[Senate Hearing 110-281]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 110-281
 
                      SERVING PATRIOTS AND HEROES:
         ENSURING HEALTH AND HEALING FOR OUR NATION'S VETERANS

=======================================================================

                             FIELD HEARING

                               before the

                       SPECIAL COMMITTEE ON AGING
                          UNITED STATES SENATE

                       ONE HUNDRED TENTH CONGRESS

                             FIRST SESSION

                               __________

                              PORTLAND, OR

                               __________

                              JULY 3, 2007

                               __________

                           Serial No. 110-11

         Printed for the use of the Special Committee on Aging



  Available via the World Wide Web: http://www.gpoaccess.gov/congress/
                               index.html


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                       SPECIAL COMMITTEE ON AGING

                     HERB KOHL, Wisconsin, Chairman
RON WYDEN, Oregon                    GORDON SMITH, Oregon
BLANCHE L. LINCOLN, Arkansas         RICHARD SHELBY, Alabama
EVAN BAYH, Indiana                   SUSAN COLLINS, Maine
THOMAS R. CARPER, Delaware           MEL MARTINEZ, Florida
BILL NELSON, Florida                 LARRY E. CRAIG, Idaho
HILLARY RODHAM CLINTON, New York     ELIZABETH DOLE, North Carolina
KEN SALAZAR, Colorado                NORM COLEMAN, Minnesota
ROBERT P. CASEY, Jr., Pennsylvania   DAVID VITTER, Louisiana
CLAIRE McCASKILL, Missouri           BOB CORKER, Tennessee
SHELDON WHITEHOUSE, Rhode Island     ARLEN SPECTER, Pennsylvania
                     Debra Whitman, Staff Director
            Catherine Finley, Ranking Member Staff Director

                                  (ii)

  


                            C O N T E N T S

                              ----------                              
                                                                   Page
Opening Statement of Senator Gordon Smith........................     1
Opening Statement of Senator Ron Wyden...........................     3

                                Panel I

Antonette Zeiss, deputy chief consultant, Office of Mental Health 
  Services, Veterans Administration, Washington, DC..............     4
Jack Heims, administrative director, Mental Health and 
  Neuroscience Division, Veterans Administration, Portland, OR...    18

                                Panel II

Nathalie Huguet, research associate, Portland State University 
  Center for Public Health Studies, Portland, OR.................    26
Ed Blackburn, deputy director, Central City Concern, Portland, OR    37
Joseph Reiley, veterans service coordinator, Lane County, OR.....    50
Keven Campbell, coordinator, Eastern Oregon Human Services 
  Consortium, The Dalles, OR.....................................    61
Stuart Steinberg, executive director, Central Oregon Veterans 
  Outreach, Crooked River Ranch, OR..............................    68

                                APPENDIX

Prepared Statement of Senator Robert P. Casey....................    79
Responses to Senator Smith's Questions from Jack Heims...........    80
Responses to Senator Smith's Questions from Nathalie Huguet......    80
Responses to Senator Smith's Questions from Mr. Blackburn........    80
Responses to Senator Smith's Questions from Mr. Reiley...........    81
Responses to Senator Smith's Questions from Kevin Campbell.......    83
Responses to Senator Smith's Questions from Stu Steinberg........    84

                                 (iii)

  


   SERVING PATRIOTS AND HEROES: ENSURING HEALTH AND HEALING FOR OUR 
                           NATION'S VETERANS

                              ----------                              --



                         TUESDAY, JULY 3, 2007

                                       U.S. Senate,
                                Special Committee on Aging,
                                                       Portland, OR
    The Committee met, pursuant to notice, at 2 p.m., in the 
auditorium of the Veterans Administration Hospital, 3710 S.W. 
U.S. Veterans Hospital Road, Portland, OR (Hon. Gordon H. 
Smith, Ranking Member of the Committee) presiding.
    Present: Senators Smith and Wyden.

  OPENING STATEMENT OF SENATOR GORDON H. SMITH, RANKING MEMBER

    Senator Smith. Good afternoon, ladies and gentlemen. On 
behalf of the U.S. Senate Special Committee on Aging, we 
welcome you to this official hearing that we have entitled, 
``Serving Patriots and Heroes: Ensuring Health and Healing for 
our Nation's Veterans.''
    I would say that Ron and I come here as Oregon Senators, 
but we also come with a common concern, as a Republican and as 
a Democrat, for our Nation's veterans, particularly as it 
relates to issues of mental health, issues that both his family 
and mine have been touched by. So mental health is a cause of 
the heart for both of us.
    I think because it is also the eve of the Fourth of July, 
we feel to wish you all a happy Fourth and a happy birthday to 
our Country. I am reminded of the noble words of Abraham 
Lincoln in his second inaugural address, when he spoke to the 
ongoing need that our Nation would have to ``bind up the wounds 
of him who shall have borne the battle and of his widow and his 
orphan.'' That is the spirit we come here in today.
    Now, I have a prepared statement that I need to deliver to 
you. I hope you find it just spellbinding. [Laughter.]
    But it is important because it needs to be on the record of 
the U.S. Senate. Then I will turn the time to my esteemed 
colleague.
    Ensuring proper physical and mental health care for our 
Nation's veterans, both old and young, is essential. In 
addition to the work we will do here today, I will also be 
meeting with facility and community mental health professionals 
as well as veterans' advocates at the V.A. facility in White 
City on Thursday.
    I will use the information we gather here today and 
Thursday to hold a follow-up hearing in Washington, DC, later 
this summer so that my colleagues in Congress can also benefit 
from the expertise and the many recommendations I have already 
heard today but which we will hear again from our witnesses 
that come from these events we are conducting.
    While we hear many news reports on the mental state of new 
veterans returning from Iraq and Afghanistan, which I believe 
our Government must do a better job in addressing, we cannot 
forget the mental health care needs of our aging veterans.
    What we now refer to as post-traumatic stress disorder was 
once described as ``soldier's heart'' in the Civil War, ``shell 
shock'' in World War I, and ``combat fatigue'' in World War II. 
Whatever the name, they are serious mental illnesses and 
deserve equal attention and care as a physical wound.
    In recent reports, we have heard that 20 to 40 service men 
and women are evacuated each month from Iraq due to mental 
health problems. In addition to those who are identified, there 
are many more who will return home after their service to face 
readjustment challenges. Some will need appropriate mental 
health care to help them adjust back to normal life, while 
others will need medical assistance to heal more serious PTSD 
issues. Yet others will need help to mentally cope with their 
physical wounds.
    A system must be in place to help our veterans as they 
adjust back to life with their families and within their 
communities. For this reason, I have introduced a bill entitled 
the ``Heroes Helping Heroes Act'' in the Senate to provide 
funding for peer support programs so that trained veterans can 
help returning veterans navigate the sometimes perilous 
adjustment process.
    So many of our veterans from previous conflicts, such as 
World War II, Korea, and Vietnam, needed similar programs when 
they returned home, yet I am sorry to say we didn't do enough 
to help them. With proper and early support systems in place, 
we can work to prevent more serious and chronic mental health 
issues that come from a lack of intervention.
    I also look forward to working with Senator Wyden on 
developing legislation to help combat the problems we see 
plaguing our mental health system for veterans. I look forward 
to working with the V.A. as well as veterans' service 
organizations, community groups and, most importantly, the 
veterans themselves to develop thoughtful legislation that 
ensures not only new veterans are being served but those who 
served us in the past are not forgotten.
    Recent reports, including a thoughtful and informative 
series done by The Washington Post, have highlighted ways we 
can and must improve the current mental health system for our 
veterans.
    Lack of culturally sensitive mental health professionals, 
inability to reach rural areas, stigma within the military, 
bureaucratic run-arounds, and long waiting times are just a few 
of the problems that we hear about both in the news and 
directly from veteran constituents.
    These are problems that must be addressed and can only be 
addressed if we all work together to find solutions.
    I am also anxiously awaiting a report from the President's 
Commission on Care for America's Returning Wounded Warriors, 
chaired by former Senator and World War II veteran Bob Dole and 
former Secretary of the Department of Health and Human Services 
Donna Shalala.
    In March of this year, I sent a letter to the commission 
asking that they give an equal review of mental health services 
as they do for physical health services. With the report 
expected to come out in mid-July, I hope that we can use their 
recommendations for thoughtful improvement.
    I hope that the commission recognizes that we cannot afford 
another generation of soldiers who lack appropriate support for 
health and healing of their physical and mental wounds.
    The Senate Special Committee on Aging has a long and 
distinguished history of leading the Senate on issues of great 
importance to our aging population. We have an opportunity 
today to focus on the ongoing and critical needs of our new and 
aging veterans and their mental health needs.
    As our Country faces new waves of veterans with mental 
health illnesses, many of whose issues arise from combat 
stress, we must ensure that we learn from the lessons of the 
past. We must ensure that they are cared for, and we must not 
leave behind those who fought for our Nation in previous 
generations.
    With that, I thank you for your attention, and turn the 
mike to my friend, my colleague, Ron Wyden.

             OPENING STATEMENT OF SENATOR RON WYDEN

    Senator Wyden. I thank you, Senator Smith. You said it very 
well. I know time is short, and I think what I will do, Madam 
Recorder, is I will make my especially profound prepared 
statement part of your hearing transcript.
    I thought Senator Smith said it very well. Let me make just 
a couple of points by way of supplementing his remarks.
    Back in April and May, I essentially went to all of the 
major veteran facilities in our State, systematically went 
through the State from La Grande, Bend, the valley, here, and 
the message I got was pretty consistent all across the State. 
The message that I got is that care is very, very good--if our 
veterans can get it.
    It really comes down to a question of funding to a great 
extent, in Oregon; that there are scores of dedicated doctors 
and hospitals and nurses doing an incredible job, but still we 
have a lot of folks falling between the cracks. I see some of 
you who give the care nodding in the audience.
    So I have supported ``The Independent Budget,'' which is 
the budget proposed by all the veterans groups, and I have 
supported what is called mandatory funding, so that we can get 
veterans funding off this roller coaster. It shouldn't be 
subject to the whims of the annual budget cycle. There ought to 
be mandatory funding so that we say if you are serious about 
taking care of the needs of our veterans, that the funding 
should be mandatory.
    The reason I feel so strongly about that is that ultimately 
much of the decisionmaking in the U.S. Senate--and we do ours 
in a bipartisan way--comes down to choices, and it comes down 
to priorities.
    This Congress, for example, has been willing to allow more 
than $10 billion in subsidies to major oil companies--not the 
small companies, not the independent companies, but the major 
companies.
    When you make cutbacks in that area--and the President of 
the United States, to his credit, says oil companies don't need 
subsidies when the price of oil is over $50 a barrel--you make 
cuts there, and it directly relates to having additional 
funding available to cut the wait times, to cut the lines for 
mental health services, and all the areas that Gordon has laid 
out very well.
    I will tell you that getting this funding is not an 
abstract issue. Much of what I saw on this tour just struck me 
as unconscionable. For example, in central Oregon, in 2007, we 
have our veterans sleeping in the woods. That is what the 
veterans told me.
    There are a couple of them who run a terrific outreach 
program. We have got one of them right here in the front row.
    Just think about that. In a Country as good and rich and 
strong as ours, for veterans who serve our Country with such 
valor and distinction, our friend in the front row has to run a 
program to reach out to veterans in central Oregon who 
certainly are in need of mental health services and a variety 
of others in order to try and get them decent health care.
    That is not acceptable to anybody. That is not a Democratic 
issue. That is not a Republican issue. That is a question of 
our values and our choices.
    So we anxiously await your testimony and your input.
    Gordon, I look forward to working with you on this.
    Senator Smith. Thank you, Senator Wyden.
    We appreciate our witnesses, one of whom has come a long, 
long way to be here, all the way over the Oregon Trail from 
Washington, DC., Dr. Antonette Zeiss, who is the deputy chief 
consultant, the Office of Mental Health Services within the 
Veterans Administration. She is going to tell us the work they 
are doing to try to meet this great challenge.
    Then Mr. Jack Heims, who is our second witness, he works at 
the V.A. center here in Portland. He is the administrative 
director of the Mental Health and Neuroscience Division. I know 
that our facility here in Portland has a number of innovative 
programs, and we look forward to hearing about your approaches 
to these issues.
    So, Dr. Zeiss, why don't we start with you?

 STATEMENT OF ANTONETTE ZEISS, DEPUTY CHIEF CONSULTANT, OFFICE 
OF MENTAL HEALTH SERVICES, VETERANS ADMINISTRATION, WASHINGTON, 
                               DC

    Dr. Zeiss. Thank you. Very glad to be here.
    Is the microphone on?
    Senator Smith. Can you hear? Yes. Just talk close to it.
    Dr. Zeiss. Good afternoon, Mr. Chairman and members of the 
committee. I am pleased to be here today to discuss how the 
Department of Veterans Affairs is addressing the mental health 
care needs of our Nation's veterans.
    V.A. provides mental health services to veterans in all our 
patient care centers. General and geriatric mental health 
services are being integrated into primary care clinics, V.A. 
nursing homes, and residential care facilities where many 
veterans receive mental health care.
    Veterans with a serious mental health illness are seen in 
specialized programs, such as mental health intensive case 
management, day centers, work programs, and social 
rehabilitation.
    V.A. employs full- and part-time psychiatrists and 
psychologists who work in collaboration with social workers, 
mental health nurses, counselors, rehabilitation specialists, 
and other clinicians to provide a full continuum of care for 
mental health services for veterans.
    We have seen returning veterans from prior eras through to 
the current Operation Enduring Freedom and Operation Iraqi 
Freedom conflict who have injuries of the mind and spirit as 
well as the body.
    From these veterans we have learned that mental disorders 
can increase the risk for certain physical illnesses and vice 
versa. Our goal is to treat a veteran as a whole patient, to 
treat a patient's physical illnesses as well as any mental 
disorders he or she may be facing.
    Post-traumatic stress disorder, PTSD, has been the focus of 
national interest as it relates to not only veterans of past 
combat service but also our current returning veterans. V.A. 
provides a full range of services related to PTSD as well as 
other military-related readjustment problems, along with the 
treatment of the physical wounds of war, in its continuum of 
health care programs.
    Our mental health services are provided in all V.A. medical 
facilities. This may include in-patient and outpatient services 
and related services in the area of substance abuse.
    Moreover, V.A.'s Vet Centers provide counseling and 
readjustment services to returning combat veterans and, in some 
cases, their family members in the community setting. Vet 
Centers provide an alternative to traditional access for 
veterans who may be reluctant to come to medical centers and 
clinics.
    V.A. plans to expand its Vet Center program. We will open 
15 new Vet Centers and eight new Vet Center outstations at 
locations throughout the Nation by the end of 2008, and seven 
of them will open this year, in 2007.
    In addition, V.A. provides services for homeless veterans, 
the ones living out in the woods, including transitional 
housing, paired with services to address social, vocational, 
and mental health problems associated with homelessness.
    Care for OEF/OIF veterans is among the highest priorities 
in our mental health care system. Since the start of combat, 
686,306 service members have been discharged and become 
eligible for V.A. care, and of those 33 percent have sought 
V.A. care.
    Among those returning veterans, mental health problems are 
the second most commonly reported health concerns, with almost 
37 percent reporting symptoms suggesting a possible mental 
health diagnosis. That is almost 84,000 veterans to date.
    The diagnosis of PTSD topped the list for possible mental 
health diagnoses, but close behind were problem drinking and 
use of drugs without addiction and oppressive disorders. So it 
is not just PTSD; we need to respond to the whole array of 
mental health problems.
    V.A. data show that the proportion of new veterans, newly 
returning veterans, who are seeking V.A. care and who have a 
possible mental health problem has been increasing over the 
past 2 years. For example, the proportion with possible mental 
health problems at the end of fiscal year 2005 was 31 percent, 
and now, in the most recent report in April 2007, it had risen 
to 37 percent. PTSD diagnoses during this same timeframe went 
from 13 percent to 17 percent.
    There are many possible explanations of this increase: 
extended deployments, more difficult combat circumstances, but 
also effective screening and outreach efforts and the positive 
impact of efforts to destigmatize seeking mental health 
services.
    Whatever the reasons for the increase, we need to follow 
closely that there is an increase and devote increased 
resources to serve these mental health needs.
    Funding resources are currently available for a V.A. Mental 
Health Initiative that supports implementation of our 
comprehensive mental health strategic plan based on the 
President's New Freedom Commission on Mental Health.
    The plan recognizes that the ongoing war effort 
necessitates special attention to the needs of returning 
veterans, and we have improved capacity and access using our 
funding. We have hired over 3,000 new mental health 
professionals to date, since the spring of 2005, and there are 
more in the pipeline to be hired.
    Senator Smith. Are you hiring them from outside? Current 
mental health professionals, you are hiring them into the V.A. 
system?
    Dr. Zeiss. Yes. Yes.
    Senator Smith. What are you doing to get them to remain?
    Dr. Zeiss. We have not had a problem with people leaving 
V.A. once they have been hired. There have been some problems 
within the Department of Defense, but we actually have a good 
retention record.
    We have recently gone through the conversion of psychology 
and some of the other professions to hybrid Title 38, which I 
think is also having some positive impact on retention. There 
has been the Physician's Pay Bill, which has increased pay for 
physicians.
    So Congress has served us well in passing legislation that 
has helped with retention of staff in V.A. We have been quite 
successful in recruiting such a large number of new staff in 
the last 2 years. We have an extensive recruitment and 
retention program.
    Those 3,000 professionals have funded a wide variety of 
programs: community-based outpatient clinics, so that we can 
get onsite staffing out to more rural areas. We are expanding 
tele-mental-health services to reach more rural veterans.
    We have enhanced PTSD, homelessness, and substance abuse 
care and programs that recognize the common co-occurrence of 
these problems. We are fostering integration of mental health 
and primary care in medical facility clinics and in the care of 
homebound veterans served by V.A.'s home-based primary care 
program.
    We have mental health staff well-integrated into the 
polytrauma care sites, and we have increased the number of 
staff in our Vet Centers, establishing outreach counselors, 
many of whom are global war on terror veterans themselves.
    Very importantly, focusing on concerns about suicide in 
veterans, we have funded a suicide prevention coordinator in 
every V.A. medical facility. A national hotline for suicide 
prevention will soon be available. V.A. staff are being 
educated about this valuable tool and how veterans will be able 
to access it.
    In addition, V.A. sponsored its first Suicide Prevention 
Awareness Day, which included every V.A. facility, and this is 
going to be an annual event with, again, a national push and 
planned local activities.
    We continue to promote early recognition of mental health 
problems, with a goal of making evidence-based treatments 
available early. Veterans are routinely screened in primary 
care for PTSD, depression, substance abuse, traumatic brain 
injury, and military sexual trauma.
    When there is a positive screen, patients are further 
evaluated and, when indicated, they are referred to a mental 
health provider for follow-up.
    Screening for this broad array of mental health problems 
helps support effective identification of veterans needing 
mental health services, and it promotes our suicide-prevention 
efforts, a major priority for V.A.
    Our goal is to make the point that in V.A., suicide 
prevention is everyone's business, not just that of our mental 
health providers. Everyone who comes into contact with our 
veterans and their families plays an important part.
    I think that covers my comments, and I want to thank you 
again----
    Senator Smith. Thank you, Doctor.
    Dr. Zeiss.--for having me here.
    [The prepared statement of Dr. Zeiss follows:]

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    Senator Smith. Very excellent.
    You heard me in my opening statement refer to this 
Washington Post article.
    Dr. Zeiss. Yes.
    Senator Smith. Have you read that?
    Dr. Zeiss. I have.
    Senator Smith. It certainly represented that there was a 
serious backlog related to mental health issues. Would you 
dispute that?
    Dr. Zeiss. The backlog that was described I would argue was 
very much about the Veterans Benefits Administration side of 
the house.
    Senator Smith. Not the mental health aspect?
    Dr. Zeiss. Not the direct provision of mental health care 
and access.
    One of the things that I felt really moved by in the story 
of the woman veteran--not everyone got to the end of the story. 
The last sentence was, ``V.A. saved my life.'' She talked about 
how meaningful the in-patient program they had was, even though 
she had complained about some aspects of it being boring. She 
said it was the right thing and offered the right program.
    Then she got to a specialized women's program with the 
latest evidence-based care for PTSD for women, and it has 
turned her life around.
    Senator Smith. If you had two or three suggestions that 
Senator Wyden and I could achieve for you in Congress, what you 
need, what would they be?
    Dr. Zeiss. Well, we have been really encouraged by the 
tremendous support for mental health. I have never in my 
professional life, of many years now, seen a time when there 
was so much bipartisan support for really caring about the 
mental health of our veterans.
    We need this to remain a priority throughout the conflict 
and to recognize that many veterans will not begin to have 
significant mental health problems until several years after 
the end of the conflict. So we need to build a system that can 
be sustained.
    Senator Smith. OK. You have participated in the roundtable 
I had before this.
    Dr. Zeiss. Yes.
    Senator Smith. You heard over and over again that in the--
not the Guard and Reserve, but in the professional military, 
there is a machismo as part of the warrior ethic that is 
taught. The comment was made that that is necessary to do what 
they have to do, apparently.
    But I wonder, when they go through that and they come home 
and they are suffering psychological setbacks from what they 
have had to do, I am wondering if there is not, with that 
warrior ethic, a stigma against people admitting that they have 
serious issues and that that is somehow professionally held 
against them.
    Are you familiar with that? Do you believe that is true? 
What can we, as lawmakers, do to remedy that?
    Dr. Zeiss. Well, I won't speak for what happens in DOD. I 
have certainly seen some evidence of that. But, you know, the 
speaker was talking particularly about the Department of 
Defense.
    I think there are two things that are really important. One 
is continuing to really make the distinction between Department 
of Defense and the Department of Veterans Affairs, and that 
when people come to seek care at V.A., it is not going back to 
any command structure, it is not having any impact on their 
military career, including if they seek care between 
deployments when they are Reserve and Guard.
    We need to really protect that and help people feel 
confident that their care in V.A. will respond to----
    Senator Smith. Are there any impediments to your protecting 
that confidentiality?
    Dr. Zeiss. I don't know that it is an impediment. There is 
much, much enthusiasm for a bidirectional, single medical 
record between V.A. and the Department of Defense. While there 
are many, many benefits to such a bidirectional record, in our 
Office of Mental Health Services--and the Under Secretary for 
Health has been supportive--we want to recognize that if a 
Guard or Reserve member comes to V.A. for mental health care 
during a time between deployments, that it is not automatically 
the case that it would be bidirectional; that all that 
information would go back. It would be treated differently in 
the Department of Defense than it would in V.A.
    If we have informed consent from that Guard or Reserve 
member, of course we would send the information. But we want to 
ensure the kind of confidentiality that you were hearing in the 
roundtable is so important to to these folks.
    Then the other thing is a national push for 
destigmatization of mental health problems, just as you are 
doing. We need total support with you.
    Senator Smith. I don't want to get in the way of military 
ethics to do their job, but I also want to say to our military 
professionals, end the stigma. Understand there are all kinds 
of wounds that come from war, and they should not be 
professional deterrents to healing.
    Dr. Zeiss. The other thing that we have tried to do, is 
more than V.A. has traditionally done for families, and of 
course we stay within our congressional authority in doing 
that, but we have funded--there wasn't time in the written 
testimony--but have funded family psychoeducation programs 
around mental health, family to-family training that is offered 
by the National Association for the Mentally Ill, and has been 
offered to some extent in V.A.
    We are looking at possible expansion of that. We are 
encouraging families to come in and be part of the evaluation 
and treatment planning process for returning veterans, again, 
within our congressional mandates. But we believe, as you heard 
in the roundtable, that reaching out and including families is 
very important for veterans' care.
    Senator Wyden. Mrs. Zeiss, thank you.
    I have a number of questions.
    Now, you state in your written testimony that the V.A. has 
plans to expand the Vet Center program and is going to open 15 
new Vet Centers and eight new Vet Center outstations by the end 
of 2008.
    Now, in our State, we don't have a Vet Center east of the 
Cascades. Can you lay out on the record the criteria and 
process the V.A. uses in determining where to open a new Vet 
Center?
    Dr. Zeiss. I can tell you who does lay out the process. The 
Vet Centers are not run through our office, the Office of 
Mental Health Services. They are a separate program of the 
Readjustment Counsel Services.
    Dr. Al Batres is the head of that, and he is currently 
guiding the process for making decisions about where those Vet 
Centers will be placed. I would be happy to get you in touch 
with him.
    Senator Wyden. So your office, with respect to looking at 
Vet Center and Vet Centers needs, does what, if anything?
    Dr. Zeiss. At this point we don't have things that our 
office does with Vet Centers.
    We have in planning the possibility of placing tele-mental-
health equipment in the Vet Centers so that they can link to 
the medical facilities and receive more specialized mental 
health care from providers.
    The Vet Centers have traditionally offered counseling and 
supportive services, and this is an opportunity--again, if 
there are Vet Centers in some more rural areas--to get more 
partnership between the medical facilities and the Vet Centers.
    But our office really works with the medical facilities and 
the community-based outpatient clinics.
    Senator Wyden. That really was my second area. So would you 
all have the authority, for example, to get into the community-
based outpatient clinics on tele-mental services?
    Essentially a fancy way of saying we are going to use 
modern technology, we are going to use computers, we are going 
to use phone networks in order to make it easier to compensate 
for distance.
    Do you have the authority to get into that?
    Dr. Zeiss. We not only have the authority, we are doing it. 
We have placed tele-mental-health equipment in many of the 
CBOCs, with planned rollout with anticipated fiscal year 2008 
funding. To the rest, we have, then, in the medical facilities 
the tele-mental-health equipment. We have staff who are 
prepared to offer specialized mental health services.
    We also have placed mental health providers directly in the 
community-based outpatient clinics, but they are generalists, 
and when there is specialty care needed, we believe that tele-
mental-health care is going to be----
    Senator Wyden. What do we need to do to convince you to 
expand services, particularly in central and eastern Oregon? I 
gather, from of your last answer, we would be talking about 
both the tele-mental services and practitioners? What we have 
in our State is a lot of veterans who simply cannot physically 
get to Portland----
    Dr. Zeiss. Yes.
    Senator Wyden [continuing]. Who find it hard to get to 
Walla Walla. I mean, we have just got scores of veterans 
falling between the cracks, and I don't think we meet our 
obligation, particularly to older veterans, to let you walk out 
the door today without getting a commitment to expanding those 
services.
    Dr. Zeiss. Absolutely. I am very willing to go back. I 
brought with me a listing--I can provide to you, I have given 
to Senator Smith already--of what we have funded here in 
Oregon. I know that we have funded community-based outpatient 
clinic enhancement in Bend, in Salem, in Eugene, in Bandon and 
Brookings. I may be missing a couple.
    But that is not the whole State by a long shot. I lived in 
Oregon for 4 years. I went to graduate school here, and I know 
the State a bit.
    Senator Smith. Are you a Duck or a Beaver? [Laughter.]
    Dr. Zeiss. A Duck. A Duck. Yes.
    There is much more to be done. There is a call for more 
community-based outpatient clinics to be developed.
    Again, our office supports the mental health component once 
the site is approved, but there is a broader approval because 
it needs to provide the whole spectrum of primary care services 
as well as mental health services.
    I am happy to work with you to try to ensure that Oregon 
services are considered, and I think there is a need. I 
certainly can make a commitment that if there are new 
community-based outpatient clinics approved, our office will 
find out about the staffing as well as tele-mental health.
    Senator Wyden. What can we do so that over, say, the next 
90 days we can get you to specifically look at expanding 
services in Oregon and tell us whether or not you can do it? 
Certainly if not, why not?
    Because I can tell you, the need is just extraordinary out 
there. I know you mean well, and my constituents very much want 
to see, in the area of mental health services, particularly in 
rural Oregon, a commitment to expanding those services.
    So question one: Can you tell us over the next 90 days 
whether you will review those services, particularly in 
community-based outpatient clinics, which you do have 
jurisdiction over?
    Dr. Zeiss. Yes, I do.
    Senator Wyden. Give us an assessment of whether or not you 
think expanded services are needed, in terms of practitioners 
and the technology, and whether or not you can deliver those 
services? Can you get that to us in the next 90 days?
    Dr. Zeiss. I can't speak beyond the Mental Health Office.
    Senator Wyden. That is what I am talking about.
    Dr. Zeiss. But I can certainly do it for the Mental Health 
Office.
    I can also say we are in the process of beginning to spend 
and making plans for rapidly spending the congressional 
supplemental budget, which is no year money, as you know, but 
we want to spend it as quickly as we can.
    One of the things we are looking at is purchasing or 
leasing more Government vehicles so that we could have circuit 
riders, so that people can go out more to provide services more 
broadly. I can commit to looking at what are we funding in 
Oregon in terms of the opportunities to get our current V.A. 
providers out into the communities more.
    I also can commit--one of our programs is the mental health 
intensive case management for veterans with serious mental 
illness, and we are currently piloting a rural model. It was 
originally developed for more areas that had higher 
concentration of veterans with serious mental illness, but we 
are piloting a rural model.
    I can go back and look at exactly what is under planning 
for Oregon and what ways we could expand the possibility of the 
mental health intensive case management for the rural areas.
    Senator Wyden. That is constructive, and to have the 
assessment within 90 days so we can get a sense of what you 
make of the current situation, because I can tell you, our 
veterans consider it just very dire whether or not you can then 
expand services both with actual practitioners and with 
technology.
    It is also our job to make sure that you have adequate 
resources. But we are going to first need to get your specific 
assessment. I appreciate that commitment today, and I think the 
veterans all over our State do as well.
    One last question with respect to what steps the V.A. is 
taking to help veterans who have trouble physically traveling 
to V.A. facilities. In other words, one of the reasons I think 
veterans are falling between the cracks is that they simply 
cannot get to facilities. We are going to need help there.
    Mr. Chairman, I just realized I have one additional 
question.
    Senator Smith. Go ahead.
    Senator Wyden. Time is tight.
    Let's get your views on help for veterans who are having 
difficulty traveling, physically traveling to V.A. facilities, 
and what additional steps the V.A. can take to help them.
    Dr. Zeiss. There are many reasons why they would have 
trouble, physically.
    I am going to start with the home-based primary care teams. 
I think this is a wonderful V.A. program. It provides medical 
care, nursing care, social services care to veterans who are 
homebound because of physical or mental health problems.
    The whole team will go out, one at a time, not en masse, to 
serve those veterans. There are programs all over the Country, 
there are programs here in Oregon. As I said in my written 
testimony, we have recently ensured that every single one of 
those teams has a mental health provider as well.
    But those are based in--you know, there are not going to be 
services that will be accessible to folks in eastern Oregon 
because the team is not out there.
    One of the things that we are trying to develop is a 
program called the Home Health Buddies, which are electronic 
devices that can be actually in the veteran's home so they 
don't have to travel. They can interact directly with their 
mental health care providers, and there is a parallel program 
for other physical health care.
    It has been deployed for many of the physical health care 
needs. I can't speak to how broadly and how much there is in 
Oregon. We are trying to develop tools so that it could provide 
safe, effective care for mental health problems. We don't want 
to place it in a home and promise care before we are confident 
that it really would meet the need and make that service 
available.
    Senator Wyden. Make that part of your 90-day assessment as 
well, this question of what do you think the present system 
offers veterans who are having trouble getting assistance to 
physically travel to the V.A. facilities and what else you can 
do about it. Because that is also very much on the minds of 
veterans in our State.
    One last question that comes from, again, the visits I made 
in April and May. I get the sense that there is still a lot of 
confusion with respect to the record systems at V.A., the 
record systems of the DOD, particularly trying to integrate the 
computer systems and trying to make sure that information is 
exchanged quickly.
    In fact, up in Walla Walla, where there is a very talented 
administrator who came in and just started. The administrator 
talked about wanting to change the records. She said there was 
going to be a special effort made in that area.
    What do you think the implications are for mental health 
services, of veterans falling between the cracks, between the 
computers at V.A. and the computers at DOD? Do you think that 
is a problem?
    Dr. Zeiss. Well, I think the V.A. electronic medical record 
system is absolutely world-class. It has been recognized by the 
Harvard Business School as--received an award for excellence in 
government, has received many other awards.
    So I think the V.A. has a splendid record system in which 
mental health records are fully integrated to the overall----
    Senator Wyden. My question is something else. My question 
is: Do you think that there is a problem coordinating the 
system at V.A. and the system in DOD? If you do, what do you 
think ought to be done?
    Dr. Zeiss. Well, I think I spoke to that a bit earlier. I 
think that it is true that they are not fully coordinated and 
bidirectional. I would like the initial push to be on ensuring 
that the DOD records can be made available to V.A. when someone 
is leaving the military and coming to V.A. I think that would 
increase our capacity to serve veterans. I would like to see 
there be continued effort to ensure that.
    I do have some concern about the concept that it should be 
completely bidirectional without the consent of the person who 
comes to us in a civilian capacity but then might return to the 
military.
    Senator Wyden. I would like to follow that up with you, 
because I think you touched on a couple of the key areas of 
change. Certainly it ought to ensure that the patients control 
their records. When you think about veterans' health care, if 
ever there was a group in this Country that deserved to control 
their records----
    Dr. Zeiss. Yes.
    Senator Wyden [continuing]. It is our courageous veterans 
and those who serve their Country. But we have got to do a 
better job of sharing information between the V.A. and the DOD. 
Call up that new administrator in Walla Walla, because I am 
telling you, I think she is going to go gangbusters on this.
    Dr. Zeiss. Yes.
    Senator Smith. I think she is here.
    Dr. Zeiss. I met her.
    Senator Wyden. Great. There she is.
    Just talk to her after you are done testifying, because she 
has got it. She is on it.
    Senator Smith. Jack Heims. Thank you.

STATEMENT OF JACK HEIMS, ADMINISTRATIVE DIRECTOR, MENTAL HEALTH 
 AND NEUROSCIENCE DIVISION, VETERANS ADMINISTRATION, PORTLAND, 
                               OR

    Mr. Heims. Good afternoon, Mr. Chairman and Senator Wyden. 
Thank you for this opportunity to share in this strong work of 
our employees to improve mental health services to our 
veterans. We know of your strong support and interest in mental 
health issues.
    My comments will focus on efforts of the catchment areas of 
the Portland V.A. Medical Center and on behalf of Operation 
Enduring Freedom and Operation Iraqi Freedom, returning 
veterans who have served primarily in the National Guard.
    We play a significant role in co-leading Oregon's post-
deployment integration effort with the National Guard. We 
worked cooperatively in compiling and keeping current a 
comprehensive resource directory Website to orient them to our 
services and to our materials.
    Semiannually we have co-led summits of 85 leaders of 
various agencies and community agencies to help in all aspects 
of veterans' re-entry into civilian and community life. This 
model, I am proud to say, has received national recognition 
from both the V.A. and the National Guard.
    We have held training conferences that highlight community 
integration processes with family organizations and with 
veterans themselves.
    Portland Medical Center also participates in the 90-day 
post-deployment health reassessment sessions. At Canby 
conference grounds, we have held two family weekend retreats, 
complete with child care, focusing specifically on the impact 
of combat veteran service as it relates to family issues.
    Military sexual trauma program is coordinated with our 
primary care service, and we have presented training on this 
and other reintegration issues for 200 community mental health 
and primary care providers.
    Most of our previous knowledge on traumatic brain injury 
care has been gained from sports injuries and auto accidents. 
Now, however, we are learning more as we treat injuries 
received because of blast events in combat. These issues may be 
coupled with other traumatic injuries. To deal with these 
specialized injuries, we have added an additional 
neuropsychologist to our staff.
    We have been meeting the mental health needs of rural 
veterans for more than 10 years through our services at 
outpatient clinics in Salem, Bend, and Warrenton. We have added 
a part-time therapist at Warm Springs Indian Reservation.
    I might add the Walla Walla facility is opening a CBOC, 
community-based outpatient clinic, in La Grande, as far east in 
eastern Oregon as you can get. It is little, and it is 
mandated.
    Senator Smith. You can actually get to Ontario. [Laughter.]
    Mr. Heims. Actually, Ontario has served as a----
    Senator Smith. Idaho?
    Mr. Heims [continuing]. Understood--as a Boise traveling 
road show.
    In addition, a new initiative involving tele-psychiatry 
will provide our outlying clinics with the ability to pull in 
subspecialty expertise such as substance abuse and PTSD in 
these locations.
    We are pleased to share that the VISN has received funding 
for 100 home-based v-tel setups, video-teleconferencing, so 
patients who live in rural areas or are incapacitated, as 
Senator Wyden indicated, can video-conference with their 
provider and obtain mental health care.
    Suicide has always been a major concern of Portland V.A. 
Medical Center due to the demographic of our veterans. Suicide 
risk increases with age. Our veteran population continues to 
age. We know that increased awareness of the possibility of 
suicide will lead not only to better identification of those 
who are at risk, but also improve our ability to implement 
appropriate suicide prevention treatments.
    We have five geriatric psychiatrists on staff for the aging 
population. This year, as Dr. Zeiss indicated, we have hired a 
full-time suicide prevention coordinator. With great pride, we 
can say our suicide screening program has been implemented at 
many sites nationally in the V.A.
    V.A. has mandated ready access to mental health treatment 
for our veterans. Portland Medical Center has 24-hours, 7-days-
a-week, emergency coverage, a phone triage system, an acute 
interim care provision, immediate OEF/OIF access, and an 
evening clinic. We are restructuring to provide full 
diagnostic, evaluation, and treatment for all patients 
requesting or referred for mental health or substance abuse 
treatment.
    Portland Medical Center has been a national leader for the 
recovery model for our shizophrenic and bipolar patients. Our 
veterans have recovered from what they were told would be a 
chronic and debilitating mental illness. As a result of 
treatment received at the Portland V.A., these veterans go on 
to become productive members of society, living the life of 
their choosing.
    The recovery model sends a message of hope. One veteran 
recently said, ``I am going on a date''--and I think he was a 
shizophrenic patient--''for the first time in 18 years.'' 
Awareness, training, and access to appropriate mental health 
care continues to be our major components of our multi-faceted 
approach to reaching out and helping veterans while we continue 
to refine our treatment strategies.
    Thank you again, Mr. Chairman, for inviting me today. I 
will be pleased to answer any questions you or Senator Wyden 
may have.
    [The prepared statement of Mr. Heims follows:]

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    Senator Smith. Thank you very much, Jack.
    We spoke a little bit about this earlier, but for the 
record, I want to talk to you about what we read about, whether 
it is true or not, in terms of the high rates of turnover and 
burnout among mental health professionals in the V.A. and the 
time it takes to fill them.
    You are not experiencing that; is that correct?
    Mr. Heims. We have had no difficulty in turnover. Our 
turnover rates are one of the lowest in our V.A. as a division. 
Our recruitment has been excellent, particularly for social 
workers, psychologists, and nurse practitioners. It is a little 
tougher for psychiatrists.
    Senator Smith. You know, with conflicts in Afghanistan and 
Iraq, there are tremendous amounts of traumatic brain injuries 
because of the kinds of weapons used against our soldiers, and 
we are finding that PTSD can even mask itself in terms of 
mental health disorders. Whether it is irritability, an 
inability to concentrate, all of these kinds of things are also 
signs of depression and other mental illnesses.
    Can you talk to us about the modeling you do to help a vet 
identify what it is they have and how you then put them on the 
right kind of therapy to get them to recovery?
    Mr. Heims. As you say, it is a tough issue, and I would add 
to our list of others that mask: substance abuse. Frequently we 
have veterans who have traumatic brain injury, PTSD, and they 
are self-medicating with substance abuse, and how to decipher 
those diseases is very difficult.
    As I said, we have two neuropsychologists on staff. We have 
a group that meets twice a month to review patients with 
traumatic brain injury. We have a screening mechanism for all 
patients coming through primary care who are OEF and OIF and 
with mental health. So I think we have a way to not only 
isolate these patients, but also decipher----
    Senator Smith. What it is they have.
    Mr. Heims [continuing]. What it is they have and what the 
treatment plan needs to be.
    Senator Smith. You have heard Senator Wyden's concern--I 
share it--as it relates to rural Oregon. I live in rural 
Oregon, and there are a lot of vets in Pendleton and many other 
surrounding communities, and I am wondering what you think of 
our outreach to mental health issues to rural Oregonians who 
are veterans.
    Mr. Heims. I feel very proud of Portland's outreach. Not 
only do we have an outreach van that goes to, oh, probably a 
200-mile radius of Portland and also to the homeless areas, 
areas such as Longview or The Dalles or these kind of areas, 
but we also through Dr. Sardo's, mentioned earlier, PTSD team 
has been sending our experts out to the small family groups in 
the rural areas talking about what they are to expect, how to 
cope with the returning vets.
    Plus, again, as I mentioned, our wonderful relationship 
with the National Guard. They have four reintegration--happen 
to be purple hearts--scattered throughout the area.
    Our main contact in eastern Oregon is Luke Wilson, an 
amputee in Hermiston, and we have worked with him in 
cooperation with his outreach to eastern Oregon. Plus, our Bend 
unit also does some work activities.
    Senator Smith. Senator Wyden.
    Senator Wyden. Just a couple.
    Doctor, in May, Thomas Insel, the director of the National 
Institute of Mental Health, testified that only 23 to 40 
percent of the veterans experiencing mental health problems 
actually seek mental health services. So his appraisal was well 
under half of the veterans in the United States who need these 
mental health services actually seek them. At some points, it 
is a quarter.
    What is your estimate here in Oregon? What percentage do 
you think, of the veterans who need mental health services, 
actually come forward? I recognize that this is an inexact 
science for you.
    Mr. Heims. It is an inexact science. As we heard in the 
roundtable, there are--for instance, pro bono counselors see 
people, and they are very hidden. People who seek help through 
their churches or synagogues also are hidden.
    I think this can also, sadly, be said for the entire 
population, those who need to seek help and those who actually 
do.
    Our experience is that 35 percent first 6 months coming 
back from OEF/OIF seek mental health care, and that is 
paralleled in the V.A. and that is paralleled----
    Senator Wyden. That is the overall. What I think Dr. Insel 
was saying is that between 23 and 40 percent of veterans 
experiencing mental health problems--these are people who 
actually had problems--came forward. I am trying to get you to 
give me a sense of what it is in Oregon.
    Mr. Heims. I would say for our area, it runs about 30 
percent.
    Senator Wyden. About 30 percent of the veterans in Oregon 
who are experiencing mental health problems are coming forward?
    Mr. Heims. Correct. May I----
    Senator Wyden. Yes.
    Mr. Heims. As we all know, particularly with substance 
abuse, which is considered mental health issues, you get into 
such denial, and with PTSD, it is hard--the old saying is you 
can lead a horse to water, but you can't make them drink. It is 
hard to make them thirsty.
    Senator Wyden. Tell us how you tailor your outreach for 
that population. In other words, my sense is--and both of us 
have been involved in mental health services--that you have the 
general outreach in terms of mental health services, but here 
you have got a situation where you said, of veterans 
experiencing mental health problems, about 30 percent are 
coming forward.
    How do you tailor your outreach to try to get those folks 
to get service?
    Mr. Heims. We saw it a little earlier today with Senator 
Smith, and that is using vets who are in recovery to show the 
way to those who want recovery. That is particularly true for 
our patients with serious mental illness, like shizophrenia, 
bipolar, and major depression.
    Senator Wyden. Just tell us for the record, because I have 
heard the story so many different ways and would appreciate 
your setting it out on record, what, if any, is the waiting 
list for mental health services in Oregon?
    I have heard it two different ways. So you can perhaps just 
work your way through it; that with the additional hirings, 
that some have said that has pretty much cleared out the 
waiting list, and I have heard others say that is not the case.
    It would be helpful for you to set out on the record, what 
is the situation today with respect to the waiting list, if 
any?
    Mr. Heims. Senator, I can't respond for the other two 
facilities in the State, but I can respond for Portland.
    Our waiting list is, again, triaged. So as a person 
presents, we determine their acuity, and obviously if they are 
in high acuity, they are either admitted or seen that minute, 
that hour. For those who are OEF/OIF with service connected, we 
are seeing them within a week or two. Those who are less than 
that, we are seeing them within the 30 days.
    We have a couple exceptions, depending on matching people. 
Somebody wants, for instance, a female counselor, a female 
psychiatrist, that may throw some things a little. We are in 
the process of doing all of this hiring. We aren't at 100 
percent yet in hiring.
    Senator Wyden. I thank you. We are also pleased that Oregon 
is out in front in the recovery model.
    Mr. Heims. Thank you.
    Senator Wyden. I think that is really important news, 
because people who can be in the vanguard of figuring out how 
to lead this Country to cure bipolar disorder and shizophrenia, 
that is the kind of leadership we want in Oregon.
    Mr. Heims. Our leader, Dr. Mark Ward, has been doing this 
for at least 4 years, and we are very proud of his work.
    Senator Wyden. Thank you both.
    Senator Smith. We are proud of both of you, and we thank 
you both, as our first panel, for sacrificing the time you have 
made to be with us.
    Our second panel is equally as important. Since we know 
that more than three-quarters of our veterans do not receive 
health care through the V.A., we also have invited a number of 
community representatives to discuss how they serve veterans 
and help them find the care that they need.
    So we call up Dr. Nathalie Huguet with Portland State 
University; Mr. Ed Blackburn with Central City Concern--he is 
here to talk about the great work they are doing in Portland--
Mr. Kevin Campbell from The Dalles, OR, who is the coordinator 
of the Eastern Oregon Human Services Consortium; Mr. Joseph 
Reiley is here from Lane County, veterans service coordinator; 
and Mr. Stuart Steinberg from the Crooked River Ranch near 
Bend.
    We thank you all.
    I would note that Mr. Steinberg is a Vietnam war veteran 
who was diagnosed with PTSD and received mental health services 
through V.A.
    So, we are anxious to hear of your experiences, Stuart. 
Thank you for being here.
    Why don't we start with Nathalie, and we will just work our 
way down.

  STATEMENT OF NATHALIE HUGUET, RESEARCH ASSOCIATE, PORTLAND 
STATE UNIVERSITY CENTER FOR PUBLIC HEALTH STUDIES, PORTLAND, OR

    Dr. Huguet. Good afternoon. My name is Dr. Nathalie Huguet, 
and I am honored to present testimony today on behalf of my 
colleagues at Portland State University and Oregon Health and 
Science University.
    Today I will address the results of a collaborative project 
that focused on suicide risk among veterans in the general 
population. The National Institute of Mental Health funded the 
study. I am a research associate at Portland State University 
Center for Public Health Studies.
    Dr. Mark Kaplan, professor of community health at Portland 
State, is the lead author and principal investigator on this 
study and is unavailable to attend this hearing today. 
Accompanying me is Dr. Jason Newsom, an associate professor at 
the Institute on Aging. He is also a co-author on this study.
    Suicide is a major cause of death in the United States. 
Approximately 30,000 people per year complete suicide, and 
nearly 650,000 people are seen in emergency departments after 
they attempted suicide. The suicide rate for men is four times 
that for women. Veterans may have an even greater risk of 
suicide than the general population.
    Previous studies conducted among veterans have focused on 
samples derived from patient populations in the Department of 
Veterans Affairs system. Equally important, much of the earlier 
suicide research has been based exclusively on Vietnam-era 
veterans.
    According to the literature, suicide risk factors common in 
the V.A. patients include male gender, older age, diminished 
social support, substance dependence, combat-related trauma, 
medical and psychiatric conditions associated with suicide, and 
the availability and knowledge of firearms.
    The reliance on V.A. clinical samples is a limitation on 
other studies because, according to the final report from the 
2001 National Survey of Veterans, three-quarters of veterans do 
not receive health care through the V.A. facilities. 
Consequently, little is known at this time about suicide risk 
factors among veterans in the general U.S. population. 
Estimates of suicide risk may be inaccurate because the 
characteristics of veteran who use the V.A. system may differ 
from those of the larger population of veterans.
    Therefore, the purpose of our study was to examine suicide 
risk factors among veterans in the general population. In 
pursuing this goal, we used a large, nationally representative, 
prospective data base to: (1), assess the relative risk of 
suicide for male veterans in the general population (2) compare 
male veteran suicide decedents with those who died of natural 
and external causes and (3) examine the effects of baseline 
sociodemographic circumstances and health status on the 
subsequent risk of suicide.
    We used data from the 1986 through 1994 National Health 
Interview Survey, which was conducted by the National Center 
for Health Statistics. The NHIS data file was linked to the 
Multiple Cause of Death file through the National Death Index. 
The total sample of male veterans for the pooled NHIS data used 
in our analysis was over 100,000 cases. We identified 508 male 
suicide cases using the International Classification of 
Disease, ninth revision; 197 of these were veterans.
    Respondents were identified as veterans if they answered in 
the affirmative to the question: Did you ever serve on active 
duty in the Armed Forces of the United States? Veterans 
represented 16 percent of the NHIS sample, but accounted for 31 
percent of the suicide decedents.
    The findings show that over time veterans were twice as 
likely to die of suicide compared to male non-veterans in the 
general population. Conversely, the risk of death from natural 
causes or external causes, accidents or homicides did not 
differ significantly between the veterans and the non veterans.
    At baseline, veteran suicide decedents were significantly 
more likely than the non veteran decedents to be older, white, 
high school graduates, and less likely to be never married. Our 
results also show that activity limitation was an important 
suicide risk factor among veterans.
    Health care providers are well-positioned to intervene with 
veteran patients who have physical or mental disabilities. 
Primary care physicians, as the gatekeeper of the health care 
system, along with other specialists, have important roles to 
play in the assessment and management of depression and 
suicidality among veterans in clinical settings.
    Another important finding was the higher probability of 
firearms use among veteran suicide decedents. Supplementary 
analyses with data from the National Mortality Followback 
Survey showed that veteran suicide decedents were 58 percent 
more likely than non veterans to use firearms than other 
suicide methods.
    Furthermore, an analysis of veteran suicide decedents in 
the NMFS revealed that those who owned guns were 21 times more 
likely to use firearms than those who did not own guns. 
According to the recent data from the 2003 Behavioral Risk 
Factors Surveillance System, veterans are substantially more 
likely to own guns than are individuals in the general 
population.
    Although there is a debate among the suicidologists and 
policymakers about the association between availability of 
firearms and the risk of suicide, the preponderance of the 
evidence from other studies suggests that a gun in the house, 
even if unloaded, increases the risk of suicide in adults. 
Case-control studies on the prevalence of guns and suicide risk 
have shown significant increases in suicide in homes with guns, 
even when adjustments were made for other factors, such as 
education, arrest, or drug abuse.
    Because veterans are familiar with and have greater access 
to firearms, health care providers need to be more attentive to 
the critical role that firearms play in suicidal behaviors 
among veterans. Unfortunately, some physicians find it 
difficult to ask directly about firearms. Previous research by 
Dr. Kaplan and colleagues found that only half of the primary 
care physicians who identified patients as suicidal would 
inquire about their access to firearms.
    In conclusion, the results have potential clinical and 
public health implications. Clinicians outside the V.A. system 
need to be alert for signs of suicidal intent among veterans as 
well as their access to firearms. Similarly, health care 
providers who serve veterans outside the V.A. system should 
also recognize the elevated risk of suicide in this population.
    With a projected rise of functional impairment and 
psychiatric mobility among veterans from the conflicts of 
Afghanistan and Iraq, clinical and community intervention 
directed toward patients in both V.A. and non-V.A. health care 
facilities will be needed.
    Thank you again for the opportunity to appear today. I will 
be happy to answer any of your questions.
    [The prepared statement of Dr. Huguet follows:]

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    Senator Smith. Thank you very much, Nathalie. We will 
probably have some questions for you. We will just go down each 
witness, and then we will go back to you.
    Ed Blackburn.

   STATEMENT OF ED BLACKBURN, DEPUTY DIRECTOR, CENTRAL CITY 
                     CONCERN, PORTLAND, OR

    Dr. Blackburn. Senators Smith and Wyden, thank you for the 
opportunity to be here. I hope I do our veterans and staff that 
work with them justice in this testimony.
    Senator Smith, your comments about peer support are right 
on. Without the peer support from veterans, we cannot be 
successful as we should be, particularly with the population I 
am about to speak of, and that is homeless vets. I think with 
all vets, a corps of veterans in recovery would be a big help.
    Senator Wyden, your observations about the housing issue, 
not in just central Oregon but here in Portland, OR, is 
critical. Peer support, supportive housing, supportive 
employment, these things are the foundation of any kind of 
recovery, particularly for the homeless population.
    I am Ed Blackburn. I am the deputy director of Central City 
Concern, which has operated in Portland for almost 30 years. We 
provide services to about 15,000 homeless people per year, and 
amongst those 15,000 are quite a few veterans. We estimate that 
there are about 17,000 homeless people in the metropolitan area 
annually, and 4,000 and 7,000 of these people are veterans.
    What do they face? Poverty, addictions, mental health 
issues, including PTSD, physical disabilities, poor health, in 
some cases criminal backgrounds, poor employment or rental 
histories, disaffiliation with service systems and social 
support network--and that is why the peer support is so 
important--post-traumatic stress disorder, traumatic brain 
injury. Some people have all these things.
    I want to talk about three programs that produce success 
for homeless veterans. One is called the Community Engagement 
Program. I am going to tell just a brief story.
    ''W'' is a veteran who had been homeless for approximately 
5 years with a substance abuse disorder. He was referred to the 
Community Engagement Program by the V.A. Medical Center and 
received housing and intensive case management through Central 
City Concern, including support from an employment specialist.
    He was connected to vocational rehab services, substance 
abuse treatment, which was successful in his case. He obtained 
his GED and his commercial driver's license and recently has 
been accepted into the truck drivers' union and has obtained a 
job with a local trucking company.
    The Community Engagement Program was funded through the 
Interagency Council on Homelessness, which the Veterans 
Administration is part of, and also Department of Labor and 
Department of Human Services. It targets chronically homeless 
adults in the Portland area and uses a multi-disciplinary team, 
including psychiatric, substance abuse, peer case managers, and 
primary care. It is out in the community, and it does outreach 
on that basis. It provides immediate access to housing, primary 
health care, and employment support.
    This program, over the last 3 or 4 years, has served about 
250 clients. That is, 250 chronic homeless clients with their 
average homelessness of about 8 years have been placed in a 
house. About 60 of those are veterans. The major barrier to 
serving more veterans is the discharge status of the veterans 
and the relationship of their injury to military service.
    So how do we fund services for those people? We find other 
ways of doing that, but that needs to be looked at, the rules 
around that, and whether exceptions can be made under certain 
circumstances.
    Next I want to talk about the Homeless Veterans 
Reintegration Project.
    ''R'' was unemployed for 3 years, homeless for 2, addicted 
to heroin and alcohol. He had a history of mental health issues 
and domestic violence and debt. He was honorably discharged 
from the Navy after 6 years of active duty.
    Through the Veterans Reintegration Project, he attended 
employment classes and moved in supportive housing. He used 
V.A. Medical for primary care, dental, mental health, substance 
abuse, and work training services. The V.A.'s Compensated Work 
Therapy program enrolled him in entrance-level custodial work, 
and the V.A. Medical Center later offered him full-time 
employment as a Federal employee with a starting salary of $26 
an hour.
    The Veterans Reintegration Project is funded by the 
Department of Labor, and it expedites reintegration of homeless 
individuals into the labor force, provides job training, 
placement assistance, and initial case management.
    Through this program in Central City Concern, we have 
enrolled 2,300 veterans. 814 obtained employment, with an 
average wage of $11.20 an hour, and over 1,600 of those 
veterans obtained housing through this program. During the last 
fiscal year, 67 percent of the HVRP participants were placed 
into employment.
    So that is another success story about what works.
    The Veterans Grant and Per Diem program. ``D'' had a 
criminal background and history of drug use and no legal I.D. 
except for documentation of his U.S. Army veteran status of 6 
years military service and honorable discharge. He had failed 
in most local service channels and had no income, no food 
sources, and was sleeping in a flower bed.
    After entering the program, he moved into housing, obtained 
employment at a local service station, and soon gained 
certification as an auto technician. He is now fully employed, 
employed full-time as a supervising mechanic at a wage of $25 
an hour.
    The Veterans Grant and Per Diem program is funded through 
the V.A. and offers transitional housing and case management 
for servicemen with an honorable discharge. Since its 
inception--it is 2 years old there are about 112 veterans that 
have been housed, 60 have been employed, and about 12 of those 
have received a V.A. pension and been able to work the system 
because they had housing. Without the housing, they would be on 
the streets, would not have obtained their benefits.
    That program has a 4-month waiting list now. In other 
words, there is a 4-months wait for a veteran to be able to get 
housing through that program.
    These are the three programs that we know work at Central 
City Concern. We provide other services in our alcohol and drug 
treatment program and our detox center and other housing 
opportunities for veterans. But these are the things that work.
    So my recommendation to you is, particularly when it comes 
to homeless vets, the peer support is essential. We ought to 
find a way of the various community-based programs with 
Veterans Affairs to fund more veterans and employment services.
    We have found that when we hire recovering people, formerly 
homeless, they bring people in. They are able to connect people 
to services, kind of break down the cynicism and the 
disaffiliation that has occurred, and encourage them to move 
forward with the recovery. They are living examples of what can 
happen when people are in the recovery process.
    Housing, there is an absolute shortage of housing, 
affordable housing, for veterans. It is the key to ending their 
homelessness and allows the mental health and clinical primary 
care services to be successful. You cannot be successful with 
these people who are homeless unless housing is available, and 
appropriate housing.
    There are rules that I would be glad to talk to your staff 
about around how that--the Per Diem program, for example, is 
financed, that make it difficult, probably unnecessarily so, 
both for Veterans Affairs and for us that we need to look at.
    What do we mean by ``recovery''? Recovery means re-
establishing the right relationship with oneself, right 
relationship with others that you need to live with, and right 
relationship spiritually or ethically to find a greater meaning 
in life. These people have been wronged, and what we are about 
is making a wrong right.
    I wish you all luck in moving forward on these issues.
    [The prepared statement of Mr. Blackburn follows:]

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    Senator Smith. Thank you, Ed. Those were terrific 
suggestions. I am grateful for your time here.
    Joseph Reiley.

STATEMENT OF JOSEPH REILEY, VETERANS SERVICE COORDINATOR, LANE 
                           COUNTY, OR

    Mr. Reiley. Thank you, Mr. Chairman, Senator Wyden.
    Senator Smith. Speak right up in that machine there.
    Mr. Reiley. Thank you for inviting me today, and thank you 
you for your interest in these issues.
    I am the Lane County Veteran Services Officer, and as you 
know, Lane County service officers and all veteran service 
officers are really dedicated to ensuring that the veterans and 
their surviving spouses and their dependents, who have the 
eligibility for V.A. benefits, obtain the maximum benefit that 
they are entitled to under the law.
    For the most part, we help veterans and claimants with VBA, 
Veterans Benefits Administration, claims for service connected 
compensation and non-service connected pension claims. We also 
help facilitate enrollment in V.A. health care.
    I took the job with Lane County Veteran Services in June of 
2003, and at that time, and still today, the majority of our 
clients are World War II veterans filing re-evaluations on old 
service-connected conditions, sometimes filing new claims for 
service connection even; also, though, accessing the non-
service-connected pension a needs-based benefit based on their 
income and medical expenses.
    Also, Korean-era veterans, similar situations, and Vietnam-
era veterans. Many of those filing initial claims for service 
connection, 20, 30 years after their service, they are coming 
to realize that the conditions which they didn't think were a 
big deal during their service really are impacting their health 
to a great degree, and they are hoping to get help with those 
conditions.
    During that summer of 2003 there was--there is an 
organization, very informal, called the Lane County Vet Net. It 
is veterans service providers. They are staff from the V.A, and 
some of the congressional veterans staffers come to these 
meetings. We meet once a month. At that time we are mostly 
focused on planning the Eugene Stand Down, an event to try to 
integrate homeless veterans into the V.A. system, reach out to 
them, get those folks benefits. It was also a Veteran 
Appreciation Day, so all veterans were, of course, welcome.
    Day to day, my work really wasn't impacted by the wars in 
Iraq and Afghanistan. Maybe once a month we would have a 
veteran out of Afghanistan that we would help enroll in V.A. 
health care or file an initial claim for service connection. 
But it wasn't really a big issue, frankly.
    Then in October 2003 it became a very big issue for Lane 
County. At that time the 2-162nd National Guard infantry unit 
was called up. They trained for 6 months here in the States and 
then deployed to Iraq for a year. That unit consisted of 700 to 
900 individuals, the vast majority of whom lived in Lane 
County. The unit is based out of Cottage Grove, but their main 
armory is the Eugene armory.
    The Vet Net organization realized that we needed to help in 
reaching out to their families who were left behind and to 
prepare for their return. We sent out word to nontraditional 
veteran service providers, folks that don't focus solely on 
serving veterans. We held a Vet Net summit in the spring of 
2004 where 30 to 40 organizations sent representatives.
    We all got together in one room at the Lane County Mental 
Health building and talked about this Title 10 call-up of the 
2-162nd and also discussed our various organizations so that 
the barriers between V.A. and veteran service providers and 
traditional community providers could start to be whittled 
down.
    I am happy to say that many of those organizations have 
continued in the Vet Net process, and so we continue to meet 
with them monthly.
    Out of that came a realization that, while there are 
concerns about the V.A.'s ability to serve these veterans, 
services for the family members really wasn't going to be 
available through the V.A. There are some services available 
for family members in the mental health realm, and I refer to 
them in my written materials, but for the most part, without 
the veteran being actively engaged in treatment, there is 
really nothing available for the family members.
    Of course while an individual is on deployment in Iraq, 
they are obviously not engaged in V.A. treatment. So Lane 
County Mental Health and LaneCare reached out to the providers 
to see if any were interested in trying to fill that gap.
    Lane County Mental Health and LaneCare organized a combat 
post-traumatic stress disorder treatment program and a 
reintegration treatment program to bring those issues to 
providers who typically treat PTSD from other stressors.
    We are fortunate at Lane County Mental Health to have on 
staff Dr. Michael Reaves, who worked for a long time here at 
the Portland V.A. Medical Center in PTSD treatment of veterans. 
He brought in some of his former colleagues, and they provided 
specific training for the local providers to address veterans' 
issues.
    That program is still in place, and veterans or their 
family members are able to access that through LaneCare. These 
providers are available on a short notice and with a sliding 
fee.
    I, frankly, have kind of a skewed perspective, I think, 
from being in Lane County and not just because I am in Eugene. 
I don't think we do anything any better or any different than 
anywhere else in Oregon, but we are really blessed in the 
fortuitous coincidences that we have had.
    When the 2-162nd was mobilized, family support 
coordinators, in my perspective, seemed to be a fairly new 
thing for the National Guard and for the military in general. 
That might just be my inexperience with the system, but that is 
how it seemed from an outsider's perspective.
    We were very fortunate in the quality of the family support 
coordinators who were based out of the Eugene armory. Darcy 
Woodke and Laura Boggs went on to win national awards for their 
services to the family members of the 2-162nd.
    Additionally, within VHA, Veterans Health Administration, 
in Eugene at the Community Reintegration Service Center, there 
is an individual who retired out of the Oregon National Guard, 
and so he was able to make sure that he and other Roseburg VHA 
employees were at the demobilizations of the 2-162nd. So all of 
those individuals had 1010EZ forms completed during their 
demobilization, and that is the application for VHA health 
enrollment. So we were able to get all of these individuals 
enrolled in V.A. health care, right on their demobilization.
    Senator Smith. So none of them have fallen through the 
cracks?
    Mr. Reiley. Well, they were enrolled, but not all of them 
went to their initial appointments. Not all have followed up 
with that initial enrollment and eligibility.
    Senator Smith. But what a good idea.
    Mr. Reiley. Again, not just Lane County, but the Oregon 
National Guard, the 2-162nd, they weren't the first major unit 
to be deployed from Oregon, but really seemed to wake up the 
V.A. providers, the National Guard command, the county veteran 
service officers, the Oregon Department of Veterans Affairs, 
that we are getting a lot of nontraditional veterans created.
    Ones that are called up under Title 10 and complete their 
call-up, they are eligible for all of the V.A. benefits that 
regular Army, regular Marines were historically eligible for. 
Traditionally, National Guardsmen aren't entitled to those 
benefits without a Title 10 call-up.
    Senator Smith. So what you did is not traditional.
    Mr. Reiley. Well, we are not in a traditional period of 
history.
    Senator Smith. Maybe it should be traditional.
    Mr. Reiley. The reintegration summits, which Dr. Heims 
mentioned, the Oregon National Guard, and Oregon Department of 
Veterans Affairs has really worked together to try to be at 
these demobilizations so that we can get these folks right at 
that point.
    There is some tension there because, you know, oftentimes 
it is somebody like me standing in front of these folks trying 
to tell them what their benefits are; on the other side of the 
door is their family that they haven't seen in a long time. So 
we have concerns about how much is being heard.
    Senator Wyden. They characterize that, that part of their 
experience, as the biggest recycling program in history, 
because what happens is people get those materials that you all 
have diligently tried to put together, but their loved ones are 
right there, so they want to see their loved ones, and off go 
those printed materials in the recycling bins.
    Senator Smith. As nice it is to see you, I imagine they 
want to see their loved ones more.
    Mr. Reiley. I imagine so, Senator.
    Senator Smith. But maybe there is a better time. Maybe on 
the plane back or some point before they get here there ought 
to be a requirement.
    Mr. Reiley. This is definitely a work in progress.
    Senator Smith. You have given us a good idea.
    Mr. Reiley. Some differences to be aware of: National 
Guard, Army Reserve called up under Title 10, demobilized, 
there is kind of a cooling-off period or an untouchable period 
for 90 days, when they don't have to attend drills, they don't 
have to go to the armories. They are allowed to, but the 
command cannot require them to attend.
    Marine Corps Reserve does it a little differently. I am not 
sure if it is 60 or 90 days, but upon their return home, they 
are kept on active duty, and so they have that period to kind 
of decompress, still while drawing active-duty pay and still 
where the command can say, you know, ``You have been home for 3 
weeks. Come on back in. We are going to have a presentation 
about your V.A. benefits.''
    So there are pluses and minuses to each procedure, but that 
is one thing that the Marine Corps does a little differently, 
which seems to allow them to get information out at perhaps 
better times.
    If I could take a moment to address some of the broader 
concerns. VBA, Veterans Benefits Administration, VHA, Veterans 
Health Administration, are in a period of prioritizing OEF and 
OIF veterans, and that is simply something which, again, has 
many pluses. If we can address these most recent veterans' 
concerns immediately, perhaps those concerns won't become the 
long-term problems that we have seen in other-era veterans.
    The problem is we establish priorities within a group that 
really is equal and within which there are no distinctions 
based on when one is served, in the sense of a period being 
better than another. So within VHA, Congress has authorized 
additional funds, additional positions are being created and 
filled to reach out to those veterans specifically. But we are 
not reaching out to, if we presume that 30 percent of those 
with a mental health condition seek treatment, those 70 percent 
from Vietnam, from the Korean era, from World War II.
    So it is a difficult issue, but it does seem to be one that 
can be fixed with additional funds. It is not one of those 
problems which isn't going to be helped by money being thrown 
at it; getting more staff within VHA, getting more outreach 
coordinators within the Vet Centers. There are ones dedicated 
to global war on terrorism veterans, but no other-era veterans. 
Getting more of those folks on board with VHA I think really 
could make a difference, getting these folks in.
    The eligibility criteria which we discussed, those 
returning from combat, one eligible for 2 years of VHA 
treatment from their date of separation, that is only for 
veterans who served in combat theater after 1998. So we have 
the Vietnam-era veteran who loses their job, the V.A. looks 
back to their income to the previous calendar year.
    Oftentimes I have to tell them, ``It is February. I 
understand you are having difficulties. But next year we will 
probably be able to make you eligible for V.A. health care 
because we will look back for this year, but right now you 
don't have eligibility.''
    So, some type of emergency period of eligibility for all 
veterans, whether it is 2 years or 5 years, that they can 
access at any point in their life might be something to 
consider.
    The last point I would like to bring to your attention or 
issue to address is the confidentiality of VHA records. Dr. 
Zeiss's testimony, I think the key word there was 
``automatically'' be shared with DOD. Also at the roundtable we 
were at earlier, you heard mention that the Oregon National 
Guard commander has stated that he will not request VHA 
treatment records. Well, he had to state that because he has 
that ability to get those records.
    It is my understanding that if DOD commanders believe that 
VHA treatment records are necessary to review to determine 
their mission readiness, whether in general or for a particular 
soldier, that they have the ability to get those treatment 
records.
    In Oregon, where nearly 7,000 of our 8,000 National 
Guardsmen have been called up since September 11th and are 
being called up again and again and are scheduled in 2009 to go 
back to Iraq, this is a great concern, whether those records 
are going to be shared. I am sure it is a law which allows 
that.
    Senator Wyden. I want to make sure I understand that point. 
When I asked Dr. Zeiss about that, the central question was 
right now there seems to be a lot of confusion about the 
records with respect to the computers at V.A. and the computers 
at DOD. She said, yes, that was the case. They were working on 
policy, but that it was the intent, at least of their program, 
that the patient should own the records, which is something I 
feel very strongly about.
    What you are saying is here is another program where it 
doesn't look like the patient's interests are paramount. Is 
that right?
    Mr. Reiley. That is my understanding, Senator.
    Senator Wyden. So we are going to have to sort out, as we 
try to coordinate how to make sure that the V.A., and the DOD 
are working together, we are going to have to coordinate 
different policies with respect to how records are handled. Is 
that right?
    Mr. Reiley. I would appreciate that, Senator.
    Senator Wyden. Very good.
    Mr. Reiley. I think the key is that it has to be requested 
by DOD, and that is why I believe the doctor mentioned that the 
records would not automatically be provided. From an outsider's 
perspective, this does not seem to be something that VHA is, 
frankly, thrilled about, but it seems to be something that they 
have to deal with.
    Senator Wyden. It ought to be that if ever there was a 
group in America that ought to control its records, it is the 
veterans. That is a part of my Healthy Americans Act, for 
example, is to make sure that as we go forward and set up 
electronic medical records, that the patient owns it. Certainly 
those who have worn the uniform of the United States deserve to 
own their medical records.
    So you have now highlighted the fact that there may even be 
different policies with differing programs, and we are going to 
have to sort through it. We will be consulting with you on it.
    Mr. Reiley. Thank you, Senator. Thank you very much.
    [The prepared statement of Mr. Reiley follows:]

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    Senator Smith. Thank you, Joe.
    Kevin. Kevin Campbell.

STATEMENT OF KEVIN CAMPBELL, COORDINATOR, EASTERN OREGON HUMAN 
              SERVICES CONSORTIUM, THE DALLES, OR

    Mr. Campbell. Good afternoon. Thank you, Senator Smith and 
Senator Wyden, for coming out here for this very important 
matter. It is a privilege to be with you this afternoon.
    My name is Kevin Campbell, for the record. I am the 
coordinator of the Eastern Oregon Human Services Consortium. 
The consortium was established in the 1980's to represent the 
mental health needs of 13 rural Oregon counties.
    In essence, counties got into this business on a Federal 
initiative. We had support from the State services, then moved 
and migrated because of lack of money, and the mental health 
directors of eastern Oregon decided very early in the system 
development that the only way we were going to be able to 
provide services to our citizens is by banding together.
    I looked on the Web to see how many vets reside in our 
counties, and there are about 23,000 vets living in the EOHSC 
catchment area. So about 23,000 vets scattered over about 
45,000 square miles. That is about two square miles per vet. 
Some of them would think that is just about right. [Laughter.]
    If you get to counties the size of Grant County, which has 
about 800 vets, they have five and a half square miles per vet. 
For Harney County, you are dealing with about 10 square miles 
per vet.
    The reason I go into this is what we discovered very early 
was you don't bring people to the services and you don't build 
facilities to treat people; you bring the services to the 
people. You do it based upon community strengths, and you do it 
based upon sensitivity to culture.
    In our part of the State, I would dare to say we are pretty 
independent, and I would say that people don't very quickly ask 
for help. If they do ask for help, they generally talk to a 
friend, a family member, or a neighbor or a clergy member, not 
somebody that is new to them or not somebody from an agency 
program that is necessarily there to help them.
    Our vets I think are tremendous volunteers, and it is their 
spirit of volunteerism that oftentimes made them veterans in 
the first place. When they come back to their communities, they 
deserve the dignity and the opportunity to continue being 
volunteers to the communities that they are from. Because of 
the way things are working together today, that is very, very 
difficult.
    A number of our folks in the current conflicts served in 
the National Guard. Many of them are nearly my age. To be 
disrupted from paying a mortgage and moving from a job to a 
period of active duty puts tremendous pressure on a family to 
just make ends meet.
    When that individual comes back from the conflict, 
regardless of whether there are mental health symptoms or not, 
there is going to be more stress than that individual and their 
family have ever had to deal with in their lives.
    All of us are very happy and very proud when vets come 
home. However, we need to be sensitive to the issues that are 
placed on them, not only by the conflicts overseas, but just 
the financial pressure of trying to reintegrate in the 
community when they come back.
    If I had one thing to say, it is very important that we 
recognize that the Federal Government has some ownership in the 
health and future of our veterans, and that if the Federal 
Government steps up and takes some ownership in that health and 
future, I think the dividends paid will be tremendous.
    I truly appreciate your idea of peer support networks. We 
in eastern Oregon are strong advocates of recovery from mental 
illness, and as in recovery from any other malady, early 
intervention is the key to it. The sooner we can get to people, 
the sooner we can work with people, and the less stigma we 
attach to needing help, then the better our outcomes are going 
to be.
    The publicly funded community mental health centers of 
eastern Oregon are there to serve all the residents of the 
county. Our primary funding source at this point in time is 
Medicaid. It is ironic that the numbers of people who are on 
Medicaid are very similar to the numbers of vets in our 
counties: approximately 7,000 in Umatilla County on both vets 
and Medicaid numbers.
    Now, some of those are going to be duplicated, but it seems 
to me that we can get economy of scale if we can leverage some 
Federal dollars to serve veterans in local community health 
programs and also use the Medicaid money that is serving the 
Medicaid population to serve that population. So maybe for 
$1.50 we can get $2 worth bigger out of the investment, if we 
think of it in that way.
    The primary thing that we have to deal with today is, in 
rural Oregon, we strongly embrace the managed care concept. We 
took responsibility for the long-term care of our folks, 
primarily with Medicaid. We created systems of care within the 
community. We did not rely upon expensive acute care in 
hospitalization. We have among the lowest hospitalization rates 
in the State.
    I believe that we are leading the State and the Country in 
recovery from mental illness in places like Wallowa County, 
Harney County, Malheur County, and now indeed in Umatilla 
County as well.
    The challenges in doing that are that you have to have some 
money to absorb risk, and you have to have a payoff. If you are 
willing to take the risk, you can't just be managed down to the 
dollar of what you spent last year, because 1 bad year could 
wipe you out.
    The Deficit Reduction Act is really moving us back to a 
fee-for-service type of system rather than a managed care 
system.
    If we are going to provide services to our vets in the 
future, then I would encourage you to think about the role of 
the community and the fact that the VFW, the American Legion, 
the veteran service officers, and the local mental health 
clinic and indeed county government all have a role in helping 
people through times of need. If we can invest only a few 
dollars in the bottom of the system, I think it will pay huge 
dividends to the top of the system.
    I was sitting next to a gentleman from Pendleton, who I 
just met. It turns out he has known my family for a hundred 
years, kind of an eastern Oregon thing. But Mr. Cook, I was 
talking to him about VFW in Grant County, and he told me that 
they were in danger of losing their post down there because 
there are so few members and people are so busy and it is very 
difficult to make a living and don't have time to volunteer.
    That has a real impact to me because in that county, that 
is one of the few natural supports that we have out there for 
vets, both new vets and vets that have been around for a while. 
I think that it is really important that we recognize the value 
of those organizations and buildupon their strength and their 
volunteerism rather than just trying to squeeze services into 
silos, if you will, or squeeze veterans into cars or buses to 
access best-of care.
    Thank you very much.
    [The prepared statement of Mr. Campbell follows:]

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    Senator Smith. Thank you, Kevin. Those were really 
excellent words. We appreciate it so much.
    Stuart, you are going to bat clean-up here.

  STATEMENT OF STUART STEINBERG, EXECUTIVE DIRECTOR, CENTRAL 
       OREGON VETERANS OUTREACH, CROOKED RIVER RANCH, OR

    Mr. Steinberg. OK. Before I actually start my formal 
testimony, I was very interested in hearing about this concept 
of peer support, and I want to just kind of briefly mention our 
organization.
    I am the executive director of Central Oregon Veterans 
Outreach, and we are a peer support organization. Eight of our 
board members and staff are combat vets: seven from Vietnam, 
one from World War II. Six of us are diagnosed with post-
traumatic stress disorder.
    I am a Vietnam veteran who has had to deal with this issue 
for many years and have a personal perspective that allows me 
to discuss this problem in detail. In addition, I have been a 
national service officer for Vietnam Veterans of America since 
1978, and in that position have assisted hundreds of veterans 
in claims for benefits from the Department of Veterans Affairs, 
but often involved mental health issues, particularly claims 
for combat-related post-traumatic stress disorder.
    Finally, directly related to veterans' mental health issues 
is the problem of alcoholism and substance abuse that is often 
secondary to the primary mental health diagnosis.
    I served in the U.S. Army from 1966 until 1971 and was in 
Vietnam from August 1968 until March 1970. I was an explosive 
ordnance disposal specialist; that is bomb squad, for those of 
you who aren't familiar with military language. I saw a lot of 
combat. I was wounded twice and decorated for heroism in ground 
combat.
    I was first diagnosed with post-traumatic stress disorder 
in 1993 by the V.A. after many years of dealing with things I 
didn't understand.
    I want to say that many people believe that everyone 
diagnosed with this disorder is incapable of functioning, and 
this is simply not true. It is unfortunate that this is a myth 
foisted upon the American public by media reports of a few 
sensational cases that leave people with the impression that 
this is the way it is with all of us diagnosed with PTSD.
    In my own case, despite my symptoms--startle response, 
hypervigilance, a sleep disorder, intrusive thoughts about the 
war, substance abuse and alcoholism, two failed marriages, and 
anger management issues--I managed to get a college degree, a 
law degree, and an advanced law degree. I was a graduate 
teaching fellow at the Georgetown University Law Center, a 
successful criminal defense attorney, and then an equally 
successful capital defense investigator for the Oregon Capital 
Defenders.
    In 2002, my PTSD symptoms finally got to a point where I 
was almost unable to function, either in the workplace or in 
social settings, and I had to give up a job that I loved.
    I am now rated by the V.A. as being totally disabled by 
PTSD and several physical problems related to being wounded and 
being exposed to herbicides. I was 55 when this happened, and I 
have learned that I am not alone in this regard.
    Because of my involvement in a PTSD group at the Bend's 
V.A. community-based outpatient clinic, I learned that a number 
of older veterans, most of whom served in Vietnam, found 
themselves finally having to deal with their issues related to 
the war late in life. I cannot tell you precisely why this is, 
but in my own case it was as simple as approaching the age of 
60 and not wanting to live the rest of my life having this 
illness interfere with virtually everything, every day.
    I, and many of the veterans I know, also have had to deal 
with alcohol and substance abuse issues that were directly 
related to our mental health problems. It was a way that we 
self-medicated so that we didn't have to deal with the primary 
problem. If it had not been for the group I was able to get 
into at the clinic--and that is a key phrase right there, 
``able to get into''--I really don't know what I would be doing 
now, but I can assure you I would not be sitting here today 
talking to you.
    The issue of veterans' mental health problems, especially 
among older veterans, is a serious and growing situation in the 
V.A. system. This has become particularly true since the 
additional burdens on the V.A. mental health system caused by 
the return of soldiers from the wars in Iraq and Afghanistan. 
Let's not forget that in addition there were combat veterans 
also being seen from the first Gulf War, the Balkans conflict, 
the Sinai, and now the Horn of Africa.
    The inability of the V.A. to adequately provide services 
for all who need them when they need them is not their fault. 
It is one of simple numbers. They do not have the funds to care 
for those who need treatment, and this is the direct result of 
the Government refusing to recognize the depth of the problem 
and failing to seek enough funding for the V.A. in their budget 
requests.
    This has been going on for years, and claims about how much 
the V.A. budget has been increased in recent years are 
disingenuous since the increases do not reflect inflation or 
the rapidly expanding costs of health care.
    Moreover, even the current Congress, while seeking greater 
funding, is still not asking for enough to care for all of 
those who need care now or those who will need care in the 
future, when they need it.
    The care we get at our clinic is absolutely top-notch--that 
is, for those of us lucky enough to be getting treated. The 
mental health staff is professional and extremely knowledgeable 
about PTSD, and they have helped hundreds of us over the years. 
The problem is that there are so many veterans in need of 
mental health services--and this is a nationwide problem--that 
the staff is overwhelmed.
    I am going to depart a little bit here. We have one 
psychiatrist who essentially is writing all of the 
prescriptions for psychotropic medication. We have one clinical 
social worker, and we have one clinical psychologist who, 
unfortunately, was recently diagnosed with a disease that he is 
probably not going to recover from. So he is out of the 
picture.
    I don't know how long it is going to take for them to 
replace this man who has helped so many of us, but however long 
it is, it is going to be too long, I can guarantee you, and the 
men and women he is treating are completely freaking out about 
this possibility.
    OK. So what it boils down to is there are too few mental 
health professionals and too many clients. I don't know where 
these 3,000 mental health professionals I heard Dr. Zeiss--
where they are, but they are not in Bend.
    Senator Wyden. We are going to try and change that.
    Mr. Steinberg. I hope so, Senator.
    Those who are being seen are typically being seen once a 
month individually, even if they should be seen weekly because 
of acute problems. As far as the groups go, there are waiting 
lists to get into them because the staff can only see so many 
in this setting.
    In fact, I have a client, as a service officer, who it is 
clear to me has post-traumatic stress disorder. He is a Vietnam 
veteran who served for 18 months as a helicopter door gunner. 
He flew more than 500 hours of combat flight time, has 21 air 
medals, one for valor, the Bronze Star, and the Army 
Commendation Medal. He is on a waiting list at our clinic for 
his initial mental health assessment, and that means that he is 
months away from actually getting into treatment, despite his 
acute symptoms.
    As far as my organization is concerned, this is immoral and 
it should be criminal. In our world, we were taught during our 
military service that you never, never leave a man or woman 
behind, yet that is precisely what happens to veterans in this 
Country every day due to a lack of adequate funding.
    This problem is not only affecting us older veterans, but 
it is also having an impact on the younger men and women 
returning from the current wars.
    There is no question that as time passes, more of the 
younger veterans will seek treatment for mental health problems 
directly related to their combat experiences, just as we 
Vietnam veterans have. If adequate funding is not available, 
you will see the results in failed marriages, lost jobs, anger 
management problems, and addiction problems.
    In terms of the addictions issue--and this is something I 
have personal experience in--the V.A. has totally failed in 
this regard. They have closed down numerous in-patient programs 
throughout the Country, and the number of beds have been cut to 
the point of near extinction.
    At a recent meeting between Senator Wyden, regional V.A. 
medical people, and local veterans, I asked about this problem. 
Incredulously, I was informed that the V.A. was shifting to 
outpatient care--and this is a quote--''because everyone knows 
it works better.''
    In the words of one my colleagues, this is a giant load. 
Anyone who knows anything about long-term alcohol and drug 
abuse knows that in-patient treatment, the famous 21 days, is 
critical to successful recovery before outpatient care can 
begin.
    I want to say to the new director who is here from Walla 
Walla that I did their in-patient program, and it is an 
incredible program. Now I hear there is talk about shutting it 
down and turning it into a giant outpatient clinic, and this is 
just wrong.
    Senator Wyden. Well, I will oppose that, too.
    Mr. Steinberg. I hope so.
    The V.A. is apparently the only provider of alcohol and 
drug rehab treatment that believes that in-patient care is less 
efficacious in successful recovery than outpatient care.
    Again, there is simply no question that the real reason for 
loss of in-patient care is money. Once again, the cause is lack 
of funding for critically needed V.A. programs.
    My program has referred more than a dozen veterans to in-
patient programs in Walla Walla and Boise, and all of them who 
have had multiple outpatient failures are still sober and now 
in a successful after-care program.
    By the way, if you expect to successfully deal with PTSD 
and other mental health problems when there is a co-existing 
substance abuse problem that is being inadequately treated, the 
likelihood of success in the mental health area is virtually 
impossible.
    The addition of the addictions therapists at the local 
clinic--and we just got one in Bend in the year 2007--is a good 
start, but it cannot replace in-patient care in the first 
instance.
    I could go on about these issues for hours, but I think I 
have said what I wanted to say. I appreciate the opportunity to 
have been able to speak about this important and serious issue, 
and hope that you were able to use all of the data you gathered 
today to help bring about long-overdue change in the way the 
V.A. has been so woefully and inadequately funded.
    When a man or woman goes off to war and defends their 
Country, they should not have to come home to continue to be at 
war with their Government over adequate medical and mental 
health treatment.
    Thank you.
    [The prepared statement of Mr. Steinberg follows:]

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    [GRAPHIC] [TIFF OMITTED] T0409.037
    
    [GRAPHIC] [TIFF OMITTED] T0409.038
    
    Senator Smith. Thank you, Stuart, so very much, for your 
service to our Country and the Vietnam conflict and for your 
courage in sharing your story and then serving other veterans.
    Senator Wyden has a few questions. I am going to submit my 
questions for the record, because if I don't get home for the 
Fourth of July activities my wife has planned in Pendleton, she 
is going to have an anger management issue with me. [Laughter.]
    So, Senator Wyden.
    Senator Wyden. I thank you, Senator Smith, and I thank you 
for the chance to work with you on this. I am going to ask a 
couple of quick questions.
    Joe, Governor Kulongoski and I were told in late spring 
that an Oregon Guard member or Reservist can be holding a gun 
in Afghanistan and then 12 days later be holding their child, 
say, in Portland or Ontario or anywhere else in Oregon.
    What are the implications of such a rapid transition for 
mental health services, and what do you think ought to be done?
    Mr. Reiley. Well, Senator, I am not a mental health 
professional, so I would defer to their judgment on how best to 
transition one from that setting to the other.
    In my perspective, when a client comes to my office, they 
are already either aware that there may be something available 
for them or aware that there is something there. Sometimes we 
have folks come in just to say, ``I am a veteran. I served 
during this period. What could I be eligible for?''
    So part of the need is to get that information out to those 
folks during that 12-day period so that they know, when they 
are home with their family, that if they feel something going 
awry, if they have some concerns, that there are folks that are 
able and willing to help them.
    Also, during the deployments we meet with the family 
members. At the Eugene armory we will typically do a couple of 
meetings with family members while troops are deployed. 
Representatives from the V.A. and myself are typically there 
and talk about the benefits.
    I think in the roundtable this came up, oftentimes the 
referrals for post-traumatic stress disorder issues come from 
spouses. They are often the first to recognize that something 
is different with this individual.
    But the best way to transition from one setting to the 
other, I cannot answer that.
    Senator Wyden. Senator Smith is on a tight timeline. I am 
going to ask all of you to answer that on the record because it 
just strikes me, given everything we are seeing about the 
nature of the conflict in Iraq and Afghanistan, that is not 
going to work. In a 12-day transition period from literally 
holding a gun to holding your child, something like that, we 
are going to have to look at this. So I will ask you do that in 
writing.
    One question for you, because I have been asking a lot of 
questions about rural areas: What do you think is the biggest 
barrier in the metropolitan area for vets getting services?
    Dr. Blackburn. I think the biggest barrier is the 
disaffiliation from the system and the reluctance to get 
involved in highly bureaucratic systems. For those with special 
needs, navigating those systems is particularly difficult.
    So I think for people that are suffering from some of the 
conditions we are talking about, I think peer advocacy is 
probably the most important thing we can do right away for vets 
coming, is that they are connected to peer advocates who can 
help them make that transition, kind of warn them what to 
expect over the next few weeks, and kind of stick with them if 
they have these special needs or state a desire to have that 
kind of service.
    Senator Wyden. You all have been an excellent panel.
    Mr. Steinberg, let me thank you again----
    Mr. Steinberg. Thank you.
    Senator Wyden [continuing]. Both for your service and your 
advocacy. As I listen to you, I think, frankly, mandatory 
funding would go a long way to handling a number of the issues 
you describe.
    Mr. Steinberg. Absolutely.
    Senator Wyden. But one of the reasons I did ask Dr. Zeiss 
to get us that 90-day assessment, we can get an assessment of 
what is actually going on in this State with respect to mental 
health services and then have a debate about where to get the 
money, because I share your view. I think a lot of people are 
falling between the cracks, and we definitely, both of us, feel 
if one veteran falls between the cracks, that is one darn too 
many.
    Mr. Steinberg. Can I say something here?
    Senator Wyden. Of course. Sure.
    Mr. Steinberg. Let me tell you the biggest reason, or at 
least the most cogent example of why mandatory funding is so 
necessary. I have mentioned this to Mike on Senator Smith's 
staff.
    A couple of years ago it was discovered that the V.A. was 
taking money from programs and spending it--I swear I am not 
making this up--on outsourcing studies, outsourcing V.A. jobs 
to some other country.
    Now, Vietnam Veterans of America, as far as I know, is the 
only organization that filed a formal complaint with the 
Department of Justice. It was my understanding at the time that 
this act may have, in fact, been criminal.
    There has been no response from either the V.A. or the 
Department of Justice about this situation. That is the first 
thing.
    The second thing, you know, you talk about these kids 
coming back from Iraq and Afghanistan, 12 days. Imagine what it 
was like when we flew back from Vietnam and went from, 
literally in my case, from being in a firefight to being in 
Oakland, California, in less than 24 hours, a little over 24 
hours.
    I don't know what the answer is, but when you talk about 
the stigma, right now I have seen probably six or seven OEF and 
OIF vets, and all of them have come to me because they have 
post-traumatic stress disorder. As I think it was Kevin said, 
they come to me through their families. In fact, I just got one 
where the mother-in-law was so concerned.
    Every one of these cases I get these kids' records, and I 
look at their post-deployment questionnaire, where it goes 
right down the list of post-traumatic stress disorder symptoms: 
startle response, hypervigilance, intrusive thoughts, and on 
and on and on. Yes or no? No. No. No. No. No. No.
    Then it gets to the question: Is your health, including 
mental health, as good as, better than, or worse than it was 
before you deployed? Every single one of them checks off ``it 
is as good as'' or ``it is better than.''
    Every single one of these kids, when I asked them, ``Are 
you going to sit here and tell me you didn't have any of these 
problems when you came back?'' ``Oh, no, I had them all.'' 
``Well, then why did you check no, no, no, no?'' ``Because I 
knew that my career would be crap if I checked yes and asked 
for help.'' Now, that is what the guys that I have seen said.
    Senator Wyden. Well, thank you all for being advocates for 
vets every day. We are grateful.
    Senator Smith. Let me join my colleague's commendation to 
each of you. I want you to know your time here is well-spent. 
It certainly has been for me. I know it has, I suspect, for 
Senator Wyden as well.
    You have added immeasurably to the record of the U.S. 
Senate. You have given us a laundry list of things to work on. 
We take on this issue with genuine concern and desire to fix it 
where we can and bind up the wounds and care for those who have 
borne the battle for our Country's sake.
    So we are grateful for your time and your attention. We 
thank all who have traveled a long way or short way for being 
here.
    With that, we are adjourned.
    [Whereupon, at 4:05 p.m., the Committee was adjourned.]


                            A P P E N D I X

                              ----------                              


             Prepared Statement of Senator Robert P. Casey

    I want to thank my colleague, Senator Gordon Smith, for 
chairing this important hearing to address mental health care 
for aging veterans. I look forward to working with him through 
this committee to meet the needs of our aging veterans.
    This hearing could not come at a more important time for 
veterans' health care in this country. In the coming months and 
years, the Veterans Administration faces the challenge of 
caring for the veterans from the wars in Iraq and Afghanistan 
that will return home in increasing numbers. Tragically, as the 
war in Iraq continues to escalate with no sign of improvement, 
we can only expect more casualties, and most will be survivors 
who return home to cope with devastating physical and mental 
injuries and illnesses as a result of their combat service.
    At the same time, in our efforts to expand our health care 
system to accommodate these young men and women, we must not 
forget or neglect our duty to our older veterans who have 
served America valiantly in previous wars. Combat veterans from 
World War II and the Korean War are now senior citizens. Many 
of those who served in Vietnam have retired, adding thousands 
of senior citizens to the VA's health care rolls. Men and women 
who fought in the Gulf War of 1991 have unique physical and 
mental health care concerns, the evidence of which has appeared 
in the years following the end of that war. We cannot allow our 
older veterans to suffer in our rush to devote health care 
resources to our returning Operation Enduring Freedom and 
Operation Iraqi Freedom soldiers and Marines.
    Addressing mental health care quality and access is 
particularly crucial to the VA's plans for the future. The high 
incidence of mental illness--including depression and Post-
Traumatic Stress Disorder (PTSD)--among OEF/OIF veterans has 
been well-documented in recent months. Sadly, patients are not 
the only victims of these terrible diseases--their families 
suffer as well, particularly children. The emotion impact upon 
children of PTSD suffered by their parent veterans has received 
very little attention and it must be addressed. Many veterans 
resist admitting their problems and seeking treatment. Mental 
and emotional illnesses are often not diagnosed for months or 
even years. The VA must prepare for the immediate influx of 
veterans needing treatment, but also for the decades ahead 
during which post-combat trauma in veterans can be identified 
and treated expediently by qualified, well-trained 
psychiatrists and other medical professionals. Again, as we 
address the specific needs of OEF/OIF veterans, we must not 
forget our older veterans, the sacrifices they made, and the 
challenges they encounter as they age.
    Pennsylvania shares many of the geographic and demographic 
characteristics of Oregon that can challenge access to and 
quality of mental health care for aging veterans. Like Oregon, 
Pennsylvania has a high rural population--thousands of citizens 
are spread throughout a large territory, and many have to 
travel for hours to access quality health care. Our state is 
home to 1.9 million citizens over the age of 65, the third 
largest number of senior citizens per capita of any state in 
the country.
    In fiscal year 2006, the VA reported that nearly 1.1 
million veterans reside in Pennsylvania. Over 480,000 were 65 
or older. In 2004, the VA spent $2.5 billion on health care for 
veterans in Pennsylvania, and that number continues to increase 
year by year.
    I am grateful to Senator Smith for calling attention to 
these critical issues and I look forward to the testimony of 
our witnesses. We must do whatever is necessary to meet the 
physical, psychological and emotional needs of our veterans and 
fulfill this nation's promise to our returning heroes of every 
age.
                                ------                                


         Responses to Senator Smith's Questions from Jack Heims

    Question. Since Portland is an urban environment and a 
vibrant city, I would imagine that some of these issues may be 
lessened at this facility, but is this something that you 
experience?
    How do you attract and retain qualified professionals?
    Answer. Our post training programs remain the major source 
of hires. We host post graduate programs in psychiatry 
(residency and fellows), psychology (intern and post doc), 
social work, art therapy, nurse practitioner, occupational 
therapy and nursing.
    Others are attracted to the rare environment where clinical 
missions are shared with the missions of education and 
research. Many like that the business end of medicine is taken 
out of their job description so they can focus on patient care. 
An increasing number are attracted to the concept of serving 
our Veterans. Also, on an increasing basis, a benefits package 
for Federal Employees becomes a beacon for recruitment.
    Typically, we advertise in various websites and national 
professional journals. Word of mouth by our own employees is 
our best advertiser.
    Retention is high for all of the aforementioned reasons. 
More often than not, when we lose someone it is to another VA 
Medical Center. Another factor is the lengths we go to to 
provide ongoing education programs through hosting conferences, 
grand rounds, brown bag seminars and et cetera.
                                ------                                


      Responses to Senator Smith's Questions from Nathalie Huguet

    In your testimony you mention that primary care physicians 
have an important role to play in the assessment and management 
of depression and suicide prevention for veterans.
    Question. What do you think is the most effective way to 
encourage physicians to do this?
    Answer. Primary care physician assessment and management of 
depression and suicide prevention for veterans could be 
encouraged by expanding reimbursement so that primary care 
providers can implement and sustain evidence-based procedures 
aimed at detection and treatment of veterans with major 
depressive disorder. Federally funded research projects over 
the past twenty years have shown that primary care providers 
can do an excellent job at detecting and treating people with 
major depressive disorder. The key to success is inclusion in 
primary care practices of ``care managers'' who have expertise 
in mental health. Care managers are nurses or couselors 
(usually with masters degrees such as social workers) who 
follow protocols for detection and treatment of people with 
depression. Primary care providers facilitate treatment by 
prescribing medication as needed. This care management approach 
has been well studied and shown to be effective. Unfortunately, 
this model has rarely been sustained owing to lack of 
reimbursement. Primary care providers nowadays are not 
infrequently in financial difficulty and are unable to sustain 
evidence-based practices such as care management. Congress 
should direct the Department of Veterans Affairs to provide 
reimbursement for primary care depression detection and 
management for veterans unable to be served within the Veterans 
Affairs system.
    Do you think that there is more that could be done in their 
general training to prepare them to identify possible mental 
illness along with physical illnesses.
    Answer. Primary care training could be expanded to provide 
education about the care management model and to facilitate 
educational experiences within a care management system. Again, 
lack of reimbursement is the chief obstacle. Academic health 
centers are not able to finance care managers. Congress should 
direct the Department of Veterans Affairs to provide funding 
for academic health centers offering care management services 
to veterans unable to be served within the Veterans Affairs 
system.
                                ------                                


       Responses to Senator Smith's Questions from Mr. Blackburn

    In your testimony you mention that there is a lack of 
supportive housing options that ensure stability of chronically 
homeless veterans. I am a cosponsor of a bill in the Senate 
that would provide services for permanent supportive housing 
programs because I understand how important and effective 
supportive housing is for this hard-to stabilize population.
    Question. How many units of supportive housing do you think 
we would need to better serve our homeless veterans here in 
Portland?
    Answer. Project CHALENG (Community Homelessness Assessment, 
Local Education and Networking Groups) is an annual survey of 
VA and local community and government agencies serving homeless 
veterans. The survey assesses the needs of homeless vets and 
rates the coordination of services with the various local 
partners.
    According to this CHALENG survey, collected in the summer/
fall of 2006, there are 1856 homeless veterans in Portland, 
including 587 chronically homeless vets. The survey is a self-
administered questionnaire completed by the local VA homeless 
veteran coordinator in collaboration with federal, state, 
county, city, nonprofit and for profit agency representatives, 
as well as local VA staff and homeless veterans. The need for 
permanent supportive housing ranks high as an unmet need. Given 
that the definition of chronically homeless includes 4 or more 
episodes of homelessness in the last 3 years of 1 continuous 
year of homelesness and one or more disabilities, we feel 
comfortable recommending that all 587 of the chronically 
homeless vets could benefit from supportive housing. Supportive 
housing for this population would need to include both housing 
subsidy and the supportive case management services needed to 
stabilize these individuals and help them access the benefits 
and entitlements for which they may qualify. The level of 
supportive services can range from minimal, with a check in 
only once per month, to frequent, with case managers needing to 
see someone several times a week ongoing for multiple years. 
Our experience working with chronically homeless individuals is 
that they typically need very intensive services over multiple 
years with step down occurring for short periods of time 
throughout.
    The remaining 1,269 episodically homeless veterans may 
benefit from limited rent assistance needed to acquire their 
own housing units. One program currently funded through the 
Housing Authority of Portland provides up to 3 months worth of 
rent and covers security deposits so that recipients can 
stabilize and secure employment. This resource has proven quite 
effective, with 70 percent of individuals served still housed 
one year after they last received rent assistance.
    In Central City Concern's experience, a high number of 
homeless veterans experience alcohol or drug addiction. These 
veterans have a need for transitional Alcohol and Drug Free 
Community clean and sober supportive housing, provided in 
conjunction with alcohol and drug treatment. We recommend 
creating 20-30 units of this type of housing for homeless 
veterans.
                                ------                                


         Responses to Senator Smith's Questions from Mr. Reiley

    In your testimony you state that claims for care from 
veterans returning from Iraq and Afghanistan have caused claims 
from other veterans to languish.
    Question. How long are older veterans waiting for services?
    Answer. There are a number of points within the VA system 
where veterans must wait. The three major bottlenecks are: 1) 
obtaining an initial appointment within Veterans Health 
Administration (VHA); 2) obtaining an appointment with one's 
VHA Primary Care Provider (PCP); and 3) having one's claim 
processed by a Regional Office (RO) of the Veterans Benefits 
Administration (VBA).
    1) Locally, the Roseburg VA Health Care System (RVAHCS) is 
usually close to the VA's mandate to enroll veterans within 30 
days of receiving their application. Enrollment consists of not 
only processing the application, but scheduling the veteran's 
``Introduction Clinic'' and initial appointment with their 
assigned PCP. Recently however, Roseburg has lost one of their 
enrollment staffers due to retirement and initial appointments 
now are taking approximately 6 weeks to obtain. This is 
understandable, but I am concerned that RVAHCS has had to go 
through a formal process to justify rehiring this position. The 
results of this process were not known as of August 2, 2007. 
Until this process has been successfully navigated, the 
position cannot be filled and thus I am concerned that the 
backlog will increase.
    2) Although RVAHCS typically does a good job scheduling 
initial appointments within or close to the goal of 30 days, 
there are problems accessing follow-up care. Often times 
veterans must wait upwards of four months in order to obtain an 
appointment with their medical PCP. Locally, the Eugene VA 
Clinic has moved to a ``same day appointment'' system within 
their mental health clinic. There was some discussion about 
expanding this type of system to the medical side, but I am 
unaware of any progress towards that end.
    3) Perhaps the most frustrating aspect of seeking services 
from the VA is the period of time it takes for VBA to 
adjudicate a claim for service-connected compensation. On the 
positive side, the Portland Regional Office has developed a 
program called ``Ready to Rate.'' If a veteran can submit a 
claim--typically a claim for Nonservice-Connected Pension with 
Aid and Attendance--which needs no development the Portland 
R.O. will rate that claim within, typically, 14 days. A claim 
needs no development if there is a complete application, proper 
proof of service, and evidence which satisfies each element of 
the benefit for which the veteran is applying. In the case of 
pension claims, that often entails a medical statement of 
disability and need for care and proof of long-term care 
expenses.
    However, the majority of claims filed are for service-
connected compensation and rarely are these able to be filed as 
``Ready to Rate.'' The barrier to accessing expedited 
processing for these types of claims is the requirement for VBA 
to obtain the veteran's service medical records (SMRs) and to 
determine the nexus, if any, between those conditions detailed 
in the SMRs and those conditions with which the veteran is 
currently diagnosed. Accordingly, claims for service connected 
compensation typically take from 9 to 12 months in Oregon.
    Some cases can take significantly longer than the average. 
Often time, claims for service connection for Post-Traumatic 
Stress Disorder (PTSD) take some of the longest periods to 
obtain a decision from VBA. It appears the problem is the time 
it takes for VBA to verify the military stressor which the 
veteran experienced which has lead to the development of PTSD. 
If the veteran does not have documentation of a military 
stressor, or an award which allows VBA to concede the stressor, 
the Regional Office must request verification from JSRCC 
(formerly USACURR). The local RO submits a request for 
verification and then will calendar the file for review every 
60 days. Unfortunately, this part of the process alone can take 
a year. Furthermore, only upon stressor verification will the 
RO further develop the claim which will include a request for a 
mental health evaluation to determine if the veteran has PTSD 
and upon completion of the development may the claim be 
adjudicated.
    Question. How would you describe the impact from the 
backlog on older veterans?
    Answer. The impact on the VBA claims backlog is significant 
and manifold. Many older veterans must first be recognized to 
have a compensable service connected condition before they are 
eligible for VA health care. Thus the delays in claims 
adjudication results in a delay in their ability to receive 
health care.
    Also, many veterans try to be self-sufficient for as long 
as possible and so only file a claim for service connection 
when a condition becomes unbearable. This often also coincides 
with when the condition negatively impacts their employment 
abilities and thus they may be suffering financial hardship 
when they initiate a claim. Waiting many months for a 
determination of eligibility can thus lead to the loss of one's 
home or other severe financial ramifications.
    Finally, there are many ramification of a less tangible 
nature. The long delays inherent in the claims process are seen 
by many veterans as based on an underlying lack of commitment 
by our government to assist those that served our country in 
times when they are in need. This leads to the often heard, yet 
still upsetting comments from veterans that, ``The VA is just 
waiting until I die so they don't have to help me.''
    Veterans in rural areas have the added burden of having to 
travel great distances to receive care at a veterans' facility. 
This is a challenge for all rural veterans, particularly 
elderly veterans.
    Question. How prevalent are the transportation issues for 
the veterans you work within Lane County?
    Answer. The transportation issues for veterans in Lane 
County are there, but not to the degree of other counties that 
have no VA facilities. Lane County veterans often face 
difficulty if they must travel to Roseburg or Portland for 
specialty care. Also, west Lane County residents sometimes have 
difficulty traveling to Eugene for primary care appointments. 
While those in Eugene-Springfield have access to the DAV van 
which runs up and down the I-95 corridor connecting VA 
facilities. Those outside the Williamette Valley are left to 
their own devices.
    Question. How is your agency preparing for the expected 
increase in the number of older veterans as the baby-boom 
generation ages?
    Answer. Lane County Veteran Services certainly recognizes 
the average age of veterans is increasing--please see my 
previously submitted written materials for demographic details 
of Lane County veterans over the next 10 years.
    As for preparing for the increases in older veterans, we 
have systems currently in place which will serve such veterans 
well, but there are concerns about our ability to continue 
these services. In January, 2006, additional State funds were 
transferred to Oregon counties in ``expand and enhance'' 
veteran services. These new funds, coupled with traditional 
support from Lane County, and the Cities of Eugene and 
Springfield, allowed us to increase our staffing levels and 
markedly increase our outreach efforts. Lane County Veteran 
Service Counselors now travel to Florence on a weekly basis and 
travel to Cottage Grove, Oakridge, Junction City, and Blue 
River once per month. The veterans seen during these outreach 
efforts are typically older and less able to either physically 
of financially afford to travel to our office. While in these 
local communities, our counselors will also conduct home visits 
or visits to veterans in long-term care facilities. 
Furthermore, once per week a counselor will also conduct local 
outreach to housebound or facility-resident veterans in the 
Eugene-Springfield area.
    But these services are in jeopardy. Lane County is facing a 
shortfall of up to 30 percent of its discretionary General Fund 
due to the possible loss of federal funding provided through 
the Secure Rural Schools and Community Self-Determination Act 
(SRS) (PL 106-393 and its recent extension of 2007). If federal 
funding is not made available under this or some similar 
program which recognizes the inability of Lane County to tax 
the large tracts of federal lands within its borders, the 
county will face financial crisis. If such a situation were to 
come to pass, the county would likely focus on its primary and 
mandated services--public safety. Under a recent potential 
budget which was premised on the loss of the SRS funding, the 
Lane County Veteran Service Office was reduced to only one 
staff person. Such a situation would obviously wreak havoc on 
the office's ability to serve Lane County's 35,000+ veterans.
                                ------                                


       Responses to Senator Smith's Questions from Kevin Campbell

    In your testimony you state that bringing mental health 
services to those in need is the best response for serving 
rural populations.
    Question. Can you explain how you do that--are you 
essentially talking about house calls from mental health 
providers?
    What sort of outreach have you seen with the VA to the 
rural areas to help soldiers identify and access care?
    Answer. No, I was not implying that mental health providers 
should be required to make house calls. What I am referring to 
is making services available to veterans in their home 
communities rather than forcing them to travel up to a hundred 
miles to access services in the nearest mental health clinic or 
well over a hundred miles to access services from a VA Clinic. 
Our efforts to bring services to veterans rather than force 
veterans to travel to services can best be summed up by three 
strategies:
    Better use of technology. We are utilizing two way video, 
tele-health, technology throughout Eastern Oregon at the 
present time. This technology allows access to specialized 
services with high quality resolution.
    Better use of natural supports such as peers who live in 
the community. Establishing peer support networks in smaller 
communities which assist veterans and their families in meeting 
challenges as they arise. Peer to Peer Support is often times 
the timeliest and effective treatment to conditions as they 
arise and it needs to be supported.
    Better use of Case Management for veterans and their 
families. Case Management is a valuable service which connects 
the veterans and their family to service providers who can best 
meet a variety of needs. Case Management services can often be 
provided by the telephone.
    In your testimony, you also mention that there has been a 
drop in the number of physicians willing to accept Tri-Care 
Insurance due to low reimbursement payments.
    Question. Are low VA and Tri-Care reimbursement rates 
resulting in access issues for military families?
    What type of incentives do you think are necessary for 
attracting and keeping mental health professionals and 
physicians in rural areas?
    Answer. My written testimony included the following; ``Once 
veterans are determined to be eligible for benefits, services 
are often times many miles away, access is commonly delayed by 
a preauthorization process, and many providers no longer accept 
Tri-Care Insurance due to difficulty being paid for their 
services. Payment rates are often so low that private 
practitioners are unable to provide services because the 
payment does not cover the cost of the needed services.''
    In using the term, ``private practitioners'', I did not 
imply that only physicians were concerned about payment rates. 
When mental health practitioners do not see people with 
insurance, these individuals come to the public mental health 
system for service. Low reimbursement rates lead to cost 
shifting or dependence on state and local funds to continue to 
support the service. By mirroring Medicare rates, Tri-Care has 
a disproportionate impact on rural practitioners. Increased 
numbers of veterans has stressed the system.
    Oregon recently passed a law to give tax credits to 
physicians who accept Tricare. Under the new law, physicians 
can claim a $2,500 tax credit the first year they accept 
patients under the federal Tricare health system and $1,000 for 
each following year.
    Continuation of programs such as the National Health 
Service Corps is essential to recruiting Mental Health 
Professionals in Rural areas. Reimbursement Rates must be 
adequate to maintain these professionals in rural areas. While 
housing is often times less expensive, gas and food are 
significantly more expensive in rural areas and it is not 
cheaper to live in a rural community than in the city.
                                ------                                


       Responses to Senator Smith's Questions from Stu Steinberg

    Unfortunately, the stigma associated with mental illness 
deters many soldiers and veterans from seeking help.
    Question. What do you think the Department of Defense and 
VA could and should do to help overcome the stigma associated 
with mental illness?
    Answer. The DOD must insure that all soldiers can seek 
mental health care without fear for their career. To the extent 
that the military denies this is occurring, it is simply a lie. 
One only need listen to the NPR story about soldiers at Ft. 
Carson, CO, to verify that this is occurring. Moreover, I have 
several recent returnee clients who have told me the same 
thing. They check ``no'' to every question asked about PTSD 
symptoms on their post-deployment questionnaire because it has 
been made very clear to them that their career will be 
negatively impacted if they say they have PTSD or other mental 
health symptoms. It has now been established that since the 
beginning of the two recent wars, the military is doing 
everything it can to discharge soldiers with personality 
disorders in order to deny them medical boards and retirement 
benefits or severance pay--the number is approximately 22,000 
soldiers. We saw this happen over and over again during 
Vietnam. I have a case now where an Iraq veteran was treated in 
Iraq for PTSD at the Combat Stress Facility, then transferred 
to Germany for further treatment. There, he was diagnosed with 
a Bipolar disorder which mysteriously existed prior to his 
enlistment more than four years earlier. Needless to say, you 
aren't Bipolar one day and then not have symptoms for more than 
four years and suddenly you have it again. Even if he did have 
it prior to enlistment, it is clear that what he had in Iraq 
was PTSD. Because it is now an EPTE thing, he gets no VA 
benefits because he had less than 24 months on active duty.
    As far as the VA is concerned, I see no Stigma issue on 
that front.
    The importance of addressing mental health problems in a 
timely manner cannot be overstated. If ignored, they can result 
in much more severe problems for the veterans and their loved 
ones.
    Answer. The VA is where the problem is, here. There are too 
few programs, not enough staff and there are waiting lists for 
initial intake and referral for individual and group treatment. 
This is particularly a problem at the CBOCs where the need is 
greatest and clients have to wait for treatment, sometimes for 
many months. The VA needs to stop building new facilities and 
use their funds for hiring more staff and treatment. It is just 
that simple. Every medical center and CBOC should have a PTSD/
mental health program and every medical center should have an 
inpatient program. As far as I know, the Portland/Vancouver 
facility does not have an inpatient PTSD programs. In addition, 
since substance abuse and alcoholism are often symptomatic of 
PTSD, it is criminal in my opinion that every medical center 
does not have an inpatient program and that every CBOC does not 
have an addictions therapist. Someone from the VA at the 
hearing stated that outpatient treatment works better. This is 
the most incredible load I have heard recently since any 
addictions thereapist or counselor will tell you that long-term 
addictions problems always require inpatient care before 
outpatient care is a possibility. Furthermore, without 
addictions therapists at the CBOCs, aftercare does not occur, 
thus, creating a situation where relapse is probable.
    Question. Based on your experience, how long do some 
veterans wait for the care they need?
    Answer. Months and in some cases I have seen it take as 
long as a year for admission to a PTSD group. Moreover, it is 
simply not useful to have individual therapy occurring on a 
monthly or even a lesser occasion. Every veteran with a mental 
health diagnosis should have the benefit of weekly therapy, bi-
weekly at the outside. No veteran who wants group therapy 
should have to wait longer than a month. Claims by the CA that 
they are providing adequate mental health care are belied by 
reports of veteran after veteran of having to wait inordinate 
lengths of time, or not receiving adequate care. They can't all 
be liars.
    Question. What other barriers to access and services do you 
see?
    Answer. Lack of funding, lack of funding, lack of funding.
    Question. What would help bring down these barriers?
    Answer. More funding, more funding, more funding.
    One of my priorities is to ensure that veterans of all ages 
and eras have access to quality mental health services and 
receive treatment in a timely manner.
    Question. How have you seen the delivery of services for 
older veterans impacted in the past few years when soldiers 
began returning from Iraq and Afghanistan?
    Answer. I really haven't seen this problem occur at the 
Bend CBOC. Veterans from all conflicts face the same problem of 
too few staff and not enough funds to make mental health and 
addictions care meaningful.
    Question. What specific improvements would have the biggest 
impact on improving mental health services for veterans in 
Oregon?
    Answer. More funding and, therefore, more staff. I hate to 
keep harping on the same issue over and over, but that's the 
simple truth. Maybe if the Army wasn't funding professional 
auto racing teams, such as their Top Fuel Dragster and Pro 
Stock Motorcycle teams in the National Hod Rod Association, the 
VA could put that money to better use. This is costing the 
American taxpayer millions of dollars each year.

                                 
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