[Senate Hearing 112-212]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 112-212
 
                VA MENTAL HEALTH CARE: CLOSING THE GAPS

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

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                      ONE HUNDRED TWELFTH CONGRESS

                             FIRST SESSION

                               __________

                             JULY 14, 2011

                               __________

       Printed for the use of the Committee on Veterans' Affairs


        Available via the World Wide Web: http://www.fdsys.gov/



                  U.S. GOVERNMENT PRINTING OFFICE
71-959                    WASHINGTON : 2012
-----------------------------------------------------------------------
For sale by the Superintendent of Documents, U.S. Government Printing Office, 
http://bookstore.gpo.gov. For more information, contact the GPO Customer Contact Center, U.S. Government Printing Office. Phone 202ï¿½09512ï¿½091800, or 866ï¿½09512ï¿½091800 (toll-free). E-mail, [email protected].  

                     COMMITTEE ON VETERANS' AFFAIRS

                   Patty Murray, Washington, Chairman
John D. Rockefeller IV, West         Richard Burr, North Carolina, 
    Virginia                             Ranking Member
Daniel K. Akaka, Hawaii              Johnny Isakson, Georgia
Bernard Sanders, (I) Vermont         Roger F. Wicker, Mississippi
Sherrod Brown, Ohio                  Mike Johanns, Nebraska
Jim Webb, Virginia                   Scott P. Brown, Massachusetts
Jon Tester, Montana                  Jerry Moran, Kansas
Mark Begich, Alaska                  John Boozman, Arkansas
                       Kim Lipsky, Staff Director
                 Lupe Wissel, Republican Staff Director


                            C O N T E N T S

                              ----------                              

                             July 14, 2011
                                SENATORS

                                                                   Page
Murray, Hon. Patty, Chairman, U.S. Senator from Washington.......     1
Burr, Hon. Richard, Ranking Member, U.S. Senator from North 
  Carolina.......................................................     3
Begich, Hon. Mark, U.S. Senator from Alaska......................     4
Brown, Hon. Scott P., U.S. Senator from Massachusetts............     5

                               WITNESSES

Williams, Daniel, Veterans Council Representative for National 
  Alliance on Mental Illness, Alabama............................     5
    Prepared statement...........................................     7
    Posthearing question submitted by Hon. Mark Begich...........    11
Sawyer, Andrea, Caregiver and Spouse of U.S. Army Sergeant Sawyer    11
    Prepared statement...........................................    13
    Response to posthearing questions submitted by:
      Hon. John D. Rockefeller IV................................    21
      Hon. Mark Begich...........................................    25
Underriner, David Thomas, Chief Executive, Providence Health & 
  Service--Oregon Region.........................................    28
    Prepared statement...........................................    30
    Response to posthearing questions submitted by Hon. Mark 
      Begich.....................................................    34
Daigh, John D., Jr., M.D., Assistant Inspector General for Health 
  Care, Office of Inspector General, U.S. Department of Veterans 
  Affairs; accompanied by Michael Shepherd, M.D., Senior 
  Physician......................................................    36
    Prepared statement...........................................    38
    Response to posthearing questions submitted by Hon. Mark 
      Begich.....................................................    42
Schoenhard, William, Deputy Under Secretary for Health for 
  Operations and Management, U.S. Department of Veterans Affairs; 
  accompanied by George Arana, M.D., Assistant Deputy Under 
  Secretary for Health for Clinical Operations; Antonette Zeiss, 
  Ph.D., Acting Deputy Chief Consultant for Mental Health; and 
  Mary Schohn, Ph.D., Acting Director, Mental Health Operations..    49
    Prepared statement...........................................    51
    Posthearing questions submitted by:
        Hon. Patty Murray........................................    56
        Hon. Richard Burr........................................    61
        Hon. Daniel K. Akaka.....................................    63
        Hon. Mark Begich.........................................    68
    Response to request arising during the hearing by Hon. Patty 
      Murray.....................................................    85


                        VA MENTAL HEALTH CARE: 
                            CLOSING THE GAPS

                              ----------                              


                        THURSDAY, JULY 14, 2011

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 10:02 a.m., in 
room 418, Russell Senate Office Building, Hon. Patty Murray, 
Chairman of the Committee, presiding.
    Present: Senators Murray, Begich, Burr, and Brown of 
Massachusetts.

       OPENING STATEMENT OF HON. PATTY MURRAY, CHAIRMAN, 
                  U.S. SENATOR FROM WASHINGTON

    Chairman Murray. Good morning and welcome to today's 
hearing on how we can close the gaps in mental health care for 
our Nation's veterans.
    We all know that going to war has a profound impact on 
those who serve. And after more than 8 years of war, in which 
many of our troops have been called up for deployments again 
and again, it is very clear that the fighting overseas has 
taken a tremendous toll and one that will be with us for years 
to come.
    More than one-third of veterans returning from Iraq and 
Afghanistan who have enrolled in VA care have Post Traumatic 
Stress Disorder. An average of 18 veterans kill themselves 
every day. In fact, the difficult truth is that somewhere in 
this country, while we hold this hearing today, it is likely 
that a veteran will take his or her own life.
    Last week, the President reversed a longstanding policy and 
started writing condolence letters to the family members of 
servicemembers who commit suicide in combat zones. This 
decision is one more acknowledgment of the very serious 
psychological wounds that have been created by the wars in Iraq 
and Afghanistan and an effort to reduce the stigma around the 
invisible wounds of war. But clearly much more needs to be 
done.
    In the face of thousands of veterans committing suicide 
every year, and many more struggling to deal with various 
mental health issues, it is critically important that we do 
everything we can to make mental health care more accessible, 
timely, and impactful.
    In fact, according to data VA released just yesterday, more 
than 202,000 Iraq and Afghanistan veterans have been seen for 
potential PTSD at VA facilities through March 31, 2011. This is 
an increase of 10,000 veterans from the last quarterly report. 
Any veteran who needs mental health services must be able to 
get that care rapidly and as close to home as possible.
    Over the years, VA has made great strides in improving 
mental health services for veterans. But there are still many 
gaps.
    As many of you know, just this past May, the 9th Circuit 
Court of Appeals issued an opinion that called attention to 
many of these gaps in mental health care for veterans. And 
while that ruling has gotten the lion's share of attention, it 
is one of far too many warning signs.
    Today, we will hear from the Inspector General about 
ongoing problems with delays in receiving health care for those 
veterans suffering from the invisible wounds of war, like PTSD.
    In one report, published just this week by the IG, several 
mental health clinics at the Atlanta VA were found to have 
unacceptably high patient wait times. The report shows that 
facility managers were aware of long wait lists for mental 
health care, but were slow to respond to the problem. The 
report also called into question the adequacy of VA's 
performance measurements for mental health access times across 
the entire system.
    And as the IG noted, the VA only tracks the time it takes 
for new patients to get their first appointment. That means 
that since the VA is not tracking the timeliness of second, 
third, or additional appointments, facilities can artificially 
inflate their compliance with mental health access times. That 
is unacceptable, and it has to change.
    In another report on veterans in residential mental health 
care, the IG found that an unacceptable number of veterans were 
not contacted by VA between the time they were accepted and the 
beginning of the program, and that staffing levels for mental 
health workers fell short of VA guidelines.
    GAO has also recently published a report on sexual assault 
complaints in VA mental health units that found many of these 
assaults were not reported to senior VA officials or the 
Inspector General. VA clinicians also expressed concern about 
referring women veterans to inpatient mental health units 
because they did not think the facilities had adequate safety 
measures in place to protect these women.
    And just 2 weeks ago GAO issued a report that found the 
Defense Centers of Excellence for Psychological Health and 
Traumatic Brain Injury cannot adequately account for tens of 
millions of dollars it spent to improve treatments for the 
invisible wounds of war.
    Taken together, these reports show very clearly that there 
is significant work to do to improve mental health care 
outreach and treatment.
    One way to fill in these gaps, to overcome the stigma 
associated with mental health care and to eliminate wait times 
is to provide primary and mental health care at the same visit.
    In the hearing today, we will hear from Providence Health 
and Services, which was recently recognized as one of the five 
most integrated health systems in the country, about how they 
have integrated mental health services into their medical home. 
I believe we need to look to Providence and those VA programs 
that work for guidance on making real progress.
    Through its suicide hotline, VA has reached many veterans 
who might have otherwise taken their own lives. Each life saved 
is a tremendous victory, and we should celebrate those with the 
VA. But we also have to recognize that these are veterans who 
reached out to VA.
    We want to hear about how VA is reaching out to veterans 
and how easy or hard it is for veterans to access the care they 
earned through their service to this country. As we will hear 
today, despite VA's best efforts, veterans continue to 
experience problems when they reach out to the VA for mental 
health care.
    I have heard from veterans who have walked into VA clinics 
and asked to be seen by a mental health provider, only to be 
told to call a 1-800 number. I have heard from VA doctors who 
have told me VA does not have enough staff to take care of the 
mental health needs of veterans. And I have heard from 
veterans' families, who have seen first-hand what effects 
untreated mental illness can have on the family. We are here 
today to see that that ends.
    I am looking forward to hearing from all of our witnesses 
today.
    And I hope it helps us to better understand these issues 
and to address them so that our veterans can receive the 
timely, quality care they earned through their service.
    With that opening statement, I do want to take a moment to 
publicly express my deepest condolences to my friend, Senator 
Burr, on the recent loss of his father. I know that Dr. David 
Burr was a Navy veteran, who left Princeton to enlist back in 
1942 and served in the Pacific Theater in a frogman unit. He 
served more than 25 years as a pastor in Winston-Salem.
    Senator Burr and I are both children of World War II 
veterans. So, I know that his father's experience and example 
are what makes Senator Burr so dedicated to the veteran's 
issues that come before this Committee.
    Senator Burr, all of our thoughts and prayers are with you 
and your family at this difficult time, and I appreciate you 
being here today.
    Senator Burr. Thank you.
    Chairman Murray. With that, I will turn it over to Senator 
Burr for his opening statements.

        STATEMENT OF HON. RICHARD BURR, RANKING MEMBER, 
                U.S. SENATOR FROM NORTH CAROLINA

    Senator Burr. Thank you, Madam Chairman, and good morning. 
And I can assure all that when you have the opportunity to live 
to the age of 90, you have not been cheated relative to the 
length of time on this earth, and my dad was certainly blessed 
and is blessed today.
    I want to particularly welcome Mr. Williams; Sergeant 
Sawyer and his wife Andrea. And I want to thank you for your 
willingness to come and to share your experiences firsthand 
with him. I know many of which are probably a little painful to 
recount.
    As Members of the Committee, it is important that we have 
an opportunity to hear firsthand from veterans and their 
caregivers about their personal experiences in seeking mental 
health services through the VA.
    Back in May, as the Chairman said, the U.S. Court of 
Appeals for the 9th Circuit issued a scathing decision 
addressing delays in providing VA mental health care to our 
Nation's veterans. While I do not intend to comment on the 
merits of the ongoing litigation, I do believe that it is worth 
our time to look into the issues raised in the case to ensure 
that veterans receive the care they deserve and have earned in 
a timely fashion.
    As I have said before, early intervention offers the best 
hope for improvement and recovery from PTSD, depression, and 
substance-abuse disorders.
    Madam Chairman, it appears that early intervention 
continues to be challenging within VA. According to the IG 
statement, even veterans who sought help and were accepted into 
the mental health program ended up waiting for the actual 
services. This is unconscionable.
    This Committee has worked aggressively over the years, 
through oversight hearings such as the one we are holding 
today, to improve the health care for our veterans and reduce 
the barriers preventing veterans and servicemembers from 
seeking mental health services.
    For example, this is the third hearing in 4 years 
conducting oversight examining the gaps that exist in VA's 
mental health care program. And yet, gauging from testimony we 
will hear from the first panel, there is still a tremendous 
amount of work that has to be done.
    It is troublesome to learn of the issues both Mr. Williams 
and Mr. Sawyer encountered in seeking care from VA. Both 
encountered problems finding someone at VA to listen to what 
they needed, more importantly, what they wanted from the 
standpoint of their treatment. Their experiences lead me to 
ask, where is the veteran in the Department of Veterans Affairs 
policies? How does VA's policy include the veteran when putting 
together a treatment plan?
    I look forward to hearing VA's testimony. I am particularly 
interested in learning how VA is working to address the issues 
raised by this first panel and the recommendations made by the 
IG reports.
    I thank you, Madam Chairman.
    Chairman Murray. Thank you very much.
    Senator Begich, we will turn to you for an opening 
statement.

                STATEMENT OF HON. MARK BEGICH, 
                    U.S. SENATOR FROM ALASKA

    Senator Begich. Madam Chair, because of limited time that I 
will have here, I will hold, and I really want to hear the 
testimony that folks have. I do have a list of questions that I 
will submit for the record, specifically about some work the VA 
is doing with regard to mental health services in Alaska and 
the coordination that is going on there.
    So, I will hold there, especially around some of our 
hospital work with Providence Hospital. So I will hold, and I 
want to hear their testimony.
    Chairman Murray. Very good.
    Senator Brown, your opening statement.

                STATEMENT OF HON. SCOTT BROWN, 
                U.S. SENATOR FROM MASSACHUSETTS

    Senator Brown of Massachusetts. Thank you, Madam Chair. The 
same as Senator Begich; I would like to hear the witness 
testimony. I appreciate your holding this hearing, and I concur 
with Senator Burr, you know, concering the veteran. I hear 
these stories all the time, and I would like some answers. So, 
thank you.
    Chairman Murray. Thank you. At this time then we will turn 
to welcome our first panel of witnesses. I very much appreciate 
all of you being here today and sharing your information. We 
are going to hear first from Daniel Williams. He is a veteran 
representing the National Alliance on Mental Illness.
    Next we will hear from Andrea Sawyer. She is a caregiver 
and a spouse representing Wounded Warrior Project, and I would 
also like to welcome her husband Loyd Sawyer, who is here with 
us in the audience today. He is truly one of America's heroes, 
and we want to thank him for his service and all of your 
family.
    We will then hear from David Underriner with Providence 
Health and Services in Oregon, and finally, we will hear from 
Dr. David Daigh from the VA's Office of Inspector General. He 
is accompanied today by Dr. Michael Shepherd.
    Mr. Williams, with that, we will begin with you and thank 
you so much for joining us today.

 STATEMENT OF DANIEL WILLIAMS, VETERANS COUNCIL REPRESENTATIVE 
      FOR THE NATIONAL ALLIANCE ON MENTAL ILLNESS, ALABAMA

    Mr. Williams. Thank you, Madam Chairman, Ranking Member 
Burr, and Members of the Committee, on behalf of the National 
Alliance on Mental Illness, NAMI, thank you for inviting me to 
speak before you all today and give my testimony.
    The VA mental health program is a program that I have been 
in since 2007, from the time that I was put out of the service. 
Earlier this week, NAMI's national office submitted my official 
statement for the record of this hearing. The statement 
contains additional information and the comments about NAMI and 
our priorities and recommendations.
    Madam Chairman, I was asked to appear at this hearing to 
tell you about the journey of my life since 2003 to 2004, I am 
sorry, to 2007. In 2003 to 2004, I was in the Army. I served as 
a biochemist. I was deployed to Iraq in 2003, was deployed with 
the 4th Infantry Division out of Fort Hood, Texas.
    During that combat deployment, I suffered mental and 
physical injuries that will forever be part of my life. I was 
exposed to an improvised explosive device that injured my body, 
my brain, and my mind.
    I received a Traumatic Brain Injury, TBI, but I believe 
that the most severe of my injuries is the Post Traumatic 
Stress Disorder, PTSD, an invisible injury that no one else can 
see, but it haunts my every move.
    From the moment I got injured until the time that I was 
honorably discharged, I received very little help from the Army 
or even acknowledgment of my mental health state.
    I went to the base clinic at Fort Hood, TX, where I was 
told that I was having an anxiety disorder and readjustment 
issues. But I would need to wait 6 months before I could get an 
appointment with a psychiatrist, just an initial appointment, 
to be looked at.
    In the winter of 2004, after receiving no help or any hope 
of help, I attempted suicide by putting a 45 caliber pistol in 
my mouth while I was locked in a bathroom. My ex- wife begged 
me to let her in, but I would not agree.
    She called the police. When they arrived, I argued with 
them. Then they kicked down the door, and at that time I pulled 
the trigger. By the grace of God, the weapon did not go off.
    The officer handcuffed me and put me in the seat in the 
back of his police car. One of the offices attempted to clear 
the weapon, but at that moment the weapon went off. The same 
round that refused to kill me went off perfectly for him. 
Thankfully no one was injured.
    I was admitted to the psychiatric ward of the base hospital 
and remained an inpatient for 2 weeks. At this time I was 
diagnosed with readjustment anxiety disorder, but the 
physicians also acknowledge that I had PTSD. I was told by the 
doctors that the treatment record would be kept confidential, 
and it was not.
    It took me over a year to be able to be put out of the 
military service because of my mental illness. I was introduced 
to the DAV, Disabled American Veterans, which handled my 
claims, taking me from the service to the VA. I was never 
contacted by the VA, only by the DAV.
    When I first went to the VA medical center in Birmingham, 
Alabama in 2007, I felt lost and had no guidance. With the 
drain of PTSD, I wanted to give up. I had to wait for hours 
just to see a doctor.
    This was unacceptable, not only to me but to watch other 
veterans having the same issue; and honestly the small little 
things were there that I could not handle, the smells, the 
sights, the sounds, the crowds. These things made my condition 
worse. I had to relive this pain over and over every time I 
went to the VA.
    I recently went to the VA, 2 days ago, and was told I could 
have my appointment rescheduled because I was coming here to 
speak and was not going to be able to make my appointment. My 
appointment was going to be put off for 4 months.
    That is not acceptable by any standard, and I am sorry that 
not only I have to go through this but my fellow soldiers and 
servicemembers do.
    There is many different issues that need to be changed in 
the VA system. Can these all be changed in 1 day? No, they 
cannot. But there are the small things that need to be looked 
at that are very huge issues to us.
    The time of care that we have for an appointment is very 
slow to the point that it is almost, it is a crawl. There needs 
to be more community services to be able to reach out to in the 
community to help the veteran through the process of the VA 
system because the VA system makes you want to give up and try 
something else.
    Madam Chairman, the VA system has its flaws and has its 
perks. There is an OEF/OIF transition team that handled my 
care, that helps me with my appointments that does try to help 
me through these times, but it is not always successful, not 
because of their efforts, because of the non-efforts on behalf 
of the VA.
    The VA has many resources open to them very freely but yet 
they stay in close knit with themselves and will not reach out 
to the local and national people that are out there and 
organizations that can help them make this a less difficult 
transition not only from a soldier but to a civilian again.
    Servicemen and women are taught to be soldiers through the 
service. We are not taught how to be civilians again; and once 
we are put out, we are left out to hang dry.
    I am asking that this Committee look at the possibility of 
having a peer movement in the VA facility, that the peers, a 
person like myself or others that have been through the same 
thing, that know the system, that know the people to talk to to 
help them through it because otherwise we are going to lose 
more than 16 people a day to suicides.
    We have got to take action now and not tomorrow. And I 
thank you. Madam Chairman, this concludes my statement and I 
will be pleased to answer any questions from other Members of 
the Committee.
    [The prepared statement of Mr. Williams follows:]

   Prepared Statement of Daniel Williams, U.S. Army Combat Veteran, 
  Resident of Homewood, Alabama, Member, National Alliance on Mental 
                             Illness (NAMI)

    Chairman Murray, Ranking Member Burr, and Members of the Committee: 
On behalf of the National Alliance on Mental Illness (NAMI), please 
accept NAMI's collective thanks for this opportunity for me to provide 
testimony at today's oversight hearing to assess the Department of 
Veterans Affairs' (VA) mental health programs.

                              INTRODUCTION

    NAMI is the Nation's largest grassroots consumer organization 
dedicated to improving the lives of individuals and families affected 
by mental illness. Through NAMI's 1,100 chapters and affiliates in all 
50 states NAMI supports education, outreach, advocacy and research on 
behalf of persons with schizophrenia, bipolar disorder, major 
depression, severe anxiety disorders, Post Traumatic Stress Disorder 
(PTSD), and other chronic mental illnesses that affect both adults and 
children. In my opinion what NAMI does best as an organization is to 
advocate for, train and educate family members of persons living with 
mental illness. In recent years NAMI began to realize that the lives of 
our newest veterans and the experiences that they've had while serving 
our country in combat necessitate not only that they receive post-
deployment services essential to get well afterward, but also that 
their families have needs that must be addressed to ensure that a 
family recovers from the experience.
    NAMI is very proud that the VA has recognized that NAMI can play an 
important role within VA mental health in helping families of veterans 
cope with, and recover from, mental illness, whether acute or chronic. 
One NAMI signature program in particular, Family-to-Family, is designed 
to meet the needs of family members who have questions relative to what 
their loved one--the veteran home from deployment in war--is 
experiencing, not only from the standpoint of what the illness is, but 
the treatment protocol, the various medications and prognosis, and what 
they can expect in supporting and caring for their loved one in gaining 
the ultimate goal of recovery.

                                MY STORY

    Madam Chairman, I was asked to appear at this hearing to tell you 
about the journey of my life since 2003 to the present day. In 2003 and 
2004 as an Army infantryman I was deployed to Iraq with 4th Infantry 
Division based at Fort Hood, Texas. During my deployment to Iraq I 
suffered mental and physical injuries that will forever be a part of my 
life. I was exposed to a detonated improvised explosive device (IED) 
that injured my body and my mind. I received a Traumatic Brain Injury 
(TBI) immediately, but I believe the most severe of these injuries is 
my Post Traumatic Stress Disorder (PTSD)--an invisible injury that no 
one can see but it haunts my every move.
    From the moment I got injured until the time that I was honorably 
discharged from the Army, I received very little help from the Army, or 
even an acknowledgement of my mental state. I went to the base clinic 
at Ft. Hood where I was told that I was having anxiety and readjustment 
issues but that I would need to wait six months before I could get an 
appointment with a psychiatrist. In the winter of 2004 after receiving 
no help or hope of help I attempted suicide by shoving a .45 caliber 
pistol in my mouth while I was locked in the bathroom. My wife Carol 
begged me to let her in but when I wouldn't agree, she called the 
police. When the police arrived I argued with them. When they kicked 
open the door I pulled the trigger, but by the grace of God the weapon 
misfired. The officers handcuffed me and seated me in the back of the 
police car. One of the officers attempted to clear my weapon, but at 
the moment he did so, the same round that refused to kill me went off 
perfectly for him. Thankfully, no one was injured.
    I was admitted to the psychiatric ward of the base hospital and 
remained an inpatient for two weeks. At this time I was formally 
diagnosed with readjustment and anxiety disorders, but my physicians 
also acknowledged that I had PTSD. I was told by the doctors that my 
treatment records would be kept confidential. However, my platoon 
sergeant was notified and she then proceeded to tell my fellow soldiers 
which in turn caused much heartache and turmoil for these guys with 
whom I had gone through war and had shed blood, sweat and tears. They 
began to look down on me, because in their eyes, I was weak and they 
thought that I would not be able to do my job, nor could they trust me 
to go back to war with them if we were called to do so.
    I think that there needs to be more punishment for non-commissioned 
officers or any other soldier who has access to soldier's private 
mental health records and does not keep that information confidential. 
As in the past and still today, if a soldier has a mental health issue 
and fellow soldiers learn about it, then confidence is broken and 
military careers unquestionably are harmed. It took over a year for me 
to receive my medical evaluation board decision, and during that entire 
period I felt the effects of almost daily ridicule from members of my 
unit, a great pressure that affected my PTSD. I felt I let my soldiers 
down--that I was of no use to them anymore. I had lost my brotherhood. 
When I was finally discharged from the Army, I was diagnosed as having 
an anxiety disorder. In clearing the post prior to being released, I 
met with the Disabled American Veterans (DAV) representative who told 
me about the VA system and the entitlements that were available to me. 
That DAV representative assisted me in filing my claim for disability. 
I am grateful for the help of the DAV.
    When I first went to the VA in Birmingham, Alabama in 2007, I felt 
lost and had no guidance. With the drain of PTSD, I wanted to give up 
due to it being so difficult. I had to wait for hours just to see a 
doctor, then also wait in lines to do anything at the VA while 
constantly hearing and seeing on the televisions while sitting in the 
waiting rooms the war and bad news of soldiers being injured and 
killed. I wanted to run and hide so I could be safe. At one point I was 
put on an OIF/OEF transition team but then was removed from it because 
I was told I did not have a high-enough disability rating. Honestly, I 
couldn't handle the smell of that hospital, the crowds and VA's 
decision to assign me a doctor of Middle Eastern origin. I requested 
another doctor at the Huntsville, Alabama VA community-based outpatient 
clinic. There, I enjoyed my regular MD but the psychiatric doctor was a 
nightmare. Her recommendation was for me to go to the Tuscaloosa VA 
Medical Center for inpatient treatment, which would have included shock 
treatments to reset my brain. I did not want to do this, so I discussed 
this with my wife and we both agreed that we would try psychotherapy 
for a while to see if there could be some improvement.
    After many sessions with my therapist, however, I could feel myself 
getting worse, not better. I began avoiding my wife and my family. I 
couldn't keep myself from crying, and I locked myself into my bedroom. 
The therapy was not working. My wife would come home from work not 
knowing what I had been going through, but she could see that I was 
despondent. I explained that I couldn't talk to my therapist, that she 
didn't listen to me, she just threw another pill at me, and I felt like 
I was getting worse, not better. I asked her to go to the therapist 
with me to see what I was talking about. She did, and she saw what I 
saw.
    My wife then proceeded to call the local VA helpline and explain 
what was happening, but still there was not much help available through 
that means. Therefore, my wife and I returned to the Birmingham VA for 
help. We argued loudly with the receptionist in the psychiatric unit to 
try to get better services for me. The VA police officers stationed on 
that unit heard our argument and came to investigate. At that critical 
moment when I felt I was in jeopardy, we met Dr. Ryan. With the help of 
my wife, we explained to him my struggles with the VA, my PTSD, and 
with my overall health, and for the first time a doctor actually 
listened to us. Dr. Ryan is still is my psychiatric doctor of 
medications and also he keeps up with my overall psychology. A 
wonderful doctor he is. Dr. Ryan arranged for me to see a therapist 
weekly, ensured that I had proper medications, was assigned to support 
groups and was able to take classes. Later I met with the local 
recovery coordinator. Since that time I was asked to serve on the 
medical center's veterans' mental health council, an activity VA 
initiated to give veterans a voice to help make the local VA system 
better for mental health.

                  MORE OUTREACH TO VETERANS IS NEEDED

    It's important for people, veterans and non-veterans, to realize 
that there are different types, causes and levels of mental illness, 
and that the most important thing they can do if they think they have 
problems is to step forward and talk to a mental health professional to 
find out, even when barriers are in the way. My experience also teaches 
that veterans need to advocate for themselves, because going to the VA 
can be a difficult experience.
    I believe that the VA must do a better job of reaching out and 
making its services known to a larger share of the veteran population 
(both those recently discharged-demobilized and older generations), and 
work more cooperatively with the military service branches, other 
Federal agencies, state governments, and private mental health 
providers. Today, we have over 23 million living veterans, yet VA sees 
only a quarter of them in its health care programs, and even a smaller 
fraction in its mental health services. Given our experience to date in 
the wars in Afghanistan and Iraq, plus the overlay of combat 
experiences of prior generations of veterans, it is obvious that more 
veterans need readjustment and mental health counseling and other 
mental health services than those who are appearing at VA facilities to 
seek these services.
    NAMI deeply appreciates the existence of 273-TALK, the nationwide 
suicide hotline. NAMI's national office has commended VA's Office of 
Mental Health Services and SAMHSA for having established this vital 
link to VA counselors, who have saved the lives of thousands of 
veterans, but we believe a larger group of veterans still is in need 
and is not being reached.

                     NAMI NATIONAL VETERANS COUNCIL

    Despite our concerns about the need for broader outreach, not only 
to prevent suicides but to ensure that more veterans can become aware 
of VA services, NAMI has enjoyed a long-term interest and involvement 
in mental health programs within the VA. For 30 years NAMI has served 
as an advocate for veterans under care in VA programs, because VA is 
caring for our family members. NAMI and its veteran members formally 
established a Veterans Council in 2004 to assure close attention is 
paid to mental health issues and policies in the VA, especially within 
each Veterans Integrated Services Network (VISN) and programs at 
individual VA facilities. Council membership includes veterans who live 
with serious mental illness, family members of these veterans, and 
other NAMI supporters with an involvement and interest in the issues 
that affect veterans living with and recovering from mental illness. 
The Council members serve as NAMI liaisons with their VISNs; provide 
outreach to veterans through local and regional veterans service 
organization chapters and posts; increase Congressional awareness of 
the special circumstances and challenges of serious mental illness in 
the veteran population; and work closely with NAMI's State and 
affiliate offices on issues affecting veterans and their families. 
Currently, NAMI's national board of directors is engaging in a 
comprehensive policy review of the role of the Veterans Council with 
the expectation of strengthening the council's involvement with both VA 
and the Department of Defense.

                NAMI FAMILY TO FAMILY EDUCATION PROGRAM

    Our members are directly involved in consumer councils at more than 
growing number of VA medical centers and we advocate for even more 
councils to be established throughout the VA system. Also, VA and NAMI 
executed an important memorandum of understanding in 2007 formally 
establishing our signature Family to Family education program within VA 
facilities. As I mentioned above, Family to Family is a formal twelve-
week NAMI educational program that enables families living with mental 
illness to learn how to cope with and better understand it. The program 
provides current information about schizophrenia, major depression, 
bipolar disorder (manic depressive illness), Post Traumatic Stress 
Disorder (PTSD), panic disorder, obsessive-compulsive disorder, 
borderline personality disorder, co-occurring brain disorders and 
addictive disorders, to family members of veterans suffering from these 
challenges. Family to Family supplies up-to-date information about 
medications, side effects, and strategies for medication adherence. 
During these sessions participants learn about current research related 
to the biology of brain disorders and the evidence-based, and most 
effective, treatments to promote recovery from them.
    Family members of veterans living with mental illness gain empathy 
by understanding the subjective, lived experience of a person with 
mental illness, and Family to Family has recently been attested as an 
evidence-based practice in a journal of the American Psychiatric 
Association. Our Family to Family volunteer teachers provide learning 
in special workshops for problem solving, listening, and communication 
techniques. They provide proven methods of acquiring strategies for 
handling crises and relapse. Also, Family to Family focuses on care for 
the caregiver, and how caregivers can cope with worry, stress, and the 
emotional overload that attends mental illness in families. We at NAMI 
are very proud of Family to Family, and we were especially pleased that 
Under Secretary for Health Dr. Robert Petzel approved a renewal of our 
Family to Family agreement. We greatly appreciate that support and 
confidence and look forward to widespread adoption of Family to Family 
programs in VA treatment settings.
    The Family to Family education program has been a great success to 
date, functioning and growing in more than 100 VA medical centers. We 
at NAMI are hoping to continue building on that success, and hope to 
introduce to VA more of NAMI's signature programs, such as our Peer to 
Peer and NAMI Connections programs. We believe veterans and their 
families could greatly benefit from these programs.

                   NAMI AND VA: PARTNERS IN RECOVERY

    Mr. Chairman, as you can see from some of these examples, and from 
my own experience, NAMI is deeply concerned about the newest generation 
of repatriated war veterans, whether they remain on active duty, serve 
in the Guard or Reserves, or return to civilian life following service. 
We want to see the Department of Veterans Affairs take a more leading 
role in coordinating both inter-governmental and public-private 
arrangements that would do a better job at outreach, screening, 
education, counseling and care of the veterans who fought and are still 
fighting these wars, and to help their families recover from these 
experiences. NAMI is committed to recovery, whether from transitional 
readjustment problems coming to a family that welcomes an Army or 
Marine infantryman back from war, or one dealing with chronic 
schizophrenia in a young adult who never served in the military. In the 
case of our professional military services, we want to ensure that 
those serving in the regular force are well cared for by DOD when they 
return to their duty stations after combat deployments; by both DOD and 
VA for those in the National Guard or Reserve components when they 
return to garrison in their armories; and, by VA for those who become 
veterans on completion of their military service obligations and return 
to their families--whether in urban or rural areas.

      INTERGOVERNMENTAL AND PUBLIC-PRIVATE SOLUTIONS ARE ESSENTIAL

    NAMI believes many tailored approaches will need to be made for 
these new veterans, but that all of the civilian efforts should be led 
by VA, in coordination with other agencies (including DOD, SAMHSA, the 
Public Health Service and the Indian Health Service), the National 
Guard Bureau, State Guard leaderships, and the leaders of State public 
mental health agencies, as appropriate to the need. In some cases, 
private mental health providers should be enlisted and coordinated by 
VA to ensure they can provide the quality of care veterans may need, 
and are trained to do so in the case of Post Traumatic Stress Disorder 
and other disorders consequent to combat exposure and military trauma, 
including military sexual trauma. We realize that finding qualified 
private mental health providers in highly rural areas is an extreme 
challenge and will require VA and other public agencies to be creative. 
Nevertheless, we believe these unmet needs can be dealt with if VA 
establishes a firm will to do so. We note in VA's Office of Rural 
Health a number of inter-governmental pilot programs are beginning to 
take hold in rural areas, in VA's effort to reach out to National 
Guard, Reserve and Native American veterans who live far from VA 
facilities. NAMI applauds this progress, and we hope these pilot 
projects can set a pattern for additional initiatives of outreach and 
care.

                    VETERANS' COURTS--A CRUCIAL NEED

    NAMI also urges this Committee and other relevant groups in 
Washington and in state capitals, to expand the establishment of 
diversionary courts for veterans. In the few instances where veterans 
courts exist, they have become effective tools to get veterans who are 
struggling with mental illnesses the help that they need. NAMI urges 
the Committee to support the development of diversionary courts for 
veterans, and especially combat veterans, and to make sure that VA 
reaches out and coordinates with the existing courts systems in cities 
and States to ensure post-deployment combat veterans receive the most 
timely and effective care possible, rather than allowing sick and 
disabled veterans suffering with mental illnesses consequent to their 
war service to be convicted of crimes and sent to jail or prison. These 
veterans need care, not confinement.
    Mr. Chairman, the National Alliance on Mental Illness is committed 
to supporting VA efforts to improve and expand mental health care 
programs and services for veterans living with serious mental illness. 
For a time, forward motion was stalled on VA's ``National Mental Health 
Strategic Plan,'' to reform its mental health programs--a plan that 
NAMI helped develop and fully endorses. NAMI wants to see VA stay on 
track to provide improved access to mental health services to veterans 
returning from Iraq and Afghanistan today, as well as to other veterans 
diagnosed with serious mental illness--all important initiatives within 
the VA strategic plan. Three years ago VA established a ``Uniform 
Mental Health Service'' benefits package, one that NAMI supports as 
beneficial to ensuring VA progress toward full implementation, and will 
provide help to the newest war veteran generation and all veterans who 
live with mental illness. We hope the Committee will through oversight 
spur VA forward in implementing and perfecting this reform.
    Finally, NAMI is an endorser organization of the Independent Budget 
for Fiscal Year 2012. In that budget and policy statement, AMVETS, 
Disabled American Veterans, Paralyzed Veterans of America and Veterans 
of Foreign Wars of the United States recommend a series of good ideas 
that, if implemented would further improve VA's mental health programs. 
I ask the Committee to consider these recommendations and to ensure, 
whether through oversight or legislation that VA (and the Department of 
Defense in some instances) carries out the intent and spirit of these 
recommendations.

    This concludes my testimony on behalf of NAMI, and I thank you for 
the opportunity. I would be happy to answer questions from you and 
other Members of the Committee.
                                 ______
                                 
Posthearing Question Submitted by Hon. Mark Begich to Daniel Williams, 
    Veterans Council Representative for National Alliance on Mental 
                            Illness, Alabama

    Question 1. You focused your prepared testimony on the difficulties 
you had in finding the proper care and provider to meet your needs. 
Based on your working knowledge of the system, what existing gap do you 
see that must be fixed?

    [Responses were not received within the Committee's 
timeframe for publication.]

    Chairman Murray. Thank you very much, Mr. Williams, for 
your very compelling testimony and your courage to be here 
today and for all the work you do for others to make a 
difference in their lives. Thank you.
    Mrs. Sawyer.

 STATEMENT OF MRS. ANDREA SAWYER, CAREGIVER AND SPOUSE OF U.S. 
                   ARMY SERGEANT LOYD SAWYER

    Ms. Sawyer. Chairman Murray, Ranking Member Burr, and 
Members of the Committee, my name is Andrea Sawyer, caregiver 
and spouse of U.S. Army Sergeant Loyd Sawyer retired, and the 
mother of our two children.
    Loyd served as an Army mortuary affairs soldier working 
first at Dover Port Mortuary with the deceased servicemembers 
and later serving in the Balaad mortuary in Iraq where he 
processed countless civilian and military casualties. While 
there, he began exhibiting signs of severe mental distress.
    Upon his return, I tried for 11 months to get him help. 
Ultimately, I sat in a room with an Army psychiatrist, watched 
Loyd pull a knife from his pocket and listened to him describe 
his plan of slitting his throat.
    Multiple episodes of hospitalization and intense outpatient 
treatment followed before he was permanently medically retired 
from the Army due to severe PTSD and major depression.
    Loyd immediately enrolled in care at the Richmond 
PolyTrauma Center. In October 2008, he received 100 percent 
permanent total disability rating from the VA.
    Given his urgent need for extensive help, we tried to get 
him into the PTSD clinic at Richmond, but the first available 
appointment required a 2-month wait. When he was finally seen, 
we were told that the only thing available in the clinic would 
be a quarterly medication management session and a once every 
6-week therapy appointment.
    Knowing that his depression was spiraling and his PTSD 
symptoms were worsening, we elected to use his TRICARE. He 
began treatment with a civilian counselor. He was able to see 
him once or twice a week. But over the next 8 months, I became 
increasingly concerned about the imminent possibility of 
suicide.
    Despite giving little help from our local VA, but thanks 
very much to our Federal recovery coordinator, Loyd was able to 
enroll in an inpatient PTSD program at the VA medical center in 
Martinsburg, West Virginia.
    We had high hopes for this hospitalization, but it turned 
out to be a nightmare. The program delivered on none of its 
promises. His counselors and doctors there never coordinated 
with his local VA mental health clinician, his civilian 
counselor, or his Federal recovery coordinator.
    He was placed on medication that made them physically and 
verbally aggressive despite having been taken off that same 
medication for the same reason while on active duty. Over the 
course of the 90-day program, Loyd had fewer than five 
individual therapy sessions; and on returning home, promptly 
discontinued all of his new medication, which was a step 
backward as he had been completely meds compliant for the 18 
months leading up to hospitalization.
    In calling the Richmond PTSD clinic for help, I was told 
that it would be 4 weeks before they could see him. I tried to 
have his primary care physician intervene but was told that I 
and his FRC were wasting the time of his primary care manager.
    Eventually, again with help from our Federal recovery 
coordinator, I was able to get Loyd an appointment within a 
week with a VA psychiatrist outside of the PTSD clinic.
    She suggested that he attend a weekly therapy group that 
met with a clinician inside the Richmond PTSD clinic. Feeling 
rather hopeless, he decided to try the therapy group and 
actually found great solace in being able to relate with others 
who were experiencing the same symptoms that he was.
    Unfortunately, four months later and without consultation 
of the patients, the medical center staff announced that the VA 
was changing its treatment model and would be disbanding the 
group by year's end.
    For those wishing to continue in a group setting, the VA 
would be turning them over to an untested, community- based 
program without a clinician.
    Despite the veterans' petitioning to remain in a VA 
clinical program, their year-long effort has been unsuccessful 
except to temporarily keep the clinician.
    The 40-member group has withered to an average of five to 
seven because now, as the support group located off the VA 
campus, veterans cannot take sick leave to attend their 
meeting.
    My husband is a veteran with a well-documented, severe, 
chronic post-traumatic stress. We have all the advantages that 
should guarantee him good treatment: an excellent, caring 
Federal recovery coordinator; 100 percent service- connected 
disability rating; a fabulous OIF case manager; and the 
assistance of the super VSO.
    If a veteran with all of these advantages can not access 
timely, consistent, appropriate veteran-centered care in this 
system, what confidence can just this Committee have that any 
OIF veteran will have any greater success?
    Loyd's experience is reflective of the challenges that the 
VA faces. A detailed VA directive identifies what mental health 
services should be available to all enrolled veterans who need 
them; but as the VA acknowledged in testifying before this 
Committee, those directives are still not fully implemented 
some 4 years later.
    VA reports its health care facilities have seen significant 
numbers of OEF/OIF veterans enrolling and screening positively 
for PTSD. A study of 50,000 of those vets with the PTSD 
diagnoses found that fewer than 20 percent had a single mental 
health follow-up visit in the first year after diagnosis. VA's 
own performance measures indicate that less than 11 percent of 
veterans are completing an evidence-based treatment program for 
PTSD.
    There is a mental health crisis. The VA cannot have a 
higher goal than helping these veterans recover from the mental 
scars of war. A Department of Veterans' Affairs that routinely 
comes before this Committee with a continuous list of mental 
health programs and initiatives is a department that is failing 
many of these warriors.
    Wounded Warrior Project and I would like to work with this 
Committee and the VA to close these gaps and to transform the 
VA mental health system into one that is truly accessible and 
veteran-centered.
    My written statement includes many suggestions that would 
help VA move toward achieving these goals, and I am happy to 
answer questions of the Committee.
    Thank you.
    [The prepared statement of Mrs. Sawyer follows:]

      Prepared Statement of Andrea Sawyer, Wounded Warrior Project

    Chairman Murray, Ranking Member Burr, and Members of the Committee: 
Thank you for holding this very important hearing and for inviting me 
to testify. My name is Andrea Sawyer, caregiver and spouse of U.S. Army 
Sgt. Loyd Sawyer, retired. My testimony will both review my husband's 
experience in seeking treatment for severe PTSD as well as provide the 
perspective of the Wounded Warrior Project, with which Loyd and I have 
been associated, on these important issues.
    I believe Loyd's story not only illuminates critical issues, but 
highlights the need for major changes. Let me share his story.
    Loyd was a civilian funeral director and embalmer before joining 
the Army Mortuary Affairs team. As a mortuary affairs soldier, Loyd did 
a tour at Dover Port Mortuary where all deceased servicemembers 
returning from Iraq and Afghanistan re-enter the United States. Loyd 
worked in the Army uniform shop (where paperwork is processed and final 
uniforms prepared for deceased servicemembers) and embalmed on the days 
he was not in the uniform shop. Loyd then served a tour in Iraq, first 
in Talil and then the Balaad mortuaries where he processed countless 
deceased civilians and servicemembers. While there, he began exhibiting 
signs of mental distress including anger, hypervigilance, and insomnia.
    Upon his return home, I tried for eleven months to get him help. We 
encountered delay in getting that help because the base had only one 
psychiatrist; but the help he ultimately got was ineffective. Finally I 
found myself in a room with an Army psychiatrist and my husband, and 
watched Loyd pull a knife out of his pocket and describe his plan of 
slitting his throat. He was clearly delusional and in great psychiatric 
distress, and shortly before Christmas in 2007, he was admitted to 
Portsmouth Naval Medical Center (PNMC). He had multiple episodes of 
intensive treatment while in service: an initial crisis hospitalization 
of five weeks (three exclusively inpatient and two intensive 
outpatient), a separate one week crisis hospitalization for homicidal 
ideations, eight months in an Army Warrior Transition Unit (WTU), and 
then appointments three days a week at PNMC two hours away from our 
home Army base of Fort Lee. Loyd then underwent a medical and physical 
evaluation (MEB/PEB) process that resulted in a 70% permanent 
Department of Defense (DOD) retirement from active duty for Post 
Traumatic Stress Disorder and a secondary diagnosis of major depressive 
disorder. The accompanying medical paperwork summed up his condition: 
``The degree of industrial and military impairment is severe. The 
degree of civilian performance impairment is severe at present, though 
over time--likely measured in years (emphasis added)--with intensive 
psychotherapy augmented by pharmacotherapy to control his anxiety and 
depressive symptoms--his prognosis MAY improve.''
    In July 2008 while still on Active Duty, but with retirement 
paperwork in hand, Loyd enrolled for care at our local VA medical 
center, the Richmond polytrauma center, better known as Hunter Holmes 
McGuire VA Medical Center (HHM VAMC). In October, with help from 
Wounded Warrior Project (WWP), Loyd received a 100% permanent and total 
disability rating from VA, thus giving him the highest priority status 
for VA care.
    Knowing that Loyd needed extensive help quickly, we tried getting 
him into the VA PTSD clinic immediately. But the first available 
appointment required a two-month wait. When he was finally seen, Loyd 
presented his history, including that he had been seen two to three 
times weekly at PNMC for the last eight months of active duty, that he 
remained suicidal, and that he needed intensive therapy. 
Notwithstanding the severity of his case, we were advised that the only 
thing available in the PTSD clinic would be a quarterly medication-
management appointment and a once-a-month to once-every-six-weeks one-
hour therapy appointment. Knowing that Loyd was spiraling into a 
depression and an unchecked increase in his PTSD symptoms, we elected 
to use our TRICARE coverage, and began treatment with a local civilian 
counselor who had trained at the VA's National Center for PTSD. The 
counselor was able to see Loyd once or twice a week depending on the 
severity of the symptoms. Throughout the winter of 2008 and the spring 
of 2009, I became increasingly concerned at the out-of-control 
depression I was witnessing, and feared that suicide was an imminent 
possibility. After getting little response from VA mental health, his 
TRICARE counselor and I discussed sending him to a VA long-term 
inpatient PTSD program for PTSD. I contacted Loyd's Federal Recovery 
Coordinator (FRC) for help in finding a program. We did eventually do 
phone interviews, made a site visit, and enrolled him in a PTSD program 
at VAMC Martinsburg, WV. I got little to no help from our local VA 
hospital in finding this program, but Loyd's Federal Recovery 
Coordinator provided invaluable assistance.
    The hospitalization was a nightmare! The program delivered on none 
of its promises. His doctors there never coordinated with his local VA 
mental health clinician, his civilian counselor, or his FRC. At one 
point, his civilian counselor, his FRC, and I were calling the facility 
daily because we were concerned the medication change they had made was 
making him physically and verbally aggressive. Even more concerning, he 
had been taken off that medication while on active duty for the same 
reasons. Over the course of this ninety-day inpatient program, Loyd had 
fewer than five individual therapy sessions. Upon completing the 
program, which I truly believe was just about marking time, he was 
released and told to follow up with his local VAMC. For my husband, who 
had already expressed suicidal ideations, there was no care-
coordination or communication between any of his treatment providers. 
He came home and promptly discontinued ALL of his medication because he 
did not like the way it made him feel. This was a step backward, since 
for the year and a half prior to the Martinsburg hospitalization, he 
had been completely compliant with his medication plan.
    When I realized that he had stopped taking his medication, I 
immediately called the Richmond PTSD clinic. I was told that it would 
be four weeks before they could see him to re-evaluate his medications. 
I asked the FRC to intervene with the primary care provider (PCM) to 
try and speed up the process, but this physician simply told me, I was 
``wasting his time.'' Eventually with the help of the FRC, I was able 
to get him an appointment within a week with a VA psychiatrist in 
general psychiatry. (Since then, this psychiatrist has managed Loyd's 
medication, as she very clearly listened to what symptoms needed to be 
controlled, and, even more importantly, listened to what he needed and 
wanted as a patient.) At that time, we agreed with her, that for 
counseling, Loyd was better off continuing with the civilian counselor 
because he could be seen once/twice a week. By involving Loyd, this VA 
clinician made it much more likely that he would continue with his 
pharmacotherapy regimen. She also asked that neuropsych testing be 
redone and suggested that Loyd try the PTSD (``Young Guns'') therapy 
group that met weekly with a clinician in the Richmond PTSD clinic.
    Loyd's repeat neuropysch testing in January 2010 showed that his 
PTSD symptoms were still severe. On a psychiatric scale test for 
symptoms of PTSD used frequently by the VA (DAPS), Loyd scored 20 out 
of 20 on all the indicators except for suicidality for which he scored 
a 16, meaning he still fell into the extremely high-risk category and 
was actively suicidal. His authenticity score was a five, which is as 
high as you can score. So after more than a year in the VA, a ninety-
day hospitalization, and weekly therapy, Loyd was not really improving. 
Feeling rather hopeless, Loyd did decide to try the Young Guns group. 
He found great solace in this group in being able to relate with others 
who experienced the same symptoms, but also because he saw people in 
different stages of recovery who, led by a clinician, were able to 
analyze their behaviors and suggest multiple positive coping strategies 
that they each found successful. Unfortunately, four months into the 
group and without consultation with the patients, medical center staff 
announced that the VAMC was changing its treatment model and would be 
disbanding the group by year's end. For those who wished to continue in 
a group setting, the VA would be turning them over to a yet untested 
regional division of a new community-based program which had only two 
employees for a twenty-three county region, neither of whom was trained 
in counseling. As discussed in more detail below, the resulting year-
long saga of trying to keep the group on campus has been unsuccessful, 
and the 40-member group has withered to an average of 7 to 10.
    I believe Loyd's experience raises a strong oversight question for 
this Committee:

        My husband is a veteran with well-documented severe chronic 
        PTSD who gets treatment at one of VA's major VA polytrauma 
        centers. We have all the advantages that should guarantee him 
        good treatment--an excellent, caring Federal Recovery 
        Coordinator; the priority associated with a 100% service-
        connected disability rating; an OIF case manager; and the 
        assistance of a super VSO. If a veteran with all these 
        advantages cannot access timely, consistent, appropriate 
        veteran-centered care in a system dedicated to the care of 
        veterans, what confidence can this Committee have that a newly 
        enrolled veteran who has recently returned from the war zone 
        will have greater success?

    This Committee has rightly identified access as a barrier to 
quality, comprehensive mental health care. Two other closely-related 
issues impact that care as well:

Despite the goal of intervening early, VA is failing to reach most 
        returning veterans.
    VA reports that nearly 600 thousand, or 49% of all, OEF/OIF 
veterans have been evaluated and seen as outpatients in its health care 
facilities, and reports further that approximately one in four showed 
signs of PTSD.\1\ But more than half of all OIF/OEF veterans have not 
enrolled for VA care. Unique aspects of this war--including the 
frequency and intensity of exposure to combat experiences; guerilla 
warfare in urban environments; and the risks of suffering or witnessing 
violence--are strongly associated with a risk of chronic Post Traumatic 
Stress Disorder.\2\ The lasting mental health toll of the wars in Iraq 
and Afghanistan are likely to increase over time for those who deploy 
more than once, do not get needed services, or face increased demands 
and stressors following deployment.\3\ Chronic post-service mental 
health problems like PTSD are pernicious, disabling, and represent a 
significant public health problem. Indeed mental health is integral to 
overall health. So it is vitally important to intervene early to reduce 
the risk of chronicity.
---------------------------------------------------------------------------
    \1\ VA Office of Public Health and Environmental Hazards, 
``Analysis of VA Health Care Utilization among Operation Enduring 
Freedom (OEF) and Operation Iraqi Freedom (OIF) Veterans,'' 
October 2010.
    \2\ National Center for PTSD. ``National Center for PTSD Fact 
Sheet.'' Brett T. Litz, ``The Unique Circumstances and Mental Health 
Impact of the Wars in Afghanistan and Iraq,'' January 2007 http://
www.nami.org/Content/Microsites191/NAMI_Oklahoma/Home178/Veterans3/
Veterans_Articles/5uniquecircumstancesIraq-Afghanistanwar.pdf (accessed 
10 June 2011).
    \3\ Ibid.
---------------------------------------------------------------------------
    In 2008, VA instituted an initiative to call the approximately half 
million OEF/OIF veterans who had not enrolled for VA health care and 
encourage them to do so. This unprecedented initiative was apt 
recognition that we must be concerned not just about those returning 
veterans who come to VA's doors, but about the entire OIF/OEF 
population. But a single telephone contact is hardly enough of an 
outreach campaign.

VA has not been successful in retaining veterans in treatment.
    Until recently, little had been known about OEF/OIF veterans' 
actual utilization of VA mental health care. The first comprehensive 
study of VA mental health services' use in that population found that 
of nearly 50,000 OEF/OIF veterans with new PTSD diagnoses, fewer than 
10 percent appeared to have received recommended mental health 
treatment for PTSD (clinically defined in this report as attending 9 or 
more mental health treatment sessions in 15 weeks) at a VA facility; 20 
percent of those veterans did not have a single mental health follow up 
visit in the first year after diagnosis.\4\
---------------------------------------------------------------------------
    \4\ Karen Seal, Shira Maguen, Beth Cohen, Kristian Gima, Thomas 
Metzler, Li Ren, Daniel Bertenthal, and Charles Marmar, ``VA Mental 
Health Service Utilization in Iraq and Afghanistan Veterans in the 
First Year of Receiving New Mental Health Diagnoses,'' Journal of 
Traumatic Stress, 2010.
---------------------------------------------------------------------------
    These data raise a disturbing concern. They show that enrolling for 
VA care and being seen for a war-related mental health problem does not 
assure that a returning veteran will complete a course of treatment or 
that treatment will necessarily be successful.
    Yet VA has set a very low bar for reversing this trend. Consider 
performance measures reported in VA budget submissions. One such 
performance measure calls for tracking the percentage of OEF/OIF 
veterans with a primary diagnosis of PTSD who receive a minimum of 8 
psychotherapy sessions within a 14-week period. The FY 2010 performance 
goal for that measure was only 20%.\5\ In other words, having only one 
in five veterans attend the recommended number of treatment sessions 
constituted ``success.'' This year's budget submission shows that 
actual performance fell short of even that very modest goal, with only 
11% of PTSD patients receiving that minimum.\6\ In contrast, VA is 
meeting its performance target that 97% of veterans are screened for 
PTSD.\7\ This wide gap between VA's high rate of identifying veterans 
who have PTSD and its low targets for successful treatment needs to be 
addressed.
---------------------------------------------------------------------------
    \5\ Department of Veterans Affairs, FY 2011 Budget Submission, Vol. 
2, p. 1J-5.
    \6\ Department of Veterans Affairs, FY 2012 Budget Submission, Vol. 
2, p. 1G-7.
    \7\ Ibid.
---------------------------------------------------------------------------
                    TWO VA ``MENTAL HEALTH'' SYSTEMS

    VA operates a vast health care system, and there are many examples 
of excellence--just as VA employs many excellent, dedicated clinicians. 
It is somewhat misleading, however, to speak of ``the VA mental health 
system,'' because not only is there wide variability across VA, but in 
some respects VA can be said to operate two mental health systems. 
First, VA provides a full range of mental health services through its 
nationwide network of medical centers and outpatient clinics. That 
system has increasingly emphasized the provision of ``evidence-based-
,'' recovery-oriented care. VA's much smaller Readjustment Counseling 
program--operating out of community-based Vet Centers across the 
country--provides individual and group counseling (including family 
counseling) to assist veterans to readjust from service in a combat 
theater. In some areas, these two ``systems'' work closely together; in 
others, there is relatively little coordination between them.
    The differences between these two systems may help explain why 
greater numbers of veterans do not pursue VA treatment, and why those 
who do often discontinue.
    In our daily, close work with warriors and their families, WWP 
staff consistently hear of high levels of satisfaction with their Vet 
Center experience. Warriors struggling with combat stress or PTSD 
typically laud Vet Center staff, who are often combat veterans 
themselves and who convey understanding and acceptance of warriors' 
problems.
    In contrast with the relative informality of Vet Centers, young 
warriors experience VA treatment facilities as unwelcoming, geared to a 
much older population, and as rigid, difficult settings to navigate. 
Warriors have characterized clinical staff as too quick to rely on 
drugs, and as often lacking in understanding of military culture and 
combat. Medical center and clinic staff sometimes have more experience 
treating individuals who have PTSD related to an auto accident or 
domestic abuse than to combat. VA treatment facilities have had little 
or nothing to offer family members. Unlike Vet Centers that have an 
outreach mission, VA treatment facilities conduct little or no direct 
outreach--placing the burden on the veteran to seek treatment.
    In essence, the strengths of the Readjustment Counseling program 
highlight the limitations and weaknesses that afflict the larger 
system. Too often, that larger system:

     Passively waits for veterans to pursue mental health care, 
rather than aggressively seeking out warriors one-on-one who may be at-
risk;
     Gives insufficient attention to ensuring that those who 
begin treatment continue and thrive;
     Emphasizes training clinicians in so-called evidence-based 
therapies but fails to ensure that they have real understanding of, and 
relate effectively to, OEF/OIF veterans' military culture and combat 
experiences;
     Fails to provide family members needed mental health 
services, often resulting in warriors struggling without a healthy 
support system;
     Largely fails to establish effective linkages and 
partnerships with the communities where warriors live and work, and 
where reintegration ultimately must occur.

    Perhaps the most disturbing perception warriors have expressed 
regarding their experiences with VA mental health treatment is that VA 
officials operate in a way that too often seems aimed at serving the VA 
rather than the veteran.

                         RICHMOND: A CASE STUDY

    In describing what it termed its ``FY 11-13 Transformational Plan 
to Improve Veterans' Mental Health,'' VA emphasizes its core reliance 
on providing evidence-based, recovery-oriented, veteran-centric care. 
But when those three concepts are not in alignment, experience now 
suggests that the veteran's voice may go unheard. The Richmond VAMC 
PTSD therapy group, described above, illustrates the point.
    The Young Guns group in which Loyd participated petitioned the 
medical center director to reinstate the group. The petition, signed by 
27 members of the group, explained both the importance to the members 
of the group therapy and expressed their strong view that VA's 
alternative--for the group to operate as a community-based peer group--
was not an effective substitute.\8\ While WWP also urged the Medical 
Center Director to reinstate the group at the medical center, the 
director's reply stated that ``while these * * * PTSD groups have 
proven effective in providing environments of social support * * *, 
they are not classified as active treatment for PTSD symptoms.'' The 
upshot of the Director's ignoring the veterans' strong views and 
proceeding with the plans was that only 7 members of the Young Guns 
group attended the initial ``community-based'' group meeting (which was 
neither adequately staffed or facilitated). Most have dropped out 
altogether--having lost trust, feeling ``discarded,'' or in some 
instances--because it is no longer a ``VA group''--they could no longer 
get approval to take time off from jobs. The all important ability to 
access the care was no longer available.
---------------------------------------------------------------------------
    \8\ WWP would be pleased to provide, at the Committee's request, a 
copy of the petition and subsequent WWP correspondence on the issue 
with VA officials.
---------------------------------------------------------------------------
    Veterans too often confront a gap between well-intentioned VA 
policy and real-world practice. In this instance, the applicable VA 
policy (set forth in a handbook setting minimal clinical requirements 
for mental health care) is clear and on point:

        The specifications in this Handbook for enhanced access, 
        evidence-based care, and recovery or rehabilitation must not be 
        interpreted as deemphasizing respect for the needs of those who 
        have been receiving supportive care. No longstanding supportive 
        groups are to be discontinued without consideration of patient 
        preference, planning for further treatment, and the need for an 
        adequate process of termination or transfer. (Emphasis added.)

    Throughout our efforts to advocate for these warriors--writing to 
the Medical Center Director, meeting with VA Central Office officials, 
meeting with the Medical Center Director, and finally writing to the 
Secretary--VA's position at every level remained inflexible. Honoring 
the veterans' wishes was simply not considered a VA option and while 
numerous ``alternatives'' were listed, few took into consideration the 
sensitivities of these particular patients.
    VA did not terminate an ineffective program at Richmond VA. Medical 
Center officials even acknowledged that it was helping these veterans. 
VA's cavalier insistence on the appropriateness of this action brings 
into question the department's ability to adequately address the 
growing mental health needs of this generation of warriors.
    va mental health care policy: still in transition, ignoring gaps
    VA has certainly instituted policies aimed at providing timely, 
effective, and accessible care to veterans struggling with mental 
illness. But as the above-cited situation at the Richmond VA 
illustrates, the gap between VA mental-health policy and practice can 
be wide.
    In 2007, VA developed an important detailed policy directive that 
identified what mental health policies should be available to all 
enrolled veterans who need them, no matter where they receive care, and 
set certain timeliness standards for scheduling treatment.\9\ But as VA 
acknowledged in testifying before this Committee on May 25th, those 
directives are still not fully implemented. Funding is not the problem, 
VA testified at the time.
---------------------------------------------------------------------------
    \9\ Department of Veterans Affairs, VHA Handbook 1160.01, Uniform 
Mental Health Services in VA medical centers and Clinics.
---------------------------------------------------------------------------
    The fact that a policy aimed at setting basic standards of access 
and timeliness in VA mental health care has yet to be fully 
implemented--four years after the policy is set--has profound 
ramifications for warriors struggling with war-related mental health 
problems, and who face barriers to needed VA treatment. Of VA's many 
``top priorities,'' the mental health of this generation of warriors 
should be of utmost importance as it will directly impact other areas 
of concern such as physical wellness, success in employment and 
education, and homelessness.
    Geographic barriers are often the most prominent obstacle to health 
care access, and can have serious repercussions on the veteran's 
overall health. Research suggests that veterans with mental health 
needs are generally less willing to travel long distances for needed 
treatment than veterans with other health problems and that critical 
aspects of a veteran's mental health treatment (including timeliness of 
treatment and the intensity of the services the veteran ultimately 
receives) are affected by how geographically accessible the care 
is.\10\
---------------------------------------------------------------------------
    \10\ Benjamin Druss and Robert Rosenheck, ``Use of Medical Services 
by Veterans with Mental Disorders,'' Psychosomatics 38 (1997) 454.
---------------------------------------------------------------------------
    VA faces a particular challenge in providing rural veterans access 
to mental health care. VA has stated that of all veterans who use VA 
health care, roughly 39% reside in rural areas and an additional 2% 
reside in highly rural areas; \11\ over 92% of enrollees reside within 
one hour of a VA facility, and 98.5% are within 90 minutes.\12\ But 
many of these VA facilities are small community-based outpatient 
clinics (CBOC's) that offer very limited or no mental health 
services.\13\ Overall, CBOC's are limited in their capacity to provide 
specialized or even routine mental health care. Indeed, under current 
VHA policy, large CBOC's (those serving 5,000 or more unique veterans 
each year), mid-sized CBOC's (serving between 1,500 and 5,000 unique 
veterans annually), and smaller CBOC's (serving fewer than 1,500 
veterans annually) have the option to meet their mental health 
provision requirements by referring patients to ``geographically 
accessible'' VA medical centers.\14\ CBOC's are only required to offer 
mental health services to rural veterans in the absence of a 
``geographically accessible'' medical center.\15\ Notably, current 
policy does not define what constitutes ``geographic inaccessibility.'' 
Moreover, in those instances in which small and mid-sized CBOC's do 
have mental health staff, VA does not require the CBOC to provide any 
evening or weekend hours to accommodate veterans who work and cannot 
easily take time off for treatment sessions.
---------------------------------------------------------------------------
    \11\ Testimony of Gerald Cross, Acting Principal Deputy 
Undersecretary for Health Department of Veterans' Affairs, before the 
House Committee on Veterans' Affairs, Subcommittee on Health, 
(Washington DC: April 18, 2007), http://www.va.gov/OCA/testimony/hvac/
sh/070418GC.asp.
    \12\ Ibid.
    \13\ John R. Vaughn, Chad Colley, Patricia Pound, Victoria Ray 
Carlson, Robert R. Davila, Graham Hill, et al, ``Invisible Wounds: 
Serving Servicemembers and Veterans with PTSD and TBI,'' National 
Council on Disability, 4 March 2009, National Council on Disability, 
[www.ncd.gov/newsroom/publications/2009/veterans.doc], Accessed 
14 May 2009, 46.
    \14\ VHA Handbook 1160.01, 8.
    \15\ Ibid., 18.
---------------------------------------------------------------------------
    Since long-distance travel to VA facilities represents a formidable 
barrier to veterans' availing themselves of mental health treatment, it 
is important that VA provide community-based options for veterans who 
would otherwise face such barriers. VA policy--as reflected in the 
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.\16\ But VA officials 
have informally admitted that, despite the policy, VA facilities have 
generally made only very limited use of this new authority--often 
leaving veterans without good options.
---------------------------------------------------------------------------
    \16\ VHA Handbook 1160.01, paragraphs 13.i.; 13.k.; 23.f.(1)(c); 
23.h.(2)(b); 28.d.(1).
---------------------------------------------------------------------------
    Yet there is evidence that this rural access problem could be 
overcome if there were the will to meet it. In Montana, for example, 
the VA Montana Healthcare System has been contracting for mental health 
services since 2001. According to a report by the VA Office of 
Inspector General (OIG), more than 2000 Montana veterans were treated 
under contracts with community mental health centers in FY 2007, and 
more than 250 were treated under fee-basis arrangements with 27 private 
therapists.\17\ The OIG report also indicates that the VA Montana 
Healthcare System has sponsored trainings for contract and fee-basis 
providers in evidence-based treatments.\18\
---------------------------------------------------------------------------
    \17\ VA Office of Inspector General, Access to VA Mental Health 
Care for Montana Veterans, (March 31, 2009), 4-5.
    \18\ Ibid., 63.
---------------------------------------------------------------------------
    It is not enough for VA simply to promulgate policies and 
directives on access-to-care and timeliness. Surely we owe those 
suffering from war-related mental health conditions real access to 
timely, effective care, not the hollow promise of a policy that is 
still not fully implemented four years later.
    Finally, a four-year-old policy must itself be open to re-
assessment. VA must continue to adapt to the needs of younger veterans 
whose obligations to employers, school, or young children may compound 
the challenge of pursuing mental health care. To illustrate, a recent 
WWP survey found that among veterans who are currently participating in 
VA medical center and Vet Center support groups, 29% said they are 
considering no longer attending due to the location of the group being 
far from their place of work or home. Another 39% of respondents 
indicated they are considering no longer attending because groups are 
held at a time that interferes with their work schedule.

  NEEDED: A VETERAN-CENTERED APPROACH TO THE MENTAL HEALTH OF OEF/OIF 
                                VETERANS

    PTSD and other war-related mental health problems can be 
successfully treated--and in many cases, VA clinicians and Vet Center 
counselors are helping veterans recover. But, as discussed above, VA is 
not reaching enough of our warriors, and is not giving sufficient 
priority to keeping veterans in treatment long enough to gain its 
benefits. What can VA do, beyond fully implementing its policies and 
commitments? What should it do? WWP asked warriors and caregivers these 
questions at a summit I attended, as well as consulted with experts. 
Our recommendations follow:

    Outreach: WWP recommends that VA adopt and implement an aggressive 
outreach campaign through its medical centers, employing OEF/OIF 
warriors--who have dealt with combat stress themselves--to conduct 
direct, one-on-one peer-outreach. Current approaches simply fail to 
reach many veterans. For example, post-deployment briefings that 
encourage veterans to enroll for VA care tend to be ill-timed, or too 
general and impersonal to address the warriors' issues. An outreach 
strategy must also take account of many warriors' reluctance to pursue 
treatment. An approach that reaches out to engage the veteran in his or 
her community, and provides support, encouragement, and helpful 
information for navigating that system can be impactful. VA leaders for 
too long have limited such outreach efforts to Vet Centers. Given what 
amounts to a public health challenge with regard to warriors at risk of 
PTSD, there is a profound need for a broad VA effort to conduct one-on-
one peer outreach to engage warriors and family in their communities.
    Cultural competence education: WWP urges that VA mount major 
education and training efforts to assure that its mental health 
clinicians understand the experience of combat and the warrior culture, 
and can relate effectively to these young veterans. Health care 
providers, to be effective, must be ``culturally competent''--that is, 
must understand and be responsive to the diverse cultures they serve. 
WWP often hears from warriors of frustration with VA clinicians and 
staff who, in contrast to what many have experienced in Vet Centers, 
did not appear to understand PTSD, the experience of combat, or the 
warrior culture. Rather than winning trust and engaging warriors in 
treatment, clinical staff are often perceived as ignorant of military 
culture or even as dismissive. Warriors reported frustration with 
clinicians who in some instances do not appear to understand combat-
related PTSD, or who pathologize them or characterized PTSD as a 
psychological ``disorder'' rather than an expected reaction to 
combat.\19\ Dramatically improving the cultural competence of clinical 
AND administrative staff who serve OEF/OIF veterans through training, 
standard-setting, etc.--and markedly improving patient-education--must 
be high priorities.
---------------------------------------------------------------------------
    \19\ Id, 9, 51.
---------------------------------------------------------------------------
    Peer-to-peer support: WWP recommends that VA employ and train peers 
(combat veterans who have themselves experienced post-traumatic stress) 
to provide support to warriors undergoing mental health care. (Peer-
support must be an adjunct to, not a replacement for, quality clinical 
care.) In describing highly positive experiences at Vet Centers, 
warriors emphasized the importance of being helped by peers on the Vet 
Center staff--combat veterans who themselves have experienced combat 
stress and who (in their words) ``get it.'' Given the inherent 
challenges facing a patient in a medical setting and data showing high 
percentages discontinuing treatment, it is important to have the 
support of a peer who, as a member of the treatment team, can be both 
an advocate and support. Public Law 111-163 requires VA within 180 days 
of enactment to provide peer-outreach and peer-support services to OEF/
OIF veterans along with mental health services, and to contract with a 
national nonprofit mental health organization to train OEF/OIF veterans 
to provide such services. It is critical that the Department design and 
establish a national peer-support program, initiate recruitment of OEF/
OIF veterans for a system-wide cohort of peer-support-specialists and 
institute the required training at the earliest possible date.
    Provide family mental health services: One of the strongest factors 
that help warriors in their recovery is the level of support from loved 
ones.\20\ Yet the impact of lengthy, multiple deployments on family may 
diminish their capacity to provide the depth of support the veteran 
needs. One survey of Army spouses found that nearly 20 percent had 
significant symptoms of depression or anxiety.\21\ While Vet Centers 
have provided counseling and group therapy to family members, VA 
medical facilities have offered little more than ``patient education'' 
despite statutory authority to provide mental health services. It took 
VA nearly two years to implement a legislative requirement to provide 
marriage and family counseling.\22\ Section 304 of Public Law 111-163 
directs VA to go further and provide needed mental health services to 
immediate family of veterans to assist in readjustment, or in the 
veteran's recovery from injury or illness. This provision--covering the 
3-year period beginning on return from deployment--must be rapidly 
implemented, particularly given its time-limit on this needed help.
---------------------------------------------------------------------------
    \20\ C.W. Hoge, Once a Warrior Always a Warrior: Navigating the 
Transition from Combat to Home, (Globe Pequot Press, 2010), 28.
    \21\ Ibid, 259.
    \22\ Veterans Health Administration, IL 10-2010-013, ``Expansion of 
Authority to Provide Mental Health and Other Services to Families of 
Veterans,'' August 30, 2010.
---------------------------------------------------------------------------
    Expand the reach and impact of VA Vet Centers: Although many OEF/
OIF veterans have been reluctant to pursue mental health treatment at 
VA medical centers, Vet Centers have had success with outreach and 
working with this population. Given that one in two OEF/OIF veterans 
have not enrolled for VA care and many are likely to be experiencing 
combat-stress problems, WWP recommends that VA increase the number of 
Vet Center locations, and give priority to locating new centers in 
close proximity to military facilities. As Congress recognized in 
Public Law 111-163, Vet Centers--in addition to their work with 
veterans--can be an important asset in helping active duty, guard, and 
reserve servicemembers deal with post-traumatic stress. Vet Centers can 
serve as an important asset to VA medical centers as well, and we urge 
greater coordination and referral between the two.
    Foster community-reintegration: VA mental health care can play an 
important role in early identification and treatment of mental health 
conditions. Yet success in addressing combat-related PTSD is not simply 
a matter of a veteran's getting professional help, but of learning to 
navigate the transition from combat to home.\23\ In addition to coping 
with the often disabling symptoms, many OEF/OIF veterans with PTSD, and 
wounded warriors generally, are likely also struggling to readjust to a 
``new normal,'' and to uncertainties about finances, employment, 
education, career and their place in the community. While some find 
their way to VA programs, no single VA program necessarily addresses 
the range of issues these young veterans face, and few, if any, of 
those programs are embedded in the veteran's community. VA and 
community each has a distinct role to play. The path of a veteran's 
transition, and successful community-reintegration, must ultimately 
occur in that community. For some veterans that success may require a 
community--the collective efforts of local community partners--
businesses, a community college, the faith community, veterans' service 
organizations, and agencies of local government--all playing a role. 
Yet there are relatively few communities dedicated, and effectively 
organized, to help returning veterans and their families reintegrate 
successfully, and other instances where VA and veterans' communities 
are not closely aligned. The experience of still other communities, 
however, suggests that linking critical VA programs with committed 
community engagement can make a marked difference to warriors' 
realizing successful reintegration. With relatively few communities 
organized to support and assist wounded warriors, WWP urges the 
establishment of a grant program to provide seed money to encourage 
local entities to mobilize key community sectors to work as partners in 
support of veterans' reintegration. In short, a grant to a community 
leadership entity (which, in any given community, might be a non-profit 
agency, the mayor's office, a community college, etc.) could enable a 
community partnership with a VA medical center or Vet Center in 
supporting veterans and their families on their path to community 
reintegration. There is ample precedent for use of modest grants to 
stimulate the development of community-based coalitions working in 
concert with government to provide successful wraparound services.\24\
---------------------------------------------------------------------------
    \23\ Hoge; Once a Warrior Always a Warrior.
    \24\ M. Libby, M. Austin. ``Building a Coalition of Non-Profit 
Agencies to Collaborate with a County Health and Human Services 
Agency.'' Administration in Social Work. 26,4 (2002): 81-99.
---------------------------------------------------------------------------
    WWP has offered most of these recommendations to VA officials, and 
urged them to implement section 304 of Public Law 111-163. The response 
was little different from the responses WWP received in advocating on 
behalf of the veterans in Richmond. In essence, the message seems to 
be, ``No thank you, we'll do it our way, and we'll do it when we get to 
it.''
    The stakes are high. With a generation of servicemenbers at risk of 
chronic health problems associated with combat stress, VA and Congress 
can have few higher priorities, in our view, than to address these 
issues. With these concerns in mind, WWP is developing draft 
legislation that incorporates the recommendations we have discussed, 
and would welcome the opportunity to work with the Committee on 
instituting these reforms.

                                SUMMARY

    In closing, VA can have few higher goals than to help veterans who 
bear the psychic scars of combat regain mental health and thrive. While 
we recognize and acknowledge that VA conducts some quality programs and 
laudable initiatives, there are regrettably too many disconnects 
between those programs and initiatives and the needs Loyd and so many 
others have. WWP's work with warriors struggling with mental health 
issues--and with the caregivers who support them--reminds us daily of 
the gaps plaguing the system: gaps arising from VA's largely- passive 
approach to outreach; gaps in access to mental health care in a system 
still marked by wide variability; gaps in sustaining veterans in mental 
health care; gaps in clinicians' understanding of military culture and 
the combat experience; gaps in family support; and gaps in coordination 
with the benefits system. We look forward to working with this 
Committee on these important issues and to witness the development of a 
truly transformative veteran-centered approach to VA mental health 
care.
                                 ______
                                 
Response to Posthearing Questions Submitted by Hon. John D. Rockefeller 
 IV to Mrs. Andrea Sawyer, Caregiver and Spouse of U.S. Army Sgt. Loyd 
                                 Sawyer

    Question 1. Mrs. Sawyer, I appreciate your compelling testimony and 
I am truly sorry for the challenges you and your husband have faced is 
seeking care. Are there specific recommendations that you could make 
about the eligibility criteria of the Caregivers and Veterans Omnibus 
Health Services Act of 2010 and how it will affect families and 
veterans dealing with severe mental health and PTSD concerns?
    Response. Congress gave VA very clear direction as it relates to 
eligibility for caregiver-assistance in cases involving veterans with 
severe PTSD or other mental health conditions. But VA's implementing 
regulation has established such restrictive eligibility criteria in the 
case of a veteran with any severe mental health condition that many 
caregiver who should be eligible under the law have been discouraged 
from even attempting to apply for the comprehensive benefits.
    The regulation states the broad criteria of the ``need for 
supervision or protection based on symptoms or residuals of 
neurological or other impairment or injury,'' but then proceeds to set 
up a very strict criterion of meeting a certain threshold using a 
subjective functional-assessment tool of a GAF (Global AFfect) score.
    Specifically, the GAF-score criterion requires that a veteran have 
a continuous GAF score of 30 or less over a 90-day period. Under the 
criterion, an examiner--someone who may see the veteran for as little 
as 15 minutes--must therefore find that ``behavior is considerably 
influenced by delusions or hallucinations OR serious impairment, in 
communication or judgment (e.g., sometimes incoherent, acts grossly 
inappropriately, suicidal preoccupation) OR inability to function in 
almost all areas (e.g., stays in bed all day, no job, home, or 
friends).''\1\ In a graphic example as to unreasonable criterion of a 
30 GAF score, on the day Loyd was admitted to the hospital, fully 
suicidal, highly egodystonic, he received a 31.
---------------------------------------------------------------------------
    \1\ Federal Register (May 5, 2011): 26150.
---------------------------------------------------------------------------
    The first problem with this criterion is that a GAF score is 
subjective. Depending on who the clinician is and how they apply the 
scale, the score can vary widely. As such, GAF by itself is never used 
as the only criterion to hospitalize or diagnose a patient for any type 
of treatment. GAF is used as an instrument in a battery of tests. Nor 
is a GAF routinely administered at every VA pysch appointment. If the 
VA is going to require this, then these scores must be put in for every 
visit as well as with notes that accompany the score.
    The second problem with using a GAF score of 30 is that a safety 
risk actually occurs at a much higher score than a 30. Suicidal 
ideation which demonstrates a risk to a veteran's safety is actually 
present at a GAF score as high as 50. At any given moment depending on 
the stressor, a fragile veteran could change from ideation to 
intention; that is why a caregiver is required for a veteran with a 50, 
and why usually veterans with scores of 50 are hospitalized.
    The third problem is that if a current caregiver is good at the job 
of caregiving they defeat themselves. For instance, were it up to Loyd, 
he would stay in bed all day--a criterion for a 30 GAF score. Many 
days, even now four years later, Loyd is in bed until one or two in the 
afternoon when I put my caregiver foot down and force him out of bed. 
This is not behavior that would be seen by the VA. It would be up to 
the veteran to self-report as the VA does not ask me what his behaviors 
are. Because I force him to bathe every other day when he is in a 
severe cycle of depression means that he appears clean for purposes of 
VA evaluation. The fact that I am doing a good job forcing him out of 
bed, forcing him to interact with others, forcing him to bathe, 
essentially means that I disqualify myself for the benefit. A GAF score 
does not take into account what goes into getting Loyd clean and awake 
to get him to the VA, it only takes into account how he appears as he 
walks into the office of the clinician.
    The fact that Loyd uses the VA for minimal mental health 
treatment--medication management only--also means that he is at a 
distinct disadvantage when qualifying for services. Loyd receives his 
mental health treatment with a civilian counselor because VA is unable 
to provide him with the care that he needs, therefore when it comes 
time to evaluate him, there are no records for the VA to evaluate, not 
to mention the caregiver criterion is evaluated by a a primary care 
physician, who is not involved in any of his mental health treatment.
    Because severe PTSD can impair memory and function at GAF scores 
much higher than 30, supervision is necessary for medical care and 
medication management. Due to Loyd's cognitive processing disorder and 
memory impairment, I monitor his medication. I am also responsible for 
supervising and coordinating his medical care. This spring that meant 
that I had to step in when the VAMC kept repeatedly saying that a part 
of his large intestine was missing when it is actually his small 
intestine. Failure to supervise his medication and to manage his 
healthcare means that at any point his situation can rapidly decline. 
All of these are safety issues which fall into nuanced definitions of 
the ADLs and have nothing to do with GAF scores.
    In a recent appeals court decision, VA's own statistics prove that 
veterans who admit suicidality are not being monitored carefully. The 
statistics show that if a veteran answers yes to only one of the two 
suicide questions no VA safety plan is triggered, yet answering yes to 
only one of those questions indicates that a veteran is at risk for 
suicide. Since the VA is not monitoring that veteran's behavior, it is 
up to the caregiver to assume that role. Caregivers are taking up the 
burden of monitoring at risk behaviors, but VA refuses to acknowledge 
our role in protecting veterans. They are setting impossible standards 
for mental health caregivers to meet in order get compensation.
    Another problem in determining need for caregiver assistance based 
on a GAF score is that it creates a disparity between physical injuries 
and mental health conditions. For example, a veteran who may need 
limited assistance with the adjustment of a prosthetic would be 
eligible for caregiver support, but a veteran who suffers from suicidal 
ideation because of his PTSD and needs another's supervision would not 
qualify. The GAF-score criterion sets an unreasonably high, arbitrary, 
subjective, and inequitable standard and should be deleted from the 
eligibility criteria.
    There is no need for a GAF score criterion since the interim 
regulation provides an eligibility criterion that can generally apply 
to veterans with caregiver needs based on a mental health condition. 
That broad criterion is ``need for supervision or protection based on 
symptoms or residuals of neurological or other impairment or injury.'' 
As written, the regulation includes seven circumstances that may 
warrant a caregiver under the criteria. But those listed factors do not 
include certain common manifestations of Post Traumatic Stress Disorder 
(PTSD) and anxiety, such as significant avoidant behaviors and 
fearfulness, that could create a need for protection or supervision. 
That list of seven factors should be expanded to include common 
symptoms of PTSD, anxiety and depression that could create a need for 
supervisory or protective assistance.

    Question 2. How would you suggest that VA improve its coordination 
efforts and use of electronic records to prevent the gaps in care and 
problems in handling your husband's case?
    Response. VA must not only set care-coordination as an 
organizational priority, but must both provide clinicians and 
administrative staff the time to do this important work and create 
system-wide incentives (or eliminate disincentives) to ensure care-
coordination occurs at all levels. This must start with committed 
leadership and consistent vision at all levels of VA.
    It is critical that VA improve clinical coordination in delivering 
mental health care both within and between VA facilities and between VA 
and non-VA mental health providers. VA and DOD must continue to 
aggressively pursue a joint electronic medical record (Joint 
Information Sharing Initiative). Not only must the systems be 
interoperable, there must be a mechanism to ensure that there is a 
coordination of medical care and records between providers, facilities, 
and VISNs, as well as a way to coordinate with civilian practitioners 
that see VA patients through the use of TRICARE and Medicare. The first 
impediment to care in my husband's case came about because VA (VISTA) 
and DOD (ALTHA) systems were not compatible. Knowing that was the case, 
in late 2008, we provided a copy of my husband's active duty medical 
(mental and physical health) records to the Hunter Holmes McGuire 
Veterans Affairs Medical Center (Richmond VA). At that time, someone 
within the VA should have scanned his active duty medical records into 
the system or at least had the critical, relevant information 
transcribed into the VISTA system. Now, three years later, despite a VA 
initiative to put these records into the system, it is my understanding 
that Loyd's ALTHA records are still not entered into the VISTA system. 
My fear is that critical information contained in my husband's DOD 
medical records will ultimately disappear rather than become a part of 
his permanent VA record.
    Despite not having direct access to his DOD records, the 
Martinsburg VAMC did have access to Loyd's Federal Recovery Coordinator 
who was located at Walter Reed. Loyd's FRC did have access to those 
records and routinely tried to convey critical treatment history 
information to Martinsburg officials through repeated phone calls. 
Since the program specifically requested information on any problems 
with prior treatments, medications, or therapies, I also took a paper 
copy of his active duty medical (both physical and mental) records to 
Martinsburg during his third week of hospitalization. Unfortunately 
when I arrived on Friday afternoon, the records office was closed and 
no one at the hospital would take his records. With young children at 
home three hours away in another state, I was unable to stay until the 
office reopened on Monday, so I left the records in Loyd's possession. 
On Monday, the FRC called to tell the program personnel that he was in 
possession of his records, yet they refused to ask him for these 
records. Loyd's civilian counselor also made repeated attempts to 
contact the program. As Loyd's healthcare power-of--attorney, I also 
gave express permission to have this counselor speak with program 
staff. In addition to a willful refusal to review critical treatment 
history record, the program also refused any professional assistance 
from a care provider familiar with this veteran's situation.
    Despite repeated assertions to the contrary, Martinsburg VAMC did 
had the ability to access and use the medical records from the Richmond 
VAMC. Clearly electronic medical records are accessible system-wide. 
Martinsburg simply chose not to or personnel did not know how to use 
them. This became blatantly obvious when Loyd broke his collarbone at 
Martinsburg and then required a visit to the Richmond VAMC that weekend 
because the bone was not set correctly and pain medication was not 
accurately prescribed. Richmond had access to all his electronic 
records from Martinsburg. They were able to compare his Martinsburg x-
rays to his Richmond x-rays and comment on the need to provide the 
proper dose of pain medication. They documented all of this information 
in his electronic medical record so that Martinsburg would be able to 
access the information when he returned after the weekend. This was a 
clear indication that the Martinsburg VA had not fully and effectively 
employed known capabilities to make coordinated care the priority it 
should be.
    While Loyd was still in the PTSD in-patient program at Martinsburg, 
they changed his drugs to substances that were previously documented, 
while he was on active duty, to make him violent. In spite of my 
repeated attempts, as well as attempts by the FRC and Loyd's civilian 
counselor to discuss this concern, Martinsburg officials simply refused 
the dialog. Following a paranoid, aggressive episode while the children 
and I were in town for a visit, I had the civilian counselor call and 
ask that the program not allow him to come home until the end of the 
program. Loyd's behavior was erratic and was creating upheaval within 
the home and with the children. The program disregarded this request 
and allowed Loyd to come home anyway, arriving at 7 a.m. on a Sunday 
morning, letting himself into the house silently. I would not have 
woken, terrified and screaming, to him standing over me staring had 
ANYONE read any of his records or even attempted to acknowledge the 
wealth of mental health history that was readily available to them.
    Following Loyd's completion of the Martinsburg in-patient program, 
no effort was made to communicate with his civilian counselor, his FRC, 
or with staff at the Richmond VAMC. His discharge instructions were 
passively typed into the computer and Loyd returned home only with a 
certificate of completion. No follow-up plan was coordinated with any 
of his practitioners. This lack of active transfer was further 
complicated when he promptly ceased taking all the ``new'' old 
medication and slipped further out of control while the medication 
worked its way out of his system. After repeated unsuccessful attempts 
to get Loyd into the PTSD clinic at the Richmond VAMC, it required 
active intervention from his FRC to have Loyd seen by a psychiatrist in 
general psychiatry at the Richmond VAMC. She asked about his active 
duty medication, saw in his prior to Martinsburg hospitalization 
records that he had been meds compliant on the old meds, saw that he 
was not appropriately medicated, and began working with him to find a 
medication regimen that did not make him feel bad physically while also 
addressing the behaviors that needed to be controlled. I believe this 
psychiatrist coordinated with the civilian counselor as has our FRC. 
Unfortunately, despite repeated attempts to get the PTSD clinic at VAMC 
Richmond to do so, that important contact outside of the VA has never 
been made. When the PTSD clinic worked to cancel the Loyd's Young Guns 
therapy, I again tried to get the clinic to reach out to the civilian 
counselor who would explain to them that it was unsafe for Loyd to be 
in a clinically unsupervised group. I finally had the civilian 
counselor write a letter detailing his concerns. In April 2011, I took 
the letter to the neuropsychiatrist and the OIF team manager and asked 
them both to see that it got put in his record. I do not know yet if it 
is actually in there.
    Electronic medical records are only effective if used as a tool to 
enhance coordination of care, otherwise the electronic format is just 
that, a mere record in an electronic form. Repeatedly, the Martinsburg 
and Richmond VAMC PTSD programs have had the opportunity to interact 
with other members of his care team, and these clinics chose to not do 
so. If the VAMC is unwilling to talk to the other non-VA members of the 
care team or to input or look at the records, electronic medical 
records make no difference. When calls from a civilian counselor, GI 
specialist, or new civilian Primary Care Manager are ignored, when 
active duty records are dismissed, and even data included in the VA's 
own electronic record is not shared--the issue becomes more than just 
about record maintenance, it is about a culture of not caring. Refusing 
to communicate with other members of the care team can lead to life-
threatening situations involving mixed medications or failure to act in 
the instance of an at-risk veteran. In our situation, simply giving the 
FRC oversight power/authority to do something if a member of the VA 
care team refuses to communicate would have helped tremendously.
    Finally, Patient Aligned Care Teams (PACTs) should be improved to 
ensure that if a warrior is identified as being at-risk for PTSD he 
actually gets follow up care. VA has testified that placing mental 
health professionals in a ``Medical Home'' model and as a part of PACTs 
should materially improve mental health care-coordination at a medical 
center. As part of the PolyTrauma clinic at Richmond, we were part of a 
PACT, as are most Polytrauma teams within the VA. The problem was, Loyd 
was supposed to be followed by PolyTrauma, but was not. Eventually we 
asked to be assigned a caseworker outside of PolyTrauma since not once 
in the entire first year did his PolyTrauma case manager ever contact 
us. Even if a PACT were to catch veterans who needed mental health 
help, they would likely just refer them to the PTSD clinic which, as of 
right now is, even as documented by the VA IG, understaffed. PACTs 
simply increase the number of patients identified as needing treatment 
without providing the clinical personnel to treat them, frustrating 
veterans even further. Models are great, but the system is filled with 
a culture of not following up, and the culture does not change just 
because the model does. Nor will the number of appointments available 
change just because a PACT refers a patient to MH treatment. When VA 
fails to serve those veterans identified as needing help, there must be 
accountability top to bottom.
                                 ______
                                 
Response to Posthearing Questions Submitted by Hon. Mark Begich to Mrs. 
   Andrea Sawyer, Caregiver and Spouse of U.S. Army Sgt. Loyd Sawyer

    Question 1. Mrs. Sawyer, in your prepared testimony, you stated 
that ``enrolling for VA care and being seen for a war-related mental 
health problem does not assure that a returning veteran will complete a 
course of treatment or that treatment will necessarily be successful.'' 
You went on to describe the VA measure of success as having 20 percent 
of veterans attend the recommended number of psychotherapy treatment 
sessions. The fact the only 11 percent of PTSD patients received that 
minimum treatment objective is concerning. What should VA do to ensure 
that the 97 percent of veterans receiving PTSD screening receive the 
recommended treatment?
    Response. Ultimately, VA must raise the bar to ensure more veterans 
who screen positively for PTSD are receiving the treatment they need. 
In order to do so, VA must involve veterans in their treatment plans, 
ensure services are delivered in a way that is truly accessible to the 
lifestyle of this new generation, and utilize peers to continue to 
engage veterans in various forms of treatment while ensuring that staff 
are properly trained and informed concerning the experiences and needs 
of this generation of warriors.
    Treatment must be made available in a timely manner. VAs new 
treatment model suggests that veterans should be seen/complete a 
minimum of nine visits with VA PTSD clinicians for either group or 
individual therapy during a period of fifteen weeks. With veterans 
currently waiting months between available appointments and many 
required to drive hours to reach these appointments, this does not seem 
to be a model that can be realistically achieved. A standard of 
treatment should be predicated on what is clinically best for the 
veteran, not a mere metric that begs the question of why so few are 
completing said treatment. If there is a shortage of providers, all 
means necessary should be used to ensure timely, quality care--to 
include using mechanisms such as fee-basis more often to accommodate 
the needs of this growing population.
    Treatment must be practical. This new generation of veterans is a 
young, working population. Veterans must be able to access services at 
times and locations that allow them to continue with other activities 
of daily living--their jobs, schooling, and family responsibilities. I 
have spoken to many veterans who were unable to continue VA mental 
health treatment because it was not offered at locations or times that 
were convenient--often forcing them to make a choice between employment 
and treatment.
    VA continues to focus on veteran unemployment, yet a veteran 
following the new VA Mental Health (MH) guidelines within the current 
scheduling and appointment constraints would require an extremely 
flexible employer in order to retain a job. Assuming a veteran attempts 
to attend nine treatment sessions in a fifteen week period. In an 
average scenario drive time to that appointment could approach an hour 
away. This veteran must tell his employer that he will miss nine half 
days of work at his job within that fifteen week period. Should this be 
a new job for newly discharged veteran, the likelihood of having this 
time available is non-existent. If the veteran required all elements of 
the recovery model, factor in additional time for recovery and 
mindfulness/anger management coping skills group meetings. This could 
mean a veteran, active in his recovery, could be required to miss 
significant hours of work and only for mental health treatment 
purposes, this does not take into consideration any other physical 
health issue for which a veteran may need treatment. Few employers 
would hire or retain that individual. It is not practical. Eventually a 
veteran would have to choose between his job and his care. That is not 
a choice a veteran should have to make.
    To complicate matters, veterans nationwide are not allowed to 
choose their appointment times, leading to inconvenient and missed 
appointments and constant rescheduling requirements. No patient-
centered medical system in this country operates in such a manner. 
Currently, the VA sets the appointment time, and veterans are simply 
expected to show up regardless of other obligations. This obviously 
prevents a veteran from scheduling appointments around employment needs 
or scheduling multiple appointments on the same day. Again, young 
veterans are forced to choose between employment and treatment.
    In light of the intensive requirements of the MH guidelines and out 
of respect for the time of individual veterans, the VA needs to allow 
veterans a choice when scheduling appointments as well as offer limited 
evening and weekend hours to accommodate working veterans and veterans 
with families. The Richmond VA has stated it will implement evening 
hours, but that ``plan'' has been promised to patients for over three 
years now.
    Treatment must be tailored to the individual. VA speaks often of 
being a ``veteran-centered'' system. But a system that put its patients 
first would not insist that veterans conform with VA's preferred care-
models. Instead it would be open to providing treatment options that 
work for its patients. Individual psychotherapy may meet the needs of 
one veteran, but another might be better served in a group setting. The 
veteran must have a voice in treatment decisions. Too often in VA, 
patients are channeled into programs where every veteran is given the 
same program regardless of their needs. A system that presupposes what 
a veteran needs does not truly serve the veteran and ultimately takes 
him out of actively pursuing the path to recovery. As the VA did in my 
husband's case, every veteran in his clinician-led group therapy 
session was relegated to a community-based group without individual 
evaluation of the veteran's preparedness for this move.
    The current MH model risks a similar checklist mentality. Channeled 
veterans through a series of modules (explaining what PTSD is, what 
changes it creates in the chemicals of the body, what changes it 
creates in thinking patterns, a series of modules on coping skills) 
lends itself to an standardized shuffling without the quality 
assessment to see if veterans have mastered the skills. Once a module 
is completed it is checked off whether or not the veteran feels he has 
mastered the skill. The veteran can become frustrated by this lack of 
recourse especially if he must have to wait months for a requested 
follow-up appointment. While education is good, this model cannot 
become so metric based that veterans will be pushed through. They will, 
and to date have, quit because they do not see it as quality therapy 
that is individually tailored or focused on making a difference, not to 
mention the time it takes away from the occupational arena.
    To encourage a veteran to seek and complete treatment, VA must 
ensure that each individual veteran is not lost in a maze of completing 
treatment that is not relevant to him as an individual patient. PTSD 
veterans like all other veterans with health conditions need to be seen 
as patients first and diagnoses second. The patient's individual 
symptoms should determine his type of treatment, not a predetermined 
course of treatment that does not account for individual variances.
    Treatment must be culturally competent. As Ranking Member Burr 
commented during the hearing, VA must transform at every level to 
ensure every employee is committed to the notion of keeping veterans 
engaged in treatment. This means that when veterans call to make 
appointments, the person on the other end of the line should be 
committed to serving the veteran. When the first interaction veterans 
have with the VA mental health system is a negative one, they aren't 
likely to come back for more. VA must also do more to ensure that 
administrative employees and clinicians alike have an understanding of 
the combat experiences of OEF/OIF veterans. Imagine the frustration of 
a veteran who finds that the clinician has no real understanding of the 
experience of being in a combat zone, or even empathy for the veteran's 
experience. VA health facilities should be places where staff have a 
baseline understanding of the combat experience and military culture, 
and clinicians are uniquely suited to meet their treatment needs.
    Most VA clinicians seem familiar with PTSD as a clinical diagnosis, 
but many do not seem to understand the difference veterans experience 
with combat PTSD verses military sexual trauma (MST) verses a routine 
car accident. Veterans are routinely frustrated by having to stop and 
explain language/command structure/nature of combat jobs/basic military 
language to clinicians. In one instance, my husband was explaining to a 
clinician the damage done to a body by an IED. She got a very puzzled 
look on her face and asked how a contraceptive device could have caused 
limbs to be blown off. The difference between an IED (improvised 
explosive device) and an IUD (a female contraceptive device) had to be 
pointed out to her. At that point, that clinician had lost all 
credibility. Therapy was over for the day.
    In another instance, a female veteran whose PTSD rating is, in 
part, due to an MST and who still experiences horrific flashbacks, was 
placed in an all-male PTSD coping skills group. She was placed with 
mostly Vietnam-era men, who, as was the case in this group, had little 
respect for female servicemembers, and certainly no understanding of or 
empathy for a veteran suffering from MST. Eventually she stopped going 
to the group as it caused her more trauma listening to the comments of 
her fellow group participants than the symptoms she already 
experienced.
    VA should engage in a program similar to the Navy's Civilian 
Familiarization for all employees. This program allows members of the 
public to experience a small taste of a sailor's occupation. Also a 
continuing education class in military terms is necessary. This could 
be easily added to the required continuing education classes that 
already exist in the VA.
    VA should support the implementation of modified evidence-based 
treatments. VA currently recommends two evidence-based therapies for 
PTSD--Cognitive Processing Therapy and Prolonged Exposure Therapy. The 
idea is that a veteran needs to have 9 or more sessions spaced weekly 
or biweekly. This therapy itself is emotionally difficult and draining, 
requiring a veteran to re-experience the trauma again and again to 
desensitize himself to the emotion associated with the trauma. While 
completing treatment does improve the severity and recurrence of 
symptoms, the therapy itself is traumatizing and lends itself to 
discouraging a veteran from completing treatment. Recognizing this, the 
incorporation of complementary and alternative therapies within this 
course of the treatment, such as coping skills sessions, exercise/yoga, 
or lower intensity therapy could be useful to help motivate continued 
engagement in the more intense mental health treatment regime.
    Treatment through community based partnerships for should be 
available to a veteran as a choice not a requirement. There is a trend 
in VA to form community partnerships for purposes of offering wider 
support for veterans and for expanding options for veterans. This is a 
good trend when considering the numerous challenges faced in providing 
a menu of services for this population. But in doing this, VA cannot 
abdicate responsibility--it is necessary for there to be some kind of 
oversight process. In the case of Richmond changing the therapy groups 
to support groups and moving them off campus, the community group 
supposedly tapped by VA to facilitate the group has yet to attend a 
meeting. Furthermore, in this case, the community group selected does 
not have the appropriately trained staff to lead this group. Also, in 
the instance of Richmond, veterans were not consulted about the change, 
it was simply dictated, without evaluation to ensure that each 
individual was ready for leaving a clinical therapeutic setting and 
transitioning to a non-clinical supportive setting.
    For purposes of treatment and compensation, administrative data 
collection to support the evidence that treatment is being provided 
must be worked out in advance. Support groups do not normally keep 
attendance records, so it is difficult to prove that a veteran is 
receiving treatment through a support group. Also, community support 
groups or community clinicians need to provide evidence-based 
treatment. It is not fair to do away with a treatment at the VA because 
it is not evidence-based only to send veterans out into the community 
to receive other non-evidence based treatments while leaving them no 
options at the VA.
    VA should use a Memorandum of Agreement (MOA) with community 
partners and fee-basis providers to ensure that veterans with PTSD may 
have the option, at the veteran's discretion, of receiving evidence-
based treatment in their home communities. This scenario would make 
treatment for veterans more accessible geographically, more time 
sensitive to the onset of the symptoms, and more practical from a 
standpoint of the availability of evening and weekend hours. Using 
MOA's would allow VA to ensure that all treatment remains evidence-
based and set a clear expectation about the administrative practices it 
requires to document a veteran's treatment regimen for purposes of 
compensation.
    VA should use peer support (firmly backed by clinical treatment) to 
outreach and provide support to warriors struggling with PTSD. VA must 
focus on more effective outreach to draw veterans needing treatment 
into the system. VA can accomplish this by meeting a long-overdue 
requirement of law--implementing provisions in the Caregivers and 
Veterans Omnibus Health Act of 2010 that requires the establishment of 
a peer-outreach program through VA medical centers pertaining to OEF/
OIF mental health. As demonstrated by the success of the Vet Centers' 
approach, peers are powerful tools to not only draw veterans into the 
system, but to keep them engaged in their treatment when things are 
difficult. VA must make an earnest attempt to harness peers as partners 
to clinical treatment by establishing this program and formalizing 
these relationships by creating permanent staff positions for this type 
of work. Communication and referral between VA medical centers and Vet 
Centers must become routine and a recognized partnership within VA.
    VA should also take the opportunity to engage veterans and draw 
them in to mental health treatment at every point in the system. A 
recent survey of warriors conducted by the Wounded Warrior Project 
found that 1 in 5, or 20%, of all mental health compensation and 
pension examinations lasted less than 30 minutes. For some veterans, 
this might be their first interaction with a clinician. This is a real 
opportunity for VA to conduct a warm handoff and ensure that veterans 
seeking compensation also know where to turn for treatment. Yet the 
evidence suggests that this does not occur.

    Chairman Murray. Mrs. Sawyer, thank you very much for 
sharing that story and for your tremendous courage as well as 
those of your husband and your family helping us understand 
what you are going through. So, thank you to both of you.
    Mr. David Underriner, please proceed.

    STATEMENT OF DAVID THOMAS UNDERRINER, CHIEF EXECUTIVE, 
           PROVIDENCE HEALTH & SERVICE, OREGON REGION

    Mr. Underriner. Chairman Murray, Ranking Member Burr, and 
Members of the Committee, I really respect what Daniel and 
Andrea and Loyd have been going through. And in the context of 
what we do at Providence, I will go through it in my testimony 
to reflect the concern that we have in caring for individuals 
in our communities.
    My name is David Underriner. I am currently serving as 
Chief Executive, Delivery System for the Oregon Region of 
Providence Health and Services. Providence Health and Services 
is a Catholic-sponsored, not-for-profit health care system 
serving communities across Oregon, Washington, Montana, 
California, and Alaska.
    It was founded by Mother Joseph of the Sacred Heart in 1856 
in Vancouver, WA. Providence Health and Services comprises 27 
hospitals, more than 34 non-acute facilities, physician 
clinics, a health plan, a liberal arts university, a high 
school, approximately 50,000 employees, and numerous other 
health, housing, and educational services.
    I am here today to describe the steps taken by Providence 
Health and Services in Oregon to improve clinical integration 
of behavioral health in to our broader health care delivery 
system over the past 25 years, including our current work to 
fully incorporate behavioral health into the care provided to 
the patient-centered health home. We thank you for the 
opportunity to present today and share what we have learned 
over the past quarter century.
    First, I would like to provide some context as to why 
behavioral health is so important to Providence. Our mission 
cause us to provide high-quality compassionate care to all 
people with a special emphasis on serving the poor and 
vulnerable in our communities. Those dealing with mental health 
conditions are amongst the most vulnerable of those we serve, 
often suffering from physical challenges directly connected to 
an underlying behavioral health condition.
    As such, Providence has striven for 150 years to ensure 
that people suffering from mental illness are able to access 
the care they need regardless of their circumstances. In fact, 
in 1861 the Sisters of Providence opened the first mental 
health facility in what was then the Washington territory.
    We believe effective behavioral health care is a key 
component of improving the health status of our communities. To 
that end, Providence developed a vision statement that guides 
our day-to-day operation and provides a roadmap for our 
strategic initiatives and planning.
    Our vision for behavioral health is as follows: 
``Providence Behavioral Health Services will be an advocate and 
leader in developing a patient-centered system of care for 
people with mental health and substance needs. The system of 
care will be evidence-based, focus on recovery and work in 
partnership with our community of providers, educators, 
consumers, and families. This connected experience of care will 
achieve superior outcomes and patient satisfaction.''
    That is what drives us.
    This vision is pursued through a comprehensive 
organizational structure led by physician and administrative 
leadership focused on patient outcomes, population health, care 
coordination, patient satisfaction, strategic partnerships in 
the community, advocacy, clinical transformation and physician 
integration, research and education.
    More than 25 years ago, as part of Providence's development 
of an integrated delivery system in Oregon, the decision was 
made to include behavioral health as a distinctive, service-
line program due to its importance as a clinical area of 
excellence.
    Providence Health and Services in Oregon has eight service 
lines, including heart and vascular, cancer, brain and spine, 
and behavioral health. Each of these service lines has defined 
leadership and strategic plans for delivery of services and 
programs in a coordinated, efficient, high quality, and cost-
effective fashion.
    This decision, perhaps more than any other, facilitated the 
integration of behavioral health services into the larger 
delivery system by elevating it as a key clinical program that 
requires overarching leadership and strategic focus. It also 
set forth the path toward full integration of behavioral health 
into our regional delivery system.
    The decision led to a series of initiatives which were 
outlined in our written testimony.
    I would like today to focus on the patient-centered medical 
home. Consistent with our vision of a connected patient 
experience through a coordinated model of ``team based'' 
behavioral health services, Providence in Oregon has set about 
to fully weave behavioral health into our patient- centered 
health home model for primary care.
    This not only includes adding a behavioral health 
specialist in our primary care clinics; it also includes 
standardization of how we identify patients in need of 
assistance, development of clinical guidelines and creation of 
a team-based model of holistic care for patients being served 
in our clinics.
    This model involves the entire care team in the primary 
care clinic, with the primary care provider in the oversight 
role in the management of the patient, both in terms of his or 
her medical and behavioral health needs.
    The Providence medical group has developed a tiered 
approach to the assessment and treatment that is both 
standardized and flexible. Specifically, the tiered approach in 
behavioral health includes the use of a patient behavioral 
health screening packet which focuses on using comprehensive 
diagnostic methods to identify specific behavioral health 
issues concerning the patient.
    A behavioral health care plan is developed and implemented 
and improvement is measured. If the patient requires a higher 
level of care, appropriate referrals are made within the 
community or within the system.
    As you can see, for the patient the team approach provides 
for a comfortable, connected experience in which his or her 
whole person can be addressed in the clinic visit. The team 
knows them, cares for them, and eases their way.
    Despite the significant challenges resulting from lower 
reimbursement and inadequate numbers of mental health providers 
in the communities, we remain committed and steadfast in our 
commitment to behavioral health as a priority service line.
    Integrating behavioral health and medical home model 
provides an important, seamless point of access for patients, 
particularly those whose medical concerns are intertwined with 
a mental health condition.
    We thank you for the opportunity to speak today. I am happy 
to answer any questions that you may have.
    [The prepared statement of Mr. Underriner follows:]

   Prepared Statement of David Underriner, Chief Executive, Delivery 
          System, Providence Health & Services, Oregon Region

                              INTRODUCTION

    Chairwoman Murray, Ranking Member Burr and Distinguished Members of 
the Senate Committee on Veterans Affairs: Thank you for providing me, 
on behalf of Providence Health & Services, the opportunity to offer 
testimony on the very important topic of behavioral health care for 
American Veterans and how the Veterans Administration can take steps to 
improve access to behavioral health services through increased 
integration of care delivery. My name is Dave Underriner and I 
currently serve as Chief Executive, Delivery System for the Oregon 
Region of Providence Health & Services. In this role I am responsible 
for management and oversight of our eight hospitals in the state, as 
well as statewide functions including nursing, pharmacy, information 
systems, ethics and foundations.
    Providence Health & Services is a Catholic-sponsored, not-for-
profit health system serving communities across the states of Oregon, 
Washington, Montana, California and Alaska. Founded by Mother Joseph of 
the Sacred Heart in 1856 in Vancouver, Washington, Providence provides 
health care across the full continuum. Today, Providence Health & 
Services comprises 27 hospitals, more than 34 non-acute facilities, 
physician clinics, a health plan, a liberal arts university, a high 
school, approximately 50,000 employees, and numerous other health, 
housing, and educational services.
    Our mission calls for us to place a special emphasis on serving the 
poor and vulnerable in our communities. As such, Providence has striven 
since our founding to ensure that people suffering from mental illness 
are able to access the care they need, regardless of their 
circumstances. In 1861, the Sisters of Providence opened the first 
mental health facility in the Washington Territory. The sisters ran the 
hospital for five years and were commended by the territorial Governor 
for their humane, conscientious and compassionate care of the mentally 
ill. This commitment continues today across our system.
    Our vision for behavioral health is as follows: ``Providence 
Behavioral Health Services will be an advocate and leader in developing 
a patient-centered system of care for people with mental health and 
substance use needs. The system of care will be evidence-based, focus 
on recovery and work in partnership with our community of providers, 
educators and consumers. This connected experience of care will achieve 
superior outcomes and patient satisfaction.''
    This vision is pursued through a comprehensive organizational 
structure led by physician and administrative leadership focused on 
patient outcomes, population health, care coordination, patient 
satisfaction, strategic partnerships in our communities, advocacy, 
ongoing clinical transformation and physician integration, research and 
education.

        INTEGRATING BEHAVIORAL HEALTH WITH PHYSICAL HEALTH CARE 
                         IN THE STATE OF OREGON

    More than 25 years ago, as part of Providence's development of an 
integrated delivery system in Oregon, the decision was made to include 
behavioral health as a distinct service line/program due to its 
importance as a clinical area. Providence Health & Services in Oregon 
has eight service lines, including heart and vascular, cancer, brain 
and spine, and behavioral health. Each of these service lines has 
defined leadership and strategic plans for delivery of services and 
programs in a coordinated, efficient, high quality and cost-effective 
fashion through development of a continuum of programs and care models.
    This decision, perhaps more than any other, facilitated the 
integration of behavioral health services into our larger delivery 
system by elevating it as a key clinical program that requires 
overarching leadership and strategic focus. It also set us on the path 
toward full integration of behavioral health in our regional delivery 
system.
    Among the noteworthy integrated behavioral health models developed 
over the past two decades include:

    1. Consult Liaison Team: The Consult Liaison Services (CLS) team 
has long been seeing patients who are admitted to Medical/Surgical 
floors in both Providence Portland Medical Center and in Providence St 
Vincent Medical Center. In 2005, the team was expanded to include 
Psychiatrists, Nurse Practitioners, Social Workers and Counselors. 
These practitioners meet with patients who have been admitted for 
physical medical procedures, but who have been identified as having 
some related mental health or chemical dependency care needs. The CLS 
assess the patient's symptoms or problems and make recommendations 
regarding ``next steps'' in the treatment of the behavioral health 
issues. Often times, the CLS is able to connect the patient with follow 
up care for these needs within Providence Health and Services or in the 
community.
    2. Access Triage Call Center: Since 1997, this service has been 
staffed by masters prepared social workers and counselors and is 
available to members of the community including referred patients, 
potential patients, concerned family members and primary care 
physicians or other healthcare providers. The call center staff have 
these primary roles:

     Assess the caller's current situation, including risk for 
harm to self or others;
     Facilitate the involvement of other 
agencies (police, crisis team, EMTs) as needed;
     Triage to the next level of care needed;
     Whenever possible, engage the caller in an intake process 
for one of the Mental Health or Chemical Dependency services offered at 
PH&S.

    In 2007, the Access Triage Call Center initiated a ``pilot'' 
program with the Providence Medical Group (PMG) Clinic in Sherwood, 
Oregon as a mechanism to respond to medical care providers concerns 
about depressed patients who may be thinking of suicide. The call 
center supported a dedicated line that PMG health care providers could 
utilize either in consultation, or to have the patient speak directly 
to a behavioral health clinician.
    In 2010, the Access Triage Call Center piloted a project to provide 
follow up calls to people who visited the Emergency Department at 
Providence Portland Medical Center for mental health or chemical 
dependency reasons. The goal of the project is to reduce the frequency 
of visits by individuals who presented repeatedly for care. Call center 
staff call out to the identified individuals and offered support for 
the person in completing their discharge plan.
    3. Behavioral Health Interface with PMG--In 2004, one of the 
masters-prepared counselors from Access Triage was placed in the PMG 
Gateway Clinic in Portland as a pilot. The counselor's appointment 
times were quickly booked up by the health care providers who had 
active patients that needed counseling support. This position has 
continued through the current time as a result of the pilot. It also 
has laid the foundation for a current plan which PMG has recently 
launched.
    In 2010, the Access Triage Call Center provided telephone support 
to PMG patients who were participating in an on-line depression study. 
Patients were identified by their primary care physician, invited to 
participate, and then began the study. Patients were able to contact 
Access Triage for support and/or intervention, if needed, at any time 
during the study.
    In 2011, seven clinics were identified for a project which would 
staff each of the chosen clinics with a Behavioral Health Specialist. 
The specialist is tasked with assessing the level of care needed by the 
PMG patient and facilitating the patient's entry into treatment, 
particularly into the Partial Hospital or Intensive Outpatient levels 
of care, before the patient's symptoms develop to a level that requires 
a hospital admission.
    Both individually and collectively, these initiatives support 
improving access for mental health patients such that they can receive 
the right level of care when they needed--to be directed to the ``right 
door'' the first time. This goal of creating a single point of access 
has evolved to provide points of access from other settings within the 
Providence delivery system and allows Providence providers to act in 
concert to ease the way of patients in need of behavioral health 
services.

       CURRENT INTEGRATION EFFORTS: PATIENT-CENTERED MEDICAL HOME

    Consistent with our vision of a connected patient experience 
through a coordinated model of ``team based'' behavioral health 
services, Providence in Oregon has set about to fully weave behavioral 
health into our Patient-Centered Health Home model for primary care. 
This not only includes adding a behavioral health specialist into our 
primary care clinics; it also includes standardization of how we 
identify patients in need of assistance, development of clinical 
guidelines and creation of a team-based model of holistic care for 
patients being served in our clinics.
    This model involves the entire care team in the primary care 
clinic, with the primary care provider (PCP) in an oversight role in 
the management of the patient, both in terms of his or her medical and 
behavioral health needs. Providence Medical Group has developed a 
tiered approach to assessment and treatment that is both standardized 
and flexible:

    1. The patient is referred to the clinic's behavioral health 
provider by his/her PCP to address any behavioral health issues that 
may be exacerbating a current physical health condition.
    2. The patient, with a behavioral health provider and medical 
assistant, completes a questionnaire and screening packet;
    3. The behavioral health provider then determines the intensity of 
the necessary intervention based on the screening;
    4. The Care Team, led by the PCP, is activated--treatment is 
planned and implemented, including facilitating connection to the 
community and specialty care if needed. This also includes consultation 
on drug therapy management with a pharmacist who is also part of the 
team.

    The behavioral health provider also educates members of the care 
team on documentation, coordination and treatment support for 
behavioral health concerns. Providence began developing the fully 
integrated PCMH model at four of our PMG clinic sites, with three 
additional clinic pilot sites scheduled to be on line by 
September 2011.
    The PCMH integration initiative will measure effectiveness using a 
variety of metrics, including:

     Improvement in patients' Patient Health Questionnaire 
(PHQ-9) scores from first to last session with their behavioral health 
provider;
     Patient and provider satisfaction improvement;
     Reduction of Emergency Department (ED) visits for patients 
seen by the behavioral health provider;
     Reduction of hospital visits for patients seen by the 
behavioral health provider
     Improvement in chronic care conditions for those patients 
seen by the behavioral health provider;
     Process and other measures, such as number of handoffs to 
behavioral health specialist, average time to initial appointment with 
behavioral health specialist, percentage of use of community support 
networks and medication adherence.

    For the patient, the team approach provides for a comfortable, 
connected experience in which his or her whole person can be addressed 
in the clinic visit: the care team knows them, cares for them and eases 
their journey to improved health.

         CONCLUSION: IMPLICATIONS FOR THE VA HEALTH CARE SYSTEM

    Despite the significant challenges resulting from low reimbursement 
and inadequate numbers of mental health providers in the communities, 
Providence has remained steadfast in its commitment to behavioral 
health as a priority service line program in Oregon. Integrating 
behavioral health into the medical home model will provide an 
important, seamless point of access for patients--particularly those 
whose medical concerns are intertwined with a mental health condition, 
in some cases one that is undiagnosed.
    The VA health system, in our view, has both an imperative and 
unique opportunity to fully integrate behavioral health care into its 
delivery models. According to recent statistics, 48 percent of veterans 
returning from duty in Afghanistan and Iraq are diagnosed with a mental 
health condition.\1\
---------------------------------------------------------------------------
    \1\ Veterans Administration, ``Analysis of VA Health Care 
Utilization Among US Global War on Terrorism Veterans, 4th Quarter, 
Fiscal Year 2009,'' March 1, 2010.
---------------------------------------------------------------------------
    Over the past two decades, the VA has greatly strengthened its 
primary care capacity and has taken important steps by developing 
integrated health networks across the Nation and re-focusing the system 
on population-based care delivery, rather than a hospital-oriented 
system. From 1995 to 2005, the VA expanded its primary care access 
points by 350 percent. The VA has been a leader in the use of 
electronic medical records (EMRs) and automating care processes.\2\
---------------------------------------------------------------------------
    \2\ Thomas L. Garthwaite, MD, Presentation to Federal Trade 
Commision workshop, ``Clinical Integration in Health Care: A Checkup, 
The Veterans Health Administration Experience,'' May 29, 2008
---------------------------------------------------------------------------
    Additionally, the VA health system's utilization of employed 
physicians provides a key structural component that allows the system 
to integrate its service lines more rapidly--including behavioral 
health. By emphasizing the primary care clinic setting as the focal 
point of diagnosis, care planning and referral for veterans' health 
concerns, there is a strong opportunity to create a more comfortable, 
safe and efficacious environment to meet their needs.
    It is our hope that the Providence experience in clinically 
integrating behavioral health with physical health in our Oregon region 
can offer some perspective that will benefit the VA health system as it 
moves forward in redesigning care systems and structures in order to 
better serve the current and future health needs of America's military 
veterans.

    Thank you for the opportunity to speak to you today.
                                 ______
                                 
  Response to Posthearing Questions Submitted by Hon. Mark Begich to 
David Underriner, Chief Executive, Delivery System, Providence Health & 
                        Services, Oregon Region








    Chairman Murray. Thank you very much for your testimony.
    Dr. Daigh.

  STATEMENT OF JOHN D. DAIGH, JR., M.D., ASSISTANT INSPECTOR 
    GENERAL FOR HEALTHCARE INSPECTIONS, OFFICE OF INSPECTOR 
 GENERAL, U.S. DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY 
            MICHAEL SHEPHERD, M.D., SENIOR PHYSICIAN

    Dr. Daigh. Madam Chairman, Ranking Member, Members of the 
Committee, it is an honor to be here to represent the work of 
the Inspector General to you today.
    I would like to first thank Andrea and Daniel for their 
courage, for the statements they made as prior to me giving 
this testimony.
    There are two gaps in the delivery of mental health care 
that I would like to emphasize in my oral statements with you. 
The first has to do with what I would call coordination of 
care. We have looked at a number of cases over the years in 
detail where veterans either committed suicide or had other 
untoward outcomes.
    It has been almost a constant in those cases that at the 
level of the patient trying to get his care coordinated either 
between CBOCs, Vet Centers, and VA medical centers, but also 
between VA-owned facilities and civilian facilities.
    Veterans that we have looked at closely almost never get 
their care entirely from the VA. They get it both from the 
community and from private practitioners.
    And third, the family of these veterans who are adults 
often feel left out at the end of the day when bad things have 
happened.
    So, I think that the coordination of care between the 
communities involved in these veterans is a very important 
issue.
    I think that the patient-aligned care teams, as I 
understand them, offer an opportunity, and I hope will address 
this problem over time. So, I think that is hopefully a good 
way to begin to look at that problem.
    The other gap that I would like to talk about would be 
access to who I would call mental health specialists, and for 
me that would be those psychiatrists, psychologists, and in the 
VA system, I would also include in that group pain management 
experts since so many of our veterans return from war with 
physical disabilities, have substance-abuse disorders and/or 
have pain syndromes that are really quite complex to deal with.
    When we looked at residential rehab programs in the report 
we recently published where VA had established staffing 
guidelines for physicians, PAs, and nursing practitioners, they 
had in these programs 73 percent of the individuals they 
thought they should have. For psychiatrists, they had 68 
percent. For psychologists, they had 49 percent. And for social 
workers, they had 65 percent.
    In the recent report we published on Atlanta waiting times, 
one of the problems that complicated the issue in Atlanta, from 
our point of view, is that there was inadequate mental health 
staffing at CBOCs, not that the VA did not try to put mental 
health providers there but they were not there; and I think 
that diminished the flexibility of Atlanta to deal with the 
issues that they had.
    So, I guess, I would make the point that when you have 
extremely complex patients presenting with very complex mental 
health conditions, I think they need to see rather quickly the 
captain of the team who, for me, would be a psychiatrist or an 
experienced provider.
    And that individual then needs to lay out a plan that the 
rest of the team, the patient-care aligned team and all the 
support staff can then follow. So, I am less comfortable that 
the patient-aligned care team will directly get individuals to 
the specialist that they need to see. It might do that. I am 
just skeptical as to whether it will do that.
    So, I think that given the staffing issues that we see, I 
think the VA ought to consider, in areas where there are a 
relative wealth of mental health providers, establishing 
arrangements with those providers that are beyond the fee-basis 
arrangement, arrangements where a medical record can easily be 
shared, where the coordination of patients is easily seen and 
easily understood and a common activity.
    Where VA does not have primary care outposts, which is a 
large part of the country, and where the communities might be 
small enough that there really is not a demand for mental 
health providers, I think VA needs to sit down and talk with 
the State and local leaders, mental health providers, to see if 
they cannot pool patients to create the demand and pool 
resources to provide the clinics that might then take care of 
those individuals where they live.
    With that, I would end my oral statement, and Dr. Shepherd 
and I will be happy to answer questions. Thank you.
    [The prepared statement of Dr. Daigh follows:]

  Prepared Statement of John D. Daigh, Jr., M.D., Assistant Inspector 
 General for Healthcare Inspections, Office of Inspector General, U.S. 
                     Department of Veterans Affairs

    Madam Chairman and Members of the Senate, Thank you for this 
opportunity to testify on the delivery and the quality of mental health 
care provided by the Department of Veterans Affairs. My statement is 
based on the many reports issued by the Office of Inspector General 
(OIG) including reports on system-wide reviews and reports on the care 
provided to individual veterans. Accompanying me today is Michael 
Shepherd, M.D., Senior Physician in the OIG's Office of Healthcare 
Inspections.

                               BACKGROUND

    The Veterans Health Administration (VHA) has been a national health 
care leader for many years due to the quality and dedication of VA 
employees, their use of the electronic medical record, their national 
patient safety program, and their commitment to use data to improve the 
quality of care. VHA's decision to provide public access to extensive 
data on quality and process measures is a further step forward as is 
the decision to limit the surgical procedures at facilities based on 
the facility's ability to handle follow-up care.
    The delivery of mental health care to veterans is a significant 
challenge for VA, especially due to the growing number of Operation 
Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) veterans seeking 
care and their often coexisting complex medical conditions. According 
to VA, more than 1.2 million of the 5.2 million veterans seen in 2009 
in VA had a mental health diagnosis. This represents about a 40 percent 
increase since 2004.
    The percentage of OEF/OIF veterans enrolled in VA is historically 
high compared to prior service eras. Among VA-enrolled OEF/OIF 
veterans, 51 percent have received mental health diagnoses and rates of 
Post Traumatic Stress Disorder (PTSD) and depression have steadily 
risen as the contemporary nature of warfare increases both the chance 
for injuries that affect mental health and the difficulties facing 
veterans upon their return home. In addition, mental health issues are 
often contributing factors to veterans' homelessness.

                         UTILIZATION OF VA CARE

    One area that many perceive as a gap is in mental health services 
for women veterans. The OIG was asked to review VA's capacity to 
address combat stress in women veterans (Review of Combat Stress in 
Women Veterans Receiving VA Healthcare and Disability Benefits, 
December 16, 2010). We assessed women veterans' use of VA health care 
for Traumatic Brain Injury (TBI), PTSD, and other mental health 
conditions. To conduct this review, we analyzed integrated data from 
almost 500,000 male and female veterans who separated from the military 
from July 1, 2005, to September 30, 2006, for their experience 
transitioning to VA and using VA health care and compensation benefits 
through March 31, 2010. Nearly half of these veterans served in OEF/OIF 
before their separation. Using this data, we described veterans' 
experience transitioning to VA and using VA health care and their 
compensation benefits through March 31, 2010.
    We found the following:

     Female veterans generally were more likely to transition 
to and continue using VA health care services--As of March 31, 2010, 
199,301 (40 percent) veterans in the study population and 52 percent 
OEF/OIF veterans used or transitioned to VA health care. Higher 
proportions of female veterans transitioned to VA care than their male 
counterparts, except for the non-OEF/OIF reserve component cohort in 
which proportions of females and males were the same. In addition, 23 
percent used Department of Defense care (including TRICARE), although 
they did not use VA care. Among veterans who transitioned to VA health 
care, female veterans generally were more likely to use VA health care 
and used it more frequently than male veterans. We examined 
individuals' numbers of VA outpatient visits by year for the 3 years 
after military separation to assess whether veterans continued their 
use of VA health care after their initial decision to use VA. Female 
veterans continued more frequent use of VA care than their male 
counterparts by years after separation. Increasing trends of 
utilization were observed for male and female veterans diagnosed with 
mental health issues, PTSD, TBI, and veterans with military sexual 
trauma.
     Higher proportions of female veterans generally were 
diagnosed with mental health conditions by VA after separation, but 
lower proportions were diagnosed with PTSD and TBI--VA diagnosed about 
22 percent of the study population with mental health conditions, with 
higher proportions of female veterans generally diagnosed than their 
male counterparts. Overall, VA diagnosed more than 9 percent of the 
study population with PTSD. The proportion of OEF/OIF veterans VA 
diagnosed with PTSD was at least 3 times higher than those of their 
non-OEF/OIF counterparts. However, VA diagnosed fewer female veterans 
with the specific mental health condition of PTSD except for the 
veterans in the non-OEF/OIF active duty cohort. VA diagnosed over 2 
percent of the study population with TBI. The proportion of OEF/OIF 
males diagnosed with TBI was twice as high as those of females across 
military components. The proportion of OEF/OIF veterans diagnosed with 
TBI was more than 3 times greater than their non-OEF/OIF counterparts.
     In keeping with the results of the VA diagnosis, higher 
proportions of female veterans generally were receiving disability 
benefits for mental health conditions, but a lower proportion for PTSD 
and TBI--As of March 31, 2010, nearly 126,500 (26 percent) veterans in 
the study population were receiving compensation for their service-
connected disabilities. Among the veterans awarded disability 
compensation, 30 percent of them were receiving some disability award 
for mental health conditions. Higher proportions of female veterans 
were receiving service-connected disability compensation and receiving 
some compensation for mental health conditions, except for the OEF/OIF 
reserve duty component cohort in which the corresponding proportion of 
females was about 1 percentage point lower than that of males. However, 
lower proportions of females generally were awarded disability 
compensation with a component for the specific mental health condition 
of PTSD.
    For OEF/OIF veterans, PTSD was the most common disability award 
component for both women and men, while major depression was the most 
prevalent for the non-OEF/OIF veterans. Higher proportions of female 
veterans received some disability compensation than their male 
counterparts for each of the five prevailing mental disability award 
components, except for PTSD. Less than 1 percent of the veterans in the 
study population were awarded service-connected TBI disability, with 
lower proportions of females than their male counterparts.

                  PROGRESS MADE, BUT MORE WORK REMAINS

VA Mental Health Residential Rehabilitation Treatment Programs
    The OIG issued a follow-up report to a comprehensive 2009 review of 
VHA residential health care facilities (A Follow-Up Review of VHA 
Mental Health Residential Rehabilitation Treatment Programs, June 22, 
2011). The 2009 report contained 10 recommendations based on identified 
areas of concerns (Healthcare Inspection--Review of Veterans Health 
Administration Residential Mental Healthcare Facilities, June 25, 
2009). Our 2011 review evaluated any improvements made or problems 
remaining in these areas since our 2009 report.
    The 2011 review found that progress was made in many areas, but in 
one key area, VHA made little interim progress--ensuring contact with 
patients during the time interval between acceptance into a mental 
health residential rehabilitation program and the start of the 
program--indicating an ongoing challenge with continuity during care 
transitions. Also, we found two other areas of concern: the actual 
staffing in place despite core mental health clinician staffing 
guidelines and, in light of the emphasis on a recovery based model, the 
4 percent of patients referred to vocational rehabilitation services. 
We also remain concerned about the provision of more than a 7-day 
supply of narcotics to veterans in residential programs. We made 7 
recommendations to the Under Secretary for Health; we will monitor 
VHA's implementation of those recommendations through the OIG's Follow-
Up Program.

Post-Traumatic Stress Disorder Counseling Services
    We conducted an inspection of the Readjustment Counseling Service 
(RSC) Vet Centers' PTSD counseling services to determine how Vet 
Centers screen for PTSD; if documentation of clients' treatment is in 
compliance with policy; and if providers are trained to provide PTSD 
counseling services according to policy (Healthcare Inspection--Post-
Traumatic Stress Disorder Counseling Services at Vet Centers, May 17, 
2011).
    In a previous OIG review of the RCS Vet Centers' operational 
services provided during FY 2008, we found that documentation in client 
treatment records and staff PTSD counseling training was in need of 
improvement (Healthcare Inspection--Readjustment Counseling Service Vet 
Center Report, July 20, 2009). As part of the 2011 review, we evaluated 
whether any improvements had occurred in these areas.
    Our 2011 review found that RCS Vet Center counselors utilized 
appropriate tools to screen clients for PTSD. Client treatment case 
file documentation improved from our FY 2009 report. While staff 
training has improved, approximately 15 percent of Vet Center providers 
have not attended RCS' required training on PTSD, and 47 percent of the 
providers have not attended VHA-sponsored PTSD training. In addition, 
some Vet Center providers received supplemental training in Evidence-
Based Therapy (EBT), and most Vet Centers were providing EBT to PTSD 
clients.
    Although RCS made improvement from our previous review, we found 
that Vet Center Directors were not consistently providing supervision 
and consultation to the Vet Center providers in accordance with RCS 
policy. We made two recommendations which the Under Secretary for 
Health concurred with and provided an acceptable implementation plan. 
We will continue to follow up until all actions are complete.

Suicide Prevention
    Veteran suicides remain an important focus of VA's mental health 
delivery plan. VHA estimates that there are approximately 1,600 to 
1,800 suicides per year among veterans receiving care within VHA and as 
many as 6,400 per year among all veterans.
    At the request of VHA, we reviewed VHA facilities' suicide 
prevention safety plan (SPSP) practices at 45 facilities as part of the 
OIG Combined Assessment Program reviews from January 1 through 
September 30, 2010 (Combined Assessment Program Summary Report--Re-
Evaluation of Suicide Prevention Safety Plan Practices in Veterans 
Health Administration Facilities, March 22, 2011). Our report found the 
VHA facilities recognized the importance of developing comprehensive 
and timely SPSPs for high-risk patients. Additionally, VHA issued 
appropriate timeframes for initiating SPSPs. However, despite VHA's 
efforts to comply with suicide prevention program requirements, 
problems with SPSP development continue to occur. We reviewed the 
medical records of 469 inpatients and outpatients placed on the high 
risk for suicide list. We found that 12 percent of these records did 
not have documented SPSPs. We recommended that the Under Secretary for 
Health, in conjunction with Veterans Integrated Service Network and 
facility senior managers, ensure that mental health providers develop 
and document timely SPSPs that meet all applicable criteria.
    Additional areas that would benefit from increased VHA attention 
include: ensuring follow-up contact with veterans who have been 
discharged from a mental health ward within 7 days of discharge to 
check on their mental health status because this is a time of high 
suicide risk (in FY 2010, only 4 of 111 medical centers met VA's 85 
percent goal for this indicator); and efforts to facilitate ongoing 
engagement and retention of OEF/OIF veterans in mental health 
treatment.

Coordination of Care
    We reviewed the quality of a veteran's care at a VA Medical Center 
to determine if the events leading to the veteran's death were 
connected to any issues with the quality of care (Healthcare 
Inspection--Review of Quality of Care at a VA Medical Center, 
December 9, 2010). Our review identified three areas that the medical 
center could improve on. Specifically, the medical center needed to 
ensure smooth transitions when there are changes in veterans' providers 
and/or care settings. The medical center also needed to improve 
internal communications between providers and external communications 
with veterans and other parts of the VA system to ensure that 
significant information is communicated timely and with individuals who 
have a need to know. Last, the medical center needed to review the 
procedures of the Disruptive Behavior Committee to ensure clear and 
consistent messages about patient risk and to promote patient-centered 
solutions when risks are identified. Whether addressing these three 
issues previously would have resulted in a different outcome for the 
veteran is unknown.
    While this report focused on one veteran's care, it follows a 
series of reports on individual veterans' care that continue to 
indicate that for those veterans with a complex interplay of mental 
health, medical, and psychosocial issues, VHA needs to better 
coordinate care internally among providers and clinics, between VBA and 
VHA, and when possible between private sector health care providers, 
families, and VA.

                 TOPICS AFFECTED BY MENTAL HEALTH CARE

Homeless Veterans and the Relationship to Mental Health
    The Secretary has committed to reducing the number of homeless 
veterans. In many instances, VHA has provided compassionate care to a 
most challenging population. We conducted a review of allegations that 
VHA staff discharged a homeless veteran to a shelter without the 
ability and appropriate supplies to care for himself, and against his 
will (Healthcare Inspection--Alleged Continuity of Care Issues VA 
Greater Los Angeles Healthcare System Los Angeles, California, March 4, 
2011). We did not substantiate the allegations.
    At the time of discharge, system staff determined that the patient 
had capacity to make decisions, was medically stable, and was able to 
care for himself. Discharge planners explored and offered appropriate 
disposition options. However, the veteran refused all available options 
because each required behavioral agreements and/or Social Security 
contributions. Throughout the discharge planning process, the veteran 
often told staff he intended to return to being homeless. Staff 
negotiated plans for him to go to a homeless shelter (which he agreed 
to do), and provided him with instructions on self-care, medication 
that did not require refrigeration, medical supplies, follow-up 
appointments, and transportation to a shelter. We found that staff made 
multiple and reasonable efforts to negotiate acceptable and safe 
disposition plans with the veteran while also respecting his right to 
make his own decision. VHA is challenged to determine which sub-
population of veterans is most at risk of becoming homeless, and of 
placing homeless or at risk veterans into programs that are 
demonstrated to be effective.
Pain Management Program Impact on Mental Health Treatment
    Pain management programs remain a difficult problem for VA to 
manage and appear to have an uneven impact upon patient care across the 
country. The OIG has published a number of hotline reports on this 
topic and is in the process of a national review of issues related to 
pain management (Healthcare Inspection--Prescribing Practices in the 
Pain Management Clinic, John D. Dingell VA Medical Center, Detroit, 
Michigan, June 15, 2011, and Healthcare Inspection--Alleged 
Inappropriate Prescription and Staffing Practices, Hampton VA Medical 
Center, Hampton, Virginia, October 12, 2010).
    The combination of physical injury, medication dependence, and 
mental illness make this an extremely difficult but important aspect of 
VA care that requires improved outcomes to assist veterans in their re-
entry into civilian society.

                               CONCLUSION

    VA continues to make progress in their mental health programs 
despite increasing numbers of veterans with significant mental health 
disorders, particularly among women veterans. Continued attention must 
be given to improving staffing and access to care, providing continuity 
during integral care transitions, coordinating care for individual 
veterans with mental health issues, and linking pain management, mental 
health, and substance use programs.

    Madam Chairman, this concludes my statement. Dr. Shepherd and I 
would be pleased to answer any questions that you or other members of 
Committee may have.
                                 ______
                                 
Response to Posthearing Questions Submitted by Hon. Mark Begich to John 
   D. Daigh, Jr., M.D., Assistant Inspector General for Health Care, 
    Office of Inspector General, U.S. Department of Veterans Affairs




    Chairman Murray. Thank you very much for your work on this. 
Dr. Daigh, let me start with you. As you mentioned, you heard 
the testimony. The stories that we have heard before the 
Committee today are not unique. I hear them everywhere I go, 
and Congress has been listening to this. We have responded with 
the resources, with legislation, new programs. The IG has 
provided the oversight.
    Yet, here we are, and these stories are still here and they 
are relevant again today. You mentioned a little bit in your 
testimony about problems in the coordination of care. I heard 
you talk about Atlanta, that they needed more clinicians but it 
is not that they did not try, I think you said. It is just that 
they were not there.
    Is it lack of providers? Is it lack of resources? Tell us 
what we need to be doing in order to make sure that the VA has 
what it needs, or what we should be telling the VA what it 
needs to do.
    Dr. Daigh. I think that from my understanding of the 
situation in Atlanta and looking at the data, there was a 
tremendous growth in the demand for mental health services over 
a relatively short period of time.
    Some of the assumptions that they made about how they would 
provide care, their inpatient ward for example, they thought it 
would be functional and it was not. So, they had to adjust.
    I think they could have made better decisions about how 
they adjusted. Our report says that we think they could have 
made better decisions about how they adjusted.
    But part of the problem is that if you have prearranged 
relationships with universities or private practices or clinics 
of specialists that you know you need and you can easily call 
on them as opposed to fee basis where you say I cannot meet 
your demand, here is a chit, go get care, if you have an 
organized way, the records are shared, they expect to see 
patients.
    Chairman Murray. Which goes to be closed system that I 
think Mrs. Sawyer was referring to, is that it?
    Dr. Daigh. I think it is along the lines of what she was 
saying where she was able to go outside the system and get some 
help that was coordinated with it but maybe not. I am not sure. 
We can talk.
    Chairman Murray. Mrs. Sawyer, tell me what your experience 
was.
    Ms. Sawyer. We actually were not able to use the fee-basis 
system in the VA as fee-basis was not an option offered. 
Because my is medically retired, we have TRICARE and so we just 
simply chose to exercise the TRICARE benefit. It was not in 
conjunction with the VA.
    Even requesting a fee basis at Richmond even for physical 
medical care is a labor-intensive process. It takes months. It 
is not easy to get done. It is really kind of a broken system.
    So, even though there has been a directive that people 
should be able to use fee-basis care, in terms of wait, you 
still have to get it approved and it almost takes, pardon the 
pun, and an act of Congress to get it done.
    Chairman Murray. Mrs. Sawyer, in your testimony, let us 
talk about that. I mean, you just told us time and time again 
that you were fighting everything to get appointments, to get 
attention. Dr. Daigh mentioned needing a captain of the team.
    Did you ever feel like there was a captain of the team?
    Ms. Sawyer. Quite honestly, I feel like I am the captain of 
the team. I feel that I monitor symptoms. I see the increase in 
symptoms, the decrease in his quality-of-life, and that at that 
time I activate the chain as it is.
    I call the FRC. I call the clinic. I call the OIF case 
manager. I do everything that I can. The problem with the VA is 
that we have found is time and time again I have gone in and 
said, ``We are seeing the civilian counselor.'' I have said it 
to neuro-psychiatrist. I have said it to the person he was 
seeing in the PTSD clinic. I have said it to his OIF case 
manager. It is in his records.
    And yet, again and again, I get comments from the PTSD 
clinic, ``We did not know he was seeing anyone else.'' I am 
sorry. You can Google it and find that he is seeing someone 
else. We have not stayed quiet about it.
    We just cannot get them to pay attention. I hand the number 
over. I ask them to call his counselor. I am his health care 
power of attorney. There is a flag on his chart. I am supposed 
to coordinate his medical information because of a cognitive 
processing disorder. I constantly say, ``Please call his 
counselor,'' and they do not.
    Chairman Murray. This is a full-time, 24/7 job for you.
    Ms. Sawyer. Yes, ma'am, I gave up my job. In order to keep 
him alive--that is what I had to do.
    Chairman Murray. I hear that all the time, and it has to 
have a huge impact on you and take a tremendous amount of 
courage. I think about all the men and women out there who do 
not have a Mrs. Sawyer as the captain of their team. I 
appreciate what you have been doing.
    Ms. Sawyer. Thank you.
    Chairman Murray. Mr. Williams, again thank you for your 
service. All of what you are talking about is echoed in many 
other stories as well. You mentioned getting a hard time geting 
an appointment. I was curious whether any of the mental health 
care you receive is offered after hours or on weekends.
    That is another thing I hear from a lot of people who have 
a job, do other things, and cannot get care because of lack of 
after hours or weekend services.
    Is that something that you have been able to access or see 
a need for?
    Mr. Williams. There needs to be a larger amount of this 
care, yes. The access, the only access I have to this is the 
Vet Center, which is not communicating with the VA actual 
facility.
    This is a center where they do after-hours counseling. They 
do marriage counseling. They are really not communicating to be 
honest with you. They have no idea what is going on. There 
needs to be more of it. There needs to be more advertised that 
there is these after-hours care that can be used when, you 
know, you have, you get off at six o'clock, well, they have 
sessions at seven or eight o'clock at night.
    You know, the family members need this care too because the 
family members have the same or gain the same PTSD or whatever 
the diagnosis may be as the veteran does.
    I know, as Mrs. Sawyer said, she gave up her, pretty much 
her life, to take over, to help her husband. And this is what 
happens not only to her but I think just about every family 
either the spouse leaves or the spouse stands behind them.
    And I know if it was not for the woman behind me, I would 
not have any care that I have today because she has given up 
her job to take care of me.
    And there does need to be some more after hours. I know 
NAMI is partnering with the VA to do family to family. Family 
to family is a program that helps the servicemember's family 
understand why they are doing the things they are doing, why 
they are trying to get an adrenaline rush, why they are doing 
these little quirks that may not make sense to the family.
    Chairman Murray. This may be a rhetorical question, but it 
seems to me like people like both of you know the system really 
well. Your family has really borne the burden of this silent 
disorder of Post Traumatic Stress Disorder and Tramatic Brain 
Injury. We have a country that says they are there for our 
soldiers, but you alone have borne this.
    Does the country understand PTSD? Do your neighbors and 
employers and people in the community know what you are going 
through? Or do you feel pretty alone?
    Mr. Williams. To be honest with you, I feel very alone. The 
only other people that understand is my family; and when I say 
my family I mean my wife, and other soldiers or other veterans. 
They are the only ones that understand the actual pain, the 
invisible pain that we live with every day.
    It is very, very hard to try to express to the Nation. We 
get condolences. Thank you for your service. We hear that very 
often. But when was the last time someone actually said, all 
right, we need to make a change in the VA center. You need more 
services.
    That is the type of thanks that I believe, I take more to 
heart action than I do words, because like I said, it is not 
only I suffer from this mental illness of Traumatic Brain 
Injury, my wife has to go through it. My kids have to go 
through it.
    So, this is a never-ending cycle. My kids will have PTSD 
because of my actions. If we could put peers together, family 
members, like Mrs. Sawyer and my wife together, more times the 
support for one another not only for themselves but for us it 
would be a stronger VA system. They have got to start looking 
at family-oriented stuff.
    It is such a just the veteran that half the time the 
veteran cannot even get stuff done. I mean, it literally takes 
my wife getting to the point of being arrested by VA police to 
be able to see my psychiatric doctor because people are sitting 
on the phones, talking on their cell phones during business 
hours, telling me to hold on a minute and I am having a crisis 
where I am fixing to honestly have a breakdown.
    And it takes people like these two women to have, not every 
veteran has that, not everyone is fortunate enough, and I think 
that needs to somehow be a mentorship to veterans that do not 
have the support system.
    Chairman Murray. Mrs. Sawyer, do you want to add anything?
    Ms. Sawyer. Truly I do not feel that the community 
understands. We spend a lot of time at the VA. Going to the VA 
is never just go-for-an-hour-for-an-appointment. It is go; you 
sit. You have a nine o'clock appointment, and you might get 
seen by eleven. Then the doctor says, ``Oh, well, we are only 
running 2 hours late today. That means we are on time.''
    Then we sit for an hour. Sometimes it is not a good 
appointment. Then it takes hours for him to wind it down, and 
we get home and the neighbors say, ``What do you do all day?''
    I talk to a lot of other caregivers who are in my 
situation. I have attempted to mentor some of the other 
caregivers because I do have a lot of time to deal with 
caregivers that I have met through the Wounded Warrior Project 
here at different stages in their recovery.
    I have been privileged that they trust me to call and ask, 
``OK, we are stuck; what do we do?'' We needed to build our own 
strong network outside of the VA and that is really what I use 
to survive.
    We have a community kind of all to ourselves. We have been 
ostracized from the community. I left my job teaching. I had 
great scores for the ``be all to end all'' test at the end of 
the year that all teachers are judged by whether we say they 
are or not, great scores.
    But I had missed a lot of work. It was my fourth year, my 
tenure year, and it was Loyd's first year after he was retired. 
We were spending a lot of time at the VA, which meant I was 
spending a lot of time out of the classroom, and my principal 
came to me and told me I had to choose between getting my 
husband better and teaching.
    So, I left. So no, the community does not understand.
    Chairman Murray. Thank you very much for sharing that with 
us.
    Mr. Williams, I know your wife is sitting directly behind 
you. We want to thank her for her being here as well and for 
all she does for you.
    I have gone way over my time. Senator Burr, I apologize. 
But I felt what they had to say was extremely important for the 
Committee. So, I will turn it over to you.
    Senator Burr. I was interested in your questions and more 
importantly the answers and, for as grateful as I am that all 
of you are on this panel, and I have got questions, I am going 
to forgo all but one because, quite honestly, I do not want 
anything to stand in the way of the VA coming to that table 
while your testimony is fresh on their minds and share with us 
where there is not a problem.
    But I will ask you, Andrea, with the exception of your 
recovery officer, was there anybody in the VA that attempted to 
solve any of the problems that you had or went the extra mile 
to try to facilitate some type of remedy to the health 
challenge?
    Ms. Sawyer. We actually have a fabulous OEF/OIF team that 
is a part of our VA. Our team at Richmond is wonderful. We have 
a patient advocate, the team leader, and then OEF/OIF case 
manager social worker. They have since added a couple of people 
to the office.
    Two of them are OEF/OIF vets, and the social worker is the 
wife of a vet. It is truly personal to them, and they take it 
personally. They have intervened countless times.
    I have watched my OEF/OIF case manager storm down and say, 
``You had 14 days to act on this referral. It is now day 30. 
What is your problem?'' She has been my champion.
    I could not have done without her, but we did not get 
introduced to that team until a year and a half into the VA; 
but once we were, they have been absolutely fabulous. They have 
done everything that they can.
    The problem is that they file complaints, and then they do 
not have the authority to act when nothing is done. So they do, 
I mean they literally do everything that they can, complain, 
marched down there, attempt to hold people accountable to see 
what they can get done. But then when they cannot get anything 
done, there is no remedy for the situation. And so, it does 
necessitate me calling DC.
    The other thing that has been helpful for me personally as 
a family member, the Memphis VA did a pilot study, a telehealth 
group for caregivers, where there are 10 of us that all knew 
each other and so we asked to be in a special group. We were 
spread across the country, and they talked with us once a month 
on a group call and really tried to give us advice as a group 
and really to just help us heal and find resources within the 
system.
    The problem with that was it was a year-long pilot and, of 
course, our year has ended and we are back floundering on our 
own again.
    So, a lot of times I feel like the VA has some great things 
inside of it, but there is a time limit and when your time 
limit is done it does not matter if your condition is done. 
They are done with you.
    Senator Burr. You have given us a number of avenues to look 
at from the standpoint of this Committee, and I am grateful to 
you for that.
    Ms. Sawyer. Thank you.
    Senator Burr. I thank the Chair.
    Chairman Murray. Senator Brown.
    Senator Brown of Massachusetts. Thank you, Madam Chair. I 
kind of concur with Senator Burr. I am curious, I mean, the 
stories are not unlike the ones that you have seen, Madam 
Chair, and others throughout the country.
    In Massachusetts, we have very similar problems. They are 
working on them. With the Guard and Reserve, we have I think a 
better handle on it than the regular Army folks.
    I just had one question of Dr. Daigh. The VA has increased 
the number of mental health staff by more than 6,800 and are 
training another 4,000 since last October. Yet, we continue to 
hear stories like this.
    Where do you think the breakdown is?
    Dr. Daigh. I am going to be a little bit of a pessimist 
here. I think that people will try very hard. I am not sure 
that all of these stories will ever end. I think there will 
always be disappointments in the delivery of care between 
patients, their needs, and providers.
    Senator Brown of Massachusetts. But this seems just so 
egregious, these stories.
    Dr. Daigh. I understand that. I am not disagreeing at all, 
and I think that the limit that I would see is that I think 
there is sort of a finite number of practitioners out there.
    And when you are in a city where there are mental health 
resources outside of what the VA owns, I think that an 
arrangement with those groups that are able to see veterans 
through a contracted or a regular occurring use would make it 
easier for the access issues that I think are at the heart of 
much of what people are talking about to be addressed where 
people can then see the experts that they need to see.
    Senator Brown of Massachusetts. So, is there a breakdown 
that we can help with? For example, I am in the military still, 
and I understand there is always rules and regulations.
    Is there a breakdown where you are not able to go and seek 
those outside entities? Is there something that we need to 
tweak and fix to make that easier?
    Dr. Daigh. I would defer to experts----
    Senator Brown of Massachusetts. Is a territorial?
    Dr. Daigh. I would defer to experts on contracting. But my 
message to you is I do not think fee basis which is, in my 
view, a blow-off valve for a temporary increase in demand that 
you cannot meet with the resources you have is working.
    And I think a more concerted effort to build relationships 
within the communities where they exist would alleviate some of 
what we hear here. And the other piece I think, I do hope that 
the patient-aligned care teams are better able to deal with the 
coordination, both within VA and with VA.
    So, that would be my view as to what we need to consider.
    Senator Brown of Massachusetts. Great. I will defer to the 
next panel.
    Chairman Murray. Mrs. Sawyer.
    Ms. Sawyer. Senator Murray, if I may, I guess, Senator 
Brown, what I would like to say about those hiring numbers, 
with the 7,500 new staff. I heard Dr. Zeiss say in a hearing on 
the House side a couple of weeks ago that not all of that new 
staff are actually clinicians. They are techs.
    So, they are not all people who are available to actually 
treat patients. Some of them are support staff. The other thing 
that I have seen in my experience at the VA is that a lot of 
people are hired on as only part-time clinicians and the rest 
of the time they are doing admin or research. They are not 
boots on the ground 100 percent of the time.
    And quite frankly, we have a crisis. They need to be there 
treating. I am not saying that research is not needed and is 
not necessary, but at this point we need people seeing 
patients.
    Senator Brown of Massachusetts. Madam Chairman, maybe there 
is an opportunity for you to inquire like what are the actual 
boots-on-the-ground numbers so we understand who is working 
part-time and who is working full time, how many people they 
are seeing, what is the breakdown so we can get a better handle 
on that sort of thing.
    Chairman Murray. I think we will have that opportunity with 
the next panel. So, we will definitely follow-up.
    Mr. Williams, do you have a comment?
    Mr. Williams. Yes, ma'am, I would like to make one more 
statement. Two things. A better way to see veterans not only 
with their crisis of not having a lot of doctors and also 
covering rural areas would be telemedication. I do not think 
that is an avenue that has been seriously looked at that would 
help a lot.
    Two, you can, right now it is hard to change things if 
there is a hiring freeze for the VA system, and you could hire 
peers or veterans that are making great progress in their 
recovery.
    I am not saying for lesser pay. The same thing you can 
spend on a psychiatrist or a psychologist when we can work 
together as a team to make a lot better place to save lives.
    Chairman Murray. All right. I may have additional questions 
to submit for the record, particularly for Mr. Underriner and 
Dr. Daigh.
    I want to thank all of you for your testimony today, and I 
concur with Senator Burr: I think it is important for us to get 
the VA up here. They had just heard your testimony. We want to 
hear their response.
    So again, thank you to each and every one of you for being 
here today and your continued input to this Committee. It is 
extremely valuable.
    With that, I want to call our second panel up for their 
testimony. We will pause for just a minute in order to change 
seats here.
    While they are getting seated, I will go ahead and 
introduce the second panel.
    We are pleased to have Mr. William Schoenhard, Deputy 
Undersecretary for Health for Operations and Management at the 
Department of Veterans Affairs.
    Mr. Schoenhard is accompanied today by Dr. George Arana, 
Assistant Deputy Under Secretary for Health for Clinical 
Operations; Dr. Zeiss, Acting Deputy Chief Consultant for 
Mental Health; and Dr. Schohn, Acting Director for Mental 
Health Operations.
    Mr. Schoenhard, I believe you are going to testify for the 
panel today. So, if you will proceed please.

  STATEMENT OF WILLIAM SCHOENHARD, DEPUTY UNDER SECRETARY FOR 
   HEALTH FOR OPERATIONS AND MANAGEMENT, U.S. DEPARTMENT OF 
VETERANS AFFAIRS; ACCOMPANIED BY GEORGE ARANA, M.D., ASSISTANT 
  DEPUTY UNDER SECRETARY FOR HEALTH FOR CLINICAL OPERATIONS; 
  ANTONETTE ZEISS, Ph.D., ACTING DEPUTY CHIEF CONSULTANT FOR 
  MENTAL HEALTH; AND MARY SCHOHN, Ph.D., ACTING DIRECTOR FOR 
                    MENTAL HEALTH OPERATIONS

    Mr. Schoenhard. Yes, ma'am. Before I begin, I would like to 
thank Mrs. Sawyer and Mr. Williams for their testimony. I for 
one, as a veteran, was very moved by their testimony. I talked 
to them briefly during this exchange and would very much like 
to personally follow-up with them and learn more of their story 
and what we can learn.
    But to these people who serve our country, whether they 
have served in uniform or as spouses of those who have served, 
their service is appreciated, and I want to express regret for 
any difficulty that they have had and a pledge to get better.
    We have, since 2005, addressed a number of gaps in mental 
health thanks to the support of the Congress with budget 
enhancements. As already has been mentioned, a number of staff 
have been hired.
    We have put together a comprehensive mental health 
strategic plan in a landmark mental health services handbook 
that was developed in 2008.
    As Madam Chairman acknowledged, with the wars our volume of 
patients served has increased significantly. In 2005 we served 
905,000 veterans for mental health services. In fiscal year 
2010, that had risen to 1\1/4\ million.
    If you consider the number served in mental health in our 
integrated setting in primary care, the number in fiscal year 
2010 was 1.9 million. So, there is a great, great need.
    Suicides are obviously of tremendous concern to all of us. 
One suicide is one too many. A crisis line was established in 
July 2007. To show you the importance of this, over 400,000 
calls have been received on that crisis line since it was 
initiated with over 15,000 rescues. There is a great need.
    Suicide prevention coordinators are now in every of our 
facilities. We have teams that work in our larger ones to be 
able to work with our rural and other clinics and CBOCs.
    One of the advances this year under Dr. Petzel's 
leadership, our Undersecretary for Health, is a reorganization, 
and that is represented here in this panel where a number of 
clinical leaders have been added to operations in management, 
where I sit.
    We have been, I think, particularly blessed to have a 
psychiatrist as the assistant deputy, Dr. Arana, who is next to 
me. And with the addition of Dr. Schohn, who has been in mental 
health operations working to deploy our uniform mental health 
handbook, we have more boots on the ground in operations to 
have consistent deployment, monitoring, and improvements as we 
go forward.
    It is extremely important that mental health be integrated 
into primary care if for no other reason than the worry that 
many fellow veterans of mine have and that is a stigma around 
accessing mental health services.
    So, I know the Committee has already received testimony 
regarding the development of patient-aligned care teams in the 
effort to integrate better the captain of the ship and the team 
to be able to forge coordinated care.
    I could not agree more with Dr. Daigh from my private-
sector experience or in VA so far that improved coordination is 
needed.
    We have made progress. In 2008, 77,000 veterans were 
treated in primary care settings for mental health. That rose 
to 155,000 in 2010, but much more is needed as we go forward.
    Earlier testimony spoke to Vet Centers. This is another 
important element of care for veterans because some veterans 
may be reticent to access traditional VHA services.
    These Vet Centers that will number some 300 in 2011 and 
include 39 rural Vet Centers, 70 mobile clinics are important 
in terms of outreach. They provide professional readjustment 
counseling for those who have suffered military sexual trauma, 
and they provide bereavement counseling for families with 
servicemembers who have lost their life while on active duty.
    In fiscal year 2010, we served 191,000 veterans in these 
Vet Centers. That is about 1.2 million visits. It is important 
also to understand that, while there were 120,000 referrals 
from Vet Centers to our facilities for mental health, 39 
percent of those who were seen in Vet Centers do not access 
traditional VHA services.
    So, that is another source of outreach to those who, for 
whatever reason, may be reluctant to access traditional 
services. Particularly in my era, the Vietnam era veteran.
    Let me just conclude by saying, there is no more important 
work we could be about than the provision of mental health 
services. I have seen firsthand, as a veteran on the deployment 
during wartime, the impact of the extended deployment. Mental 
health is integral to the quality of care and the quality-of-
life for our veterans.
    I come with 34 years of private sector experience. This is 
the most mission-driven organization I have ever been a part 
of. I came too from a Catholic system, but this is an area 
where one suicide is one too many. We can do better and we will 
do better. Learning from people like Mrs. Sawyer and Mr. 
Williams today is an important activity for us, and I would 
again thank the Committee for its focus, its leadership, its 
support of our efforts. I am happy to answer any questions.
    [The prepared statement of Mr. Schoenhard follows:]

   Prepared Statement of William C. Schoenhard, FACHE, Deputy Under 
    Secretary for Health Operations and Management Veterans Health 
          Administration, U.S. Department of Veterans Affairs

    Chairman Murray, Ranking Member Burr, and Members of the Committee: 
Thank you for the opportunity to appear and discuss the Department of 
Veterans Affairs' (VA) provision of mental health care to America's 
Veterans. I am accompanied today by my colleagues Dr. George Arana, 
Assistant Deputy Under Secretary for Health for Clinical Operations; 
Dr. Antonette Zeiss, Acting Deputy Chief Consultant for Mental Health; 
and Dr. Mary Schohn, Acting Director for Mental Health Operations.
    Mental health care is an important component of overall health care 
and well being. VA recently realigned the Veterans Health 
Administration (VHA) to enhance effective oversight and to better 
support VA's health care programs, including mental health. By 
establishing the Office of Mental Health Operations in the Office of 
the Deputy Under Secretary for Health for Operations and Management, VA 
ensures that there is a structure for implementing policies developed 
by VHA under the guidance of the Office of Mental Health Services. The 
Office of Mental Health Operations reports to me, and I work closely 
with the Directors of all of the Veterans Integrated Service Networks 
(VISNs), thereby making one entity responsible for ensuring that 
organizational priorities concerning mental health are met. The Office 
of Mental Health Operations will monitor compliance and provide 
technical assistance to networks to support implementation of national 
policies. Priorities will continue to be guided by the Office of Mental 
Health Services, which serves as the locus of policy development for 
mental health care in VA. The Offices of Mental Health Services and 
Mental Health Operations work very closely, supporting each other's 
efforts fully. This realignment is expected to reduce variance across 
clinical specialties, including mental health, and to promote an 
integrated approach to the delivery and management of health care for 
America's Veterans.
    My testimony today will discuss our initiatives to improve access 
to and the availability of mental health services, and our initiatives 
to enhance the quality of mental health care VA delivers.

                            IMPROVING ACCESS

    Access to care is the first step toward treatment and recovery. One 
particularly important barrier to accessing care is the stigma that 
some believe comes from seeking mental health care. To reduce this 
stigma and improve access, VA has integrated mental health into primary 
care settings to provide much of the care that is needed for those with 
the most common mental health conditions, when appropriate. Mental 
health services are incorporated in the ongoing evolution of VA primary 
care to Patient Aligned Care Teams (PACT), an interdisciplinary 
structure to organize holistic care of the Veteran in a single primary 
health care team. Between fiscal year (FY) 2008 and FY 2010, the number 
of unique individuals receiving mental health care in a primary care 
setting increased by 102 percent, from 77,041 to 155,554. Recent 
program evaluation studies demonstrate the integration of mental health 
services into primary care settings has increased access to large 
numbers of younger, elderly, and women Veterans; these cohorts do not 
typically access specialty mental health services to the same degree as 
other populations. In parallel with the implementation of these 
programs, VA has been modifying its specialty mental health care 
services to emphasize psychosocial as well as pharmacological 
treatments and to focus on principles of rehabilitation and recovery. 
In addition, VA is designing and will deploy this fall important public 
messaging campaigns to combat stigma and emphasize the strengths of 
Veterans and the invaluable contributions they make to our country.
    VA has responded aggressively since FY 2005 to address previously 
identified gaps in mental health care by expanding our mental health 
budgets significantly with the support of Congress. In FY 2011, VA's 
budget for mental health services, not including Vet Centers, pharmacy, 
and primary care, reached over $5.7 billion, while the amount included 
in the President's budget for FY 2012 is $6.15 billion. Both of these 
figures represent dramatic increases from the $2.4 billion obligated in 
FY 2005. This funding has been used to greatly enhance mental health 
services for eligible Veterans. VA has increased the number of mental 
health staff in its system by more than 7,500 full time employees since 
FY 2005. There has been recent concern over the use of resources to 
fill vacant positions, and we share this concern. We will discuss these 
vacancies with VISN leadership and ask for reports to determine if 
recent evidence is simply an aberration or a part of a larger trend. If 
the latter, we will develop strategies and action plans to rapidly 
address this issue.
    For Veterans under VA care, identifying and treating patients with 
mental health conditions is paramount. VA's efforts to facilitate 
treatment while removing the stigma associated with seeking mental 
health care are yielding valuable results. VA screens any patient seen 
in our facilities for depression, Post Traumatic Stress Disorder 
(PTSD), problem drinking, and a history of military sexual trauma, 
usually on their first visit. Thereafter, screenings for depression and 
problem drinking are repeated annually throughout the time the Veteran 
comes for care. PTSD screening is annual for the first 5 years and 
subsequently is done every 5 years. Screening for MST is only formally 
done once, though the response on the electronic health record screen 
can be changed at any time if the Veteran volunteers new information 
suggesting a past history that was not reported on the initial screen. 
Any positive screen must be followed by a full diagnostic evaluation; 
if the screening is positive for PTSD or depression, an additional 
suicide risk assessment is conducted. This screening and treatment have 
been incorporated into primary care settings, resulting in the 
identification of many Veterans who benefit from early treatment, 
before they may have reached the point of initiating discussion of 
mental health difficulties they are facing.
    VA's enhanced mental health capabilities include outreach to help 
those in need to access services, a comprehensive program of treatment 
and rehabilitation for those with mental health conditions, and 
programs established specifically to care for those at high risk of 
suicide. VA has a full range of sites of care, including inpatient 
acute mental health units, extended care Residential Rehabilitation 
Treatment Programs, outpatient specialty mental health care, 
telehealth, mental health care in integrated physical health/mental 
health settings such as the PACT, geriatrics and extended care 
settings, and Home-Based Primary Care, which delivers mental health 
services to eligible home-bound Veterans and their caregivers in their 
own homes. VA also offers ``after hours'' clinics that make services 
available to Veterans during non-regular hours, such as evenings and 
weekends.
    Our efforts to improve access and provide the full range of needed 
mental health services have increased the numbers of Veterans receiving 
mental health care in VA. In FY 2010, VA treated more than 1.25 million 
unique Veterans in a VA specialty mental health program within medical 
centers, clinics, inpatient settings, and residential rehabilitation 
programs; this was an increase from 905,684 treated in FY 2005. If 
including care delivered when mental health is an associated diagnosis 
in integrated care settings, such as primary care, VA treated almost 
1.9 million Veterans in FY 2010, an increase of almost a half million 
Veterans since FY 2005.
    The policy guiding VA's significant advances in mental health 
services since 2005 was developed by the Office of Mental Health 
Services, beginning with the VA Comprehensive Mental Health Strategic 
Plan, which was implemented utilizing special purpose funds available 
through the Mental Health Enhancement Initiative. In 2008, 
implementation of the strategic plan culminated in development of the 
VHA Handbook on Uniform Mental Health Services in VA medical centers 
and Clinics, which sets mental health policy for VA by defining what 
mental health services should be available to all enrolled Veterans who 
need them, no matter where they receive care. Current efforts focus on 
fully implementing the Handbook, and continuing progress made, 
emphasizing additional areas for development, and sustaining the 
enhancements made to date. These implementation efforts have the 
promise of being even more fully successful, with the reorganization 
described in my opening comments that created the office of Mental 
Health Operations.
    According to VHA policy guidelines, all new patients requesting or 
referred for mental health services must receive an initial evaluation 
within 24 hours, and a more comprehensive diagnostic and treatment 
planning evaluation within 14 days. These guidelines help support VA's 
Suicide Prevention Program which is based on the concept of ready 
access to high quality mental health care and other services, and is 
discussed in more detail later in this testimony. Data closely 
monitored by VA confirm that our established standards for access to 
mental health care have generally been met through FY 2010 and the 
first half of FY 2011; however, we have noted some concern that the 
system may not be fully meeting this requirement in the most recent 
month. Up to the most current data, over 96 percent of all Veterans 
referred for new mental health care receive an appointment leading to 
diagnosis, and when warranted a full treatment plan, within 14 days. 
Similarly, data showed that over 95 percent of established mental 
health patients were receiving appointments for continuing care within 
14 days of their preferred date, based on the treatment plan. As 
successful as this appears, we note that the waiting time data is 
starting to show some decline, with the percentage of patients meeting 
the requirement falling from a high of 96 percent in 2010 to just over 
95 percent in 2011. Because of the importance of this indicator, and 
because the Uniform Mental Health Services Handbook is not yet fully 
implemented, the Office of Mental Health Operations is developing a 
comprehensive monitoring system to identify problems proactively in 
conjunction with the VISNs and to develop action plans to ensure that 
full implementation occurs. Based on assessments already conducted, 
current efforts at improving implementation are targeted toward 
increasing utilization of the psychosocial and recovery model across 
all areas of mental health service delivery, increasing development and 
integration of mental health into primary care, geriatric and specialty 
care services, and increasing the utilization of specialty substance 
abuse services.
    The VA Suicide Prevention Program builds on all of the components 
described above; it is based on the concept of ready access to high 
quality mental health care and other services. VHA has added Suicide 
Prevention Coordinators (SPC) at every facility and large community-
based outpatient clinics (CBOC); these are an important component of 
our mental health staffing. The SPCs ensure local planning and 
coordination of mental health care and support Veterans who are at high 
risk for suicide, they provide education and training for VA staff, 
they do outreach in the community to educate Veterans and health care 
groups about suicide risk and VA care, and they provide direct clinical 
care for Veterans at increased risk for suicide. One of the main 
mechanisms to access enhanced care provided to high risk patients is 
through the Veterans Crisis Line, and the linkages between the Crisis 
Line and the local SPCs. The Crisis Line is located in Canandaigua, New 
York, and partners with the Substance Abuse and Mental Health Services 
Administration National Suicide Prevention Lifeline. All calls from 
Veterans, Servicemembers, families and friends calling about Veterans 
or Servicemembers are routed to the Veterans Crisis Line. The Crisis 
Line started in July 2007, and the Veterans Chat Service was started in 
July 2009. To date the Crisis Line has:

     Received over 400,000 calls;
     Initiated over 15,000 rescues;
     Referred over 55,000 Veterans to local VA SPCs, who are 
available in every VA facility and many large CBOCs, for same day or 
next day services;
     Answered calls from over 5,000 Active Duty Servicemembers; 
and
     Responded to over 16,000 chats.

    VA also has put in place sensitive procedures to enhance care for 
Veterans who are known to be at high risk for suicide. Whenever 
Veterans are identified as surviving an attempt or are otherwise 
identified as being at high risk, they are placed on the facility high-
risk list and their chart is flagged such that local providers are 
alerted to the suicide risk for these Veterans. In addition, the SPC 
will contact the Veteran's primary care and mental health provider to 
ensure that all components of an enhanced care mental health package 
are implemented. These include a review of the current care plan, 
addition of possible treatment elements known to reduce suicide risk, 
ongoing monitoring and specific processes of follow-up for missed 
appointments, individualized discussion about means reduction, 
identification of a family member or friend with the Veteran's consent 
(either to be involved in care or to be contacted, if necessary), and 
collaborative development with the Veteran of a written safety plan to 
be included in the medical record and provided to the Veteran. In 
addition, pursuant to VA policy, SPCs are responsible for, among other 
things, training of all VA staff who have contact with patients, 
including clerks, schedulers, and those who are in telephone contact 
with Veterans, so they know how to get immediate help when Veterans 
express any suicide plan or intent.
    So far, I have been describing mental health care provided in VA 
facilities and their associated CBOCs. VA also offers important 
services through the national system of Vet Centers. Vet Centers 
provide a non-clinical environment that addresses the needs of Veterans 
as individuals and as members of families and communities. Vet Centers 
are community-based counseling centers that provide a wide range of 
social and psychological services, including professional readjustment 
counseling, military sexual trauma (MST) counseling, and bereavement 
counseling for families of Servicemembers who died while on Active 
Duty.
    A core value of the Vet Center program is to promote access to care 
by helping Veterans and families overcome barriers that impede them 
from utilizing other benefits or services. A recent survey found that 
97 percent of Vet Center clients would refer a fellow Veteran to a Vet 
Center. Vet Centers remain a unique and proven component of care not 
found in any other government or private sector organization by 
providing an alternate door for combat Veterans not ready to access the 
VA health care system. By the end of 2011, VA will operate 300 Vet 
Centers across the country and in surrounding territories (the U.S. 
Virgin Islands, Puerto Rico, Guam, and American Samoa). Thirty-nine 
(39) of these Vet Centers are currently located in rural or highly 
rural areas. Seventy (70) Mobile Vet Centers provide early access to 
returning combat Veterans through outreach to a variety of military and 
community events, including demobilization activities.
    Vet Centers are designed to be both accessible and welcoming. 
Veterans who walk into a Vet Center will talk to a Counselor on the 
same day, and Vet Centers frequently maintain evening and even weekend 
hours to better serve Veterans. Approximately 72 percent of all Vet 
Center staff are Veterans, and almost one-third have served in Iraq or 
Afghanistan. The Vet Center Combat Call Center (1-877-WAR-VETS, or 1-
877-927-8387) is available for Veterans and their families to speak 
confidentially to a fellow combat Veteran about their military 
experience and transition home. Family members are central to the 
combat Veteran's readjustment, and every Vet Center is adding a 
licensed family counselor to help meet the specialized needs of the 
readjusting family.
    In FY 2010, Vet Centers provided more than 191,500 Veterans and 
families support through 1.2 million visits. While Vet Centers annually 
make approximately 120,000 referrals to VA medical facilities and 
collaborate with these facilities to enhance the continuum of care 
available to those who have served, more than 39 percent of Veterans 
did not access service at any other VA facility.
    Vet Centers maintain a trained and professional workforce 
consisting of mental health and other licensed counselors. More than 60 
percent of Vet Center direct readjustment counseling staff members are 
VHA-qualified mental health professionals (licensed psychologists, 
social workers, and psychiatric nurses). If a Veteran requires more 
complex mental health care, Vet Centers actively refer Veterans to VA 
medical facilities. Each Vet Center also has an assigned external 
clinical consultant, who provides peer consultation services for 
complex and emergent cases. External clinical consultants are VHA-
qualified mental health professionals who support referrals to VA 
medical facilities.

                       IMPROVING QUALITY OF CARE

    Improving access is important to ensuring more Veterans receive our 
care, but VA is equally focused on continuing to improve the quality of 
care Veterans receive. In addition to general mental health care 
services, VA offers a range of specialty care programs for Veterans 
with substance use disorders, PTSD, depression, homelessness, or other 
mental health conditions. It is essential that mental health 
professionals across our system provide the most effective treatment 
for PTSD, once the diagnosis has been identified. In addition to use of 
effective psychoactive medications, VA supports use of evidence-based 
psychotherapies. VA has conducted national training initiatives to 
educate therapists in two particular exposure-based psychotherapies for 
PTSD that have especially strong research support, as confirmed by the 
Institute of Medicine in their 2008 report, Treatment of Posttraumatic 
Stress Disorder: Cognitive Processing Therapy (CPT) and Prolonged 
Exposure (PE). To date, VA has trained over 3,400 VA clinicians in the 
use of CPT and PE. For both of these psychotherapies, following 
didactic training, clinicians participate in clinical consultations to 
attain full competency in the therapy. VA is also using new CPT and PE 
treatment manuals developed for VA, with inclusion of material on the 
treatment of unique issues arising from combat trauma during military 
service.
    VA has developed Staff Experience and Training Profiles (STEP) 
criteria to establish the qualifications of family counselors working 
in Vet Centers. All Vet Center clinical staff are trained in relevant 
evidence-based practices to better serve the needs of Veterans and 
their families. Recently, 100 Vet Center staff participated in 
Cognitive Processing Therapy (CPT) training, and many more are working 
toward certification. Eleven (11) Vet Center counselors have received 
training that will allow them to train fellow staff on CPT. Vet Center 
counselors are also trained to help identify and refer Veterans who are 
at risk for suicide. VA will continue to train and prepare these 
professionals to ensure they provide the highest quality readjustment 
counseling to combat Veterans.
    With the publication and dissemination of VHA Directive 1160.01, 
Uniform Mental Health Services in VA medical centers and Clinics, in 
September 2008, VHA required that all mental health services must be 
recovery-oriented, with special emphasis on those services provided to 
Veterans with serious mental illness. VA has adopted the definition of 
recovery as developed by the Substance Abuse and Mental Health Services 
Administration (SAMHSA), which states: ``Mental health recovery is a 
journey of healing and transformation enabling a person with a mental 
health problem to live a meaningful life in a community of his or her 
choice while striving to achieve his or her full potential.'' It is 
important to note that this definition does not refer to the individual 
being ``cured'' of mental illness. Rather, it is a functional 
definition that describes an improved quality of life--often while 
managing ongoing symptoms of mental illness--as a result of engaging in 
recovery-oriented services.
    Recovery-oriented services are strengths-based, individualized, and 
person-centered. These services strive to help the Veteran feel 
empowered to realize his or her goals and to engender hope that 
symptoms of mental illness can be managed and integration into the 
community can be achieved. They rely on support for the Veteran from 
clinical staff, family, and friends and allow the Veteran to take 
responsibility for directing his or her own treatment, within the range 
of viable, evidence-based approaches to care.
    Although reducing the symptoms of mental illness that the Veteran 
is experiencing is important, the goal of recovery-oriented treatment 
services does not focus solely on symptom reduction, as symptoms may 
wax and wane over the course of the individual's life. While reducing 
the symptoms of mental illness the Veteran is experiencing is 
important, the reduction of symptoms alone does not mean that the 
Veteran has the skills necessary to lead a meaningful life. The goal of 
recovery is to help Veterans with mental illness achieve personal life 
goals that will result in improved functioning, while managing the 
symptoms they experience to the extent possible. It is important to 
emphasize that the path to recovery is not necessarily linear. Periods 
of significant growth, improvement, and stability in functioning are 
sometimes interrupted by periods of increased difficulty that may be 
accompanied by a worsening of symptoms or other setbacks. Such setbacks 
may have a significant effect on Veterans' ability to reach their 
goals. In addition, while life events or environmental stressors might 
cause a relapse, there are many times when there is no identifiable 
cause. Because experiencing a relapse can be significantly disruptive, 
and because relapses are often unpredictable, Veterans with serious 
mental illness are sometimes hesitant to engage in recovery-oriented 
activities without assurance that their basic needs can be met during 
times when they are unable to work.
    Evidence indicates our mental health programs are successful. We 
have seen a continuing decline in the number of homeless Veterans over 
the last several years. Our suicide prevention efforts have saved 
hundreds of Veterans, and our programs are reaching those in greatest 
need. A recent research study found that evidence-based psychotherapies 
for PTSD are more effective approaches to treatment and are more cost 
effective in the long run as well.\1\ VA participated from FY 2006 
through FY 2010 in a Government Performance and Results Act review, 
which was recently submitted to Congress. That review, conducted by 
RAND/Altarum, concluded that VA mental health care was superior to 
other mental health care offered in the United States on almost all 
dimensions surveyed. These data speak to the great strides made in the 
mental health care VA provides.
---------------------------------------------------------------------------
    \1\ See Beau Kilmer, et al., Invisible Wounds, Visible Savings? 
Using Microsimulation to Estimate the Costs and Savings Associated with 
Providing Evidence-Based Treatment for PTSD and Depression to Veterans 
of Operation Enduring Freedom and Operation Iraqi Freedom, 3 American 
Psychological Association, 201 (2011).
---------------------------------------------------------------------------
                               CONCLUSION

    While we have made progress in improving the availability and 
quality of our mental health services, new information suggests we can 
strengthen and sustain the growth we have accomplished. In addition, we 
continue to follow research, best practices, and other emerging 
information that can guide policy development and focused concurrent 
implementation efforts. No matter how strong our mental health programs 
are, they can and should continually strive for constant, evolving 
improvement. We will continue to monitor the outcomes and utilization 
of our programs and will regularly update the Committee on any changes 
in conditions. We appreciate your attention to this matter and look 
forward to working with the Committee to ensure Veterans receive the 
quality mental health care they deserve.

    Thank you again for this opportunity to speak about VA's efforts to 
improve access to quality care for Veterans with mental health 
concerns. My colleagues and I are prepared to answer any questions you 
may have.
                                 ______
                                 
  Response to Posthearing Questions Submitted by Hon. Patty Murray to 
 William Schoenhard, Deputy Under Secretary for Health for Operations 
  and Management, Veterans Health Administration, U.S. Department of 
                            Veterans Affairs

    Question 1. The Air Force has a program for suicide prevention in 
which they identify high risk events (i.e. servicemembers under 
investigation), and then track individuals affected by those events. 
Does VA have any similar suicide prevention program that tracks high 
risk events in veterans' lives, such as arrests or domestic disputes?
    Response. The Veteran population is different from the Air Force 
population, so our programs differ, but retain some similarities. In 
the Department of Veteran Affairs (VA), we identify risk factors as a 
part of all suicide risk assessments, mental health intake forms and 
medical evaluations, but it is solely dependent on the Veteran 
revealing this information to VA voluntarily. For example, Veterans (as 
with members of the general population) are under no obligation to tell 
their health care providers about arrests, a significant stressor, and 
often do not. We encourage Veterans to share with us the stressors in 
their lives so that we can work with them to deal effectively with 
these issues. We closely track Veterans who have been identified as 
being at high risk (e.g., those who have expressed suicidal thoughts, 
have demonstrated suicidal behaviors, or who have multiple risk 
factors), and we have developed an intense suicide prevention strategy 
for these Veterans, including an enhanced care package and safety 
planning. That enhanced care includes mandatory frequent follow-up 
visits, a flag in the Veteran's medical record to ensure immediate 
assistance, follow-up for missed appointments, and strict attention to 
the Veteran's treatment plan. In addition, all of our high risk 
patients develop Safety Plans in collaboration with their health care 
providers. This is a plan designed to help the Veteran stay safe when 
under stress or when the Veteran otherwise has increased suicidal 
thoughts or urges. It may include the use of a mobile application for 
the reduction of PTSD symptoms, the use of gun locks, emergency service 
information, the identification of a support system, or whatever is 
useful to the Veteran. We constantly track the development of these 
plans.

    Question 2. How many staff in Central Office, as defined by the 101 
stop code, are in the mental health program? Please break this down 
into how many staff are devoted to mental health policy, and how many 
are devoted to mental health operations (implementation of policy)?
    Response. The total number of permanent full-time employee 
equivalents (FTEE) assigned to the Office of Mental Health Services and 
devoted to mental health policy is 159.08; 17 FTEE are Station 101 
employees, and the balance are decentralized employees.
    The total number of permanent FTEE assigned to the Office of Mental 
Health Operations and devoted to mental health operations is 267.11; of 
that number, 10 FTEE are Station 101 employees, and the balance are 
decentralized employees.

    Question 3. In response to a QFR following the Committee's 2010 
hearing on suicide and mental health, VA stated that, in accordance 
with Title I, Section 107 of the Veterans' Mental Health and Other Care 
Improvements Act of 2008, three pilots would be implemented in Veterans 
Integrated Service Networks 1, 19, and 20 to assess the feasibility and 
advisability of providing mental health services to OEF/OIF Veterans 
who reside in rural areas and do not have ready access to mental health 
services through VA facilities. VA said at that time all the pilot 
programs would be operating by October 2010. Please provide an update 
on these pilot programs.
    Response. VA completed the contracting process for the Section 107 
pilot program in fall 2010. The pilot programs began in January 2011 
and will run for a period of 3 years. The three Veterans Integrated 
Service Networks (VISNs) in which the pilot programs are taking place 
are in regular contact with the chosen contractors who have hired peer 
outreach workers, arranged for training of the peer outreach workers, 
and conducted outreach events in a wide variety of venues. These 
workers are making referrals for mental health services. The pilot 
programs have been supported by funds from VA's Office of Rural Health. 
The VA Acquisitions and Logistics Center in Denver, Office of Rural 
Health, and the Office of Mental Health Services are monitoring 
implementation of Section 107 and providing guidance to the pilot 
sites.

    Question 4. How many CBOCs in VA currently offer tele-mental health 
services? How many total CBOCs that VA directly operates or contracts 
with offer mental health services in general (defined for this purpose 
as those provided using a mental health stop code)? How do wait times 
compare between facilities offering tele-mental health services and 
those that do not?
    Response. Tele-mental health services are currently provided at 394 
community-based outpatient centers (CBOCs) from 96 parent facilities. A 
total of 683 (94 percent) out of 728 VA CBOCs that coded any care in 
the fiscal year (FY) 2010 National Patient Care Data base offered 
mental health services, defined as services coded with a mental health 
stop code.
    Mental health wait times are similar among facilities that offer 
tele-mental health services and those that do not. There was no 
difference in the percentage of new mental health patients that 
received a mental health evaluation and initiation of mental health 
services within 15 days of referral between facilities that offer tele-
mental health services at their CBOCs from those who do not. We did not 
expect that availability of tele-mental health services would have a 
large impact on wait time for mental health services; tele-mental 
health has been primarily used for delivering group psychotherapy, 
facilitating transitions between levels of care in rural communities, 
and for monitoring and aftercare inpatients following intensive 
treatment. Thus, tele-mental health services are generally used for 
purposes other than for initial visits for assessment and treatment 
planning with a new, acute mental health patient, and we would instead 
expect to see improvements in care transitions, aftercare, and 
treatment completion rates at facilities with tele-mental health 
services. For example, facilities that offer tele-mental health 
services with their CBOCs show significantly better rates of follow-up 
within 1 week of medically managed withdrawal from alcohol or opioids. 
Specifically, facilities with tele-mental health services successfully 
transition 42.3 percent of patients completing alcohol or opioid 
detoxification into outpatient mental health services in the first week 
compared with 37.4 percent of facilities without tele-mental health 
services available.

    Question 5. Residential care is a critical part of VA's safety net 
for veterans with PTSD and other invisible wounds of war. As you know, 
the Inspector General released a report in 2009, which found these 
facilities were not meeting staffing requirements. They also found that 
medications were not being managed properly. Recently, the IG released 
a follow-up report and found that VA has not fixed these problems. 
Please explain why these issues have not been fully addressed, and also 
discuss how the Department will ensure that the Inspector General's 
recommendations are implemented. When will corrective actions be 
complete?
    Response. In 2007, the Veterans Health Administration (VHA) 
National Leadership Board--Health Systems Committee charged VHA's 
Office of Mental Health Services (OMHS) with reviewing the current 
status of care delivery in Mental Health Residential Rehabilitation 
Treatment Programs (MH RRTPs) to improve and enhance services to 
Veterans. Subsequently, OMHS developed a MH RRTP Transformation Plan, 
which included a full review of all MH RRTPs and the development of a 
unified VHA MH RRTP Handbook. In May 2009, OMHS finalized VHA Handbook 
1162.02, Mental Health Residential Rehabilitation Treatment Programs. 
The Handbook was further amended in December 2010 to address issues 
identified in the OIG's initial MH RRTP report dated June 25, 2009.
    As recommended by the initial OIG review, VHA developed specific 
requirements for minimum staffing for all MH RRTPs in May 2009, with 
the initial publication of VHA Handbook 1162.02. The OIG noted in the 
recent follow-up inspection that most sites met requirements for 24/7 
coverage by staff; however, there were identified gaps in discipline-
specific staffing. Since publishing the Handbook in May 2009, programs 
have made some progress in addressing identified staffing gaps with 145 
additional FTEE hired in FY 2010; however, as noted by the OIG, gaps in 
meeting the minimum staffing requirements remain. VHA concurred with 
the OIG's recommendation and the initial findings concerning staffing 
were shared with the Network Directors, who were asked to assure that 
these staffing gaps are closed. At this point, given continued 
difficulties in filling these positions, the Office of Mental Health 
Operations is taking specific steps to address staffing. All MH RRTPs 
are required to:

    (1) submit a detailed staffing plan that includes required staffing 
levels as specified in the Handbook as well as current program FTEE by 
discipline; and
    (2) provide an action plan where staffing gaps are identified that 
will be updated quarterly until minimum staffing requirements are met.

    All staffing plans will be reviewed and approved by the medical 
center and VISN Director and are due to the Office of Mental Health 
Operations by September 15, 2011. Senior leadership will also review 
the staffing and action plans and these will be discussed with the 
Network Directors at an upcoming VISN Director meeting later in 
September. It has been made clear that this is not an optional 
component of the Handbook and that routine staffing assessments will be 
made by both VHA and the VA's external review consultants, Mathematica. 
Specific timeframes will be set for each Network by which the staffing 
requirements will be met.
    The Handbook outlined significant changes in how medications are to 
be managed on residential units, with a transition from ``Self-
Medication Management'' to ``Safe Medication Management.'' This 
includes specific requirements for documentation, as well as 
administration of controlled substances. The OIG follow-up report noted 
moderate progress in meeting initial recommendations, noting in 
particular that compliance with prescribing requirements for controlled 
substances was high but not yet at 100 percent. This was disappointing 
and since the initial OIG review, we have focused on educating 
providers and program leadership on requirements for safe medication 
management. These education efforts have included development of a Web-
based training curriculum specific to medication management in the MH 
RRTPs. We are continuing our efforts to further educate program, 
medical center, and VISN leadership about the recent OIG findings and 
recommendations, along with the specific requirements for safe 
medication management. Our external consultant (Mathematica) will 
continue to monitor medication management procedures on these units.

    Question 6. Given that symptoms of PTSD can manifest months or even 
years after veterans return home, what is VA doing to proactively reach 
out to those veterans who have been home a year or more?
    Response. VHA has employed various mechanisms to reach out to 
recently returned/released Servicemembers. Since 2006, VHA has 
coordinated referrals from the National Guard and Reserve Components 
for Veterans who have completed the Post Deployment Health Reassessment 
(PDHRA), a Department of Defense (DOD) program, which requires 
assessments at 90 and 180 days post-deployment. The PDHRA is a global 
health assessment, with an emphasis on behavioral health and service-
related conditions, conducted between 90 and 180 days post-deployment. 
The intent of the PDHRA is to identify deployment-related physical 
health, mental health, and readjustment concerns, and to identify the 
need for follow-up evaluation and treatment. VA has supported over 
2,200 PDHRA events and the DOD PDHRA 24/7 Call Center since 
November 2005, resulting in over 94,000 referrals to VAMCs and nearly 
37,000 referrals to Vet Centers.
    In addition to these outreach activities for new Veterans there are 
programs that continue far beyond the first year when Veterans are very 
involved with re-adjustment issues and concerns and may not recognize 
their need for services. VA regularly screens all of its patients and 
all new Operation Enduring Freedom/Operation Iraqi Freedom/Operation 
New Dawn (OEF/OIF/OND) Veterans to determine if they may have PTSD, are 
at risk of suicide, or in need of additional mental health counseling. 
VA's nearly 3,000 community-based Vet Centers also provide mental 
health screening and PTSD counseling. To reduce the stigma of seeking 
care and to improve access, VA has integrated mental health into 
primary care settings to provide much of the care that is needed for 
those with the most common mental health conditions, when appropriate.
    VA also uses internet Web page http://www.mentalhealth.va.gov/
PTSD.asp to provide a self-assessment tool to screen for PTSD. The 
screen is a very short list of questions to determine if the Veteran 
needs to be assessed further. A positive screen instructs the Veterans 
to see their physician or a qualified mental health professional 
immediately for a complete assessment and for advice about different 
treatment alternatives.
    VA has also developed the PTSD Coach smart phone app which can help 
Veterans learn about and manage symptoms that commonly occur after 
trauma. Features include:

     Information on PTSD and treatment options;
     Tools for screening and tracking symptoms;
     Convenient, easy-to-use skills to help the Veteran handle 
stress symptoms; and,
     Direct links to support and help.

    Focusing on Veterans that have returned at any point in the past 
several years a new anti-stigma campaign has been developed to provide 
outreach at various points in their readjustment. The next question and 
response address this also.

    Question 7. What is VA doing to reduce the stigma associated with 
seeking mental health services? How is it working with DOD on this 
issue?
    Response. VA is working to reduce stigma associated with seeking 
mental health services through a number of strategies, many of which 
include collaboration and coordination with the DOD. First, VA will 
launch a public awareness and outreach campaign this fall aimed 
specifically at reducing the stigma Veterans may associate with seeking 
mental health treatment. The campaign will target specific audiences, 
tailor messaging, and optimize communications channels for a 
comprehensive, integrated stigma reduction communications and outreach 
campaign. This effort will engage Veterans and their families and 
friends, key community-based groups, Veterans Service Organizations 
(VSOs), traditional and online media, and internal VA stakeholders. The 
overall goal of the outreach campaign is to reduce the stigma Veterans 
and their loved ones associate with seeking mental health services and 
increase the number of Veterans with mental health needs who seek 
mental health care. For this campaign, as well as for VA's ongoing 
suicide prevention communication efforts, VA has contracted with an 
experienced public relations firm that understands the need to project 
these messages in a way that does not stigmatize mental health 
services. Veterans' groups have been consulted and messages crafted to 
demonstrate that seeking mental health care when needed can lead to 
improved life functioning. This campaign is complementary to the DOD 
Real Warriors campaign that was previously launched to reduce stigma 
associated with seeking mental health treatment among active duty 
Servicemembers.
    Second, to further reduce perceived stigma related to Veterans 
seeking mental health care, VA is integrating mental health into 
primary care settings across the country. Mental health services are 
also incorporated in the evolution of VA primary care to Patient 
Aligned Care Teams (PACT), an interdisciplinary model to organize a 
site for holistic care of the Veteran in a single location. In parallel 
with the implementation of these programs, VA has also spent several 
years enhancing its mental health care services to emphasize a 
positive, recovery-oriented model of care. All of these efforts are 
aimed at engaging Veterans in effective mental health services across a 
variety of treatment settings.
    In addition, VA is using new technological solutions to help reduce 
the stigma associated with seeking mental health services. For example, 
the VA National Suicide Hotline has been re-branded as the Veterans 
Crisis Line and provides anonymous services to Veterans and 
Servicemembers who do not want to be identified. Further, the Veterans 
Chat service is completely anonymous and provides a way for Veterans 
and Servicemembers to seek help in a completely non-stigmatizing way. 
Another example of technological approaches VA and DOD are utilizing to 
address stigma-related barriers is the launch of the PTSD Coach, which 
has been downloaded over 20,000 times in 51 countries since its launch 
in April 2011. The smart phone app is one of the first in a series of 
jointly designed resources by VA's National Center for PTSD and DOD's 
National Center for Telehealth and Technology to help Servicemembers 
and Veterans manage their readjustment challenges and receive just-in-
time assistance.
    All of the efforts described above are supported by the DOD/VA 
Integrated Mental Health Strategy (IMHS). This level of collaboration 
between VA and DOD is providing unique opportunities to coordinate 
stigma reduction efforts across the two Departments, for the benefit of 
all of our Servicemembers, Veterans, and their family members.

    Question 8. In the Committee's 2010 hearing on suicide and mental 
health, VA said there were a total of 237 operational Mental Health 
Residential Rehabilitation Treatment Programs (MH RRTPs) providing more 
than 8,440 treatment beds, which included 252 beds dedicated to women 
veterans in 35 of the programs (NEPEC). Of those, there were six MH 
RRTP dedicated to serving women veterans in a setting where no male 
patients would be receiving care on the same unit at the same time, 
with a total of 50 beds. In light of GAO's report on sexual assault 
complaints, do you intend to increase the number of women-only units in 
MH RRTPs?
    Response. There were seven MH RRTPs dedicated to serving women 
Veterans with an additional 30 programs with specialized tracks for 
women Veterans as part of mixed-gender MH RRTPs. These programs are 
considered regional or national resources, not just a resource for the 
local facility. Clinically, there are advantages to models where 
treatment occurs in an environment where all Veterans are of one 
gender. Mixed gender programs also have advantages, including helping 
survivors challenge assumptions and confront fears about the opposite 
sex, fostering respect for appropriate boundaries in relationships, and 
promoting an emotionally corrective experience. Given the advantages 
associated with both models, VA does not promote one model as 
universally appropriate for all treatment settings and is focusing 
attention toward ensuring the safety, security, and comfort of women 
Veterans admitted to all residential units, rather than increasing the 
number of women-only MH RRTPs.

    Question 9. Medical literature has clearly identified risk factors 
for certain diseases, like coronary artery disease, and can therefore 
predict a veteran's risk of getting coronary artery disease. Is VA 
pursuing any similar research for risk factors associated with suicide 
or suicide attempts? If so, what is its status?
    Response. VA's research portfolio includes studies focused on 
identifying risk factors for suicide, prevention, and treatment. Risk 
factors under study include co-morbid disorders, medications, and 
behaviors. A few specific study examples include:

     In one study, VA researchers seek to determine the 
prevalence of suicide ideation, plans, and attempts resulting in 
medical treatment among Veterans currently enrolled in VA's health care 
system. The researchers will also collect data on a limited number of 
established risk factors and characteristics unique to military service 
that can be used to understand correlates of non-fatal suicidal 
behaviors.
     A VA Suicide and Self-Harm Classification System (SSHC) 
and Clinical Tool is being evaluated to determine the feasibility for 
implementation in diverse VA treatment settings and to assess its 
impact on health care system processes pertaining to the assessment and 
management of suicide risk.
     The VISN 2 Center of Excellence, in collaboration with the 
National Center for Homelessness among Veterans, is conducting a study 
of risk factors for suicide among Veterans with a history of 
homelessness or housing instability. Characteristics of service 
utilization, the independent effect of homelessness, and differences in 
risk associated with psychiatric diagnoses are being studied through 
the use of homeless intake assessments, non-fatal suicide event data 
(SPAN), and data obtained from the National Death Index.
     VA researchers are determining the role of a brain 
chemical called serotonin in suicide and seek to discover whether 
alterations in levels of this chemical impact suicide.
     The Suicide Assessment and Follow-up Engagement: Veteran 
Emergency Treatment Project (SAFE VET) is a clinical demonstration 
project that focuses on providing a brief intervention and follow-up 
for suicidal Veterans who present to the Emergency Department (ED) and 
Urgent Care Services and who do not require hospitalization. This study 
also permits us to longitudinally follow risk factors in Veterans 
identified as being at moderate risk for suicide.
     Motivational Interviewing to Prevent Suicide in High Risk 
Veterans is a study to test the efficacy of an adaptation of 
Motivational Interviewing to Address Suicidal Ideation (MI-SI) on the 
severity of suicidal ideation in psychiatrically hospitalized Veterans 
at high risk for suicide. The researchers also are examining the impact 
of MI-SI on risk factors for suicide in Veterans, such as treatment 
engagement and psychiatric symptoms.
     Many completed studies addressing suicide epidemiology 
have been published by VA investigators, providing important 
information related to risk factors.

    VA is also doing extensive work in Traumatic Brain Injury (TBI), 
including how Veterans with a TBI may be at risk for mental health 
issues and suicide. Our work in TBI will also give us a broader 
knowledge about suicide in general. A few examples of ongoing studies 
investigating the risk factors for suicide in those with TBI include:

     Executive Dysfunction and Suicide in Psychiatric 
Outpatients and Inpatients: The goal of this project is to maximize 
recovery in those with TBI by potentially: 1) increasing clinicians' 
ability to identify neuropsychological correlates of suicidal behavior 
for those with TBI; 2) identifying measures of executive functioning 
that correspond to real-life behaviors that impact treatment response 
and recovery; 3) facilitating the creation of innovative assessment 
techniques and psychosocial interventions (e.g., safety planning) to 
minimize complications in the management of suicidal behavior due to 
TBI-related impairments; and 4) creating a basis for further and much-
needed research in this area.
     Neurobiology of Suicide Risk in Traumatic Brain Injury and 
Substance Abuse: Veterans with TBI are often co-morbid for substance 
abuse, and it has been shown that use of alcohol and illicit drugs can 
further compromise executive mediated functions known to depend on the 
frontal cortex. It has been proposed that these functional deficits may 
lead to cognitive rigidity and psychological distress and thus may 
serve as markers for suicidal risk. Using functional and white matter 
brain imaging techniques, the investigators will test the hypothesis 
that reduced white matter integrity and reduced activation in frontal 
regions in both substance abusing and non-substance abusing TBI Veteran 
groups is significantly correlated with suicidal ideation, and that the 
correlation will be stronger for the TBI plus substance abuse cohort.

    Recently published research on suicide risk factors in those 
Veterans with TBI include:

     Suicide and Traumatic Brain Injury among individuals 
seeking Veterans Health Administration services. VA researchers found 
that those Veterans who sustained a TBI were almost twice as likely to 
die from suicide when compared to those Veterans that had no diagnosis 
of TBI.\1\
---------------------------------------------------------------------------
    \1\ Brenner, L., Ignacio, R. V., & Blow, F. C. (2011). Suicide and 
Traumatic Brain Injury among individuals seeking Veterans Health 
Administration services. Journal of Head Trauma Rehabilitation. 26:4, 
257-264.
---------------------------------------------------------------------------
     Neuroimaging Correlates of Traumatic Brain Injury and 
Suicidal Behavior. VA researchers examined the relationship between the 
integrity of major frontal white matter systems on measures of 
impulsivity and suicidality in Veterans with TBI. Results indicated 
that white matter damage was present in 2 frontal white matter areas. 
The damage to these white matter tracts was correlated with impulsivity 
and suicidal ideation. These data demonstrate a significant reduction 
in frontal white matter integrity in Veterans with mild TBI that was 
associated with both impulsivity and suicidality. These findings may 
reflect a neurobiological vulnerability to suicidal risk related to 
white matter microstructure.\2\
---------------------------------------------------------------------------
    \2\ Yurgelun-Todd, D.A., Bueler, C. E., McGlade, E. C., Churchwell, 
J. C., Brenner, L. A., Lopez-Larson, M. P. (2011). Neuroimaging 
correlates of Traumatic Brain Injury and suicidal behavior. Journal of 
Head Trauma Rehabilitation. 26:4, 276-289.
---------------------------------------------------------------------------
    Additionally, other studies incorporate suicide assessment measures 
to determine whether there are risks identified during the course of a 
study that require preventative measures. While not focused directly on 
suicide, these studies will also provide important information about 
risk factors.

    Question 10. CARES underestimated future outpatient demands for 
mental health care by more than 30 percent because of the differences 
in utilization of mental health care services between veterans and the 
general population. How is VA projecting future demands for mental 
health services?
    Response. VA employs several techniques to forecast Veteran 
enrollee needs for VA mental health services including: the 
incorporation of the latest scientific evidence about effective mental 
health interventions; data analysis of Veteran demographics; access to 
care data; national trends in service utilization projections; and 
staffing levels at each facility. With input from VHA's OMHS, VA's 
Enrollee Health Care Projection Model (Model) projects future demand 
for mental health services and accounts for: enrollee age; gender; 
morbidity; and the unique utilization patterns of specific cohorts such 
as OEF/OIF/OND.
                                 ______
                                 
  Response to Posthearing Questions Submitted by Hon. Richard Burr to 
 William Schoenhard, Deputy Under Secretary for Health for Operations 
  and Management, Veterans Health Administration, U.S. Department of 
                            Veterans Affairs

    According to VA's testimony ``all new patients requesting or 
referred for mental health services must receive an initial evaluation 
within 24 hours, and a more comprehensive diagnostic and treatment 
planning evaluation within 14 days.'' However, testimony before the 
Committee by Veterans has communicated instances of long wait times for 
follow up mental health appointments at VHA facilities.

    Question a. What metrics does VA use to ensure the Veterans Health 
Administration's (VHA) guidelines are complied with at VHA facilities?
    Response. There are two metrics that VA uses to ensure VHA 
guideline compliance with respect to mental health patient 
appointments: a performance measure for ``new'' patients, and a 
timeliness measure for ``established'' patients.
    The Mental Health (MH) performance measure: ``Percent of Eligible 
Patient Evaluations Documented within 14 days of New MH Patient Index 
Encounter'' is the metric used to assess the requirement that new 
patients to mental health (new patient defined as a Veteran not having 
been seen in any mental health program in the last 24 months) are seen, 
assessed, and have treatment initiated within 14 days.
    VHA also has a timeliness measure for all patient appointments such 
as primary care and specialty care; these include mental health 
clinics. The timeliness standard is that patients be seen within 14 
days of the desired date. This timeliness standard applies to both new 
and established patients. Desired date is defined as the date 
determined by the Veteran and the provider as the date the Veteran 
should be seen. The timeliness measure is a quality indicator for 
facilities.
    A new patient under the timeliness measure is any patient who has 
not been seen in the last 24 months in the particular stop code for 
which the appointment is requested. This differs from the definition of 
new patient in the performance measure ``Percent of Eligible Patient 
Evaluations Documented within 14 days of New MH Patient Index 
Encounter,'' as patients who have been seen in one of the mental health 
clinics will not be ``new'' by the performance measure but will be 
``new'' in the timeliness measure, if they are being referred to a 
different mental health clinic.

    Question b. When it is found that a VHA facility is not meeting the 
access guidelines, what steps does VA take to bring that facility back 
into compliance?
    Response. Access guidelines are monitored at the facility and 
Veterans Integrated Service Network (VISN) level. If there are access 
delays, facilities and VISNs will identify the problems associated with 
those delays and then determine an appropriate action plan. The range 
of problems identified may include data issues (scheduling errors); a 
temporary shortage of providers due to vacation, family leave or staff 
loss; inefficient scheduling or clinic processes that may need to be 
redesigned; seasonal spikes in appointment demand; or more ongoing 
provider shortages. The action plan developed by the facility will 
address the root cause of the problem and indicate the timeline for 
achieving compliance with VHA access guidelines. For example, action 
plans associated with provider shortages usually include strategies 
such as the use of fee basis care, locum tenens mental health staff, 
per diem, or contracted providers, or the use of overtime while 
recruiting for more permanent staff.

    Question c. What are VA's access standards to provide an 
established patient with follow up appointments for mental health 
visits?
    Response. See response to ``a'' above. VHA timeliness standards for 
all clinics state that patients should be seen within 14 days of the 
desired date for established patients.

    Question d. When access standards for established patients are not 
met to what extent does VA use fee basis care to ensure veterans 
receive mental health care in a timely fashion?
    Response. Decisions to use VA versus non-VA care are determined on 
a case-by-case basis and in concert with the most appropriate clinical 
decision for providing the services. Factors such as the extent of the 
Veteran's eligibility, patient's ability to travel, the urgency of the 
care required, and other VA capacity issues are considered in these 
decisions. VA does not record and calculate fee basis use on each of 
the various factors involved in addressing access issues.

    Question e. Please provide the Committee with the average wait time 
by facility type (VAMC's, CBOC's and Vet Centers) and by VISN, for 
follow up mental health appointments.
    Response. Please see attached list of Fiscal Year 2011 year-to-date 
(YTD) wait times by VISN and by facility for mental health 
appointments. Included are both new and established patients. Wait time 
data is not kept by Vet Centers, however, context is provided below.

    [The extensive list was received and is being held in Committee 
files.]

    Vet Center Response: Per VHA Handbook 1500.01, Readjustment 
Counseling Service Vet Center Program, September 8, 2010, the Vet 
Center service mission, by Congressional intent, is designed to remove 
all unnecessary barriers to care for combat Veterans and family 
members. One of the means by which this is accomplished is for Vet 
Centers to maintain non-traditional appointment schedules, after normal 
business hours during the week and on weekends, to accommodate working 
Veterans and family members. Non-traditional appointment scheduling is 
a quality performance criteria that is reviewed during every Vet 
Center's annual quality site visits. Within this context, Vet Centers 
welcome Veteran callers and walk-ins, who are provided with an 
assessment by a qualified counselor on the same day. The Vet Center 
Program standard for scheduling follow-up appointments is from 24 to 48 
hours contingent upon the severity of need.
    Community outreach services outside of the Vet Center also 
facilitate Veterans' access to care via staff making strong empathic 
connections with Veterans and family members, and by providing them 
with the information needed to access the full range of VA services. 
Effective outreach services indirectly reduce waiting times for 
services by overcoming Veterans' post-combat stigma and trauma induced 
alienation. Vet Centers also help Veterans access other needed VHA care 
by providing over 100,000 referrals every year to VA medical facilities 
for primary and mental health care.
                                 ______
                                 
Response to Posthearing Questions Submitted by Hon. Daniel K. Akaka to 
 William Schoenhard, Deputy Under Secretary for Health for Operations 
  and Management, Veterans Health Administration, U.S. Department of 
                            Veterans Affairs

    Question 1. Several veterans who testified on the first panel 
hearing expressed concern over a lack of communication and coordination 
among VA care teams and centers regarding the overall awareness of 
patient treatment plans.
    What steps, if any, has VA taken to address this concern?
    Response. The Uniform Mental Health Services Handbook requires the 
identification of a Mental Health Treatment Coordinator (MHTC) for 
every Veteran receiving mental health services. The role of the MHTC is 
to ensure coordination and development of the Veteran's treatment plan 
and communication with the Veteran (and the Veteran's authorized 
surrogate or family or friends when appropriate). To assist in 
implementation of, and compliance with this role, the OMHS has two 
initiatives to support treatment planning and easy identification of 
the MHTC.
    First, VHA has purchased and installed a treatment planning 
software program on every facility server. We are training providers in 
the use of the software, which will assist MHTCs in coordinating mental 
health services and ensuring that each Veteran has one treatment plan 
that provides a single place in the medical record documenting the 
Veteran's individualized mental health treatment plan across programs 
and disciplines.
    Second, VA's Office of Information and Technology is working with 
the OMHS to develop a software upgrade for the Computerized Patient 
Record System that will easily display the MHTC in the medical record. 
Similar to the identification of the primary care provider, the MHTC 
will be visible for all providers to see in the medical record, so that 
the MHTC can be contacted by any provider seeking information about the 
treatment plan or wishing to add information to the treatment plan. The 
software allows for reports that will enable managers and the Office of 
Mental Health Operations to track assignment of the MHTC and to monitor 
compliance to further ensure Veterans needing mental health services 
will have coordinated care.

    Question 2. The Healthcare Inspections Office in the VA Office of 
Inspector General found at several VA mental health clinics in Georgia, 
that some patients who had been waitlisted for an extended period of 
time attempted suicide or had to be hospitalized. The findings indicate 
that the clinics were not resourced to handle the increase in the 
demand for services.
    As you look to the future, do you see other regions of the country 
that might see an increase of new patients? What are some lessons 
learned from the Atlanta situation that can be applied in a similar 
situation?
    Response. VA employs several techniques to forecast Veteran 
enrollee needs for VA mental health services including: the 
incorporation of the latest scientific evidence about effective mental 
health interventions; data analysis of Veteran demographics; access to 
care data; national trends in service utilization projections; and 
staffing levels at each facility. With input from VHA's OMHS, VA's 
Enrollee Health Care Projection Model (Model) projects future demand 
for mental health services and accounts for: enrollee age; gender; 
morbidity; and the unique utilization patterns of specific cohorts such 
as OEF/OIF/OND Veterans.
    Across VHA from FY 2009 to FY 2010, there was an 8.9 percent 
increase in patients with mental health diagnoses, and all VISNs noted 
an increase in the number of patients with mental health diagnoses who 
were treated (range of 4.78 percent to 14.34 percent increases). Those 
VISNs with an increase of over 10 percent in patients with mental 
health diagnoses include VISNs 4, 6, 7, 11, 19, 20, and 21. In a 
projection of overall enrollment growth from 2010-2020 (including all 
patients), we estimated that the VISNs with greatest projected increase 
in enrollment include VISNs 6, 7, 9, 16, 17, 18, 19, and 20. However, 
when reviewing performance indicators, increases in the number of 
patients seen do not uniformly co-occur with problems in access.
    To improve our ability to identify and respond to mental health 
access problems like those observed in Atlanta, we examined VA 
performance and administrative tracking data for signs that might have 
predicted the problems. It was difficult to identify an individual 
measure that would have conclusively highlighted Atlanta as 
problematic; however, we found that there was a pattern of generally 
lower than average performance across administrative measures of 
staffing, wait-time and access to specialty care at the facility.
    These analyses suggest the need for comprehensive, multi-measure 
monitoring of a broad array of administrative and clinical mental 
health measures, including tracking of both absolute levels and trends 
over time to adequately detect and address concerns. To facilitate 
cross-administrative and clinical assessment of performance and trends 
in mental health care, the Office of Mental Health Operations is 
developing a dashboard and technical assistance program that will look 
both broadly and specifically across administrative and clinical care 
delivery measures to assess access to mental health care within each 
VHA facility and VISN. Evaluation of VHA facility and VISN status based 
on this dashboard will guide collaborative development by Veterans 
Affairs Central Office (VACO) Mental Health staff, and VISN and 
facility leadership of action plans to address gaps in services. The 
Office of Mental Health Operations will then monitor progress on VISN/
facility action plans and provide technical assistance to resolve 
barriers to implementation of services to ensure on-demand access to 
high-quality mental health care at all VHA facilities.

    Question 3. According to the VA's National Registry for Depression, 
11 percent of veterans over the age of 65 have been diagnosed with a 
major depressive disorder, which is twice the rate found in the general 
population of adults in the same age group.
    What steps has the VA taken to address the unique mental health 
needs of our older veterans?
    Response. VHA has implemented several initiatives designed to 
promote mental health care access and treatment for older Veterans. 
These new initiatives incorporate innovative and evidence-based mental 
health care practices, as well as person- and family-centered care 
approaches.\3\ One major national initiative has involved the 
integration of mental health care into VA's Home-Based Primary Care 
(HBPC) Program, which provides comprehensive, interdisciplinary primary 
care services in the homes of primarily older Veterans with complex and 
chronic, disabling disease. The HBPC Mental Health Initiative involved 
the placement of a full-time mental health provider on each of the more 
than 130 VA HBPC teams, establishing a new model of care to best meet 
the significant mental health needs of older and younger homebound 
Veterans. The VA HBPC Mental Health Provider functions as an integral 
member of the HBPC team and provides a full range of psychological 
assessment and intervention services to HBPC patients and their 
families. This initiative has received overwhelmingly positive response 
from HBPC patients and their families. VHA Handbook 1160.01, Uniform 
Mental Health Services in VA medical centers and Clinics, now requires 
that all Community Living Centers (CLC) and HBPC teams have fully 
integrated mental health providers, sustaining and further expanding 
the successful initiatives described above.
---------------------------------------------------------------------------
    \3\ Karlin, B. E., & Zeiss, A. M. (2010). Transforming mental 
health care for older Veterans in the Veterans Health Administration. 
Generations, 34, 74-83.
---------------------------------------------------------------------------
    In addition to the geriatrics settings identified above, VA has 
also integrated mental health services in Hospice and Palliative Care 
settings, Spinal Cord Injury Disability (SCID) Centers, and Blind 
Rehabilitation Centers, who each serve a large proportion of older 
Veterans. VA has also implemented a national initiative to integrate 
mental health services in general primary care settings, incorporating 
evidence-based integrated care models, which have been shown to 
increase mental health care access, utilization, and quality, including 
specifically with older patients.\4\
---------------------------------------------------------------------------
    \4\ Bartels, S. J., Coakley, E. H., Zubritsky, C., Ware, J. H., 
Miles, K. M., Arean, P. A., et al. (2004). Improving access to 
geriatric mental health services: A randomized trial comparing 
treatment engagement with integrated versus enhanced referral care for 
depression, anxiety, and at-risk alcohol use. American Journal of 
Psychiatry, 161, 1455-1462. See also: Hedrick, S. C., Chaney, E. F., 
Felker, B., Liu, C., Hasenberg, N., Heagerty, P., et al. (2003). 
Effectiveness of collaborative care depression treatment in Veterans' 
Affairs primary care. Journal of Internal Medicine, 18, 9-16.
---------------------------------------------------------------------------
    Furthermore, VA has developed a pilot initiative to disseminate and 
implement an evidence-based approach to managing challenging dementia-
related behaviors of Veterans in VA CLCs. The intervention was adapted 
by VA staff and implemented in 21 CLCs. Program evaluation data are 
being analyzed and results will be available by the end of FY 2011.
    In addition, VA's OMHS and Office of Geriatrics and Extended Care 
have developed a training program and materials related to suicide risk 
assessment and safety planning with older Veterans, specifically. This 
training program has been launched nationally and is intended for use 
by a wide variety of VHA staff. Representatives of the Office of 
Geriatrics and Extended Care and geriatrics field-based staff also 
serve on VHA's Suicide Prevention Steering Committee. Furthermore, 
leaders from the OMHS are regular members of VHA's Dementia Steering 
Committee, which is chaired by the Office of Geriatrics and Extended 
Care.

    Question 4. A recent Government Accountability Office report 
indicated that there were 284 alleged sexual assaults from January 2007 
through last July. The report made a number of recommendations to help 
make VA facilities more secure and reduce the chances of offenses 
occurring.
    What is the Department's position on these recommendations? Please 
provide an update on those recommendations the VA plans to implement.
    Response. In response to the Government Accountability Office (GAO) 
report highlighting the need for the VHA to improve its data reporting 
streams, we plan to extract data from three sources:

    1. The Police Service Management Information System. This is the 
most comprehensive and timely data source for the initial report of 
sexual assault and other safety incidents.
    2. The Automated Safety Incident Tracking System (ASISTS) is an 
Employee Accident Reporting package with data and information about 
employee accidents and incidents.
    3. The issue brief is used by the field to report to management in 
VA Central Office. One type of incident reported in the issue brief is 
sexual assault. VA is currently developing an automated system for 
submitting issue briefs. This system is being tested in 9 VISNs and 
will be tested in all 21 VISNs in September 2011.

    Merging and evaluating data on sexual assault incidents from these 
three sources will allow VHA management to trend and track sexual 
assault incidents more accurately and precisely in the future.
    A more detailed timeline is below:


------------------------------------------------------------------------
              Action                    Target Date           Status
------------------------------------------------------------------------
Design and implement manual system           July 2011                 Complete
 for recording and reporting......
------------------------------------------------------------------------
Consolidate and reconcile data          September 2011      On Schedule
 from the three sources...........
------------------------------------------------------------------------
Determine new report requirements.      September 2011      On Schedule
------------------------------------------------------------------------
Roll out the automated Issue Brief      September 2011      On Schedule
 to all VISNs.....................
------------------------------------------------------------------------
Determine technology to combine           October 2011      On Schedule
 SharePoint Issue Brief data with
 data from the Police Application
 data and ASISTS..................
------------------------------------------------------------------------
Determine report needs for                October 2011      On Schedule
 clinical and administrative
 leadership.......................
------------------------------------------------------------------------
Combine the data and build the           December 2011      On Schedule
 report...........................
------------------------------------------------------------------------
Test the report...................        January 2012      On Schedule
------------------------------------------------------------------------
Make final enhancements and              February 2012      On Schedule
 implement system-wide............
------------------------------------------------------------------------

    On June 16, 2011, VA's Assistant Secretary for Operations, Security 
and Preparedness issued a Memorandum to all VA Under Secretaries, 
Assistant Secretaries, and other key officials re-emphasizing the 
requirements of VA Directive 0321, which requires all serious 
incidents, including incidents on VA property that result in serious 
illness or bodily injury, be reported as soon as possible, but no later 
than 2 hours after the incident. The Deputy Under Secretary for Health 
for Operations and Management issued a Memorandum to all Network 
Directors on July 7, 2011, directing them and their subordinate 
managers to ensure that all allegations of sexual assault on VA 
property (or off-property in the execution of official VA duties) 
involving a Veteran, VA employee, contractor, visitor, or volunteer be 
reported within 2 hours, in accordance with VA Directive 0321.

    Question 5. The VHA Handbook 1160.01, Uniform Mental Health 
Services in VA Hospitals and Clinics, was published in 2008, but, as 
Doctor Zeiss' testified, has yet to be fully implemented. Dr. Zeiss 
stated that part of the reason for not fully implementing the policies 
within the handbook was based on the VA's organizational structure.
    What internal oversight mechanisms do you have in place now to 
ensure that official policies are being implemented and are effective? 
How will VA's reorganization affect implementing policies?
    Response. VHA's internal oversight mechanisms include: the 
Executive Career Field performance system and the Transformation-21 
(Transformation for the 21st Century) VISN performance review process 
that identify key areas for regular review between the Deputy Under 
Secretary for Health for Operations and Management (DUSHOM) and VISNs 
or facilities; follow-up on data generated by external bodies such as 
the Joint Commission and Commission on Accreditation of Rehabilitation 
Facilities (CARF); governmental reviews through the Office of the 
Inspector General and the GAO; and internal reviews such as System-wide 
Ongoing Assessment and Review Strategy (SOARS) that assess compliance 
and identify areas needing improvement.
    VHA's reorganization effectively places clinical expertise under 
VHA Operations to allow clinical review of policy implementation in the 
field. This aligns responsibility with authority and resources in the 
implementation of policy. Currently, the Office of the Assistant Deputy 
Under Secretary for Health for Operations and Management (ADUSHOM) for 
Clinical Operations is developing a comprehensive dashboard monitoring 
system that will help identify gaps in the implementation of policies. 
This information will also be valuable in identifying ways to increase 
consistency in performance across facilities. The ADUSHOM for Clinical 
Operations has staff dedicated to the provision of technical assistance 
to VISNs and facilities. Technical assistance may be provided in the 
form of consultation, site visits, connection with subject matter 
experts, and follow-up on strategic plans to address key areas of 
concern.

    Question 6. It has been estimated that almost 200,000 veterans may 
be homeless on any given night. Additionally, about half of all 
homeless veterans suffer from mental illness with more than two-thirds 
suffer from alcohol or drug abuse problems. It is believed that the 
lack of a permanent address contributes to the problem, because of the 
inability to receive needed medication. Federal agencies abroad are 
currently using facial recognition, or retinal scanning technologies as 
a way to identify citizens for a variety of purposes.
    Is the VA looking at alternative solutions such as facial 
recognition or retinal scanning to verify homeless veteran's 
identification as a way to provide needed medicines to help counter 
their illness or addictions?
    Response. VA is not presently considering facial recognition or 
retinal scanning technology to verify the identities of homeless 
Veterans. VA does, however, recognize the importance of incorporating 
technology into the Homeless Program Office's work in the field. For 
example, VA has initiated a handheld device project to design and 
implement a software system on mobile devices that can be used by VA 
outreach workers in capturing and securely transmitting homeless 
Veterans' information to and from the Homeless Operations Management 
and Evaluation System (HOMES). HOMES is a centralized information 
management system designed to consistently measure and monitor homeless 
Veteran information and program outcomes throughout VA's continuum of 
care. The application and device design have the capability to capture 
the Global Positioning System coordinates of the encounter with the 
homeless Veteran as well as to photograph the Veteran.
    The handheld device project will be a proof-of-concept system to be 
evaluated by VA for the efficacy of using mobile communications in 
assisting outreach workers and the Veterans they serve.

    Question 7. VA has identified that Prolonged Exposure (PE) is one 
therapy that is effective for many people who have experienced trauma. 
It also has been shown to be one of the most effective treatments for 
PTSD. VA has indicated that they are rolling out a national plan using 
PE.
    Please describe the VA's plans to make this program available 
nationally.
    Response. As part of its strong commitment to make evidence-based 
psychotherapies available to Veterans with PTSD, VA has implemented a 
national initiative to disseminate and implement Prolonged Exposure 
Therapy (PE) and Cognitive Processing Therapy (CPT) for PTSD. PE and 
CPT are recommended in VA/DOD Clinical Practice Guidelines for PTSD at 
the highest level, indicating ``a strong recommendation that the 
intervention is always indicated and acceptable.'' Moreover, in 2007, 
the Institute of Medicine (IOM) conducted a review of the literature on 
pharmacological and psychological treatments for PTSD and concluded in 
its report, Treatment of Posttraumatic Stress Disorder: An Assessment 
of the Evidence, that there was sufficient evidence to support the 
efficacy of these therapies. As part of its efforts to disseminate PE 
and CPT, VA has implemented national programs to train mental health 
staff in the delivery of PE and CPT. As of July 1, 2011, VA has 
provided training to more than 3,500 VA staff in the delivery of CPT or 
PE, and many of these clinicians have been trained in both therapies.
    VA's PE and CPT training programs are competency-based training 
programs that involve intensive, highly experiential learning 
opportunities. The training model for these initiatives involves two 
key components designed to build skill mastery and promote successful 
implementation and sustainability: (1) participation in an in-person, 
experientially-based, workshop; followed by (2) ongoing telephone-based 
clinical consultation on actual therapy cases with a training program 
consultant who is an expert in the psychotherapy, lasting approximately 
6 months. The average timeline for completion of the overall training 
is 7-9 months.
    The PE and CPT training workshops provide educational and 
experiential training on the theoretical basis of PTSD and the specific 
therapy being trained, assessment of PTSD and trauma-related symptoms 
prior to and during treatment, implementation of therapy components and 
processes (e.g., imaginal and in-vivo exposure for PE, cognitive 
restructuring for CPT), recommended session structure, and logistical 
and practical implementation issues. The consultation phase that 
follows the training workshop provides in-depth training and experience 
with the application of the therapy to actual therapy cases with an 
expert in the treatment who serves as a training consultant. The 
consultation further provides an opportunity for training participants 
to receive extensive feedback on their implementation of the therapy. 
Initial program evaluation results indicate that the PE and CPT 
training and implementation of the therapies have resulted in 
significant positive patient outcomes.\5\
---------------------------------------------------------------------------
    \5\ Karlin, B. E., Ruzek, J. I., Chard, K. M., Eftekhari, A., 
Monson, C. M., Hembree, E. A., Resick, P. A., & Foa, E. B. (2010). 
Dissemination of evidence-based psychological treatments for Post 
Traumatic Stress Disorder in the Veterans Health Administration. 
Journal of Traumatic Stress, 23, 663-73.
---------------------------------------------------------------------------
    In addition to training, VA has developed other mechanisms to 
support the implementation of PE, CPT, and other evidence-based 
psychotherapies. This includes the appointment of a Local Evidence-
Based Psychotherapy Coordinator at each VA medical center to serve as a 
champion for evidence-based psychotherapies at the local level and 
provide longer-term consultation and clinical infrastructure support to 
allow for the full implementation and ongoing sustainability of 
evidence-based psychotherapies at each VA site. VA has also developed a 
national evidence-based psychotherapy public awareness campaign. As 
part of this campaign, VA's OMHS has developed evidence-based 
psychotherapy brochures, fact sheets, and posters designed to provide 
education on and promote awareness of evidence-based psychotherapies 
among staff and Veterans at VA facilities and community agencies. This 
is designed to promote requests for evidence-based psychotherapy, by 
encouraging Veterans to ask informed questions to their providers 
(e.g., primary care providers) and other staff that ultimately will 
promote engagement in treatment. Furthermore, VA is also working to 
promote initial and ongoing engagement in evidence-based 
psychotherapies for PTSD by promoting the implementation of these 
therapies through tele-mental health modalities. Evidence-based 
psychotherapy for PTSD using tele-mental health services offers an 
opportunity to overcome physical and related access barriers (e.g., 
physical distance, transportation costs and difficulties, job 
responsibilities) to initial and ongoing participation in evidence-
based psychotherapy.

    Question 8. Researchers at the Yale University School of Medicine 
found that of the more than 1 million U.S. veterans who have been 
diagnosed with a mental disorder, the rates of substance abuse among 
them is between 21 and 35 percent. Also, DOD separately reported that 
between 25 and 35 percent of patients assigned to special wounded-care 
units are addicted or dependent on drugs.
    How are the Department of Veterans Affairs (VA) and the Department 
of Defense (DOD) collaborating to address the issue of substance abuse 
within care facilities as servicemen and women transition to veteran 
status?
    Response. Until Servicemembers receive a DD 214 releasing them from 
active duty, DOD is responsible for providing substance use disorder 
care. Nevertheless, individual VA medical facilities may choose to 
develop local memoranda of understanding with military installations to 
provide substance use disorder and other mental health services prior 
to release from active duty.
    At the national level, the InTransition program is one part of the 
VA/DOD Integrated Mental Health Strategy. The InTransition program is 
designed to address the care needs of Servicemembers with mental health 
problems during the process of leaving active duty. An InTransition 
coach, typically a master's level social worker, is assigned to work 
with Servicemembers enrolled in the program to sustain their motivation 
and engagement in the treatment regimen until they come under VA care. 
The coach also provides healthy lifestyle information, answers 
questions about treatment modalities, and suggests community resources. 
The program is voluntary and confidential. Coaches thus ``close the 
loop'' between DOD and VA care by following up with the receiving VA 
case manager to ensure that the patient has arrived at the VA health 
care facility and has successfully engaged with a new care provider.
                                 ______
                                 
  Response to Posthearing Questions Submitted by Hon. Mark Begich to 
 William Schoenhard, Deputy Under Secretary for Health for Operations 
  and Management, Veterans Health Administration, U.S. Department of 
                            Veterans Affairs

    Question 1. Alaska's veterans need additional mental health 
services. The Alaska VA system's participation in the Alaska Psychiatry 
Residency would improve access to mental health care for Alaska's 
veterans. What financial and political support is necessary for the 
Alaska VA system to participate in the Alaska Psychiatry Residency? Can 
you report any progress?
    Response. The Alaska VA Healthcare System has agreed to participate 
in the Alaska Psychiatry Residency program, which is operated by the 
State of Alaska. VA can provide funds to cover the salary costs of a 
resident while the resident is providing care at a VA facility; when 
the resident is providing services elsewhere, his or her salary will be 
covered by the facility where the resident is working. VA understands 
there have been issues with securing funding from the State of Alaska 
for this initiative, which has contributed to the delay in 
implementation. VA refers you to officials from the State of Alaska for 
additional information concerning these issues.

    Question 2. Rural veterans are a major concern in my state and 
across the country. With a push from me, I am glad to see plans to 
coordinate with the IHS and Community Health Centers in rural areas to 
provide ``seamless'' services for rural vets. For example, veterans 
should be able to go to the clinic in their village and receive mental 
health care and not have to worry about paperwork or denials or to 
travel over 500 miles for an appointment. Are the plans to include in 
the MOU mental health services?
    Response. VA, in consultation with the Indian Health Service (IHS), 
has established a workgroup specific to Alaska for the implementation 
of the VA/IHS Memorandum of Understanding (MOU) signed by the two 
agencies on October 1, 2010. Alaska is home to nearly half (229 of 565) 
of the federally-recognized tribes with unique characteristics and 
needs. The initial face-to-face meeting of this group is scheduled to 
take place September 30, 2011, in Anchorage. This meeting will be co-
chaired by VA and the Alaska Area Native Health Service, IHS, and the 
Department of Health and Human Services. The Alaska Native Health Board 
is facilitating the selection of volunteers for tribal representation. 
The workgroup will follow the VA Tribal Consultation process and will 
be driven by consensus as MOUs are established with the tribal 
entities. The workgroup will establish guidelines identifying what it 
believes should be included in the MOUs; mental health services may be 
one of the areas identified.

    Question 3. In states such as Alaska, where psychological health, 
TBI, and suicide resources are minimal and there is a workforce 
concern, is there a mechanism to encourage VA to work with state/
community leaders that are working hard to develop the same care in the 
civilian sector and having similar workforce, access, or outreach/
identification challenges?
    Response. The Uniform Mental Health Service Handbook requires that 
each VISN and VA medical center have liaisons identified for state, 
county, and local mental health systems. This allows for coordination 
of VA mental health activities with the private sector and includes 
informing community providers about VA services, coordinating with Vet 
Centers and DOD, building VA awareness of community-based mental health 
programs for Veterans and their families, including sharing agreements 
and co-location of staff, providing service on States' council on 
suicide prevention, providing spokespersons for mental health, 
coordinating outreach efforts, and creating Consumer-Advocate Liaison 
Councils which include the National Alliance on Mental Illness, 
Veterans Service Organizations, local employment and housing 
representatives, and other mental health advocacy groups from the 
community. Additionally, the OMHS encourages regular engagement with 
state and community leaders in addressing the mental health needs of 
the Veteran population. One endeavor includes outreach efforts to 
community organizations with the provision of training in Veteran and 
military culture, readjustment issues, and deployment-related mental 
health concerns. VA facilities report quarterly to OMHS on the number 
and types of outreach programs provided to community organizations. For 
example, in the first two quarters of FY 2011, VA mental health staff 
provided 28 outreach programs in Alaska to community organizations, 
such as DOD, community medical facilities, universities, the Salvation 
Army, Alaska Coalition on Housing and Homelessness Annual Conference, 
various mental health conferences where community providers 
participated, probation offices, and police services. A variety of 
topics were addressed including suicide prevention, violence 
prevention, substance abuse treatment, PTSD treatment, readjustment 
concerns, Traumatic Brain Injury and homelessness concerns. These 
provided opportunities for exchange of best practice information and 
sharing of resources for the improved treatment of Veterans both in VA 
and for those served by community providers. Another example is the 
provision of the Flex Rural Veterans Health Access Program (RVHAP), a 
3-year grant program recently funded to improve service access for 
rural OEF/OIF/OND Veterans in Alaska, Montana, and Virginia. Program 
activities include crisis intervention, including screenings for PTSD 
and TBI, referral services to VA, and telehealth enhancement to support 
care for rural Veterans.

    Question 4. How will (or can) telemedicine be used to increase 
access to psychological health, TBI, and suicide services and support? 
What are the detail steps you are taking to increase access and 
services for veterans?
    Response. VA has systematically adopted tele-mental health as a 
means of enhancing access to care for Veteran patients since 2002. In 
FY 2010, this ongoing process of development resulted in 49,531 Veteran 
patients receiving 112,332 consultations via tele-mental health. VA 
routinely uses tele-mental health between 96 VA medical centers and 394 
community-based outpatient centers (CBOC) for the assessment and 
management of Veterans with mental health disorders, psychological 
conditions and suicide risk. In appropriately assessing and managing 
the risk of suicide via tele-mental health, VA has established 
processes and procedures that ensure the ``at risk'' patient is linked 
to VA's comprehensive program for suicide prevention. In addition to 
tele-mental health services provided via videoconferencing between 
hospital and clinics, VA currently supports 12,870 Veterans with mental 
health conditions with services directly in their own homes using home 
telehealth monitoring and messaging devices. This number includes 664 
patients with substance abuse disorder, 8,571 with depression, and 
3,635 with PTSD.
    VA is aggressively expanding its capacity to support tele-mental 
health with both general and specific initiatives. VA's general support 
of telehealth takes the form of its FY 2011 and FY 2012 Telehealth 
Expansion Initiative, which will ensure nationwide availability of the 
technology, support staff, and telecommunications requirements needed 
for all VA medical centers to undertake clinical videoconferencing with 
all their associated sites of care, thus making all specialty care 
services, including tele-mental health and assessment of Traumatic 
Brain Injury, more widely available. Specific initiatives for tele-
mental health in VA include: (1) Current integration of tele-mental 
health, and other mental health care interventions into VA's patient 
aligned care team model (PACT); (2) VA's current implementation of 
telehealth technology that enables Internet Protocol (IP) 
videoconferencing directly to Veteran patients' homes by VA providers, 
which will increase the capacity for tele-mental health services 
provided via videoconferencing directly into the home; and (3) a FY 
2012 initiative to systematically implement the delivery of evidence-
based psychotherapy services for PTSD into tele-mental health services 
across VA.

    Question 5. Are there telemedicine options for specialty therapies 
for TBI, such as physical therapy, speech therapy, occupational 
therapy, or counseling?
    Response. VHA tele-rehabilitation utilizes telehealth technologies 
to connect Veteran patients with rehabilitation providers separated by 
distance or time. Tele-rehabilitation services that involve clinical 
videoconferencing make specialist expertise available across VA medical 
centers and from VA medical centers to CBOCs. The advantage of these 
services is that they increase the timely access of Veteran patients to 
specialist services and reduce their need for avoidable travel. Tele-
rehabilitation services that are routinely provided via clinical 
videoconferencing in VHA cover the provision of care for: audiology, 
speech pathology, management of Traumatic Brain Injury, physical 
therapy, occupational therapy, recreation therapy services, spinal cord 
injury, post-amputation care, polytrauma, and provision of durable 
medical equipment. In FY 2010, 1,168 Veteran patients received care via 
tele-rehabilitation. There was a 49 percent growth of tele-
rehabilitation encounters between FY 2009 and FY 2010. VHA recorded a 
96 percent growth of tele-rehabilitation encounters through the second 
quarter of FY 2011.
    In addition to tele-rehabilitation services provided via clinical 
videoconferencing, VA supports the care of Veteran patients with 
complex care needs in their own homes using home telehealth 
technologies. The home telehealth technologies employed by VA include: 
videoconferencing directly into the home that replicates a face-to-face 
visit; and messaging and monitoring devices that monitor symptom 
progression and vital signs.

    Question 6. I continue to hear about the value of Assistance Dogs/
Service Dogs with respect to our service men and women as well as our 
veterans who are experiencing mental health and/or mobility issues. 
Considering the Pilot Program in place within the VA and the funding 
that has been allocated to that program, what are we doing to make this 
valuable resource available to those who would benefit?
    Response. VA has a number of efforts in place to increase awareness 
of the benefits of obtaining a Service Dog or Guide Dog (SDGD). VA has 
published numerous articles in national Web sites, and has participated 
in public affairs articles across the Nation. VA is currently working 
with a number of the VSOs and National Service and Guide Dog 
Organizations to gather and disseminate accurate information regarding 
the benefits of obtaining a service dog or guide dog, the processes and 
requirements that must be met to obtain a trained dog, and what it 
takes to sustain a long-term Veteran and SDGD partnership. These 
dialogs have served the organizations, VA, and the Veterans.
    One product of this collaboration has been the development and 
completion of two video presentations which will be made available 
during the fourth quarter FY 2011 to all VA facilities and clinics. One 
of the videos is a short film targeted for use in lobbies, clinic 
waiting areas, and other sites where Veterans congregate. This short 
film introduces the concept of SDGDs, talks about the benefit of having 
a SDGD, and encourages viewers to ask about this benefit at their local 
medical center or CBOC. The second video's target audience is VA staff 
and provides education on the benefits of SDGDs, provides general 
information about the cohort of Veterans that might want to consider 
obtaining a SDGD, and encourages the staff to learn more about the VA 
SDGD Program. Fact Sheets will be made available to the staff and 
Veterans along with the videos, providing additional information about 
SDGDs and contact information. VA plans for FY 2011 and FY 2012 include 
additional education, publication, communication, and advocacy efforts 
targeting Veterans, dog organizations, DOD, and VA clinical and 
benefits staff. VA's efforts will support the increase in the number of 
Veterans interested in obtaining SDGDs, and provide a mechanism to 
promote VA staff support and advocacy resulting in improvement to the 
overall provision on SDGDs for all Veterans needing the services of a 
SDGD.
    In FY 2010, VA spent $180,410 from the prosthetics budget to 
support Veteran/SDGD teams through provision of veterinary services, 
prescribed medications, and needed equipment such as harnesses, 
leashes, vests, etc. In 2010, VA provided veterinary care and equipment 
to 254 Veterans in support of their SDGDs. In 2010, that number 
included payment to provide care and equipment for 66 new Veteran/SDGD 
teams. In May 2011, with over 4 months of the year remaining, VA has 
provided veterinary care and equipment to 224 Veteran or SDGD teams, 41 
of these teams were new to the VA in 2011, at a cost of $161,643 It is 
important to remember that SDGDs do not require services every year, 
and this being the case, the numbers provided (254 and 224) include 
only those dogs that required a service during the fiscal year 
reported. At this time, the number of unique Veteran or SDGD teams who 
have already received services and are currently eligible for VA 
services is estimated to be slightly over 450.
    VA welcomes the possibility of expanding the use of trained dogs to 
provide appropriate services to Veterans diagnosed with certain mental 
illnesses. At this time, valid and reliable scientific evidence is not 
available to determine, from a clinical standpoint, whether or when 
SDGDs are most appropriately provided to Veterans with mental illness, 
including Veterans diagnosed with PTSD.
    The National Defense Authorization Act (NDAA) for Fiscal Year 2010, 
Public Law 111-84, Sec. 1077 authorized VA to conduct a 3-year research 
study to assess the benefits, feasibility, and advisability of using 
service dogs for the treatment or rehabilitation of Veterans with 
physical or mental injuries or disabilities, including PTSD. Passage of 
this measure provided VA with an excellent vehicle to examine the 
issues and possibly accumulate valid and reliable clinical evidence 
necessary to proceed.
    We are pleased to report that VA's implementation of Public Law 
111-84, Sec. 1077, is underway. VA's Office of Research and 
Development's study proposal completed all of the development and 
preliminary review required for a research study. The study received 
approval from the Institutional Review Board for human subjects on 
January 10, 2011, and from the Institutional Animal Care and Use 
Committee for animal subjects on January 28, 2011. VA's Privacy Officer 
and Chief Veterinarian completed the review and granted approval 
shortly thereafter.
    This is a fairly complex and novel study involving advanced design 
and statistical analyses. The research study is specifically designed 
to evaluate use of service dogs for individuals who have been diagnosed 
with PTSD. The study objectives include: (1) Assess the impact service 
dogs have on the mental health and quality of life of Veterans; (2) 
Provide recommendations to VA to serve as guidance in providing service 
dogs to Veterans; (3) Determine costs associated with total health care 
utilization and mental health care utilization among Veterans with 
PTSD; and (4) Explore meanings and perceptions of roles that service 
dogs fill in the lives of the Veterans and their caregivers.
    The study will involve the partnering of approximately 200 PTSD-
diagnosed Veterans with specially trained dogs. The number of dogs 
involved required contracting with more than one vendor. VA has 
successfully completed blanket purchase agreements with three vendors, 
ensuring an ample number of dogs will be available when and where they 
are needed. Per the requirements of the NDAA, two of the vendors are 
accredited by Assistance Dogs International (ADI), and the third vendor 
demonstrated adherence to standards comparable to those of ADI. 
Veterans are now being recruited for enrollment in the study, and two 
Veterans were partnered with dogs in July 2011. These first two 
Veterans served in the Vietnam era, and the OEF/OIFOND era; one Veteran 
is female, and one is male.
    It is very important to note that, based on previous studies in 
which Veterans were matched with dogs, we can anticipate that 
recruitment may take longer than one might expect because of the unique 
needs of each Veteran with mental health issues, and the logistics of 
finding the best possible service dog match. This study is of the 
utmost importance to VA as we continue to work toward providing top 
quality care to our Nation's Veterans. The study is expected to be 
completed by March 2014.
    If the results of the research study demonstrate the clinical 
effectiveness of this effort, VA will then evaluate how best to modify 
existing regulations to ensure Veterans can access this benefit.

    Question 7. What are you doing to ensure that veterans are being 
provided the best possible psychiatric care? Statistics show that a 
large percentage of those servicemembers who die by suicide had 
previously been seen at behavioral health.
    Response. Please see the response below to question 13.

    Question 8. What are you doing to reach out to families, especially 
parents, to provide education on emergency mental health issues, how to 
identify them, and what to do about it?
    Response. Please see the response below to question 15.

    Question 9. How does one diagnose, treat and prevent depression and 
mental health disturbances in remote areas for veterans or civilians? 
This is a difficult task. The use of telepsychiatry and methods of 
selecting high risk populations after discharge are important. What 
methods are being used? Any evidence they are successful?
    Response. VA has been studying and implementing a variety of tele-
mental health programs to increase access to mental health specialty 
treatment for patients in rural areas or areas lacking specialty 
providers. These include videoconferencing-based consultation and 
training for specialty care delivery by primary care providers, 
telephone-based care management for mental health patients, 
videoconferencing-based psychotherapy at CBOCs, and in-home mental 
health visits via videoconferencing. Many of these programs have been 
studied in clinical trials and have been adopted based on evidence that 
outcomes of care delivered by these mechanisms are at least as good as 
outcomes delivered in face-to-face modalities, and that Veterans and 
other patients are satisfied by care delivered using telehealth. Brief 
summaries of some of these programs and evidence of their success 
follow:

     Videoconference-based Specialty Care consultation and 
training program for primary care clinicians allows rural primary care 
providers to provide specialty treatments with specialist expertise and 
success rates--Project Extension for Community Health Outcomes/VA 
Specialty Care Access Network (ECHO/VA SCAN)

    To address the difficulties associated with access to specialty 
care services in rural areas, a video-teleconferencing based system 
named Project ECHO was developed at the University of New Mexico for 
training primary care providers through video-based consultation with 
specialists in treatment of high prevalence disorders for which medical 
specialists may not be available in rural areas. Project ECHO focused 
initially on primary care training and consultation for Hepatitis C 
treatment. Outcomes for Project ECHO patients did not differ 
significantly, demonstrating that the treatment model is as successful 
as specialty care for treating Hepatitis C in underserved communities
    Based on these impressive results, Project ECHO has expanded to 
improve care for 19 other disorders including psychiatry, and VA is 
being trained in and adopting this model in a nationwide project. The 
VA SCAN project will initially focus on four types of disorders: 
chronic pain, Hepatitis C, cardiology and diabetes mellitus. Using 
high-resolution video equipment provided by VA SCAN, participating 
sites will be able to access real-time video consultations with 
specialists regarding high priority conditions, as well as free, 
formalized, accredited, continuing education credits. Participating 
sites will also benefit from enhanced connectivity, equipment, and the 
training necessary to successfully build and maintain a telemedicine 
consultation program through participation with VA SCAN. Notably, 
chronic pain problems are extremely prevalent and complicate treatment 
for substance use disorders, depression, PTSD and suicidality, and non-
optimal chronic pain care can increase risk for abuse and misuse of 
prescription medication. The disorders covered will be expanded as 
implementation progresses and will provide a mechanism for increasing 
mental health specialty access in rural areas.

     Delivery of evidence-based psychotherapy for PTSD by 
videoconferencing is as effective as in-person counseling

    VA psychologists conducted the first randomized controlled trial 
investigating the effectiveness of using video-teleconferencing (VTC) 
to deliver cognitive behavioral group psychotherapy.\6\ The study 
delivered anger management therapy to rural combat Veterans with PTSD. 
Using a highly rigorous methodology, the study found that delivery of 
psychotherapy via VTC was as clinically effective as traditional face-
to-face delivery.\7\
---------------------------------------------------------------------------
    \6\ Morland LA, Greene CJ, Rosen CS, Mauldin PD, Frueh BC. (2009). 
Issues in the design of a randomized noninferiority clinical trial of 
telemental health psychotherapy for rural combat veterans with PTSD. 
Journal of Contemporary Clinical Trials 30(6): 513-522.
    \7\ Morland LA, Greene CJ, Rosen CS, Foy D, Reilly P, Shore J, He 
Q, Frueh BC. (2010) Telemedicine for anger management therapy in a 
rural population of combat veterans with Posttraumatic Stress Disorder: 
A randomized non-inferiority trial. Journal of Clinical Psychiatry 
71(7): 855-863.
---------------------------------------------------------------------------
    Additionally, research has found that attrition, treatment 
adherence, satisfaction, and group cohesion were comparable between the 
two modalities.\8\ The only significant difference was in therapeutic 
alliance or the level of perceived connection between the therapist and 
the patient. Although alliance was strong in both conditions, alliance 
with the therapist was lower in the VTC condition. However, the 
relatively lower alliance was not sufficiently powerful to result in 
substantially lower clinical outcomes for participants in the VTC 
condition.
---------------------------------------------------------------------------
    \8\ Greene, C.J., Morland, L.A., McDonald, A., Frueh, B. C., 
Grubbs, K.M. & Rosen, C.S. (2010). How does telemental health affect 
group therapy process? Secondary analysis of a noninferiority trial. 
Journal of Consulting and Clinical Psychology 78(5): 746-750.
---------------------------------------------------------------------------
    Both clinical and process outcomes of this trial indicate that 
delivering cognitive behavioral group psychotherapy via VTC is an 
effective and feasible way to increase access to evidence-based care 
for Veterans residing in rural or remote locations. In addition, 
further analyses supports that therapist fidelity to a manualized 
cognitive-behavioral group psychotherapy is similar whether the 
treatment is delivered via a VTC modality or the traditional in-person 
means, and VTC does not compromise a therapists' ability to effectively 
structure sessions and build rapport with patients.\9\
---------------------------------------------------------------------------
    \9\ Supra note 3.
---------------------------------------------------------------------------
    There are currently three additional trials underway testing the 
clinical effectiveness and cost-effectiveness of video-
teleconferencing-based cognitive processing therapy for the treatment 
of PTSD in male and female Veterans. Additionally, a VA task force is 
beginning a roll-out of video-conferencing based PTSD psychotherapy 
across the country.
    Finally, the Portland VAMC began a home-based mental health 
videoconferencing program which allows Veterans to receive treatment 
from mental health providers via Web-cameras on their personal 
computers in their own home. While this has not been studied in a 
clinical trial, based on the acceptability and successful patient and 
provider experiences with this mode of mental health treatment, this 
program has been expanded throughout VISN 20.

     Substance use disorder (SUD) aftercare following intensive 
services via telephone is acceptable and at least as effective as face-
to-face care

    McKay and colleagues compared telephone-based continuing care to 
two more intensive face-to-face continuing care interventions for 
patients with alcohol or cocaine dependence who had just completed 4 
week intensive outpatient substance use disorder treatment programs. 
The trial included 359 patients from either a VA or a community based 
treatment program and compared: (1) 12 weekly monitoring and brief 
counseling calls plus 4 weekly supportive group therapy sessions, (2) 
12 weeks of twice-weekly cognitive-behavioral relapse prevention 
sessions, and (3) 12 weeks of twice-weekly standard group counseling. 
Participants who received the telephone-based continuing care had 
better substance use outcomes over the next 2 years including higher 
rates of abstinence, better alcohol biomarkers levels, and lower rate 
of cocaine-positive urine samples. Higher risk patients did better in 
face-to-face treatment, but lower risk patients had better outcomes 
with telephone aftercare.
    A second VA-funded study randomized 667 drug and alcohol disorder 
patients to telephone treatment versus face-to-face continuing care at 
two VA facilities (one urban, one rural). One year after entering the 
treatment study, patients receiving telephone care reported rates of 
recovery that were equal to those receiving face-to-face treatment. 
Veterans found the telephone treatment to be highly satisfactory and 
the benefits of telephone treatment were not diminished for Veterans 
with an additional psychiatric disorder or for those who lived farther 
from a VA facility.
    Based on the success observed in these trials, 126 of 140 VA 
facilities have incorporated telephone-based SUD treatment services 
into their specialty SUD treatment programs to reach more patients and 
keep patients engaged in care.

     Telephone case monitoring for patients with PTSD is 
feasible and improves continuity of care and detection of emergent 
mental health problems

    A quasi-experimental cohort study looked at whether continuity of 
mental health care following residential PTSD care could be improved by 
adding telephone care, using bi-weekly telephone calls, to standard 
referral to outpatient mental health care. This study found that 
telephone monitoring was feasible, reaching 95 percent of patients, and 
successful for improving outpatient treatment engagement and improving 
patient satisfaction with care. Specifically, patients receiving 
telephone support were twice as likely (88 percent versus 43 percent) 
to complete an outpatient mental health visit within 1 month of 
discharge and 85 percent wished the intervention could continue beyond 
the 4-month study.\10\ A multi-site randomized controlled trial is 
currently underway testing this intervention, and full results will be 
available soon. Preliminary findings confirm that VA was able to reach 
most patients by phone (76 percent completed at least three of six 
planned calls) and that calls are helpful in detecting and alerting 
clinicians about emergent clinical problems.
---------------------------------------------------------------------------
    \10\ Rosen CS, DiLandro C, Corwin KN, Drescher KD, Cooney JH, 
Gusman F. (2006) Telephone monitoring and support for Veterans with 
Chronic Posttraumatic Stress Disorder: A pilot study. Community Mental 
Health Journal 42(5): 501-508.

    Question 10. There are cases in which family members have been 
encouraged to seek help for their spouse or child when they fear they 
may be suicidal as a result of combat related PTSD. Is there a plan to 
provide families with a safe place to call where they can access care 
for their loved ones?
    Response. VA has implemented a call center to coach family members 
and friends on how to talk to a Veteran about mental health issues, 
particularly when that Veteran is not receiving care. The program, 
Coaching Into Care (1-888-823-7458), receives calls actively from 8am 
to 8pm (EST). After hours, a Veterans Crisis Line responder will take a 
message from callers to be returned the next business day. The Veterans 
Crisis Line and Veterans Chat service are available to family members 
and friends 24 hours a day, 7 days a week, to assist with any crisis or 
emotionally challenging situation and can make direct referrals and 
mobilize immediate help if needed. This new service provides 
information and problem solving regarding mental health issues free of 
charge to callers. There is no limit to the number of calls. The 
service is designed to connect the family member caller and his or her 
Veteran to their local VA facility and other resources in their 
community.

    Question 11. What are the staffing levels in VA facilities in 
Alaska and how do you see that growing and sustaining? For example, the 
Kenai Peninsula has had a need for clinicians for over a year.
    Response. The Alaska VA Healthcare Care System (AVAHS) has 
continued to increase the size of its staff to meet the growing number 
of Veterans accessing care. Since FY 2009, AVAHS has added three new 
sites of care: the Mat-Su VA CBOC, the Homer VA Outreach Clinic (an 
extension of the Kenai CBOC), and the Juneau VA Outreach Clinic. These 
clinics are staffed with Primary Care and Mental Health staff.
    As of July 28, 2011, current staffing levels at VA facilities in 
Alaska are:

     Anchorage VA Outpatient Clinic: 475.3
     Fairbanks CBOC: 7
     Kenai CBOC: 8
     Mat-Su CBOC: 12
     Juneau CBOC: 5

    In addition, the Anchorage VA Outpatient Clinic and Fairbanks CBOC 
are augmented by on-station fee basis, VA Locum Tenens Program, and 
contract staff.
    Recruitment and retention are ongoing challenges in Alaska, 
particularly for specialty care. The total number of full time 
employees has increased by 42 between FY 2010 and FY 2011. As of 
July 28, 2011, AVAHS currently has 57 positions approved for 
recruitment and hire, with 10 tentative offers pending. AVAHS recently 
selected two primary care physicians for the Fairbanks CBOC. These 
recruitments had been ongoing since 2006 and 2010.
    At the Kenai CBOC, the first psychiatrist recruitment resulted in a 
selection; however, the individual decided not to accept the offer. The 
position was re-posted and a psychiatric nurse practitioner was 
selected; however, human resources staff members were not able to reach 
her after the selection. The mental health positions have been re-
posted for recruitment effective July 26, 2011. While the Kenai CBOC 
mental health positions have been vacant, coverage has been provided by 
telehealth using video-teleconference from the Anchorage VA Outpatient 
Clinic, as well as the Mat-Su and Juneau clinics.
    Recognizing potential retirements during the next 2 years, AVAHS is 
developing succession planning for key positions.

    Question 12. Should the mental health professionals who are working 
with DOD transition with their patients to VA? For example, the 
professionals (case manager, etc.) follow the person as they go from 
DOD to VA (continuity of service provider).
    Response. No, mental health professionals, such as case managers, 
should not transition with their patients from DOD to VA. Although both 
VA and DOD professionals work for the Federal Government, they are 
hired to each work within a specific Department and cannot transition 
schedules, locations, pay, and benefits back and forth between the two. 
Furthermore, there are several reasons why this kind of movement of 
staff from one care system to another is not needed to ensure 
continuity of care and a ``warm hand-off'' of care for the patient.
    Each VA medical center has an OEF/OIF/OND Care Management team in 
place to coordinate patient care activities and ensure that 
Servicemembers and Veterans are receiving patient-centered, integrated 
care and benefits. Members of the OEF/OIF/OND Care Management team 
include: a Program Manager, Clinical Case Managers, and a Transition 
Patient Advocate (TPA). The Program Manager, who is either a registered 
nurse or licensed social worker, has overall administrative and 
clinical responsibility for the team and ensures that all OEF/OIF/OND 
Servicemembers/Veterans are screened to see if they require case 
management. Those severely ill or injured are provided with a case 
manager, and other OEF/OIF/OND Servicemembers/Veterans are assigned a 
case manager as indicated by a positive screening assessment or upon 
request. Clinical Case Managers, who are either registered nurses or 
licensed social workers, coordinate all patient care activities, using 
an integrated approach across all systems of care. The TPA helps the 
Servicemember/Veteran and family/caregiver navigate the VA system by 
acting as a communicator, facilitator, and problem solver. VA case 
managers maintain regular contact with Servicemembers/Veterans and 
their families/caregivers to provide support and assistance to address 
any health care and psychosocial needs that may arise based on an 
agreed upon and clinically appropriate contact plan. The OEF/OIF/OND 
Care Management program now serves over 53,000 Servicemembers and 
Veterans, of whom over 6,400 are severely ill or injured.
    In addition to the comprehensive and coordinated work of DOD and VA 
case managers cited above, there are other supports available to 
enhance continuity of care. Servicemembers with mental health problems 
who are moving from DOD to VA care can also take advantage of the 
InTransition program. The InTransition program is a component of the 
VA/DOD Integrated Mental Health Strategy in which Servicemembers are 
assigned a coach to work with them during this period of change to keep 
them motivated and engaged in their treatment regimen. The coach will 
assist in bridging the gap from their current/referring provider to the 
new/gaining mental health provider. The coach is also available to 
provide healthy lifestyle information, answer questions about treatment 
choices, and provide community resources to the Servicemember. The 
program is voluntary and confidential. The telephonic coaching 
generally takes place at least weekly, but more often if deemed 
appropriate. The coaches all have experience working with the military 
and understand military culture. At minimum, each coach has a master's 
degree in social work.
    It is important to recognize that an InTransition coach does not 
provide clinical treatment, does not provide therapy, and is not a case 
manager. Coaches differ from case managers because they enhance care 
that is already in place. They do not make assessments or develop new 
treatment plans, but rather serve to complement the plans already 
established by the DOD provider or case manager. Also the coaches work 
to ``close the loop'' between DOD and VA care by following up with the 
receiving VA case manager to ensure the patient has arrived at the VA 
health care facility and is engaged with a new care provider.

    Question 13. Statistics show that 40 percent of those 
servicemembers who die by suicide had previously been seen at 
behavioral health.
    a. What are we doing to ensure that Veterans are being provided the 
best possible psychiatric care?
    Response. VA is strongly committed to providing the best mental 
health care available. Our suicide prevention strategy is based on the 
premise of ready access to quality mental health and other health care. 
All Veterans who are identified as being at high risk for suicide 
receive an enhanced level of care that includes frequent visits with 
their mental health provider, safety planning and treatment planning 
that must address the suicidality, attention to means restriction and 
medication management as well as ongoing treatment for any mental 
health conditions. VA has instituted Suicide Prevention Coordinators 
(or Suicide Prevention Teams) at each VA medical center and the largest 
CBOCs to monitor the care of high risk patients, provide training and 
outreach concerning risk factors and warning signs, and to track 
suicidal events.
    In an effort to provide the best possible psychotherapy, VA has 
developed national initiatives to disseminate and implement evidence-
based psychotherapies (EBPs) for PTSD, depression, serious mental 
illness, and other mental health conditions and behavioral health 
conditions (e.g., insomnia). For example, VA has implemented a national 
initiative to disseminate and implement Prolonged Exposure Therapy (PE) 
and Cognitive Processing Therapy (CPT) for PTSD. PE and CPT are 
recommended in VA/ DOD Clinical Practice Guidelines for PTSD at the 
highest level, indicating ``a strong recommendation that the 
intervention is always indicated and acceptable.'' As part of its 
efforts to disseminate EBPs, VA has implemented national programs to 
train mental health staff in the delivery of specific EBPs, including 
PE, CPT, Cognitive Behavioral Therapy and Acceptance and Commitment 
Therapy for depression, and other therapies. As of July 1, 2011, VA has 
provided training in one or more EBPs to more than 4,500 out of 21,000 
eligible VA staff. VA has also instituted the Local Evidence-Based 
Psychotherapy Coordinator at each VA medical center to serve as a 
champion for evidence-based psychotherapies at the local level and 
provide longer-term consultation and clinical infrastructure support to 
allow for the full implementation and ongoing sustainability of 
evidence-based psychotherapies at each VA site.
    VHA's system of National Mental Health Centers of Excellence and 
Mental Illness Research, Education and Clinical Centers (MIRECCs) 
focuses on specific solutions to mental health problems such as PTSD, 
serious mental illness, suicidality, and women's mental health. They 
are continually developing and disseminating new and promising 
interventions for mental health treatment and are, in fact, leading the 
Nation in developing strategies for treating PTSD and other conditions.
    b. Are the treatments appropriate, timely, and effective?
    Response. As noted above, VHA is committed to the use of evidence-
based practice in providing mental health care for Veterans. The 
psychotherapies being promoted throughout VHA were chosen based on 
their effectiveness as shown in clinical trials in improving patient 
outcomes for the specific diagnoses being targeted. VHA monitors access 
to care through evaluation of performance metrics. At this time, it is 
not possible to directly track national access to the evidence-based 
psychotherapies, although software improvements to allow this to happen 
are being developed. However, all patients new to mental health must be 
seen and evaluated within 24 hours and seen for full evaluation and 
treatment initiation within 14 days. VHA reports on this measure 
monthly; current data show that 95.4 percent of patients are seen and 
evaluated within this timeframe, which is slightly lower than the 96 
percent benchmark. The Office of Mental Health Operations is currently 
looking at additional methods of evaluating access to mental health 
care.

    Question 14. Why do suicide investigations take so long? Why they 
are not made a priority in the labs when we know that families need 
this information in order to fully grieve their loss?
    Response. Suicide investigations can vary considerably as to the 
time needed for completion. Non-VA entities have initial responsibility 
for investigations under their authority. They conduct a thorough 
review that can include forensics, autopsies, and post mortem 
psychological reviews. There will be variability among these non-VA 
entities in accomplishing a suicide investigation, given the processes 
and procedures that they utilize.
    Likewise, suicide investigations under VHA's authority have similar 
requirements for review. VHA's commitment is to provide a timely review 
of the Veteran's medical care prior to the Veteran's death and 
disseminate the results of this review as appropriate. VHA provides a 
number of services to family members. Meeting and exceeding the needs 
and expectations of our Veterans and their families is a priority. VHA 
will continue to make every effort to ensure that every applicable 
resource is made available at the time of need.

    Question 15. What are we doing to reach out to our families, 
especially parents, to provide education on emergency mental health 
issues, how to identify them, and what to do about it?
    Response. VA Suicide Prevention Coordinators include family and 
community groups and organizations in their outreach efforts on a 
monthly basis to make sure everyone knows how to get help in an 
emergency situation. We have developed an overarching information 
program concerning the Veterans Crisis Line and Veterans Chat service 
to make sure that everyone knows that 24/7 help is available for any 
emotional crisis. We have developed a community-based program titled 
Operation SAVE that teaches family members and friends the signs of 
emotional distress and suicide risk. Each Suicide Prevention 
Coordinator is required to present this educational program in the 
community a minimum of five times per month. OEF/OIF/OND coordinators 
also reach out to families of returning Servicemembers to make sure 
they are aware of available programs, and all new enrollees receive an 
information letter about the warning signs of crisis and available 
crisis intervention services from the Under Secretary of Health. In 
addition, the Coaching into Care line is available for more general 
help to family members when needed.

    Question 16. Servicemen and women consistently tell me that they 
want peer based support to help them with their behavioral health 
issues. Is there anything we are doing to try to build that peer based 
support? Is the VA utilizing peer-based support to help them with their 
behavioral health issues? What are you doing to try to build peer-based 
support for veterans?
    Response. VHA's OMHS strongly supports the use of peers in its 
mental health programs and has implemented several efforts to provide 
peer services nationwide. As part of the overall effort to transform 
VHA's mental health programs to the recovery model, peer support 
services are an integral adjunct to the clinical services provided by 
degreed professionals.
    Peer support services have a long history in the substance use 
disorder programs in VHA. In addition, as a result of the Mental Health 
Enhancement Initiatives, over 250 peers have been hired, most of whom 
deliver services to Veterans with a serious mental illness. Programs 
like the Psychosocial Rehabilitation and Recovery Centers and Mental 
Health Intensive Case Management teams now have peers providing 
services. OMHS has been working with the Office of Human Resources 
Management to develop a career ladder for peers that will recognize 
their valuable services and compensate them fairly for the work they 
provide.
    As authorized by Public Law 110-387, Section 107, OMHS is 
conducting a pilot program of peer-provided outreach and support 
services to rural OEF/OIF/OND Veterans. These pilot projects are 
currently active in VISNs 1, 19, and 20, all of which have large rural 
populations. In addition, Public Law 111-163, Section 304, authorizes 
access to peer outreach and peer support services for all OEF/OIF/OND 
Veterans and specifies that VA develop a contract with a national 
organization to carry out a program of training for Veterans to provide 
peer outreach and peer support services. VA is currently in the 
contract development process for that effort.
    Furthermore, VHA has developed the Buddy-to-Buddy peer support 
program jointly with the University of Michigan and in partnership with 
the Michigan Army National Guard and Michigan State University. This 
program addresses the unique challenges facing returning National Guard 
citizen soldiers, who are often isolated from those with whom they 
served once they return to their home communities and who face 
challenges reintegrating into civilian communities and returning to the 
civilian work force. The primary goal of the program is to intervene 
early so that identified concerns and stressors do not escalate into 
PTSD, family disruption, or suicidal crises. This program is now 
implemented throughout the Michigan National Guard.

    Chairman Murray. Thank you very much. Dr. Zeiss, I wanted 
to ask you. I noticed that you were shaking your head during 
Mr. Williams' and Mrs. Sawyer's testimony.
    Do you have anything you want to say to them?
    Ms. Zeiss. I respect and really appreciate what they say, 
and I am shaking my head only in the sense of listening and 
trying to incorporate and understand the issues that they are 
raising for us.
    Chairman Murray. I think you have been with the VA system 
longer than anybody on this panel, and you have made some great 
strides, and I know you are writing the policies. Do you think 
the facilities are listening to what you are telling them to 
do?
    Ms. Zeiss. I think that there has been tremendous progress 
in all of the facilities but inconsistent, and I very much 
support the reorganization that Mr. Schoenhard was just 
describing.
    I think that we have come to a much clearer delineation of 
what policy offices, like the office of mental health services, 
can do and can accomplish. To be able to work in a much more 
interwoven fashion with operations and management is going to 
be very powerful I believe.
    Ms. Schohn and I work very closely together in terms of 
looking not only at how policies are being implemented, but I 
think the other part of the question is, are we in central 
office listening to the facilities, and are we learning from 
them about the challenges they are having in implementing 
policy, and how do we do a much more coordinated job of coming 
up guidance for the field that really can be implemented in a 
consistent way throughout. And I think this organization is 
going to be very, very helpful.
    Chairman Murray. Mr. Schoenhard, we heard from the IG that 
Atlanta was not prepared to handle the influx of new veterans 
who needed mental health.
    This is not the beginning of this war. It has been going on 
for a very long time. We have been talking on this Committee 
for a very long time about PTSD and TBI and the invisible 
wounds of war and the high number of soldiers coming back who 
need this access.
    How can it be that the VA was not prepared for this?
    Mr. Schoenhard. Madam Chairman, that is a tremendously 
important question. In Atlanta, and it is true of VISN-7 where 
Atlanta is part. This is one of our fastest growing areas for 
veteran enrollment. We have there 7 to 8 percent increase.
    We concur with the IG, and I have talked with Mr. Clark, 
who is the director there. We were not as quick as we should 
have been, and we are going to learn from this. We are taking 
this report, not just for Atlanta but for other facilities 
particularly in high-growth areas. We need to improve the 
process that occurred in VISN-7, but I think with delay, to 
secure additional funding from the VISN in order to observe the 
growth.
    Every opportunity we have to learn from this and especially 
apply those lessons across is important. I do not know if Dr. 
Arana may want to elaborate on that a little bit or Ms. Schohn 
because I am looking to them for help with this.
    Dr. Arana. Madam Chairman, before I make my comments, I 
would like to thank Mr. Williams and Mrs. Williams, Mrs. Sawyer 
and Mr. Sawyer for being here.
    I have been a practicing psychiatrist for over 30 years. 
Their stories are just unacceptable in terms of practice. I 
have been in the VA system for over 28 years. I know we can do 
better. I have treated hundreds of PTSD patients.
    And so I am very sorry that you have had the experience you 
had. I am sure hopeful that we can be able to make that better 
in the next few months and the next few years.
    To the point of the reorganization, over the past 4 months 
re-aligned in VA particularly in terms of operations, and one 
of the key areas that we have realigned is mental health.
    The idea of the realignment is to have more clinical muscle 
in operations so that we can better implement the policies that 
Ms. Zeiss has developed over the past few years, and the plan 
is very much to do that in an aggressive way.
    Our hope is to get out to the facilities in the very 
regular way. In fact, much the way the IG does with on the 
ground visits with experts who know the business, who know how 
to ask the questions, who know how to find out where the gaps 
are.
    Our hope is to deploy this effort very strongly over the 
next six to 8 months and hope to come back and tell you about 
our progress with that.
    Chairman Murray. As you have heard, the wait times for 
appointments have a huge impact not only on veterans, but on 
their entire family and the stress that they are going through.
    I know we do not even know the scope of all this from the 
VA itself because they are only measuring the wait times for 
the first time mental visit. We are not seeing data for the 
second time or the third time, and I know that is what both of 
our witnesses before were talking about. It is not just the 
first appointment. It is when you called yesterday and you were 
told: well, because you are going to be at this hearing it is 
going to be 4 months before you get in. Unacceptable.
    How are we or you, how are you empowering managers to be 
more flexible with their money to do what they need to do to 
make sure that that is not what veterans hear on the first, 
second, third, or hundredth time that they call?
    Mr. Schoenhard. Madam Chairman, I am going to ask Dr. 
Schohn perhaps to add to this if it is OK.
    But what I would begin with is that the performance 
measurement that we have for new patients is important. We 
already heard testimony this morning that in this case a new 
patient presenting was not served in a timely fashion. And 
while that is necessary, I do not believe it is sufficient.
    The performance measures that we work with facilities on 
and understand their difficulties with is an evolving 
methodology. I think from the Atlanta IG report and from other 
indications we have, we need to look at what support needs to 
be given to being able to insure that timely appointments are 
made for existing patients as well.
    We do measure that, but what I am hopeful for in terms of 
the deployment of Uniform Mental Health Handbook is that all of 
this is laid out there for existing and new patients.
    What we need to do is to get better deployment, do the site 
visits, and as you infer in your question, understand what, if 
any, barriers exist, what difficulties the facilities are 
having, the clinicians are having, what are the root causes of 
any gaps in that care and address those whether they be 
staffing, facility, or whatever.
    Chairman Murray. Are you doing that or are you just 
identifying that as a problem?
    Mr. Schoenhard. Yes, we are doing that. And if I could ask 
Ms. Schohn to elaborate.
    Chairman Murray. And then I need to turn it over to Senator 
Burr so if you can answer quickly.
    Ms. Schohn. Yes. We are in the process of developing a 
comprehensive monitoring system that looks at all of the 
issues, the implementation rates, really combining the date for 
all into one place so that we can red-flag quickly based on our 
available data.
    By the same token, we are also looking to develop new 
databased on our site visits that might give a more accurate 
reflection of what is really going on in the facilities, and 
finally, we are going to be----
    Chairman Murray. When will you see that? How long does it 
take to collect all of this data?
    Ms. Schohn. We hope to have the full package in place by 
the end of the year. We are looking at pieces of the data right 
now so we can again begin to address it as it comes up but we 
hope to have the full package available by the end of the year.
    Chairman Murray. And then you will have to analyze it and 
then go back to the facilities?
    Ms. Schohn. No, no. It will be put together as an analysis 
that we can work with the VISNs.
    Chairman Murray. My question is: does everybody have to 
wait another year?
    Ms. Schohn. No, no. We will be working on this, as I said, 
concurrently with putting the information together.
    Chairman Murray. If you see information coming in that 
second, third, fourth, fifth visits are taking too long, can 
you do something immediately about that?
    Ms. Schohn. Yes, we can.
    Chairman Murray. OK. Senator Burr.
    Senator Burr. Mr. Schoenhard, how do you define ``timely'' 
for a veteran with a gun in his mouth?
    Mr. Schoenhard. Instantaneous, sir.
    Senator Burr. So, is that the directive that comes out of 
the VA Central Office to all individuals at all locations that 
would come in contact for the first time with a veteran with 
mental health needs?
    Mr. Schoenhard. Well, we do have a requirement that those 
who present with serious issues, and I might ask Dr. Zeiss to 
elaborate on this, be seen within 24 hours. But to your 
question specifically, a veteran with a gun in his or her 
mouth, our expectation would be immediate help starting with 
whatever would be available on the crisis line and any other 
intervention that could be provided.
    Senator Burr. Does the VA have written access standards for 
behavioral health care for both urgent care and routine care?
    Mr. Schoenhard. Yes, sir, we do.
    Senator Burr. And what are those?
    Mr. Schoenhard. Could you elaborate, Dr. Zeiss?
    We do, for urgent care, require an appointment within 24 
hours, and 14 days for other new patients. But you may want to 
elaborate on that.
    Ms. Zeiss. There are a number of components. I will try to 
lay it out, but we can also give you some additional 
information later. We do have very clear directives about 
having mental health providers in emergency departments where 
many of these issues might come up, having 23-hour observation 
beds in those emergency departments. We also have requirements, 
as Mr. Schoenhard said, that if there is a referral for a new 
individual who has not been seen in mental health in the last 2 
years they require a contact within 24 hours.
    Senator Burr. Dr. Zeiss, where is our problem? Is our 
problem that the VA really does not put these directors out? Is 
the problem that the VISNs really do not read the directives 
that you put out and do not share it with the facilities? Is 
the problems that individuals that comprise the medical staff 
at the facilities believe that the guidelines that come from 
the VA Central Office are not enforceable?
    Let me just ask this. Has anybody involved in the mental 
health delivery of care around the country in the VA been fired 
because of some of the issues that have arisen from veterans 
like the two that we heard today?
    And, Mr. Schoenhard, I have to tell you. Your opening 
statement, I had heard it before. I just had not heard it from 
you.
    So, now that we have gotten that out of the way, the 
purpose of this Committee is hopefully to partner with the VA 
to solve the problem, and we keep going back to the things that 
are in place.
    If you only take one thing away from this, please 
understand it does not work. There are gaps. There are holes. 
There are veterans that are falling through the cracks with 
mental health problems that I do not think were on detected. I 
think there is a professional on the other end who works for 
the VA that really did not give a damn whether they got the 
care in a timely fashion or not.
    So, I fear that your definition of ``timely'' and the front 
line's definition of ``timely'' is extremely different. Yours 
is genuine and theirs is whenever I have time to deal with it 
versus the human face on the other end of a phone.
    I have complained to the Secretary before. If the 
relationship between the VA and veterans is going to change, it 
starts with hiring somebody that answers the phone and makes 
appointments that actually cares about whether the appointment 
is made or not, because when you get that bad taste in a 
veteran's mouth to begin with, no matter where you navigate 
through the system, the fact is that that is always going to 
stick in your craw if the first person you talked to really 
could care less who you were or what your problem was.
    Now, let me ask, Ms. Zeiss, you stated that the VA Central 
Office continually updates guidelines. I am paraphrasing, but I 
think that is what you said. As we update those, should it not 
eliminate some of the things we constantly hear?
    Ms. Zeiss. That is certainly our goal and that is the 
intent of any guideline that we develop because we have seen a 
problem or have been asked by the field for more clear 
guidance. The guidance is developed and disseminated, and I 
will again say what I did before. I think that this new 
organization so that we in policy now have a clear team to turn 
to who will be working directly with the network directors is a 
tremendously positive step.
    Senator Burr. My time has expired. I will have some written 
questions for the panel.
    Let me just make this statement because it is highlighted 
in every hearing that we have on mental health, and it is how 
well the suicide prevention hotline works, and I applauded that 
when it was added. I think it is absolutely a necessity.
    But I want to suggest to you that the ultimate prevention 
of suicide is to supply the treatment in a timely fashion that 
our veterans need. To walk away and feel good because somebody 
can pick up the phone when they want to kill themselves, I am 
worried about the ones that never pick up the phone. I am 
worried about the ones that naturally we are not going to 
affect the outcome of what they intend to do.
    And the only assured way that we can make sure that we 
minimize the number of people that call that line is to make 
sure that, in fact, the service we provide is effective.
    So, as we hear about the numbers increasing on the hot 
line, understand with as many hearings as I have been in and 
with all of the new programs that I hear we are going to start, 
with an increasing number who call the hotline, it tells me 
that everything that we are trying really is not working for 
the ones who need it the most.
    And as long as we have veterans who come before the 
Committee and tell us their horror stories, it is the 
responsibility of this Committee to remind you that everything 
we have in place is not perfect.
    We have got a lot of work to do. And I might say, just for 
the record, this year we budgeted $5.7 billion to mental 
health; in 2012 it is $6.1 billion to mental health.
    Trust me, if you look at the last 9 years in the VA, if 
increasing funding solved the problems, this would be the model 
of government. But the challenges exist in every area of the 
VA, and they are not limited by how much money we have been 
willing to pump into the program.
    I thank you, Madam Chairman.
    Chairman Murray. Thank you very much, Senator Burr, for 
your passionate statement. The only thing I would add, and I 
share everything you said, is that the VA is the receiver of 
all of this and ends up having to deal with it.
    We have to go back to the Department of Defense and the 
military itself and make sure that we are doing the right thing 
for our servicemen and women while they are on the ground to 
make sure that they know where to go so that they do not get 
into some of the gaps that we hear that end up in the laps of 
this Committee as well.
    Senator Brown.
    Senator Brown of Massachusetts. Thank you, Madam Chair.
    You know, listening to and reflecting on what you just 
said, there needs to be a top-to-bottom review from the minute 
the soldier is getting out to determine what their status is; 
how they are mentally and physically. I know we do a pretty 
good job on that depending on what branch of service you are 
in, depending on whether you are Guard, Reserve, active Army.
    But I will tell you what. You know, like I said, I have 
been here only a year and a half and I have heard these stories 
more than any other Committee, any other Committee that we have 
had these are the most consistent stories I have heard is the 
complete breakdown between the soldier when they get out, when 
they are in such desperate straits that they would think of 
taking their own life.
    I do not understand where the breakdown is. And I know that 
you are in a tough situation. I understand that. But when you 
are dealing with people's lives, you know, the response rate 
needs to be perfect because every lack of perfection equals a 
death--bottom line.
    Interestingly, it was commented on about video links, video 
treatment, to have a video treatment for some of these areas 
that are out in kind of the boonies, so to speak. It makes 
sense if they can get to a facility and at least speak to 
somebody.
    I am finding from everything that has been told to me--and 
I am still serving, 32 years in. I deal with this regularly, 
and it is just having a warm body on the other end, a smile, a 
handshake, a hug to say, hey, we care, we may not be able to 
help you right now but, you know, to have the cold, calculating 
statement, it is 4 months, sorry, we do not really give a crap, 
that is where the breakdown is.
    There is a complete lack of trust between the veteran and 
the Department. As a result, there is so much desperation right 
now in this area that I do not know what you have to do to 
shift assets and resources and bodies and whatever, but you 
have got to get a handle on this stuff or you are going to be 
back here every month, every week answering to us.
    And the amount of money that is being sent forth to the 
Department to solve these problems needs to be fixed, and it is 
going to take draconian efforts and Herculean efforts I should 
say on your part to send the message out that this is 
unacceptable, these stories are unacceptable.
    That being said my question is: if the VA is placing an 
emphasis on recovery-based models, then why are only 4 percent 
of its patients referred to vocational rehabilitation services?
    I am curious as to why that is such a low number.
    Mr. Schoenhard. Senator, before I answer that, could I just 
say to your very, very important point regarding transition 
from active duty or Reserve or Guard service: there is a lot of 
collaboration. I was in a meeting over at the Pentagon this 
week working this issue between DOD and VA, and this is an area 
where we need to continue to work together to improve.
    Senator Brown of Massachusetts. How do these people then 
come to us? It has been years. It is not like you could Google 
them and find out. How does it take them screaming with MPs 
breaking down doors to come to this point? If that is the case, 
there is all this amazing coordination, everything is great, 
great, great; I love Washington; everything is great here but 
outside it is not. People are hurting.
    So, how do you get there?
    Mr. Schoenhard. In my view it is what we are working on in 
terms of OEF/OIF reach, outreach. It is the warm handoff 
between active duty----
    Senator Brown of Massachusetts. It is not only a handoff, 
it is a continuation.
    Mr. Schoenhard. That is right.
    Senator Brown of Massachusetts. It is not the handoff. The 
handoff. You can give a box of candy and flowers and a big hug. 
The handoff is great; boy, what a great experience. That is not 
where the breakdown occurs. The breakdown is from the handoff 
to the actual treatment that follows.
    Mr. Schoenhard. Yes, sir.
    Senator Brown of Massachusetts. That is the problem.
    Mr. Schoenhard. And that is how I intend--what I am saying 
is that we get visibility of these folks, that there is not 
that kind of delay in what we have for those who have served 
this country, particularly in multiple deployments in the 
current wars, an excellent transition going forward. And that 
requires, I mean, is in place right now, and present in 
cooperation and work. But it is an area where we are focused 
and where we are going to continue to improve.
    As it relates to the vocational rehabilitation, if I could 
yield to Dr. Zeiss or Dr. Schohn. That may be a question we 
would have to take for the record, sir.
    Senator Brown of Massachusetts. Yes. I have a whole lot of 
questions for the record. But I am concerned and I will just 
tell you where my mind is.
    I am concerned about the process for follow-up 
consultations, what are the procedures and standards in place 
to contact the individuals who have been discharged that are 
still at risk.
    I mean, the fact that, the testimony we heard that they 
were even allowed to go home, it just mystifies me. How is VA 
going to improve its coordination in partnership with local 
community organizations and really just have everybody in the 
ballgame, everyone has some skin in the game.
    Listen, I know this has not been just your problem. I 
understand that. I am not just going to come in and throw 
bombs. That is why the Chairwoman is having this hearing. And I 
have often said, if there is a problem and you need help, we 
need to know about it.
    Where is the breakdown? You give them the money. Is it 
regulatory help you need? Are there roadblocks that you are 
seeing that we can kind of push the doors opened a little bit? 
Is it the Administration that needs to do something? Is it we 
in Congress? What is it?
    Because all I hear are the stories and stories. Oh, yeah, 
we are working on it, we are working on it, were working on it, 
we are working on it. It is like, OK, it is 10 years now. We 
have known about this for at least seven. So where are we?
    Mr. Schoenhard. Well, sir, I think we are going to have 
greater visibility with the site visits and targeting 
clinicians in a more focused way than we have had before in 
talking with veterans and in talking with other providers, and 
we certainly will brief the Congress on any barriers that 
require your help.
    Senator Brown of Massachusetts. Thank you. I will submit 
questions for the record, Madam Chair. Thank you.
    Chairman Murray. Following up on Senator Brown, Mr. 
Schoenhard, I would like you to go back to each one of the 
VISNs to survey the clinicians on the ground that are dealing 
with wait lists that we are hearing about and report back to 
this Committee on your findings.
    I think it is really imperative that we hear directly from 
the VA's mental health care providers who are on the front 
lines treating our veterans. We need to know if the providers, 
not the administrators, but the providers think that they have 
sufficient resources to manage the waiting lists that they 
have.
    So, I would like you to commit to doing that for this 
Committee.
    Mr. Schoenhard. We will do that, Madam Chairman.

Response to Request Arising During the Hearing by Hon. Patty Murray to 
 William Schoenhard, Deputy Under Secretary for Health for Operations 
  and Management, Veterans Health Administration, U.S. Department of 
                            Veterans Affairs














    Chairman Murray. OK. I have a couple of more questions that 
I want to ask and I will have some I will submit for the 
record. But, Mr. Schoenhard, while you are here, I wanted to 
ask you about this issue of sexual assaults.
    I was very troubled by the GAO's recent report on sexual 
assaults. They started this work because clinicians were not 
referring female patients or veterans to inpatient PTSD 
treatment because of safety concerns.
    I am paraphrasing but the GAO found that clinicians were 
concerned about the safety of women veterans in residential 
mental health programs. Part of this was that a program housed 
both women veterans and male veterans who had committed sexual 
crimes in the past.
    Clinicians expressed concerns about inadequate safety 
precautions in place to protect those women that were admitted 
to the units.
    Now, I am shocked that this would happen at even one 
medical center. It is entirely unacceptable, and I am afraid 
that there may be other places in the VA that this could be 
true as well.
    So, I want to know this morning what you are doing to 
correct that problem at this unnamed medical center and what 
you are doing to make sure this is not happening anywhere else 
in the system.
    Mr. Schoenhard. I am going to ask Dr. Arana to add to this, 
but let me begin. This report from GAO had eight 
recommendations that we fully concur with, four that had to do 
with prevention which gets to your question, Madam Chairman, 
and four which had to do with reporting.
    Just as with the case of suicide, one sexual assault, one 
instance where someone feels victimized, is one too many. We 
take this report extremely seriously. The Under Secretary for 
Health, Dr. Petzel, has chartered a workgroup chaired by Dr. 
Arana and Dr. Patty Hayes, who is the Chief Consultant for 
Women's Services at VA.
    We wanted both operational and program leadership to 
address these recommendations, particularly having to do with 
prevention. And there are a series of findings that are coming 
out of the Committee, out of the workgroup, that are due July 
15.
    We have been in touch with the facility that was addressed. 
Again, as I mentioned earlier in my testimony, when we have a 
report like we did in this case of sexual assault where they 
visited five of our facilities, what is it that we learn from 
that that we apply systemwide, not just to answer compliance 
with that.
    Dr. Arana, if you could please give some update on your 
work.
    Dr. Arana. Madam Chairwoman, what we are doing is 
essentially taking the GAO report and have extracted six major 
areas that we are going to pursue. One of the criticisms was we 
do not have a clear definition for sexual assault. That we have 
done.
    Chairman Murray. We do not have a definition?
    Dr. Arana. A clear definition for all of VA for sexual 
assault. GAO has a definition. CDC has a definition. So, the VA 
has----
    Chairman Murray. You talk to any of the women. They can 
define it for you.
    Dr. Arana. Yes, ma'am.
    So, the VA has used the definition that the GAO used. Going 
forward, we will be using their definition for the VA.
    We are also relooking at our databases and our report 
structures. Right now they are imperfect. That was pointed out 
by the GAO. The plan is to have police reports and management 
reports basically integrated and have 100-percent coincidence 
so that we know that they agree with each other. That we are 
also doing right now.
    The other thing is we are doing behavioral surveillance 
education. We are working, we are partnering with DOD. They 
have a very strong program with us. The hope is to learn from 
them about how to educate all staff and all patients and all 
visitors at our health care centers and also all of our care 
areas about vigilance and prevention.
    And the fourth point is what we call technical surveillance 
which goes to cameras, panic buttons, locks on doors, adequate 
staffing of police.
    So, we are looking at those four areas aggressively and 
hoping to be able to report back here and tell you about 
progress.
    Chairman Murray. OK, look. I have to tell you in terms of 
sexual assault, I am deeply concerned about this. This has been 
a hidden problem coming home from our veterans for far too 
long.
    Part of the work that I have done on this Committee is to 
put in place a new focus on women's veterans so that all of our 
facilities have a place for women to go to. I have been out 
looking at many of the women's facilities, talking to the 
caregivers on the ground. A high number, much higher than I 
thought, are reporting military sexual trauma, definition or 
not.
    We cannot leave this as a hidden problem or something we 
are looking at and report back a year from now and hear the 
same things are going on. We have to all take this as a serious 
issue, bring it out into the light and deal with it. These 
kinds of reports to me are very, very troublesome, and I am 
angry about it.
    So, I do not want this to be a report back to this 
Committee months from now. I want to know immediately what is 
being done, immediately what is being done to make sure that 
this is not happening to anybody.
    Mr. Schoenhard. Madam Chairman, if I could just clarify as 
it relates to the definition, that had to do with the 
reporting. Any time, anyone--visitor, patient, employee--
anyone, feels that they have been victimized in some way that 
is where we need a report. We need an immediate follow up, and 
we need intervention.
    Chairman Murray. And that needs to be systemwide in the VA.
    Mr. Schoenhard. Yes, ma'am.
    Chairman Murray. Immediately.
    Mr. Schoenhard. Yes, ma'am.
    Chairman Murray. I have a number of questions, but we have 
run out of time, so I am going to submit them for the record.
    I want to know about the peers--the use of veterans' peers 
in particular. We heard that from our veterans today.
    I would like you to get back to this Committee on what you 
are doing on that.
    The wait times, as you heard from this Committee, are a 
huge concern. VA reported that 95 percent of the veterans 
seeking mental health were seen within 14 days. That is not 
what we are hearing on the ground. So again, that is going to 
be an issue we want to follow up on and several others.
    You are hearing the frustration from the Members of this 
Committee. You are all wonderful people. I know you work hard 
every day. I know you work with people who care. But I have to 
tell you this war has been going on a long time. There are not 
surprises about the number of people out there suffering from 
PTSD and TBI.
    We, as a country, cannot allow this to be a report or a 
report back or to have it be hidden in a corner. We have to 
bring it out in the open. If we need more resources, if we 
need, you know, America to stand up taller, if we need more 
clinicians, boots on the ground, we need to know that because 
this Committee is going to make sure that we do not continue to 
hear these stories year after year.
    We need your help to find out the real answers to this so 
we can have the right policies and resources in place. That is 
why you are hearing the passion from this Committee.
    With that, we have run out of time this morning, and I do 
want to thank all of our witnesses for being here today to 
share their views and experiences.
    Some steps have been taken. This Committee knows that and 
we appreciate what the VA has been doing. But it is very clear: 
a lot more needs to be done; and it is really crucial that we 
have the resources, that we have the personnel in the right 
places.
    As Senator Burr has reminded us time and time again, that 
first person who answers the phone has to be responsive because 
that is how our veterans feel that they are treated. So it goes 
across the board.
    With that, I look forward to working with the VA in the 
months ahead to address these issues and appreciate again all 
of you being here.
    Thank you very much, and this hearing is adjourned.
    [Whereupon, 11:46 a.m., the Committee was adjourned.]
      

                                  
