[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
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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:]
[GRAPHIC] [TIFF OMITTED] T0409.036
[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
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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.
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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.
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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.