[House Hearing, 111 Congress]
[From the U.S. Government Publishing Office]




 
                    CHARTING THE U.S. DEPARTMENT OF
                 VETERANS AFFAIRS' PROGRESS ON MEETING
                     THE MENTAL HEALTH NEEDS OF OUR
                    VETERANS: DISCUSSION OF FUNDING,
                   MENTAL HEALTH STRATEGIC PLAN, AND
                       THE UNIFORM MENTAL HEALTH
                           SERVICES HANDBOOK
=======================================================================

                                HEARING

                               before the

                         SUBCOMMITTEE ON HEALTH

                                 of the

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                     ONE HUNDRED ELEVENTH CONGRESS

                             FIRST SESSION

                               __________

                             APRIL 30, 2009

                               __________

                           Serial No. 111-17

                               __________

       Printed for the use of the Committee on Veterans' Affairs


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                     COMMITTEE ON VETERANS' AFFAIRS

                    BOB FILNER, California, Chairman

CORRINE BROWN, Florida               STEVE BUYER, Indiana, Ranking
VIC SNYDER, Arkansas                 CLIFF STEARNS, Florida
MICHAEL H. MICHAUD, Maine            JERRY MORAN, Kansas
STEPHANIE HERSETH SANDLIN, South     HENRY E. BROWN, Jr., South 
Dakota                               Carolina
HARRY E. MITCHELL, Arizona           JEFF MILLER, Florida
JOHN J. HALL, New York               JOHN BOOZMAN, Arkansas
DEBORAH L. HALVORSON, Illinois       BRIAN P. BILBRAY, California
THOMAS S.P. PERRIELLO, Virginia      DOUG LAMBORN, Colorado
HARRY TEAGUE, New Mexico             GUS M. BILIRAKIS, Florida
CIRO D. RODRIGUEZ, Texas             VERN BUCHANAN, Florida
JOE DONNELLY, Indiana                DAVID P. ROE, Tennessee
JERRY McNERNEY, California
ZACHARY T. SPACE, Ohio
TIMOTHY J. WALZ, Minnesota
JOHN H. ADLER, New Jersey
ANN KIRKPATRICK, Arizona
GLENN C. NYE, Virginia

                   Malcom A. Shorter, Staff Director

                                 ______

                         SUBCOMMITTEE ON HEALTH

                  MICHAEL H. MICHAUD, Maine, Chairman

CORRINE BROWN, Florida               HENRY E. BROWN, Jr., South 
VIC SNYDER, Arkansas                 Carolina, Ranking
HARRY TEAGUE, New Mexico             CLIFF STEARNS, Florida
CIRO D. RODRIGUEZ, Texas             JERRY MORAN, Kansas
JOE DONNELLY, Indiana                JOHN BOOZMAN, Arkansas
JERRY McNERNEY, California           GUS M. BILIRAKIS, Florida
GLENN C. NYE, Virginia               VERN BUCHANAN, Florida
DEBORAH L. HALVORSON, Illinois
THOMAS S.P. PERRIELLO, Virginia

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.


                            C O N T E N T S

                               __________

                             April 30, 2009

                                                                   Page
Charting the U.S. Department of Veterans Affairs' Progress on 
  Meeting the Mental Health Needs of Our Veterans: Discussion of 
  Funding, Mental Health Strategic Plan, and the Uniform Mental 
  Health Services Handbook.......................................     1

                           OPENING STATEMENTS

Chairman Michael Michaud.........................................     1
    Prepared statement of Chairman Michaud.......................    24
Hon. Henry E. Brown, Jr., Ranking Republican Member..............     2
    Prepared statement of Congressman Brown......................    24
Hon. Ciro D. Rodriguez...........................................    11
    Prepared statement of Congressman Rodriguez..................    25

                               WITNESSES

U.S. Department of Veterans Affairs:
    Michael L. Shepherd, M.D., Senior Physician, Office of 
      Healthcare Inspections, Office of Inspector General........    15
        Prepared statement of Dr. Shepherd.......................    38
    Ira Katz, M.D., Ph.D., Deputy Chief Patient Care Services 
      Officer for Mental Health, Veterans Health Administration..    19
        Prepared statement of Dr. Katz...........................    42

                                 ______

Disabled American Veterans, Adrian Atizado, Assistant National 
  Legislative Director...........................................     3
    Prepared statement of Mr. Atizado............................    26
Wounded Warrior Project, Ralph Ibson, Senior Fellow for Health 
  Policy.........................................................     4
    Prepared statement of Mr. Ibson..............................    33

                       SUBMISSIONS FOR THE RECORD

American Veterans (AMVETS), Christina M. Roof, National Deputy 
  Legislative Director...........................................    47
Kaptur, Hon. Marcy, a Representative in Congress from the State 
  of Ohio........................................................    50
Woods, Christine, Hampton, VA, Former Program Specialist and 
  National Consultant, Office of Mental Health, Veterans Affairs 
  Central Office, U.S. Department of Veterans Affairs............    51

                   MATERIAL SUBMITTED FOR THE RECORD

Post-Hearing Questions and Responses for the Record:
    Hon. Michael H. Michaud, Chairman, and Hon. Henry E. Brown, 
      Ranking Republican Member, Subcommittee on Health, 
      Committee on Veterans' Affairs, to Hon. Eric K. Shinseki, 
      Secretary, U.S. Department of Veterans Affairs, letter 
      dated May 5, 2009, and VA Responses........................    59


                    CHARTING THE U.S. DEPARTMENT OF
                 VETERANS AFFAIRS' PROGRESS ON MEETING
                     THE MENTAL HEALTH NEEDS OF OUR
                    VETERANS: DISCUSSION OF FUNDING,
                   MENTAL HEALTH STRATEGIC PLAN, AND
                       THE UNIFORM MENTAL HEALTH
                           SERVICES HANDBOOK

                              ----------                              


                        THURSDAY, APRIL 30, 2009

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                                    Subcommittee on Health,
                                                    Washington, DC.

    The Subcommittee met, pursuant to notice, at 10:03 a.m., in 
Room 334, Cannon House Office Building, Hon. Michael Michaud 
[Chairman of the Subcommittee] presiding.
    Present: Representatives Michaud, Brown of Florida, Snyder, 
Rodriguez, McNerney, Perriello, Brown of South Carolina, and 
Moran.

             OPENING STATEMENT OF CHAIRMAN MICHAUD

    Mr. Michaud. I would like to call the Subcommittee on 
Health to order. I would like to thank everyone for coming 
today. We are here today to talk about the U.S. Department of 
Veterans Affairs' (VA's) progress on meeting the mental health 
needs of our veterans. Specifically, we will be discussing 
issues of funding and implementation of the Mental Health 
Strategic Plan and the Uniform Mental Health Service Handbook.
    Many in this room are familiar with the daunting statistics 
on mental health from the April 2008 RAND Corporation Report on 
``Invisible Wounds of War.'' The RAND Report estimated that of 
the 1.64 million Operation Enduring Freedom/Operation Iraqi 
Freedom (OEF/OIF) servicemembers deployed to date, about 18 
percent suffer from post-traumatic stress disorder (PTSD) or 
major depression, and about 20 percent likely experienced a 
traumatic brain injury (TBI) during deployment. In addition, 
the report showed that despite our current efforts about half 
of our servicemembers are not seeking and receiving the mental 
health treatment that they need. This raises serious concerns 
about the long term negative consequences of untreated mental 
health problems, not only for the affected individuals but also 
for their families, their communities, and our Nation as a 
whole.
    To address this problem the VA has focused their efforts on 
improving mental health care for our veterans. For example, the 
VA has set aside substantial funding for mental health care, 
which amounts to $3.8 billion in fiscal year 2009. The VA also 
approved a Mental Health Strategic Plan in November of 2004, 
which is a 5-year action plan with distinct mental health 
enhancement initiatives. Additionally, I am aware of the 2008 
Uniform Mental Health Service Handbook, which defines standards 
and minimum clinical requirements for mental health services 
that the VA will implement nationally.
    I applaud the VA on these efforts, and it is important for 
the Committee to ensure proper oversight. Today's hearing will 
explore the concern raised in the 2006 U.S. Government 
Accountability Office (GAO) Report which found that the VA 
spent less on mental health initiatives than planned and lacks 
the appropriate mechanism for tracking the allocated mental 
health funding. We will also seek a better understanding of the 
successes and the challenges faced by the VA in implementing 
the Mental Health Strategic Plan and the Uniform Mental Health 
Service Handbook. Today we will hear from various experts in 
the field, including the Disabled American Veterans (DAV), the 
Wounded Warrior Project (WWP), the Office of Inspector General 
(OIG), and the VA, and I look forward to the different panels 
today and their testimony.
    I now would recognize a distinguished Member of this 
Committee, Ranking Member Brown, for any opening statement that 
he may have.
    [The prepared statement of Chairman Michaud appears on p. 24
.]

         OPENING STATEMENT OF HON. HENRY E. BROWN, JR.

    Mr. Brown of South Carolina. Thank you, Mr. Chairman. I 
appreciate you holding this hearing today. Mental health is a 
critical component of a person's well-being and essential to 
the mission of the Department of Veterans Affairs, ``To care 
for those who have borne the battle is to effectively intervene 
and to care for the invisible wounds of war.'' The 
psychological toll of war is not always apparent and sadly has 
not always received the attention it should. However, I think 
we can all agree that the VA has come a long way, especially in 
the past few years, to improve mental health services and 
encourage veterans in need of care to get help.
    Even though significant progress has been made, there is no 
doubt that we must still do more, as we continue to hear about 
veterans facing barriers and gaps in service. We must ensure 
that when a veteran needs and seeks help, that veteran gets the 
right care at the right time. In the past decade, we have made 
a substantial investment in VA mental health, increasing 
funding by 81 percent from $2.1 billion in fiscal year 2001 to 
no less than $3.8 billion in fiscal year 2009. That is why it 
was very disturbing when the Government Accountability Office, 
in November of 2006, reported that VA had not allocated all 
available funding to implement the Mental Health Strategic 
Plan.
    It is our responsibility to see that the funding we provide 
is spent as intended to support a complete array of mental 
health prevention, early intervention, and rehabilitation 
programs for our Nation's veterans. I look forward to hearing 
from our witnesses and having the opportunity to take a look at 
where we stand in taking care of the mental health needs of our 
veterans. With that, Mr. Chairman, I yield back.
    [The prepared statement of Congressman Brown appears on
p. 24.]
    Mr. Michaud. Thank you very much, Mr. Brown. We will start 
off with panel two. Congresswoman Kaptur is going to be delayed 
so we will move directly to panel two, Adrian Atizado from the 
Disabled American Veterans and Ralph Ibson from the Wounded 
Warrior Project, I would like to thank both of you for coming 
here this morning to talk about this very important issue that 
our veterans are facing. And we will start off this morning 
with Mr. Atizado.

 STATEMENTS OF ADRIAN ATIZADO, ASSISTANT NATIONAL LEGISLATIVE 
 DIRECTOR, DISABLED AMERICAN VETERANS; AND RALPH IBSON, SENIOR 
       FELLOW FOR HEALTH POLICY, WOUNDED WARRIOR PROJECT

                  STATEMENT OF ADRIAN ATIZADO

    Mr. Atizado. Thank you, Mr. Chairman, Members of the 
Subcommittee. I would like to thank you for inviting the DAV to 
testify today. We appreciate this opportunity to discuss our 
views on meeting the mental health needs of our veterans.
    We, as an organization, strongly believe that all enrolled 
veterans, and particularly every servicemember returning from 
war, should have maximum opportunity to recover and 
successfully readjust to life. We recognize the unprecedented 
effort made by VA, as you had mentioned in your opening 
statement, Mr. Chairman, over the past several years to improve 
the consistency, timeliness, and effectiveness of mental health 
services in VA. We also appreciate Congress' continued support 
to help VA achieve this momentous goal. Nevertheless, we 
believe much still needs to be accomplished to fulfill our 
obligations to those who have serious mental illness and post-
deployment mental health challenges.
    The development of the Mental Health Strategic Plan by VA, 
as well as the Uniform Mental Health Services Handbook, provide 
an impressive and ambitious roadmap for the Veterans Health 
Administration's (VHA's) mental health transformation. However, 
we have expressed, and continue to express, our concerns about 
the oversight of the implementation phase. VA specifically 
developed its new policy so that veterans nationwide can be 
assured of having not only accessible but timely access to the 
full range of high quality mental health and substance use 
disorder services at all VA facilities.
    On April 6, 2009 the OIG issued two reports focused on VA 
mental health services. We had expected that these reports' 
would provide an in-depth nationwide assessment. Unfortunately, 
they fell far short of this expectation. We note that the 
report on the VA Handbook predominantly relies on self-reports 
from leadership at various VA facilities as to whether they 
have a particular program, and generally without any clear 
criteria on services offered, their intensity or capacity to 
provide such services.
    The report does note that evidence-based services for PTSD 
are labor intensive, but that VA has no current means of 
tracking the true accessibility of such services. Moreover, the 
recent OIG report makes no attempt to calculate the intensity 
of PTSD services although OIG quoted VA research reports that 
raised concerns that intensity levels have been falling despite 
the fact that effective services for PTSD require very 
intensive services.
    We are pleased that VA plans better tracking of true access 
to evidence-based PTSD therapies in its response to the report, 
and believe that this is an achievable goal and should be 
accomplished as soon as possible. We are pleased the OIG 
reported that Central Office, the Department of Veterans 
Affairs Central Office, had adequately tracked funds allocated 
for the mental health initiative in fiscal year 2008, and that 
the funds allocated were used as intended. While it is 
encouraging that the funds allocated are being predominantly 
utilized for the purposes intended, the report does not address 
two of the most pressing issues regarding true augmentation of 
VA mental health services. First, it does not calculate the 
actual increase in the number of providers. It merely audits 
the hiring of new staff. Second, their funds have been 
allocated as time limited or special purpose, although the need 
for additional services will clearly extend into the 
foreseeable future. We are concerned that if all mental health 
funds move into Veterans Equitable Resource Allocation (VERA) 
and are mixed with other funds allocated to medical centers, 
mental health and substance use disorder programs will, again, 
erode over time.
    Based on the two recent OIG reports it is unclear if 
sufficient resources have been authorized given the 
comprehensive requirements outlined in VA's Handbook. While we 
agree with OIG that implementation of the Handbook is 
ambitious, it must be approached with clear recognition that 
delays in immediate implementation inflict heavy costs on 
veterans.
    The oversight process we envision, and which we recommend 
in mental health, is one that is data driven, transparent, and 
includes local evaluations and site visits to factor in local 
circumstances and needs. And empowered VA organization 
structure is needed to carry out this task. Such a structure 
would require VHA to collect and report data at national, 
network, and medical center levels.
    We believe the recommendations further outlined in our 
written testimony, Mr. Chairman, could provide the architecture 
for effective oversight and improvement in VA programs. In 
summary, comprehensive, independent oversight is necessary to 
assure the current policy and new funding result in immediate 
access for all veterans who need such services.
    Mr. Chairman, this concludes my testimony. I would be happy 
to answer questions that you or other Members may have.
    [The prepared statement of Mr. Atizado appears on p. 26.]
    Mr. Michaud. Thank you very much. Mr. Ibson.

                    STATEMENT OF RALPH IBSON

    Mr. Ibson. Chairman Michaud, Ranking Member Brown, Members 
of the Subcommittee, thank you for inviting Wounded Warrior 
Project to offer our views on VA's progress in meeting the 
mental health needs of our veterans. Wounded Warrior Project 
brings an important perspective to this issue given our 
founding principle of ``Warriors Helping Warriors'' and the 
organization's goal of ensuring that this is the most 
successful, well-adjusted generation of veterans in our 
history.
    This Committee has recognized that mental health care is a 
key VA mission and has provided critical leadership over the 
years. Your oversight efforts have been invaluable.
    VA has taken important steps toward improving mental health 
care, beginning particularly in 2004 with its development of a 
strategic mental health plan and last year in establishing 
minimum clinical requirements for mental health services with 
its Uniform Mental Health Services Handbook. This hearing asks 
timely questions as we approach the 5-year mark since adoption 
of the strategic plan, and as VA is apparently moving toward 
ending a special funding initiative that had supported the plan 
and Handbook's implementation.
    VA has clearly made strides toward realizing its strategic 
mental health goals but in our view large gaps and wide 
variability in programs remain. Let me illustrate. While the 
strategic plan acknowledges the importance of specialized PTSD 
services for returning veterans, our warriors are experiencing 
both long waits for inpatient care and a dearth of OIF/OEF-
specific programs. For the first time, VA policy calls for 
ensuring the availability of meeting mental health services, to 
include providing services through contracts and similar 
arrangements, but VA facilities have made only limited use of 
that contracting authority. Mental health care is increasingly 
being integrated into primary care clinics, but at any given VA 
Medical Center or large clinic, mental health may be integrated 
into only a single primary care team. Further, VA facilities 
have yet to fully incorporate a recovery orientation into their 
care delivery programs. And VA, while it has trained clinicians 
in two evidence-based therapies for PTSD, has no comparable 
initiative to ensure integrated or coordinated care of co-
occurring PTSD and substance use disorders. Integrated 
treatment of these often co-occurring health problems appears 
to be the exception rather than the rule.
    In our view, a strategic plan by its very nature should be 
revisited periodically, and while the current plan provides a 
credible foundation, we encourage the Committee to press the 
Department to reexamine that blueprint and take account of what 
has changed in the 5 years since the plan's adoption. For 
example, it is not clear that the plan anticipated the 
increased prevalence of PTSD and other behavioral health 
conditions affecting this and other generations of veterans. 
The plan also emphasizes screening as a tool to foster early 
intervention, but fails to address the problem of veterans who 
are identified in screening as needing follow up but who elect 
not to pursue further evaluation or treatment. The plan also 
includes initiatives to foster peer-to-peer services, but only 
in the context of veterans with severe mental illnesses such as 
schizophrenia. In our experience, peer support can be powerful 
in helping OIF/OEF veterans with PTSD as well.
    Whether we gauge VA's progress through the lens of its 2004 
strategic plan, or as we recommend in the context of an updated 
plan, we share DAV's view that the transformation of VA's 
mental health delivery system remains a work in progress. 
Accordingly, we believe it is critical to sustain robust 
funding for VA mental health programs. Without question, VA's 
special mental health funding has supported a very substantial 
increase in staffing and expanded services at many facilities. 
But we understand that special funding will be phased out next 
year, with 90 percent of those special funds reverting to VA's 
general health care funds to be allocated through the VERA 
system. The implications of that shift could be very 
detrimental, given that funding for veterans mental health care 
during a still evolving major transition would be allocated 
primarily based on the numbers of veterans under treatment 
rather than on improving the intensity of care provided current 
patients. Absent a special funding mechanism, there is real 
risk that critical mental health policy goals will not be 
realized, and that prior gains may be eroded.
    Given that concern, we urge continued strong oversight to 
ensure that the Department does have a sound funding plan to 
support and sustain its still evolving transformation of mental 
health care. Let me emphasize, funding alone will not achieve 
strategic goals. Leadership is equally important. Finally there 
is a keen need for close monitoring and evaluation. We must 
bring each of those elements to bear to ensure that VA programs 
are meeting veterans' mental health needs.
    Mr. Chairman, that completes my statement. I will be happy 
to answer any questions.
    [The prepared statement of Mr. Ibson appears on p. 33.]
    Mr. Michaud. Thank you very much. I have one question. Mr. 
Atizado, in your testimony you recommended that the VA develop 
an accurate demand model for mental health and substance use 
disorder services. Can you explain this point a little further, 
as far as what factor the VA should look at when developing a 
demand model?
    Mr. Atizado. Well, much like VA's overall health care 
demand model I believe it has to reflect that. It has to be 
very comprehensive. It has to take into account this new 
paradigm of care that VA has embraced and wants to provide. The 
amount and the intensity of service that is required under this 
transformation is much different from their previous way of 
caring for serious mental illness and post-traumatic stress 
disorder, as well as substance abuse disorder. And I think the 
current model does not accurately capture that, and doing so 
does not necessarily provide the bottom line that would allow 
VA in the field to implement these initiatives.
    Mr. Michaud. Mr. Ibson, the Wounded Warriors Project is a 
great organization, and we appreciate all the work that you do. 
My question is, when you look at PTSD or TBI, how much concern 
do you hear from family members as far as the lack of service? 
Are the family members out there really more prevalently than 
the soldiers in looking at services, particularly relating to 
TBI or PTSD?
    Mr. Ibson. Mr. Chairman, I think you hit on an important 
point. That these are not issues of the veteran alone. They are 
very much family issues. We do have very active engagement with 
our families. And they do bring those concerns to us. Concerns 
regarding the variability in service, concerns regarding the 
lack of inpatient programs, particularly for PTSD, and the 
dearth of programs that are specific to OIF/OEF veterans. 
Concerns around the challenges facing a young veteran who, in 
seeking treatment, may find himself or herself in a program 
with older veterans who have continued to suffer with these 
problems and have not made the progress that a young veteran 
might hope to make. That can be a real disincentive to, or 
impede the kind of progress that the veteran and family would 
hope to expect from a program. And it underscores the need for 
age appropriate services.
    Mr. Michaud. The next question is actually for both of your 
organizations. In 2004, VA came forward with their Capital 
Asset Realignment for Enhanced Services (CARES) process, which 
looked at where there is a need for access points, particularly 
in the rural areas throughout the country. Have either of you 
heard concerns about lack of services in areas where there is 
supposed to be an access point, but currently is not an access 
point because the VA and Congress has not appropriated the 
funding needed for those access points? Is there more of a 
concern in those areas where you have not even kept track of 
the areas that you are hearing concerns in both the Wounded 
Warrior Project as well as the DAV?
    Mr. Atizado. Well Mr. Chairman, we do not know specific 
instances. We do have written, in fact, in our testimony that 
the VA's Office of Inspector General did a combined assessment 
report on Montana. And in there, and that is obviously a highly 
rural area. And in there it does talk about the inability for 
that facility to attract and retain mental health provides. Not 
only that, that also impinges on the availability of services 
as well as the quality of services that can be provided. If a 
facility does not have enough direct mental health providers 
the intensity may not be provided, or not enough veterans can 
be served. So at least in that one report we know that there is 
a direct impact.
    Mr. Ibson. I am not sure that I can speak to the 
implications of the issue as it relates to the CARES process, 
sir. But I think the Montana report is interesting as it goes 
to concerns you have spoken to, with regard to rural veterans 
and the success in Montana of working with the private sector 
to make access points for mental health care available. So I 
think in some marked contrast to the experience in other parts 
of the country, the underlying theme of equity of access I 
think continues to be a challenge for the Department.
    Mr. Michaud. Thank you. Mr. Brown.
    Mr. Brown of South Carolina. Yes, thank you, Mr. Chairman. 
In fact, I am going to just kind of throw this question out and 
either one can respond or both. Given the scope of the Mental 
Health Handbook that was last updated in September of 2008, do 
you think it is realistic for VA to implement all of the 
initiatives by the end of the fiscal year?
    Mr. Atizado. Well Mr. Chairman, as I have stated, it is a 
very ambitious goal. I think that if things go the way they are 
now, how it is currently being implemented, I think VA will be 
seriously challenged to meet that deadline. Which is why we are 
very hopeful that something will come of this hearing. That 
better metrics will be provided to the field so that they have 
better guidance to meet the over 400 services that the Handbook 
is supposed to require.
    Mr. Ibson. I think that is an excellent question, sir. And 
it is important to appreciate, I think, that underlying that 
Handbook is a vision of a real transformation in the way care 
is delivered, and the philosophy underlying that care. And 
emphasis on a recovery orientation is intended to supplant a 
focus on simply managing symptoms. And that is not simply a 
matter of funding. It is not simply a matter of programs. It is 
a real culture change that mirrors a change going on in the 
health care system generally, but one that has not preceded 
with great speed. And it is difficult to imagine that 
transformation reaching a culmination by the end of this year.
    Mr. Brown of South Carolina. Okay, thank you both. Let me 
throw out another question and I would ask for a similar 
response. For a person to seek mental health services they must 
recognize that they need help. To what extent do you think the 
stigma associated with mental health care is affecting 
veterans' willingness to seek help?
    Mr. Ibson. I think there is no question but that, 
notwithstanding public education efforts to diminish stigma, it 
continues to play a role, and that it does play a role among 
returning servicemembers and to some extent among veterans as 
well. At the same time, I think we do see larger numbers of 
veterans turning to VA for mental health care. And this 
Committee, I think, certainly can take pride in the work that 
it has done to underscore the importance of mental health and 
to diminish somewhat the still lingering stigma.
    Mr. Atizado. That is an excellent question, sir. I would 
like to first make a comment about what is being done upstream 
to sensitize servicemembers to the fact that mental health is 
just as important as physical health, that the U.S. Department 
of Defense (DOD) is doing. And I think it is providing some 
impact. I think VA's outreach, while excellent and they have 
done quite a bit, requires a little bit great customer service. 
We are aware of a program that was instituted in Veterans 
Integrated Service Network (VISN) 12 called the Vet Advisor 
Program. And what that does, sir, is it actually contacts 
veterans who have self-identified, or who have been screened 
positive, such that they have the intention of seeking mental 
health services and they, for whatever reason, did not come 
back to VA to do so. And what this program does is it, VA 
trains these individuals specifically on the screening tools 
and verbiage, the culture. And they seek out these veterans. 
They call them. They make person contact. And they are very 
clear. The idea is to make sure that veterans are provided the 
greatest amount of an offer. Because if it is a very good 
offer, one tends not to ignore it. Not only that, they also 
walk them through what they can expect once they contact their 
VA Medical Center, what should happen next. And it really 
empowers them and educates them on a very personal level. And 
it has turned out to be a very successful program.
    Mr. Brown of South Carolina. I know that if we let them 
fall through the process then they will end up homeless 
someplace, and that is a major concern of mine. Thank you both.
    Mr. Perriello [presiding]. Thank you. We will turn now to 
Mr. McNerney.
    Mr. McNerney. Thank you, Mr. Chairman. Mr. Atizado?
    Mr. Atizado. Adrian.
    Mr. McNerney. Adrian? Adrian, thank you. You know, I am 
going to sort of follow up a little bit on some of the prior 
questions. Many veterans service organizations (VSOs) have 
noted a slow start in implementing new mental health services 
and substance abuse programs. What do you think would be 
beneficial in terms of speeding up the VA's response to these 
needs?
    Mr. Atizado. Sir, that is a good question. I think one of 
the things that really hampered the speed of the implementation 
that we were hoping was that the Mental Health Handbook did not 
have objective metrics that the field would have to comply 
with. In other words, the perfect example is this OIG report. 
It did a survey based on self-reports and it did not dig any 
deeper than that. So when I am a mental health chief, or 
medical center director, and OIG calls me up and says, ``Do you 
have this program?'' I will say, ``Oh, yes.'' But they never 
really quite asked what services do you have available in that 
specific program? How many people do you expect to need to meet 
the demand in your facility? And that never really was provided 
to the field at the outset. And I think the strict monitoring 
and oversight really needs to get ramped up in order for these 
challenges to be met.
    Mr. McNerney. So, I mean, when you use the word ``metric'' 
in my mind that means results, or outcomes, rather than 
facilities or services?
    Mr. Atizado. Yes, sir. For example, when the Handbook was 
issued publicly, and the field was asked, service chiefs in 
local facilities were asked, ``What do you need to make this 
happen?'' That was the only question, really, that was asked. 
There was not clear guidance on these new initiatives, these 
new intensive programs. Some places did not even have a program 
that is included in the Handbook and they had to start from 
scratch. With very little guidance it is extremely hard for the 
field to be responsive and provide the data needed at the 
highest levels in the VA for them to provide the resources and 
the support.
    Mr. McNerney. Thank you. Mr. Ibson, I am going to sort of 
paraphrase something you said. I did not have time to write it 
down word for word. Funding alone is necessary but not 
sufficient. You also need strong leadership and good oversight. 
Are we having, are we seeing the strong leadership that you 
refer to? And is the oversight that this Committee is supplying 
sufficient? Or do you have recommendations on how to improve on 
those two issues?
    Mr. Ibson. Well I think your earlier question is an 
illustration of the point, sir. We saw leadership exercised at 
the VA in terms of adoption and issuance of a very forward 
looking and aggressive policy, a policy that could well be 
applauded. But what was missing, I think, as your question 
suggested and as Adrian's response indicated, was a sufficient 
architecture or mechanisms to ensure that the broad policy 
directive could and would be implemented in an appropriate and 
timely way. I do think there has been a real focus on 
establishing broad policy and to get funding out to the field, 
and the challenge of how and when to get the policy fully 
implemented has been something of a catch up. And I think this 
hearing is certainly an important step to continue to 
underscore the importance of moving beyond policy and to 
realization of those goals and very specific measures.
    Mr. McNerney. So one of the things I am hearing is that the 
element of leadership that is missing as a clear, concise 
metrics, or both in terms of what facilities should provide in 
detail and also metrics in terms of what the outcomes are. If 
you are having good outcomes then you are going to get a good 
mark. If you are not having good outcomes you are not going to 
get a good mark.
    Mr. Ibson. I think that is right, sir.
    Mr. McNerney. Thank you, Mr. Chairman.
    Mr. Perriello. Thank you. Mr. Moran, do you have questions?
    Mr. Moran. Mr. Chairman, thank you very much. I apologize 
for not hearing your testimony. If this is not a question for 
you, I would be happy to have you tell me that. One of the 
concerns I always have about the provision of health care 
services for our veterans is the geographic disparity, and from 
my perspective a rural disparity. I wondered if you have 
thoughts about the services different between urban, suburban 
areas of the country and the ability to access mental health 
services in rural America?
    Mr. Ibson. I think there is no question but that that is 
the case, sir. And as we have discussed a little bit earlier 
there is still significant disparity across the country. I 
think there are important efforts in the VA's Strategic Plan 
and the Uniform Services Handbook that we have been discussing 
to try and narrow that gap. One of the elements in the recently 
issued Handbook is an effort to ensure that there is service 
availability without regard to where the veterans may be 
living. And indeed, a directive for the first time for 
facilities if they cannot provide services in-house to provide 
them through contract or similar mechanisms.
    Two problems with that: one is that there is no real 
requirement to assure that that private sector provider has the 
capability, the expertise, to provide, for example, care for 
individuals with post-traumatic stress disorder or a combat-
related condition. And secondly, the facilities have not taken 
particularly aggressive steps to use that mechanism, even where 
capable providers might exist in the community. So I think it 
is yet another illustration of a transformation or a work in 
progress.
    Mr. Moran. In Kansas we have a reasonably comprehensive 
mental health delivery system with a series of mental health 
area agencies covering a very rural State. On numerous 
occasions those mental health centers have indicated a strong 
willingness to figure out how to connect with the VA system to 
provide services. I guess part of what you may be telling me is 
that they may not be totally trained in some of the needed 
aspects of mental health care that are required for our 
veterans, for our servicemen and women. I am looking for the 
ability to put those to use. We do not, I do not think we need 
to reinvent the system. Maybe we need to augment it. I think 
there is a delivery system that exists, at least in our State, 
that perhaps is underutilized.
    I also know that we have been successful in Kansas of 
having a second Vet Center. We have had one in Wichita for a 
long time, and one now in Manhattan. Their plan is to place 
mobile vans in which they provide family counseling mental 
health services out to rural areas of Kansas. I am interested 
in your thoughts of whether those kind of services can be 
provided in that kind of setting. Is that something that is 
going to be effective?
    Mr. Ibson. I think from my perspective, the jury is still 
out as to whether that is an optimal means of providing care. 
But certainly, given the needs across the system and given the 
needs of rural America, it is important that one explore all 
alternatives.
    Mr. Moran. This Congress has seen in the past significant 
improvements on our funding for health services. One of the 
common themes when I talk to those who provide services at home 
is, despite the additional money, we still cannot attract and 
retain the necessary professionals to provide the services. So, 
it is nice of you to give us the additional resources, 
important, but there is a general shortage of health care 
professionals, particularly in the mental health area, that the 
private sector is not meeting. They cannot come up with the 
necessary folks as well. So, it is a very broad issue that 
needs broad attention about attracting, retaining, and 
educating a necessary workforce. The demands are great; the 
numbers of people in the profession are too shy.
    Mr. Ibson. Yeah. It is not a complete answer to your point, 
sir. But I think one of the themes reflected in VA's planning, 
and a theme that I think can be continued, is greater reliance 
on peer-provided services. Not as a substitution for clinician 
services but as a complement to them, and as an important 
element of a system that, in philosophy, is moving toward 
recovery, toward enabling individuals to lead productive, 
fulfilling lives. And peer mentoring, which is a program 
Wounded Warrior Project fosters and runs, is an illustration of 
that kind of program. You know, veterans helping veterans----
    Mr. Moran. Thank you for that reminder. One of the ironies 
of the expansion of mental health services at one of our 
military installations in Kansas is that the neighboring 
hospital, the public hospital, closed its mental health 
facilities. Again, the inability to compete with the number of 
professionals. It sort of works both ways in the private 
sector. I do appreciate the idea that there are other 
possibilities. This mentoring program may be an opportunity, at 
least, to provide a level of services that would not otherwise 
be there. I am sorry, I have allergies. I can hardly talk. 
Thank you for your response. Thank you, Mr. Chairman.
    Mr. Perriello. Yes. Mr. Rodriguez.

          OPENING STATEMENT OF HON. CIRO D. RODRIGUEZ

    Mr. Rodriguez. Thank you, Mr. Chairman. I would like to ask 
permission to be able to submit some comments for the record, 
if possible. Thank you.
    Let me first of all also take this opportunity to thank you 
for your testimony, and thank you for the written comments that 
you made. I am extremely pleased with the things that you 
stressed in terms of the importance of peer-to-peer. And if you 
have an opportunity after I stop talking, maybe you might 
suggest as to how we might go about making that happen.
    Secondly, the other issue that was brought up regarding 
staffing. There is no doubt that looking at the vacancies, it 
is something that is essential and important, and how to best 
do that. I know we have a lot of great staff working for the 
VA. But I also know that we have a lot of staff that maybe 
should not be there now. And some that have been burned out 
because of the workload, and especially mental health services. 
They tell me that in England in mental health they work for a 
certain period of time then they are off for a good chunk of 
time because of the burn out factor. And I do not know if you 
want to make comments on that.
    The third area that, and I am going to give a case on this 
one at the end, is the issue of working with the families, and 
how critical it is to reach out to those families of those 
soldiers and those veterans. And how important that is, 
especially when we deal with post-traumatic stress disorders. 
And there is one over with Congressman Brown, who talked about 
when they suffer from mental health problems the soldier is not 
going to say, you know, when they come out, they are going to 
say, ``Hey, I am okay. I do not have a problem.'' And part of 
the fact is that they have not acknowledged that and that is a 
serious situation. But the ones who catch on to this is the 
family. The family knows sometimes, ``Hey, my son has a 
problem.'' You know? ``He is not the same young man that was 
here and has come back.'' And so that somehow making some kind 
of outreach also to those soldiers that are out there is really 
important.
    I wanted to also just kind of stress, I think it was 
mentioned, preventative maintenance and checking services that 
is also so, I think it is important in the process. I had 
gotten testimony in San Antonio from a psychiatrist. And there 
was some basic questions that were asked then about post-
traumatic stress disorder. And he gave us a beautiful 
presentation about the fact that we have always had it. We have 
just called it Gulf War Syndrome. We have called it adjustment 
reaction. We have called it other things. And he said all you 
have to go back in history and read the Iliad. And I said I had 
not seen that since high school, but that you can, you know, 
that we have always had some of those difficulties. So I know 
that we are going to have to kind of push forward and see what 
we can make happen.
    Congressman Moran also mentioned the importance of 
community health centers that we have back home. We have some 
great ones in San Antonio, where they are ready to provide 
access to services. And they have some great community mental 
health people out there that could be utilized, and that is not 
happening. And so I wanted to, you know, see if you might be 
able to make some comments on that. But before I do I want to, 
if Mr. Chairman, I want to be able to read this comment that I 
have. Because it is an incident that just occurred right 
outside that district. But the family lives in my district and, 
anyway, please allow me, you know, for a minute.
    I wanted to bring up a situation that occurred Friday at 
Fort Bliss, Texas. And this is DoD, not VA, but DoD. A soldier 
who returned fifteen months ago from deployment then 
immediately relocated to new assignment, had Post Traumatic 
Stress Disorder. And I do not know exactly, you know, how much 
services he was provided with. What I do know is that the 
family, his mother lives in my district, cried out for help, 
you know, for a long time, for assistance. They had repeatedly 
raised concerns that the soldier had Post Traumatic Stress 
Disorder and needed some immediate attention. And again, I am 
not sure how much attention he received. But the family 
indicates that it was insufficient. The last call for help was 
last Wednesday and Thursday to the unit there in El Paso. And 
Friday morning the soldier turned himself into the military 
police after allegedly having shot and killed an eighteen-year-
old on his way to school and having also shot and wounded 
another soldier. And I just wanted to make it, you know, clear 
that the ultimate victims on this, of course, the young people 
that were killed and the soldier. But that soldier, a lot of 
times, it was the result of the Post Traumatic Stress Disorder, 
is also a victim in a lot of ways.
    But I do not, you know, I wanted to kind of mention that 
particular case because it just happened. And we are kind of 
helpless. You know, these families are calling us for help and 
assistance, and we try to call, and I know it is, you know, 
that it is difficult. But yet, you know, they are becoming too 
numerous. And that is just one incident. We have soldiers right 
now committing suicide while in service. If they do that we 
know that they do not get any compensation whatsoever. In fact, 
I had a soldier commit suicide and was almost treated very 
poorly, you know, when the body came into the community. And so 
somehow we have got to do more. And so I wanted to get some 
feedback from you in terms of how do we make this happen?
    [The prepared statement of Congressman Rodriguez appears on
p. 25.]
    Mr. Ibson. Congressman, thank you for raising those issues. 
Wounded Warrior Project certainly works closely through our 
service teams, with military personnel. And if your caseworkers 
come across problems that we can help with, our doors are 
certainly open. We are certainly happy to engage.
    You posed a question earlier about the peer-to-peer 
services and I want to acknowledge the work of this Committee 
and the Congress in passing legislation last year that 
authorizes VA to employ peer specialists. I believe they have 
begun to do so, though primarily to work with individuals with 
the most severe mental illnesses. And our testimony is to the 
effect that there are opportunities to expand those programs, 
in our view, to work effectively with younger veterans with 
other diagnoses, particularly PTSD. And we would see that as an 
area that VA could pursue, the Committee as well.
    I want to cite your important remarks on the role of the 
families and I would very much like to underscore on behalf of 
Wounded Warrior Project the importance of family caregiver 
legislation, which we have discussed informally with the 
Committee staff, and to mention S. 801, a bipartisan bill 
introduced by Senator Akaka and Senator Burr, which would 
establish a foundation for supporting family caregivers of 
severely wounded servicemen and veterans as a very important 
step toward sustaining the caregiving that is enabling severely 
wounded warriors to remain at home rather than becoming 
institutionalized.
    Mr. Rodriguez. Mr. Chairman, I apologize for taking more 
than my time. Thank you.
    Mr. Perriello. Next we will go to Ms. Brown.
    Ms. Brown of Florida. Thank you, Mr. Chairman. Thank you 
for your testimony. And I have to tell you, I am very concerned 
about the mental health situation with VA. When you gave your 
testimony you indicated that some of the agencies, or some of 
the hospitals, you did not know whether or not they were 
qualified to work with the veterans' situation. Well, that is 
what I am finding, that VA does not want to contract out mental 
health services. But we are not serving the population. All we 
have to do is look at the homeless. I mean, one-third of them 
are veterans. They either have drug problems, or they have 
alcohol problems, and we are not addressing them. Yes, it is a 
role for peer counseling. But these people need professionals. 
And we do not have enough professionals in VA. And they resist, 
they resist farming out, partnering with agencies that do 
mental health services. And I do not know why. The situation 
can only get worse. And if you have certain standards, certain 
guidelines, that is where you could bring in these agencies and 
work with them, and partner. But there is no role for peer 
counseling for severe problems. I am, that is my training. I am 
a counselor, at least back in my real life. So, I mean, what 
are we going to do?
    Mr. Ibson. I certainly share your view that there is an 
important role for partnerships. And I would not want to 
represent that VA fails to partner. Certainly, there are some 
core VA homeless programs that had their genesis in this very 
hearing room which represent very fine partnerships. I think 
there is an opportunity for VA to employ its contracting 
authority. At the same time, it is important to recognize, I 
think, that when we are dealing with the very specialized 
condition like post-traumatic stress disorder it is important 
for VA to be assured that community providers have the capacity 
and training and expertise to do that. But----
    Mr. Ibson [continuing]. There is an opportunity for VA to 
do that kind of training, I think.
    Ms. Brown of Florida. Right. But the problem is, VA has 
resisted contracting out, working with agencies. If the VA, 
puts out a contract and say, ``We want this, this, and this, 
and you want this training,'' I do not see why we cannot work 
more with community agencies and community groups that provide 
these mental, they are doing it anyway, they are just not 
getting paid for it.
    Mr. Ibson. I share your view. There certainly is an 
opportunity for greater partnership here. And particularly in 
areas of the country, as Mr. Brown was indicating, where there 
is a dearth----
    Ms. Brown of Florida. Well, he is a rural area, I am in the 
inner city. But the question is, the problem exists in both 
places. What can we do to encourage VA to expand their mental 
health services working with other agencies? Because it is not 
happening, and the veterans are not getting served.
    Mr. Ibson. Well certainly a hearing like this one today 
will be a very rich opportunity and a first step toward that. 
There is a certainly an opportunity to do more.
    Ms. Brown of Florida. Well, I believe that you are correct. 
Because failure is not an option. We are going to have more 
suicides, more problems in our community, if we do not address 
the problem with this new group that is coming back. And VA is 
just not geared up to handle it. We just need to, and I am not, 
it is not negative. VA has good services. But we need to expand 
what we are doing. We need the partnership.
    Mr. Ibson. I would agree.
    Ms. Brown of Florida. Does VA have the authority to do it?
    Mr. Ibson. Yes. I believe VA has very expansive contracting 
authority. And particularly, most particularly in areas where 
they either lack the capacity in-house to provide needed 
services or where geographic distance is a barrier. But I think 
this Committee has given VA very broad authority and there is 
certainly opportunity to use it.
    Ms. Brown of Florida. Thank you, Mr. Chairman.
    Mr. Perriello. Thank you very much, Mr. Atizado and Mr. 
Ibson for your testimony and for your service. And with that, 
let us call up panel three. Panel three will be Dr. Michael 
Shepherd, Senior Physician from the Office of Healthcare 
Inspections, Office of the Inspector General, U.S. Department 
of Veterans Affairs. He is accompanied by Larry Reinkemeyer, 
Division Director, Kansas City Office of Audit, Office of the 
Inspector General, U.S. Department of Veterans Affairs. Thank 
you, gentlemen, for being here today and sharing your comments 
with us. Dr. Shepherd?

   STATEMENT OF MICHAEL L. SHEPHERD, M.D., SENIOR PHYSICIAN, 
OFFICE OF HEALTHCARE INSPECTIONS, OFFICE OF INSPECTOR GENERAL, 
   U.S. DEPARTMENT OF VETERANS AFFAIRS, ACCOMPANIED BY LARRY 
 REINKEMEYER, DIVISION DIRECTOR, KANSAS CITY OFFICE OF AUDIT, 
   OFFICE OF INSPECTOR GENERAL, U.S. DEPARTMENT OF VETERANS 
                            AFFAIRS

             STATEMENT OF MICHAEL L. SHEPHERD, M.D.

    Dr. Shepherd. Mr. Chairman and Members of the Subcommittee, 
thank you for the opportunity to testify today regarding VA's 
progress toward meeting the mental health needs of our 
veterans. I will focus on our report, Implementation of VHA's 
Uniform Health Services Handbook, and my colleague, Larry 
Reinkemeyer, will be able to answer questions related to 
another OIG report, ``Audit of VHA Mental Health Initiative 
Funding.''
    In 2004, VHA developed its 5-year mental health strategic 
plan which included more than 200 initiatives. Because the plan 
is organized by the broader goals and recommendations of the 
2003 ``President's New Freedom Commission Report,'' rather than 
specific mental health programs, some initiatives do not 
delineate specific actions----
    Mr. Perriello. Excuse me, doctor, could you move the 
microphone closer?
    Dr. Shepherd. Sure. Is this better?
    Mr. Perriello. Yes.
    Dr. Shepherd [continuing]. That should be carried out to 
achieve these goals and are not readily measurable. The 
Handbook notes that when fully implemented these requirements 
will complete the patient care recommendations of the mental 
health strategic plan. Overall, medical facilities are expected 
to implement the Handbook requirements by the end of fiscal 
year 2009.
    Because there are over 400 items in the Handbook we limited 
the scope of our review to the Medical Center level, where full 
implementation is more likely to occur prior to community-based 
outpatient clinic (CBOC) level implementation. Based on 
clinical judgment we chose 41 items from throughout the 
Handbook to evaluate. OIG inspectors agreed on what criteria 
constituted a positive response and affirmative responses were 
queried for demonstration of their validity.
    We believe the items chosen reasonably estimate the present 
extent of implementation at the Medical Center level. Although 
it is an ongoing process, the data presented do not credit 
partial implementation. We found that 31 of 41 items reviewed 
were implemented at more than 75 percent of Medical Centers. 
For example, a mental health intensive case management program 
is in place at all facilities with more than 1,500 seriously 
mentally ill veterans.
    We identified items indicative of areas in which VHA is at 
risk for not meeting the implementation goal, including timely 
outpatient follow up after mental health hospitalization; 
provision of intensive outpatient treatment for substance use 
disorders; provision of psychosocial rehabilitation and 
recovery programs at centers with more than 1,500 seriously 
mentally ill patients; and the provision of sufficient clinical 
psychologist staffing for VA community living centers.
    Additionally, we are concerned that while a section of the 
Handbook addresses access to specific evidence-based 
psychotherapies for PTSD, it appears that VA does not have in 
place a national system to reliably track provision and 
utilization of these therapies. A national system would allow 
for a population-based assessment of treatment outcomes with 
implications for treatment of other veterans presenting for 
PTSD-related care. While VA has relevant process measures in 
place to monitor program implementation, we believe that VA 
should develop more outcome measures where feasible to allow 
for dynamic refinement of program requirements in order to meet 
changes in mental health needs and to optimize treatment 
efficacy.
    Although this inspection contains some items related to 
suicide prevention, as a component of OIG's CAP review process, 
in January 2009 we began a separate medical record-based review 
of suicide prevention items. We will conclude our inspection in 
June 2009 and then issue a roll up report on our findings.
    In conclusion, the Handbook is an ambitious effort to 
enhance the availability and provision of mental health 
services to veterans. VHA has made progress in implementation 
at the medical center level. Because our review was limited to 
medical centers, we plan to conduct an inspection in fiscal 
year 2010 on implementation at the CBOC level where factors 
such as geographic distance and the ability to recruit mental 
health providers may pose greater obstacles to implementation.
    In regard to mental health initiative funding, we found 
that VHA adequately tracks and uses mental health initiative 
funding as intended. Mr. Chairman, thank you again for this 
opportunity to appear before the Subcommittee. We would be 
pleased to answer any questions that you or Members of the 
Subcommittee may have.
    [The prepared statement of Dr. Shepherd appears on p. 38.]
    Mr. Perriello. Thank you very much for being with us today, 
and thank you for your thoughts. What would you say at this 
point are the main limiting factors for you to be able to 
produce the kind of metrics that you have in mind?
    Dr. Shepherd. For this report--limiting factors for us to 
produce the metrics, or for VA to produce, for VA? Well, one of 
the issues, again, which we cited and the previous panelists 
cited is, for example, in terms of provision of evidence-based 
treatments for PTSD. In the absence of knowing who you have 
provided these treatments to, whether they have done part of 
these treatments, completed these treatments, whether they have 
opted not to pursue these treatments, in the absence of a data 
system that is able to capture that, you really down the road 
do not have the structure you need to make outcome judgments in 
terms of evidence-based therapies for PTSD. And so I think, as 
we say in the report and in the San Diego report that we 
issued, we think there is a real urgent need for VA to adjust 
their data system, or their electronic medical record system, 
to allow for capture of what type of services are provided, not 
just that a service was provided.
    Mr. Perriello. Thank you. Your written testimony includes a 
list of VA mental health services and the extent of 
implementation of the Uniform Mental Health Services Handbook 
for each of these services. How do you respond to DAV's 
concerns that this data is based on self-reports from VA 
leadership? And did the OIG consider other ways of assessing 
the implementation which are perhaps more objective?
    Dr. Shepherd. We provide independent oversight in response 
to questions we are asked. In terms of the method we chose, I 
point out, again, that this was mostly a structured interview, 
not a purely passive survey. That we had developed and agreed 
upon among the inspectors, criteria we were looking for that 
constituted an affirmative response. When we asked mental 
health directors a question if we had an affirmative response, 
we basically kept pushing them with further queries to try to 
get demonstration of the criteria we were looking for. In 
addition, if someone gave an affirmative response but in 
response to queries, the affirmative response did not match 
what we were hearing, we took that to be a negative response.
    Again, if there were further systems in place to allow for 
better capture within, the electronic medical record, or 
through the administrative sources, the types of services and 
not just that services are performed, that would also enhance 
the oversight ability.
    Mr. Perriello. Let me turn to the Ranking Member Mr. Brown.
    Mr. Brown of South Carolina. Thank you very much for your 
testimony, and I know that maybe you might have emphasized some 
of these questions before. You described the Uniform Mental 
Services Handbook as an ambitious effort that may require 
ongoing adjustment based on patient utilization and needs. In 
your opinion, is there a section of the Handbook that may 
require adjustment in the near term?
    Dr. Shepherd. In looking at the Handbook, it does seem that 
two sections that I think are going to need adjustment in the 
near term are: as baby boomer veterans age and we start to see 
a growing number of older veterans coming into VHA for care, I 
am concerned that the part of the Handbook that addresses 
services to older veterans may need further adjustment in the 
near term to meet the changing utilization patterns. In 
addition, in the Handbook there is not much in the way of 
addressing the concomitance of recent veterans with both 
traumatic brain injury and PTSD. And I think that bears looking 
at further.
    Mr. Brown of South Carolina. Thank you very much for your 
testimony.
    Mr. Perriello. Mr. McNerney?
    Mr. McNerney. Thank you, Mr. Chairman. And I want to thank 
you, Dr. Shepherd, for sitting in front of us this morning. In 
your written testimony, well, and your written testimony 
includes a list of the VA mental health services and the extent 
of implementation in the Uniform Mental Health Services 
Handbook for each of these services. Now, the DAV's testimony 
was that some of these reports are generated within the VA and 
so they might be self-serving. Can you respond to that? Do you 
think there is a better way to go about finding, you know, 
finding what the outcomes are of these services?
    Dr. Shepherd. Well, again, part of the data that was 
presented was from our structured interviews of all of the 
medical center mental health directors. Some of the data was 
performance measure data from VHA. One example of other ways, 
as mentioned in our look at suicide prevention initiatives from 
the Handbook, that is ongoing. That is a chart-based review 
from patient records. We have an ongoing review right now of 
residential treatment programs that has extensive chart-based 
review as part of it.
    Mr. McNerney. So you feel these are objective enough, then, 
to be valuable?
    Dr. Shepherd. I think this report reasonably reflects the 
state of the system at this point.
    Mr. McNerney. Well, I mean, we have heard a lot about 
outcome measures here this morning in this panel and the prior 
panel. Could you elaborate on how these measurements are taken? 
And how you would use the information in a specific setting to 
improve the performance at that location?
    Dr. Shepherd. You are referring to outcome measures in 
terms of outcomes of treatment?
    Mr. McNerney. Yes.
    Dr. Shepherd. One of the reasons I think we really need to 
keep prodding for further development of outcome measures is if 
your outcomes at some facilities really vary when you take into 
account risk adjustment, it would tell you that you need to 
look closer at what is happening at that facility, such as who 
is getting services, the fidelity of the treatment going on. In 
addition, at the facility level every facility may have 
different patient subpopulations. Certain facilities may have a 
greater proportion of patients with certain needs. And outcomes 
at those facilities would help to better tailor what you are 
doing at those sites to the specific needs at that site.
    Mr. McNerney. So you may not use that to adjust funding for 
a specific site, but you may use that to direct more services 
of a certain kind?
    Dr. Shepherd. And the quality of the services provided.
    Mr. McNerney. And the quality. But we always want to see 
good quality. I mean, that is always an issue. And another 
thing that the DAV mentioned was that in the Handbook there is 
not specific enough guidelines in terms of what should be 
provided in terms of the services. Do you have any comment on 
that?
    Dr. Shepherd. I think that would probably better responded 
to by VHA.
    Mr. McNerney. Okay. All right. Thank you for your 
testimony. I yield back.
    Mr. Perriello. Mr. Brown.
    Mr. Brown of South Carolina. I have no further questions 
for this panel.
    Mr. Perriello. Thank you very much for your time. Thank you 
for traveling. And we appreciate your testimony today. We will 
call up the next panel. Our next panel will include Dr. Ira 
Katz, M.D., Ph.D., Deputy Chief of Patient Care Services 
Officer for Mental Health Services, Veterans Health 
Administration, U.S. Department of Veterans Affairs; 
accompanied by Dr. Antonette Zeiss, sorry if I got the name 
wrong, Deputy Consultant for Mental Health Services; and James 
McGaha, Deputy Chief Financial Officer. Thank you very much, 
and we will begin. Dr. Katz?

 STATEMENT OF IRA KATZ, M.D., PH.D., DEPUTY CHIEF PATIENT CARE 
      SERVICES OFFICER FOR MENTAL HEALTH, VETERANS HEALTH 
     ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; 
ACCOMPANIED BY ANTONETTE ZEISS, PH.D., DEPUTY CHIEF CONSULTANT, 
       OFFICE OF MENTAL HEALTH SERVICES, VETERANS HEALTH 
   ADMINISTRATION; AND JAMES MCGAHA, DEPUTY CHIEF FINANCIAL 
  OFFICER, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF 
                        VETERANS AFFAIRS

    Dr. Katz. Good morning, Mr. Chairman, and Members of the 
Subcommittee. I would like to request that my written statement 
be submitted for the record. Thank you for the opportunity to 
discuss VA's progress on meeting the mental health needs of our 
veterans. With the support of Congress, VA has received record 
increases in funding over the past several years, almost 
doubling our mental health budget from the start of the War in 
Afghanistan to today. During the same time, VA developed the 
VHA Comprehensive Mental Health Strategic Plan and the Handbook 
on Uniform Mental Health Services in VA Medical Centers and 
Clinics. My testimony will address these advances, recognizing 
that VA's overall mental health programs include strengths in 
other areas, including research and the Vet Center program, but 
focusing on mental health services in medical centers and 
clinics.
    The mental health strategic plan was developed in 2004 to 
incorporate new advances in treatment and recovery, and to 
address the needs of returning veterans. It was based on the 
principle that mental health was an important part of overall 
health. Its 255 elements could be divided into six key areas: 
enhancing capacity and access for mental health services; 
integrating mental health and primary care; transforming mental 
health specialty care to emphasize recovery and rehabilitation; 
implementing evidence-based care with an emphasis on evidence-
based psychosocial treatments; addressing the mental health 
needs of returning veterans; and preventing veteran suicides.
    In 2005, VA began allocating substantial funding through 
its mental health enhancement initiative to support the 
implementation of the plan. We are now in the 5th year of 
implementation, and it is a critical time to review progress. 
Currently, substantially more than 90 percent of the items in 
the plan are now part of ongoing operations and clinical 
practice. Therefore, it is a time for us to move from a focus 
on rapid transition to one of sustained delivery. This was the 
impetus for the new Handbook on Mental Health Services in VA 
Medical Centers and Clinics, published in September 2008. It 
established clinical requirements for VA medical health 
services at the network, facility, and clinic levels, and 
delineated the essential components of the mental health 
programs that are to be implemented nationally. It consolidated 
requirements for completing and sustaining implementation of 
the mental health strategic plan by defining the services that 
must be provided in all facilities and those that must be 
available to all veterans. It established standards for mental 
health programs, guides program plannings, and serves as a tool 
for treatment planning. Most significantly, the Handbook 
represents a firm commitment to veterans, families, advocates, 
and Congress about the nature of the mental health services VA 
is providing.
    At present, VA's goals must be to consolidate the gains of 
the past 4 to 5 years by implementing the Handbook and 
sustaining the operation of mental health services meeting this 
new standard. To achieve these goals VA will ensure 
implementation through a stringent series of monitors and 
metrics. They will, first, evaluate the development of new 
clinical capacities. Second, monitor the access and utilization 
of new capacities by facilities and by increasing numbers of 
veterans. Third, evaluate the quality of new services, 
including monitors for the fidelity of delivery of evidence-
based interventions. And fourth, evaluate the impact of 
enhanced programs on the clinical outcomes of care. The first 
two sets of monitors will be implemented later this calendar 
year and the latter two during the following year. It is 
through these measures that VA leadership will hold itself, and 
its facilities, responsible for mental health services.
    Thank you again for this opportunity to speak. Along with 
my colleagues, I am prepared to answer any questions you have.
    [The prepared statement of Dr. Katz appears on p. 42.]
    Mr. Perriello. Thank you very much for your testimony, Dr. 
Katz. We have been called to vote so Mr. Brown and I are going 
to be submitting our questions for the record. But we are going 
to go to Mr. Moran to ask a question now.
    Mr. Moran. Mr. Chairman, thank you for your and Mr. Brown's 
courtesy. I have just one observation and one question. The 
question is, it has been nearly 2\1/2\ years since the Veterans 
Benefits Healthcare and Information Technology Act of 2006 was 
signed into law. That legislation added licensed marriage and 
family therapists, MFTs, and licensed professional mental 
health counselors, LPCs, to the list of eligible VA health care 
providers. I thought at the time that this would be a great 
opportunity for the VA to expand its ability to meet the needs 
of veterans, and I have championed this cause. But 2\1/2\ years 
later I am seeing little evidence that the VA has actually 
implemented the law. Is there a justifiable explanation for the 
delay? Or am I misunderstanding the situation?
    Dr. Zeiss. Well we welcome the question. At this point, we 
have met extensively with the professional organizations that 
represent both licensed professional counselors and marriage 
and family therapists through our office in Mental Health, and 
have been very impressed with the potential to add these 
professionals to the team that would serve veterans. The issues 
are with human resources (HR). The law also stated clearly that 
new Hybrid Title 38 job series needed to be created for each of 
these. The law did not allow them to enter through the 
mechanisms of other existing series. So there are a number of 
licensed professional counselors and marriage and family 
therapists who work in VA under other series, and that has 
continued to increase. And we look forward, as you do, to HR 
reaching the point of having the qualification standards 
developed and having the Hybrid Title 38 job series in place so 
they can be hired directly under the auspices of their 
professions.
    Mr. Moran. So there is no impediment from the health care 
side of the VA? This is what I would describe as the 
bureaucratic process of bringing these people onto the payroll?
    Dr. Zeiss. We do not, yeah, we certainly support this and 
have tried to be very available to these organizations, and to 
feed forward information to support the process of developing 
these new Hybrid Title 38 job series.
    Mr. Moran. Mr. Chairman, we have been through this numerous 
times that we have tried to add professional categories to the 
VA list of appropriate providers, the chiropractors are one. It 
is an enormous undertaking, apparently. I would welcome anyone 
on the Committee who would like to work with me to see if we 
cannot get the VA to move in a more expeditious manner. I think 
this is important. While we are sitting here talking about the 
lack of professionals, there is an opportunity for these 
services to be provided. Yet, because of the nature of the VA 
and its credentialing and accounting process, it is not 
happening. I think it is, it is not only disappointing to me, 
to the professionals who want to provide the services, but more 
important it means that there are veterans who could be served 
that are not because of the bureaucratic nature of the VA's 
process. If, particularly you, Doctor, if you are interested in 
my help in encouraging the other side of the VA to get on the 
dime, please consider me an ally.
    The only other item I wanted to mention, Mr. Chairman, I 
know we are short of time, is that Kansas and a number of other 
States were designated in a pilot program for services, health 
care services, to be provided through the private sector in the 
absence of a VA, or an outpatient clinic, or mental health 
services, in the absence of them being in close proximity to 
the veteran. We are in the process, the VA is in the process, 
of implementing this program this year. I just wanted to make 
sure that you are aware of it, because it covers mental health 
services as well. So in those pilot VISNs, in the absence of 
those services being available within a certain distance of 
where the veteran lives, the VA is now obligated to provide 
those services through contract with the private sector, local 
hospital, local mental health. I want to make sure that you all 
are participating in that process. Because mental health 
services needs to be a significant component. I thank you for 
your time, sir.
    Mr. Perriello. Thank you for keeping an eye on that issue. 
Mr. McNerney?
    Mr. McNerney. Thank you, Mr. Chairman. Dr. Katz, I 
certainly want to thank you for your service to our country 
through our veterans. The DAV, just a while ago, highlighted a 
need to collect more results-oriented data. And they have also 
spoken about the need for leadership in terms of providing a 
little bit more of a picture of how to provide services, a 
little bit more detail. Could you respond to those two? What 
might be in the works, or how we could best approach those two 
questions?
    Dr. Katz. Yes. Everyone agrees that metrics and measures of 
the implementation of the Handbook, and of completion of the 
implementation of the strategic plan are necessary. VA has an 
extensive quality program that has numerous metrics related to 
mental health. But I want to speak specifically to the 
Handbook.
    I am a clinician, and was a practicing psychiatrist until I 
came to Washington. To be honest, the Handbook is written 
primarily to be understood by clinicians about the clinical 
services that should be available and the services to be 
provided. It is not meant primarily to be read by accountants, 
or inspectors. It is written to be read by providers. And this 
year is the time for implementation to be guided by clinicians 
to meet the needs of our veteran patients. There will be a time 
for metrics, and VA is committed to having the metrics 
available to assess implementation, by October 1st. To get them 
out concurrently with the Handbook would have been to encourage 
practice to the test rather than practice to address clinical 
standards and clinical visions. So the staging of clinical 
guidance, then accountability through quantitative metrics, is, 
I believe, the appropriate way to unfold this process.
    Mr. McNerney. Well, thanks for that viewpoint, Dr. Katz.
    Dr. Katz. Thank you.
    Mr. McNerney. And I am going to yield back in the interest 
of letting Mr. Snyder have a question.
    Mr. Perriello. Mr. Snyder?
    Mr. Snyder. Thank you, Dr. Katz. And in your statement you 
make reference to the need to perhaps add other employees to 
CBOCs to handle mental health issues. Did I read your statement 
right?
    Dr. Katz. Well, there have been extensive enhancements in 
VA mental health staffing, including staffing in CBOC.
    Mr. Snyder. How do you do that when those are private 
contractors that have got a set amount of overhead? I mean, you 
cannot just pick up the phone and say, ``Hey, put on two more 
people.''
    Dr. Katz. Some community-based outpatient clinics are 
contract-based, but most are VA-owned and operated with Federal 
employees.
    Mr. Snyder. So you do not do that to the ones that are 
contract-based?
    Dr. Katz. We are committed to enhancing services, ensuring 
we provide or make available the services that veterans need, 
whether we provide them by VA employees, by contract, or fee-
based, or other mechanisms.
    Mr. Snyder. Maybe I will do that for the record, then. Why 
do you not respond to the question, how do you do an 
enhancement of mental health services at a privately contracted 
CBOC, since they have a contractual arrangement with a set 
overhead?
    Dr. Katz. I will have to take that for the record, thank 
you.
    [The VA subsequently provided the following information:]

          Question: How does VA enhance mental health services at a 
        privately contracted CBOC if the contractual agreement has 
        already set an amount for overhead?

          Response: The Department of Veterans Affairs (VA) includes 
        clauses in contracts for community-based outpatient clinics 
        (CBOCs) that allow the Department to establish quality monitors 
        and to negotiate to amend the contract. Each facility arranging 
        a contract for CBOC care includes provisions to ensure quality 
        patient care, including medical record review, accreditation 
        surveys by The Joint Commission and other bodies, and the 
        collection of quality and performance data, similar to what we 
        require for VA owned-and-operated CBOCs. This allows the agency 
        to assess adherence to evidence-based standards of care and to 
        investigate further if facilities fall short of requirements or 
        expected standards.

    Mr. Perriello. Thank you so much, Doctors, for your time 
and testimony. We are truly sorry that we were not able to get 
all of the questions out, but know how important these issues 
are to this Committee and that we will continue to pursue your 
expertise and advice as we address these important issues. All 
other questions will be submitted for the record, and the 
hearing is now adjourned.
    [Whereupon, at 11:25 a.m., the Subcommittee was adjourned.]



                            A P P E N D I X

                              ----------                              

             Prepared Statement of Hon. Michael H. Michaud,
                    Chairman, Subcommittee on Health
    The Subcommittee on Health will now come to order. I would like to 
thank everyone for coming today. We are here today to talk about the 
VA's progress on meeting the mental health needs of our veterans. 
Specifically, we will discuss issues of funding and implementation of 
the Mental Health Strategic Plan and the Uniform Mental Health Services 
Handbook.
    Many people in this room are familiar with the daunting statistics 
on mental health from the April 2008 RAND Corporation report on the 
invisible wounds of war. The RAND report estimated that of the 1.64 
million OEF/OIF servicemembers deployed to date, about 300,000 or 18 
percent suffer from PTSD or major depression and about 320,000 or 20 
percent likely experienced TBI during deployment. In addition, the 
report showed that despite our current efforts, about half of our 
servicemembers are not seeking and receiving the mental health 
treatment that they need. This raises serious concerns about the long-
term negative consequences of untreated mental health problems, not 
only for the affected individuals but also for their families, their 
communities, and our Nation as a whole.
    To address this problem, the VA has focused their efforts on 
improving mental health care for our veterans. For example, the VA has 
set aside substantial funding for mental health care, which amount to 
$3.8 billion in fiscal year 2009. The VA also approved a Mental Health 
Strategic Plan in November of 2004, which is a 5 year action plan with 
distinct mental health enhancement initiatives. Additionally, I am 
aware of the 2008 Uniform Mental Health Service Handbook, which defines 
standard and minimum clinical requirements for mental health services 
that the VA will implement nationally.
    I applaud the VA on these efforts, and it is important for the 
Committee to ensure proper oversight. Today's hearing will explore the 
concerns raised in the 2006 GAO report which found that the VA spent 
less for mental health initiatives than planned and lacks the 
appropriate mechanism for tracking the allocated mental health funding. 
We will also seek a better understanding of the successes and the 
challenges faced by the VA in implementing the Mental Health Strategic 
Plan and the Uniform Mental Health Service Handbook.
    Today, we will hear from various experts in the field including the 
Disabled American Veterans; Wounded Warrior Project; the Office of the 
Inspector General; and the VA. I look forward to hearing their 
testimonies.

                                 
            Prepared Statement of Hon. Henry E. Brown, Jr.,
           Ranking Republican Member, Subcommittee on Health
    Thank you, Mr. Chairman.
    I appreciate your holding this hearing today.
    Mental health is a critical component of a person's well-being. 
And, essential to the mission of the Department of Veterans Affairs 
(VA) ``to care for those who have borne the battle'' is to effectively 
intervene and care for the ``invisible wounds'' of war.
    The psychological toll of war is not always apparent and sadly has 
not always received the attention it should. However, I think we can 
all agree that the VA has come a long way, especially in the past few 
years, to improve mental health services and encourage veterans in need 
of care to get help.
    Even though significant progress has been made, there is no doubt 
that we must still do more--as we continue to hear about veterans 
facing barriers and gaps in services. We must ensure that when a 
veteran needs and seeks help, that veteran gets the ``right'' care at 
the ``right'' time.
    In the past decade, we have made a substantial investment in VA 
mental health, increasing funding by 81 percent, from $2.1 billion in 
fiscal year 2001 to no less than $3.8 billion in fiscal year 2009. That 
is why it was very disturbing when the Government Accountability Office 
(GAO) in November of 2006 reported that VA had not allocated all the 
available funding to implement the Mental Health Strategic Plan.
    It is our responsibility to see that the funding we provide is 
spent as intended--to support a complete array of mental health 
prevention, early intervention and rehabilitation programs for our 
Nation's veterans.
    I look forward to hearing from our witnesses and having the 
opportunity to take a good look at where we stand in taking care of the 
mental health needs of our veterans.
    With that, Mr. Chairman, I yield back.

                                 
             Prepared Statement of Hon. Ciro D. Rodriguez,
          a Representative in Congress from the State of Texas
    I want to thank the Disabled American Veterans and the Wounded 
Warrior Project for their candid comments and specific recommendations 
for oversight. I think it is important to highlight that if mental 
health professionals are ``feeling overwhelmed due to increasing 
numbers and mental health needs,'' it is a pretty clear indication that 
we don't have enough mental health professionals. I understand the VA 
not wanting to make conclusions about staffing needs, but if the mental 
health professionals are overwhelmed then we need to ask why and 
address that issue. I'd hate to see our mental health professionals 
needing mental health counseling because of work stress.
    I think the Disabled American Veterans hit the nail on the head 
when it comes to staffing needs. We can't report staffing needs based 
on the offers we've made and the responses received. We must look at 
our manpower authorizations, vacancies of those positions, and then the 
workload that each of those professionals face to determine how many 
more mental health professional positions we still need beyond what is 
currently authorized.
    The recommendation of an independent mental health advisory body 
with direct access to the Secretary is a great idea and we should 
explore that possibility.
    The Wounded Warrior Project testimony touched on the fact that 60 
percent of the returning troops who screened positive for PTSD never 
reached out for help. Yet at the same time the need is for early, 
preventative intervention being critical to identification and 
recovery. The dilemma is trying to identify the need for help in those 
that do not identify themselves as needing help.
    The Army used to use a term (they may still use it): PMCS--
Preventative Maintenance, Checks, and Services. We do PMCS on vehicles 
and equipment, but we need to do it on our people as well. Early 
screening and proactive, preventative treatment for PTSD is needed. It 
is simply post-operation PMCS on a returning troop. And you don't just 
check it once. You do daily, weekly, monthly PMCS. In this case it 
should be done by a team of individuals actively working together to 
include the therapists, chain of command (if they're active, guard, or 
reserve), family members, and peers. And the same must happen for the 
family members of returning troops. For some, being left alone to 
handle all the rigors of life and events that occur in a single-parent 
household can be traumatic as well. For family members of veterans, 
trying to be there through many years of undiagnosed or untreated PTSD 
can affect them as well. Many spouses and family members are 
overwhelmed and need PMCS. We have to find a way to help the family 
members of all our troops, active and veteran, and provide them 
counseling as well.
    Counseling should be mandatory at regular intervals for every 
returning troop and should continue for months or years after returning 
from deployment. The family members should be actively involved in 
post-deployment counseling. The family often knows more than the 
doctors and may often identify more than the member themselves. The 
spouse knows if the servicemember is different. They know if something 
is wrong. Too often the family member may cry out for help to the 
military, normally the member's chain of command, and be ignored, not 
taken seriously, or in some cases even belittled. The spouses must be 
included and taken seriously when they identify a problem with the 
servicemember when identifying possible PTSD symptoms or other work-
related stressors.
    I want to bring up a situation that occurred last Friday at Fort 
Bliss, Texas. A soldier who returned 15 months ago from deployment, 
then immediately relocated to a new assignment, had PTSD. I do not yet 
know how much help he'd been given. What I do know is that the family--
his mother lives in my district--has cried out for help for a long 
time. They have repeatedly raised concerns that the soldier had PTSD 
and needed some immediate attention. Again, I am not certain how much 
attention he received, but the family indicates that it was 
insufficient. The last call for help was last Wednesday and Thursday to 
the unit. Friday morning the soldier turned himself in to the military 
police after allegedly having shot and killed an 18-year-old on his way 
to school and having shot and wounded another soldier.
    I want to make it clear that the ultimate victims here are the 
young man whose life was cut short and the soldier who was wounded. I 
do not want to diminish their loss in any way.
    But I do want to point out that this is a situation where 
intervention was needed . . . early and continual. . . . We cannot take 
``I'm okay'' for an answer, especially if someone screens positive for 
possible PTSD, but even if they have not initially screened positive. 
It may harvest and grow over time, like when you put a frog in water 
and slowly raise the temperature. He won't jump out because he doesn't 
realize anything's wrong. This soldier needed PMCS and he wasn't 
getting it.
    We, as a community, have to ensure our troops are being helped. We 
have to take their family seriously when they give us clues that there 
is something wrong. We have to pay attention. In this case, one 
innocent life was lost and countless lives were impacted forever 
because we, as a community, didn't pay attention.

                                 
                 Prepared Statement of Adrian Atizado,
  Assistant National Legislative Director, Disabled American Veterans
    Mr. Chairman and other Members of the Subcommittee:
    Thank you for inviting the Disabled American Veterans (DAV) to 
testify at this oversight hearing of the Subcommittee on Health. We 
appreciate the opportunity to offer our views on progress by the 
Department of Veterans Affairs (VA), and the Veterans Health 
Administration (VHA) on meeting the critical mental health needs of 
veterans.
    We recognize the unprecedented efforts made by VA over the past 
several years to improve the consistency, timeliness, and effectiveness 
of mental health programs for disabled veterans. We are pleased that VA 
has committed through its national Mental Health Strategic Plan (MHSP) 
to reform VA mental health programs by moving from the traditional 
treatment of psychiatric symptoms to embracing recovery potential in 
every veteran under VA care. We also appreciate the will of Congress in 
continuing to insist that VA dedicate sufficient resources in pursuit 
of comprehensive mental health services to meet the needs of veterans.
    Despite obvious progress, we believe much still needs to be 
accomplished to fulfill the Nation's obligations to veterans who have 
serious mental illness, and post-deployment mental health challenges. 
Our duty is clear--all enrolled veterans, and particularly 
servicemembers, Guardsmen and reservists returning from war, should 
have maximal opportunities to recover and successfully readjust to life 
following military deployment and wartime service. They must have user-
friendly access to VA mental health services that have been 
demonstrated by current research evidence to offer them the best 
opportunity for full recovery.
    We must stress the urgency of this commitment. Sadly, we have 
learned from our experiences in other wars, notably Vietnam, that 
psychological reactions to combat exposure are common. If they are not 
readily addressed, they can easily compound and become chronic. Over a 
long period of time, the costs mount in terms of impact on personal, 
family, emotional, medical and financial damage to those who have 
honorably served their country. Delays in addressing these problems can 
result in self-destructive acts, including suicide. Currently, we see 
the pressing need for mental health services for many of our returning 
war veterans, particularly early intervention services for substance-
use disorders and evidence based care for those with post-traumatic 
stress disorder (PTSD), depression and other consequences of combat 
exposure.
    The development of the MHSP and the new Uniformed Mental Health 
Services (UMHS) policy (detailed in VHA Handbook 1160.01, dated 
September 11, 2008) provide an impressive and ambitious roadmap for 
VHA's transformation of mental health services. However, we have 
expressed continued concern about need for improved oversight of the 
implementation phase of these initiatives.
    Although we realize that VA is faced with a significant challenge 
in transforming its mental health services, this is not a time for the 
usual barriers that frustrate change. This is a time for extraordinary 
action to fulfill our commitments, and we believe extraordinary action 
can overcome the usual time delays. Surely, just as we owed it to our 
servicemembers to outfit them with the best possible protective 
equipment as they prosecute war, we now owe it to these same men and 
women to provide immediate access to the best VA evidence-based mental 
health treatments and early intervention services available so that 
they can quickly recover and successfully readjust to civilian life 
after war.
    Historically, VA has been plagued with wide variations among VA 
medical centers related to the adequacy of the continuum of mental 
health services offered. To address these concerns, VA has provided 
facilities with targeted mental health funds to augment mental health 
staffing across the system. This funding was intended to address widely 
recognized gaps in the access and availability of mental health and 
substance-use disorder services that existed prior to the development 
of the MHSP, to address the unique and increased needs of veterans who 
served in Operations Iraqi and Enduring Freedom (OIF/OEF), and to 
create a comprehensive mental health and substance-use disorders system 
of care within VHA that is focused on recovery--a hallmark goal of the 
2003 New Freedom Commission on Mental Health. In addition, VHA 
developed its UMHS policy so that veterans nationwide can be assured of 
having access to the full range of high quality mental health and 
substance-use disorder services in all VA facilities where and when 
they are needed. Timely, early intervention services can improve 
veterans' quality of life, prevent chronic illness, promote recovery, 
and minimize the long-term disabling effects of undetected and 
untreated mental health problems. We understand that these funds have 
been dispersed as part of a special Mental Health Initiative (MHI), 
with clear direction that they be used to augment current mental health 
staffing, not merely to replace vacant positions that facilities could 
not afford to fill without extra funding.
    On April 6, 2009, the VA Office of Inspector General (OIG) issued 
two reports focused on VA mental health services: (1) Healthcare 
Inspection: Implementation of VHA's Uniform Mental Health Services 
Handbook; and, (2) Audit of Veterans Health Administration Mental 
Health Initiative Funding. In anticipation of them, we had expected 
these reports would provide an in-depth assessment of the consistency 
of mental health services, and access across the Nation to evidence-
based treatments. Unfortunately, they fall far short of this 
expectation. The OIG report on the UMHS Handbook was intended to review 
progress on the implementation of the MHSP and specifically to assess 
whether the identification and treatment of PTSD was being uniformly 
accomplished across the system.
    The OIG noted that given the dimension of the handbook, a 
comprehensive review of the extent of implementation is challenging. 
For these reasons, the OIG limited the scope of review to the medical 
center level and reviewed only a limited selection of items from the 
handbook. OIG states that the Office of Healthcare Inspections, the 
community-based outpatient clinic (CBOC) Project Group, will inspect 
implementation of mental health services at the CBOC level at a later 
date. In addition, it was noted that the implementation of the handbook 
is a dynamic and ongoing process during fiscal year (FY) 2009 and that 
data in its report do not capture partial implementation. The OIG was 
also required to present its findings on uniformity of identification 
and treatment policies for PTSD.
    The UMHS handbook clearly defines specific requirements for 
services that must be provided and those that must be available when 
clinically needed by patients receiving health care from VHA. Overall, 
facilities are expected to implement handbook requirements by the end 
of FY 2009, less than 6 months from now. Modifications or exceptions 
for meeting the requirements must be reported to, and approved by, the 
Deputy Under Secretary for Health.
    VHA Central Office and the Office of Mental Health Services (OMHS) 
staff, and several Veterans Integrated Service Network (VISN) mental 
health liaisons and directors were interviewed during the inspection. 
Reports and data on locations, clinical staffing, and caseload on the 
mental health case management program and other relevant mental health 
programs were evaluated, including data and information on 
dissemination of training in evidenced-based psychotherapies. The 
inspection also included a web-based survey sent to all VA medical 
centers, including questions related to availability of certain mental 
health clinical services, (i.e., OIF/OEF specialty clinics and evening 
mental health hours). Responses were received from 149 of the 171 
medical center sites. In addition to the web-based survey, structured 
phone interviews were conducted with directors or designees at 138 VA 
medical centers, containing 39 index questions. The report noted that 
during the telephone interviews, OIG staff had an opportunity to obtain 
feedback and to hear about potential barriers to implementation of the 
UMHS handbook.
    The OIG commented on the individual areas evaluated in the 
inspection, but made no recommendations because facilities have until 
the end of FY 2009 to fully meet the handbook requirements. However, 
the inspection report noted areas for specific review to include 
community mental health; gender-specific care and military sexual 
trauma treatments; around-the-clock care and emergency department care; 
inpatient care; ambulatory mental health care; care transitions; 
specialized PTSD services; substance use disorders; seriously mentally 
ill and rehabilitation and recovery services; homeless programs and 
incarcerated veterans; integrating mental health into medical care 
settings; care of older veterans; suicide prevention; and uniformity of 
PTSD diagnosis and use of evidenced-based treatments. Findings in the 
report were tallied by the above-identified categories and displayed by 
facility in percentages of the extent of implementation.
    We note that the report predominantly relies on self reports from 
leadership at each of the VA medical facilities as to whether they have 
established a particular program, generally without any clear criteria 
as to what minimal services the program must offer, the intensity at 
which services are offered, or facility capacity to provide services at 
required levels of intensity. Self-reported rates of the existence of 
programs were high. However, in the few cases where intensity of the 
service is included or implied (e.g. intensive outpatient services or 
Psychosocial Rehabilitation and Recovery Centers), compliance is 
significantly lower (71 percent and 51 percent, respectively).
    The report notes that evidence-based services for PTSD are labor-
intensive but that currently VA has no means for tracking the true 
accessibility of such services across the system. VA, in conjunction 
with the Department of Defense (DoD), has made important efforts in 
developing evidence-based guidelines for mental health treatments, 
including those used for PTSD. VA has also commissioned independent 
reviews to establish which PTSD treatments are most effective. 
Consequently, much is known about the types and intensity of treatments 
that are optimal and effective. In the case of PTSD, the evidence-based 
treatments require careful training of staff and must be delivered at a 
high level of intensity, specifically--multiple hours of intensive 
treatment over several weeks or months, with subsequent followup care.
    The recent OIG report makes no attempt to calculate the intensity 
of PTSD services delivered, even those that are not evidence based; 
nevertheless, VA research reports cited by the OIG in other reports 
(e.g. OIG August 2008 report: Healthcare Inspection: Post-traumatic 
Stress Disorder Program Issues, VA San Diego Healthcare System) raise 
concern that intensity levels have been falling, even in the face of 
evidence that effective services for PTSD require much greater 
intensity of services. The OIG report on national implementation of the 
UMHS Handbook acknowledges that extensive training is required to 
deliver evidence-based PTSD care, and reported that it collected data 
on such training nationally; nevertheless, no data are presented on how 
many staff have been trained, how many still require training, or the 
timeline needed for training completion. The only data reported is 
self-reported by local officials on compliance questions.
    Within the past 8 months, the OIG conducted two other detailed 
inspections (including the San Diego inspection cited above) that 
attempted to look in depth at the provision of evidence-based PTSD 
care, including the critical issues of the availability of fully 
trained staff and the availability of time for staff to provide the 
intensive services required. In both cases, the results are in contrast 
to the optimistic tone of the self-reported data from local officials 
in this new report. In the San Diego report it is noted that ``it would 
be inappropriate to make conclusions about staff resource needs based 
on such inaccurate information''; that PTSD therapists reported 
``feeling overwhelmed due to increasing numbers and mental health 
needs'' of patients; and that ``only a few patients actually received'' 
evidence-based therapies.\1\ In a report on the Montana VA Health 
System, the OIG reported that: ``specific evidence-based therapies for 
PTSD have limited availability for Montana veterans.''\2\
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    \1\ Department of Veterans Affairs, Office of Inspector General. 
Healthcare Inspection: Post-Traumatic Stress Disorder Program Issues, 
VA San Diego Health Care System. Report 08-01297-187. August 26, 2008.
    \2\ Department of Veterans Affairs, Office of Inspector General. 
Healthcare Inspection: Access to VA Mental Health Care for Montana 
Veterans. Report 08-00069-102. March 31, 2009.
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    The concerns expressed to the OIG in the San Diego reportby local 
PTSD providers, particularly that they do not have the resources or 
time required to provide evidence based care at the intensity it 
requires, resonate with feedback we have received from clinicians and 
veterans who complain that they are providing and receiving PTSD 
therapies and other services, respectively, at only a limited intensity 
level.
    In VHA's response to the most recent 2009 OIG report, the Under 
Secretary for Health acknowledged that VHA lacks a system that reliably 
tracks the provision and utilization of evidence-based PTSD therapies. 
He noted in fact that no health system offers such a mechanism. This 
response might imply that the task is unachievable. Given the 
importance of combat-related PTSD to VA's core missions, we believe it 
should certainly be the first to do so and the evidence is ample that 
this task is an achievable goal.
    Over twenty years ago, VHA began translating one of the best 
established evidence-based approaches for care of the severely and 
chronically mentally ill, specifically--Intensive Case Management 
(ICM)--into general VHA practices. It did so with clear guidelines for 
conducting interventions to assure that the results would be comparable 
to the results found in the research studies that established the 
efficacy of the intervention strategy. This included measures of 
intensity of services, frequency of services and caseloads for 
providers. It should be noted that, in the current OIG report, the 
inspection found 100 percent compliance to the standards for having 
intensive case management services across the system. Based on 
extensive, available data from national VHA performance monitoring 
sources, not simply self-reported sources, it was possible for the OIG 
to assess the intensity and adequacy of staffing at the sites with ICM 
programs and identify that 24 out of 111 programs were below required 
staffing levels. We understand that all VA ICM programs are required to 
report regularly to a central monitoring center on their staffing 
levels, the number of patients per therapist, and other measures of 
fidelity to the delivery of true ICM services. Therefore, we believe it 
is clearly possible to track the implementation of an evidence-based 
therapy if the will and resources exist to do so, since VA has already 
done so with regard to ICM services.
    We are pleased that VHA reported plans for improving the tracking 
of veterans' access to evidence-based PTSD therapies, as detailed in 
the Under Secretary's response to the 2009 OIG report. Again, we 
believe this is clearly an achievable goal, and adequate resources 
should be devoted to the task to assure that it can be accomplished 
immediately.
    Mr. Chairman, let me now address the second OIG report before the 
Subcommittee today. The purpose of the OIG audit of VA's Mental Health 
Initiative (MHI) funding was to determine if VHA had an adequate 
process in place to ensure that funds that were allocated for the MHI 
were properly tracked and used for these purposes. According to the 
report, in FY 2008, VHA allocated $371 million to fund mental health 
initiatives outlined in the MHSP and UMHS handbook. The OIG visited six 
randomly selected VA medical facilities and reviewed allocation records 
related to MHI funding. According to the OIG staff from the OMHS and 
the Office of Finance in VA Central Office were interviewed to 
determine the process for funding the MHI and the mechanisms for 
tracking and ensuring accountability of these funds. Interviews also 
were conducted with VISN and medical facility staff, including new 
mental health staff hired to determine if they were performing MHI-
creditable duties. Award memorandum sent by the OMHS staff to the 
medical facilities were reviewed as well as MHI tracking reports, 
payroll reports and transfer of disbursement authorities (TDA). It was 
noted in the report that VHA had not developed performance metrics to 
identify the intended outcome(s) of each initiative. In a subsequent 
memorandum, VA commented that these metrics for monitoring 
implementation of the requirements listed in the UMHS handbook are 
currently under development.
    The OIG concluded that at the six sites reviewed, the OMHS had 
adequately tracked funds allocated for the MHI in FY 2008, and that the 
funds allocated for the MHI were used as intended. The OIG confirmed 
that 94 percent of the funds allocated in the six sites reviewed were 
used for initiatives outlined in the MHI. It reviewed the remaining 
funds to confirm they were used by, or for, mental health services. The 
OIG evaluated mental health personnel costs for FY 2008 and reported 
that VHA spent approximately $16.4 million of the $17.7 million 
allocated for 225 positions at the six sampled sites. Medical facility 
personnel reported the remaining funds ($1.3 million) allocated for 
hiring mental health staff, were not expended for that purpose because 
of delays in the hiring process. Finally, $1.8 million of some 
additional $3 million in funds not related to personnel costs were 
determined to have been expended on the MHI specifically, and on other 
mental health-related activities such as purchasing equipment and 
furniture, and paying travel costs to provide home-based primary care.
    While it is encouraging, based on this report, that the funds 
allocated are being predominantly utilized for the purposes intended, 
the report does not address two of the most pressing issues regarding 
true, long-term augmentation of mental services in VHA: the net 
increase in actual providers of care; and, the availability and 
accessibility of early intervention services.
    First, it does not calculate the actual increase in providers of 
care; rather, it merely audits the hiring of new staff. In the past, 
mental health augmentations have been offset by reductions in other 
areas of mental health services, leaving a smaller net gain than 
intended, or no gain at all. Secondly, the funds have been allocated as 
time-limited funds, although the need for additional services will 
clearly extend well into the foreseeable future. Supplementary mental 
health funds were allocated as time-limited, annual ``special purpose'' 
funding allocations that occurred outside of the usual Veterans 
Equitable Resource Allocation (VERA) process. Although there was a 
clear expectation by Congress that the services based on these funds 
would be maintained well into the foreseeable future, we understand 
that within VA the continued enhanced MHI funding has not been promised 
or assured. It is critical that these programs and the UMHS package be 
fully implemented and then maintained over time, since, as was learned 
tragically after Vietnam, many veterans of that era first sought care 
long after the conflict had ended. Furthermore, we understand that VHA 
now proposes to move funding for these programs into the VERA process. 
We are concerned that if all new mental health funds were moved into 
VERA and mixed with other medical care funds allocated to the VISNs, 
mental health and substance-use disorder programs will again be at risk 
for erosion. In fact this has been the case in the past when mental 
health and substance-use disorder funds were allocated under VERA and 
were required to compete directly with other acute care programs.
    Based on these findings, it is still unclear if sufficient 
resources have been authorized given the comprehensive requirements 
outlined in the UMHS handbook (approximately 400 mental health 
services). In our opinion, there is still much to be done to assure 
equity of access to mental health services for all veterans enrolled in 
and using the VA health care system. According to the OMHS, following 
the development of the UMHS handbook, each facility mental health chief 
was asked to prepare an analysis comparing the services identified in 
the handbook to the services they already provided at their facility. 
We understand that this analysis (one that VA has not released to 
Congress or the veterans service organization community) did not 
reflect the full recommendations made by mental health staff asked to 
complete the survey with regards to the actual number of full-time 
employee equivalents (FTEE) needed, in their estimation, to implement 
and carry out the services required in the UMHS handbook. Furthermore, 
we understand it did not fully take into account many important factors 
such as the cost and effort required to provide newer evidence-based 
treatments for priority conditions such as PTSD, or the extra efforts 
required to hire, train and orient new providers to VA, and to launch 
the new programs they would be expected to then manage.
    We also point out that the IG report does not specifically focus on 
the availability and accessibility of early intervention services. When 
combat veterans return from war, it seems there is a tendency to 
underestimate and ignore the early signs of psychological distress. At 
a recent Department of Defense (DoD) conference, we understand that one 
expert inferred that a significantly higher percentage than we are 
seeing in the current literature (70 percent, versus 30 percent or 
less), of servicemembers and veterans who were in harm's way during 
their deployments experience some level of residual stress and may 
incur resulting problems that need DoD or VA attention.\3\ According to 
mental health experts, these problems often first surface and come to 
the attention of the veteran or family members and friends, and 
manifest as relationship and marital problems, problems at work or 
school, or newly uncharacteristic and hazardous use of alcohol or other 
substance-use disorders. A number of new research studies underscore 
this point.\4\ These symptoms often indicate broader problems needing 
attention. When a veteran approaches VHA with one of these early signs, 
VA must have available a user-friendly, accessible early intervention 
program that immediately provides the services identified (e.g. early 
substance use disorder services or relationship counseling). Also, we 
believe VA should be able to use such opportunities to further assess 
the veteran for other health problems needing VA's attention. If the 
veteran encounters a complicated, bureaucratic system, where services 
are fragmented, complicated, delayed or not available, he or she will 
likely reject VA. Thereby, VA loses an opportunity to address such 
problems early on, when early interventions can have a long-term and 
even life-saving impact. At minimum, later interventions in chronic 
illness will be more expensive and even more complicated. Data from a 
newly published VHA national study of 1,530 users of VHA outpatient 
services underscores the challenge. While 40 percent of the sample 
screened positive for potentially hazardous alcohol use and 22 percent 
screened positive for full alcohol abuse, only 31percernt of those who 
screened positive reported being counseled about their hazardous 
alcohol use.\5\
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    \3\ Castro C. Oral Remarks at the Combat Stress Intervention 
Program Research Conference on Post Deployment Challenges: What 
Research Tells Practitioners. Washington and Jefferson College. April 
4, 2009.
    \4\ Scotti J, Crabtree M and Bennett E. Presentation at Combat 
Stress Intervention Program Research Conference on Post Deployment 
Challenges: What Research Tells Practitioners. Washington and Jefferson 
College. April 4, 2009.
    \5\ Calhoun PS, Elter JR, Jones ER, Kudler H, Straits Troster K. 
Hazardous Alcohol Use and Receipt of Risk Reduction Counseling Among 
U.S. Veterans of the Wars in Iraq and Afghanistan. Journal of Clinical 
Psychiatry, 69, 1686-93. November 2008.
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    Although there are many programs that support OIF/OEF veterans, few 
are true outreach programs designed to motivate veterans to take action 
to address their behavioral health concerns. However, the DAV recently 
learned about one such program in VISN 12--the ``VetAdvisor Support 
Program.'' VetAdvisor is a proactive, telephonic outreach program that 
employs techniques to identify veterans (rural, suburban, and urban) 
who may be in need of behavioral health care and then helps to connect 
them directly to their local VA facilities.
    VetAdvisor provides ``Care Coaches'' who are licensed, trained and 
experienced behavioral health clinicians. Through a series of VA-
approved screenings, the Care Coaches telephonically assess veterans 
for medical and behavioral health conditions associated with serving in 
combat. The results of such screenings are provided to the VA facility 
concerned for follow-up and further evaluation.
    VetAdvisor also incorporates an extended solution-focused Care 
Coaching Program (i.e., non-medical facilitation) which is provided 
telephonically or through virtual collaboration technology. The program 
is designed to recognize behavioral challenges and empower veterans to 
successfully overcome setbacks. The Care Coaches employ motivational 
interviewing techniques, with an emphasis on encouraging change.
    We understand that the VetAdvisor concept was piloted in VISN 12 to 
a population of over 5,000 veterans and after positive screenings, 
directed over 1,100 veterans to VA facilities for follow-up services. 
We see the expansion of this pilot program as one possible alternative 
to increasing outreach to OIF/OEF veterans who may otherwise fall 
through the cracks and go untreated. As we have learned from Vietnam, 
later on in life untreated sick and disabled veterans often discover 
VA, but are much more challenging cases for whom to provide assistance.
    While we agree with the OIG that implementation of the UMHS 
handbook is an ambitious effort, it must be approached with a clear 
recognition that delays in immediate implementation inflict a heavy 
cost on those who have honorably served their country. We strongly 
believe that comprehensive and detailed oversight and monitoring is 
imperative at this juncture if immediate progress in filling critical 
gaps in mental health services across the nation is to be assured and 
recovery is to be fully embraced.
    The oversight process we envision in mental health would be a 
constructive one that is helpful to VA facilities, rather than 
punitive. It should be data-driven and transparent, and should include 
local evaluations and site visits to factor in local circumstances and 
needs. Such a process could assure that immediate progress is made in 
achieving the goal of the VA MHSP and UMHS package to provide easily 
accessible and comprehensive mental health services equitably across 
the nation.
    An empowered VA organizational structure should be established 
within VA to assure that this oversight process is robust, timely and 
utilizes the best clinical and research knowledge available. Such a 
structure would require VHA to collect and report detailed data, at the 
national, network and medical center levels, on the net increase over 
time in the actual capacity to provide comprehensive, evidence-based 
mental health services. Using data available in current VA data 
systems, such as VA's payroll and accounting systems, supplemented by 
local audited reports where necessary, could provide information down 
to the medical center level on at least the following from the period 
of fiscal year 2004 to the present fiscal year:

      the number of full-time and part-time equivalents of 
psychiatrists and psychologists;
      the number of mental health nursing staff;the number of 
social workers assigned to mental health programs;
      the number of other direct care mental health staff (e.g. 
counselors, outreach workers);
      the number of administrative and support staff assigned 
to mental health programs;
      the total number of direct care and administrative FTEE 
for all programs, mental health and others, and as a basis for 
comparison;
      the number of unfilled vacancies for mental health 
positions that have been approved, and the average length of time 
vacancies remain unfilled.

    The current practice of reporting only the number of offers made to 
prospective new mental health staff members, and not the number who are 
actually on board, should be immediately halted, since we know there 
are often lags of several months in actually bringing these new 
clinicians on board, getting them trained and finally seeing patients.
    VA should also develop an accurate demand model for mental health 
and substance-use disorder services, including veteran users with 
chronic mental health conditions and projections for the unique needs 
of OIF/OEF veterans. This model development should be created in 
coordination with the VA mental health strategic planning process and 
include estimated staffing standards and optimal panel sizes for VA to 
provide timely access to services while maintaining sufficient 
appointment time allotments.
    Assuming the creation of these resource tools, Congress should also 
require VA to establish an independent body, a ``VA Committee on 
Veterans with Psychological and Mental Health Needs,'' (or a similar 
title) with appropriate resources, to analyze these data and 
information, supplement its data with periodic site visits to medical 
centers, and empower the Committee to make independent recommendations 
to the Secretary of Veterans Affairs and to Congress on actions 
necessary to bridge gaps in mental health services, or to further 
improve those services. Membership on the Committee should be made up 
from VA mental health practitioners, veteran users of the services and 
their advocates, including veterans' service organizations and other 
advocacy organizations concerned about veterans and VA mental health 
programs. The site visit teams should include mental health experts 
drawn from both within and outside VA. These experts should consult 
with local VA officials and seek consensual, practical recommendations 
for improving mental health care at each site. This independent body 
should be responsible for synthesizing the data from each of the sites 
visited and make recommendations on policy, resources and process 
changes necessary to meet the goals of the MHSP and UMHS Handbook.
    In addition to these changes, VA should be directed to conduct 
specialized studies, under the auspices of its Health Services Research 
and Development Program and/or by the specialized mental health 
research centers such as the Mental Illness Education, Research and 
Clinical Centers (MIRECCs) in several sites, the Seriously Mentally Ill 
Treatment, Research Education and Clinical Center (SMITREC) in Ann 
Arbor; and the Northeast Program Evaluation Center in West Haven, among 
others, on equity of access across the system; barriers to 
comprehensive substance use disorders rehabilitation and treatment; 
early intervention services for harmful/hazardous substance use; 
couples and family counseling; and programs to overcome stigma that 
inhibits veterans, particularly newer veterans, from seeking timely 
care for psychological and mental health challenges.
    As an additional validation, we believe that the Government 
Accountability Office (GAO) should be directed to conduct a follow on 
study of VA's mental health programs to assess the progress of the 
implementation phase of the MHSP, the status of the UMHS Handbook at 
the end of 2009, and to provide its independent estimate of the FTEE 
necessary for VA to carry out the above-noted program initiatives. 
Congress should also require GAO to conduct a separate study on the 
need for modifications to the current VERA system to incentivize VA's 
fully meeting the mental health needs of all enrolled veterans.
    We believe the ideas above--ideas that we have gleaned from a 
number of mental health and research professionals both within and 
outside of VA, and from scientific literature, are necessary to fully 
ensure VA is moving its mental health policy and program infrastructure 
in a proper direction, and with the sense of urgency that the current 
shortfalls require. We believe it is essential that VA provide 
immediate evidence-based mental health services for all veterans 
returning from wartime deployments, including time-sensitive early 
intervention services before VA misses the opportunity to restore these 
veterans to a level of full functioning.
    Also, we urge this Subcommittee, which would be the major recipient 
of this new approach to reporting true VA mental health capacity, to 
continue to provide VA strong oversight to assure VA's mental health 
programs, and the reforms it is attempting, meet all their promises, 
not only for those coming back from war now, but for previous 
generation of veterans who need these specialized services.
    In summary, while much progress has been achieved toward reforming 
VA mental health care and the programs that provide it, many more 
challenges lie ahead for VA to achieve the level and scope of reforms 
VA has laid out as its near-term goal. We again call your attention to 
DAV's testimony \6\ at your March 3, 2009, legislative hearing with 
respect to H.R. 784, a bill introduced by Ms. Tsongas. That testimony 
embraced many similar points that we raise again today. We believe 
comprehensive, independent oversight is crucial to assure veterans and 
their advocates, including DAV, that current mental health policy 
mandates outlined in the UMHS handbook and MHSP, with stable, 
predictable funding augmentations, truly result in appropriate high 
quality treatment and immediate access to critically important mental 
health services for all veterans who need them. This is as important 
for older generations of disabled war veterans with chronic mental 
health problems, as it is for our newest generation of veterans from 
Iraq and Afghanistan, some of whom are surely suffering from more acute 
forms of these mental health challenges and readjustment difficulties. 
We urge the Subcommittee to act with dispatch to address these 
responsibilities.
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    \6\ Ilem, J Statement of the Disabled American Veterans before the 
Committee on Veterans Affairs, Subcommittee on Health, U.S. House of 
Representatives, 3-3-09 http://www.dav.org/voters/documents/statements/
Ilem20090303.pdf.
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    Mr. Chairman, this concludes my statement. I will be pleased to 
respond to any questions you may wish to ask with regard to these 
issues.

                                 
                   Prepared Statement of Ralph Ibson
        Senior Fellow for Health Policy, Wounded Warrior Project
    Chairman Michaud, Ranking Member Brown and Members of the 
Subcommittee:
    Thank you for inviting Wounded Warrior Project (WWP) to offer our 
views on VA's progress in meeting the mental health needs of our 
veterans, with particular emphasis on VA's mental health strategic 
plan, its uniform mental health services handbook, and the funding to 
support those initiatives.
    The Wounded Warrior Project brings an important perspective to 
these issues in light of the organization's goal--namely to ensure that 
this is the most successful, well-adjusted generation of veterans in 
our Nation's history. That perspective provides the framework for our 
testimony this morning.
    Wounded Warrior Project was founded on the principle of warriors 
helping warriors, and we pride ourselves on outstanding service 
programs built on that principle. Our signature service programs 
include peer mentoring, adaptive sporting events, and Project Odyssey--
a potentially life-changing program that engages groups of veterans 
with combat stress and post-traumatic stress disorder in outdoor 
adventure activities that foster coping skills and provide support in 
the recovery process. WWP aims to fill gaps--both programmatic and 
policy--to help wounded warriors thrive. We recognize, of course, the 
critical role that the Department of Veterans Affairs can and must play 
in providing needed health care services to wounded veterans. We 
welcome the opportunity, accordingly, to offer our views on VA's 
progress in meeting veterans' mental health needs.
    That progress certainly owes much to this Committee's leadership 
over the years in highlighting the importance of veterans' mental 
health and pressing to reverse the underfunding of VA mental health 
programs. Oversight hearings like this one are vital to sustaining the 
gains that have been made, and realizing goals that have not yet been 
fully attained.
Mental Health: A Vital VA Mission
    We have certainly come a long way in this country in understanding 
the importance of mental health, and in diminishing the stigma that for 
too long surrounded mental illness and mental health treatment. We have 
come to understand that mental health is integral to overall health. We 
know too that mental health problems are a leading cause of disability. 
Yet mental disorders can be readily diagnosed and treated. Those who do 
not get that needed treatment, however, likely face a more difficult 
reintegration into their communities, and are at increased risk for 
chronic illness, poor general health, and unemployment.
    VA's role as a provider of mental health care is particularly 
important. Recently, the Institute of Medicine reported trends in the 
numbers of veterans receiving disability compensation for a primary 
rated disability (which is defined as either the condition rated as the 
most disabling or equal to the highest rated condition). From 1999 to 
2006, of all veterans receiving disability compensation, the primary 
rated disability diagnosis category with the largest percentage 
increase was major depression (474-percent increase). Two other mental 
health categories--``other mood disorders'' and PTSD--experienced 
increases of 264 percent and 126 percent respectively.\1\ While some 
5.5 million veterans use VA health care services annually, most 
veterans have other health care coverage and do not rely on the VA 
health care system. Veterans who need mental health care, however, 
generally do not have good alternatives. Neither Medicare nor most 
employer-provided health plans cover the

broad range of mental health services recommended by the Institute of 
Medicine, the Surgeon General, and the 2003 report of the President's 
New Freedom Commission on Mental Health. As a system, VA provides a 
broad range of services not generally available through other programs, 
but its facilities are not easily accessible to all veterans. Given the 
limited mental health coverage available through non-VA sources, it is 
particularly important that VA maintain and indeed augment its capacity 
to provide veterans such needed services.
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    \1\ Institute of Medicine and National Research Council of the 
National Academies, PTSD Compensation and Military Service (Washington, 
DC: The National Academies Press, 2007), 145.
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OIF/OEF Veterans
    Recent research indicates that we face substantial mental health 
challenges as a result of our engagement in Iraq and Afghanistan. A 
widely cited longitudinal study reports that some 20 percent of active 
duty returning servicemembers and 42 percent of reserve component 
soldiers were found to need mental health treatment.\2\ VA reports that 
mental disorders are among the three most common health problems 
experienced by new veterans who seek VA care. VA's experience and 
research data suggest that we can expect the number of OIF/OEF veterans 
with mental health problems to increase. While PTSD is especially 
prevalent among veterans seeking VA care, the literature also makes 
clear that PTSD often co-occurs with other mental health disorders, 
particularly depression, anxiety, and substance-use disorders. Indeed 
one study reports that there is an 80 percent likelihood that a patient 
with PTSD will also meet diagnostic criteria for at least one other 
mental health disorder.\3\ These substantial co-morbidities have been 
linked to significant impairment in social and occupational 
functioning, as well as to suicide. As this Committee knows, there has 
been a dramatic increase in the number of soldiers who have attempted 
or committed suicide since 2003.
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    \2\ Charles S. Milliken, Jennifer L. Auchterlonie, and Charles W. 
Hoge, ``Longitudinal assessment of mental health problems among active 
and reserve component soldiers returning from the Iraq War,'' Journal 
of the American Medical Association 298, no. 18 (2007): 2143.
    \3\ RC Kessler, A Sonnega, E Bromet, M Hughes and CB Nelson, 
``Posttraumatic stress disorder in the national comorbidity survey,'' 
Archives of General Psychiatry 52, 1995: 1048-1060. As cited in Matthew 
Friedman, ``Posttraumatic stress disorder among military returnees from 
Afghanistan and Iraq,'' American Journal of Psychiatry 163, no. 4, 
2006: 589.
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    VA has acknowledged that it is experiencing an increase in the 
numbers of OIF/OEF veterans treated for mental health disorders, and 
expects a further increase. That trend is concerning. Yet VA officials 
have maintained that the increased workload associated with mental 
health problems among returning veterans is manageable. We question 
that view, given our understanding that there is already a significant 
vacancy rate in VA mental health staffing and a nationwide shortage of 
mental health clinicians. While VA policy has encouraged facilities to 
use community resources to obtain needed mental health care when VA 
cannot provide needed services or where VA care would be geographically 
inaccessible to the veteran, community providers rarely have expertise 
in addressing military trauma. Moreover, sources of community-based 
mental health care do not exist in many parts of the country. Half the 
counties in the United States do not have a single mental health 
professional, according to a recent Federal report.\4\
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    \4\ Annapolis Coalition on the Behavioral Health Workforce, ``An 
Action Plan for Behavioral Health Workforce Development, Executive 
Summary,'' report prepared for the Substance Abuse and Mental Health 
Services Administration (SAMHSA), 2007.
---------------------------------------------------------------------------
    Compounding the challenges associated with the increasing numbers 
of OIF/OEF veterans with mental health problems, it seems clear that VA 
is not reaching all who need mental health care. It is striking, for 
example, that of the veterans RAND surveyed, only about half of those 
with a probable diagnosis of PTSD or major depression had sought help 
from a health professional.\5\ Another study found that approximately 
60 percent of all ground combat troops in Iraq who screened positive 
for PTSD, generalized anxiety or depression did not seek treatment.\6\ 
RAND suggested a number of factors that may inhibit some returning 
veterans from seeking VA mental health treatment, including the stigma 
associated with seeking mental health treatment, concerns about 
confidentiality, perceptions about feeling out of place among older 
patients in VA facilities, attitudes about the effectiveness of mental 
health treatment and medications, and logistical barriers.\7\ The 
experience of some of our wounded warriors and their family care givers 
indicate some inconsistency in outreach efforts, and suggest that the 
goal of a ``seamless transition'' from DoD to VA has yet to be fully 
realized.
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    \5\ Terri Tanielian, Lisa Jaycox, Terry Schell, Grant Marshall, M. 
Audrey Burnam, Christine Eibner, Benjamin Karney, Lisa Meredith, Jeanne 
Ringel, Mary Vaiana, and the Invisible Wounds Study Team, Invisible 
Wounds of War: Summary and Recommendations for Addressing Psychological 
and Cognitive Injuries (Santa Monica, CA: The RAND Corporation, 2008), 
13-14.
    \6\ Charles Hoge, Carl Castro, Stephen Messer, Dennis McGurk, Dave 
Cotting and Robert Koffman, ``Combat duty in Iraq and Afghanistan, 
mental health problems, and barriers to care,'' The New England Journal 
of Medicine 351, no. 1, 2004:16.
    \7\ Terri Tanielian, Lisa Jaycox, Terry Schell, Grant Marshall, M. 
Audrey Burnam, Christine Eibner, Benjamin Karney, Lisa Meredith, Jeanne 
Ringel, Mary Vaiana, and the Invisible Wounds Study Team, Invisible 
Wounds of War: Psychological and Cognitive Injuries, Their 
Consequences, and Services to Assist Recovery (Santa Monica, CA: The 
RAND Corporation, 2008): 282, 301, 278, 302.
---------------------------------------------------------------------------
    Also troubling are reports that veterans with a co-occurring 
substance-use disorder--a high risk category--are less likely to use VA 
mental health services than those who simply have a mental health 
disorder. One study found that only 3 percent of OIF/OEF veterans 
surveyed who had co-occurring PTSD and a substance-use disorder 
actually received chemical dependency treatment, although evidence-
based care calls for integrated treatment of these co-occurring 
conditions.\8\
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    \8\ Christopher Erbes, Joseph Westermeyer, Brian Engdahl and Erica 
Johnsen, ``Post-traumatic stress disorder and service utilization in a 
sample of servicemembers from Iraq and Afghanistan,'' Military Medicine 
172, no. 4, 2007: 359.
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    Veterans with untreated mental health problems can face long-term 
consequences both in terms of their ability to reintegrate successfully 
in their communities as well as to their overall health. PTSD, for 
example, is associated with reported reductions in quality of life 
across several domains, including general health, energy, emotional 
well-being, emotional role limitation, physical role limitation, and 
social functioning. Studies have shown a strong correlation between 
PTSD and physical health measures, including missed workdays, among 
this generation of veterans.\9\ Studies have also linked PTSD with 
illnesses such as cardiovascular disease,\10\ nervous system 
disease,\11\ and gastrointestinal disorders.\12\ Given the potential 
chronicity of mental health conditions, a failure to intervene early 
and effectively could have profound long-term costs for this generation 
of veterans as well as for society, including lost productivity, 
reduced quality of life, strain on families, domestic violence, and 
homelessness.
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    \9\ Charles Hoge, Artin Terhakopian, Carl Castro, Stephen Messer 
and Charles Engel, ``Association of posttraumatic stress disorder with 
somatic symptoms, health care visits, and absenteeism among Iraq war 
veterans,'' American Journal of Psychiatry 164, no. 1, 2007:151-2.
    \10\ Laura Kubzanksy, Karestan Koenen, Avron Spiro III, Pantel 
Vokonas and David Sparrow, ``Prospective study of posttraumatic stress 
disorder symptoms and coronary heart disease in the normative aging 
study,'' Archives of General Psychiatry 64, no.1, 1997: 112-3.
    \11\ J Boscarino, ``Diseases among men 20 years after exposure to 
severe stress: Implications for clinical research and medical care,'' 
Psychosomatic Medicine 59, no. 6, 1997: 604-14. As cited in Jennifer 
Vasterling, Jeremiah Schumm, Susan Proctor, Elisabeth Gentry, Daniel 
King and Lynda King, ``Posttraumatic stress disorder and health 
functioning in a non-treatment-seeking sample of Iraq war veterans: A 
prospective analysis,'' Journal of Research & Development 45, no. 3, 
2008: 348.
    \12\ P Schnurr, A Sprio III and A Paris, ``Physician-diagnosed 
medical disorders in relation to PTSD symptoms in older male military 
veterans,'' Health Psychology 19, no. 1, 2000: 91-97. As cited in 
Jennifer Vasterling, Jeremiah Schumm, Susan Proctor, Elisabeth Gentry, 
Daniel King and Lynda King, ``Posttraumatic stress disorder and health 
functioning in a non-treatment-seeking sample of Iraq war veterans: A 
prospective analysis,'' Journal of Research & Development 45, no. 3, 
2008: 348.
---------------------------------------------------------------------------
VA's Strategic Mental Health Plan
    With those concerns as background, we acknowledge that VA has taken 
important steps toward refocusing the system to meet veterans' mental 
health needs. In 2004, VA developed a strategic plan to transform 
mental health care in the VA. The plan was built on the foundation of 
the President's New Freedom Commission on Mental Health, one of whose 
core principles remains vitally important to the mental health of our 
newest generation of veterans. That ``blue ribbon'' Commission 
emphasized that the goal of mental health care must be recovery--not 
simply the management of symptoms. By recovery, the Commission meant an 
individual's being able to live a fulfilling, productive life in the 
community--even with a mental health condition that may elude ``cure.''
    VA became the first Federal department to embrace the Commission's 
recommendations, and VA's strategic plan was hailed for the breadth and 
boldness of its vision. Among its key elements were:

      Adoption of the recovery model, emphasizing each 
veteran's rehabilitation;
      Integration of medical and mental health care to ensure 
coordinated, comprehensive care;
      Providing veterans equitable access to a comprehensive 
continuum of mental health services; and
      Intervening early to identify and address mental health 
needs among returning OIF/OEF veterans.

    The plan documented large areas of unmet current and future need, 
and candidly acknowledged that closing those gaps and realizing its 
goals would require an expansion of facilities, services, and 
personnel--in short, vibrant funding--as well as fundamental changes in 
culture.
    Last year, VA took its strategic mental health plan a step further 
in issuing a Uniform Mental Health Services Handbook. That far-reaching 
directive, for the first time, established a policy calling for a 
``Uniform Services Package''--a requirement that veterans must be 
afforded access to a specific array of needed mental health services, 
regardless of where they live.
    The question underlying this hearing--what has been VA's progress 
in meeting the mental health needs of our veterans?--is critically 
important as we approach the 5 year mark since adoption of the 
strategic mental health plan. That question is also vitally important 
as the Department is apparently moving toward ending a several-year 
long special funding initiative that had supported the strategic plan's 
implementation.
    The VA has clearly made major strides in carrying out many of the 
plan's near-term initiatives and in closing the size of the gaps that 
had been identified. But gaps and wide variability in programs remain. 
By way of illustration:

      While the strategic plan acknowledges the importance of 
specialized PTSD treatment services for returning veterans, our 
warriors have experienced both long waits for inpatient care and a 
dearth of OIF/OEF-specific programs. (Young veterans with acute PTSD 
understandably question how they can be expected to feel confident 
about treatment when placed into treatment programs with older veterans 
who have been struggling with chronic PTSD and other health problems 
for decades.)
      For the first time, VA policy--as reflected in the new 
uniform services handbook--calls for ensuring the availability of 
needed mental health services, to include providing such services 
through contracts, fee-basis non-VA care, or sharing agreements, when 
VA facilities cannot provide the care directly. That policy has 
particular relevance to the large number of OIF/OEF veterans who live 
in rural areas and for whom VA facilities are often geographically 
accessible. We understand, however, that VA facilities have made only 
very limited use of this new authority. Moreover, the new policy makes 
no provision for assuring that community mental health professionals 
have appropriate expertise to effectively treat veterans with combat-
related mental health conditions.
      VHA has employed special mental health funding to support 
major efforts to train VA clinicians in two evidence-based therapies 
for treatment of PTSD. But no comparable initiative has been mounted to 
ensure integrated or coordinated care of co-occurring PTSD and 
substance-use disorders, one of the many requirements of the uniform 
services handbook. Integrated treatment of these often co-occurring 
health problems appears to be the exception rather than the rule in VA 
facilities.
      Mental health care is increasingly being integrated into 
primary care clinics; but at any given medical center or large clinic, 
mental health may be integrated into only a single one of its primary 
care teams.
      VA facilities have yet to fully incorporate recovery-
oriented services, including peer-support programs, into their care-
delivery programs.

Re-examining VA's Strategic Plan
    The overarching vision underlying VA's strategic plan is sound. But 
a strategic plan, by its very nature, should be revisited periodically. 
While the current plan continues to provide a credible foundation, we 
encourage the Committee to press the Department to re-examine that 
blueprint and take account of what has changed in the nearly 5 years 
since the plan's adoption. For example, it is not clear that the plan 
anticipated the increased prevalence of PTSD and other behavioral 
health conditions affecting this and other generations of veterans. 
Another example is that the plan emphasizes screening as a tool to 
foster early intervention services, but fails to address the problem of 
veterans who are identified in screening as likely needing follow-up, 
but who elect not to pursue further evaluation or treatment.
    The strategic plan also includes initiatives to foster peer-to-peer 
services but does so only in the context of veterans with severe mental 
illnesses (such as schizophrenia and bipolar illness). In WWP's 
experience, peer support can be powerful in helping OIF/OEF veterans 
cope with PTSD, and there is ample research to suggest that peers' 
social support is an important influence on psychological recovery and 
rehabilitation. Moreover, we see evidence that this generation of 
veterans value peer-services. To illustrate, a recent WWP survey of 
wounded warriors with whom we have worked showed that:

      75 percent of respondents reported that talking with 
another OIF/OEF veteran was helpful in dealing with mental health 
concerns;
      56 percent expressed the belief that peer-to-peer 
counseling would be helpful in addressing their mental health concerns; 
and
      43 percent reported that talking with another OEF/OIF 
veteran had been the one most effective resource in helping with mental 
health concerns.

    In short, a revised strategic plan should, in our view, promote the 
use of such peer-to-peer supports for wounded warriors with mental 
health needs, without regard to diagnosis.
VA Mental Health Funding
    Whether we gauge VA's progress in meeting the mental health needs 
of our veterans through the lens of its 2004 strategic plan, or--as we 
recommend--in the context of an updated strategic plan, WWP believes 
the transformation of VA's mental health delivery system remains a work 
in progress. Given that view, and given the unique importance of VA's 
mental health mission, it is critical to sustain robust funding for VA 
mental health programs.
    As VA officials have previously testified, the Veterans Health 
Administration (VHA) has allocated special funding in the form of a 
``Mental Health Initiative'' every year since Fiscal Year 2005 to 
implement the Mental Health Strategic Plan. It is our understanding 
that VHA allocated some $600 million in special funding for mental 
health this fiscal year. Funds supporting this initiative have 
supplemented the resources provided through VA's resource allocation 
system, VERA.
    Without question, VA's special mental health funding has supported 
a very substantial increase in the Department's mental health 
workforce, the development of new programs at many facilities, and 
expansion of existing services at others--consistent certainly with a 
bold vision of system ``transformation.'' It is our understanding, 
however, that special funding will be phased out next year, with 90 
percent of those special funds reverting to VHA's general health care 
funds, to be allocated through the VERA process.
    The implications of that shift could be profoundly detrimental, 
given that veterans' mental health care needs--during a still-evolving 
major strategic transition--would no longer be subject to a special 
funding mechanism. Instead, as the General Accounting Office and other 
oversight entities have reported, moneys would be allocated to the 
networks under the VERA process based primarily on the numbers of 
veterans under treatment without any new funding or fiscal incentives 
to improve the intensity of care provided current patients. Yet 
improved patient care is precisely what the Strategic Plan aims to 
achieve. It is not at all clear that any targeted funding mechanism has 
been devised to sustain the gains that have been made in VA mental 
health care and to support those initiatives that have yet to be 
completed. In short, VA network directors and facility directors--who 
are charged to continue implementation of the strategic plan and the 
uniform services handbook, but who face an end of special mental health 
funding--may well be left with an unfunded mandate. Given that 
conundrum, there is a great risk that critical policy goals will not be 
realized, and that prior gains will be eroded.
    It seems clear that policy goals critical to meeting the mental 
health needs of current veterans, and any surge of new veterans likely 
to need VA care, will not be met or sustained without either changing 
the resource allocation system or revisiting prior decisions regarding 
special mental health funding. Given the profound transformation in VA 
mental health service-delivery still underway, we urge continued strong 
oversight to ensure that the Department has a sound funding plan to 
support and sustain its still evolving mental health transformation.
    We recognize that funding alone will not achieve a real system 
transformation. Leadership is equally critical. With that in mind, VA 
must ensure adequate resources are allocated to mental health 
programming. At the same time, the Department must closely monitor and 
evaluate program implementation, and report at least annually to 
Congress on its progress. That combination of adequate mental health 
funding and keen oversight offer the best promise, in our view, for 
ensuring that we meet the mental health needs of our veterans, and 
fostering the goal of ensuring that this generation of wounded warriors 
is the most well-adjusted, mentally healthy generation of veterans in 
our history.

                                 
            Prepared Statement of Michael L. Shepherd, M.D.
           Senior Physician, Office of Healthcare Inspections
    Office of Inspector General, U.S. Department of Veterans Affairs
    Mr. Chairman and Members of the Subcommittee, thank you for the 
opportunity to testify today regarding VA's progress toward meeting the 
mental health needs of our veterans. I will focus on the results of two 
reports that we recently released in this area: Healthcare Inspection--
Implementation of Veterans Health Administration's Uniform Mental 
Health Services Handbook and Audit of Veterans Health Administration 
Mental Health Initiative Funding. I am accompanied by Larry 
Reinkemeyer, Director of the Office of Inspector General's (OIG) Kansas 
City Audit Operations Division, who directed the audit project.
Background
    The 2003 President's New Freedom Commission Report identified 6 
goals and made 19 broad recommendations for transforming the delivery 
of mental health services in the United States. In 2004, the Veterans 
Health Administration (VHA) developed its 5-year Mental Health 
Strategic Plan (MHSP) that included more than 200 initiatives. Because 
the MHSP is organized by the goals and recommendations of the 
Commission's report rather than by a mental health program or 
operational focus, some MHSP initiatives do not delineate what specific 
actions should be carried out to achieve these goals and are not 
readily measureable.
    The VHA Handbook 1160.01, Uniform Mental Health Services in VA 
Medical Centers and Clinics, issued in June 2008 and updated in 
September 2008, establishes minimum clinical requirements for VHA 
mental health services. The handbook outlines those services that must 
be provided at each VA Medical Center (VAMC), and services required by 
the size of community based outpatient clinics (CBOCs).
    Although there is overlap between MHSP and handbook items, the 
handbook more clearly defines specific requirements for services that 
must be provided (i.e., those services that must be delivered when 
clinically needed to patients receiving health care at a facility by 
appropriate staff located at that facility) and those that must be 
available (i.e., those that must be made accessible when clinically 
needed to patients receiving health care from VHA). The handbook has an 
operational focus and is organized by mental health program areas 
(e.g., Homeless Programs) rather than by broader Commission goals. The 
handbook notes that ``when fully implemented these requirements will 
complete the patient care recommendations of the Mental Health 
Strategic Plan and its vision of a system providing ready access to 
comprehensive, evidence-based care.''
    Overall, VA medical facilities are expected to implement the 
handbook requirements by the end of fiscal year (FY) 2009. Each 
Veterans Integrated Service Network (VISN) must request approval from 
the Deputy Under Secretary for Operations and Management for 
modifications and exceptions for requirements that cannot be met in FY 
2009 with available and projected resources.
Healthcare Inspection--Implementation of VHA's Uniform Mental Health 
        Services Handbook
    Because there are over 400 implementation items in the handbook, we 
limited the scope of our review to the medical center level where full 
implementation is more likely to occur prior to CBOC level 
implementation. Accordingly, the extent of implementation presented in 
the findings represents the highest level currently attained for the 
system as a whole.
    Given the dimension of the handbook, a comprehensive review of the 
extent of implementation is challenging. Based on our clinical 
judgment, we chose 41 items from the handbook to evaluate for 
implementation. We believe the items chosen reasonably estimate the 
present extent of handbook implementation at the medical center level. 
Implementation of the handbook is an ongoing process and the data 
presented does not capture partial implementation.
    We found that 31 of the 41 items reviewed were implemented at more 
than 75 percent of VAMCs. For example, evening mental health clinic 
hours were in place at 99 percent of VAMCs. As another example, Mental 
Health Intensive Case Management programs were in place at 100 percent 
of facilities with more than 1,500 seriously mentally ill (SMI) 
patients from the VA National Psychosis Registry. A complete listing of 
items reviewed and implementation rates is included at the end of the 
statement.
    We identified the following items indicative of areas in which VHA 
is at risk for not meeting the implementation goal:

      Ensuring a follow-up encounter within 1 week of discharge 
from an inpatient mental health unit.
      Accessing timely a VISN specialized post-traumatic stress 
disorder (PTSD) residential program.
      Providing Intensive Outpatient Services (at least 3 hours 
per day at least 3 days per week) for treatment of substance use 
disorders.
      Availability of 23-hour observation beds.
      Availability of substitution therapy for narcotic 
dependence.
      Providing a psychosocial rehabilitation and recovery 
center program at facilities with more than 1,500 SMI patients.
      Availability of peer support counseling for SMI patients.
      The presence of at least one full-time psychologist to 
provide clinical services to veterans in VA community living centers 
(formerly nursing home care units) with at least 100 residents.

    Additionally, we are concerned that while a section of the handbook 
addresses access to specific evidence-based psychotherapies and somatic 
therapies, it appears that VA does not have in place a system to 
reliably track provision and utilization of these therapies on a 
national level. VHA's Office of Mental Health Services (OMHS) began a 
system-wide effort to train VA clinicians in core mental health 
disciplines in cognitive processing therapy for PTSD in the summer of 
2007 and in prolonged exposure therapy in the fall of 2007. Evidence-
based PTSD therapies are relatively time and labor intensive, requiring 
regular sessions for multiple and consecutive weeks. At a given 
facility, factors limiting provision and/or utilization of available 
evidence-based PTSD therapies may include the number of trained 
providers; availability of provider time, especially at medical centers 
in areas where there is a high concentration of returning Operation 
Iraqi Freedom/Operation Enduring Freedom veterans; geographic distance 
to care; availability of mental health providers in rural areas; and 
patient preference for other treatment choices. Implementation of a 
national system to track provision of evidence-based PTSD therapies and 
their utilization by returning veterans would allow for a population-
based assessment of treatment outcomes with implications for treatment 
of other veterans presenting for PTSD-related care.
    Program evaluation and development of mental health outcome 
measures can be challenging. While VA has relevant performance measures 
and systems in place to monitor handbook implementation, VA should 
develop outcome measures where feasible to allow for dynamic refinement 
of program requirements in order to meet changes in mental health needs 
and to optimize treatment efficacy.
    While this review contains items related to suicide prevention, we 
began a separate review of implementation of suicide prevention items 
in the handbook in January 2009. During our combined assessment program 
reviews, OIG inspectors have been conducting a focused, chart-based 
review of implementation. We will conclude our review in June 2009 and 
then issue a roll-up report on our findings.
Audit of Veterans Health Administration Mental Health Initiative 
        Funding
    In the FY 2008 budget submission to Congress, VHA requested $27.2 
billion for medical services which included $360 million for the mental 
health initiative (MHI). Congress appropriated $29.1 billion to VHA for 
medical services but did not specify an amount for the MHI. In FY 2008, 
VHA augmented the $360 million it requested for the MHI with funds 
received as part of its overall funding for medical services and 
allocated $371 million to medical facilities for the MHI.
    OMHS refined their method of allocating the MHI funding over the 
years. In FYs 2005 and 2006, OMHS allocated MHI funds to medical 
facilities based on proposals that detailed the specific projects and 
how the facilities would spend those MHI funds. In FY 2007 and 2008, 
OMHS allocated funds to continue the initiatives started in prior 
fiscal years (primarily to pay the salaries of MHI staff already hired) 
and to implement selected new nationwide initiatives, such as having a 
Suicide Prevention Coordinator at each facility.
    In the FY 2008 VA budget submission, VHA requested funding to 
provide resources to continue the implementation of the MHI. VHA 
allocated these funds to programs that covered the specific initiatives 
identified in the MHSP.
    Our objective for this audit was to determine if VHA had an 
adequate process in place to ensure funds allocated for the MHI were 
tracked and used accordingly. We found that VHA staff adequately 
tracked $371 million allocated for the MHI in FY 2008. At the six 
locations reviewed (New York, NY; Miami, FL; Milwaukee, WI; Jackson, 
MS; Alexandria, LA; and San Diego, CA), medical facilities' fiscal 
staff established multiple fund control points and tracked salary and 
purchase order costs for the MHI. VHA's Office of Finance staff 
compared the amounts spent to the amounts allocated. OMHS staff used 
reports from medical facilities to track the hiring status of MHI 
positions. Although our review covered only FY 2008 processes, in FY 
2009, the Office of Finance established standardized account 
classification codes for MHI funds that could further enhance 
transparency and accountability over how MHI funding is spent in the 
future.
    We also found that medical facilities used funds allocated for MHI 
as intended. VHA allocated $19.4 million for the MHI to the six medical 
facilities we reviewed and confirmed that $18.2 million (94 percent) of 
the $19.4 million were used for the MHI. The remaining $1.2 million 
consisted of numerous small dollar purchases; therefore, we reviewed 
those purchases only to the extent we were able to confirm the funds 
were used for mental health.
Conclusion
    We believe that VHA Handbook, Uniform Mental Health Services in VA 
Medical Centers and Clinics, is an ambitious effort to enhance the 
availability, provision, and coordination of mental health services to 
veterans and that VHA has made progress in implementation at the 
medical center level. Because our review was limited to medical 
centers, we plan to conduct a review in FY 2010 on implementation at 
the CBOC level where such factors as geographic distance to care and 
ability to recruit mental health providers may pose greater obstacles 
to implementation. In regard to MHI funding, we found that VHA 
adequately tracks and uses MHI funding as intended.
    Mr. Chairman, thank you again for this opportunity to appear before 
the Subcommittee. We would be pleased to answer any questions that you 
or Members of the Subcommittee may have.


------------------------------------------------------------------------
        VHA Mental Health Services          Extent of Implementation (%)
------------------------------------------------------------------------
Community Mental Health                     ............................
------------------------------------------------------------------------
Collaboration with Vet Centers for          87
 Outreach
------------------------------------------------------------------------
Gender-Specific Care and MST                ............................
------------------------------------------------------------------------
Separate and Secure Sleeping and Bathroom   97
------------------------------------------------------------------------
Tracking of MST Treatment                   82
------------------------------------------------------------------------
Availability of evidence-based care for     96
 MST
------------------------------------------------------------------------
24 Hours a Day, 7 Days a Week (24/7) Care   ............................
------------------------------------------------------------------------
24/7 ED On-Call MH Coverage                 98
------------------------------------------------------------------------
Urgent Care On-Call Coverage                100
------------------------------------------------------------------------
Availability of 23 Hour Observation Beds    54
------------------------------------------------------------------------
Inpatient Care                              ............................
------------------------------------------------------------------------
Onsite Inpatient Care                       79
------------------------------------------------------------------------
Ability to Admit Involuntary Patients       92
------------------------------------------------------------------------
Ambulatory Mental Health Care               ............................
------------------------------------------------------------------------
Follow-Up for new MH Patients               97
------------------------------------------------------------------------
Evening MH Clinic Hours                     99
------------------------------------------------------------------------
Care Transitions
------------------------------------------------------------------------
Set MH Appointment Provided at Discharge    97
------------------------------------------------------------------------
Seen for Follow-Up within 1 Week Post--     57
 Discharge
------------------------------------------------------------------------
Specialized PTSD Services                   ............................
------------------------------------------------------------------------
 PCT or Specialized Clinic for Patients     91
 with PTSD
------------------------------------------------------------------------
OIF/OEF Outpatient Clinic Specialized MH    65
 Clinic
------------------------------------------------------------------------
(or) Specialized PTSD Services for OIF/OEF  96
------------------------------------------------------------------------
Access to a VISN Specialized PTSD Program   91
------------------------------------------------------------------------
Ability to Reliably Access the VISN         73
 Program
------------------------------------------------------------------------
Efforts to Address Concomitant PTSD and     90
 SUD
------------------------------------------------------------------------
Coordination of PTSD and SUD Care           76
------------------------------------------------------------------------
Substance Use Disorders
------------------------------------------------------------------------
Available Motivational Counseling           76
------------------------------------------------------------------------
Treatment of Patients Awaiting Admission    94
 to Residential SUD Settings
------------------------------------------------------------------------
Inpatient Withdrawal Management             95
------------------------------------------------------------------------
Intensive Outpatient Services for SUD       71
------------------------------------------------------------------------
Buprenorphine Opioid Agonist Therapy        38
------------------------------------------------------------------------
(or) Methadone Opiate Substitution Therapy  20
------------------------------------------------------------------------
SMI and Rehabilitation and Recovery         ............................
 Oriented Services
------------------------------------------------------------------------
MHICM Program if More than 1,500 SMI        100
 Patients
------------------------------------------------------------------------
At Least 4 FTE MHICM Team Members           88
------------------------------------------------------------------------
Presence of a Local Recovery Coordinator
--------------------------------------------93--------------------------
PRRC Program if More than 1,500 SMI         51
 Patients
------------------------------------------------------------------------
Social Skills Training                      74
------------------------------------------------------------------------
SMI Peer Counseling                         60
------------------------------------------------------------------------
Compensated Work Therapy                    90
------------------------------------------------------------------------
Homeless Programs and Incarcerated Vets     ............................
------------------------------------------------------------------------
Arrangements with Community Providers for   93
 Temporary Housing
------------------------------------------------------------------------
At Least One Grant and Per Diem             87
 Arrangement
------------------------------------------------------------------------
VISN Health Care for Reentry Veterans       95
 Specialist
------------------------------------------------------------------------
Integrating Mental Health into Medical      ............................
 Care Settings and in the Care of Older
 Vets
------------------------------------------------------------------------
Integrated MH in Primary Care Clinics       78
------------------------------------------------------------------------
At least 1 FTE Psychologist for 100 Bed     67
 CLC
------------------------------------------------------------------------
FT Psychologist /Psychiatrist HBPC Core     81
 Team Member
------------------------------------------------------------------------
Suicide Prevention                          ............................
------------------------------------------------------------------------
Documentation of a Formal Risk Assessment   95
------------------------------------------------------------------------
Suicide Prevention Coordinator in Place     95
------------------------------------------------------------------------
Evidence Based Treatment                    ............................
------------------------------------------------------------------------
Availability of CPT for PTSD                89
------------------------------------------------------------------------
Availability of PE for PTSD                 63
------------------------------------------------------------------------


                                 
              Prepared Statement of Ira Katz, M.D., Ph.D.,
     Deputy Chief Patient Care Services Officer for Mental Health,
  Veterans Health Administration, U.S. Department of Veterans Affairs
    Good afternoon, Mr. Chairman and Members of the Subcommittee. Thank 
you for the opportunity to discuss VA's progress on meeting the mental 
health needs of our Veterans. I am accompanied today by Dr. Antonette 
Zeiss, Deputy Chief Consultant for Mental Health Services in the 
Veterans Health Administration (VHA), and Mr. James McGaha, Deputy 
Chief Financial Officer for VHA. With the support of Congress, VA has 
received record increases in mental health funding over the past 
several years, doubling our budget from the start of the war in 
Afghanistan to today. During this same time, VA developed and 
implemented the VHA Comprehensive Mental Health Strategic Plan (MHSP), 
and produced the Handbook on Uniform Mental Health Services in VA 
Medical Centers and Clinics to guide the sustained operation of its 
enhanced program. My testimony will address each of these areas today.
    I will discuss VA's recognition of its need to enhance its mental 
health services, and its implementation of substantial enhancements 
within a highly compressed period of time. VA was able to do this 
because of the insight of VHA's senior leadership on the importance of 
mental health and the mental health needs of returning Veterans; the 
allocation of needed funding; and the mobilization of the entire 
system. Unique in America, VA is a provider of health and mental health 
care services, a payer, a policy environment, and a research 
organization. Moreover, coordination throughout the system is supported 
through an electronic health record. It is by aligning actions of all 
of the components of this integrated care system that VHA was able to 
achieve such significant progress.
    In discussing VA's mental health services, it is important to 
provide information on their scale. Of the 5.1 million individual 
Veterans VA treated last year in its medical centers and clinics, 
approximately 1.6 million or 31 percent had a mental health diagnosis 
and 1.1 million or 22 percent were seen in mental health specialty 
care. Last year, VA provided care in ambulatory, residential care, or 
inpatient settings to 442,000 Veterans with a diagnosis of Post-
Traumatic Stress Disorder (PTSD), making care for this condition an 
important part of its mental health program. The scope of the mental 
health needs for returning Operation Enduring Freedom/Operation Iraqi 
Freedom (OEF/OIF) Veterans may be even greater. Of the 400,304 OEF/OIF 
Veterans who received care at VA medical centers and clinics through 
the end of the fiscal year 2008, 178,493 (45 percent) had a possible 
mental health diagnosis, and 92,998 (23 percent) had possible Post-
Traumatic Stress Disorder (PTSD). Among Veterans using VA health care 
services, the rates of mental health conditions and the use of mental 
health services are higher than these rates in the population as a 
whole. This probably suggests that those Veterans who need these 
services are more likely to seek care from VA. These issues are 
discussed below in more detail with respect to Post-Traumatic Stress 
Disorder in Veterans returning from Iraq and Afghanistan.
    My testimony will begin by describing the Mental Health Strategic 
Plan and the Uniform Mental Health Services Handbook. From there, I 
will discuss three additional topics: program funding and metrics; 
other components of VA's overall mental health program; and a sampling 
of success stories, each of which has been made possible because of the 
advances achieved as a result of the Mental Health Strategic Plan and 
the Uniform Mental Health Services Handbook. We recognize these 
accomplishments, but we remain committed to outreach to Veterans who 
continue to suffer from mental health conditions without seeking 
treatment. As a matter of public health, it is important to emphasize 
to those Veterans that VA offers world-class mental health services and 
that Veterans in need of care can and should come to us for safe, 
effective and compassionate care.
Mental Health Strategic Plan and Uniform Mental Health Services 
        Handbook
    The VHA Comprehensive Mental Health Strategic Plan was developed in 
2004 in response to the Department's recognition that its mental health 
programs needed enhancement. This plan helped VA identify gaps in the 
mental health services provided at the local level and to identify 
additional initiatives needed at the national level by reinforcing the 
principle that mental health was an important part of overall health. 
The 255 elements of the Plan could be divided into six key areas: (1) 
enhancing capacity and access for mental health services; (2) 
integrating mental health and primary care; (3) transforming mental 
health specialty care to emphasize recovery and rehabilitation; (4) 
implementing evidence-based care, with an emphasis on evidence-based 
psychosocial treatments; (5) addressing the mental health needs of 
returning Veterans; and (6) preventing Veterans' suicides.
    In 2005, VA began allocating funding for its Mental Health 
Enhancement Initiative. We allocated funds to promote specific programs 
that supported the implementation of the Mental Health Strategic Plan. 
These included:

      extending the mental health services available in 
community-based outpatient clinics (CBOCs), both by increasing the 
staff assigned to these clinics and by promoting telemental health 
services;
      establishing programs integrating mental health services 
with primary care, and with other medical care services including 
rehabilitation, geriatrics, and other medical specialties;
      establishing clinical programs and staff training to 
support the rehabilitation of those with serious mental illnesses in 
ways that help them pursue their own life goals;
      supporting the implementation of evidence-based care with 
a focus on evidence-based psychotherapies for PTSD, Depression, 
Anxiety, and Problem Drinking; and
      developing comprehensive and innovative programs designed 
to prevent suicide.

    VA is currently in the fifth year of the implementation of the 
Mental Health Strategic Plan, and it is a critical time for us to 
evaluate our progress. Substantially more than 90 percent of the items 
in the plan that were aspirations in 2004 and 2005 are now part of 
ongoing operations and clinical practice. Mental Health staffing has 
increased by approximately 4,000 Full Time Equivalents from 14,000 to 
18,000 since 2004. The proportion of America's Veterans who receive 
mental health services from VA has increased by 26 percent, and, over 
the same time, the continuity and intensity of care has also increased. 
For example, VA has modified its standard of care to require immediate 
care in urgent cases and an initial triage evaluation within 24 hours 
after a new request or referral for mental health services, and a full 
diagnostic and treatment planning evaluation within 14 days. We are now 
meeting the 14-day standard more than 95 percent of the time. 
Additionally, the number of outpatient mental health or substance abuse 
visits during the first 6 months after discharge from a mental health, 
substance abuse or dual diagnosis hospitalization increased by 15 
percent or more.
    In 2008, as VA approached the fifth year of the implementation of 
the Mental Health Strategic Plan, its task was to move from a focus on 
rapid transition to one of sustained delivery of a comprehensive array 
of services. This was the impetus for the new Handbook on Uniform 
Mental Health Services in VA Medical Centers and Clinics (the 
Handbook), published in September, 2008. The Handbook establishes 
minimum clinical requirements for VA mental health services at the 
Veterans Integrated Service Network (VISN), facility, and Community 
Based Outpatient Clinic (CBOC) level, and delineates the essential 
components of the mental health program that are to be implemented 
nationally, to ensure that all Veterans, wherever they obtain care from 
VA, have access to needed mental health services. The Handbook 
specifically requires VA to assign a principal mental health provider 
to every Veteran seen for mental health services. This principal 
provider is responsible for maintaining regular contact with the 
patient, monitoring each patient's psychiatric medications, 
coordinating, developing and revising the Veteran's treatment plan, and 
following-up to ensure that the course of treatment reflects the 
Veteran's goals and preferences, and that it is working. The Handbook 
further requires each VISN and medical center to appoint staff 
responsible for working with state, county and local mental health 
systems and community providers to coordinate VA activities and care. 
In this, the goal is to ensure that the each VA facility is functioning 
as a part of its community, as well as a part of the national VA system 
of health and mental health care.
    Other important features of the Handbook include requirements:

      Integrating mental health care into primary care 
settings, other medical care settings, and providing services for older 
Veterans;
      Mandating screening for common mental health conditions, 
with follow-up clinical evaluations for positive screens;
      Expanding first line treatments for substance use 
conditions within primary care and general mental health services;
      Identifying requirements for specialized treatment 
programs for PTSD and for mental health conditions related to military 
sexual trauma;
      Recognizing the need for gender-specific care;
      Staffing for 24-hours-a-day, 7-days-a-week care within VA 
emergency departments;
      Establishing requirements for substance use disorder 
programs and care;
      Employing evidence-based psychotherapies, including 
Cognitive Processing Therapy and Prolonged Exposure Therapy for PTSD 
and Cognitive Behavioral Therapy and Acceptance and Commitment Therapy 
for Veterans with anxiety or depression disorders;
      Reinforcing clear guidelines for suicide prevention 
programs; and
      Addressing the concerns of rural mental health care.

    The Handbook is an important step forward. It is a tool that 
defines the mental health services that must be provided in all 
facilities and must be available to all Veterans. It also consolidates 
requirements for completing and sustaining the implementation of the 
clinical components of the Mental Health Strategic Plan. The Handbook 
guides VISNs and facilities in planning mental health programs and for 
the system as a whole for estimating care needs. It documents standards 
of care that can be translated into monitors for the scope and quality 
of services at each facility and in the system as a whole, while also 
serving as a guide, for Veterans and their families, and as a tool for 
processing treatment planning. Most importantly, the Handbook 
represents a firm commitment to Veterans, their families, advocates, 
and Congress about the nature of mental health services VA is prepared 
to provide to Veterans who need them. It has served as a conceptual 
model to guide planning for an approach to defining uniform health care 
services for the VA system as a whole.
Funding and Metrics
    As discussed above, the VA Mental Health Enhancement Initiative has 
been successful as a catalyst, accelerating the implementation of the 
Mental Health Strategic Plan by augmenting the core mental health 
program funding with a separate funding source of approximately 15 
percent for program enhancements and to support rapid innovations. The 
use of the VA's Mental Health Enhancement Initiative has created a 
partnership between VA Central Office, the VISNs, and the Medical 
Centers to demonstrate our commitment to maintaining the strengths of 
existing programs while at the same time reconfiguring and expanding 
them to meet new standards.
    VA has dedicated dramatically more enhancement funds for mental 
health since FY 2005, increasing from $100 million in FY 2005 to $557 
million in Fiscal Year (FY) 2009. These enhancement funds have 
paralleled overall mental health spending.
    While we are pleased with the increased level of funding, the most 
important concern, however, must be maintaining programs that are 
effectively serving Veterans. At present, VA's goals must be to 
consolidate the gains of the past 4 to 5 years by implementing the 
Handbook and sustaining the operation of mental health services meeting 
this new standard. To achieve these goals, VA will ensure the 
implementation of the requirements of the Handbook at each medical 
center and clinic through a stringent series of monitors and metrics.
    As part of this process, VA is developing methods and metrics for 
assessing the implementation of the Handbook and the outcomes of 
enhanced mental health services. The implementation of the Handbook can 
be divided into four overlapping stages, each monitored through a 
distinct series of metrics.
    The first stage is development of new clinical capacities. This 
will be accomplished through hiring, credentialing, and training new 
staff, and providing them with the space and related supports that they 
need to function. VA will monitor successful recruitment of new mental 
health staff positions and increases in the total number of positions. 
Other monitoring strategies will include identifying specific programs 
(including those for inpatient, residential, and outpatient care and 
those for PTSD, serious mental illness, substance abuse, psychosocial 
rehabilitation, and others) and ensuring they are adequately supplied 
with staff, space and other resources.
    The second stage is the utilization of new capacities by the 
facilities and the use of new or enhanced services by increasing 
numbers of Veterans. VA will monitor this stage by following the number 
of unique Veterans, the number of encounters and access times for 
specific services, as well as overall mental health care.
    The third stage is ensuring the quality of new services. For 
evidence-based interventions, this includes monitors for the fidelity 
of programs to the specifications for the interventions that have been 
found to be effective. In general, this component of the monitoring 
will build upon VA's current program for quality and performance 
monitoring. It will emphasize the integration and coordination of the 
components of care, as well as the quality of the services delivered 
within each component.
    The fourth and final stage will evaluate the change in Veterans' 
treatment outcomes as a result of the impact of services. Increasingly, 
it is apparent that ongoing monitoring for critical outcomes with 
standardized instruments is necessary to both guide clinical 
decisionmaking about the need for modifying care and to support program 
evaluation. VA is developing specific initiatives to establish 
processes for monitoring outcomes for PTSD, depression, substance 
abuse, and serious mental illness.
    Over time, the strongest approach to ensuring ready access to high 
quality mental health services must be based on monitoring the 
structure, processes and outcomes of these services. This will be the 
basis by which VA leadership will hold itself and its facilities 
responsible for mental health services.
Other Components of VA's Overall Mental Health Program
    Although direct mental health services provided in VA's medical 
centers and clinics include an extensive array of services, they are 
only one component of VA's overall mental health programs. Other key 
components include the Vet Center program and the research programs 
supported through the Office of Research and Development.
    VA provides mental health care in several different environments, 
including Vet Centers. There are strong, mutual interactions between 
Vet Centers and our clinical programs. Vet Centers provide a wide range 
of services that help Veterans cope with and transcend readjustment 
issues related to their military experiences in war. Services include 
counseling for Veterans, marital and family counseling for military-
related issues, bereavement counseling, military sexual trauma 
counseling and referral, demobilization outreach/services, substance 
abuse assessment and referral, employment assistance, referral to VA 
medical centers, Veterans Benefits Administration (VBA) referral and 
Veterans community outreach and education. Vet Centers provide a non-
traditional therapeutic environment where Veterans and their families 
can receive counseling for readjustment needs and learn more about VA's 
services and benefits. By the end of FY 2009, 271 Vet Centers with 
1,526 employees will be operational to address the needs of Veterans. 
Additionally, VA is deploying a fleet of 50 new Mobile Vet Centers this 
year that will provide outreach to returning Veterans at demobilization 
activities across the country and in remote areas. Vet Centers 
facilitate referrals to either VBA offices or VHA facilities to ensure 
Veterans have multiple avenues available for receiving the care and 
benefits they have earned through service to the country.
    Collaboration between Vet Centers and VA medical centers at the 
local level is a long established VHA policy. Vet Centers will refer 
Veterans to medical centers or clinics when they have symptoms or signs 
of mental health conditions that have not responded to care in Vet 
Centers; likewise, medical centers and clinics will refer Veterans to 
Vet Centers after successful completion of medical center treatment 
programs to receive social support and after-care services. To address 
these issues, and to strengthen collaborations, the Handbook on Uniform 
Mental Health Services in VA Medical Centers and Clinics includes a 
requirement that, ``Each facility must designate at least one 
individual to serve as a liaison with Vet Centers in the area (if any), 
to ensure care coordination and continuity of care for Veterans served 
through both systems.''
    VA's Office of Research and Development supports well-designed, 
scientifically meritorious clinical trials to examine effective 
treatments for PTSD and other mental health conditions, as well as 
other clinical, health services and pre-clinical research. For years, 
mental health research has been among its top priorities. VA continues 
to serve as a leader in advancing knowledge and treatment for 
psychiatric and behavioral disorders. In 2008, VA's Office of Research 
and Development convened an expert panel to consider the methodological 
issues raised by the 2007 Institute of Medicine report on PTSO 
treatment effectiveness. The VA, the Department of Defense (000) and 
the National Institute of Mental Health (NIMH) have worked together to 
disseminate the guidance offered by the panel for rigorous trial 
designs. VA has used related processes to establish suicide prevention 
as another priority for VA research and to coordinate research 
activities between VA and both DoD and the National Institutes of 
Health. In 2008, a central Data Monitoring Committee has been 
provisioned as a resource to ensure independent assessment and ongoing 
evaluation of clinical trials. Just recently (in 2009), VA jointly 
sponsored two national conferences--one to consider the research agenda 
for the co-morbid mental health conditions in veterans returning from 
Iraq and Afghanistan, and one to define common approaches for research 
in traumatic brain injury and psychological health. These overarching 
efforts will lead to even more significant scientific discoveries for 
mental health.
Successes
    VA can report a number of recent successes in its overall mental 
health programs.
PTSD
    Population-Based Care: The 2008 RAND Report, ``Invisible Wounds of 
War: Psychological and Cognitive Injuries, Their Consequences, and 
Services to Assist Recovery,'' estimated that approximately 14 percent 
of servicemembers who served in Iraq and Afghanistan experienced PTSD. 
Although there may be conches about this estimate, including the 
validity of using a single interview rather than progress over time, 
the accuracy of a screening interview rather than a clinical diagnosis, 
and the nature of the sample selection process. Nevertheless, the 
estimate is in the mid-range of other available figures. For example, 
it is comparable to Milliken's published 2007 findings of positive 
findings from Post Deployment Health Re-Assessment evaluations of Army 
National Guard and Reserve Personnel, but greater than his report from 
active duty servicemembers. It is less than Hoge's published 2004 
survey findings for the Army or Marines in Iraq, but somewhat greater 
than his findings for the Army in Afghanistan. Finally, it is 
comparable to findings from the 2008 report from the Army's Mental 
Health Assessment Team V. In the absence of any definitive information 
on the prevalence of PTSD in the population of returning servicemembers 
and Veterans; it may be interesting to explore the significance of 
these estimates.
    Given that 945,423 Veterans have returned from OEF/OIF through FY 
2008, the 14 percent estimate corresponds to 132,359 returning Veterans 
who may have PTSD. If this is the case, the 92,998 returning Veterans 
with possible PTSD who were seen in VA medical centers and clinics 
represent about 70 percent of the total and the 105,465 who have been 
seen in medical centers, clinics, OJ Vet Centers represent about 80 
percent of the total. If these estimates are correct, VA has already 
seen a significant majority of returning veterans with PTSD. Moreover, 
calculations using these estimates for the rates of PTSD, the total 
number of returning Veterans, and the number of Veterans with PTSD seen 
in VA programs suggest that OEF/OIF Veterans with PTSD are about twice 
as likely to come to VA than those without this condition.
    Evidence-Based Psychotherapy: In 2007, a VA cooperative study 
provided evidence for the efficacy of prolonged exposure therapy for 
PTSD. The Institute of Medicine later included this research in a 
comprehensive review which concluded that the nest established 
treatments for PTSD were prolonged exposure therapy and cognitive 
processing therapy, a different therapy developed by VA investigators 
and classified by the Institute of medicine as also being exposure-
based. Given the importance of PTSD treatment for Veterans, VA 
translated these research findings into clinical care as rapidly as 
possible. Even before the results of the prolonged exposure trial Were 
published, VA was developing large scale training programs for mental 
health providers in both cognitive processing therapy and prolonged 
exposure. To date, over 1,500 providers have been trained in these two 
evidence-based therapies, which are currently being delivered in all 
but eight VA medical centers. Six of these eight have formulated plans 
with milestones and timelines, and the remaining two are receiving 
technical assistance from VA Central Office about developing such 
plans. While experts often bemoan the delay in turning research into 
practice, VA as a health and mental health care system has been able to 
accelerate this process dramatically. In working to ensure these 
advances in clinical practice are translated into public health 
benefits, VA is meeting the needs of Veterans and contributing to 
mental health care everywhere. We have trained enough providers in 
these evidence-based psychotherapies to offer cognitive processing 
therapy or prolonged exposure to OEF/OIF veterans to complete a course 
of treatment. To facilitate this process, VA Central Office has asked 
each VISN to submit plans for making these treatments available to 
returning Veterans with PTSD. The goal is to provide these effective, 
evidence-based treatments already as possible to those Veterans who 
need them. Our hope is that we can prevent much of the chronicity from 
PTSD that has, all too often, affected Veterans from prior eras who 
served before these treatments were developed.
    New Treatments: For years, Dr. Murray Raskin, a psychiatrist at the 
Puget Sound VA Medical Center, has been conducting research on the 
clinical care of older Veterans and on the effects of noradrenalin and 
other stress-related neurotransmitters. As a clinician scientist, he 
also treated Veterans. Based on his clinical wisdom and scientific 
knowledge, he began to suspect that medications that blocked the 
actions of noradrenalin could decrease nightmares and possibly other 
related symptoms in patients with PTSD. To test this hypothesis, he 
used resources from the VA Mental Illness Research Education and 
Clinical Center (MIRECC) in Seattle to conduct a small clinical trial; 
based on early evidence, he found prazosin, a noradrenalin-blocking 
drug already approved for treating hypertension and urinary 
difficulties, appeared to be effective in treating nightmares in PTSD. 
Based on his preliminary findings, he obtained approval from VA's 
Office of Research and Development for a large-scale clinical trial of 
prazosin for PTSD; this study is currently underway. Meanwhile, because 
prazosin is already an FDA-approved drug, many providers are already 
making it available to informed patients with PTSD who continue to 
experience sleep disturbances not responsive to other treatments.
Suicide Prevention
    Much has been said and written about Veteran suicides and VA's 
program for suicide prevention. As part of its overall program, VA has 
been publicizing the availability of the national suicide prevention 
Lifeline (1-800-273-TALK) through advertising and public service 
announcements. The Lifeline is supported by Substance Abuse and Mental 
Health Services Administration in the Department of Health and Human 
Services.
    Case Report: On April 7, a mother was using an Internet video 
conferencing service to talk to her son, who is currently a soldier 
serving in Iraq. During the conversation, the soldier placed a gun to 
his head and threatened suicide. The mother quickly called the National 
Suicide Prevention Lifeline, connected to the Veterans Call Center, and 
used the service to prevent her son's death. The Lifeline contacted 
Military One Source and the Red Cross and arranged for them to notify 
the soldier's unit who intervened while the mother was still watching 
on the Internet. The soldier was taken to an Army hospital in Iraq and 
is currently receiving care. The mother stayed on the line for 
additional counseling.
    VA's strategy for suicide prevention is built upon the basic 
principle that prevention requires ready access to high quality mental 
health care plus programs designed to help those in need access care, 
plus programs designed to identify those at high risk and to provide 
intensified care. This case demonstrates that VA has created resources 
that can promote public awareness and respond to the needs of 
individuals at risk. Evidence for the impact of the overall mental 
health program comes from analyses of suicide rates across VA 
facilities.
    Potential Impact of Mental Health Enhancements: VA has information 
on the causes of death for all Veterans who utilized VHA health care 
services between 2000 and 2006, and it will update its databases when 
new information is available through the Centers for Disease Control 
and Prevention. One significant finding is that there is significant 
variability in suicide rates across facilities; about half of the 
variability can be explained on the basis of the region, geographic 
size, and the nature of patients seen. When VA tested to see if 
differences in suicide rates across facilities could be explained, in 
part, by the nature of the mental health services provided, the closest 
association it found was an inverse relationship between suicide rates 
in a facility and the intensity of the follow-up provided for patients 
with dual diagnoses (both mental health and substance use conditions), 
after they were discharged from inpatient mental health care. This is 
important because this measure of the quality of mental health services 
was among those that were substantially improved in recent years 
through the Mental Health Enhancement.
    Together, these findings begin to demonstrate the complex nature of 
VA's activities in suicide prevention. Prevention utilizes highly 
specific resources that can demonstrate dramatic case reports. But, 
most basically, it relies on a well-functioning health and mental 
health care system. Suicide as an issue demonstrates that mental health 
conditions are real illnesses that can be fatal. It is with this always 
in its mind that VA has been implementing the Mental Health Strategic 
Plan and the Handbook on Uniform Mental Health Services in VA Medical 
Centers and Clinics. VA now and will always continue to enhance and 
sustain its mental health services.
Conclusion
    Thank you again for this opportunity to speak about VA's progress 
in meeting the mental health needs of Veterans. I am prepared to answer 
any questions you may have.

                                 
                    Statement of Christina M. Roof,
    National Deputy Legislative Director, American Veterans (AMVETS)
    Mr. Chairman, Ranking Member Brown, and distinguished Members of 
the Subcommittee, on behalf of AMVETS, I would like to extend our 
gratitude for being given the opportunity to discuss and share with you 
our views and recommendations on ``Charting the VA's Progress on 
Meeting the Mental Health Needs of Our Veterans: Discussion of Funding, 
Mental Health Strategic Plan, and the Uniform Mental Health Services 
Handbook.''
    AMVETS is privileged in having been a leader, since 1944, in 
helping to preserve the freedoms secured by the United States Armed 
Forces. Today our organization prides itself on the continuation of 
this tradition, as well as our undaunted dedication to ensuring that 
every past and present member of the armed forces receives all of their 
due entitlements. These individuals, who have devoted their entire 
lives to upholding our values and freedoms, deserve nothing less, if 
not more.
    Given the extent of the matters at hand, AMVETS has chosen to focus 
primarily on the ``Uniform Mental Health Services in VA Medical Centers 
and Clinics'' (Veterans Health Administration (VHA) Handbook 1160.01, 
September 2008) and its implementation. VHA Handbook 1160.01 was 
designed to incorporate the new minimum clinical standards and 
requirements for all VHA mental health services. It delineates the 
essential components of the mental health program that are to be 
implemented nationally by every Department of Veterans Affairs (VA) 
Medical Center and each Community-Based Outpatient Clinic (CBOC). These 
requirements are to be in place by fiscal year ending September 30, 
2009. May it also be noted that any modifications or exceptions for 
meeting the requirements must be reported to, and approved by, the 
Deputy Under Secretary for Health. All facilities are expected to be in 
full compliance by the date set forth, however AMVETS was unable to 
acquire any data on what the consequences of non-compliance will be.
    Although there is overlap between the ``Mental Health Strategic 
Plan'' (MHSP), developed in 2004 as a 5 year plan of action of over 200 
initiatives, and ``VHA Handbook 1160.1'' VA has used the handbook as a 
more operational approach to organizing all aspects of veterans' lives 
affected by mental health issues, including, but not limited to, 
homelessness, substance abuse, and Post Traumatic Stress Disorder 
therapies. VA has stated that when the handbook is fully implemented 
and all patient care recommendations are in place, that every veteran 
will have ready access to comprehensive, evidence-based care. Mr. 
Chairman, AMVETS believes that VA should be held accountable for 
fulfilling that statement. Never has there been a time when such care 
has been needed. VA/VHA set forth and agreed to that promise of care 
and system improvement and AMVETS strongly believes that this Committee 
should do everything in their oversight to ensure all requirements are 
met by VA/VHA no later than the deadline VA set for themselves, year 
ending FY09.
    AMVETS is fully aware that the handbook is an ambitious 
undertaking; however VA/VHA has had 5 years to implement these changes. 
It is in the opinion of AMVETS that the standards of care set forth by 
the handbook guidelines will dramatically increase the quality of 
mental health care and enhance VA's overall availability, provision, 
and coordination of mental health programs. But only if the handbook is 
implemented correctly, uniformly, and in a timely manner, can the 
result benefit the mental health well-being of our veteran community.
    AMVETS would also like to notify Mr. Chairman and the Subcommittee 
on Health of several inadequacies within the system we have unearthed 
while researching the future of VA health care. These concerns range 
from minor errors to critical errors that we feel could be resulting in 
unnecessary deaths of veterans. Today I will impart to you an overview 
of our findings and recommendations to address each concern.
    As the end of FY09 rapidly approaches, AMVETS fervently believes 
that VA must immediately augment the evaluations of current facilities, 
development and training of staff, and overall outreach efforts to all 
medical facilities and personnel to ensure the timely implementation of 
the handbook's requirements. These basic, yet fundamentally critical 
guidelines will provide the foundation for the stability and 
reliability of the entire VHA mental health care system. Moreover, 
while AMVETS believes that the measures laid out by the handbook should 
have already been uniformly implemented, AMVETS is still very hopeful 
on the success of the handbook and all the agencies involved in this 
undertaking. AMVETS does acknowledge the significant challenges that 
are inevitably faced when transforming a mental health care system. 
However this is not a time for hindrance or hesitations that will 
impede the implementation of a stable and successful uniform standard 
of mental health care.
    On April 6, 2009 the Department of Veterans Affairs Office of the 
Inspector General (OIG) issued Report No. 08-02917-105 entitled, 
``Healthcare Inspection: Implementation of VHA's Uniform Mental Health 
Services Handbook.'' As required by the Military Construction, Veterans 
Affairs, and Related Agencies Appropriation Bill, fiscal year 2009, the 
OIG conducted a review on the progress of the implementation of VHA's 
Mental Health Strategic Plan. Additionally, the Committee was also 
concerned that the VHA policy on the diagnosis and treatment of Post 
Traumatic Stress Disorder (PTSD) had not been uniformly applied as 
directed. These concerns are what prompted this review, thus leading to 
Report No. 08-02917-105.
    OIG affirmed that due to the given dimension of the handbook, a 
comprehensive review of the implementation would be challenging, and 
thus decided to limit their scope of the review to the medical center 
level. In addition, they chose selected items from the handbook to 
evaluate for implementation, which did not include the review of 
suicide prevention-related items. AMVETS also noted that Community 
Based Outpatient Clinics (CBOCs) were not included at all in this 
review. OIG has stated that a separate review of CBOCs is occurring and 
the results of the review will be released in June 2009. AMVETS 
believes that these factors are very important to keep in mind when 
using the data of this review as an overview of the entire plan, and 
will address this later in our testimony.
    The OIG report was compiled of data gathered from 149 of the 171 VA 
medical center sites. In addition, OIG administered web-based surveys, 
comprised of 39 index questions, to be completed by the individual 
medical directors of each of the 171 sites. Of the surveys mete out by 
OIG, they received 138 responses either from the directors themselves 
or a designee. OIG then performed telephone interviews to obtain 
further feedback on the potential barriers to the implementation of the 
UMHS handbook. AMVETS has thoroughly reviewed the OIG's final report 
and is very distressed by many of their findings.
    According to the handbook, regarding community mental health care, 
Veterans Integrated Service Networks (VISNs) and facilities must 
collaborate with Vet Centers in outreach to returning veterans and 
their families. OIG found that 87 percent of the facilities they spoke 
with (138 of 171 or only 81 percent of total VA medical sites) had 
affiliated themselves with at least one Vet Center as laid out by the 
handbook. Unfortunately, OIG also found that 5 percent of facilities 
they interacted with had no affiliations what so ever to a Vet Center. 
AMVETS is very concerned that if OIG found non-compliance in their 
review (composed of only 81 percent of total VA medical facilities' and 
excluding CBOCs) of one of the most basic requirements set forth by the 
handbook, what is occurring at the facilities not included in the 
review? AMVETS finds it absolutely unacceptable that 100 percent of the 
facilities contacted by VA's OIG did not respond to the request for 
review, and respectfully asks the Committee why this was permitted to 
occur, and if it was not permitted what actions have been taken in 
regards to said facilities?
    The handbook also requires that all VHA emergency departments have 
mental health coverage by an independent, licensed mental health 
provider either onsite or on-call, on a 7 day a week, 24 hours basis. 
Additionally, for level 1A medical centers: mental health coverage 
must, at minimum, be onsite from 7 am to 11 pm and VA facilities with 
urgent care centers must have onsite or on-call coverage during their 
times of operation. Of the facilities interviewed by OIG, only 79 
percent had emergency departments. OIG reported that they had initially 
attempted to ascertain the extent of 1A facilities with onsite 
emergency department coverage from 7am to 11pm, but it became clear 
that that many (no specific number given) do not even have the required 
1A emergency departments. Even more disturbing is that many of the 
mental health facilities' directors were not aware that there facility 
level had been changed to 1A. One director suggested to OIG that it 
would be helpful for central office to send all facility Mental Health 
Directors a list of up to date facility level designations so they 
could meet the handbook requirements. If VA/VHA is having difficulties 
in communicating the most basic, yet most critical, information to 
their own facilities as of March 2009, AMVETS respectfully inquires as 
to how VA/VHA plans on implementing an entire mental health care 
handbook? AMVETS also respectfully asks the Committee what steps it is 
taking to ensure the FY09 deadline is met and that veterans will have 
access to the mental health services they need?
    One of the most glaring deficiencies AMVETS observed in OIG's 
report is in regards to ``Issue G: Specialized PTSD Services.'' The 
handbook requires that all VA medical centers have specialized 
outpatient PTSD programs, either a PTSD Clinical Team (PCT) or PTSD 
specialists based on locally determined patient populations needs. It 
is also a requirement of the handbook that every facility have staff 
with training and expertise to serve the Operation Iraqi Freedom (OIF)/ 
Operation Enduring Freedom (OEF) team or PTSD program staff. OIG 
reported that of the VA medical centers surveyed 80 percent reported 
having a PCT and of those 65 percent reported having an OIF/OEF PTSD 
Specialty Clinic. However, AMVETS was made aware of the fact that in 
the smaller facilities a single PTSD specialist that is available in 
that facility was often classified as a ``clinic or program.'' It 
should be noted that these are self reported numbers and AMVETS was 
unable to locate any documentation showing that the reported numbers 
were valid and accurate.
    The handbook also requires that all VISNs must have specialized 
residential or inpatient care programs to address the needs of veterans 
with severe systems and impairments related to PTSD and that each VISN 
must provide timely access to residential care to address the needs of 
those veterans with severe conditions. According to OIG: specialized 
inpatient PTSD programs are unusual, as most PTSD care was moved to 
residential and outpatient basis. The Mental Health Directors surveyed 
reported having a residential PTSD program or inpatient PTSD program at 
only 33 percent of all facilities. Several directors, not included in 
the 33 percent, pointed out that their facilities had reliable access 
to the VISN program, but did not mention the fact that the average 
waiting period before entry into a VISN program was 4-8 weeks, often 
longer. AMVETS finds this completely unacceptable and almost negligent 
due to VA's own evidence that untreated veterans suffering from PTSD 
are more likely to become suicidal or violent. AMVETS measured the 
success and suicide rates among veterans who have had extended waiting 
periods before admittance into a PTSD program versus those who had 
timely access to care and was astounded at the higher rates of suicide, 
substance abuse, and domestic violence among those who were put on VISN 
PTSD waiting lists. Upon further review AMVETS observed that OIG 
presented similar concerns in their May 10, 2007 ``Review of the Care 
and Death of a Veteran Patient--VA Medical Centers St. Cloud and 
Minneapolis, Minnesota.'' AMVETS finds it unfortunate that these trends 
are continuing to be over looked or hindered by either lack of public 
knowledge or funds. What ever the hesitation reasoning is on behalf of 
VA AMVETS respectfully asks the Committee to again use all oversight 
and guidance to prevent any more losses of life, due to non-uniformed 
access to care and the non-compliancy of many VA medical facilities. 
AMVETS recommends the immediate formation of a task force on oversight 
and compliancy to help ensure the integrity and implementation of the 
handbook. Furthermore AMVETS believes that if VA/VHA desires to enact 
the handbook by their self set deadline they will fully support the 
formation of such actions. These are only a few of the observations and 
reports that AMVETS found unacceptable and no where near meeting the 
requirements set by the handbook.
    It has always been the belief of AMVETS that to successfully 
implement change, we must understand the current policy and procedure 
to which change is needed. For without full knowledge and understanding 
all of our efforts are in vein. Our veterans deserve immediate action 
by all parties involved in the implementation of the handbook. We must 
all work together to ensure our veterans mental health care needs are 
fully met.
    Mr. Chairman, this concludes my testimony. I thank you again for 
the privilege to present our views, and I would be pleased to answer 
any questions you might have.

                                 
                    Statement of Hon. Marcy Kaptur,
          a Representative in Congress from the State of Ohio
    I want to begin today by thanking Chairman Michaud and Ranking 
Member Miller for permitting me to join you today to discuss a matter 
that is near and dear to my heart--the mental health of our veterans.
    I have worked on the issue of our veterans' mental health since I 
was a Member of this esteemed Committee during the eighties. I applaud 
your leadership in holding a hearing on this subject, which were few 
and far between during my tenure on the Veterans Affairs Committee.
    Throughout my career, our Ohio office has been ably staffed by a 
Vietnam veteran, Dan Foote, who handles an enormous veteran's caseload 
among many other issues.
    Dan shared this story with me, and I want to share it with you:

          It is not unusual to have 5-8 phone messages on his voice 
        mail at least once a week. One constituent, Tom, a Vietnam 
        veteran who was a mechanic and a door gunner, medicates himself 
        with alcohol starting around 7 or 8 p.m. and will drink well 
        into the night.
          Tom's first call usually is a thank you call for assisting 
        him in obtaining his air medals from his 12-month service in 
        Vietnam in the late 60's. As the night wears on, Tom's phone 
        messages become garbled and unclear and around 3:00 a.m., his 
        calls are incoherent. Tom finally sleeps and the messages end 
        until next time.
          Tom is one of many Vietnam Vets treating their PTSD with 
        alcohol. The trauma of war was so severe they use alcohol to 
        numb the feelings in order to get through the day or night. Tom 
        has told my staff, `When you lay down at night the demons 
        come.' Alcohol chases away the demons if only for a few hours 
        or a night.
          In 1967, Tom, arrived in Vietnam. As a helicopter mechanic he 
        was assigned to an Aviation Unit. Tom's first challenge was to 
        learn to fire the 60 mm machine guns mounted in the cargo doors 
        of the Bell Huey chopper. A crew took him over the South China 
        Sea to practice shooting and on their way back inland to their 
        base the pilot spotted five Vietnamese running on the beach and 
        into the jungle.
          The pilot ordered the newest crewmember to open fire on the 
        Vietnamese assuming they were Viet Cong (Communist Guerillas). 
        The ship landed to search for weapons and intelligence only to 
        find a mother, father and three children dead from the machine 
        gun fire. This occurred in his first week in Vietnam.
          Tom has never been the easygoing teenage auto mechanic that 
        left Toledo, Ohio, in 1966. His life can best be described as a 
        soldier who has never come home from Vietnam.
          Tom receives VA services to include counseling and 
        psychiatric services, but medical science still must do more. 
        Tom's service to his Nation was 42 years ago. His treatment and 
        suffering continue.

    Tom, and every other Veteran in my district and across the country, 
inspires work we have championed to support research in the 
understanding and treatment of PTSD and other neuropsychiatric war 
wound that can onset at any time during or post conflict. We must give 
proper care to those who have valiantly served their Nation. I know the 
Commander of the Ohio Purple Hearts would not mind my sharing with you 
that he suffers from PTSD and tinnitus for going on 40 years. His best 
buddy took his own life.
    From September 11, 2001, until March 2009, our Nation has asked new 
generation to American military service men and women to serve 
including 401,840 Army National Guard Soldiers.
    Dr. Milliken, of Walter Reed Army Hospital, recently reported that 
of 88,000 soldiers returning from Iraq, 20 percent of the active 
component and 42 percent of the reserve component had mental health 
concerns requiring treatment within 6 months of returning from combat. 
Our men and women are returning with deep scars that are not seen.
    Why people develop PTSD is clear--you have to experience a trauma. 
Why the majority who experience a trauma do not develop PTSD and appear 
resilient is not understood. In order to reduce the immediate and long-
term human and economic costs of this disorder, additional research is 
essential. Furthermore, it is essential that neuropsychiatries are 
included on the VA's peer review panels that review VA mental health 
research proposals and that we increase the training and preparation of 
neuropsychiatric nurses.
    Currently, a Congressionally directed, Department of Defense 
landmark assessment of Ohio Guard veterans and soldiers is underway to 
detect or prevent neuropsychiatric war wounds associated with modern 
warfare. This 10-year prospective follow-up study represents the first 
ever detailed long-term study of mental health of the same soldiers.
    Associated with this research will be the largest epidemiological 
DNA sampling of our 3,000 veterans and family members known to this 
field of science.
    Studies such as these are vital to the continued care of our 
Nation's service men and women and our veterans. We know that science 
can unlock hidden passages of the brain and nervous system. We must 
maintain a course of care for those who have borne the battle and 
pledged their lives to our Republic.
    Thank you for your leadership in convening this critical hearing so 
America can provide the promised care they have so nobly earned.

                                 
               Statement of Christine Woods, Hampton, VA,
           Former Program Specialist and National Consultant,
       Office of Mental Health, Veterans Affairs Central Office,
                  U.S. Department of Veterans Affairs
    Mr. Chairman and Members of the Subcommittee, thank you for the 
opportunity to submit a statement for the record regarding VA's 
progress toward meeting the mental health needs of America's veterans. 
My testimony will convey both broad and specific insights that I 
believe will ultimately assist the Department of Veterans Affairs. I 
will primarily focus on aspects of the Mental Health Strategic Plan 
(MHSP) designed to ensure that VA Mental Health is Veteran and Family 
Driven. Goal #2 of the MHSP calls for transformation of VA's mental 
health system to a recovery-orientation, based on recommendations of 
the President's 2003 New Freedom Commission Report, which itself, 
stemmed from groundbreaking findings of the 1999 Surgeon General's 
Report on Mental Health.
Background
    As a bit of background from which my personal insights are gleaned: 
Prior to my retirement in 2007, I worked nearly 30 years for the 
Department of Veterans Affairs; the last sixteen of which were as a 
Program Specialist in the VACO Office of Mental Health Services (OMHS). 
In the early 1990's, I led the development of VA's most comprehensive 
and effective psychosocial residential rehabilitation program; followed 
by VA's conversion of traditional inpatient psychiatry units to 
residential rehabilitation and treatment programs. In response to the 
1999 Surgeon General's Report on Mental Health, I began promoting (in 
2000) the concept of ``recovery'' in the VA Mental Health System, which 
led to the establishment and recent funding of Psychosocial 
Rehabilitation and Recovery Centers, incorporation of Peer Support 
positions as VA staff, and plans for system-wide transformation to a 
recovery-orientation of VA mental health services. Most of these 
initiatives were often characterized as ``can't be done in VA''; and it 
would be an understatement to say that promoting the ``concept of 
recovery'' for those with the most serious mental illnesses was ``a 
tough sell'' in the OMHS. But, the need was obvious; and with the 
support of the (then) VA Committee on Care of Veterans with Serious 
Mental Illness, the President's New Freedom Commission, and the Mental 
Health Strategic Planning process, the opportunity was within reach by 
2005.
    While in VACO, I also worked on a number of systems-related 
initiatives associated with mental health information management and 
quality improvement activities. Most directly related to this hearing, 
I served as the initial mental health liaison for CARF Accreditation of 
VA Mental Health programs, and as a key mental health representative 
for Decision Support System (DSS) mapping for capture of mental health 
workload and costs. I also chaired and/or was a member of Mental Health 
Strategic Planning workgroups on Employment, Family Psychoeducation, 
Peer Support and Residential Rehabilitation Services, as well as Anti-
Stigma, Knowledge Management, and Recovery Transformation planning.
VA Progress to Date:
    I wish for my testimony today to appropriately acknowledge the 
significant accomplishments of the Department of Veterans Affairs in 
initiating and funding a number of new mental health programs and 
initiatives over the past few years. VA's current Uniformed Mental 
Health Services Handbook (UMHSH) details expectations to fill many 
longstanding gaps in care. It describes more integrated care 
approaches, and more comprehensive rehabilitation services. Several 
evidence-based and emerging best practices are beginning to be 
implemented; and VA is even hiring people with a history of mental 
illness to incorporate peer support into more traditional mental health 
services. These efforts should by all means be roundly applauded.
    Yes, despite these positive accomplishments, I believe the 
effectiveness of all mental health services remains at serious risk 
until the culture of VA mental health services is transformed to a 
recovery-orientation. Long-held attitudes, beliefs, and resulting 
clinical and administrative practices remain barriers, both to 
encouraging veterans to access mental health services, and to their 
achievement of the positive outcomes that should be expected. It is 
important to note that the true success of these new services should 
not be measured in their mere existence, or in the amount of funding 
distributed to make them operational. Their success should not even be 
exclusively measured by the degree to which they are evidence-based or 
recovery-oriented--although those measurements are necessary to chart 
VA's progress. But, the true measure of accountability for VA mental 
health services is the extent to which veterans actually experience 
recovery: that is, the extent to which each veteran with mental health 
challenges has the ability to live a fulfilling, productive life in the 
community, even with a mental health condition that may elude a full 
``cure.''
Concern Regarding the Uniformed Mental Health Services Handbook 
        Replacing the Mental Health Strategic Plan
    I believe it is important to highlight for the Subcommittee some 
serious concerns regarding VA's Uniform Mental Health Services Handbook 
(UMHSH), and in particular, how this document states that ``when fully 
implemented, these requirements will complete the patient care 
recommendations of the Mental Health Strategic Plan. . . .'' It is my 
intention to demonstrate, through some specific examples, how the UMHSH 
lacks incorporation of many of the most important MHSP recommendations 
necessary to achieve the patient care goals of a recovery-oriented, 
veteran and family driven mental health system.
    Important facility-level MHSP patient care recommendations not 
reflected in the Uniform Guidelines are in the key areas of:

      Mental health leadership composition,
      Issuance of policy and procedural guidance, and
      Use of standardized metrics to measure both VA's progress 
in meeting the recovery-oriented transformational changes called for in 
the MHSP, and for measuring the actual recovery outcomes of veterans 
served by the VA MH system.

    These, and other, specific MHSP recommendations are not only 
inadequately conveyed in the UMHSH, but, in some cases are abandoned or 
even contradicted. One must question if unprecedented mental health 
enhancement funding for new recovery-oriented programs and initiatives 
can be expected to achieve desired outcomes without the associated 
leadership enhancement, new policy infrastructure, and perhaps most 
importantly, the charting of progress toward those outcomes.
    Certainly, in any three to 5-year strategic planning process some 
recommendations may, over time, be determined to be unnecessary, or 
even ill-advised. Additionally, expansive goals which are as 
transformative as Goal #2 of the MHSP will generally require additional 
detailed planning to facilitate implementation. Indeed, a number of 
specific recommendations to further realize the goal of a Veteran and 
Family Drive Mental Health System were developed by the Recovery 
Transformation Workgroup in March of 2005. (RTWG 2005).
    Ensuring that VA Mental Health is Veteran and Family Driven may 
well be considered the most transformative and over-arching goal of the 
MHSP. The Center for Mental health Services' premier issue of Mental 
Health Transformation Trends (March/April 2005) defines transformation 
as ``a deep, ongoing process along a continuum of innovations.'' This 
document further emphasizes that ``Transformation implies profound 
change--not at the margins of a system, but at its very core. In 
transformation, new sources of power emerge. New competencies develop. 
When we do transformative work, we look for what we can do now that we 
couldn't do before.''
    VA Mental Health Leadership Composition is perhaps the most obvious 
and critical example of incomplete mental health strategic plans. The 
MHSP recommendation to appoint a permanent veteran mental health 
consumer in the VACO Office of Mental Health Services, to represent the 
unique perspective of veterans served, remains a critical step not yet 
taken. In addition to requirements for Facility Consumer Councils, the 
Recovery Transformation Workgroup further recommended that, at the 
facility level, ``veteran consumers and family representatives should 
participate in facility mental health leadership meetings and 
participate in decisionmaking about program changes.'' Leadership, 
after all, drives systems, and transformational change requires ``buy 
in,'' clear messaging, and modeling from the highest leadership levels.
    One must question how a Veteran and Family Driven System can be 
achieved if veteran mental health consumers and their family members 
have no seat at the leadership table. Yet, the Uniform Mental Health 
Services Handbook (UMHSH) only ``encourages'' Facility Consumer 
Councils, and fails to include any mention of veterans or their family 
members being represented on Facility Mental Health Executive 
Leadership Councils. Clearly, these Leadership Councils have an impact 
on patient care services. To quote from the UMHSH, these Councils are 
responsible for: ``reviewing the mental health impact of facility-wide 
policies that include but are not limited to policies on patient 
rights, privileges, and responsibilities; restraints and seclusion; 
management of suicidal behavior; and management of mental health 
emergencies,'' and ``proposing strategies to improve care and consult 
with management on methods for improving innovation in treatment 
programs.'' Removing the requirement for veteran mental health 
consumers to be represented at the VACO and Facility levels represents 
a significant disregard for the most powerful means by which a Veteran 
and Family Driven System can be realized. This apparent indifference to 
the value of veteran/family participation in leadership suggests that 
the VA mental health system has still not made meaningful progress 
toward becoming a system that is driven by the expressed needs of 
veterans and their families--the individuals for whom the very system 
exists.
    In fact, Veteran Services Organizations (VSOs) and other advocacy 
groups have actually lost influence in organizational oversight of VA's 
Mental Health Services since approval of the Mental Health Strategic 
Plan. Prior to December 23, 2005, VSOs, professional organizations, and 
consumer advocacy groups were generally considered full (although non-
voting) members of the VA Committee on Care of Veterans with Serious 
Mental Illness, which met face-to-face, bi-annually, for 2-3 days each 
year. However, with the December 2005-appointment of the current SMI 
Committee Chair, and replacement of all VA Committee members (except 
one), VSO's and other advocates have since been afforded only a half 
day of participation in one meeting each year. This diminishing of 
veteran and consumer advocate participation has resulted in denial of 
their opportunity to participate in the Committee's full discussion of 
issues or even to observe formal decisionmaking.
    Clear operational policies and procedures are required in all 
healthcare systems, especially to guide major cultural and operational 
changes. VA's Mental Health Strategic Plan included action items 
requiring the issuance of broad conceptual guidelines for new 
initiatives, to be further followed by detailed policies and 
procedures. Content for many such documents was outlined in the 
Recovery Transformation Work Group Report (RTWG 2005). In many 
instances these recommended policies even had targeted dates of 
issuance to chart a detailed course for strategic implementation. Yet, 
despite nearly 5 years and millions of dollars expended, these policies 
and procedures for totally new initiatives, such as the work of the 
Recovery Coordinators, and the integration of Peer Support services, 
have yet to be issued. While the Uniform Mental Health Services 
Handbook (UMHSH) details requirements for facility-level mental health 
services, these facilities lack the detailed policies, procedures, and 
other necessary infrastructure to actually meet these requirements.
    Likewise, the new Psychosocial Rehabilitation and Recovery Center 
(PRRC) programs were carefully designed to not only minimize the well 
known ``silos effect'' of traditional VA mental health programs. They 
were intended to actually integrate fragmented services and incorporate 
the fundamental elements and guiding principles of recovery-oriented 
system, i.e., those of being truly person-centered, consumer empowered, 
self-directed, holistic, etc. Yet, without clear operational 
guidelines, these new Recovery Centers (while expanding needed 
services) run the risk of becoming ``more of the same'' rather than the 
hub of integrated, recovery-oriented services that demonstrate the 
transformational change envisioned by the President's New Freedom 
Commission.
    Standardized metrics for baseline, continuous quality improvement 
monitoring, and ultimate goal attainment represents another standard 
tool used in systems transformation. Metrics for use by the Office of 
Mental Health Services (OMHS) were well delineated in the Recovery 
Transformation Work Group (RTWG) report. For example, recommendations 
to guide and monitor the utilization of Local Recovery Coordinator 
(LRC) positions included tracking methods and reporting requirements to 
facilitate national monitoring of LRC achievement of goals. These goals 
included, but were not limited to: appointment of ``local champions'', 
consumer-led anti-stigma and educational activities, veteran/family 
representation in mental health leadership, establishment of consumer/
advocate liaison councils, implementation of individual recovery plans, 
etc.
    Equally important, a rigorous professional review of validated 
recovery measures was conducted, resulting in the selection of measures 
to be used for charting VA progress. (See appendix for full references) 
These included measures of staff competency to deliver recovery-
oriented services (CAI 2003), veteran and staff perceptions of the 
system's recovery-orientation, (ROSI 2005 & RSA 2005, respectively) and 
veteran self-reported measures (MHRM 1999) designed specifically to 
focus on his/her individual recovery. Some specific indicators 
encompassed in these measures include: degree of consumer choice and 
self-determination, activities geared toward expanding social networks 
and social roles, staff attitudes and philosophy toward recovery, etc. 
As noted in the RTWG report, ``these attitudinal and structural changes 
are critical first steps in supporting a system wide transformation. . 
. . This major undertaking will only be successful when it is clearly 
coordinated by strong (OMHS) leadership . . . and local efforts are 
held accountable to the national implementation plan. . . .''
    While different measures may have since been determined to be more 
suitable for use in charting VA systems transformation and veteran 
self-perception of recovery/quality of life, the UMHS Handbook makes no 
mention of these facility-level recovery assessment functions. No such 
measures have yet to be employed for even a baseline assessment of the 
recovery-orientation of the VA's mental health system.
    As I acknowledged previously, I appreciate that times change, and 
so do specific strategic plans. However, if VA is to achieve its stated 
goals of the MHSP--indeed, to successfully achieve the Department's 
primary mission--then transformational change is required. The VA has 
had the opportunity to make profound change over the past decade--and 
has even had the mandate to do so over the past (nearly) 5 years. The 
MHSP charted a course for VA transformation to an evidence-based, 
recovery-oriented, veteran and family driven mental health system. Yet, 
contrary to VA's testimony before your Subcommittee, this 
transformational change appears to be far from ``90 percent complete.'' 
Our Nation's veterans, and their families (as well as patriotic 
Americans indebted to them for their service and sacrifice) are seeing 
hope for VA transformational change slipping away. Regrettably, for 
some, whose lives or loved ones have been lost to the hopelessness that 
results in suicide, it is already too late. . . . But for millions, 
there is still time to ``achieve the promise.''
Suggestions for Moving Forward:
    Changing the organizational culture of a huge bureaucracy is 
difficult work that takes years to achieve, even with the strongest 
leadership, the best infrastructure, and a carefully charted course 
that is closely monitored. Considerable resources have been directed 
toward VA mental health becoming a recovery-oriented, veteran and 
family driven system. However, the most essential infrastructure for 
transforming the system is missing. Absent these cornerstone elements, 
issuance of the UMHS Handbook may only complicate the way forward by 
its failure to adequately support the goal for a veteran and family 
driven mental health system. Given these circumstances, the following 
recommendations are offered to assist the Subcommittee in re-directing 
VA toward Goal #2 of the MHSP before the window of opportunity for true 
transformation closes completely:
    1. Establish an Office of Mental Health Recovery and Resiliency 
Initiatives (suggested within the Office of the Assistant Secretary for 
Public and Intergovernmental Affairs--or similar to that of VA's 
Homeless Initiatives). This office would:
        a. Ensure that VA's Mental Health Recovery Transformation has 
        the internal external priority, and public affairs visibility, 
        to be effectively re-initiated, through the strength of 
        leadership associated with the Office of the Secretary of 
        Veterans Affairs.
        b. Ensure that VA's effective Federal Partnership Activities 
        include equal inclusion of recovery and resiliency initiatives 
        to facilitate full collaboration with other Federal Agencies, 
        State and Local governments and broad community resources. This 
        collaboration will maximize VA and community resources to 
        foster successful community re-integration of newly returning 
        OEF/OIF veterans as well as veterans of previous eras who have 
        become psychologically dependent on the traditional VA mental 
        health system.
        c. Assist the National Recovery Coordinator to convene an 
        ``expert panel'' for revisiting (and updating) Mental Health 
        Strategic Plans associated with stigma reduction and recovery-
        orientation. Immediate special attention should be directed 
        toward:
                i. the involvement of veterans and their families in 
                the design, delivery, and evaluation of mental health 
                services,
                ii. national policy development for all new recovery 
                programs and initiatives, and
                iii. the application of metrics to measure progress of 
                system transformation as well as the progress toward 
                meeting the individual and collective needs and outcome 
                goals of veterans for whom the VA mental health system 
                exists.
    2. Realign the National and Local Recovery Coordinator positions to 
function as direct advisors to the highest levels of mental health 
leadership. In this capacity, they will serve as both a ``recovery 
lens'' for viewing the implications of all mental health clinical and 
administrative practices, and as a ``recovery filter'' for ensuring 
that any future impediments to transformational change are caught 
early, brought to the attention of mental health leadership and then 
addressed, as needed, by the (above-recommended) Office of Mental 
Health Recovery and Resiliency Initiatives.
    3. Implement MHSP recommendations to recruit a permanent veteran 
mental health consumer as staff to the VACO OMHS to represent the 
unique veteran consumer perspective in all OMHS endeavors, and to 
require both Facility Consumer/Family Councils and veteran consumer and 
family representation on Facility Mental Health Executive Councils.
    4. Conduct a serious inquiry into the multi-faceted organizational 
value of utilizing the clinical capabilities of VA's Decision Support 
System (DSS) to inform the Office of Mental Health Services (and 
ultimately the Subcommittee) on the provision of VA mental health 
services. In addition to capabilities briefly listed below, this 
suggestion proposes transitioning the OMHS' existing focus on mental 
health program-evaluation to a new focus on veteran outcomes of an 
integrated healthcare delivery system. VA's Decision Support System 
(DSS) could be utilized for mental health services to:
        a. Measure outcomes-based performance and the effectiveness of 
        healthcare delivery processes,
        b. Benchmark VA comparative aggregate data at network or 
        national levels,
        c. Provide information on a corporate roll-up of both financial 
        and clinical information, to include (but not be limited to) 
        monitoring the provision of evidence-based practices, through 
        ``products'' delivered in accordance with clinical practice 
        guidelines.
    Indeed, these recommendations represent profound change-- not at 
the margins, but at the core of VA Mental Health Services. I believe 
all are of equal importance, but they are listed in suggested priority 
order. Transparency for strategic plan implementation and 
accountability for veteran mental health outcomes can no longer be 
bogged down by the ``strongholds of the status quo.'' More than a great 
slogan, ``Putting Veterans First'' must lead the way forward.
Overcoming Current Barriers to Family and Peer Support Services:
    New perceived barriers, such as requiring Title 38 provisions for 
the hiring of Marital and Family Therapists, and new clinic stop codes 
for peer and family services, are among the most recent examples of the 
Department seemingly resisting change, rather than facilitating it. 
These cited barriers to meeting the mental health needs of veterans and 
their families are either demonstrations of organizational reluctance, 
incompetence, or worse. . . .
    It is true that Title 38 authorities should ultimately be sought 
for Marital and Family Therapists. However, as a rapidly increasing 
number of new veterans' families are experiencing unprecedented 
hardship and stress, these Congressionally mandated therapists can be 
employed by VA under Title 5 Position Classifications. Aggressive 
hiring could be well underway-- a full 2 years after a law requiring 
it. As for clinic stop codes: VA's VERA system reimburses VISNs based 
on diagnosis and complexity of care required, not on workload capture 
in particular therapist or non-professional clinic stop codes. Adding 
new evidence-based services such as Family Psychoeducation or Peer 
Support are actually more likely to reduce costs in the 2-year VERA 
funding cycle than to increase them. Also, establishing unique clinics 
for delivery of each new mental health service is a process wedded to 
the Cost Distribution Reporting system that was replaced nearly a 
decade ago. Requiring new clinic stop codes for peer and family 
services only further invests the OMHS in the past, rather than 
ushering in the more transparent and clinically informative Decision 
Support System of the present and future.
Informing the Future: National Vietnam Veterans Readjustment Study 
        (NVVRS) and Future VA Mental Health Oversight:
    As VA charts progress on its efforts to improve current and future 
mental health care, it is my impassioned belief that as a society, our 
Nation can now best honor VA psychologically dependent Vietnam Veterans 
by fostering their community integration with the dignity and respect 
they've so often been denied. Congress should ensure that VA take 
immediate action to comply with PL-106-419, requiring completion of the 
National Vietnam Veterans Readjustment (aka ``Longitudinal') Study to 
ensure that the lessons learned from their ``Long Journey Home'' are 
used to at least inform our Nation's moral response to newly returning 
OEF/OIF Veterans and their Families. Completing this study will not 
only assist Vietnam Veterans of America (VVA) in fulfilling their motto 
of ``Never Again Will One Generation of Veterans Abandon Another,'' but 
it will forever document the true costs of modern warfare on our 
military personnel, their families, and American society as a whole.
    Concurrently, VSOs and new veteran coalitions, family members, and 
consumer advocacy groups should have equal membership (in numbers and 
voting rights) on VA Oversight Committees such as VA's Committee on 
Care of Veterans with Serious Mental Illness. This long-overlooked need 
for system-wide veteran empowerment, self-determination, and oversight 
will ensure that VA's Mental Health transformation to a Veteran and 
Family Driven System actually occurs. Now is the time for new sources 
of power to emerge; for new competencies to develop. It is the time to 
do transformative work.
Summary:
    My testimony brings me full circle to VA work I did back in the 
early eighties when, as a Personnel Staffing Assistant at the Hampton 
VA Medical Center, I began working daily with veterans, primarily of 
the Vietnam Era. Many of these veterans were not only unemployed, but 
by the 1980's they had poor employment histories, substance abuse and 
mental health problems, marital and legal issues, and were often 
homeless or at high risk of homelessness. Many were living in the 
Hampton Virginia Domiciliary, or cycling through the Inpatient 
Psychiatry Unit.
    It was at that time I realized the VA mental health system needed 
to do more than reduce symptoms of mental illness, or help veterans 
achieve sobriety. The system also needed to assist veterans (and their 
families) with the complications of these disorders: problems with 
employment, housing, social, legal, financial issues, etc. And equally 
important, I've believed since then that if our country ever became 
involved in another Vietnam-like conflict, the VA needed to be a place 
where veterans would want to come--with their families--and to come as 
a first, rather than a last resort. It would be a place where they felt 
heard, empowered to determine their future; and a place with a track 
record of positive outcomes. Every war era is a bit different, but the 
many ``lessons learned'' from the Vietnam Era should inform the current 
VA mental health system--lessons about what worked, and what didn't. 
The Vietnam Vet Centers brought veterans in, (in part) because they 
were designed by Vietnam Veterans and therefore offered convenient, 
relevant, veteran and family driven services that supported community-
living, and offered empathy and hope. This important lesson, combined 
with the findings of renowned scientific studies and ``blue ribbon'' 
commissions should chart the course for the current and future VA 
mental health system. Such a system would go a long way toward reducing 
the long-term, intergenerational consequences of delayed post-
deployment readjustment services for new OEF/OIF veterans and their 
families.
    VA has made considerable progress with many aspects of the Mental 
Health Strategic Plan. As I stated earlier, this progress should be 
roundly applauded. Herein, however, I've provided only a sampling of 
mental health strategic plans seemingly gone awry; and only a few new 
recommendations for getting back on track 5 years later. The 2004/2005 
concerted effort to impede VA's provision of evidence-based peer 
support services is perhaps testimony for another time or another 
Subcommittee. For now, I offer these insights to the Subcommittee on 
Health to help ensure the transformative work of the Mental Health 
Strategic Plan is, in fact, ``90 percent completed.'' I admire the 
Subcommittee's commitment to ensuring VA mental health services 
facilitate recovery and build veteran and family resilience to face 
life's challenges. Much of the planning and initial work is already 
done. It will need review, minor refinement and stronger leadership. 
But we (largely) know the way. We have the tools. We need only the 
will--the moral compass--to transform the VA system to meet the mental 
health needs of America's Veterans and their Families.
    The road ahead for today's Wounded Warriors and their families will 
also be a ``Long Journey Home,'' and sadly some will not make it 
successfully. However, through full implementation of the Mental Health 
Strategic Plan, we have the opportunity to prevent another generation 
of wounded warriors from falling through the cracks of a fragmented VA 
mental health system that ``is not oriented to the single most 
important goal of the people it serves--the hope of recovery'' (Interim 
Report of President's New Freedom Commission).
    Again, I extend my sincere appreciation to the Chairman, Members 
and Subcommittee staff for inviting my testimony on Charting VA's 
Progress on Meeting the Mental Health Needs of Veterans. I would be 
honored to be of further service as you pursue this important work. To 
quote from President Theodore Roosevelt: ``This is work worth doing.''
Appendix
References
Competency Assessment Instrument (CAI):
    Chinman, MJ, Young, AS, Rowe, M, Forquer S, Knight, E, Miller, A. 
(2003). An instrument to assess competencies of providers treatment of 
severe mental illness. Mental Health Services Research, 5,97-108.
Mental Health Recovery Measure (MHRM):
    Young, S.L., & Ensing, D.S. (1999). Exploring recovery from the 
perspective of people with psychiatric disabilities. Psychiatric 
Rehabilitation Journal, 22, 219-231.
Recovery Self-Assessment--Provider Version (RSA):
    O'Connell, M., Tondora, J., Evans, A., Croog, G., & Davidson, L. 
(2005). From rhetoric to routine: Assessing Recovery-oriented Practices 
in a State Mental Health and Addiction System. Psychiatric 
Rehabilitation Journal, 28 (4), 378-386.
Recovery-Oriented Services Indicators (ROSI):
    Dumont, J.M., Ridgway, P., Onken, S.J., Dornan, D.H., & Ralph, R.O. 
(2005). Mental health recovery: What helps and what hinders? A national 
research project for the development of recovery facilitating system 
performance indicators. Phase II technical report: Development of the 
recovery oriented system indicators (ROSI) measures to advance mental 
health system transformation. Alexandria, VA: National Technical 
Assistance Center for State Mental Health Planning. Soon available 
online through the NTAC Web site: http://www.nasmhpd.org/ntac.cfm.
    Interim Report of President's New Freedom Commission (2002)
    President's New Freedom Commission Report--Achieving the Promise: 
Transforming Mental Health Care in America (2003).
    United States Public Health Service Office of the Surgeon General 
(1999). Mental Health: A Report of the Surgeon General. Rockville, MD; 
Department of Health and Human Services., U.S. Public Health Services.
    Recovery Transformation Workgroup Report, dated March 31, 2005. 
(Unpublished-- DVA internal document), Bellack, A., Losonczy, M., et al
    Substance Abuse and Mental Health Services Administration, Center 
for Mental Health Services (2005) Mental Health Transformation Trends--
A Periodic Briefing. Department of Health and Human Services, U.S. 
Public Health Services.

                                 
                   MATERIAL SUBMITTED FOR THE RECORD
                                     Committee on Veterans' Affairs
                                             Subcommittee on Health
                                                    Washington, DC.
                                                        May 5, 2009

Honorable Eric K. Shinseki
Secretary
U.S. Department of Veterans Affairs
810 Vermont Avenue NW
Washington, D.C. 20240

Dear Secretary Shinseki:

    Thank you for the testimony of Dr. Ira Katz, Deputy Chief Patient 
Care Services Officer for Mental Health of the Veterans Health 
Administration at the U.S. House of Representatives Committee on 
Veterans' Affairs Subcommittee on Health Oversight Hearing on 
``Charting the VA's Progress on Meeting the Mental Health Needs of Our 
Veterans: Discussion of Funding, Mental Health Strategic Plan, and the 
Uniform Mental Health Services Handbook'' that took place on April 30, 
2009.
    Thank you again for taking the time to answer these questions. The 
Committee looks forward to receiving your answers by June 16, 2009.

            Sincerely,

                                                HENRY E. BROWN, JR.
    MICHAEL H. MICHAUD
                                                     Ranking Member
    Chairman
                               __________
                        Question for the Record
              The Honorable Michael H. Michaud, Chairman,
        The Honorable Henry E. Brown, Ranking Republican Member,
      Subcommittee on Health, House Committee on Veterans' Affairs
                             April 30, 2009
                     Charting the VA's Progress on
            Meeting the Mental Health Needs of Our Veterans:
 Discussion of Funding, Mental Health Strategic Plan, and the Uniform 
                    Mental Health Services Handbook
    Question 1: How does the VA develop the funding it needs for mental 
health services and the Mental Health Initiative? Specially, what 
factors are considered in developing the funding level that's required 
to meet the mental health needs of Veterans? And what are your thoughts 
on DAV's recommendation for the VA to develop an accurate demand model 
for mental health and substance-use disorder services?

    Response: The Department of Veterans Affairs (VA) believes that it 
has an accurate demand model for mental health and substance use 
disorder services and a robust approach to developing funding for 
mental health services. In the fiscal year (FY) 2010 budget, VA 
requested $4.6 billion to expand inpatient, residential, and outpatient 
mental health programs. This represents an increase of $288 million 
over the FY 2009 funding level.
    Each year, VA assesses the expected demand for inpatient and 
ambulatory medical services based on its most recent experience for 
both VA and fee-based care provided to enrolled Veterans. Projections 
are updated to reflect the changing demographics of the enrolled 
Veteran population, including factors such as aging, priority group 
transition and geographic migration. VA also conducts a rigorous review 
to understand health care trends in VA, which impact the number of 
services and the expected cost of providing these services to enrolled 
Veterans. VA has also conducted a detailed analysis to understand the 
expected impact of expanding Priority Group 8 enrollment eligibility.
    The mental health modeling assumptions used by the VA enrollee 
health care projection model, which supports the VA budget development 
process, are developed annually by subject matter experts on a VA 
workgroup. This workgroup determines policy goals for VA mental health 
programs, which are then incorporated into the assumptions for the 
model. The adjustments to the model needed to achieve these goals are 
phased in over a multiple year timeframe, depending on the time needed 
to build the capacity for the particular service.
    Since the beginning of FY 2009, a newly formed group of subject 
matter experts has been reviewing the adjustments that were 
incorporated into the model by earlier workgroups. This review was 
guided in large part by anticipated changes in the delivery of mental 
health and substance use treatment services as articulated in the 
Veterans Health Administration (VHA) Handbook 1160.01, Uniform Mental 
Health Services in VA Medical Centers and Clinics. The updated 2009 
model will reflect the implementation of specific handbook guidelines 
including transition of day hospital/day treatment programs to the 
psychosocial rehabilitation and recovery center model in all medical 
centers with 1,500 or more patients on the National Psychosis Registry, 
access to residential rehabilitation treatment programs in every 
Veterans integrated service network (VISN), and adherence to evidence-
based psychotherapy regimens in outpatient mental health programs. In 
addition, the updated 2009 model will propose a new approach to 
projecting demand for homeless program services that is tied to 
homeless population counts rather than the total enrolled Veteran 
population. Also, the updated 2009 model will incorporate higher costs 
per service due to increased case mix and staffing intensity as 
required under the handbook. The requirements for uniformity in mental 
health services throughout the system, as specified in the handbook, 
together with improved methods for projecting the number of homeless 
Veterans requiring care, should improve the reliability and precision 
of the estimates of the demand for services, and, therefore, the costs.

    Question 2: What progress has the VA made in implementing the 
Mental Health Strategic Plan (MHSP)?

    Response: The Mental Health Strategic Plan (MHSP) was developed in 
2004 to incorporate new advances in treatment and recovery, and to 
address the needs of returning Veterans. This plan was based on the 
principle that mental health was an important part of overall health. 
In 2005, VA began allocating substantial funding through its mental 
health enhancement initiative to support the implementation of the 
MHSP. Currently in the 5th year of implementation, more than 95 percent 
of the items in the MHSP from 2004 and 2005 have now been implemented 
and are part of ongoing operations and clinical practice. VA has moved 
the focus from implementation, emphasizing rapid transition and 
enhancement of mental health services, to a focus on sustained delivery 
of the mode of care the MHSP generated. This shift in focus was the 
impetus for the new VHA Handbook 1160.01: Handbook on Uniform Mental 
Health Services in VA Medical Centers and Clinics, published in 
September, 2008. This handbook lays out the requirements for mental 
health services to be delivered consistently across the VA health care 
system and describes key elements of the recovery process requirements 
for all VA medical centers and clinics. VA plans full implementation of 
the handbook's requirements by the end of FY 2009.

    Question 2(a): VSOs note that the recovery programs have had a 
slow, prolonged startup period; program managers have not made a 
consistent effort to involve Veterans and family members locally; and 
regulatory impediments to the recovery transformation process must be 
removed. What is the VA's response to these concerns?

    Response: VHA officials are not aware of any specific regulatory 
impediments to the recovery transformation process. We welcome the 
Subcommittee's identification of specific regulatory impediments so 
that we may address any concerns at our next Veterans service 
organizations (VSO) quarterly meeting.
    In spite of a firm commitment to recovery transformation by VA 
leadership, and the appointment of recovery coordinators at each 
medical center, transformation is, in fact a challenge. Of all of the 
elements of the MHSP, recovery transformation is the most distant from 
many of the usual practices of bio-medically oriented mental health 
care.
    Recovery transformation requires a change in the culture for 
providing care, and this type of change is always challenging to 
achieve. For providers, it means changing from clinical strategies 
based on professional judgments of what is best for the patient, to 
strategies based on determining what goals are most important to the 
patient, and helping him or her achieve them. The transformations in 
programs that are needed to ensure that they follow recovery models are 
so profound that they will take time to achieve.

    Question 2(b): What updates can the VA provide on integrating 
mental health into primary care in more than 100 pilot program sites? 
(e.g., duration of the pilot; planned evaluation; planned evaluation 
and funding).

    Response: The overall purpose of the VA primary care-mental health 
integration (PC-MHI) program is to promote the effective treatment of 
common mental health and substance use disorders in the primary care 
environment, and thus improve access and quality of care for Veterans 
across the spectrum of illness severity. This is consistent with the 
recommendations of the President's New Freedom Commission on Mental 
Health, which emphasizes that mental health and physical health 
problems are interrelated components of overall health and are best 
treated in a coordinated care system. To that end, one goal of the MHSP 
is to ``develop a collaborative care model for mental health disorders 
that elevates mental health care to the same level of urgency/
intervention as medical health care.''
    PC-MHI program funding began during FY 2007 under the mental health 
enhancement initiative, through a request for pilot program proposals 
that was issued to the VISNs. VA facilities were asked to implement co-
located collaborative or care management programs, consistent with 
evidence-based best practices. Funding during FY 2007 was $23 million, 
representing 409 full-time employee equivalents (FTEE) throughout 
programs located in 94 facilities. These pilot programs continued with 
funding of $32 million during FY 2008, and program growth occurred at 
additional facilities through VISN and local initiatives. An additional 
142 FTEE for the program are being funded during FY 2009. VA 
disseminated the Uniform Mental Health Services Handbook (VHA Handbook 
1160.01) in September 2008. It sets clinical expectations and 
structural requirements for FY 2009 and beyond. For PC-MHI, the 
handbook directs that these programs continue as routine practice, and 
that full primary care mental health integration be delivered at all VA 
medical centers and large community-based outpatient clinics (CBOC).
    Formative program evaluation has assisted implementation greatly, 
and is coordinated through the VA National Serious Mental Illness 
Treatment Research and Evaluation Center in Ann Arbor, Michigan. Upon 
the start of the initial program funding, a request for a new clinic 
stop code for PC-MHI was made effective beginning in FY 2008. This 
enabled tracking of pilot program activities through encounter data. 
From FY 2008 through 2nd quarter FY 2009, 103 of 139 VA facilities have 
posted an aggregate total of 308,035 PC-MHI encounters. All VISNs have 
facilities represented in the data. The prevalent diagnoses in these 
encounters are those consistent with the evidence base for 
collaborative, primary care-based mental health screening and care: 
depression and anxiety disorders, alcohol and other substance use 
disorders, and post-traumatic stress disorder (PTSD). Notable current 
activities include ongoing program evaluation; developing service 
delivery models combining co-located collaborative care and care 
management; identification and dissemination of best practices, tools 
and procedures; and education and training centered on both program 
implementation and training of frontline integrated care staff.

    Question 3: How does the VA know that MHSP was a success and helped 
to improve mental health care for our Veterans?

    Response: The MHSP and the mental health initiative led to 
increases in VHA mental health staffing from 13,950 FTEE in 2004-2005 
to 18,844 at the end of the second quarter of FY 2009. This staffing 
has allowed a 26.2 percent increase in the number of Veterans receiving 
mental health services since 2004; this represents an increase from 3.1 
to 3.9 percent of all of America's Veterans. Over the same time, the 
continuity and intensity of care also increased. For one example, VA 
modified its standard of care to require an initial triage evaluation 
within 24 hours after a new request or referral for mental health 
services, and a full diagnostic and treatment planning evaluation 
within 2 weeks, and it is now meeting that standard more than 95 
percent of the time. Another example is the number of outpatient mental 
health or substance abuse visits during the first 6 months after 
discharge from a mental health or substance abuse hospitalization 
increased by 15 percent. Overall, these measures and others indicate 
that VA is now providing more services to more Veterans.

    Question 4: What is the future of MHSP when the 5-year plan ends in 
November 2009?

    Response: VA will use the 5-year anniversary as a milestone for 
evaluating progress. At present, considerably more than 95 percent of 
the recommendations of the MHSP are now parts of ongoing policy and 
practice. Activities related to the remaining items are being 
developed. Those components of the MHSP that are related to clinical 
care have been incorporated into VHA Handbook 1160.01, Uniform Mental 
Health Services in VA Medical Centers and Clinics, with a requirement 
for implementation of the handbook by the end of FY 2009. The purpose 
of the MHSP was to catalyze a rapid enhancement of VA's mental health 
care programs. Since the MHSP was adopted, these enhancements have 
occurred, and VA's goal is now to ensure the sustained operation of the 
enhanced system.

    Question 5(a): There have been concerns raised here today and 
recently with the Subcommittee concerning the ongoing cost of 
implementation of the Uniform Services Handbook and the lack of 
resource support. What is the level of support and buy-in from 
decisionmakers at the VISN and local levels? Also, what roles have VA's 
stakeholders (e.g., Veterans themselves, Veterans Service 
Organizations, and mental health professional associations) had in the 
development of the plan? What is their anticipated role in the 
implementation of the plan?

    Response: Implementation of the Uniform Services Handbook by the 
end of FY 2009 is VHA policy. It has the highest level of support from 
the Acting Under Secretary for Health, and from each level of 
leadership, nationally and regionally. The handbook was developed on 
the basis of extensive dialog and interactions with mental health 
consumers, advocates, providers, and researchers, both within VA and 
beyond.
    Similar to all mental health care systems, VA relies on 
organizations and individuals in the community to be watchful for 
warning signs of mental health problems in Veterans, and when they are 
observed, to help guide Veterans to care. VA hopes that VSOs and other 
advocates for mental health services familiarize themselves with the 
publicly available handbook and use it as a resource in working with 
Veterans. Specifically, mental health staff from VA Central Office is 
in the process of working with VSOs, mental health advocacy 
organizations, and mental health professional organizations to ensure 
consumers, families, advocates, and community-based professionals are 
aware of the requirements for services that are included in the 
handbook. Working to align guidance from Central Office with local, 
patient-by-patient advocacy should enhance implementation.

    Question 5(b): What are the prior resource commitments that VA has 
made to develop and initiate the implementation of the handbook? Also, 
can the VA quantify future resource levels needed to fully implement 
the handbook system-wide?

    Response: VA has increased its overall mental health budget from 
approximately $2.1 billion in FY 2001 to about $4 billion in FY 2009. 
During FY 2009, $557 million from the mental health enhancement 
initiative was allocated to enhancing mental health services. Of this, 
$380 million was used to support the sustained operation of programs 
and positions in medical centers and clinics that were funded through 
the initiative in prior years, and $127.5 million was allocated 
specifically to support implementation of the handbook. The remainder 
of the Initiative was used to support national programming in support 
of implementation.
    In addition, approximately $29 million from ``no year'' 2007 
supplemental funding was allocated this year to the VISNs and medical 
centers to support implementation of the handbook, and other special 
purpose funding was allocated to enhance PTSD, substance use, and 
homeless programs.
    Future resource levels needed to fully implement the handbook 
system-wide will be projected and allocated through the models 
discussed in the response to question 1.

    Question 5(c): Are equipment, space, and personnel office needs 
accounted for in the budget and implementation plan? Have VISN and 
local authorities allocated those resources?

    Response: In FY 2008, the Office of Mental Health Services used 
supplemental funding to allocate $42 million in non-recurring 
maintenance projects to assist in improving the space and the care 
environment for mental health and substance abuse programs. An 
additional $7 million was allocated from the mental health enhancement 
funding to support required equipment and supplies related to increased 
staffing. At the end of FY 2008, the field reported the obligation of 
all funds.

    Question 5(d): Will other sources of funding be required at the 
VISN, medical center and local levels to fully implement the plan? If 
so, how much will be required? Will they be expected to absorb the 
funding using its annual VERA allocations or will there be special set-
aside funding for this, such as funding through Mental Health 
Enhancement Initiative?

    Response: During FY 2009, approximately $600 million of the total 
VA mental health budget of $4 billion (15 percent) has been in the 
form of special purpose funds. The remaining (85 percent) is derived 
from the Veterans equitable resource allocation (VERA). The mental 
health enhancement initiative and other special purpose funds have 
never represented more than a small component of the total funding 
required for mental health services.
    For FY 2010, VA plans to include the initiative as a new element in 
the VERA allocation, to ensure the sustained operation of the programs 
that were established through the use of the special purpose funds, VA 
will require accountability for maintaining enhanced funding, programs, 
and staffing on a facility by facility basis.

    Question 6: Are there challenges outside of funding, such as the 
lack of qualified mental health professionals, in implementing the 
handbook in a timely manner?

    Response: The implementation of the handbook will be accomplished 
through the activities of current mental health staff, as well as 
recruitment for increased staffing. VA is making steady progress toward 
recruiting mental health staff. During the 1st quarter of 2009, VA 
added 991 FTEE in mental health staffing and in the 2nd quarter added 
726 for a total this year of 1,717 FTEE. VA does not anticipate being 
limited in the implementation of the handbook by the lack of qualified 
mental health professionals. However, we do anticipate other 
challenges.
    The handbook includes requirements to complete the implementation 
of the clinical components of the MHSP. It is a broad-based, far-
reaching document with multiple requirements for the provision of 
evidence-based, Veteran-centric care. It is the sense of VA that in its 
requirements, it is establishing VHA as the most comprehensive mental 
health care system in America. In this, there are multiple challenges. 
Some of these are expected and inevitable. They are the sorts of 
challenges that occur whenever change is mandated in a large system. 
Some are related to the stigma associated with mental illness and its 
treatment. Others are related to difficulties for some providers and 
patients in transitioning from older, traditional approaches to mental 
health care to evidence-based treatments. Still others are related to 
the time and training that may be required to achieve the recovery 
transformation, with an appropriate balance between the ethical 
principles of beneficence and of autonomy in defining the goals for 
treatment, especially for patients with serious mental illness.
    Finally, it may be important to recognize that the coordination of 
information technology (IT) with clinical services may present another 
series of challenges. Specific areas in which further advances in 
mental health services will depend on IT developments include 
organizing the activities of patients, families, and providers to 
develop and monitor individualized treatment plans; systematic 
assessments of the outcomes of clinical interventions; documentation of 
the session-by-session delivery of evidence-based psychotherapy; and 
tracking of patients in care management programs.

    Question 7: In what ways might the implementation of the Uniform 
Mental Health Services Handbook contribute to reducing the barrier that 
stigma plays in keeping Veterans from seeking mental health and 
substance use services?

    Response: The handbook has been designed to empower Veterans as 
consumers and to support Veteran-centric care. It requires Veteran 
input into treatment planning. It defines those services that must be 
available to all eligible Veterans who need them and those that must be 
provided in each VA medical center, and each very large, large, mid-
sized and small CBOC. In this, the handbook is intended to empower 
Veterans, families, and advocates in dialogs with providers about 
setting the goals for treatment. By laying out alternative approaches 
to care, it is intended to encourage the expression of Veterans' 
preferences. By requiring the integration of mental health services 
with primary care, it is designed to make mental health care for the 
most common conditions available in those settings where Veterans are 
most comfortable. By requiring that services for Veterans with serious 
mental illness emphasize the principles of recovery, it works toward 
establishing the principle that care must be provided to all Veterans 
in a manner that enhances their sense of control over their own lives.

    Question 8: There is heightened awareness on the increased need for 
Veteran access to behavioral health and substance abuse providers, yet 
there is an ever-present VA mental health provider shortage. Why is it 
that the VA has yet to show evidence of substantial increases to the 
provider pool, particularly when there are almost 150,000 readily 
accessible marriage and family therapists (MFT) and Licensed 
Professional Counselors (LPC) waiting in the wings for final VA 
implementation?

    Response: There have been substantial increases in the pool of VA 
mental health providers. Over the past 4 years, VA has increased its 
core mental health staff by almost 5,000 FTEE from 13,950 in 2005 to 
18,844 at the end of the 2nd quarter of FY 2009, an increase of over 35 
percent. Certainly VA is working to add job series for marriage and 
family therapists (MFT) and licensed professional counselors (LPC) and 
will welcome them into the VA mental health team. However, they have 
not been needed in order to accomplish dramatic growth in the number of 
mental health providers in the VA system.

    Question 9: How can the VA justify the lack of readily available 
mental health services and the slow rate of provider increases, 
particularly in rural communities, when the need for this care is so 
great?

    Response: VA does not agree with the premises that there is a lack 
of readily available mental health services and a slow rate of provider 
increases. With respect to the availability of services, VA requires 
that all new requests or referrals for mental health services must be 
evaluated within 24 hours to determine the urgency of the need for 
care, and, if there is no immediate need for services, a full 
diagnostic and treatment planning evaluation must be conducted within 
14 days. At present, VA is meeting the 14 day standard for over 95 
percent of cases. With regard to staffing, since 2005, VA has increased 
its mental health staffing by almost 5,000 FTEE.

    Question 10: Where is proof that VA has made mental health services 
and substance abuse providers appropriately available for smooth and 
efficient readjustment of OEF/OIF Veterans?

    Response: In addition to increases in mental health staffing in VA 
medical centers and clinics, VA has increased the number of 
readjustment counseling centers (Vet Centers), and the staffing for the 
readjustment counseling program. This has allowed VA to expand outreach 
to returning servicemembers, including VA participation in all 
scheduled post-deployment health reassessment events, outreach to 
National Guard and Reserve Units, and community programs. It has also 
allowed increased screening for mental health conditions in medical 
care settings, and the integration of mental health services with 
primary care.
    One way to evaluate the availability of mental health services for 
returning Veterans is to compare estimates of the needs of the 
Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) population 
with the number of Veterans actually seen in VA. A recent publication 
by Milliken estimates the prevalence of PTSD as detected in Army 
National Guard and Reserve members at post-deployment health 
reassessments events is 14.3 percent. This figure is comparable to the 
estimate from last year's RAND study of 13.8 percent for servicemembers 
and Veterans. Although there may be reasons to question the precision 
and validity of any single estimate, these findings taken together 
support a prevalence of about 14 percent. It may be useful to use this 
figure to estimate the extent to which VA services address the needs of 
the population.
    From the start of the war in Afghanistan to the end of calendar 
year 2008, 981,834 Veterans returned from deployment to Afghanistan or 
Iraq. An estimate of 14 percent for the prevalence of PTSD corresponds 
to approximately 137,457 cases. During this time, VA has seen 114,908 
Veterans in its medical centers, clinics, and Vet centers who have 
received a diagnosis of PTSD on at least one occasion. This number of 
Veterans seen corresponds to about 84 percent of all of those with 
PTSD, suggesting that VA is addressing a substantial component of the 
needs of the population. Clearly, there is a need for continued 
outreach and related programs, but review of these estimates suggests 
that a majority of those in need for specific services for PTSD may be 
accessing care in VA.

    Question 11: Now 7 years into war, how many VA mental health 
providers have been trained to provide evidence-based PTSD treatments? 
What is the average timeline for completing staff training nationally, 
and what are its elements?

    Response: Since findings from VA research supported the 
effectiveness of evidence-based psychotherapy for PTSD, and since the 
Institute of Medicine's (IOM) review confirmed the power of the 
evidence, VA has trained more than 1,700 VA providers in the delivery 
of cognitive processing therapy and prolonged exposure therapy. All of 
those have been licensed and credentialed VA providers, experienced in 
providing psychotherapy and related clinical interventions. Training 
for a provider in these therapies takes approximately 4 to 6 months. 
The training can be divided into three phases:

      Workshops, usually lasting several days, with review of 
the principles underlying the treatments and demonstration of the 
techniques;
      Trainees provide treatment using these therapies to a 
number of cases over the course of several months with case by case, 
session by session mentoring from a therapist experienced in the 
specific treatment; at the successful conclusion of these mentored 
treatments, the trainee will be considered to have mastered the skills 
needed for providing the treatment; and
      Ongoing discussion, communication, and peer supervision 
to maintain skills.

    Question 12: Can any Veteran who needs VA care for acute PTSD 
receive that care immediately? Can you give the Subcommittee staff a 
report on the average waiting time for starting specialized therapy or 
counseling once it is requested?

    Response: Yes, VA requires that every Veteran who comes to a VA 
medical center or clinic with a mental health concern is evaluated for 
urgent medical needs, including danger to self or others and if found 
to need care immediately; that care is provided. There is a requirement 
for initial assessment within 24 hours of requests for service or 
positive screens, and for a diagnostic and treatment planning 
evaluation within 14 days. At present, VA is meeting the 14-day 
standard for over 95 percent of cases.

    Question 13: Early intervention services are critical to prevent 
chronic mental health problems among returning Veterans. Has VA 
increased its focus on early, accessible intervention services, such as 
relationship counseling, and motivational counseling to prevent 
hazardous alcohol or drug use, and made sure that they are available at 
all sites of care, including Vet Centers?

    Response: An important part of VA's increasing emphasis on the 
integration of mental health services with primary care is a focus on 
early screening, early brief intervention, and the early implementation 
of treatment for problem drinking. VA currently requires annual 
screening for problem drinking in all primary care settings, and, when 
Veterans screen positive, provision of treatments. When the problem 
persists, the requirements are for motivational interventions, and, 
then for referral to specialty care. The same treatment and 
motivational intervention strategies are also used in Vet centers.

    Question 14(a): DAV recommended that Congress should require VA to 
establish an independent body, with appropriate resources, to analyze 
data and information, supplement its data with periodic site visits to 
medical centers and make independent recommendations to the Secretary 
and to Congress on actions necessary to bridge gaps in mental health 
services, or to further improve those services. This sounds much like 
the ``Committee on Care of Severely Chronically Mental Ill Veterans'' 
that was mandated by Congress in 1996. Please answer the following 
questions on that: What is the current role of mental health consumer 
organizations, Veterans service organizations, and professional 
organizations in the ongoing work of the VA's Committee on Care of 
Severely and Chronically Mentally Ill Veterans (``SMI Committee'')?

    Response: In the authorization by Congress, membership of the 
Committee on Care of Severely Chronically Mentally Ill Veterans defined 
to include VA staff, and not mental health consumer organizations, 
Veterans service organizations, or professional organizations. To 
establish a mechanism for obtaining input about mental health services 
from these groups, VA established a Committee consumer council 
consisting of a representative group of mental health consumers, 
including representatives from major mental health professional and 
consumer organizations and VSOs. Membership on the consumer council 
allows them to share their views with the Committee. However, following 
the initial authorization, they are not members of the Committee and do 
not have a vote.

    Question 14(b): Was there a change in the role of these stakeholder 
groups as a result of the SMI Committee's re-chartering in 2006? If so, 
why?

    Response: There was no change in the role of these stakeholder 
groups as a result of the serious mental illness (SMI) Committee's re-
chartering in 2006. The SMI Committee has always served as an internal 
work group, reporting primarily to the Under Secretary for Health. It 
was never intended to function as a Committee that would be subject to 
Federal Advisory Committee Act (FACA). Over time, there has been an 
ongoing need to review its processes to ensure that it had not taken on 
activities that would lead to FACA requirements.

    Question 15: Concerns have been raised about VA plans to shift 
funding for the Mental Health Initiative from general health care to an 
allocation through the Veterans Equitable Resource Allocation process. 
How would you respond to these concerns? Do you believe VA's funding 
plan will support and sustain the Mental Health Initiative over the 
long term?

    Response: The mental health enhancement initiative was established 
by VA as a funding stream outside of VERA to support the rapid 
implementation of the VHA comprehensive MHSP. It has led to rapid 
enhancements in staffing that have allowed increases in the number of 
Veterans with mental health concerns to be seen in VA medical centers 
and clinics and in the intensity of services provided to them. With the 
rapid enhancement of staffing levels that has already been 
accomplished, and with the handbook's establishment of requirements for 
the services that must be available to all eligible Veterans in need 
and those that must be provided in each facility, the focus for VA must 
shift. At this time, VA's focus should be on monitoring the mental 
health services that are provided in all facilities and those that are 
available to all Veterans rather than on spending of specific funds. FY 
2010, VA will ensure that spending and staffing levels for mental 
health are maintained, while it implements measures and monitors to 
ensure that the handbook is fully implemented. The current level of VA 
funding for mental health as specified in the President's budget is 
adequate to support and sustain the goals of the mental health 
initiative; implementation of the MHSP through implementation of the 
handbook.

    Question 16: Is there a timeframe for VISNs to request modification 
or exceptions for Uniform Mental Health Services (UMHS) Handbook 
requirements that cannot be met? Have any VISNs requested modification 
or exceptions, and if so, how many? What will be done to bridge the gap 
in services between requirements in the UMHS Handbook and facility 
capabilities?

    Response: VISNs are required to implement the requirements of the 
handbook by September 30, 2009 unless they apply for and are granted 
exceptions. Thus, the deadline for submission, review, and approval of 
exceptions is September 30, 2009.
    In this context, it is important to emphasize several of the key 
provisions of the handbook. It includes requirements for the services 
that must be available for each eligible and enrolled Veteran, and 
those that must be provided at each VA facility (medical centers, and 
very large, large, mid-sized, and small CBOCs). An application for an 
exception is for a waiver for the requirement to provide specific 
services at specific facilities. There is no provision for applications 
for exceptions for services that must be made available to all eligible 
and enrolled Veterans who need them. Accordingly, the handbook requires 
that facilities bridge the gap between requirements in the UMHS 
handbook and facility capabilities by referral to geographically 
accessible VA services, and referral to community providers by sharing 
agreements, contracts, or fee-basis services provided that requirements 
for eligibility are met.

    Question 17: In their testimony, the DAV highlights the need for 
better outreach and the success of the ``VetAdvisor'' program being 
piloted in VISN 12. Do you have any plans to expand this pilot?

    Response: VA agrees that early findings from the VetAdvisor program 
appear promising. In brief, VISN 12 contracted with Three Wire, a 
serviced-disabled Veteran owned business. Its initial pilot project on 
telephone outreach provided screening to over 5,000 OEF/OIF Veterans 
who were identified as not having previously contacted VA. Over 1,100 
of those contacted screened positive on at least one measure and were 
referred to VA for services. Recently VISN 12 renewed the contract and 
extended the scope of work to go beyond outreach and screening to 
include telephone coaching to promote access to services. More detailed 
findings from an evaluation of this program are needed, and they are 
anticipated by the end of calendar 2010.
    There are also a number of other promising programs being piloted 
in other components of the system, including Web-based services in 
Texas, family based services in VISN 4, and others. The Vet center 
program is developing a call center for returning Veterans, and VA is 
working with the Department of Defense (DoD) to design a ``coaching'' 
program to facilitate the continuity of care for servicemembers who 
received mental health care while on active duty. Other relevant 
activities include advertising, public services announcements, and 
educational programs in the community.
    VA recognizes the importance of outreach to encourage returning 
Veterans (as well as those from prior eras) to engage in care when they 
need it. The specific programs for outreach, overall and at each 
location are continually under review. Given the number of promising 
programs, and the need for further evaluation of the VetAdvisor 
program, it would be premature to make decisions about the expansion of 
this program. Instead, VA has developed a number of pilot and 
demonstration projects and will decide which should be rolled out on a 
national basis when evidence on their effectiveness becomes available.

    Question 18: The OIG testified to a number of items in which VA is 
at risk for not meeting its implementation goal, specifically concerned 
with VA's not meeting the goal to follow up with Veterans within 1 week 
of discharge from an inpatient mental health unit. What is VA doing to 
improve its follow-up practices?

    Response: VA would like to clarify the fact that Report 08-02917-
105 from the VA Office of the Inspector General, dated April 6, 2009, 
made no specific recommendations related to the implementation of the 
handbook. It stated: ``Consistent with the handbook requirements for 
timely follow-up after discharge from a mental health inpatient unit, 
the VHA Office of Quality and Performance, Office of Patient Care 
Services, and Office of Mental Health Services introduced a new quality 
monitor for FY 2009. The monitor measures the percent of inpatient 
discharges that include at least a bed day of care in a mental health 
bed-section of care during which the patient received a face-to-face, 
telehealth, or telephone encounter within 7 days following the 
discharge date; and if the initial follow-up encounter was by 
telephone, a face-to-face follow-up encounter must occur within 14 
days. VHA pulls the data for these measures from the VA National 
Patient Care Database Outpatient and Inpatient Workload files. In March 
2008 prior to the handbook, 46 percent of total patient discharges were 
seen within 7 days. For February 2009, this increased to 57 percent. 
The monitor target is 85 percent.''
    By including follow-up after hospital discharge as a performance 
monitor, VA is bringing a high level of scrutiny and accountability to 
this area. With ongoing monitoring, feedback, and direction to the 
facilities VA anticipates that the target for follow-up will be met by 
the end of the fiscal year.

    Question 19: How is VA using its contract authority to enhance its 
mental health services, especially in rural areas where it is hard to 
recruit mental health professionals?

    Response: VA is currently in the process of implementing a number 
of pilot or demonstration projects for the delivery of services in 
highly rural areas, including a number that use contracting for mental 
health services. This includes the pilot project authorized under 
section 107 of Public Law 110-387.
    More generally, the UMHS handbook requires that when enrolled 
Veterans requiring specified mental health services are beyond the 
geographic reach of the services provided at VA medical centers and 
clinics, these services should be provided by referral to other VA 
facilities, when these are geographically accessible, through 
telemental health services, or through sharing agreements, contracts, 
or fee-basis services when the Veteran is eligible.

    Question 20: What lessons have been learned from implementing the 
Mental Health Strategic Plan?

    Response: VA's lessons learned about translating the 
recommendations of the MHSP into requirements for specific services 
have been incorporated into the UMHS handbook. The handbook will serve 
as the vehicle for ensuring the sustained operation of those programs 
and services that were implemented under the strategic plan.
    The 255 recommendations of the strategic plan can be summarized in 
terms of 6 principal components:

      Addressing the needs of returning Veterans;
      Ensuring that the access and capacity of mental health 
services is adequate;
      Integrating mental health with primary care;
      Transforming the specialty mental health care system to 
focus on rehabilitation and recovery;
      Implementing evidence-based practices with an emphasis on 
evidence-based psychosocial and behavioral interventions; and
      Preventing suicide.

    The first of these is, more or less, specific to VA. The others are 
important goals for the enhancement of mental health services for 
America as a whole. In this context, the lessons learned by VA may be 
relevant to understanding the mental health services that should be 
available to the population as a whole under health care reform.

                                 
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