[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
U.S. GOVERNMENT PRINTING OFFICE
49-915 WASHINGTON : 2009
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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
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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
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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.
---------------------------------------------------------------------------
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.
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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.
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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.
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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.