommittee to provide VA the necessary tools for it to
continue the program adjusts it has made in a way that provides
a more welcoming, age appropriate, culturally sensitive, and
responsive service.
The DAV stands ready to work with this Committee, Congress
and the Administration to do everything in our power to bring
needed resources into place to promote early and intensive
interventions which are critical in stemming the development of
chronic post traumatic stress disorder and other related health
problems. We must ensure that family members and veterans
devastated by the consequences of PTSD, adjustment disorders
and other injuries have access to appropriate and meaningful VA
services. Finally, we want to ensure all this occurs without
simultaneously displacing older veterans with chronic mental
illness under VA care.
Mr. Chairman, this concludes my statement. I would be happy
to answer any questions you may have.
[The prepared statement of Mr. Atizado on pg. 32.]
Mr. Michaud. Thank you. Mr. Cullinan.
STATEMENT OF DENNIS M. CULLINAN
Mr. Cullinan. Thank you, Mr. Chairman, Members of the
Subcommittee. On behalf of the men and women of the Veterans of
Foreign Wars, I want to thank you for inviting us to
participate in today's forum.
Vet Centers are an integral part of the Department of
Veterans Affairs capacity to care for veterans. They provide
readjustment counseling to veterans who were exposed to the
rigors of combat, and who may need services to help them cope
with the traumas after war.
The program is so essential because its design helps to
break down most of the stigma of treatment. Vet Centers, by and
large, are accessible and welcoming. Over time, the mission has
rightly expanded to provide a number of essential services
beyond counseling, and has begun providing services to the
families of servicemembers, who often are affected just as much
by the difficulties of their loved one's combat service.
Their less formal setting helps to encourage those veterans
who need its services to utilize them. Vet Centers aim to
eliminate many of the barriers to care and its employees are
adept at breaking down those barriers.
The quality and variety of services provided at Vet Centers
is excellent. We have heard few complaints about the quality of
care and the treatment vets receive in these facilities. Our
concern lies with access to these services.
The October 2006 report, ``Review of Capacity of Department
of Veterans Affairs Readjusting Counseling Service Vet
Centers,'' conducted by the then-minority staff of the
Subcommittee on Health, provided many details of the access
problems veterans face in these centers.
The Subcommittee found that many Vet Centers have scaled
back services. ``Forty percent have directed veterans for whom
individualized therapy would be appropriate to group therapy.
Roughly 27 percent have limited or plan to limit veterans'
access to marriage or family therapy. Nearly 17 percent of the
workload affected Vet Centers have or plan to establish waiting
lists.''
These are worrisome trends. But they tell just part of the
story.
In conversations, representatives of our national Veterans
Service have had with Vet Centers throughout the country, their
greatest concern is not with the demands for service today, but
with the future. Although the Subcommittee report noted that
the number of OEF/OIF veterans accessing care at Vet Centers
had doubled, they are still just a portion of the population to
be served. As more come back and more start to access the
benefits and services provided by VA, we can anticipate even
larger demand for these Vet Center services.
This is especially true of mental health service provided
at these centers. We are all aware of the difficulties
returning servicemembers are having because of the unique
stress of this conflict, and there correctly has been an
increased emphasis on overall mental health well-being. VA's
most recent data, through the first quarter of 2007, shows that
around 36 percent of hospitalized OEF/OIF veterans are
returning with some degree of mental disorder. If these numbers
hold firm, as they have in previous VA reports, it will
represent a challenge for those Vet Centers.
We are pleased to see the Secretary's recent decision to
add 23 new Vet Centers throughout the country. Expending access
is clearly a good thing. Accordingly, we need to see that each
center, new and existing, is fully staffed, and that the areas
that report exceptionally high demands for service are staffed
sufficiently so that these centers can retain one of their
characteristics that make them unique and a convenience for
veterans. And that is the drop-in aspect.
We urge this Subcommittee to utilize its oversight
authority by continuing to monitor the demand for services. As
demand rises, funding priorities must adapt.
There are a few other concerns we have. First, these
centers must be able to handle the increasing number of women
veterans sure to seek treatment and increase treatment options
and outreach efforts to them. While all centers are required to
have sexual trauma treatment, we must ensure that services are
available to address any issues that arise from them--from
women serving in a war zone where there is no true frontline.
Second, the original version--vision of Vet Centers was of
veterans helping veterans. That is still a worthy goal, but we
understand the need for qualified and highly trained counselors
and staff members, especially those dealing with the
complexities of mental impairments and traumatic brain injury
who might not always be veterans. What is important here is
that they are caring, compassionate and capable. We must be
mindful of drawing on the experience of younger veterans,
including OEF and OIF veterans and those who served in the
Persian Gulf. VA must do more to educate and train these men
and women so that they can play an active role in their fellow
veterans' treatment.
Mr. Chairman and Members of the Committee, thank you very
much. That concludes my statement.
[The prepared statement of Mr. Cullinan on pg. 35.]
Mr. Michaud. Thank you. Ms. Edgerton.
STATEMENT OF SUSAN C. EDGERTON
Ms. Edgerton. Chairman Michaud and Congressman Hare, first
of all, let me say what a pleasure it is to be back here on
this side of the dais this afternoon. On behalf of the Vietnam
Veterans of America, thank you for providing us the opportunity
to present testimony regarding the Vet Center Program. This
Committee (and Subcommittee) continues to distinguish itself
for the attention it has focused on the important issue of
post-deployment mental health and VVA wants to thank you for
your continuing efforts.
VVA has always strongly supported the Vet Center Program
because of its cost effectiveness, staff commitment and solid
leadership, but especially because of the high quality of its
services. It is a truly unique resource within the system. Vet
Centers offer veterans and their families a haven in which to
gather in an atmosphere of trust that relieves them from stigma
and shame often associated with care-seeking for mental illness
elsewhere.
Happily, there has been much good news for the Vet Centers
lately. VVA was pleased to learn that the VA plans to open 23
new Vet Centers nationwide and we are pleased that Congress and
even VA are now acknowledging programmatic deficiencies in the
mental health programs and that Congress has added much needed
funds in the appropriation for VA healthcare and in the
supplemental. New centers will obviously help with access.
Funding increases are much needed and we hope that Congress
will be rigorous in monitoring how these funds are used to
augment much needed capacity in all of the mental health
programs.
Unhappily, experts note the demand for post-deployment
mental healthcare services will continue to grow and many
veterans are not receiving the proper screenings, referrals or
care. Yet, even with so much unmet demand, Vet Centers are
struggling. Visits per veteran dropped from 8.2 in FY 2004 to
7.9 in FY 2005 to 5.1 in FY 2006. New centers will help, but
existing centers need staff too.
As Vet Centers hire new employees, VVA is concerned that
these mental health professionals have the right veteran-
specific experience in dealing with the issues that they will
address. To that end, we recommend that Congress fund PTSD
scholarships to fund the education of peer counselors who are
prepared to pursue advanced degrees in clinical psychology.
This would create a new stream of Vet Center counselors who
have both shared the experiences of their comrades and received
adequate professional training to address their issues.
We have called upon Vet Centers to do a great deal for our
veterans and yet, ideally, they would do even more. VVA would
like to see more family services, counseling for military
sexual trauma available at every Vet Center, and a strong role
for Vet Centers in VA's recently announced suicide prevention
efforts. We hope that Vet Centers are integral in sharing their
experience and expertise with community providers who may be
called upon to help with the post-deployment mental health
needs of vets.
We would like to see Vet Centers become more accessible,
particularly for crisis intervention, ideally offering round-
the-clock consultation. We would like to see Vet Centers employ
nontraditional hours of operation.
As you know, Mr. Chairman, Vet Centers are just one venue
that the VA employs to address post-deployment mental health
issues. Vet Centers cannot be effective without accessible VA
treatment programs for substance abuse, mental illness,
homelessness and post traumatic stress disorder. Access to all
VA mental healthcare remains problematic.
Finally, Mr. Chairman, we could not leave any debate
related to post-deployment health without urging you and the
Committee to support efforts to reinvigorate the National
Vietnam Veterans Longitudinal Study. This study is not just
important to the veterans of the Vietnam era, but would provide
important findings about the long-term consequences of post
traumatic stress disorder and other stressors related to
deployment to generations of future veterans.
The Senate Appropriations Committee has addressed the issue
in its report language accompanying the Military Construction
bill and we hope that you will urge your colleagues on the
House Committee on Appropriations to accept and even strengthen
this language.
Mr. Chairman, this concludes my statement. I will be happy
to answer any questions you may have.
[The prepared statement of Ms. Edgerton on pg. 37.]
Mr. Michaud. Thank you very much, each of you, for your
testimony this afternoon.
I will start off with the American Legion. First all of, I
want to thank you for your report, ``A System Worth Saving,''
that you come out with each year. I read it and find it very
helpful and enlightening. So thank you.
You mentioned that this year's focus is on Vet Centers.
Could you tell us if there are any areas of the country, such
as rural areas, that are experiencing staffing challenges more
than others?
Ms. Middleton. So far I haven't seen any trends. We did
only see 46 of the 209 Vet Centers, but I haven't noticed any
trends and I am still in the process of editing the reports.
But I haven't seen any trends yet. And basically--well, no
trends. So in some places the staffing was adequate and
management was satisfied, had no complaints. And in other
places, there were some issues that did arise.
Mr. Michaud. Okay. What about waiting lists?
Ms. Middleton. None of them reported any wait lists. They
just, you know, said that the veterans are seen as soon as they
come in, within minutes they are assessed. So no one was
waiting for anyone to meet with them and, and give them care.
Mr. Michaud. Great. Thank you. Actually, to the VFW, you
had talked about military sexual trauma and the fact that we do
have an increased number of women veterans out there. Have any
of the four organizations at the table been hearing complaints
about the lack of military sexual trauma counselors at Vet
Centers? We will start off with you, Mr. Cullinan.
Mr. Cullinan. Yeah, thank you, Chairman Michaud. At this
point, the direct contacts our national Veterans Services have
with the sexual trauma centers, there haven't been those kind
of complaints. However, it is our assessment and in the view of
some of the individuals working at these centers that there are
other things that have to be considered. It is not just the
issue of sexual trauma, but other types of traumas. I mean
everything from PTSD to things like traumatic brain injury, to
simply the stress of combats affects women differently. And
there is a concern that there is not enough attention being
placed on that--on those differences.
It is not that there is everything expressly wrong right
now, but, you know, we expect, the VFW expects and the people
we have talked to expect to have quite an increased number of
veterans seeking services and associated with that will be the
need to address their specific needs.
Mr. Michaud. The other three organizations, have you heard
any complaints?
Ms. Edgerton. I have not heard any specific complaints, Mr.
Chairman, but I guess there may be some problems even if women
aren't talking about them. In my view, the issue would be if
you don't have women counselors and don't have military sexual
trauma counseling at every Vet Center, you may have a lot of
unmet demand. It is kind of the ``if you build it, they will
come'' sort of phenomenon. If there are services available and
women become aware of them, I think they would use them. We are
not sure that women veterans who do show more propensity toward
PTSD, are making as much use of the Vet Centers as they might.
Mr. Michaud. Mm-hmm.
Ms. Middleton. I just have a comment. I haven't heard any
complaints. But I just wanted to note that in the 6 years I
have been at the American Legion, I have had several calls, not
a whole lot of them, but several calls from veterans who had
experienced military sexual trauma. And I don't think any of
them were women. So I think that--and it was in combat setting
also. So it is important when we are thinking about military
sexual trauma that we don't just think about women, because
there are some men who experience it in theater also.
Mr. Michaud. And DAV?
Mr. Atizado. Thank you for that question, Mr. Chairman. I
think the only thing I can add to what has already been said is
the realization from our organization that women who serve in
combat who are suffering from post traumatic stress disorder,
we are hearing that they actually like to be in the same group
as men when it comes to mental health counseling for combat
experiences, as opposed to military sexual trauma, either men
or women who tend to not be in that kind of a setting.
Mr. Michaud. We heard a suggestion from the Vietnam
Veterans of America to establish a PTSD scholarship. How do the
other three organizations feel about that?
Mr. Cullinan. Mr. Michaud, I would have to say at this
point we would have to look at what that means exactly,
scholarship. The devils are the details and so are the angels.
And I will look at it in that perspective.
Mr. Michaud. Thank you. Same for DAV and American Legion?
Ms. Middleton. Yes, sir.
Mr. Michaud. Okay. Great. Thank you.
Mr. Hare.
Mr. Hare. Thank you, Mr. Chairman.
I have two questions for the whole panel and I know you
touched a little bit on this, so I think it gives us another 5
minutes to sort of talk and flesh out some of these things.
Mr. Atizado, you said that the DAV is concerned that the
expanding role of Vet Centers has increased and the workload
for OEF and OIF veterans from less than 20,000 in fiscal year
2004 to 242,000 visits in fiscal year 2006; is that----
Mr. Atiazdo. That is correct.
Mr. Hare. Given that, I would like to know from all of you
what can the VA--starting with you, Mr. Atizado, what can the
VA do to improve their staffing recruitment and retention at
the facilities and is it a matter of just funds or the policies
or a combination of both?
And then with regard--we have heard a little bit about
funds and I am not asking necessarily for a specific dollar
amount, but organizationally, does anybody have an idea of how
much money it would take to be able to get these centers the
way we need to get them? So I would just throw that open to the
panel.
Mr. Atizado. I will answer first. Thank you for that
question, Mr. Hare. I would like to say first and foremost,
that along with the other organizations, we think this is a gem
of a program that VA has, and that the burden that it is
absorbing in treating our combat veterans is--goes without
saying that they are doing a tremendous job. We like the fact
that they have hired a hundred new peer counselors as was
testified to as far as their effectiveness with regard to the
first panel and would like to see more of that come about.
We do have a concern, as was actually mentioned earlier,
with the ability for VA to recruit mental health providers,
whether they be peer counselors all the way up to
psychologists, psychiatrists. There is a workforce shortage in
practically every aspects of the medical field and VA is not
isolated in that. In fact, it is hampered more, considering the
way they are--because there are some shortcomings, not only
with statutory authority, but also their funding process.
So they are hampered in that sense. I just--the reason why
I had outlined the increase in workload, as well as just as
importantly the budget request, which is actually, you know, as
we all know, is a signal from leadership as to where they want
this program to go, there seems to be some kind of conflict.
The very same month that they issued their budget request,
which as I had said, is a downtrend in obligations and
workload, they in the same month announce that they are going
to increase their capacity, as they say their largest expansion
since this program was stood up.
So it is a conflicting message and we urge this Committee
to figure out what is going on with this, because as my other
colleagues have mentioned, this is one program we cannot lose
sight of.
Mr. Hare. Anybody else?
Mr. Cullinan. I would just associate myself with Mr.
Atizado's remarks. We can't help but believe that there is
going to be a considerable increase in demand at Vet Centers.
And the fact that conflicting signals come out of VA is
troubling and as Ms. Edgerton has already pointed out, if we do
things right, more women are going to start coming into the
system if it is made more hospitable for them. So these are all
things that need to be addressed. And it comes to--we don't
have a specific dollar figure. But it comes down to the
funding, staffing, and statutory authority.
Ms. Edgerton. I just might add, it is great to have peer
counselors. Primarily, as I understand it, their job is
outreach and it is nice to have them to bring people into the
system, but if you have nothing to bring them into, they have
to wait in long lines for services or they don't have access to
services at the VA medical centers that are needed, it may not,
you know, that may not be an appropriate way to focus VA's
resources.
I think that that is one of the reasons VVA is thinking
about the PTSD Scholarship Program because we see that these
are valuable people in the system. But if they could go on and
learn clinical psychology, learn skills in counseling, we see
those as being very productive employees in the future.
Mr. Hare. Ms. Edgerton, and hopefully I won't go too far
over my time. But I am trying to remember, I don't know who
said it or where I read it, the numbers of suicides committed
by Vietnam veterans is staggering and I am trying to remember
what that number was. It was an incredible amount in terms of
where we are at. I am very concerned about this, obviously, in
terms of not just for the present wars we are doing now, but
for our Vietnam vets.
And I am wondering if you do have that information, if you
could get that to me, because I would really like to see if
there are figures on it, or if any of you have it. What can we
do, do you think, to address this problem in a hurry, because
it seems to me we better be doing something yesterday and not
today?
Ms. Edgerton. Well, Mr. Hare, I would certainly be happy to
get you that number for the record. And I will definitely let
VVA know that you are interested in that. I think one of the
things that we see as, as really, really, really important for
Congress to pursue is that National Vietnam Veterans
Longitudinal Study. And as I said, the Senate has included
language to reiterate its concerns about that study being done.
It has been bogged down in VA for a number of years now, even
though it is mandated by Congress.
So whatever you can do to work with your peers on the
Appropriations Committee, we would certainly appreciate that.
[The information was not provided to the Committee.]
Mr. Hare. I would be happy to. Thanks very much. I yield
back.
Mr. Michaud. Dr. Snyder.
Mr. Snyder. Thank you, Mr. Chairman. I just had one
question that I think one of you had touched on earlier, but I
wanted to have you supplement the answer a little bit. The
issue from Dr. Batres' statement who is going to be testifying
here next, that the ``Vet Centers have no waiting lists and
veterans may be seen by a counselor the same day they stop by
for an assessment.'' You all are in agreement, I understand,
that they don't have waiting lists; is that correct? Or do you
agree with that statement?
Mr. Cullinan. Mr. Snyder, I testified earlier we have had
contact direct, our National Veteran Service Representatives
have had contact with some of the Vet Centers, certainly not
all of them. And what we are hearing is right now there is
adequate access to services. They like the care they are
getting. They find them welcoming. But there is real concern
that they are going to run out of resources soon.
And I can't say that there are no waiting list at all Vet
Centers. In fact, you know, given what Mr. Atizado was just
talking about with the deficit in funding and resources, it is
hard to believe that there aren't any where there is not some
problem. But our direct contacts that we have had, not yet, but
it is coming.
Ms. Middleton. And from our--excuse me--the American
Legion's site visits during the ``System Worth Saving,'' for
the ``System Worth Saving'' report, that was the report we got
back from the 46 Vet Centers that we visited also.
Mr. Snyder. Which was that there is no waiting lists?
Ms. Middleton. Yes, sir.
Mr. Snyder. So that was inconsistent with what Dr. Batres'
written testimony says. The real question--I mean I can
probably say that of my congressional offices too. We have no
waiting list. If somebody walks in the door, they will see
somebody. The question is, I may not be there, which is true
most of the time for my Little Rock office because I am here.
The staff person that is the expert in the area they want to
see may not be there.
I mean so, again, I think we want to define what it means
by no waiting lists. And are you all satisfied also from what
you have been hearing that they are getting to see the kind of
person, the level of counselor they need? I mean that is a
pretty high bar to expect a system to say a person will walk in
the door and we will have the appropriate level of counselor
for them to see that same day. I mean that may well be what is
going on, but what are you all hearing, or do you know?
Mr. Atizado. If I may, I would be hard-pressed to believe
that there isn't a waiting list already. There may be, I don't
know. One of my concerns are is the model by which they provide
treatment, as you said, even the person that is providing
mental health services, and if you need a--if you have a
veteran that is going to--that is on the brink between
requiring one-on-one intensive care versus one-on-one regular
mental healthcare versus group care, then you have, in fact,
built in extra capacity to meet the demand. Whether or not the
quality is the same or the horizon for them to readjust
appropriately in civilian life may be lengthened, I don't know.
I don't have this information. In fact, you know, panel three
may have that.
Mr. Snyder. And they may have a real good system of
triaging, that someone comes in and what is going on. I need a
referral for marital counseling. And obviously not an
emergency, but then somebody comes in who says I think I am
going to hurt myself today. And they respond appropriately to
emergency care. I mean so I don't have any reason to doubt Dr.
Batres' statement and he can flesh that out when he testifies.
I just wanted to--but what you are telling is you are not
hearing anything--you don't have any evidence to say that Dr.
Batres' statement is inaccurate, that--no?
Mr. Atizado. No, sir.
Mr. Snyder. Great. Thank you. Thank you, Mr. Chairman.
Mr. Michaud. Thank you very much. And once again, I would
like to thank all the panelists for your testimony this
afternoon and thank you also for all the work that you are
doing to ensure that veterans are getting appropriate
healthcare. So thank you.
On the last panel today is Alfonso Batres who is the Chief
Readjustment Counseling Officer for Veterans Health
Administration. He is accompanied by Greg Harms who is the
Program Analyst of the Readjustment Counseling Service within
the Department of Veterans Affairs.
I want to thank both of you gentlemen for coming here
today. I look forward to hearing your testimony, Doctor, and
without further ado, I will turn it over to you.
STATEMENT OF ALFONSO R. BATRES, PH.D., M.S.S.W., CHIEF
READJUSTMENT COUNSELING OFFICER, VETERANS HEALTH
ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS;
ACCOMPANIED BY GREG HARMS, PROGRAM ANALYST, READJUSTMENT
COUNSELING SERVICE, VETERANS HEALTH ADMINISTRATION, U.S.
DEPARTMENT OF VETERANS AFFAIRS
Dr. Batres. Thank you, Mr. Chairman. Thank you, sir. Mr.
Chairman and Members of the Subcommittee, I appreciate the
opportunity to appear before you today to discuss the Vet
Center Program of the Department of Veterans Affairs and the
role it plays in providing care and services to veterans.
This year marks our 28th anniversary of the Vet Center
Program. Based on the program's record of success in serving
the Nation's veterans, eligibility to Vet Center services have
been extended by Congress to currently include all veterans
that served in combat during any period of armed hostility.
The Vet Center Program is a unique Veterans Health
Administration program designed to provide readjustment
counseling services to help combat veterans make a successful
transition to civilian life. Through their local Vet Centers,
eligible veterans have access to professional readjustment
counseling for war-related, social and psychological
readjustment problems, family and military-related readjustment
services, substance abuse screening and referral, military
sexual trauma counseling, bereavement services, employment
services and multiple community-based support services such as
preventative education, outreach, case management and very
importantly, referral services.
VA's Vet Center Program currently consists of 209
community-based Vet Centers located in all 50 States, the
District of Columbia, Guam, Puerto Rico and the U.S. Virgin
Island. Designed to remove all unnecessary barriers to care for
veterans, the Vet Centers are located in convenient settings
within the community outside of the larger medical facilities.
With the onset of hostilities in Afghanistan and Iraq, the
Vet Centers commenced to actively outreach and extend services
to veterans returning from Operation Enduring Freedom and
Operation Iraqi Freedom. From early in fiscal year 2003 through
the end of the third quarter in fiscal year 2007, the Vet
Centers provided readjustment counseling services to over
242,000 veteran returnees from OEF and OIF.
To promote early interventions, the Vet Centers initiated
an aggressive outreach campaign to locate and form and
professionally engage veterans as they return from the war in
Afghanistan and Iraq. Over the 2-year period from fiscal year
2004 through fiscal year 2005, the Vet Center Program hired 100
OEF and OIF veteran returnees to provide outreach services to
their fellow combatants.
The Vet Centers also provide bereavement counseling to
surviving family members of Armed Forces personnel who died
while on active duty in service to their country. Vet Centers
are providing bereavement services to military family members
whose loved ones were killed in Afghanistan and Iraq. Since
2003 to the end of the third quarter in FY 2007, 1,045 cases of
active military, or active duty military-related deaths have
been referred to the Vet Center for bereavement services.
Vet Centers are staffed by small multi-disciplinary teams
composed of a mix of mental health professionals, which
represents over 50 percent of our treatment staff, counselors
from other disciplines and outreach specialists. A majority of
Vet Center service providers are themselves veterans, most of
whom served in a combat theater of operations.
Having a large number of veterans on staff is a
distinguishing characteristic of the Vet Centers and enables
the program to maintain a veteran-focused treatment environment
that communicates a welcome home attitude and respect for
veterans' military service.
Today, the Vet Center Program is undergoing the largest
expansion in its history since the days of the program's
founding. The planned expansion complements the efforts of the
Vet Center outreach initiative by ensuring sufficient staff
resources be available to provide the professional readjustment
services needed by the new veterans as they return home.
In fiscal year 2006, VA announced plans for establishing
two new Vet Centers and augmented staff at 11 existing Vet
Centers, bringing the current number of Vet Centers to 209. In
February 2007, VA announced plans to increase the number of Vet
Centers to 232 and to augment the staff at 61 existing sites.
In May of 2007, VA announced that it planned to hire an
additional 100 new staff positions to the Vet Center Program in
FY 2008.
The Under Secretary of Health has also targeted an
additional number of sites that are being assessed in 2009
which will further augment the Vet Centers' ability to address
the readjustment needs of war veterans and their family.
The Vet Center Program reports the highest level of veteran
satisfaction recorded by any VA program. For the last several
years, only 99 percent of veterans using the Vet Centers
consistently reported being satisfied with services received
and responded in addition to that, that they would recommend
the Vet Center to another veteran.
Mr. Chairman, this concludes my oral statement. I am happy
to answer any questions that you or other Members of the
Subcommittee may have.
[The prepared statement of Dr. Batres on pg. 40.]
Mr. Michaud. Thank you very much, Doctor. I really
appreciate your testimony. Would you tell the Subcommittee what
criteria you use to establish a Vet Center?
Dr. Batres. Yes, sir. We are using demographic data such as
the total veteran population in the Vet Centers veteran service
areas, measure of market penetration, i.e. how many veterans
have been seen within the area. We also looked at the
geographical proximity to the VA medical centers, community-
based outreach clinics, in that particular area.
In addition, we included an analysis of information from
the DMDC which is the DoD Defense Manpower Data Center, as to
the current number of separated OEF/OIF veterans and their
reported distribution of home zip code codes of those
separated, as well as a number who were married and those who
had children. All of the above formed the main criteria for our
selections.
In addition, through our reports from our regional
structures in Vet Centers, we looked at rural areas where you
had large concentration of veterans distributed over large
geographical areas and where there were no local medical
centers or community based outpatient clinics or other services
available as part of our criteria.
Mr. Michaud. In that DoD information, does that number also
include the National Guard and Reserves?
Dr. Batres. Yes, sir.
Mr. Michaud. Okay. Good. Do you know what the projected
cost is for the 23 new Vet Centers and does that include the
appropriate funding for staff, appropriate staff?
Dr. Batres. Yes, sir. The amount for the 23 new Vet Centers
was $14 million and that included the 61 augmented sites.
Mr. Michaud. Okay. Why are there such few number being
activated this year and the bulk next year? Could you speed
that up more?
Dr. Batres. Yes, sir. And we are making every effort. We
actually will exceed our target by the end of the fiscal year.
We look to have--currently I think we are on target to maybe
open seven to ten of those Vet Centers. We projected to have
six. It is a long process that involves us working with private
sector landlords and the like. Bids have to go out by
regulation.
It takes a while to select a site. We are hiring people at
these sites. We have a fair number already hired. I expect to
be ahead of target by the end of the fiscal year and we are
already hiring staff that we had planned to open in 2008. So we
are speeding it up, sir.
Mr. Michaud. Okay. Have you done long-term projections as
far as the workload, say, within the next five to 10 years, and
in those projections, are you considering what is happening
particularly in Iraq and Afghanistan, assuming that we are
there for longer periods of time than is sometimes estimated?
Dr. Batres. Well, like everybody else, sir, we--I
personally did not know, like everyone else, how long the war
would go. So it has been very difficult to project those kinds
of numbers. However, our Office of Policy and Planning are
doing those projections as we speak and we are interfaced with
them and we will be the number projected. We are getting
numbers from DoD. So we are planning for the 5-10-year plan.
Mr. Michaud. And when will you have those numbers back?
Dr. Batres. I will check and get back to you on that.
[The response is included in the answer to Question 3A in
the Questions for the Record provided by Dr. Batres, which
appears on pg. 53.]
Mr. Michaud. I appreciate that. I would be interested in
knowing that assumption because we have heard in the past, when
we were dealing with budgets within the VA, that they do not
calculate the fact of the war.
My last question is, have the Vet Centers seen an increase
in women veterans seeking assistance and what are you doing to
make sure that assistance is there--are you providing more
contract services relating to female veterans?
Dr. Batres. Yes, sir. We do have a contract program that
has been in existence for 28 years. We have over 200 private-
sector contractors that we fund primarily for rural areas. We
are seeing an increase in women veterans. As I understand it,
they reflect about, depending on the estimates, 12 to 13
percent of all in-country service-members. We currently are
seeing female veterans from OEF/OIF at about the 11 percent
rate among all of the folks that we are treating. So we also
have about 10 percent of our OEF/OIF outreach workers are women
also, which helps in terms of doing the kind of sensitive,
effective outreach that is needed.
So we are seeing an increase in the number of women
veterans who are coming in. And they are reflective of how they
serve in the theater.
Mr. Michaud. Thank you.
Mr. Hare.
Mr. Hare. Thank you, Mr. Chairman. Doctor, I was wondering,
the current number of Vet Centers that you talked about and the
ones that are online to be opened up, and I wasn't sure of the
Chairman's question in terms of the number of veterans, but you
are still looking at how many additional Vet Centers you would
need in the next 5 years, correct?
Dr. Batres. We are looking at the demand and then based on
that demand we would be looking at whether we would augment
existing sites if they are going to be coming back, or if
needed, to create outstations in other places or new Vet
Centers. For example, we just opened up--we are opening another
Vet Center, I believe, next week in Phoenix, Arizona. Phoenix
only had one Vet Center. It has grown into a very large
community. So we would want to fund those.
Mr. Hare. Mm-hmm.
Dr. Batres. And we are also opening one in Grand Junction,
Colorado, which is a more rural area, but it has a high level
of veteran population.
Mr. Hare. What challenges, Doctor, have you faced in trying
to recruit and to retain staff, appropriate staff that you need
for the centers? I am assuming that that is probably a big
problem for you.
Dr. Batres. Well, I have an aging staff up until about 5
years ago when we started to heavily recruit the new veterans.
We now have hired over 150 younger OEF/OIF veterans to
complement our existing cadre. We were predicated on serving
Vietnam veterans and for many, many years that is what we did.
We served the Vietnam era veterans. So I guess I am about the
average age for my staff and I am close to 60. However, in the
last 5 years, the average age of the Vet Center employee has
dropped by over 10 years.
Mr. Hare. All right. So----
Dr. Batres. So we are hiring the newer, younger veteran,
encouraging to come in and serve. Over 50 percent of my cadre
are VA mental health providers. They are either social workers
and/or clinical psychologists. And given our mission which is a
non-medical setting, I think that that is a pretty effective
balance from where I stand in terms of meeting the need for
folks who walk in.
Keep in mind also that in the work that we do, we refer a
lot of people. We actually are brokers for the veteran when
they come in. We cannot provide all the services. So we make
over 250,000 referrals to VA medical centers that are
appropriate referrals depending on the individual, and we make
many more referrals to the VBA for benefits and those types of
services. We don't provide every service that a veteran may
walk in for.
As Congressman Snyder alluded to, we triage and we get the
people to the right places for that type of service. Sometimes
when they are not eligible for VA services, we will broker with
the local community resources and get them to those places
also. We case manage those cases.
Mr. Hare. I just have two real quick questions for you,
quick from my perspective, probably longer for you. But in your
estimation, where is the biggest gap in service for the Vet
Center in the Vet Center Program? And, you mentioned--I have a
lot of rural community in my congressional district, 23
counties, a pretty big one. What are the toughest things trying
to meet the readjustment needs for veterans that you found in
the rural communities?
Dr. Batres. Well, thanks to Congressman Michaud, we are
initiating surveys of the field. We have historically relied on
our side visits to assess need and work with our teams. But by
initiating questions directly to the folks out in the field, we
have gotten a different perspective. And what really seems to
be the field's perspective right now is a need for increased
family members with the veteran that are coming back and
needing assistance.
And those types of services include everything from
brokering them like we do with the bereavement cases. In that
population, most of them don't need psychiatric help. They need
someone to help them manage the huge transition from being in a
supportive active military base community as a dependent and
then all of a sudden having to move off the base and then move
back into civilian life. So we help them to make those
transitions as we provide professional counseling where
available to those individuals.
Certainly, I think that family services, especially for the
wounded and the caregivers, is an area that we need to look
more closely and also sustaining our services to the growing
number of Vietnam veterans who are accessing care at the Vet
Centers. Vietnam veterans and families are also a growing
number for us. So it is kind of a mix between those two.
Mr. Hare. Okay. Thank you, Doctor.
Dr. Batres. Yes, sir.
Mr. Michaud. Dr. Snyder.
Mr. Snyder. Thank you, Mr. Chairman.
Dr. Batres, I am pursuing a little bit this bereavement
counseling. We had a hearing last week on the Armed Services
Committee on the presentation by the Commission that was set up
on mental health services for active-duty personnel. And one of
the things that was brought out by Dr. McDermott, not our
fellow member Dr. McDermott of Washington, but a woman doctor
who is I think the Co-Chair of the Commission or certainly was
one of the members of the Commission, was that TRICARE doesn't
cover bereavement counseling and I guess we seem to have been
surprised since we have a real problem in our country with
health insurance covering mental health issues.
But a lot of us were surprised that the TRICARE, being the
healthcare system set up for our men and women in uniform, that
it didn't cover bereavement counseling for our military
families. Were you aware of that? I noticed that you have,
specifically in your opening statement, you all do enough
bereavement counseling that you included it in your statement.
Were you aware that TRICARE didn't cover bereavement counseling
for our active-duty military families?
Dr. Batres. I was not aware of that, but I would not be
surprised. I think that historically, the DoD has done a very
good job of treating the next of kin and assisting them through
that process. Our services are extended to all family members.
That would be the children, significant other, grandparents.
The extended family is provided counseling. And it is
coordinated through DoD. But I was not aware of the TRICARE
situation.
Mr. Snyder. I suspect, and I don't know this, I suspect
that it is not so much an issue for those that are on the basis
as you talked about, the military families there. While I think
you very appropriately pointed out that abrupt transition that
can occur for those families when their loved one is killed,
but for our activated and deployed Reserve component troops
where the family is not on a military base but is in a
community, perhaps a civilian community a long ways away from a
military base whose healthcare system has been the same local
physician for some time and this issue of coverage for
bereavement counseling may be something that we need to look
at.
I wanted to just flesh out briefly this issue I brought up
with the previous panel on your statement where the Vet Centers
have no waiting lists and veterans may be seen by a counselor
the same day. From what you have said, I assume that you are
not saying--and that counselor that they see is the one that is
going to meet their every need. It is more of a triage
function; is that correct?
Dr. Batres. Yes, sir, and that is a very important
distinction. I think it is in many ways, how you ask the
question and what the person interprets the question to be.
What we mean by no waiting list is that we will see the veteran
when they come in, make an assessment, schedule them, and/or
refer them. If they come in with co-morbid or other kinds of
needs that we cannot provide, we will refer them to the medical
center, many times scheduling, helping to schedule their
appointments and making sure that they get there.
It also means that if they come in and they are non-
emergent, that we will schedule them with the appropriate
counselor, he or she, whoever is available. And then they will
be seen a week or 2 weeks later. What we found in the field
after our survey was that what was taking longer was not the
initial visit, but that it was taking some of our counselors
longer to see clients. And that is a concern. So we are making
steps to make sure that we get the right resources to those Vet
Centers.
Mr. Snyder. So your counselors buildup a caseload and then
they go to follow-up appointments and then your triage person
calls up Mr. Harms who is going to be the counselor and Mr.
Harms says great. I have got my earliest appointment is 6 weeks
and that is not--is that the kind of thing you are looking at?
Dr. Batres. We are, except there is no 6 weeks. We would
consider 2 weeks a long time to wait.
Mr. Snyder. A long time.
Dr. Batres. Yes, sir.
Mr. Snyder. What is your--what is the worst thing that has
happened in one of your Vet Centers in terms of inappropriate
care in the last few months? I mean how--do you hear about
incidents where someone came in, was triaged, yeah, we can see
you 2 days from now and something terrible happened that night?
What is the reporting system that you have so that you all are
aware of when things don't go right?
Dr. Batres. They are required to report immediately any
type of negative impact and----
Mr. Snyder. Report to whom?
Dr. Batres. They report directly to us, meaning we have a
chain of command directly to the regional office, to our office
and we monitor that very closely. May I say that in 28 years of
existence, 26 of which I spent in the program, we have never
had a tort claim. We have never been charged with any type of
malpractice or anything like that, to my knowledge. So we get
very few, if any, of those types of complaints.
And some of the things that concern me are, we had an
unfortunate event where a veteran at a post deployment health
reassessment committed suicide after being screened. That
concerns me a lot. As soon as I find out about it, I informed
the Under Secretary for Health and we had our medical inspector
do a review of the case routinely and we look at things for
lessons learned and we try to improve from those tragic kinds
of events that happen.
The most tragic are those that we can't reach because of
either stigma or the veteran not being able to be----
Mr. Snyder. The ones that don't ever get through your door.
Dr. Batres. The ones that never come to the door.
Mr. Snyder. Thank you, Mr. Chairman.
Mr. Michaud. Yeah. I would like to actually follow up on
one of Dr. Snyder's question about the complaint. You said they
go to the regional office and then you. Why would they report
to the regional office?
Dr. Batres. Because that is their chain of command. Our
organizational structure is, and we are a very small
organization. We are lean and mean, if you will. Central
Office, one regional office, and then all, all the Vet Centers,
that is our chain of command.
Mr. Michaud. Is that regional office a VISN office?
Dr. Batres. No.
Mr. Michaud. Okay. The regional Vet Center office.
Dr. Batres. Yes, sir.
Mr. Michaud. Oh, okay.
Dr. Batres. In your area, sir, it would be in New
Hampshire.
Mr. Michaud. Okay. I thought it was the regional VISN
office and I couldn't----
Dr. Batres. No, sir.
Mr. Michaud [continuing]. Figure out why they would report
there. Following up on Mr. Hare's question as it deals with
hiring appropriate staff, because I do know that in a lot of
States there is a shortage of healthcare professionals. Did I
understand you correctly saying you do not have a problem
hiring the medical staff that you need to work at the Vet
Centers?
Dr. Batres. It is a challenge to hire. We hire social
workers, psychologists and psychiatric nurses. We are a non-
medical setting. Those are getting harder to recruit. We do
hire a lot of retirees from DoD though that are coming out and
that is a very nice pool. They are veterans. And again, one of
our hallmarks is hiring veterans. We feel that that is a
strength in the program and we are tapping that pool.
And we have not had the opportunity in the past with this
kind of increase in capacity. We are recruiting and I think we
are getting a fairly decent initial group of folks into the
centers.
Mr. Michaud. Good. To followup on that same line of
questioning, I have been seeing at Walter Reed and Bethesda, a
definite need for healthcare providers out there because of
what is happening in Iraq and Afghanistan. So there is a huge
influx of need there.
Ultimately, when the war does end, I think you are going to
see Walter Reed and Bethesda not needing the capacity that they
are building up currently. But within the VA system, there will
probably be a higher need.
So my question is, what is the VA doing to work in
conjunction with the DoD to see that the healthcare providers
that are currently working at DoD are going to be needed,
instead of getting laid off? Are you going to have that--can
you visualize or are you working to talk about how can you
utilize those healthcare providers versus going out and
actually hiring someone outside of the Federal Government?
Dr. Batres. Well, first of all, I don't think that I have
not gotten to that point because we routinely screen and
actually outreach the recruiting mental health provider
population at DoD consistently for that reason. But your point
is well-taken. The hundred GWOTs--by the way we have over 150
GWOT veterans to include the hundred GWOTs. We have over 50
staff that are OEF/OIF veterans as regular counselors.
It is a dilemma. Part of the job of the outreach workers is
to go out and encounter these folks and get them resources.
After the war ends, there should be a downsizing of those
efforts. What is happening with our GWOT staff is that many of
them are going to school and getting their degrees and their
education. And like many of us who served in the Vet Center
Program after the war, we got our degrees and then went to work
at VA, they, I think, present a pool for hiring down the road.
But I think it is an excellent idea and I can pursue that
and get back with you, because I think the last I heard, DoD
was also struggling. But once the war ends, there may be a
group of folks there that could present a potential pool, if I
am hearing you right, for us to hire.
Mr. Michaud. Mr. Hare or Dr. Snyder, any additional
questions?
Well, once again, I would be remiss if I did not thank you,
Doctor, and the entire Vet Center staff for all that you do for
our veterans, as well as for your high approval rating of the
services that the Vet Centers give to our veterans nationwide.
You are all to be commended for what you are doing in such a
highly satisfactory manner as well. So I want to congratulate
you and thank you personally, as well as your entire staff, for
what you are doing.
And once again, I thank all of the other previous panel
members for coming today. The hearing is closed. Thank you.
Dr. Batres. Thank you, sir.
[Whereupon, at 3:33 p.m., the Subcommittee was adjourned.]
A P P E N D I X
----------
Prepared Statement of the Hon. Michael H. Michaud,
Chairman, Subcommittee on Health
The Subcommittee on Health will come to order. I would like to
thank everyone for coming today.
Before we begin, I ask unanimous consent that all written
statements be made part of the record. Without objection it is so
ordered.
I ask unanimous consent that all Members be allowed five
legislative days to revise and extend their remarks. Without objection
it is so ordered.
Today we are here to discuss Vet Centers--the benefits that they
have provided to our current population of veterans and the important
and growing role they will have in helping veterans from Afghanistan
and Iraq.
The Vet Center program was established in 1979 to help Vietnam Era
veterans with readjustment challenges.
Vet Centers provide an alternative environment outside of the
regular VA system for a broad range of counseling, outreach, and
referral services.
Most importantly, Vet Centers provide an environment in which
veterans can speak openly to veterans about their experiences.
Vet Centers have been a success, and now they have a new mission.
In 2003, then Secretary Principi extended Vet Center eligibility to
OEF, OIF, and Global War On Terror veterans as well as bereavement
counseling to survivors of military personnel who die while on active
duty, to include federally activated Guard and Reservists.
Not surprisingly, workload at Vet Centers continues to increase.
This trend will likely continue as OEF/OIF veterans deal with
everything from mild readjustment issues to serious mental health
challenges.
VA currently has 209 Vet Centers located throughout the United
States, Guam, Puerto Rico and the U.S. Virgin Islands.
There are five Vet Centers in Maine that do great work (Bangor,
Caribou, Lewiston, Portland, and Sanford).
VA has scheduled 23 new centers to open in the next 2 years. There
has also been an effort to hire GWOT veterans to serve as peer-to-peer
counselors.
The purpose of this hearing is to determine how Vet Centers can
continue to fulfill their unique and critical role within the VA
continuum of care.
Each generation of veterans has its own unique needs. It is
important that Vet Centers are prepared to meet the needs of our new
veterans while still caring for veterans from previous conflicts.
I look forward to hearing from our witnesses on:
How we can maintain and improve services provided by Vet
Centers;
If we have appropriate facilities and staffing;
What role can and should other resources within our
communities play to help veterans and improve care; and
Most importantly, what should we do to strengthen the
invaluable peer-to-peer counseling available through Vet Centers?
Prepared Statement of Sue Bergeson, President, Depression and Bipolar
Support Alliance
Chairman Michaud and members of the Committee:
On behalf of the Depression and Bipolar Support Alliance (or DBSA),
thank you for the opportunity to testify today about mental health
services offered to and needed by our veterans through the veterans
centers of the Veterans Administration. DBSA further thanks you and the
other members of the Committee for your efforts in focusing the
attention of the nation on the plight of the men and women of our
military forces who are returning from combat with their mental health
devastated.
DBSA is the nation's largest peer-run mental health organization,
with more than 1,000 state and local affiliates in all 50 states. By
peer-run, we mean that our organization is led by staff and volunteers
living with mental illnesses--people like me--people who experience the
debilitating effects of mental illnesses first-hand. Our organization
focuses on the power of peer support as a key component in recovery
from mental illnesses.
DBSA regularly partners with the VA on peer support training and
technical assistance for veterans, both nationally and at local
facilities. Additionally, DBSA has long been represented on the
Consumer Liaisons Council to the VA Committee on Care of Veterans with
Serious Mental Illness.
One of the most important services DBSA offers--indeed, our
cornerstone--is helping people diagnosed with mental illnesses to help
each other. We train individuals and establish support groups
throughout the country, preparing them to assist their peers on the
road to recovery.
Let me first briefly describe our perspective on the need faced by
veterans today, a need of which I know this Committee is all too aware,
but which helps lay the groundwork for an effective and cost-effective
solution.
Recent and continuing conflicts in Afghanistan and Iraq have placed
a heavy burden on our country's National Guard and Reserves, in
addition to the standing armed forces. Not unexpectedly, these
conflicts have taken a toll on the mental health of the men and women
serving.
With more than a quarter million individuals returning from active
military service in FY2006, many of them coming from postings of
extreme danger and stress, there is an overwhelming need for mental
health care for veterans. More than 35 percent of Afghanistan and Iraq
veterans treated at the VA have been diagnosed with mental disorders.
The Defense Medical Surveillance System, in data reflecting the
health self-assessments of service members who had returned from Iraq
since June 2005, showed that 50 percent of Army National Guardsmen and
approximately 45 percent of Army and Marine reservists reported mental
health concerns. Much of the mental health treatment these service
members receive is provided by the VA, which estimates that 35 percent
of the care provided through its facilities from 2002 to 2006 was
related to the diagnosis or treatment of a mental health disorder.
According to a recent article published in the Archives of Internal
Medicine, veterans ages 18 to 24 returning from Afghanistan and Iraq
are nearly three times more likely to be diagnosed with mental health
or posttraumatic stress disorders, compared with veterans 40 years or
older.
Dr. Karen Seal, a physician at the San Francisco VA Medical Center
and lead author of this new research, states, ``You have a young
population possibly not getting treatment for these conditions, and
going on to have chronic mental illness . . . It's potentially a big
public health problem.''
In answer to calls by veterans and their families, screening of
returning veterans for symptoms of mental illness is now more
widespread. Yet this screening does not identify many affected
individuals. Some veterans do not immediately experience symptoms,
which arise much later after their return to civilian life. A high
proportion of soldiers misinterprets or ignores symptoms in order to
return home more quickly, or in response to the pervasive stigma of
mental illness in the military.
At the very time the need for mental health services is the
greatest, sadly, the Veterans Administration does not have the capacity
to deliver these services to all veterans in need. Despite the valiant
efforts of the many dedicated service providers working throughout the
VA, current capacity cannot meet demand. News reports continue to
document a staggering number of unfilled VA mental health positions.
These shortages result in long waits for appointments and care,
sometimes with tragic consequences for veterans in need.
Many veterans, distrustful of VA services and mental health
professionals, or wanting to put all reminders of military service
behind them, never seek available care or seek it only after reaching
the crisis point.
In 2006, a committee of VA experts declared that the ``VA cannot
meet the ongoing needs of veterans of past deployments while also
reaching out to new combat veterans . . . and their families by
employing older models of care. We have a new job and we need to do it
in a new way. ''
Chairman Michaud, Today we have the greatest resource to help
combat these grim statistics right at our fingertips--and that resource
is our veterans themselves. The members of our armed forces pledge to
leave no comrade behind on the battlefield. When the enemy becomes
mental illness, our nation's veterans stand willing to help each other
in this new conflict. Such support comes naturally to veterans who have
been trained to rely on each other in battle, and who now face the
biggest battle of their lives--the struggle to overcome mental illness.
Veterans, who have successfully recovered from mental illnesses,
reaching out to other veterans with mental illnesses, are an authentic
source of hope for the future. Veteran peer supporters can connect with
other veterans at a level no clinical provider, however dedicated, can
match.
Let me illustrate the value of veteran peer support services
through the example of a resident of the Chairman's home state of
Maine. Jack Berman is a resident of South Portland, Maine. He is a
disabled veteran who has served as vice president of the Maine Military
Coalition, and as president of the Military Officers' Association of
America (MOAA).
Seventy-nine-year-old Jack Berman is a man of many talents--in
spite of the adversity he has faced in his life. An entrepreneur, a
rehabilitation counselor, a highway-planning engineer for the New York
Port Authority--these are just a few of his accomplishments.
Mr. Berman was appointed first lieutenant during the Korean war and
fought on the front lines. In 1953, he finished his tour of duty and
was awarded five medals, including three bronze stars for Korean
service, the United Nations medal and the American National Defense
medal.
Yet while in training to go overseas, he was hospitalized and
diagnosed with bipolar disorder with episodes of severe depression. As
an individual living with a mental illness, how did Mr. Berman survive
and excel in so many areas? The answer was connecting with individuals
just like him.
As Mr. Berman tells us, veterans are not often inclined to share
their stories about the terrible experiences of war with those who may
not be able to understand or identify with them. As he told DBSA,
``These guys are willing to get their medications from a psychiatrist,
but they don't want to talk to them. They want to talk to others like
them.''
That is why Mr. Berman believes that peer-to-peer support is the
ideal solution for our country's many veterans who are now experiencing
the impact of returning from active duty. ``When a soldier is able to
openly share his feelings with another soldier like himself, someone
else with a mental illness, something magical happens,'' Mr. Berman
says. ``Talking to my peers was the healing factor in my recovery.''
Our country's third President, Thomas Jefferson, said, ``Who then
can so softly bind up the wound of another as he who has felt the same
wound himself?''
Peer support in the mental health arena represents a bond between
two individuals who share the common experience of a mental illness,
and who commit themselves to helping each other achieve lasting
recovery. Peer support services have been demonstrated to be an
effective supplement to clinical care for mental illnesses.
Solid research shows that peer support is an effective tool in
improving mental health, leading to improvement in psychiatric
symptoms, decreased hospitalization and decreased lengths of hospital
stays, enhanced self-esteem and social functioning of those served, and
lower services costs overall.
A proven method to harness the power of peer support and overcome
the significant barriers to successful treatment is the Certified Peer
Specialist. These individuals are trained and certified to help their
peers--other people with mental illnesses--deal successfully with their
challenges and move forward with their lives. Peer Specialists help
those they assist to make informed, independent choices, and to gain
information and support to achieve those goals. They demonstrate
recovery from mental illness and how to maintain ongoing wellness.
Peer Specialists offer more regular interaction with others than
overworked clinical staff can provide. The outreach they provide in the
community and through veterans centers makes support accessible to
larger numbers of veterans than can be reached through traditional
means alone. And this new role provides opportunities for meaningful
work and financial independence for veterans with mental illnesses, who
otherwise may have difficulty finding employment.
Peer Specialist services are also significantly cost-effective and
have been shown to cost up to 5 times less than older models of care,
with improved clinical outcomes. The VA has already identified paid
Peer Specialist services as a priority in its Mental Health Strategic
Plan and has provided very limited funding for implementation at local
VA facilities. DBSA is proud to have assisted in many of these efforts.
However, barriers to full VA implementation of Peer Specialists
remain. Some voluntary veteran peer support initiatives exist but are
not always integrated into care and/or seen as effective by providers.
Veterans need quality training to help them work effectively as peers,
and VA providers need preparation to help them fully understand and
accept this new approach. Many VA facilities are moving to hire
veterans as Peer Support Technicians (the VA's terminology for Peer
Specialist), but no consistent guidelines and standards exist for
training and integrating these positions as a key element of mental
health services.
There is a critical need for implementation of a national-level
pilot project that sets the gold standard for VA Peer Specialist
training and delivery of services. Current and future needs require a
large-scale and coordinated national effort to make quality peer
support services a reality nationwide through the VA.
Therefore, we urge the committee to encourage the VA Office of
Mental Health Services to take these three steps:
Identify and allocate a significant increase in funding
for a national veterans mental health peer training and employment
initiative.
Establish and fund a VA Technical Assistance Center for
Peer Support Services, partnering with an established national
organization with demonstrated experience in peer support training.
Create and pilot national veteran Peer Support Technician
training and certification projects in multiple locations throughout
the country.
These actions are just a small part of what we can do to provide
our veterans with the necessary tools to fight this new battle on their
return home.
DBSA stands ready to assist the committee in its efforts. I thank
you for this opportunity to offer our input and would be happy to
answer any questions.
Prepared Statement of Shannon Middleton, Deputy Director for Health,
Veterans Affairs and Rehabilitation Commission, American Legion
Mr. Chairman and Members of the Subcommittee:
Thank you for this opportunity to present The American Legion's
views on the current and future services provided by Vet Centers. Vet
Centers provide a necessary service and are an important resource for
combat veterans experiencing readjustment issues, especially those who
do not live in close proximity to a Department of Veterans Affairs (VA)
medical facility.
Current and Future Services Provided by Vet Centers
Vet Centers are a unique, invaluable asset to the VA healthcare
system. They were designed to provide services exclusively for veterans
who served in theaters of conflict, or experienced military sexual
trauma. Because Vet Centers are community based and veterans are
assessed the day they seek services, they receive immediate access to
care and are not subjected to wait lists. They provide mental health
counseling to not just the veteran, but those in his or her support
system--like the spouse and children. Services are provided in a non-
clinical environment, which may appeal to those who would be reluctant
about seeking care in a medical facility. A high percentage of the
staff, more than 80 percent, are combat veterans and can relate to the
readjustment issues experienced by those seeking services.
Vet Centers assist veterans with enrollment into the VA healthcare
system. They provide timely assessments and referrals to the local VA
medical centers (VAMCs) to ensure a continuum of care. Furthermore,
their services encompass more than mental health issues, providing
assistance with applying for VA benefits, providing employment
counseling, participating in homeless veteran stand-downs, working non-
traditional hours or contracting services for the veteran's
convenience. Vet Centers have also expanded their services to
accommodate the growing needs of veterans and their families, such as
providing bereavement counseling to family members of servicemembers
who die in combat.
As a tacit rule, Vet Centers never turn anyone away, providing
alcohol and drug assessments, or referrals to other VA or community
programs, even for those who are not eligible for care.
Since Vet Centers provide such an important service to combat
veterans, The American Legion visited several of them to see how their
resources are meeting the increasing demand of returning combat
veterans. Mandated by Resolution 206, entitled ``Annual State of VA
Medical Facilities Report'', The American Legion publishes an annual
report on VA medical centers and other healthcare facilities. This
report is a compilation of information gathered from a series of site
visits conducted by appointed System Worth Saving Task Force Members
and The American Legion's National Field Service Representatives.
Since the initial report in 2003, each year's report has focused on
different facilities. Past reports have covered VA medical centers
(VAMCs) and Community Based Outpatient Clinics (CBOCs). The System
Worth Saving report is delivered each year to the President of the
United States, the leadership of the Department of Veterans Affairs,
members of Congress and to the public.
The 2007 System Worth Saving Report will focus on select Vet
Centers and select Polytrauma Centers. Task Force members and National
Field Service staff visited several Vet Centers around the nation to
see how they were servicing veterans, with emphasis on outreach to
veterans who served in Operation Iraqi Freedom (OIF) and Operation
Enduring Freedom (OEF). National Field Service Staff selected 46 Vet
Centers that were located near demobilization sites in Arizona,
California, Colorado, Florida, Illinois, Indiana, Maryland,
Massachusetts, Minnesota, Missouri, Nevada, New York, Ohio, Oregon,
Puerto Rico, South Carolina, Texas, Virginia, and Washington State.
Since many returning servicemembers would most likely reside near the
site of demobilization, the Vet Centers selected had particular
significance.
Information collected on the respective Vet Centers include: number
of veterans seen within the Vet Center's catchment area; a breakdown by
war era of the veterans seen--when possible; budget; staffing; outreach
activities; physical plant issues; and, challenges as identified by
staff and management. In an effort to ascertain the effects of OIF on
utilization of services and available resources, the Task Force and
National Field Service Staff solicited information on enrollment,
fiscal, and staffing issues for fiscal year (FY) 2003--the year OIF
began--and FY 2006.
The Vet Center
The Vet Center site visit reports differ among the Vet Centers
visited. In general, they all have extensive outreach plans that reach
many counties in their respective regions. Most have at least one
position for a GWOT Technician. Most are active in participating in
National Guard/Reserve demobilization activities, to include providing
availability at post deployment health reassessment activities and
conducting briefings about Vet Center services.
Many Vet Centers have community partnerships and participate in
their local college work-study programs, allowing OIF/OEF veterans who
are enrolled in college to assist with administrative tasks at the Vet
Centers.
Although most were satisfied with their facilities, indicating
recent upgrades and new furniture, a few indicated space challenges
such as being forced to use remote parking due to the location of the
leased space, having inadequate office space, and needing a new
facility because the owner of the leased building was planning other
use for the space.
The Vet Centers all work with Veteran Service Organizations (VSO)
to provide assistance for veterans in filing claims; some Vet Centers
even reserve space for service officers to make weekly visits. They all
illustrated productive referral systems between the Vet Center and the
local VAMCs.
Some Vet Centers have tailored their programs to accommodate
veterans and families that speak languages other than English as a
first language, or those who practice other customs. Some Vet Centers
indicated that they needed to enhance their services to accommodate
cultural differences and to target rural, women and minority veterans.
Since many combat veterans visit Vet Centers because of urging from
family members, The American Legion believes that enhancing outreach to
target minorities is an important aspect to minority veterans accessing
Vet Center services.
Staffing of Vet Centers
In general, the Vet Centers visited by The American Legion had the
same staff composition, usually a four-person team to include a team
leader, office manager, social worker, and a psychologist or mental
health counselor.
However, a few indicated that limited staffing was an overall
challenge, given an anticipated influx of returning OIF/OEF veterans in
the catchment area. Some Vet Centers shared GWOT Technicians and sexual
trauma counselors with other Vet Centers, or had a part time staff
member.
Some Vet Centers had vacancies because the GWOT Technician, as well
as other key staff members, had been or would be soon deployed again to
serve in Iraq or Afghanistan.
A few indicated the need for a family therapist or a military
sexual trauma counselor. Some of the vacancies had been funded but not
filled as management was seeking qualified individuals to hire.
Still other Vet Centers indicated that they just needed staff
augmentation to handle existing and anticipated workloads.
The American Legion believes that all Vet Centers need to be fully
staffed to ensure that combat veterans seeking care for readjustment
are afforded the same standard of quality care, no matter which Vet
Center they utilize, this includes cross training staff to speak other
languages when necessary--or hiring qualified bilingual staff--and
training staff to learn different mental health specialties.
VA's 23 New Vet Centers
The most important aspect of the Vet Centers is that it provides
timely accessibility. Since Vet Centers are community-based and
veterans are assessed within minutes of their arrival, eligible
veterans are not subjected to long wait times for disability claims
decisions to determine eligibility for enrollment, or long wait times
for available appointments. The Vet Center can provide immediate
attention to the veteran, either directly or through contracted care
when necessary. VA's plan to create 23 new Vet Centers within the next
2 years will bring the number of Vet Centers to 232. This will improve
access to readjustment services for many combat veterans and their
families, some of which reside in underserved areas. The American
Legion believes that VA needs to ensure that future Vet Centers are
positioned to reach as many rural veterans as possible.
Although Vet Centers have extensive outreach plans, more outreach
is needed to reach other groups of veterans who may not know they are
eligible to use Vet Centers or those who may not be familiar with the
program in general. Many veterans learn of Vet Centers by word of
mouth. Reaching veterans residing in rural areas will be a challenge.
Surely, the 100 new Vet Center GWOT outreach coordinators that will be
hired will also enhance outreach to eligible veterans.
The American Legion will do all it can to inform, not only veterans
and their families, but also all other advocates about the service
provided by Vet Centers as well. Combat veterans facing readjustment
issues require immediate access to mental health assessment and
counseling. Vet Centers make this possible. Making more communities
aware of Vet Center services will likely improve the quality of life
for many families.
Again, thank you Mr. Chairman for giving The American Legion this
opportunity to present its views on such an important issue. We look
forward to working with the Subcommittee to address the needs of all
veterans.
Prepared Statement of Adrian M. Atizado, Assistant National Legislative
Director, Disabled American Veterans
Mr. Chairman, Ranking Member Miller and other Members of the
Subcommittee:
Thank you for inviting the Disabled American Veterans (DAV), an
organization of 1.3 million service-disabled veterans devoted to
rebuilding the lives of disabled veterans and their families, to
testify at this important hearing to examine the Department of Veterans
Affairs' (VA) Readjustment Counseling Service provided to veterans by
its ``Vet Center'' program.
Mr. Chairman, we appreciate your decision to hold this hearing,
since many years have passed since this Subcommittee has examined the
Readjustment Counseling Service of the Veterans Health Administration
(VHA). This examination is extremely timely, given the ongoing wars in
Iraq and Afghanistan.
PROGRAM HISTORY
Congress in Public Law 96-22 established the Readjustment
Counseling Service in 1979. President Jimmy Carter proposed a similar
program of readjustment services for veterans in a special Presidential
Message sent to Congress October 10, 1978. That Presidential Message
recognized a number of unmet health, benefits, employment, financial,
and readjustment needs in the population of veterans that had served
our Nation during the Vietnam Era.
It should be remembered from that time that Vietnam Era veterans, a
group of over 8.7 million individuals who were called to service mostly
by involuntary conscription in a very unpopular and politically charged
overseas war, came home from that service with medical, personal and
psychological burdens that the U.S. Government minimized and largely
ignored for years. The Veterans' Administration, which at that time was
an Independent Establishment of the federal government rather than a
Cabinet Department, was managed by World War II and Korean war
veterans, and its patient population consisted primarily of veterans of
those same eras. The VA then was steeped in the traditions and cultures
of that generation's experience in war and of the post-war boom years.
For a variety of reasons, a wide gulf developed between veteran
populations and seemed to become essentially a reflection of a
``father-prodigal son'' relationship. As a general matter, Vietnam
veterans did not seek out traditional VA healthcare and other benefits
or services, and in particular, VA mental health services.
Additionally, World War II-veteran influenced VA facilities did not
reach out to them as a new generation of combat veterans in need. There
was a sense that Vietnam veterans had ``lost'' the war in Vietnam, and
the entire nation and the Veterans' Administration turned its back on
them, confusing the war with the warriors. However, because of the
leadership of one of those Vietnam veterans--the Honorable Max Cleland,
who at that time was serving as Administrator of Veterans Affairs--the
specialized and emerging readjustment services, healthcare and other
needs of Vietnam veterans were brought to the forefront of concerns of
this Committee, its counterpart in the other Body, and the
Administration of President Carter.
Max Cleland went on from his VA position to other positions of
public trust, including serving as a U.S. Senator from Georgia, but we
at DAV believe that former VA Administrator Cleland's greatest personal
legacy to Vietnam veterans is the establishment of the VA Readjustment
Counseling Service. Hundreds of thousands, and perhaps millions, of DAV
members and other disabled veterans have regained their health because
of the existence of the Vet Center program. Today, the Readjustment
Counseling Service conducts its programs through 209 facilities called
``Vet Centers.'' These facilities have grown and matured over the years
since first established as ``storefronts'' primarily in urban areas,
into highly skilled, specialized psychological counseling centers that
meet vital needs of multiple generations of veterans and their
families.
DEMANDS FOR SERVICES
VA estimated the number of Operations Enduring and Iraqi Freedom
(OEF/OIF) veterans it will see in fiscal year (FY) 2007 to be 209,308;
however, as of April 2007, VA reported that 229,015 OEF/OIF veterans
had actually sought VA healthcare since FY 2002. Of those OEF/OIF
veterans that have sought VA care, a total of 83,889 (36.6 percent)
received an initial diagnosis of a mental health disorder such as
adjustment disorder, anxiety, depression, post-traumatic stress
disorder (PTSD) and the effects of substance abuse. Some 39,243 (17.1
percent) unique enrolled OEF/OIF veterans have received a diagnosis of
PTSD at VA medical facilities.
The most recent data available to DAV indicates the Vet Centers are
providing over 1.17 million counseling visits annually to veterans.
However, we are concerned that the expanding role of Vet Centers which
now includes providing military casualty assistance functions in
coordinating and directly providing bereavement counseling to families
of those who have been lost in the current wars; newly energized
outreach activities averaging more than 13,000 outreach contacts each
month to bring knowledge of VA services to the newest generation of
combat veterans; and, other new responsibilities that may be assumed by
Vet Center personnel, has increase this program's workload for OEF/OIF
veterans from less than 20,000 visits in fiscal year 2004, to about
242,000 visits in fiscal year 2006.
VA has intensified its outreach efforts to OEF/OIF veterans through
the Vet Centers. Those centers now make an annual average of 250,000
referrals to the VHA. The department reports relatively high rates of
healthcare utilization among this veteran population. Nevertheless,
with such ready access to VA healthcare provided without cost for 2
years following separation from service for problems related to combat
exposure, it should be noted that roughly two-thirds of separated OEF/
OIF veterans have not yet turned to VA for healthcare. Furthermore,
with post-deployment positive screening rates for mental health
concerns around 32 percent-36 percent and 1.5 million individuals
having served in OEF/OIF, a very rough estimate is that there may be
480,000 to 540,000 OEF/OIF veterans who have mental health concerns but
VA is only seeing a fraction of them.
STRAINING TO MEET THE NEEDS
In October of 2006, subsequent to the VA Secretary's announcement
of the permanent hiring of 100 OIF/OEF combat veterans to serve as peer
counselors \1\ at Vet Centers and the opening of 2 new Vet Centers \2\
for a total of 209, the House Committee on Veterans Affairs issued a
staff report on the capacity of the Vet Centers. The report found that
in the nine months from October 2005 to June 2006, the number of OEF/
OIF veterans turning to Vet Centers for PTSD services had doubled. All
of the Vet Centers surveyed reported a significant increase in outreach
and services to OEF/OIF veterans. Half of the Vet Centers reported that
this increase affected their ability to treat existing workloads.
---------------------------------------------------------------------------
\1\ VA Press Release April 6, 2005 and confirmed during the House
Committee on Veterans' Affairs, Statement of the Honorable R. James
Nicholson, Secretary, U.S. Department of Veterans Affairs, Testimony
Before the House Committee on Veterans' Affairs, May 9, 2007
\2\ VA Press Release June 28, 2006
---------------------------------------------------------------------------
According to news reports on a subsequent internal Vet Center
report, 114 of the 209 Vet Centers need at least one additional
psychologist or therapist to help with the influx of new veterans.
Twenty-two Vet Centers reported that they couldn't provide family
counseling when necessary (``Staffing at Vet Centers Lagging,'' USA
Today, April 19, 2007). We at DAV believe that VA staffing should be
increased in existing centers to ensure all veterans--including
previous generations of combat veterans--who need help at Vet Centers
can gain access to these important readjustment services.
Moreover, we are concerned that highly dedicated Vet Center
personnel may be nearing their maximum efficiency and ability to
maintain their professional effectiveness. We believe the Subcommittee
should exercise strong oversight in this area to ensure that Vet
Centers are being properly staffed for the expanding functions they are
expected to perform. We believe VA has the resources available to
increase Vet Center staffing, and should do so at the earliest possible
date.
In February of 2007, the Department of Veterans Affairs Fiscal
Year 2008 Budget Estimate indicates that VA plans to operate 209 Vet
Centers in 2008, and that, ``Vet Centers are located in the community,
outside of the larger medical facilities, in easily accessible,
consumer-oriented facilities highly responsive to the needs of the
local veterans. As provided at Vet Centers, VA's readjustment
counseling mission features community-based service units emphasizing
post-war rehabilitation, a varied mix of social services addressing the
social and economic dimensions of post-war readjustment, extensive
community outreach and brokering activities, psychological counseling
for traumatic military-related experiences to include PTSD, and family
counseling when needed for the veteran's readjustment. In carrying out
its mission, the Vet Centers prioritize services to high-risk veterans
to include high-combat exposed, physically disabled, women, ethnic
minority, homeless, and rural veterans.''
As shown below, VA states that the increase in requested funding is
required to provide readjustment counseling at VA's Vet Centers to
veterans who have served in the Global War on Terrorism (GWOT). VA
plans to operate 209 Vet Centers in 2008 that are essential for
accessing and treating PTSD or other conditions experienced by our
veterans. VA also states that it expects an increase in PTSD as
veterans return from OEF/OIF after multiple tours of duty.
Readjustment Counseling
------------------------------------------------------------------------
2006 2007 2008
------------------------------------------------------------------------
Obligations ($000)............ $100,333 $110,300 $114,822
------------------------------------------------------------------------
Visits (000).................. 1,170 1,185 1,200
------------------------------------------------------------------------
Concurrent to this budget request, VA announced its intention to
establish 23 additional Vet Centers distributed throughout the nation,
which would bring its total capacity to 232 service delivery points.
According to VA, only three of these centers will be opened this year
and the remainder are planned to be activated in 2008. Given growing
demand for Vet Center services for chronic and acute PTSD and other
adjustment disorders, substance abuse, marital dissolution, and
financial problems among active duty, National Guard, and Reserve
forces who have been deployed in these wars, and given the availability
of significant new Medical Services funding in VA healthcare, we
question why the bulk of these Vet Center openings are being delayed.
ADAPTING TO A NEW GENERATION OF VETERANS
Mr. Chairman, in examining the needs of the newest generation of
veterans disabled by war, the Independent Budget for Fiscal Year
2008recommended and urged that both VA and DoD adapt their programs to
the needs being presented by new veterans, rather than require new
veterans to adapt their needs to the programs traditionally offered.
DAV believes that, particularly in respect to mental healthcare needs,
significant VA adaptation is still imperative. As indicated earlier,
the Vet Centers were established because Vietnam veterans saw little
about the ``old' Veterans' Administration of thirty-five years ago that
appealed to them. That gulf provided the impetus for the creation of
the Vet Center program.
From our contacts today with veterans of the wars in Iraq and
Afghanistan, we are learning that today's VA, including its
Readjustment Counseling Service, may not generally be perceived as an
organization that is tailoring its programs to meet the emerging needs
of our newest generation of veterans. Many of these veterans are asking
the government to allow them a choice of private care rather than be
relegated to care in the VA system. Others wounded in these wars seem
to be resisting or delaying a smooth transition to VA healthcare
Rather than react swiftly in authorizing dramatic shifts to private
healthcare of uncertain quality and questions in continuity, we urge
prudence on the part of the Subcommittee. We hope VA will adjust its
programs in a way that provides a more welcoming, age appropriate,
culturally sensitive and responsive service to our newest generation of
combat veterans, in particular the wounded, whether with ``visible'' or
invisible injuries. We do note that VA's recent announcements of
employing outreach specialists with direct OEF/OIF experience,
designating case managers and others to assist with OEF/OIF veterans'
special needs, and other similar initiatives, are moves in the right
direction. We appreciate these initial changes. We hope more of these
kinds of initiatives can be sustained and expanded where appropriate,
to make VA services more relevant, age appropriate and more effective
in meeting these new veterans' needs. We would be pleased to follow up
with you and your Committee staff to ensure you gain full understanding
of our views on these matters.
CLOSING
Without question, Americans are united in their desire and
obligation to care for those who have been severely wounded as a result
of military service. This obligation is a continuing cost of national
defense. Servicemembers who have suffered catastrophic wounds with
multiple amputations, traumatic brain injury, or severe burns draw
great public sympathy and admiration for their sacrifices. But a
greater challenge exists for those that suffer the devastating effects
of PTSD and other injuries with mental health consequences that are not
so easily recognizable and can lead to serious health catastrophes,
including suicide and other social pathologies, if they are not
treated.
We can meet that challenge by doing everything in our power to
bring these resources into place to promote early and intensive
interventions, which are critical in stemming the development of
chronic PTSD and other related problems, without simultaneously
displacing older veterans with chronic mental illnesses under VA care.
Finally, we must also ensure that family members of veterans devastated
by the consequences of PTSD, adjustment disorders, and other injuries
have access to appropriate and meaningful VA services.
Mr. Chairman, thank you for considering the views of DAV on the
status of the Readjustment Counseling Service of the Veterans Health
Administration. I will be pleased to address any questions from you or
other Members of the Subcommittee. This concludes my testimony.
Prepared Statement of Dennis M. Cullinan, Director, National
Legislative Service, Veterans of Foreign Wars of the United States
MR. CHAIRMAN AND MEMBERS OF THIS SUBCOMMITTEE:
Thank you for the opportunity to present the view of the Veterans
of Foreign Wars of the U.S. (VFW) on this important subject. Vet
Centers are an integral part of the Department of Veterans' Affairs
(VA) capacity to care for veterans. They provide readjustment
counseling to veterans who were exposed to the rigors of combat, and
who may need services to help them cope with the traumas of war. The
community-based services provided at Vet Centers are a helping hand,
giving these brave men and women assistance in obtaining the benefits
and healthcare they are entitled to through VA.
The program began in 1979, when Congress gave VA--then the Veterans
Administration--the authority to provide readjustment counseling
services to Vietnam Veterans, many of whom were encountering serious
problems that interfered with their work, education and personal and
family lives. The centers were created as outpatient treatment
facilities to increase the ease and availability of services. Over
time, the mission has rightly expanded to provide a number of essential
services beyond counseling, and has begun providing services to the
families of servicemembers, who often are affected just as much by the
difficulties of their loved one's combat service.
This program is so essential because its design helps to break down
much of the stigma of treatment. Vet Centers, by and large, are
accessible and welcoming. The less formal setting helps to encourage
those veterans who need its services to utilize them. Vet Centers aim
to eliminate many of the barriers to care, and its employees are adept
at breaking down these barriers.
The quality and variety of services provided at Vet Centers is
excellent. We have heard few complaints about the quality of care, and
the treatment vets receive in these facilities.
Our concern lies with the access to these services. The October
2006 report, ``Review of Capacity of Department of Veterans Affairs
Readjustment Counseling Service Vet Centers,'' conducted by the then-
minority staff of the Subcommittee on Health provided many details of
the access problems veterans face at these centers.
The Subcommittee found that many Vet Centers have had to scale back
services: ``40 percent have directed veterans for whom individualized
therapy would be appropriate to group therapy. Roughly 27 percent have
limited or plan to limit veterans' access to marriage or family
therapy. Nearly 17 percent of the workload affected Vet Centers have or
plan to establish waiting lists.''
These are worrisome trends. But they tell just a part of the story.
In conversations representatives of our national Veterans Service
have had with Vet Centers throughout the country, their greatest
concern is not with the demands for service today, but with the future.
Although the Subcommittee report noted that the number of OEF/OIF
veterans accessing care at Vet Centers had doubled, they are still just
a portion of the population served. As more come back, and more start
to access the benefits and services provided by VA, we can anticipate
an even larger demand for these services.
This is especially true of the mental health services provided at
these centers. We are all aware of the difficulties returning
servicemembers are having because of the unique stresses of this
conflict, and there correctly has been an increased emphasis on their
mental well-being. VA's most recent data, through the first quarter of
2007, shows that around 36 percent of hospitalized OEF/OIF veterans are
returning with some degree of mental disorder. If these numbers hold
form, as they have with previous VA reports, it will represent a
challenge for these Vet Centers.
Mental impairments affect veterans in different ways. Some are able
to easily adapt. Others have intense and immediate needs. Still others
require time and patience to come to terms with what they are feeling,
and to make the sometimes difficult decision to accept treatment. That
latter group is the one that is going to affect these Vet Centers the
most in the future. We must be prepared to handle their growing needs,
and the demands they place on the system. While the Subcommittee had
reported on the problems of today, it is 5 to 8 years from now that
must also be of concern.
To that end, we are pleased to see the Secretary's recent decision
to add 23 new Vet Centers throughout the country. Expanding access is
clearly a good thing. Accordingly, we need to see that each center, new
and existing, is fully staffed, and that areas that report
exceptionally high demands for service are staffed sufficiently so that
these centers can retain one of the characteristics that make them
unique and a convenience for veterans, the drop-in aspect. The
informality of not having to make an appointment is one of the things
that makes these Vet Centers an attractive option for veterans. With
rationed treatments, veterans may be less likely to utilize these
essential services.
We would urge this Committee to utilize its oversight authority by
continuing to monitor the demand for services. As demands rise, funding
priorities must adapt.
There are a few other concerns we have:
First, these centers must be able to handle the increasing number
of women veterans sure to seek treatment, and increase treatment
options and outreach efforts to them. While all centers are required to
have sexual trauma treatment, we must ensure that services are
available to address any issues that arise from them serving in a war
zone where there is no true frontline.
Second, the original vision of the Vet Center was of veterans
helping veterans. That is still a worthy goal, but we understand the
need for qualified and highly trained counselors and staff members--
especially those dealing with the complexities of mental impairments--
who might not always be veterans; what's important is that they are
caring, compassionate, and capable. A number of senior Vet Center
counselors and staff, though, are Vietnam Veterans and are edging
closer toward retirement age. We must be mindful of finding
replacements, especially if we can draw on the experiences of the
younger veterans, including OEF/OIF veterans and those who served in
the Persian Gulf War. VA must do more to educate and train these men
and women, so that they can play an active role in their fellow
veterans' treatment.
Mr. Chairman, I again thank you for the opportunity to present the
VFW's testimony. I would be happy to answer any questions that you or
the members of the Subcommittee may have.
Prepared Statement of Susan C. Edgerton, Senior Health Care Consultant,
Vietnam Veterans of America
Chairman Michaud and Distinguished Members of the House
Subcommittee on Health, on behalf of our officers, Board of Directors
and members, thank you for providing the opportunity for Vietnam
Veterans of America (VVA) to present testimony regarding the Department
of Veterans Affairs' (VA) Readjustment Counseling Services (RCS), or
Vet Center program. This Committee is distinguishing itself for the
attention it has focused on the important issue of post-deployment
mental health and VVA wants to thank you for your continuing efforts.
VVA has always strongly supported the community-based Vet Center
program because of its cost effectiveness, staff commitment, and solid
leadership, but especially because of the high quality of its services,
including individual and group counseling, marital and family
counseling, bereavement counseling, employment counseling, military
sexual trauma (MST) counseling, substance abuse assessments, medical
referrals, assistance in applying for VA benefits, outreach, and
community education. It is a truly unique resource within the system.
Vet Centers, which operate as a non-medical setting, independent from
the Veterans Health Administration main facilities, offer veterans and
their families a haven in which to gather in an atmosphere of trust
that relieves them from the stigma and societal perceived shame often
associated with care-seeking for mental illness elsewhere.
Because of our core belief in the value of the Vet Center services,
VVA was very pleased to learn that in 2007 the VA plans to open new Vet
Center facilities in Grand Junction, CO; Orlando, FL; Cape Cod, MA;
Iron Mountain, MI; Berlin, NH; and Watertown, NY, (with others located
in Montgomery, AL; Fayetteville, AR; Modesto, CA; Fort Myers and
Gainesville, FL; Macon, GA; Manhattan, KS; Baton Rouge, LA; Saginaw,
MI; Las Cruces, NM; Binghamton, Middletown, and Nassau County, NY;
Toledo, OH; Du Bois, PA; Killeen, TX; and Everett, WA scheduled for
opening in 2008). While we are grateful that new centers will offer
access to veterans, it is not just the new centers that require staff.
VVA has called on the VA to increase staff at existing centers for the
past 3 years.
Vet Centers are asked to do a great deal for our veterans and yet,
ideally, they would do even more. VVA would like to see more family
services, including bereavement counseling, counseling for military
sexual trauma available at every Vet Center, and a strong interface
between the Department's recently announced suicide prevention efforts
at the VA medical centers. Recent legislation has also called on
federal community mental health centers to aid in the identification
and treatment of post-traumatic stress and other post-deployment mental
health issues. We hope that Vet Centers are integral in sharing their
expertise with these community providers and become the hub for strong
national networks devoted to this type of care.
As you know, Mr. Chairman, Vet Centers are just one venue the
Department of Veterans Affairs system employs to address post-
deployment mental health issues. Without a host of accessible
healthcare options to which it can refer veterans, Vet Centers alone
cannot be effective. So while this hearing is assessing the Vet Center
program, it is important to acknowledge that Vet Centers cannot be
successful without VA's other treatment programs for substance abuse,
mental illness, homelessness and post-traumatic stress disorder.
Accessibility to post-deployment mental health programs within VA
may diplomatically be referred to as ``uneven''. Unfortunately, stories
of suicides among servicemembers returning from Iraq and Afghanistan
with severe and acute mental illness are likely to continue to make the
system's accessibility problems all too visible. We understand that VA
has conducted a study of the prevalence of suicide among recent
veterans and hope that the results are available to guide policymaking
in the near future. We are pleased that VA plans to also roll out a
national 24-hour hotline and hire suicide prevention counselors at each
VA medical center to assist suicidal veterans as recommended by its own
Inspector General, but once the crisis passes, VA must have services
available to ensure that such veterans receive the care they need. As a
point of entry into the system for many veterans, Vet Centers should
also have a strong role in suicide prevention. In order to be most
effective, Vet Centers require trained personnel and non-traditional
hours of operation. Ideally, each Vet Center would be able to provide
round-the-clock crisis intervention services.
Access to mental healthcare remains problematic even for veterans
currently enrolled. As thousands of troops who have been or are now
deployed in operations in Iraq and Afghanistan return home in need of
post-deployment mental health services--chiefly, treatment for Post-
traumatic Stress Disorder (PTSD), anxiety, depression, and substance
abuse--most experts agree access problems will only worsen. One study
found that about 17 percent of troops from Iraq were returning with
post-deployment mental health issues that required treatment.\1\ A new
study has found significantly higher rates of post-deployment mental
health and psychosocial conditions (31 percent), particularly among the
youngest veterans.\2\ Anecdotally, VVA is aware of veterans of earlier
combat eras who have increased demand for services because of the
effects of aging and exacerbations of existing conditions caused by
exposure to the ongoing deployments in Iraq and Afghanistan.
---------------------------------------------------------------------------
\1\ Charles W. Hoge, MD, et al. ``Combat Duty in Iraq and
Afghanistan, Mental Health Problems and Barriers to Care'', The New
England Journal of Medicine, Vol. 351, No. 1:13-22, July 1, 2004.
\2\ Karen H. Seal, MD, MPH, et al. ``Bringing the War Back Home:
Mental Health Disorders Among 103,788 U.S. Veterans Returning from Iraq
and Afghanistan Seen at Department of Veterans Affairs Facilities,''
Archives of Internal Medicine, Vol. 167, No. 5, March 12, 2007.
---------------------------------------------------------------------------
VA estimates it will treat more than a quarter of a million
veterans (263,000) of Operation Enduring Freedom and Operation Iraqi
Freedom in FY 2008--54,000 more than will have been treated in FY 2007.
This may be an underestimate, just as the VA figures have
underestimated the demand for services by recent returnees the past 3
years. These veterans are seen for a wide variety of problems and
concerns, but more than one-third use some sort of post-deployment
mental health services. Experts recognize that the number of those
veterans seeking services may grow as veterans readjust to civilian
life and they or their loved ones recognize symptoms or signs of PTSD,
substance abuse, anxiety or depression that have commonly been
associated with combat exposure or long-term deployment.
In FY 2006, the readjustment counseling service estimates it
offered 1,170,439 visits to the 228,612 veterans it treated. In FY
2005, it offered 1,046,624 visits to 132,853 veterans. As you might
assume, the workload increase is attributable to the almost five-fold
increase in OIF/OEF veterans, but these numbers tell a more subtle
story. While veterans who use the Vet Centers almost doubled (+72
percent), visits only increased by about 12 percent. Visits per veteran
dropped from 8.2 in FY 2004 to 7.9 in FY 2005 to 5.1 in FY 2006. These
statistics show a system under duress in which many veterans who had
previously been using the system are not getting the same level of
services they once did and new users are probably not getting what they
need.
Staffing patterns have also evolved somewhat in the Vet Centers
with a greater part of the workforce comprised of peer support or
outreach counselors--in FY 04 such counselors made up 10.6 of the
workforce while in FY 06 they comprised 18.2 percent. Perhaps it is not
surprising there has been such an increase in workload--peer counselors
primarily assigned to outreach are doing their jobs! Mental health
professional staff has comprised about 60 percent of the workforce, but
there are now more social workers and fewer psychologists than in years
past. VVA is concerned that these mental health professionals have the
right veteran-specific experience in dealing with the issues they will
address--trauma exposure, sexual trauma, or substance abuse. To that
end, we recommend that Congress fund ``PTSD scholarships'' to fund the
education of peer counselors who are prepared to pursue advanced
degrees in clinical psychology. This would create a new stream of Vet
Center counselors who have both shared the experiences of their
comrades and received adequate professional training to address their
issues.
Vet Center funding also tells us a story. The FY 2007 budget
request for VA estimated that its obligations for readjustment
counseling centers would be $106 million. A $20 million supplement
targeted at the Vet Centers seems generous, but actually represents
only a 19 percent increase in funding to address the large increases in
workload the centers have faced annually during the OIF/OEF deployment
(for example, there was a 72 percent increase in FY 2006).
The story is also incomplete without discussing unmet need.
Notwithstanding the swells within the ranks of the Vet Centers, recent
studies have also shown that four out of five veterans who may need
post-deployment mental healthcare are not properly referred for an
evaluation and that many veterans of operations in Iraq and Afghanistan
who are using VA facilities have failed to seek care for identified
mental and psychosocial conditions.\3\ A June 2006 study conducted by
the Institute of Medicine recommended that all veterans deployed to a
war zone receive a face-to-face screening for PTSD from an experienced
health professional, yet to date this has not taken place for
servicemembers returning from current deployments.\4\
---------------------------------------------------------------------------
\3\ Government Accountability Office. ``Post-Traumatic Stress
Disorder: DOD Needs to Identify the Factors Its Providers Use to Make
Mental Health Evaluation Referrals for Servicemembers,'' GAO-06-397,
May 11, 2006.
\4\ Subcommittee on Posttraumatic Stress Disorder of the Committee
of the Committee on Gulf War and Health, Physiologic, Psychologic, and
Psychosocial Effects of Deployment Related Stress. ``Posttraumatic
Stress Disorder: Diagnosis and Assessment,'' Institute of Medicine of
the National Academy of Sciences, June 16, 2006.
---------------------------------------------------------------------------
Indeed, if these veterans were seeking care in accordance with
their demonstrated need, they would overwhelm VA's current capacity. In
recent years, VA's internal champions--the Committee on Care of
Seriously Chronically Mentally Ill Veterans and the Special Committee
on Post-Traumatic Stress Disorder, for example--have expressed doubts
about VA's mental healthcare capacity to serve these veterans of
ongoing deployments. Last March, the Under Secretary for Health Policy
Coordination told a Presidential commission that mental health services
were not available everywhere, and that waiting times often rendered
some services ``virtually inaccessible.''
New Vet Centers will certainly help in dispersing needed expertise
and accessibility to services throughout the system. However, as
Chairman Michaud well remembers, in the fall of 2006, the Democratic
staff of the House Committee on Veterans Affairs surveyed 64 Vet
Centers. The subsequent report entitled ``Review of Capacity of
Department of Veterans Affairs Readjustment Counseling Services Vet
Centers'' noted that ``the Vet Centers have seen a significant increase
in outreach and readjustment counseling services to OIF/OEF veterans''.
The report also stated that ``. . . from October 2005 through June
2006, the number of returning veterans from Iraq and Afghanistan who
have turned to the Vet Centers for PTSD services and readjustment
concerns has doubled. Without an increase in counseling staffing this
increase in workload has affected access to quality care. Some Vet
Centers have started to limit access.''
Other survey findings noted that ``. . . one in four Vet Centers
has taken or will take some action to manage their increasing workload,
including limiting services and establishing waiting lists'' and
``thirty percent of the Vet Centers explicitly commented that they need
more staff.'' So while additional RCS facilities and the additional
funding Congress provided through its supplemental appropriation for
the VA will certainly help, VVA remains concerned that Vet Center
services may still not be uniformly available throughout the system.
Obviously, VVA is also concerned that services needed by Vietnam
veterans and other earlier conflicts, who also have valid needs, may be
curtailed or delayed so long as to not be useful and therefore
effectively denied.
VVA is therefore compelled to ask the following questions--
Because of the ebbs and flows in its funding, VA has often been
reluctant to invest funding in new staff (an ongoing commitment) in
times it has additional resources. Does the RCS have plans to hire more
professional staff for the remainder of FY 2007, given that it has
received an additional $20 million in the Supplemental Appropriation
for the purpose of hiring more staff? And does the RCS have plans to
hire more professional staff in FY 2008, given that the VA will get a
$6+ billion increase over FY 2007?
If the RCS is not planning to spend the entire $20 million on
adding staff to keep up with the demand for the continually rising
demand for services from veterans and their families, what is the RCS
plan for how these recently provided funds will be effectively spent?
Does the RCS have plans to hire more peer counselors in FY 2007?
And does the RCS have plans to hire more peer counselors in FY 2008
than it currently has on board?
What are the plans to use the $20 million for substance abuse and
the $100 million to enhance other mental health services that address
post-deployment mental health issues?
VVA hopes that the Committee will require detailed plans from VA
that ensure these questions are answered and Congress's goals for the
system are implemented.
Finally, Mr. Chairman, we could not leave any debate related to
post-deployment health without urging you and the Committee to support
efforts to reinvigorate the National Vietnam Veterans Longitudinal
Study. This study is not just important to the veterans of the Vietnam
era, but would provide important findings about the long-term
consequences of post-traumatic stress disorder and other stressors
related to deployment to generations of future veterans. As you know,
VA has found ways to thwart this study, which is already required by
law, for several years, but the Senate Appropriations Committee has
addressed it in the report language accompanying the Military
Construction bill. We hope that you will urge your counterparts on the
House Committee on Appropriations to accept and even strengthen this
language.
Mr. Chairman, this concludes my statement. I will be happy to
answer any questions you may have.
Prepared Statement of Alfonso R. Batres, Ph.D., M.S.S.W., Chief
Readjustment Counseling Officer, Veterans Health Administration, U.S.
Department of Veterans Affairs
Mr. Chairman and Members of the Subcommittee, I appreciate the
opportunity to appear before you today to discuss the Vet Center
program of the Department of Veterans Affairs (VA) and the role it
plays in providing care and services to veterans.
VA's authority to provide readjustment counseling to eligible
veterans was established by law in 1979 to alleviate the specific
psychological symptoms and social readjustment problems that arose from
veterans' traumatic combat experiences in Vietnam. Today, in the
anniversary of the program's 28th year, the Vet Center program's
eligibility includes veterans that served in combat during any period
of war or armed hostility. In 1993, following the legislative authority
for VA to provide military-related sexual trauma counseling, Vet
Centers were designated as one of the main VHA sites for providing
these services to veterans of any era who were sexually assaulted
during military service.
SERVICES
The Vet Center program is a unique Veterans Health Administration
(VHA) program designed to provide readjustment counseling services to
help veterans exposed to the stressful conditions of combat military
service make a successful transition to civilian life. In terms of
service mission, readjustment counseling consists of a more-than-
medical, holistic system of care that provides professional
readjustment counseling to help veterans cope with and transcend the
psychological traumas and other readjustment problems related to their
military experiences in war. Vet Center services also include a number
of other community-based services to help veterans improve the whole
range of their post-military social, economic and family functioning.
One of the distinguishing features of the Vet Center program is the
authority to provide services to veterans' immediate family members as
part of the treatment and readjustment of the veteran. Veterans'
immediate family members are eligible for care at Vet Centers and are
included in the counseling process to the extent necessary to treat the
readjustment issues stemming from the veterans' military experience
and/or post-deployment homecoming. Vet Centers promote preventive
educational services to help veterans and immediate family members
stabilize post-deployment family readjustment problems and assist the
veteran to a successful post-war readjustment.
VA's Vet Center program currently consists of 209 community-based
Vet Centers located in all 50 states, the District of Columbia, Guam,
Puerto Rico and the U.S. Virgin Islands and operates in the community
outside of the larger medical facilities. Designed to remove all
unnecessary barriers to care for veterans, the Vet Centers are located
in convenient settings within the community, and services are tailored
in every community to meet the specific needs of the local veteran
population. To further promote ease of access, veterans are always
welcome to stop by their local Vet Center at any time. Vet Center staff
members are available to welcome veterans and family members, and to
provide useful information about available services. Vet Centers have
no waiting lists and veterans may be seen by a counselor the same day
they stop by for an assessment. Vet Centers also maintain
nontraditional after-hours appointments to accommodate veterans' work
schedules.
The Vet Center program is the primary outreach arm of VHA. All Vet
Centers engage in extensive community outreach activities to directly
contact and inform area veterans of available VA services and maintain
active community partnerships with local leaders and service providers
to facilitate referrals for veterans. Vet Center community-based
outreach and referral services also provide many veterans with a point
of contact for access into the larger VA healthcare system and benefits
programs. The Vet Centers make over 200,000 veteran referrals annually
to VA medical centers and regional offices combined.
With the onset of the hostilities in Afghanistan and Iraq, the Vet
Centers commenced to actively outreach and extend services to the new
cohort of war veterans returning from Operation Enduring Freedom (OEF)
and Operation Iraqi Freedom (OIF). From early in fiscal year (FY) 2003
through the end of the third quarter in FY 2007, the Vet Centers
provided readjustment services to over 242,000 veteran returnees from
OEF and OIF. Of this total, more than 183,500 veterans were provided
outreach services often through group settings, and approximately
58,500 were provided substantive clinical readjustment services in Vet
Centers.
The Vet Center philosophy is early intervention through outreach
and preventive educational services. Research indicates that this may
result in the best outcomes for successful post-war readjustment. To
promote early intervention, VA initiated an aggressive outreach
campaign to locate, inform, and professionally engage veterans as they
return from theaters of combat operation in Afghanistan and Iraq. Over
the 2-year period from FY 2004 through FY 2005, the Vet Center program
hired 100 OEF and OIF veteran returnees to provide outreach services to
their fellow combatants. Since 2004 when the initial OEF and OIF
veteran outreach specialists were recruited, the focus of the Vet
Center program has been on aggressive outreach at military
demobilization and at National Guard and Reserve sites as well as at
other community events that feature high concentrations of veterans.
These fellow veteran outreach specialists are effective in successfully
gaining the immediate trust of returning veterans and help them
mitigate the fear and stigma associated with seeking professional
counseling services.
The Vet Centers also provide bereavement counseling to surviving
family members of Armed Forces personnel who died while on active duty
in service to their country. Vet Centers are providing bereavement
services to military family members whose loved ones were killed in
Afghanistan and Iraq. Since 2003 through the end of the third quarter
FY 2007, 1,045 cases of active duty, military-related deaths have been
referred to the Vet Centers for bereavement counseling, resulting in
services provided to more than 1,570 family members.
STAFFING
Vet Centers staffed by small multidisciplinary teams are highly
responsive to the needs of the local veterans. The team comprises a mix
of mental health professionals, other professional readjustment
counselors, outreach specialists and administrative personnel. In FY
2006, the Vet Center program had 1066 assigned staff positions of which
876 were authorized counseling staff and 159 were outreach specialist
positions. Of the total counseling staff, 507, or 58 percent, were VHA
qualified licensed mental health professionals, i.e., licensed clinical
social workers, doctoral level clinical psychologists with an American
Psychological Association approved internship, and psychiatric clinical
nurse specialists. Every Vet Center has at least one VHA qualified
mental health professional on staff.
A majority of Vet Center service providers are themselves veterans,
most of whom served in a combat theater of operations. Having a large
cadre of veterans on staff is a distinguishing characteristic of the
Vet Centers, and enables the program to maintain a veteran-focused
treatment environment that communicates a welcome home attitude and
respect for veterans' military service. The high percentage of combat
veteran Vet Center service providers facilitates immediate rapport and
promotes a sense of camaraderie within the local veteran community. Vet
Centers also tailor services delivered to meet the specific cultural
and psychological needs of the veteran populations they are serving by
promoting representative diversity among the staff.
FUTURE PLANS
Today the Vet Center program is undergoing the largest expansion in
its history since the early days of the program's founding. The planned
expansion complements the efforts of the Vet Center outreach initiative
by ensuring sufficient staff resources are available to provide the
professional readjustment services needed by the new veterans as they
return home. In FY 2006, VA announced plans for establishing two new
Vet Centers in Atlanta, GA and Phoenix, AZ, and augmenting staff at 11
existing Vet Centers, bringing the current number of Vet Centers to
209. In February 2007, VA announced plans to increase the number of Vet
Centers to 232. Over the remainder of this and the next fiscal year, VA
will establish new Vet Centers in 23 communities and augment the staff
at 61 existing Vet Centers. The following communities will be receiving
new Vet Centers: Montgomery, Alabama; Fayetteville, Arkansas; Modesto,
California; Grand Junction, Colorado; Orlando, Fort Meyers, and
Gainesville, Florida; Macon, Georgia; Manhattan, Kansas; Baton Rouge,
Louisiana; Cape Cod, Massachusetts; Saginaw and Iron Mountain,
Michigan; Berlin, New Hampshire; Las Cruces, New Mexico; Binghamton,
Middletown, Nassau County and Watertown, New York; Toledo, Ohio; Du
Bois, Pennsylvania; Killeen, Texas; and Everett, Washington.
In May 2007, VA announced that it planned to add 100 new staff
positions to the Vet Center program in FY 2008. Together with the 100
OEF and OIF outreach specialists hired in FY 2004 and 2005, these
program expansions represent an increase in Vet Center staffing by 369
positions over pre-2004 staffing levels, a 39 percent increase.
The Vet Center program reports the highest level of veteran
satisfaction recorded for any VA program. For the last several years,
over 99 percent of veterans using the Vet Centers consistently reported
being satisfied with services received and responded that they would
recommend the Vet Center to other veterans.
In summary, through their local Vet Centers, eligible veterans have
access to professional readjustment counseling for war-related social
and psychological readjustment problems, family military related
readjustment services, substance-abuse screening and referral, military
sexual trauma counseling, bereavement services, employment services,
and multiple community-based support services such as preventive
education, outreach, case-management and referral services.
To locate their local Vet Center, veterans can consult the yellow
pages, as well as the federal government listings. In both places the
listing is under ``Vet Center.'' Vet Centers are also listed on the
following Web site: www.va.gov/rcs.
Mr. Chairman, this concludes my statement. I am happy to answer any
questions that you or other Members of the Committee may have.
Prepared Statement of Hon. Jeff Miller, Ranking Republican Member,
Subcommittee on Health, and a Representative in Congress from the State
of Florida
Thank you Mr. Chairman.
The Vet Center program was established by Congress more than 25
years ago as a means of providing readjustment counseling to many
Vietnam era veterans that were experiencing difficulties readjusting to
civilian life after returning home from the war. Vet Centers were
specifically designed to be separate from VA hospitals to overcome
concerns about stigma and offer easy access in friendly community-based
settings.
Over the years, the mission of the Vet Centers has been broadened
to provide counseling, outreach and referral services to all veterans
who served in a combat zone and to include their family members. On the
home front, Vet Centers are increasingly becoming an active support
system for a new generation of returning soldiers and their families--a
place where they can find other veterans who have experienced combat
themselves to help them make a successful readjustment to civilian
life.
Last Congress, we enacted Public Law 109-461 that required VA to
hire not less than 100 additional OEF/OIF veterans to provide
specialized peer-to-peer counseling and outreach to these newly
returning veterans from the Global War on Terror. The law also
authorized $180 million in funding for the Vet Centers.
About forty-one percent of OEF and OIF veterans come from and
return to rural communities. Access to VA services for these veterans
is far more challenging than for their fellow comrades who live in
urban areas.
It is especially important that rural veterans are provided with
the same initial outreach to facilitate subsequent access to all VA
services.
I welcome our witnesses and appreciate this opportunity to obtain
your guidance on how Vet Centers are being used and staffed, the
effectiveness of the services, and ways in which provision of services
can be improved.
Committee on Veterans' Affairs
Subcommittee on Health
Washington, DC.
August 2, 2007
Sue Bergeson
President,
Depression and Bipolar Support Alliance
730 North Franklin Street, Suite 501
Chicago, IL 60610-7224
Attn: Ariel Brenner
Dear Sue:
In reference to our Subcommittee on Health hearing on ``Vet
Centers'' held on July 19, 2007, I would appreciate it if you could
answer the enclosed hearing questions by the close of business on
October 2, 2007.
In an effort to reduce printing costs, the Committee on Veterans'
Affairs, in cooperation with the Joint Committee on Printing, is
implementing some formatting changes for materials for all full and
Subcommittee hearings. Therefore, we would appreciate it if you would
provide your answers consecutively and single-spaced. In addition,
please restate the question in its entirety before the answer.
Please provide your response to Cathy Wiblemo. If you have any
questions, please call 202-225-9154.
Sincerely,
MICHAEL H. MICHAUD
Chairman
__________
Depression and Bipolar Support Alliance,
Responses for the U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Health,
Followup Questions from Sue Bergeson
1. Capacity--You stated that over 35 percent of OEF/OIF veterans
treated by VA have been diagnosed with mental disorders and also that
VA ``does not have the capacity'' to deliver mental health services to
all veterans in need.
Is this a statement applicable to VA overall, suggesting
that even with the Vet Center program VA does not have the capacity to
treat veterans?
Bergeson: I'm referring to the VA overall. Veterans Centers in the
community are a critical part of care and they reach veterans who are
not receptive to visiting VA facilities or who live far from such
facilities. However, VA administrative and clinical personnel have
indicated capacity was already stretched before OEF-OIF. We are now
facing an onslaught. Peers offer a kind of help that clinicians cannot
and can help engage their fellow veterans in needed services. They are
not a replacement for clinical care, but a different form of support.
They also can serve as a cost-effective means of outreach and
encouragement to veterans.
2. Treatment--You cited the Archives of Internal Medicine
statistic that veterans who are between the ages of 18-24 and returning
from Afghanistan and Iraq are nearly three times more likely to be
diagnosed with a mental health disorder, compared with veterans 40
years or older.
Is this reflected in the composition of veterans visiting
Vet Centers today and, in your opinion, how is VA working to address
this?
Bergeson: I cannot speak to the composition of veterans visiting
Veterans Centers. But I can say that we believe many new veterans have
not yet experienced symptoms or have not yet recognized these symptoms
as signs of mental illness. In addition, many veterans (OEF/OIF and
overall) are resistant to using traditional VA facilities, preferring
to access help through Veterans Centers or through non VA-affiliated
veterans' service or mental health organizations.
The VA could benefit from using OEF/OIF veterans who have
experienced mental illnesses as a resource for serving their peers.
Since Veterans from the current war will often respond most readily to
their peers, training our newest veterans to serve in this support and
outreach role will extend peer support services to the thousands of
returning veterans in need of understanding and support.
3. Peer Support--You stated that the greatest resource to help
veterans suffering with mental illness is veterans themselves and that
peer specialist services cost five times less than older models of
care.
In your opinion, is VA utilizing enough peer support?
Bergeson: As I mentioned earlier, I do not believe the problem is
whether the VA is utilizing or even wanting to utilize peer support,
but rather providing consistent and effective peer training throughout
the VA. Numerous VA facilities are hiring veterans as Peer Support
Technicians, but what is needed are consistent preparation, guidelines
and standards so that the VA provides the best peer support possible.
That's why the creation of a VA Technical Assistance Center for Peer
Support Services is a crucial component to stimulating and sustaining
an effective VA-wide program.
4. Training--You have offered three suggestions: increase funding
for peer training; establishing a technical assistance center; and
piloting peer support technician training and certification projects
throughout the country. Could you go into more detail on how this would
work?
Bergeson: In addition to its own emerging expertise, a great deal
of experience in peer support and the use of consumers as service
providers already exists outside the VA. It is critical that the VA, as
the nation's largest healthcare delivery system, utilize all existing
knowledge and lessons learned in order to craft training and jobs that
are authentic. This will maximize the use of currently stretched
resources.
As to possible scenarios, the VA should utilize outside
organizations to serve as a peer support Technical Assistance Center
for the VA, as recommended in the VA's own Mental Health Strategic
Plan. The VA could use current Peer Support Technician job descriptions
along with a survey of actual/potential peer roles to determine the
necessary competencies for veteran-consumers working as Peer Support
Technicians and in other peer support roles
Based on these competencies, pilot Peer Support Technician training
and certification projects with a strong evaluation component could be
initiated. The evaluation should measure veteran satisfaction and the
relevance of training topics to jobs within the VA.
It should also measure outcomes for veterans served by Peer Support
Technicians as compared with outcomes of veterans in traditional
services only.
Finally, the VA could initiate pilot distance learning and train-
the-trainer projects internally and utilize the results of these
programs to create peer training continuing education through its
existing Employee Education System. Especially needed in addition to
veteran training efforts are training programs that are designed to
orient VA providers to the unique role of peer supporters and to allay
any concerns about that role in the VA's mental healthcare delivery
system. Toward that end, the VA could utilize the current supervisors
of Peer Support Technicians as mentors for new supervisors.
Committee on Veterans' Affairs
Subcommittee on Health
Washington, DC.
August 2, 2007
Shannon L. Middleton
Deputy Director, Veterans Affairs and Rehabilitation Commission
The American Legion
1608 K Street, NW
Washington, DC 20006
Dear Shannon:
In reference to our Subcommittee on Health hearing on ``Vet
Centers'' held on July 19, 2007, and our joint Subcommittee hearing on
``Issues Facing Women and Minority Veterans'' held on July 12, 2007, I
would appreciate it if you could answer the enclosed hearing questions
by the close of business on October 2, 2007.
In an effort to reduce printing costs, the Committee on Veterans'
Affairs, in cooperation with the Joint Committee on Printing, is
implementing some formatting changes for materials for all full and
Subcommittee hearings. Therefore, we would appreciate it if you would
provide your answers consecutively and single-spaced. In addition,
please restate the question in its entirety before the answer.
Please provide your response to Cathy Wiblemo. If you have any
questions, please call 202-225-9154.
Sincerely,
MICHAEL H. MICHAUD
Chairman
__________
Questions for the Record
Joint Subcommittee Hearing,
Issues Facing Women and Minority Veterans,
Held on
July 12, 2007, 10:00 a. m.
Followup Questions for Shannon L. Middleton
1. In testimony provided, DAV gives 8 recommendations to better
serve women veterans from combat theaters. The first recommendation
concerns barriers to seeking healthcare through VA.
In your estimation, what are the three biggest barriers
female veterans encounter when trying to access healthcare through VA?
The three biggest barriers female veterans encounter when trying to
access healthcare through VA are: lack of knowledge about VHA services,
not knowing that they may be eligible for healthcare benefits, and the
perception that VA only caters to male veterans.
2. Women and minority OEF/OIF veterans returning from theater
face, what I believe, are additional challenges than their returning
peers, due, in part, to the lack of cultural education, lack of
adequate research on meeting their unmet needs and other issues.
What has your organization done to help in the outreach
efforts?
The American Legion publishes a booklet entitled Guide for Women
Veterans that provides information about VA healthcare, services
provided by The American Legion, information about health issues (like
breast cancer, PTSD, sexual trauma, heart disease, drug and alcohol
addiction) and a list of resources to enable them to find information
about various issues. We disseminate them through our department
service officers, outreach events, on our website and make them
available upon request to the public.
In the past, The American Legion has participated in a homeless
female veteran workgroup for the Southeast Veterans Service Center and
served on Subcommittees for the 2004 Women Veterans Summit hosted by
the Department of Veterans Affairs.
The American Legion is currently planning to collaborate with the
Center for Women Veterans to organize a Women Veterans' Forum to be
held in conjunction with the organization's mid-winter conference. The
American Legion is also participating in the 2008 Women Veteran's
Summit. We are constantly seeking new ways to bring information to
veterans, all veterans.
Does your organization have any recommendations as to how
to address the growing need for specialized services for both women and
minority veterans?
One effective way to ascertain the need for specialized services is
to find various ways to ask women and minority veterans what needs they
have that are not being met by current services. This can be patient
survey, or an outreach initiative that includes a survey that VA
disseminates by mail or via web. The information gathered would be
useful in determining system-wide need for specific programs or
services and may be useful in depicting geographical or population
trends for needed services.
Once these needs are identified, The American Legion recommends
that VA develop and implement policy to address these deficiencies in a
timely manner and conduct an extensive outreach campaign to make these
special populations--and those who serve them--aware of the
enhancements. The organization also recommends that Congress
appropriate adequate funding to maintain these enhancements, once they
are in place.
Finally, DAV's recommendations that VA and DoD collaborate to
conduct surveys of recently discharged active duty women and recently
demobilized female Reserve component members to assess the barriers
that they perceive or have experienced in seeking healthcare through VA
and that VA Medical Centers establish a consumer council that includes
veterans' service organizations, family members, and veterans--
especially OEF/OIF veterans--would be excellent approaches as well.
Committee on Veterans' Affairs
Subcommittee on Health
Washington, DC.
August 2, 2007
Shannon Middleton
Deputy Director for Health
Veterans Affairs and Rehabilitation Commission
The American Legion
1608 K Street, NW
Washington, DC 20006
Dear Shannon:
In reference to our Subcommittee on Health hearing on ``Vet
Centers'' held on July 19, 2007, I would appreciate it if you could
answer the enclosed hearing questions by the close of business on
October 2, 2007.
In an effort to reduce printing costs, the Committee on Veterans'
Affairs, in cooperation with the Joint Committee on Printing, is
implementing some formatting changes for materials for all full and
subcommittee hearings. Therefore, we would appreciate it if you would
provide your answers consecutively and single-spaced. In addition,
please restate the question in its entirety before the answer.
Please provide your response to Cathy Wiblemo. If you have any
questions, please call 202-225-9154.
Sincerely,
MICHAEL H. MICHAUD
Chairman
__________
Questions for the Record
Subcommittee Hearing
Vet Centers
Held on
July 19, 2007
2:00 p.m.
Follow-Up Questions for Shannon L. Middleton
1. Staffing--The American Legion focused on Vet Center visits this
year as part of the System Worth Saving Report that your organization
has released since 2003. In your testimony you wrote that there were
some Vet Centers that indicated that limited staffing was an overall
challenge.
Could you tell us if there were certain areas, such as
rural areas, that experienced staffing challenges more than others?
The site visits did not illustrate any defined areas, like rural
areas, that experienced staffing challenges. This may be due to the
fact that we only selected Vet Centers that were near demobilization
sites and did not select many truly rural areas.
However, some Vet Centers did indicate the need for outstations to
reach more veterans. For instance, East St. Louis Vet Center (Illinois)
is located on the western boarder of Southern Illinois and has a
catchment area extending to the Eastern boarder of Illinois. It covers
35 counties; the location of the Vet Center is an obstacle for some.
The Syracuse Vet Center's (New York) staff indicated the need for a
satellite office in the Utica/Rome area. Oak Park Vet Center (Illinois)
expressed a need for satellite offices in St. Charles and Geneva.
During your visits, did you find that any of the Vet
Centers were actually maintaining a waiting list for veterans to
receive services?
Fortunately, our visits did not uncover that the Vet Centers were
maintaining wait lists for service. We found that veterans were
vested--or put in the system--upon arrival. When necessary, the Vet
Centers used contracted services, or facilitated coordination of care
within the Veterans Health Administration (VHA). We also found that Vet
Center staff worked extended hours to accommodate the needs of working
veterans.
2. Military Sexual Trauma--In testimony, the VFW stated that they
had some concerns with the Vet Centers being able to handle the
increasing number of women veterans sure to seek treatment.
Additionally, they stated that they would like to see an increase in
treatment options and outreach efforts to women.
Has your organization been hearing complaints about the
lack of MST counselors at the Vet Centers?
The American Legion has Departments in every state, as well as in
Puerto Rico, Mexico, the District of Columbia, France and the
Philippines. There have been no reports or complaints on the lack of
MST counselors at Vet Centers from the Departments, or Department
Service Officers and none made to our National office. However, several
of the Vet Centers have identified this deficiency as an obstacle to
providing sexual trauma counseling to veterans.
3. Challenges--In your organization's estimation, what are the top
three challenges facing the Vet Center program today?
In The American Legion's estimation, the top three challenges
facing the Vet Center program today are acquiring adequate funding for
training, hiring or training staff who specialize in needed fields
(sexual trauma counseling, family counseling, Global War on Terror
(GWOT) Outreach), and, for some, obtaining a facility that can provide
adequate space.
The Vet Centers that identified funding for training as an obstacle
indicated that counselors are receiving between $125-$200 per team
member annually for continuing education. This does not cover the
mandatory 40-hour education and will not cover travel expenses. After
the amount has been depleted, other expenses will have to be paid by
the individual. Thus, classes and training events must be local.
Although System Worth Saving Task Force and Field Service
Representatives visited about a third of the existing Vet Centers, many
of them listed the lack of staff trained in sexual trauma counseling
and marital counseling challenges. Some Vet Centers found resourceful
ways to mitigate this lack, for instance training an existing staff
member to provide these specialties or sharing the sexual trauma
counseling, GWOT or marital counselor of a neighboring Vet Center.
Military sexual trauma is not a women veterans' issue and treating
it as such will further isolate men, who are very reluctant to seek
care. For example, the Portland Vet Center is noticing an influx of men
seeking MST counseling. Unfortunately, the facility will be losing its
MST counselor.
Because MST victims are both male and female, these veterans
require choices when seeking counseling. Some men may not be
comfortable with a male sexual trauma counselor for the same reason
some women may be uncomfortable with a male counselor: similarity with
the assailant. Conversely, some men may not feel comfortable working
with a female sexual trauma counselor, for fear of appearing less
manly.
A few Vet Centers noted the need for larger facilities, due to an
increase in workload, the expansion of additional services and to
accommodate the need for group sessions. The workload increase stemmed
from multiple sources, from an influx of returning Operation Iraqi
Freedom/Operation Enduring Freedom (OIF/OEF) veterans to successful
outreach efforts.
3. Education--Vietnam Veterans of America recommends that Congress
fund ``PTSD scholarships'' to fund the education of peer counselors who
are prepared to pursue advanced degrees in clinical psychology. How
does your organization feel about this idea?
Retaining highly educated staff is a problem for VA system-wide.
Some of the Vet Centers indicated that the private sector offers more
attractive salaries, making retention a challenge. Also, it is our
understanding that approximately 85 percent of current Vet Center staff
are combat veterans. So, providing doctorate level scholarships for
peer counselors may not remedy the staffing problem. However,
increasing funding available for training so that Vet Center peer
counselors and other professional staff members could gain
certifications and enhanced training may be more beneficial.
Committee on Veterans' Affairs
Subcommittee on Health
Washington, DC.
August 2, 2007
Adrian M. Atizado
Assistant National Legislative Director
Disabled American Veterans
807 Maine Avenue SW
Washington, D.C. 20024
Dear Adrian:
In reference to our Subcommittee on Health hearing on ``Vet
Centers'' held on July 19, 2007, I would appreciate it if you could
answer the enclosed hearing questions by the close of business on
October 2, 2007.
In an effort to reduce printing costs, the Committee on Veterans'
Affairs, in cooperation with the Joint Committee on Printing, is
implementing some formatting changes for materials for all full and
Subcommittee hearings. Therefore, we would appreciate it if you would
provide your answers consecutively and single-spaced. In addition,
please restate the question in its entirety before the answer.
Please provide your response to Cathy Wiblemo. If you have any
questions, please call 202-225-9154.
Sincerely,
MICHAEL H. MICHAUD
Chairman
__________
POST-HEARING QUESTIONS FOR
ADRIAN M. ATIZADO
OF THE
DISABLED AMERICAN VETERAN
FROM THE
COMMITTEE ON VETERANS' AFFAIRS
SUBCOMMITTEE ON HEALTH
UNITED STATES HOUSE OF REPRESENTATIVES
JULY 19, 2007
1. Staffing--The American Legion focused on Vet Center visits this
year as a part of the System Worth Saving Report that your organization
has released since 2003. In your testimony you wrote that there were
some Vet Centers that indicated that limited staffing was an overall
challenge.
Could you tell us if there were certain areas, such as
rural areas, that experienced staffing challenges more than others?
Response: We at DAV will defer to the American Legion any response
in particular to its System Worth Saving initiative. As for our
concerns about Vet Center staffing, as a part of the Independent Budget
we have expressed our concerns about the apparent flat staffing levels
of Vet Centers in the face of dramatic growth in their workloads.
However, in consultation with VA program officials we have learned that
a large percentage of the growth in Vet Centers over the past few years
relates to activity in the outreach arena. Vet Centers are dispatching
their peer counselors with direct experience serving in Operations
Iraqi and Enduring Freedom (OIF-OEF) to demobilization posts, National
Guard armories and Reserve barracks, to be sure that all returning OIF-
OEF service personnel are fully aware, not only of potential Vet Center
assistance but other VA benefits and services that might help them with
their transition needs. We believe, in this regard, that the Vet
Centers could use additional personnel. This is particularly true,
given the Vet Centers' new work in bereavement counseling to surviving
families of those lost in OIF-OEF.
During your visits, did you find that any of the Vet
Centers were actually maintaining a waiting list for veterans to
receive services?
Response: To our knowledge the Vet Center program, which like other
VA programs, has limited resources, needs to prioritize its workloads.
While the Vet Centers do not maintain a formal waiting list, they
attempt to deal with crisis first and handle their general caseloads in
ways that maximize the resources available.
2. Military Sexual Trauma--In testimony, the VFW stated they had
some concerns with the Vet Centers being able to handle the increasing
number of women veterans sure to seek treatment. Additionally, they
stated that they would like to see an increase in treatment options and
outreach efforts to women.
Has your organization been hearing complaints about the
lack of MST counselors at the Vet Centers?
Response: We believe that the Vet Centers that care for veterans
who raise this issue are primarily referred to the VA military sexual
trauma counselors at the nearest VA medical center. We are informed
that, following initial counseling by specially trained MST counselors
and other mental health professionals, individuals often return to the
referring Vet Center for follow up counseling. As far as we know, this
arrangement is working well.
3. Challenges--In your organization's estimation, what are the top
three challenges facing the Vet Center program today?
Response: The Vet Center program is soon to enter its thirtieth
year of operations. It is one of the most successful programs
functioning within VA, and DAV has been a strong supporter of the
concept since its inception. Over the years, the program has been
challenged because it is outside the medical model otherwise used
within the Veterans Health Administration. The 209 Vet Centers do not
employ physicians but rely instead on counselors, and in particular,
trained peer counselors to aid veterans in their transitions from
military exposures, to a return to civilian society.
Another challenge to the Vet Center program is resources. All VA
resources are limited, but since the Vet Center program is funded
outside of VA's medical model, the ``Veterans Equitable Resource
Allocation'' or ``VERA'' system, the program must present a different
justification for annual resources, and these debates, when considered
within VA's overall need for funding, have been rigorous.
The third biggest challenge is in keeping the Vet Center program
contemporary and attractive to new generations of veterans.
Historically, the Vet Center program was designed for Vietnam veterans.
As it has matured, it has been challenged to maintain relevance for
newer generations of veterans from the Persian Gulf War and the current
conflicts. We believe that Dr. Alfonso Batres, the current Readjustment
Counseling Service Director, has done an excellent job in maintaining a
flow of new counselors with relevant experience, and updating
appropriate training programs, so that the Vet Centers of today are
very much desired and valued by veterans of OIF-OEF.
4. Education--Vietnam Veterans of America recommends that Congress
fund ``PTSD scholarships'' to fund the education of peer counselors who
are prepared to pursue advanced degrees in clinical psychology. How
does your organization feel about this idea?
Response: DAV has no adopted resolution from membership on this
particular issue, and prior to the hearing was not aware of the
proposal, but would have no objection to it since it is intended to
improve clinical care programs for those who may be suffering the
effects of PTSD.
Committee on Veterans' Affairs
Subcommittee on Health
Washington, DC.
August 2, 2007
Dennis M. Cullinan
National Legislative Director
Veterans of Foreign Wars of the United States
200 Maryland Avenue, NE
Washington, DC 20002
Dear Dennis:
In reference to our Subcommittee on Health hearing on ``Vet
Centers'' held on July 19, 2007, I would appreciate it if you could
answer the enclosed hearing questions by the close of business on
October 2, 2007.
In an effort to reduce printing costs, the Committee on Veterans'
Affairs, in cooperation with the Joint Committee on Printing, is
implementing some formatting changes for materials for all full and
Subcommittee hearings. Therefore, we would appreciate it if you would
provide your answers consecutively and single-spaced. In addition,
please restate the question in its entirety before the answer.
Please provide your response to Cathy Wiblemo. If you have any
questions, please call 202-225-9154.
Sincerely,
MICHAEL H. MICHAUD
Chairman
__________
Responses to Post-Hearing Questions by
Dennis M. Cullinan, Director,
National Legislative Service,
Veterans of Foreign Wars of the U.S.
1. Staffing--The American Legion focused on Vet Center visits this
year as part of the System Worth Saving Report that their organization
has released since 2003. In your testimony, you wrote that there were
some Vet Centers that indicated that limited staffing was an overall
challenge.
Could you tell us if there were certain areas, such as
rural areas, that experienced staffing challenges more than others?
During your visits, did you find that any of the Vet
Centers were actually maintaining a waiting list for veterans to
receive services?
We have not found any results that differ from the Subcommittee's
October 2006 report, ``Review of Capacity of Department of Veterans
Affairs Readjustment Counseling Service Vet Centers.'' Certainly, rural
areas are going to have a more difficult time finding and hiring
qualified counseling professionals, which is a challenge the entire
Department faces in all of its operations.
Although our staff have not found any Vet Centers actually
maintaining waiting lists, from conversations that our staff has had
with many of these centers, they are on the verge of needing to do so.
They are barely keeping their head afloat today, and with demand
projected to increase, it will create a special challenge in the
future.
2. Challenges--In your organization's estimation, what are the top
three challenges facing the Vet Center program today?
The largest challenge the system faces is in how it is going to
handle the demands of tomorrow, as the number of veterans from OIF/OEF
continues to grow, and the number of family members impacted by the
conflicts goes up. We are concerned that Vet Centers may not have the
dedicated resources to handle the influx that is likely to occur as
these former warriors transition into civilian life.
We are also concerned with the staffing levels of these centers,
especially in the future as more veterans and families utilize the Vet
Centers' terrific array of services. Additionally, a number of the most
experienced Vet Center counselors and staff are from the Vietnam era
and are nearing retirement age. They have a wealth of experience and
training, and losing them would be a blow to the system if there are
not capable and experienced replacements waiting in the wings.
A third issue we are concerned with is how these clinics adapt to
the unique needs of women veterans. With the current conflict, there
are no true frontlines, and everyone in the area is exposed to the
rigors and challenges of combat. There must be outreach efforts and
sensitivity to any unique needs or challenges women veterans face as a
result of conflict. This extends beyond just sexual trauma treatment
but to the entire range of mental health services provided at these
centers. It is an issue that these centers should strive to stay on top
of.
3. Education--Vietnam Veterans of America recommends that Congress
fund ``PTSD scholarships'' to fund the education of peer counselors who
are prepared to pursue advanced degrees in clinical psychology. How
does your organization feel about this idea?
VA has had success with scholarships in other medical fields, such
as with the nursing program. Given some of the challenges VA faces in
attracting and retaining qualified mental health personnel, we feel
that this could be an excellent program that could help fill the
staffing needs Vet Centers are sure to face in the coming years.
Committee on Veterans' Affairs
Subcommittee on Health
Washington, DC.
August 2, 2007
Susan Edgerton
Senior Health Care Consultant
Vietnam Veterans of America
8605 Cameron Street, Suite 400
Silver Spring, MD 20910
Dear Susan:
In reference to our Subcommittee on Health hearing on ``Vet
Centers'' held on July 19, 2007, I would appreciate it if you could
answer the enclosed hearing questions by the close of business on
October 2, 2007.
In an effort to reduce printing costs, the Committee on Veterans'
Affairs, in cooperation with the Joint Committee on Printing, is
implementing some formatting changes for materials for all full and
Subcommittee hearings. Therefore, we would appreciate it if you would
provide your answers consecutively and single-spaced. In addition,
please restate the question in its entirety before the answer.
Please provide your response to Cathy Wiblemo. If you have any
questions, please call 202-225-9154.
Sincerely,
MICHAEL H. MICHAUD
Chairman
__________
Questions for the Record
Subcommittee on Health Hearing on ``Vet Centers'', July 19, 2007
Follow-up Questions for Susan Edgerton
1. Staffing: The American Legion focused on Vet Center visits this
year as part of the System Worth Saving Report that your organization
has released since 2003. In your testimony you wrote that there were
some Vet Centers that indicated that limited staffing was an overall
challenge.
a. Could you tell us if there were certain areas, such as rural
areas, that experienced staffing challenges more than others?
b. During your visits, did you find that any of the Vet Centers
were actually maintaining a waiting list for veterans to receive
services?
During the hearing, Dr. Batres stated that Vet Centers were able to
provide intake services the same day the veteran requests help. We have
no reason to dispute Dr. Batres, although it is unclear that there is
equally ready access to requested services. We do note that the
Chairman's own Oct. 2006 report on Vet Centers cited staffing
challenges and waiting times in many of the 60 sites it reviewed. Since
demand has grown since this time, we believe that any waiting times
identified at that time have likely been exacerbated.
VVA does not collect waiting time data systematically, anecdotally
we have heard that there is pressure on the Vet Centers systemwide.
Rural areas are disproportionately represented by servicemembers in
current deployments and most return to these areas after their service.
It would be likely then that Vet Centers that serve largely rural
populations of veterans may be subject to disproportionate demand.
Recent press, including an April 29, 2007 article in the Boston Globe,
``For Veterans in Rural Areas, Care Hard to Reach'' spoke in general of
problems severely injured service members have receiving follow up care
for chronic illnesses and injuries. Such press suggests that there
continues to be real challenges in these areas.
2. Military Sexual Trauma: In testimony, the VFW stated that they
had some concerns with the Vet Centers being able to handle the
increasing number of women veterans sure to seek treatment.
Additionally, they stated that they would like to see an increase in
treatment options and outreach efforts to women.
a. Has your organization been hearing complaints about the lack
of MST counselors at the Vet Centers?
We are not aware of large numbers of women veterans who have
complained about the lack of MST services, but that should not be
confused for their lack of demand for services. Studies have identified
high rates of sexual trauma among both genders during military service
that continue in current deployments so there is clearly still a need
for counseling. MST may reflect the experience of the women veterans
clinics in that once women veterans knew there were services
specifically available for them, they came to use them.
VA is required to provide assessment and referral for MST
counseling at each VAMC. This may not be enough. VVA strongly urges the
Committee to investigate how many qualified staff VA has recently hired
to provide military sexual trauma counseling, how many veterans are
being served by these programs, and whether veterans face obstacles
accessing appropriate counseling services.
3. Challenges: In your organization's estimation, what are the top
three challenges facing the Vet Center program today?
The continuing challenge for the Vet Center program is to provide
high-quality, timely services to all eligible veterans. From VVA's
perspective this requires not only staff with the right credentials,
but also with the right experience. Staff should be bolstered at most
Vet Centers to allow visits per veteran to return to pre-OIF/OEF
levels. In addition, since the location of Vet Centers now reflects a
pattern of need demonstrated by past generations of veterans,
additional Vet Centers may be necessary to meet the needs of veterans
returning from current deployments. Since Vet Centers rely upon VA
medical centers to provide more specialized medical care, VA mental
health services should be bolstered across the board.
4. Education: Vietnam Veterans of America recommends that Congress
fund ``PTSD scholarships'' to fund the education of peer counselors who
are prepared to pursue advanced degrees in clinical psychology. How
does your organization feel about this idea?
VVA supports the concept of PTSD scholarships to fund the education
of peer counselors who are prepared to pursue advanced degrees in
clinical psychology. VA is already authorized to fund training for
``professional, paraprofessional, and lay personnel'' in order to
provide readjustment counseling and related mental health services
under Sec. 1712A of USC 38. Clinical psychology scholarships could
follow models already in law in Chapt. 76, health professionals
education assistance program which have funded education of other types
of VA clinical personnel. Such assistance has included scholarships,
scholarships in return for a pre-determined time of VA service, tuition
reimbursement, or education debt reduction. The Committee might
additionally consider specifically earmarking funding for PTSD
training. VA might additionally consider programs for recruiting
psychologists and psychiatrists specializing in PTSD who are already in
practice.
Committee on Veterans' Affairs
Subcommittee on Health
Washington, DC.
August 2, 2007
Alfonso Batres, Ph.D., M.S.S.W.
Chief Readjustment Counseling Officer
Veterans Health Administration
U.S. Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, D.C. 20420
Dear Alfonso:
In reference to our Subcommittee on Health hearing on ``Vet
Centers'' held on July 19, 2007, I would appreciate it if you could
answer the enclosed hearing questions by the close of business on
October 2, 2007.
In an effort to reduce printing costs, the Committee on Veterans'
Affairs, in cooperation with the Joint Committee on Printing, is
implementing some formatting changes for materials for all full and
Subcommittee hearings. Therefore, we would appreciate it if you would
provide your answers consecutively and single-spaced. In addition,
please restate the question in its entirety before the answer.
Please provide your response to Cathy Wiblemo. If you have any
questions, please call 202-225-9154.
Sincerely,
MICHAEL H. MICHAUD
Chairman
__________
Questions for the Record
The Honorable Michael Michaud, Chairman
Subcommittee on Health
House Committee on Veterans' Affairs
July 19, 2007
Vet Centers
Question 1: Services: In your testimony you stated that in terms of
service mission, readjustment counseling consists of a more-than-
medical, holistic system of care and that Vet Center services include a
number of other community-based services:
Question 1(a): Could you explain in more detail what you mean by
``more-than-medical'' and also give us some examples of the types of
community-based services you work with?
Response: The term ``more-than-medical,'' or more accurately
``beyond medical,'' refers to the Vet Center program's unique role in
attending to all of the service needs of the veteran considered as a
whole person. Through this role Vet Centers go beyond clinical
counseling to help veterans transcend and cope with war-related
traumatic experiences from combat. These services include providing, or
coordinating, services for veterans related to family and work
readjustment; post-military education and career planning; and other
general issues related to the adoption of a satisfying and productive
role in the civilian community. The latter serves to help veterans gain
a sense of pride and confidence from having served their country
through the military. Through outreach activities Vet Centers work to
contact and inform veterans and family members of the services they
provide. Vet Centers are active throughout the community offering
educational sessions to community leaders and service providers about
veterans and their service needs. Community-based interventions are
necessary for establishing local contacts and building service
partnerships that lead to veteran referrals to the Vet Center and VA.
Vet Centers use these partnerships to help refer and coordinate
services not directly provided by the Vet Center.
Question 2: Vet Center Expansion: In Fiscal Year (FY) 2007 and 2008
VA plans to expand the Vet Centers from the existing 209 locations to
232 locations.
Question 2(a): Would you tell us what the criteria is to establish
a Vet Center?
Response: The site selection was based on an evidence-based
analysis of demographic data from the U.S. Census Bureau and the
Department of Defense (DoD) Defense Manpower Data Center (DMDC) and by
input from the seven Readjustment Counseling Service (RCS) regional
offices. The main criteria for new Vet Center site selection was the
veteran population, area veteran market penetration by Vet Centers,
geographical proximity to VA medical centers and community based
outreach clinics, in the Vet Center's veterans service area (VSA). This
analysis included information from the DMDC as to the current number of
separated Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF)
veterans and the reported distribution of home zip codes of separated
OEF/OIF veterans as well as the number who were married and those with
children. For some of the new Vet Centers special consideration in site
selection was given to relatively under-served veterans residing in
rural areas at a distance from other Department of Veterans Affairs
(VA) facilities.
Question 2(b): Do you know what the projected cost of establishing
these 23 new Vet Centers is?
Response: The projected cost for establishing the 23 new Vet
Centers is $8.780 million.
Question 2(c): Does the cost include the appropriate level of
staffing at each of the new Vet Centers?
Response: The planned Vet Center expansion calls for 17 new four-
person Vet Centers and six new three-person Vet Centers for a total of
86 new staff positions. The projected cost is sufficient to support the
planned staffing level, and the planning staffing is anticipated to be
sufficient based upon the primarily demographic criteria used for
targeting each site.
Question 2(d): Why are only three being activated this year? What
is the reason for delay?
Response: While it is true that only three are currently planned to
be activated this year, in 2007 the Secretary's February 7, 2007 news
release regarding the Vet Center program expansion announced that six
new Vet Centers were planned to be opened in fiscal year (FY) 2007. And
yet by the end of FY 2007, VA had actually opened 10 of the new Vet
Centers.
Question 3: Workload: There is concern that only a fraction of the
OEF/OIF veterans that could potentially seek care at VA Vet Centers are
actually seeking that care.
Question 3(a): Do you have a sense of your projected workload in
the next 5 years?
Response: In terms of actual numbers of veterans served cumulative
through the end of the FY 2007, the Vet Centers served a total of
254,784 OEF/OIF veterans. Of the total, 196,966 veterans were provided
with outreach services primarily at demobilization sites, and 57,818
were seen in Vet Centers for substantive readjustment services. It is
anticipated that the number of OEF/OIF veterans accessing Vet Center
services will continue to increase as more veterans return from combat
and as more veteran recipients of outreach services come into the Vet
Centers for readjustment counseling.
Question 3(b): Have the Vet Centers seen an increase in women
veterans seeking services for MST?
Response: No, the number of female veterans accessing services at
Vet Centers for military sexual trauma (MST) has remained steady at
approximately 2,000 a year for FYs 2005, 2006, and 2007.
Question 3(c): In your estimation, what is the fastest growing
population that the Vet Centers are providing services to?
Response: Based upon the workload numbers provided above the OEF/
OIF veteran population is the fastest growing veteran population served
by Vet Centers. The total number of OEF/OIF veterans served by the Vet
Centers more than doubled between FY 2005 and FY 2006, increasing from
approximately 30 percent of all veterans served in FY 2005 to
approximately 60 percent in FY 2006. These percentages include both
OEF/OIF veterans provided with outreach services and those receiving
readjustment services in the Vet Centers.
Question 4: Staffing: I believe that most would agree that the
quality and satisfaction of services that the Vet Centers provide are
very high. To maintain that level, adequate, appropriate staffing is
needed.
Question 4(a): What challenges have you faced in trying to recruit
and retain appropriate staff for the Vet Center mission?
Response: In general, Readjustment Counseling Service (RCS)
recruits for qualified mental health professionals and other master
degree counselors. Office managers and outreach specialists are
recruited under separate skill sets. The Vet Centers also promote the
hiring of veterans and staff diversity representative of the local
veteran population. The hiring of staff from among the new OEF/OIF
veteran population is a high priority to ensure cultural competence in
serving this new veteran population. The Vet Centers have been
successful in establishing a new cadre of 100 OEF/OIF veterans charged
with the mission of providing outreach services to their fellow
returning veterans. In addition to the cadre of OEF/OIF outreach
workers, the Vet Centers have hired approximately 50 more OEF/OIF
veterans into other Vet Center positions. A significant index to the
Vet Centers' success in staff retention is reflected in the program's
responses to the VA All Employee Survey. Results show Vet Center
employees have a significantly higher level of job satisfaction.
Question 5: Gaps in Service: By the end of 2008, there should be
232 active Vet Centers. We know VA is continuously faced with providing
care to the rural veteran Community.
Question 5(a): What challenges has the Readjustment Counseling
Service faced in trying to meet the readjustment needs of the veteran
in the rural community?
Response: The challenges to serving veterans are the same
everywhere, to reach small populations of veterans dispersed over large
geographic areas. Readjustment Counseling Service (RCS) has responded
to the needs of rural veterans by locating several Vet Centers in areas
accessible to rural veterans, by establishing Vet Center outstations in
rural areas, and expanding outreach services into rural areas. In
addition, the Vet Center program used its share of the FY 2007
supplemental funds provided by Congress to purchase mobile vans to be
assigned to 50 Vet Centers to extend services into rural areas. Vet
Center outreach efforts at National Guard and Reserve demobilization
sites also enables Vet Center staff to track veterans to their home
communities following their release from the demobilization site.
Question 5(b): In your estimation, where is the biggest gap in
service for the Vet Center program?
Response: The Vet Center program expansion referenced above was
planned to complement the efforts of the Vet Center OEF/OIF aggressive
outreach campaign in effect since FY 2004. The expansion is essential
to ensure sufficient staff resources are available to provide the
professional readjustment services in Vet Centers needed by the new
veterans as they return home from Afghanistan and Iraq. In addition to
the 23 new Vet Centers, RCS is augmenting the staff at 61 existing Vet
Centers. This entails a total of 150 new staff of which 78 have been
hired. In addition, the Vet Centers have been authorized to hire an
additional 100 staff each year in FY 2008 and FY 2009, to further
augment the Vet Centers ability to address the readjustment needs of
war veterans and their families. Collectively, starting from the first
50 OEF/OIF outreach specialists in 2004, the Vet Center program will
realize a total of 473 new positions by the end of 2009, or a 50-
percent increase over pre-2004 staffing levels.
Question 6: Outreach Efforts: Ensuring that veterans are aware of
their benefits and services can be an enormous challenge.
Question 6(a): What efforts have you put forth to ensure that women
and minority veterans are aware of services?
Response: Community outreach and education services have been an
integral part of the Vet Center service mission for the 27 years of the
program's history. Demographic analysis of the local veteran population
is the prerequisite for effective outreach. Vet Centers have long
maintained and exceeded the standard of serving local veterans in
numbers representative in the military and in the local veteran
population served by the Vet Center. Vet Centers promote representative
diversity in staff composition and plan outreach events to target
minority and women veterans in the community. Vet Center outreach
activities also include veterans' family members to the extent
feasible.
Question 6(b): Are Vet Centers experiencing an increase in these
veteran populations seeking services at your locations?
Response: Vet Center levels of service delivery to these veteran
populations consistently increases in proportion to their
representation in the military.
In FY 2007, veteran clients served and staffing levels both
exceeded levels of veteran representation for all ethnic groups
facilitating culturally competent services. The information for each
ethnic group is presented in the table below.
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Clients
Ethnic Group Served Staff All Veterans U.S. Population
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African American 17.0% 19.0% 9.7% 11.3%
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Hispanic/Latino 11.7% 9.8% 4.3% 11.0%
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Asian American 1.4% 1.4% 1.1% 3.7%
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American Indian 1.6% 1.7% 0.7% 0.8%
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Hawaiian/Pacific Islander 1.7% 0.9% 0.1% 0.1%
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Question 7: Staffing Composition: The American Legion described the
four-person staff composition that is standard at Vet Centers.
Question 7(a): Is there a standard composition and can you please
give us a brief description of the roles of team leader, office
manager, social worker and psychologist?
Response: The four-person Vet Center team is the original prototype
for a Vet Center dating back to 1979 when the program was established.
Since then, some variability has been developed resulting in some Vet
Center teams being established with three-person teams and others with
five-person teams. In every case, a Vet Center team is structured with
one team leader, one office manager and the remaining one to three
positions functioning as Vet Center counselors. Team leaders divide
their duties equally between direct service provision to veterans,
supervisory and administrative functions. Office managers provide
reception and administrative duties. Vet Center counselors spend their
time in activities related to providing direct care to veterans and
family members. Social workers, psychologists and other masters level
counselors provided readjustment counseling tailored to their specific
professional competencies.