[Senate Hearing 112-508]
[From the U.S. Government Publishing Office]
S. Hrg. 112-508
VA MENTAL HEALTH CARE: EVALUATING ACCESS AND ASSESSING CARE
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HEARING
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES SENATE
ONE HUNDRED TWELFTH CONGRESS
SECOND SESSION
__________
APRIL 25, 2012
__________
Printed for the use of the Committee on Veterans' Affairs
Available via the World Wide Web: http://www.fdsys.gov
_____
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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
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April 25, 2012
SENATORS
Page
Murray, Hon. Patty, Chairman, U.S. Senator from Washington....... 1
Brown, Hon. Scott P., U.S. Senator from Massachusetts............ 3
Tester, Hon. Jon, U.S. Senator from Montana...................... 57
Moran, Hon. Jerry, U.S. Senator from Kansas...................... 59
WITNESSES
Schoenhard, William, FACHE, Deputy Under Secretary, Health,
Operations and Management, U.S. Department of Veterans Affairs;
accompanied by Antonette Zeiss, Ph.D., Chief Consultant, Office
of Mental Health Services; and Mary Schohn, Ph.D., Director,
Office of Mental Health Operations............................. 5
Prepared statement........................................... 7
Response to posthearing questions submitted by:
Hon. Patty Murray.......................................... 11
Hon. Bernard Sanders....................................... 16
Hon. Johnny Isakson........................................ 18
Hon. Roger F. Wicker....................................... 20
Halliday, Linda, Assistant Inspector General for Audits and
Evaluations, Office of Inspector General, U.S. Department of
Veterans Affairs; accompanied by Larry Reinkemeyer, Director,
Kansas City Office of Audits and Evaluations................... 27
Joint prepared statement..................................... 28
Response to posthearing questions submitted by:
Hon. Bernard Sanders....................................... 32
Hon. Johnny Isakson........................................ 32
Daigh, John, 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, Office of Healthcare Inspections.................... 33
Tolentino, Nicholas, OIF Veteran and Former VA Mental Health
Officer........................................................ 34
Prepared statement........................................... 36
Jones, MajGen Thomas S., USMC (Ret.), Founder and Executive
Director, Outdoor Odyssey Youth Development and Leadership
Academy........................................................ 43
Prepared statement........................................... 44
APPENDIX
Altman, Claire Haaga, Executive Vice President/Chief Operating
Officer, HealthCare Chaplaincy; prepared statement............. 69
American Society for the Advancement of Pharmacotherapy; prepared
statement...................................................... 70
VA MENTAL HEALTH CARE: EVALUATING ACCESS AND ASSESSING CARE
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WEDNESDAY, APRIL 25, 2012
U.S. Senate,
Committee on Veterans' Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 9:35 a.m., in
room SD-138, Dirksen Senate Office Building, Hon. Patty Murray,
Chairman of the Committee, presiding.
Present: Senators Murray, Tester, Brown, and Moran.
STATEMENT OF HON. PATTY MURRAY, CHAIRMAN,
U.S. SENATOR FROM WASHINGTON
Chairman Murray. Good morning. This hearing will come to
order. I would like to welcome all of you to today's hearing to
evaluate VA access to mental health care services.
Today's hearing builds upon two hearings held last year. At
each of the previous hearings, the Committee heard from the VA
how accessible mental health care services were. This was
inconsistent with what we heard from veterans and the VA mental
health care providers. So last year, following the July
hearing, I asked the Department to survey its own mental health
care providers to get a better assessment of the situation.
The results, as we all now know, were less than
satisfactory. Among the findings, we learned that nearly 40
percent of providers surveyed could not schedule an appointment
in their own clinic for a new patient within the VA-mandated
14-day window; and 70 percent reported inadequate staffing or
space to meet mental health care needs.
The second hearing, held in November, looked at the
discrepancy between what the VA was telling us and what the
providers were saying. We heard from a VA provider and other
experts about the critical importance of access to the right
type of care, delivered timely by qualified mental health
professionals.
At last November's hearing, I announced that I would be
asking VA's Office of Inspector General to investigate the true
availability of mental health care services at VA facilities. I
want to thank the IG for their tremendous effort in addressing
such an enormous request. The findings of this first phase of
the investigation are substantial and troubling. We have heard
frequently about how long it takes for veterans to get into
treatment, and I am glad the IG has brought those concerns to
light.
The IG will also discuss an entirely different and more
useful way of understanding access to care. This model would
give more reliable data and reduce the rampant gaming of the
system that we have seen thus far. The IG has also found the
existing scheduling system is hopelessly insufficient and needs
to be replaced.
VA has struggled with developing a new scheduling system. I
understand VA is working to get a replacement system in place.
I would like the Department's commitment that they will work to
get this done right and get it done soon.
The IG findings also show some serious discrepancies in
what VA has been telling this Committee and veterans. VA stated
that 95 percent of veterans received mental health evaluation
within 14 days. In reality, it was only about 50 percent. VHA
data reported that after the evaluation was completed, 95
percent of veterans received a treatment appointment within 14
days. In reality, it was only 64 percent. For those in
treatment, 12 percent were scheduled beyond the 14-day follow
up appointment window, with providers telling the IG that they
were delaying follow up for months, not because of the
veterans' needs, but because their schedules were too full.
VA is failing to meet its own mandates for timeliness and
instead is finding ways to make the data look like they are
complying. VA can and must do much better. Important steps have
been taken in the right direction by the Department. Last week,
VA announced the addition of 1,600 mental health providers. And
late last year, VA announced an increase in staffing levels at
the Veterans Crisis Line.
As we will see today, the hard work remains in front of us
at a time when veterans are dying by suicide at an alarming
rate. We know that the sooner a veteran can get a mental health
care appointment after they request it, the more likely they
are to follow through with care.
We cannot afford to leave them discouraged when trying to
access care, and when in care, we must be getting veterans
their next appointment in a clinically appropriate time. We
need to be sure there are enough resources so providers do not
have to delay treatment because their schedules are too full.
While I commend VA for the decision to hire another 1,600
mental health providers, there is still no reliable staffing
model to determine where these individuals are needed. Without
that model, VA needs to explain how they will know where to
place these additional providers.
There are other challenges with getting the best providers
into the system. I understand that nationally there are
shortages of mental health providers, and it is even harder for
VA because they cannot always pay the highest salaries in the
community. There are still a large number of vacancies in VA's
mental health ranks.
I want to hear from the Department how they will fill the
existing gaps and ensure the new positions they have announced
do not become 1,600 empty offices. Ultimately, what really
matters is how long it takes for a veteran to start that first
treatment session. What really matters is not abandoning that
veteran.
I recently saw Andrea Sawyer whose husband Lloyd suffers
from PTSD and depression. Andrea bravely testified before this
Committee last July about the tremendous difficulties she and
her husband faced in getting him into care. Lloyd still faces
challenges, but he is now getting the care he needs. That is
what matters. We cannot let our veterans down, especially when
they have shown the courage to stand up and ask for help.
I look forward to hearing from VA how they intend to
address the issues the IG has found. Now more than ever is the
time for action and for VA to show effective leadership. Let
the hearing today serve as an unequivocal call to action. The
Department must get this right.
In closing, I do want to be clear that while we have
discussed a number of problems with the system at large, none
of this reflects poorly on VA's providers. I believe I can
speak for all of us in thanking VA's many mental health
providers for the incredible job that they do. Let there be no
mistake, these individuals are incredibly dedicated to their
mission. They choose to work harder than most of their peers,
often for less lucrative benefits, all because they believe in
what they do and because they have a deep and unshaking
commitment to our veterans.
To all of VA's psychiatrists, psychologists, social
workers, and other providers, and to all the administrative
staff who support them, thank you so much for the good job, and
keep up the good work.
With that, I want to turn it over to Senator Brown who is
standing in for Senator Burr today.
STATEMENT OF HON. SCOTT P. BROWN,
U.S. SENATOR FROM MASSACHUSETTS
Senator Brown. Thank you, Madam Chair. It is good to be
here as the Ranking Member in place of Senator Burr. It is good
to be back on the Committee serving with you. I want to thank
you for holding this very important hearing.
Some of these I am still serving, I see and hear of these
types of situations regularly. $5.9 billion, that is the
increase that VA got. And out of that, do you think we could
hire some more people to address these very real concerns? $5.9
billion.
To read some of the things that we have been reading about
the suicidal veteran calling for help, gone unanswered, one
more person killing themselves, and the veteran's mental health
care is delayed--put out by the Washington Post, actually
yesterday, talking about how the system is being gamed by the
VA, and not actually scheduling and following through with
scheduling and providing a good opportunity for these soldiers
to get the care and coverage that they need--it is mind
boggling.
I mean, I understand the delay. I understand that there are
problems. I understand that claims go over a year. But for
somebody who calls and says, ``Hi, I'm thinking of killing
myself.''
``Well, do you feel that way right now?''
``Well, not right in this moment. But I tried to hang
myself yesterday. Does that count?'' And then to be blown off;
it just makes absolutely no sense to me at all.
So I am glad you are holding this hearing. I want to
continue to look into mental health services. Your insights in
this Committee help perform the oversight to ensure that
veterans get the services they need, and that is a good thing.
As you know, one of the several hearings regarding mental
health services--this is another one--last year, I remember we
did learn about the various serious mental health services that
were needed and, quite frankly, lacking. I want to just say
that today's hearing will focus on evaluating the availability
of these services and accessing the care that is delivered.
The testimony we hear today will be from VA's Inspector
General, as well as Iraq veteran and former VA mental health
officer, Nick Tolentino, who feels there is an ongoing cultural
problem at the VA.
Nick, I want to thank you for your testimony and pointing
out where the loopholes are sought and openly shared to hide
the fact that the facilities are not meeting their performance
metrics. And I have got to tell you, it is unacceptable, as I
said, for some of you who still serve and see and speak
regularly with people that are affected by these various
serious ailments.
The gaming of the system has to stop. The IG found in their
audit, and Nick confirmed in his testimony, that our veterans
are not given the opportunity to actually offer a desired date
for their next appointment. They were simply told when and
where to show up and no consideration or compassion to address
the very real concerns that they have.
The scheduling system is not the only problem with
delivering mental health care. Even though the VA has increased
the staffing by 48 percent between 2006 and 2010, both the IG
and Nick point out that it is understaffed and lacks a
methodology to assess their staffing needs. And it is no
surprise that just 1 week after this hearing, VA announced they
are hiring 1,900 additional mental health staffers.
Well, that is great. It is a good start. But, man, what
have we been doing up to this point? We need to do it better.
We have people's lives depending on these decisions that we are
making. And it is a good step, as I said, but how long will it
take to actually fill these positions? And what happens to that
soldier who calls, as been happening with Jacob Manning and
others.
We will hear today from community groups that are helping,
General Tom Jones, founder of Semper Fi Odyssey, to help
veterans from the current conflicts manage their mental health.
And I want to thank you, sir, for that effort, going above and
beyond. It will help veterans volunteer their time to help
fellow soldiers cope with those invisible wounds of war, which
we all know about. It is a great example of the community
coming forward and addressing needs not currently being met. So
thank you for that.
In the end, simply hiring more staff and fixing VA's broken
scheduling system will not cure all the issues, but it will
certainly take a combination of changes at the facility level
and the VA office level. And the VA will use all available
resources, including fee bases, care, staffing increases, and
developing better performance metrics to fix a severely broken
system.
I concur with you that the individual people that are
there, they are doing yeoman's work, but it is still not
enough. Is it you need more people? You need more computers?
What is it? $5.9 billion should go a long way to addressing
those issues.
Madam Chair, as I reference, I am heading upstairs just to
give HSGAC a quorum, then I will be right back down. So I look
forward to everybody's testimony. Thank you.
Chairman Murray. At this time, I would like to introduce
the first panel. Representing the VA is Mr. Bill Schoenhard,
VA's Deputy Under Secretary for Health, Operations and
Management. He is accompanied today by Dr. Antonette Zeiss,
Chief Consultant for the Office of Mental Health Services, and
Dr. Mary Schohn, Director of Mental Health Operations with the
Veterans Health Administration at the Department of Veterans
Affairs.
From the Office of Inspector General, we have Dr. David
Daigh, Assistant Inspector General for Healthcare Inspections,
accompanied by Dr. Michael Shepherd, senior physician in the
IG's Office of Healthcare Inspections. Also from the Office of
Inspector General, we have Ms. Linda Halliday, Assistant
Inspector General for Audits and Evaluations, accompanied by
Mr. Larry Reinkemeyer.
Next, we will hear from Nick Tolentino. He is a Navy
veteran of the Iraq War and a former mental health
administrative officer in the VA.
Finally, we will hear from the founder and executive
director of Outdoor Odyssey, retired U.S. Marine Corps, Major
General Thomas Jones.
So, Mr. Schoenhard, we will begin with your testimony. We
have a lot of answers we need from you, so please begin.
STATEMENT OF WILLIAM SCHOENHARD, FACHE, DEPUTY UNDER SECRETARY,
HEALTH, OPERATIONS AND MANAGEMENT, U.S. DEPARTMENT OF VETERANS
AFFAIRS; ACCOMPANIED BY ANTONETTE ZEISS, PH.D., CHIEF
CONSULTANT, OFFICE OF MENTAL HEALTH SERVICES; AND MARY SCHOHN,
PH.D., DIRECTOR, OFFICE OF MENTAL HEALTH OPERATIONS
Mr. Schoenhard. Thank you.
Chairman Murray, we appreciate the opportunity today to
address the access to and the quality of mental health care
services to our Nation's veterans. And we appreciate so much
discussion of a topic that is integral to the well being and
full living out of a fulfilled life of our Nation's veterans.
Mental health is integral to the overall well being and
physical health of a veteran. It is important, if there is
underlying depression, problem drinking, or substance abuse, or
other medical mental ailment, that this be diagnosed in order
to ensure that those who have served our country have the full
treatment of something that is so core to their overall well
being and to their ability to also implement the physical
health aspects of medication management, staying employed and
the rest, which is so important to the quality-of-life of a
veteran who has served this country.
It is the sacred mission of VA to ensure that this very
integral part of our care is well delivered.
I appreciate so much your comments regarding the 20,500
providers who on the ground work so hard every day to serve our
Nation's veterans in this important mission.
In the written statement, I have outlined three areas of
improvement and concern, but I would like to first mention that
we appreciate so much your leadership, the Committee's review,
and the Inspector General's review. This is an important aspect
of care, and we appreciate all of the assistance.
We will be working very closely with the Inspector General
as we go forward with their report as it relates to the first
recommendation that I would like to address. And that is that
we agree with the Inspector General that our appointment
measurement system should be revised to include a combination
of measures that better capture the overall efforts throughout
a course of treatment for a veteran, while maintaining
flexibility to accommodate a veteran's unique condition and
phase of treatment.
We must also continue our efforts to strengthen mental
health integration into our primary care in order to ensure in
the primary care settings that we are assessing mental health
needs of our Nation's veterans and also be able to address the
stigma that is often associated with this, that can be
discussed in a primary-care setting.
The second point I would like to make, as announced by
Secretary Shinseki last week, we are increasing staff to
enhance both the access to and the quality of mental health
care by hiring 1,900 additional staff, more than 1,600 of those
who are mental health clinicians. As I mentioned, this will
augment the current complement of 20,500 mental health
employees in our system and is designed to provide additional
staff in our facilities.
It is also designed to increase our staffing of our crisis
line, which is so integral to the identification and treatment
of people who are in crisis, as Senator Brown spoke of so
eloquently. And it is also an important aspect of increase in
that we will be adding additional examiners for compensation
and pension examinations.
It is an important transition from active duty to veteran
status for those who are currently on active duty and for those
who present with new conditions. We have a solemn
responsibility to ensure that we increase our staff to ensure
that we can handle this volume in a timely fashion, and that we
can do this in a way that does not erode our capacity to serve
our existing patients.
I want to emphasize that this additional staffing will
continue to be evaluating and assess data and refine the
staffing model. We are currently piloting this in three VISNs,
and this is a work in progress that will be continually
improved as part of our comprehensive approach to ensuring that
our facilities have the resources to ensure that we accomplish
this mission.
The third point I would like to make is that deploying
evidence-based therapies to ensure veterans have access to the
most effective methods for PTSD and other mental health
ailments, we are making more widespread and improving our
training for those who are receiving care and delivering care
of evidence based treatments. We are shifting from a more
traditional approach to one with newer treatments.
We would acknowledge that we have not always communicated
these changes as clearly as we might to our Nation's veterans,
so we are redoubling our efforts to improve communication not
only to our providers but to our veterans to ensure that these
evidence based therapies are implemented in a way that can be
supported by the veteran, and fully educated and trained
personnel assuring that that is delivered.
In summary, we just thank you again for your encouragement,
for your support. This is an important part of care that is
fundamental to the well being of our Nation's veterans. We look
forward to answering your questions and those of the Committee.
[The prepared statement of Mr. Schoenhard follows:]
Prepared Statement of William Schoenhard, FACHE, Deputy Under Secretary
for Health for Operations and Management, Veterans Health
Administration (VHA), Department of Veterans Affairs (VA)
Chairman Murray, Ranking Member Burr, and Members of the Committee,
I appreciate the opportunity to address access to, and quality of, VA's
mental health care. I am accompanied today by Mary Schohn, Ph.D.,
Director, Office of Mental Health Operations and Antonette Zeiss,
Ph.D., Chief Consultant, Office of Mental Health Services.
VA has testified twice within the past 12 months on its mental
health programs, and values the feedback received from those hearings.
From these hearings and subsequent field visits, VA has learned a great
deal about the strengths of our mental health care system, as well as
areas that need improvement. VA's Office of Inspector General (OIG)
also recently completed a review of VA's mental health programs and
offered four recommendations. The OIG cited a need for improvement in
our wait time measurements, improvement in patient experience metrics,
development of a staffing model, and provision of data to improve
clinic management. VA is using the OIG results in concert with our
internal reviews to plan important enhancements to VA mental health
care. VA constantly strives to improve, and we will use any data and
assessments--positive or negative--to help us enhance the services
provided to our Veterans.
Reviews have confirmed that Veterans seeking an initial appointment
for a mental health evaluation generally receive the required rapid
triage evaluation in a timely manner; this was confirmed by the OIG
report on mental health access. While a mental health evaluation within
14 days of the triage referral generally occurs, we were concerned to
learn from the OIG report that those evaluations do not always result
in the full diagnostic and treatment evaluation required by VA
policies. Further, Veterans seeking follow up appointments may
experience waits of longer than 14 days, especially for some intensive
services such as beginning a course of evidence-based psychotherapy.
While the explanations for these findings are varied, none are
satisfactory--we must do more to deliver the mental health services
that Veterans need. My written statement will describe how we have
traditionally evaluated access to mental health care and how we propose
to evaluate access in the future. It will then explain how we assess
the quality of care delivered and potential new considerations on this
topic. Both sections will address the need for increased staffing and
better data collection.
access to care
Ensuring access to appropriate care is essential to helping
Veterans recover from the injuries or illnesses they incurred during
their military service. Over the last several years, VA has enhanced
its capacity to deliver needed mental health services and to improve
the system of care so that services can be more readily accessed by
Veterans. Mental health care must constantly evolve and improve as new
research knowledge becomes available, as more Veterans access our
services, and as we recognize the unique needs of Veterans--and their
families--many who have served multiple, lengthy deployments. In
addition, enhanced screening and sensitivity to issues raised by
Veterans are also identified as areas for improvement.
In an effort to increase access to mental health care and reduce
the stigma of seeking such care, VA has integrated mental health into
primary care settings. The ongoing transfer of VA primary care to
Patient Aligned Care Teams will facilitate the delivery of an
unprecedented level of mental health services. Systematic screening of
Veterans for conditions such as depression, Post Traumatic Stress
Disorder (PTSD), problem drinking, and military sexual trauma has
helped us identify more Veterans at risk for these conditions and
provided opportunities to refer them to specially trained experts.
Research on this integration shows that VA is seeing many Veterans for
mental health care who would not otherwise be likely to accept
referrals to separate specialty mental health care. These are important
advances, particularly given the rising numbers of Veterans seeking
mental health care. In an informal Mental Health Query administered by
VA in August 2011, VA learned that many of its providers in the sites
queried believe that Veterans' ability to schedule timely appointments
may not match data gathered by VA's performance management system.
These providers also identified other constraints on their ability to
best serve Veterans, including inadequate staffing, space shortages,
limited hours of operation, and competing demands for other types of
appointments, particularly for compensation and pension or disability
evaluations. In response to this query, VA took two major actions.
First, VA developed a comprehensive action plan aimed at enhancing
mental health care and addressing the concerns raised by its staff.
Second, VA conducted external focus groups to better understand the
issues raised by front-line providers. As part of this action, VA is
visiting every VA facility this year to conduct a first-hand review of
its mental health program. As of April 25, 2012, 63 of 140 (45 percent)
site visits have been completed, one to each VA health care system,
with the remainder scheduled to be completed by the end of the fiscal
year.
As part of this ongoing review of mental health operations,
Secretary Shinseki recently announced that VA will be adding
approximately 1,600 mental health clinicians--including nurses,
psychiatrists, psychologists, social workers, marriage and family
therapists and licensed mental health professional counselors--as well
as 300 support staff to its existing workforce of 20,590 mental health
staff. This addition was based on VA's model for team delivery of
outpatient mental health services, and as these increases are
implemented, VA will continue to assess staffing levels. Further, as
part of VA's efforts to implement section 304 of Public Law 111-163
(Caregivers and Veterans Omnibus Health Services Act of 2010), VA is
increasing the number of peer specialists working in our medical
centers to support Veterans seeking mental health care. These
additional staff will increase access by allowing more providers to
schedule more appointments with Veterans. VA began collecting monthly
vacancy data in January 2012 to assess the impact of vacancies on
operations and to develop recommendations for further improvement. In
addition, VA is ensuring that accurate projections for future needs for
mental health services are generated. Finally, VA is planning
proactively for the expected needs of Veterans who will separate soon
from the Department of Defense (DOD) as they return from Afghanistan.
We track this population to estimate the number of such Veterans, how
many are anticipated to seek VA care, and how many who seek care are
anticipated to need mental health evaluation and treatment services.
These processes will continue, with special attention to whether
patterns established up to this point may change with the expected
increase in separations from active duty military.
Historically, VA has measured access to mental health services
through several data streams. First, VA defined what services should be
available in VA facilities in the 2008 Uniform Mental Health Services
in VA medical centers and Clinics Handbook and tracks the availability
of these services throughout the system. Moreover, VA has added a five-
part mental health measure in the performance contracts for VHA
leadership, effective starting in fiscal year (FY) 2012. The new
performance contract measure holds leadership accountable for:
The percentage of new patients who have had a full assessment and
begun treatment within 14 days of the first mental health appointment;
The proportion of Operation Enduring Freedom/Operation Iraqi
Freedom/Operation New Dawn (OEF/OIF/OND) Veterans with newly diagnosed
PTSD who receive at least eight sessions of psychotherapy within 14
weeks;
Proactive follow-up within 7 days by a mental health professional
for any patient who is discharged from an inpatient mental health unit
at a VA facility;
Proactive delivery of at least four mental health follow-up visits
within 30 days for any patient flagged as a high suicide risk; and
The percentage of current mental health patients who receive a new
diagnosis of PTSD and are able to access care specifically for PTSD
within 14 days of referral for PTSD services.
VA policies require that for established patients, subsequent
mental health appointments be scheduled within 14 days of the date
desired by the Veteran. This has been a complicated indicator, as the
desired date can be influenced by several factors, including:
The Veteran's desire to delay or expedite treatment for personal
reasons;
The recommendation of the provider; and
Variance in how schedulers process requests for appointments from
Veterans.
VA understands virtually every health care system in the country
faces similar challenges in scheduling appointments, but as a leader in
the industry, and as the only health care system with the obligation
and honor of treating America's Veterans, we are committed to
delivering the very best service possible. As a result, VA has decided
to modify the current appointment performance measurement system to
include a combination of measures that better captures overall efforts
throughout all phases of treatment. VA will ensure this system is
sufficiently flexible to accommodate a Veteran's unique condition and
the phase of treatment. Some Veterans may need to be seen more
frequently than within 14 days (for example, if they need weekly
sessions as part of a course of evidence-based psychotherapy), while
others may not (for example, if they are doing well after intensive
treatment and will benefit most from a well-designed maintenance plan
with far less frequent meetings). A thoughtful, individualized
treatment plan will be developed for each Veteran to inform the timing
of appointments.
VA has formed a work group to examine how best to measure Veterans'
wait time experiences and how to improve scheduling processes to define
how our facilities should respond to Veterans' needs. In the interim,
the work group has recommended a return to the use of the ``create
date'' metric, which will minimize the complexity of the current
scheduling process. The ``create date'' refers to the date on which a
Veteran requested an appointment, and the wait time will be measured as
the numbers of days between the create date and the visit with a mental
health professional. The work group is currently developing an action
plan to be reviewed by the Under Secretary for Health by June 1, 2012.
Performance measurement and accountability will remain the cornerstones
of our program to ensure that resources are being devoted where they
need to go and being used to the benefit of Veterans. Our priority is
leading the Nation in patient satisfaction with the quality and
timeliness of their appointments.
Decisions concerning staffing and programs were determined
historically at the facility level to allow flexibility based on local
resources and needs. However, as evidence accumulates, it is clear that
sites can benefit from more central guidance on best practices in
determining needed mental health staff. Therefore, we recently
developed a prototype staffing model for general mental health
outpatient care using a methodology that considered findings in the
academic literature, consultation with other health care systems, and
productivity data. We are using these results to pilot this staffing
model in Veterans Integrated Service Networks (VISN) 1, 4, and 22, and
we anticipate national implementation of this new model by the end of
the fiscal year. While the model may be refined as a result of the
pilot testing, it provides a clear basis for assessing staffing for
mental health services, and shows that currently there are shortfalls
at some sites nationally.
By adding staff, offering better guidance on appointment scheduling
processes, and enhancing our emphasis on patient and provider
experiences, we are confident we are building a more accessible system
that will be responsive to the needs of our Veterans while being
responsible with the resources appropriated by Congress.
quality of care
VA has made deployment of evidence-based therapies a critical
element of its approach to mental health care. Mental health
professionals across the system must provide the most effective
treatments for PTSD and other mental health conditions. We have
instituted national training programs to educate therapists in two
particularly effective exposure-based psycho-therapies for PTSD:
cognitive processing therapy and prolonged exposure therapy. The
Institute of Medicine and the Clinical Practice Guidelines developed
jointly by VA and the DOD have consistently concluded the efficacy of
these treatment approaches.
Not everyone with PTSD who receives evidence-based treatment may
have a favorable response. Although VA uses the most effective
treatments available, some Veterans will need lifetime care for their
mental health problems and may see slow initial improvement. Almost
everyone can improve, but some wounds are deep and require a close,
consistent relationship between VA and the Veteran to find the most
effective individualized approaches over time. Veterans and their
families should not expect ``quick fixes,'' but they should expect an
ongoing commitment to intensive efforts at care for any problems.
A recent analysis of data from VA's large Cooperative Study (CSP#
494), a study on prolonged exposure to the stress factors associated
with and contributing to PTSD symptoms among female Veterans and active
duty Servicewomen, identified those factors that predict poor treatment
outcome. This is the largest randomized clinical trial of prolonged
exposure treatment ever conducted (284 participants), and the first one
focusing solely on Veterans and military personnel. VA staff would be
pleased to brief you in greater detail on the methodology and results
of this study. Our analysis shows that Veterans with the most severe
PTSD are least likely to benefit from a standard course of treatment
and to achieve remission. Other factors that predicted poor response
were unemployment, co-morbid mood disorder, and lower education. In
other words, those with the worst PTSD are least likely to achieve
remission, as is true with any other medical problem.
Even when Veterans are able to begin and sustain participation in
treatment, timing, parenting, social, and community factors all matter
a great deal. Treatment, especially treatment of severe PTSD, may take
a long time. During this period, Veterans with PTSD are at risk for
many severe problems including family and parenting issues, inability
to hold a job or stay in school, and social and community function.
Further, evidence also shows that whereas a positive response to
treatment may reduce symptom severity and increase functional status
among severely affected Veterans, the magnitude of improvement may not
always be enough to achieve full clinical remission. This is no
different than what is found with other severe and chronic medical
disorders (such as diabetes or heart disease) where effective treatment
may make a substantial and very important difference in quality of life
without eradicating the disease itself. Thus, providing the best
treatments with the strongest evidence base is crucial to care, but
that must be placed within an ongoing commitment to recognize that
initial care may need to be followed by ongoing rehabilitative care,
for the major diagnostic problem, for other co-occurring mental health
problems, and for the host of psychosocial problems that may accompany
the diagnosis (or diagnoses).
Outcome evidence generated from cases involving Veterans who are
receiving these therapies in VA substantiate that they are effective
for Veterans participating in ongoing clinical care not associated with
research projects. Based on ongoing surveys, we know that all VA
facilities have staff trained at least in either prolonged exposure or
cognitive processing therapy, and usually both. In addition, one of the
preliminary results of our site visits found that many facilities have
a strong practice of training more staff in these and other evidence-
based therapies for a wide array of mental health problems.
As more providers are trained in these approaches to care,
facilities are shifting from their more traditional counseling approach
to these newer treatments. We have not always communicated well enough
to Veterans the nature or reason behind these changes. These new
programs emphasize a recovery model, which is strengths-based,
individualized, and Veteran-centered. A recovery-oriented model does
not focus exclusively on symptom reduction, but has as its goal helping
Veterans achieve personal life goals that will improve functioning
while managing symptoms. These efforts have been recognized as
successful in the academic literature and through a Government
Performance and Results Act review conducted by RAND/Altarum, which
concluded that VA mental health care was superior to other mental
health care offered in the United States in almost every dimension
evaluated.
Before the development of these evidence-based approaches, VA made
every effort to offer clinical services for PTSD based on clinical
experience and innovation. Some of these approaches have developed into
the evidence-based approaches we have now, while others have not been
shown to offer the help that was expected. Even those therapies that
did not help in truly alleviating PTSD could come to feel like
``lifelines'' to those receiving them. For example, some sites hold
group educational sessions to help Veterans understand PTSD symptoms
and causes, and these sometimes developed into ongoing groups. While
group therapy for PTSD can be effective and is cited in the VA/DOD
Clinical Practice guidelines, group therapy is understood (and
validated) as possible only in fairly small groups--usually fewer than
10 participants. Educational groups often have far more members,
sometimes up to 50 or more; while this can be an effective way to
conduct psycho-education, it cannot be considered ``group therapy.''
Veterans who have used some of the PTSD services previously adopted
by VA may not be familiar or comfortable with newer approaches, and we
must continuously educate Veterans and others about what treatments are
most likely to be effective and how Veterans can access them. Some of
our own providers have not understood these changes. The National
Center for PTSD has been providing guidance through the PTSD mentoring
program to help facilities collaborate with providers and Veterans in
the transition. We have developed educational processes to help clarify
the need for and rationale behind efforts to change clinical practice
patterns to ensure best possible care for VA.
The Under Secretary for Health's realignment of the Veterans Health
Administration last year created an Office of Mental Health Operations
with oversight of mental health programs across the country. This has
aligned data collection efforts with operational needs and connected
resources across the agency to bring the full picture of VA's mental
health system into focus. In fiscal year 2011, VA developed a
comprehensive mental health information system that is available to all
staff to support management decisions and quality improvement efforts.
This year, a collaborative effort between VA Central Office and field
staff is underway to review mental health operations throughout the
system and to develop quality improvement plans to address
opportunities for improvement through dissemination of strong practices
across the country.
conclusion
VA remains fully committed to delivering high quality, timely
mental health care. VA defined this commitment in 2004 with the
Comprehensive Mental Health Strategic Plan, which was fully implemented
and evolved into the Uniform Mental Health Services Handbook in 2008.
Efforts to implement the Handbook have been largely successful, but
more effort is needed to ensure full implementation at every
appropriate VA facility. In addition, new challenges and opportunities
continuously require response. For example, OEF/OIF/OND Veterans have
faced more and longer deployments than previous generations of
Servicemembers, and their families have shared these challenges. Many
of these Veterans also have survived battlefield injuries that
previously would have been fatal. Other challenges are presented by
Vietnam era Veterans who seek mental health care at far higher levels
than prior generations of older adults. In part, that is because we did
not have the effective treatments for them when they returned from
service more than 40 years ago. We know that the therapies discussed
previously are effective for this population, and we welcome their
search for mental health care. As VA reaches out to serve all
generations, and as our intensive, effective outreach programs bring in
greater numbers of Veterans to VA's health care system, we must
constantly find ways to keep pace with the need for expanded capacity
for mental health services and for those services to be based on the
best possible known treatments. Secretary Shinseki's recent
announcement that VA will add approximately 1,600 mental health
clinicians and 300 support staff reflects VA's continuing commitment to
meet the needs of Veterans. As these increases are implemented, VA will
continue to assess staffing levels.
New technologies, staff, training, approaches to care, and data
measurement will provide VA the mechanisms it needs to deliver the
necessary quality and timely mental health care. VA is developing
solutions in each of these areas or is currently implementing new
efforts to offer better access to and quality of mental health care.
Madam Chairman, we know our work to improve the delivery of mental
health care to Veterans will never be done. We appreciate your support
and encouragement in identifying and resolving challenges as we find
new ways to care for Veterans. This concludes my prepared statement. My
colleagues and I are prepared to respond to 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
health care
Question 1. The Department has conducted several site visits to
medical facilities across the country to get a better sense of what is
happening at various points of access to mental health care. Please
provide the Department's assessment of the findings from these site
evaluations.
Response. Site visit teams review the implementation of the Uniform
Mental Health Services Handbook (UMHSH) across 18 domains; these
domains capture all components of the mental health program that are to
be implemented nationally. The team identifies strengths and
opportunities for growth in each of these domains based on facility
data submitted as pre-work, data from the Mental Health Information
System, information gathered at the site through interviews with
facility and mental health leadership; information gathered during
interviews with front-line staff; and finally information gathered from
Veterans, Veterans' family and friends and community stakeholders.
Prior to the facility debrief at the end of the visit, the site visit
team determines the top five strengths and opportunities for growth at
the facility. Strengths are determined by the team as practices which
exceed the UMHSH guidance in any of the 18 areas, while opportunities
for growth are areas in which the facility would benefit from targeted
approaches for improvement.
An analysis of the initial 55 site visits completed through
March 31, 2012, has been completed based on the summaries of the top
five strengths and top five growth areas aggregated across facilities.
Common Strengths:
Identification of the mental health staff as hard working,
mission-oriented individuals focused on the care of Veterans.
Numbers of staff trained in Evidence-Based Psychotherapy and
supported by mental health leadership to complete all necessary
training requirements.
Suicide prevention services, including providing education to
staff on suicide prevention while simultaneously providing continuity
of care services for Veterans at high risk for suicide.
Substance Use Disorder treatment.
Provision of services to Veterans who are homeless.
Development of excellent community partnerships to assist in
providing the best care for Veterans.
Common Opportunities for Growth:
Identification of opportunities for growth does not mean it is not
present at a facility, but rather that this area is in need of further
development. The most common opportunities for growth identified were:
Expansion of recovery-oriented programming, especially in
inpatient settings, and further developing Psychosocial Rehabilitation
and Recovery Centers (PRRCs) while increasing the presence and role of
Local Recovery Coordinators.
Expansion of peer support services.
Need to fill vacancies and/or address concerns related to staff
members covering multiple roles related to covering for staff
vacancies.
Need to expand the Primary Care-Mental Health Integration program
to include both co-located collaborative care providers and care
management services within primary care.
Need to continue to improve transitioning of Veterans between
different levels of care, including tracking and follow-up of Veterans
as care is transferred from various settings such as inpatient to
residential, residential to outpatient, and outpatient to inpatient.
Need to improve wait times, access, and scheduling of appointments
for Veterans.
Question 2. OIG found VA's performance measures do not accurately
convey whether patients are being provided timely access to mental
health care. How will VA ensure medical centers are reliably and
accurately reporting whether they are providing patients timely access
to mental health care service, as well as verify those reports?
Response. The Department of Veterans Affairs (VA) has formed a
workgroup, including leadership from VHA clinical operations, mental
health operations, systems redesign, and field representation, to make
recommendations on methods to measure Veterans' wait time experiences
and to improve scheduling processes based on Veterans' needs. The
Veterans Health Administration (VHA) has piloted the use of metrics
that will simplify the interactions required between a scheduler and a
Veteran as well as increase the number of measurement points to include
the full continuum of care. In the interim, the workgroup has
recommended using the ``create date'' metric for new patients, which
minimizes the complexity of the current scheduling process. The
``create date'' is captured ``automatically'' by the computer when an
appointment is made. VHA has also developed and successfully piloted a
proposed standard process to more reliably capture ``desired date'' for
established patients. The work group recommendations were accepted by
the Under Secretary for Health (USH) on July 1, 2012. To support
implementation of the new metrics, VHA has established a workgroup to
develop training materials and processes to educate clinicians and
schedulers about the new requirements. As part of implementation, an
auditing process will be developed to assess reliability and accuracy
with the new reporting requirements. In addition, VHA will continue to
use the site visit methodology to verify the process. Full
implementation of the new metrics is anticipated by the start of fiscal
year (FY) 2014.
Question 3. OIG indicated VA's mental health care measures for
evidence based therapies are not valid. How will VA hold medical
centers accountable to ensure evidence based therapies are being
provided as treatment guidelines state?
Response. The measure evaluated by the VA Office of Inspector
General (OIG) as the evidence-based psychotherapy measure was still in
draft form at the time of the audit. This measure is not directly a
measure of evidence-based practice, but is a proxy measure to assess
the percent of patients receiving an intensity of treatment (eight
sessions in fourteen weeks) deemed as adequate for effective provision
of psychotherapy. A software development project is underway to develop
templated progress notes that will more directly measure implementation
of evidenced-based therapies. These templates provide a mechanism of
tracking utilization of evidence-based psychotherapies (EBP), currently
not available in our system, and will be required for use whenever EBPs
are employed. Once these become available, Veterans Integrated Service
Network (VISN), facility and VA Central Office Leadership will be able
to review the data to follow-up on practices that do not meet the
treatment guidelines.
Question 4. How will OMHS ensure a non-clinical encounter with
veterans related to the mental health care services is not recorded as
a session of treatment for performance measure purposes?
Response. Encounters which are entered in the Electronic Health
Record (EHR), include information about the clinic where a visit
occurred (documented with a stop code), the provider who met with the
Veteran, and a Current Procedural Terminology (CPT) code. CPT codes
describe what medical and diagnostic services occurred during a
particular visit. Certain CPT codes are used to reflect the delivery of
mental health treatment. If an encounter is non-clinical in nature, it
would be reflected in the CPT code utilized, and it would not include a
CPT code that is reflective of treatment. Based on the logic of the
mental health metrics, non-clinical encounters would not be recorded
with treatment CPT codes, and thus would not be recorded as a session
of treatment for performance measure purposes.
Question 5. Psychotherapy session note templates were proposed by
VA's Office of Patient Care Services, Mental Health Services to help
clinicians consistently document use of evidence-based psychotherapies
and accurately track use of these treatments, as well as allow program
evaluators to monitor treatment outcomes. Please provide the Committee
with the status of the implementation of these session note templates.
Response. Mental Health Services has developed session-by-session
documentation templates for evidence-based psychotherapies being
nationally implemented in VHA. The first set of evidence-based
psychotherapy documentation templates is on the current Work Plan of
the Office of Information and Technology for planned distribution to
the field by the end of fiscal year (FY) 2013.
Question 6. Please describe the methodology used to allocate
special funding for mental health initiatives. What steps is VA taking
to hold recipients of such funding accountable for its targeted use and
to prevent recipients from reallocating the funds to be used for other
priorities set forth by VISN or medical center leadership?
Response. VHA, through the offices of Workforce Management and
Consulting (WMC) and the Office of Mental Health Operations (OMHO) is
closely tracking the hiring of the additional staff recently funded as
well as the filling of existing vacancies to ensure the monies are
being spent for mental health staff. WMC and OMHO are providing
biweekly reports and as needed to VHA senior leadership on the hiring
status.
Question 7. After the Department concludes its site visit reviews
of mental health care services, how will VA ensure systematic
surveillance efforts are carried out to better understand care trends,
links between care processes and treatment outcomes, and facility-by-
facility differences in performance?
Response. OMHO is currently completing site visits at all 140 VHA
facilities this fiscal year. Upon receipt of the site visit report, the
facility schedules a meeting with Director of OMHO, the OMHO technical
assistance specialist, facility leadership, facility mental health
leadership, and VISN mental health leadership. On this call, the
findings are reviewed and the facility is asked to submit an action
plan to address the recommendations. OMHO provides ongoing
consultation, at a minimum on a quarterly basis, with the facility to
ensure implementation of the action plan. VHA is aggregating the data
across facilities to look for systemic areas that require improvement
across the system.
Question 8. In 2005, and again in 2007, OIG released reports
highlighting problems with VA's patient scheduling system, including
the calculation of wait times and inconsistent practices used by
schedulers to capture appointment information. Despite the
identification of these issues nearly seven years ago, the most recent
IG report again identified these same issues as significant challenges.
Please explain how recommendations issued by OIG and concurred with by
the Under Secretary for Health remain unresolved for so long, and
discuss the lessons learned.
Response. In response to problems identified by OIG in 2005 and
again in 2007, VHA stepped up its efforts to systematically train
schedulers on correct scheduling practices and to audit their
performance. These requirements were outlined in VHA policies published
in 2008 and 2009. Internal VHA surveys show that compliance with VHA
policy, especially in the area of entering desired date correctly has
improved from the 60 percent range when OIG first studied the problem
to the current 90 percent range in Mental Health. Because of the large
number of employees scheduling appointments (50,000+) and the large
number of appointments made each year (over 80 million), even a small
rate of error will result in a large absolute number of desired date
inaccuracies. While the problem is not completely solved, performance
has improved. VHA has learned that training alone will not solve the
problem, and is working to improve the reliability of Desired Date
entry again by piloting efforts to standardize communication processes
and electronically audit desired date accuracy.
Additional Information:
VHA has, over the years, attempted to improve and strengthen the
policy direction, measure, display, and report waiting times, and
respond to all known issues. Appendix 1 and 2 provide detailed
timelines of significant activities. The following table is a brief
summary of major events:
----------------------------------------------------------------------------------------------------------------
Events VHA Responses
------------------------------------------------------------------------------------------------------------------------------------------------------------- GAO/IG Report Findings ---------------------------- Directives
Timeline VHA Waiting Time Metric
--------------------------------------------------------------------------------------------------------------------------1999--- ------------------------------------------Third Next Available-------------------------------
----------------------------------------------------------------------------------------------------------------
2000-2004 Next Available 2002-028
----------------------------------------------------------------------------------------------------------------
Jan-03 Audit of Veterans Health Administration's Electronic Waiting List
Reported Medical Care Waiting Lists
----------------------------------------------------------------------------------------------------------------
Jan-04 Beginning of Time Stamp Measures
----------------------------------------------------------------------------------------------------------------
Create Date for New Patients
----------------------------------------------------------------------------------------------------------------
Desired Date for Established
Patients
----------------------------------------------------------------------------------------------------------------
2005 Audit of Outpatient Scheduling Procedures
----------------------------------------------------------------------------------------------------------------
2007 Audit of the Veterans Health Access List
Administration's Outpatient Waiting Times
----------------------------------------------------------------------------------------------------------------
2008 Audit of Efforts to Reduce Unused Consult Wait Time Measures Started 2008-056
Appointments
----------------------------------------------------------------------------------------------------------------
Audit of Alleged Manipulation of Waiting
Times in Veterans Integrated Service
Network3
----------------------------------------------------------------------------------------------------------------
Review of Alleged Manipulation of Waiting 2009-070
Times, North Florida/South Georgia
Veterans Health System
----------------------------------------------------------------------------------------------------------------
2009 Recall Scheduling System
----------------------------------------------------------------------------------------------------------------
Oct 1 2009 Veterans Health Administration Review of Desired Date for New and 2010-027
(FY2010) Alleged Use of Unauthorized Wait Lists at Established Patients
the Portland VA Medical Center
----------------------------------------------------------------------------------------------------------------
Audit of VA's Efforts To Provide Timely
Compensation and Pension Medical
Examinations
----------------------------------------------------------------------------------------------------------------
2012 Review of Veterans' Access to Mental
Health Care
----------------------------------------------------------------------------------------------------------------
Specific Explanation of Issues:
Appointment waiting times are a negotiation between patients,
providers, and the schedule capacity considering a number of factors.
Experience has taught that there is no one perfect way or ``solution''
to the measurement of waiting times.
Private sector waiting time methods focus on capacity measures
such as time to the third next available open appointment slot. VHA
possesses and uses third next (and first next available) capacity
measures and has since 1999.
Because of the weaknesses in capacity measures to show the
individual patient experience, beginning in 2004, VHA went well beyond
other healthcare systems to measure 4 time stamps for every one of the
approximately 80 million appointments per year.
Each one of the time stamp points (Desired Date, Create Date,
Scheduled (future) Appointment and Completed Appointment) has its
strengths and weaknesses. Appendix 4 provides a comprehensive
explanation of these strengths and weaknesses. The challenges in
measuring waiting times exist for every healthcare system, not just
VHA.
Based on VA commissioned research studies that have just recently
become available, VHA has new information on which measures are best
associated with patient satisfaction and patient outcomes. VHA has
learned:
- Create Date has the strongest association with New Patient
Satisfaction and outcomes
- Desired Date (prospective) has the strongest association
with Established Patient Satisfaction and outcomes
Limitations of the Desired Date (DD) measure include reliance on
schedulers to accurately determine Desired Dates. Multiple OIG reports
since 2005 found the DD was not entered correctly in some cases.
Internal audits of VA's scheduler performance in 2005 found DD
correctly entered about 60 percent of the time. VHA agreed with the OIG
finding and undertook mandatory scheduler training, yearly scheduler
audits and feedback, facility certification of scheduling directive
compliance, nationally hosted educational sessions, etc. The most
recent audit of 43,643 appointments, done about 54 months ago,
indicated that Mental Health Schedulers correctly entered the DD 91.61
percent of the time.
It should be pointed out that there is yet another approach to
measure wait times and that is from one completed appointment to
another completed appointment. This is the method used in the widely
debated Mental Health access performance measure looked at by the OIG
recently where the time from completion of initial evaluation to
completion of final evaluation was used. This method attempted to
``zero in'' on the experience of these specific mental health patients,
required complex programming of the system, and does not measure the
entire waiting time experience of the patient. The OIG attempted to
combine the wait time methods of measuring one completed appointment to
another completed appointment combined with DD wait times. The system
was not designed to make this connection limiting the ability of the
system to see the patient experience accurately.
As stated earlier, wait time measurements are only one piece of
information that a clinic needs in order to manage their clinic
operations. In addition to wait time, the clinic needs to know at a
minimum, the panel size (or case load), the appointment demand, supply
and activity, the no-shows, the cancel and reschedule rate, and the
appointment continuity. This information is used to manage day-to-day
clinic flow to optimize access.
Lessons Learned:
(1) There is no perfect measure of waiting times in the VA, or
probably in private sector for that matter.
(2) With more than 50,000 people making appointments in VHA, many
of whom are entry level employees and with the high turnover in that
job, it is probably unrealistic to expect DD will be entered correctly
in every case.
(3) VHA should use different methods for measuring wait times in
different sub- populations of patients (see appendix 4 and above). This
is the best information on the ``correct'' methods to measure wait
times that is known to exist at this point.
(4) It is important to clearly understand the method used to
measure wait times when interpreting actual patient experience. For
example, Mental Health measure reflects only a portion of the entire
patients wait time, but was reported as reflecting the entire patient
wait time.
(5) Management of wait times would be enhanced by a better
scheduling system.
Question 9. Following the November 30, 2011, hearing on mental
health care, VA indicated in questions for the record that off-hours
care for mental health is available widely available. Based on
completed site visits, has VA found discrepancies with what facilities
have reported and what the site visits discovered regarding off-hours
availability? Are facilities meeting the Extended Hours Access for
Patients policy requirements?
Response. The Mental Health After Hours Report was reviewed through
the second quarter of FY 2012. All medical centers visited through
April 2012 have confirmed mental health clinic activity in off-hours as
confirmed by medical record encounters. However, the site visits have
identified three large CBOCs that had no confirmed off-hours services
in the first two quarters of FY 2012. These CBOCs are associated with
two medical centers visited by OMHO through April 2012. Final site
visits reports for these facilities have not yet been generated.
However, overall, there does not appear to be a discrepancy between the
Mental Health After Hours Report and what has been found on the site
visits to date. As part of the site visit feedback, some facilities
have been encouraged to expand the utilization of extended hours to
assist with increasing access and reaching out to meet particular needs
of Veterans.
Question 10. An OIG report identified that VA does not have a
scheduling system that works. VA is replacing the medical scheduling
software but will not be available for full implementation until 2014
at the earliest. Given VA has a scheduling system that is simply
insufficient, what steps is the Department taking to expedite the
replacement of this system so that veterans who need access to mental
health care services can be scheduled for appointments in a timely and
reliable way?
a. What steps is the Department taking to expedite the replacement
of this system?
Response. In February 2009, the previous effort to replace VHA's
25-year-old scheduling system was ended without success. Work to
examine the reasons for failure, including a comprehensive risk
assessment concluded in 2010. At that point, VA reactivated the project
with a decision to pursue a Commercial Off-The-Shelf software package
to replace VistA Scheduling and be compatible with the current open
source version of VistA.
In December 2011, VA published a Request for Information about
scheduling software and received 35 responses from a broad range of
industry sources. These responses validated the assumption that
commercial products can meet most of our needs.
VA is in the process of designing a contest under the America
Competes Act to address the most difficult component of the scheduling
module: the ability to schedule across all facilities in the system.
In April 2012, Information Technology leadership led a joint VHA/
OIT/CTO workgroup which defined the projected outcomes from conducting
a contest under the America Competes Act. A draft integrated project
team (IPT) charter was completed and an OIT project manager was
assigned full-time to the project in May 2012.
b. What is VA doing now to make immediate access improvements for
Veterans?
Response. In the interim, VA is contracting to develop two near
term improvements to the current scheduling system. The first is a
Veteran-facing application intended to reside on handheld devices that
would allow a Veteran to request an appointment within a Veteran-
specified date range. The second is a scheduler-facing application
which would change the scheduler's view from the current blue-screen
roll-and-scroll to a more user friendly calendar view of the schedule.
Both of these short term improvements would provide significant
improvements as the Veteran would be able to express their desired
appointment date (improving the reliability of wait time measurement)
and the scheduler would be able to much more efficiently find an
available clinic slot. These improvements are being pursued along with
the ultimate solution of replacing the scheduling system.
In addition to software efforts, VA continues to train key staff in
``Advanced Clinic Access'' principles through multiple internal venues.
An initiative focused on improvements in Specialty Care, including
access improvements was piloted in every network in 2012. This
initiative will expand in 2013. VA is also working to decrease the rate
of no-shows through system-wide initiatives including network and
facility collaborations, virtual phone educational sessions, change
strategies customized to individual facility problems. These
initiatives are working to enhance the information available to local
managers to pinpoint problematic clinics.
______
Response to Posthearing Questions Submitted by Hon. Bernard Sanders to
William Schoenhard, Deputy Under Secretary for Health for Operations
and Management, Veterans Health Administration, U.S. Department of
Veterans Affairs
Question 1. As of today, how confident are you that schedulers are
fully complying with the 2008 Uniform Mental Health Services in VA
medical centers and Clinics Handbook with regard to performance
compliance standards?
Response. We are confident that schedulers correctly establish
Desired Date more than 90 percent of the time. In the first quarter of
FY 2012, VA conducted an internal audit of a sample of mental health
schedulers at each VA facility and the results demonstrated that
schedulers were accurately capturing the Veteran's Desired Date 91.61
percent of the time.
Question 2. Can you explain why the performance compliance
standards could be so universally ``misunderstood'' or
``misinterpreted'' throughout the VA health care system?
Response. We believe the question refers to the performance
standard regarding scheduler entry of Desired Date. Desired Date is a
time-stamp used to measure waiting times. VA has the experience of many
approaches to the measurement of wait times. The table below shows the
high level timeline of these events and measures for the past 11 years.
In response to congressional and oversight bodies, VHA has gone well
beyond other healthcare systems (that measure access at the ``clinic''
level) in implementing a measurement of ``Desired Date'' in order to
understand access at the individual patient level. ``Desired Date''
means the date which the patient or provider wants the patient to be
seen. The definition is necessarily broad in order to accommodate all
scheduling situations. For example an established patient scheduling an
agreed-upon future appointment with their provider is very different
than a new or established patient requesting an out-of-cycle
appointment for a new problem. Training 50,000 people who schedule
appointments to enter Desired Date correctly for each situation for
over 84 million appointments per year is a daunting task. The turnover
of schedulers alone requires constant vigilance and training. However,
internal VHA reviews show the performance has improved from correct
entry about 60 percent of the time (in 2005) to more than 90 percent
currently. VHA is currently taking steps to improve the reliability of
Desired Date entry by piloting standard communication and electronic
audit processes. The aim of these efforts is to improve the reliability
of Desired Date information even more.
Question 3. Were any schedulers reprimanded or fired because they
were accurately reporting lower percentages in performance compliance
standards than their counterparts who deviated from the VA Directives?
Response. Although VHA's Office of Workforce Services maintains
data regarding adverse employee actions for senior staff, they do not
have data regarding whether schedulers were reprimanded or fired due to
inaccurate reporting of lower percentages in performance compliance
standards.
Question 4. Do you have any idea how many veterans decided not to
participate in VA Mental Health Care programs because they didn't want
to wait beyond 14 days to be evaluated or have an appointment? Would
the veteran's decision be documented as ``resistant to treatment'' or
``denied treatment'' or ``no show'' in his or her medical record?
Response. VHA does not currently collect data on Veterans who have
decided that they did not wish to be evaluated due to having to wait
beyond 14 days for a full evaluation appointment. If a Veteran decided
that they did not wish to engage in VA mental health programs, the
clinician who met with the Veteran should document an accurate
reflection of the interaction with the Veteran. In the situation
described in your question, such a statement might be ``Veteran did not
wish to engage in mental health care programs due to an extensive wait
for an appointment.'' Such electronic health record entries cannot be
readily pulled at a national level.
If a Veteran had an appointment scheduled and did not attend, they
would be identified as a ``no show'' and attempts would be made to
reschedule the appointment. The requirement is to attempt at least
three times to reach the patient to reschedule or determine that they
no longer are requesting services. There would never be a presumption
of ``resistance to treatment.''
Question 5. Who is responsible for quality control assurance of the
Performance and Accountability Report (PAR)? Knowing that clinical
scheduling has been identified as a problem by VA's Office of Inspector
General since 2005, how did the flawed data get past quality control
reviews?
Response. There is no recognized ``gold standard'' in the health
care industry for calculating appointment timeliness, and no best way
to capture the needs of patients and clinicians in a single access
number. The metrics used in the Performance Accountability Report were
developed with the input of subject matter experts and approved by
senior agency leadership. VA made the decision to calculate waiting
times using the ``Desired Date'' methodology after several options were
assessed by an internal working group. At the time, we believed this
approach, while imperfect, would provide the most patient-centered
perspective possible within our decades-old scheduling system, and that
the improvement trends in the metrics, rather than their absolute
values, would help gauge VA efforts at improving access.
Although the metrics themselves were calculated electronically from
automated data systems, we were aware that over 50,000 staff across VA
had the capability of scheduling appointments and that their individual
actions would impact the validity of the data. Taking that into
account, we thoughtfully designed staff education and a process of
periodic auditing to assure our numbers were as accurate as humanly
possible. Seven years ago, compliance with policy was assessed at
approximately 60 percent; a level of performance that we recognized was
insufficient. As a result of continued education and feedback, the most
recent audits of mental health scheduling have indicated over 90
percent compliance with the capture of ``Desired Date'' as dictated by
VA policy.
In order to eliminate any ambiguity about our intent or our
performance, we will report to Congress from this point forward
appointment times calculated using the ``create date'' entered into our
scheduling package, while continuing to internally track waiting times
based on Desired Date of appointment as well. We now have evidence from
internal research that, for Veterans seeing us for the first time,
waiting times calculated using ``create date'' may be overall more
predictive of patient satisfaction. The same research also suggests
that for established patients, waiting times calculated using ``Desired
Date'' is the better predictor of satisfaction.
It is important to point out, however, that we capture only an
incomplete picture of access with such measured waiting times. Holistic
mental health care requires the engagement of a team of professionals,
including psychiatrists, psychologists, social workers, advanced
practice nurses, and primary care providers to assure access to
appropriate evaluation and treatment. VA has done considerable work
over the past decade to integrate mental health evaluation and
treatment into team-driven primary care settings, including
collaborative care models and the extensive use of telemedicine. These
modalities assure that Veterans experiencing emotional distress can be
seen immediately, without the additional step of scheduling a separate
consultation or appointment and waiting for a response. While such
approaches are truly Veteran-centered and appreciated by patients and
clinicians, ironically, they are not captured in our scheduling system,
which was designed decades before such approaches were made part of our
clinical routine.
Question 6. If an active-duty servicemember is diagnosed with PTSD
by a military behavioral health care professional and is subsequently
medically discharged from the Armed Forces, is there a formal process
between the Military Health Care System and VA to make sure the
veteran's treatment plan is successfully transferred between the two
Federal agencies?
Response. VA has a formal process in place to transition ill and/or
injured Servicemembers from DOD to VA. VA has 33 VA Liaisons for
Healthcare, registered nurses or licensed social workers, stationed at
18 Military Treatment Facilities (MTFs) with concentrations of
recovering Servicemembers returning from Iraq and Afghanistan. These
staff transition ill and/or injured Servicemembers from DOD to the VA
system of care. VA Liaisons are co-located with the DOD case managers
at the MTFs and provide onsite consultation and collaboration regarding
VA resources and treatment options. Each referral from the DOD
treatment team, including referrals for Servicemembers being medically
discharged with PTSD, utilizes a standardized referral form completed
by the DOD Nurse Case Manager identifying the ongoing treatment needs.
In addition, each referral to a VA medical center (VAMC) includes
supporting medical documentation such as progress notes and narrative
summaries. At MTFs without an onsite VA Liaison, DOD Case Managers can
refer Servicemembers directly to the Operation Enduring Freedom/
Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) Program
Manager at the Servicemember's home VAMC. These referrals also utilize
the standardized referral form identifying the ongoing treatment needs
as well as the supporting medical documentation. As part of this
process, a Servicemember's treatment plan is transferred from DOD to
VA, though the Servicemember/Veteran has a choice whether or not to
enroll and participate in the VA health care system.
Question 7. Did the VA pay any bonuses to employees based on the 95
percent compliance rate for new patients receiving an evaluation within
14 days or appointments within 14 days of their desired date?
Response. This information is local information that is not
available centrally.
______
Response to Posthearing Questions Submitted by Hon. Johnny Isakson to
William Schoenhard, Deputy Under Secretary for Health for Operations
and Management, Veterans Health Administration, U.S. Department of
Veterans Affairs
Question 1. The OIG has reported several times on inappropriate and
inconsistent scheduling practices in 2005, 2007, and now again in 2012.
VHA has taken steps to address these issues, however, the problem
persists.
(a) Why does this continue to be an issue and what is contributing
to the inappropriate practices?
Response. Establishment of Desired Date (DD) requires knowledge of
the patient and provider negotiation (for return appointments) and an
understanding of what the patient wants under IDEAL circumstances (for
new appointments, or for established patients who request a new
appointment). Schedulers must enter the correct date in a roll-and-
scroll line in the middle of a complex computer appointing process. If
they are pressed with other duties (checking in, checking out,
answering phones and questions from staff and patients), it is easy for
the scheduler to be expedient and accept the default on the DD
question.
(b) Is it simply a lack of training for schedulers?
Response. Not entirely. The process of establishing DD can be
difficult. VHA is pushing to simplify and standardize the parts of the
communication between the provider and patient so the establishment of
DD in that situation (which is the majority of the cases) should be
simpler and more reliable.
(c) Are the schedulers receiving the required annual trainings and
taking the annual tests to ensure they are properly carrying out VHA
directives?
Response. The schedulers are required to successfully complete the
scheduler modules and Soft Skills training at the time they are hired.
The scheduler supervisors are responsible for conducting a yearly audit
on their performance, and addressing performance gaps. Additional
training is available and should be undertaken by those schedulers who
are uncomfortable with the scheduling protocols.
Question 2. According to the OIG, this is leading to skewed data
that is not helpful to key decisionmakers from the managerial level to
the administrative level to Congress.
(a) Do these inconsistencies occur in all the VISNs, or some
performing better than others?
Response. The inconsistencies in question are the correct entry of
the Desired Date (DD) into the VistA scheduling system. The latest VHA
self-study on entry of DD, completed December 23, 2011, looked at
43,643 mental health records from the five busiest Mental Health
Clinics in all VISN's. Overall, VHA found DD was entered accurately
91.67 percent of the time. Since most appointments made are for
established patients rather than new patients, this study is thought to
include predominately established patients; therefore, VHA is less
certain about the accuracy of DD for new patients.
No VISN enters DD correctly all of the time. This is because of
several factors, including: the difficulty associated with determining
the DD (as noted in the examples below); reliance on humans who may
make mistakes to enter the DD; variation in systems and processes
within and between clinics; and high turnover rates of scheduling
clerks, resulting in less experienced staff performing the task at
times.
Some examples of different approaches to determining the Desired
Date follow:
If the patient has an established relationship with the provider
and agrees to return for a future appointment, the date the patient and
provider agree upon as the desired return date is the DD. This
situation is often called ``internal demand'' in the Advanced Access
literature and comprises the majority of appointments in VHA. For
example, a patient with diabetes may be due for a return visit in 6
months, in which case the Desired Date for the follow-up appointment
would be the date 6 months from the present appointment, regardless of
when the follow- up appointment is ultimately scheduled.
Alternatively, if an established patient requests a previously
unanticipated appointment, or a new patient requests their first
appointment, the scheduling clerk is instructed to ask the patient when
they would like to be seen (regardless of when they are able to be seen
in an open slot). The answer to this question establishes the DD for
this ``external demand'' situation. For example, if a Veteran calls on
a Monday requesting an appointment right away and says Thursdays are
good, the following Thursday (e.g., 3 days from the appointment
request) is entered as the Desired Date. The appointment is then
negotiated and created without changing the Desired Date, even if there
is no appointment availability on the date the patient initially
requested.
(b) What is VHA doing to correct this problem?
Response. VHA chartered a workgroup to make recommendations to the
USH on developing new metrics to better measure the Veteran waiting
experience. The workgroup made a number of recommendations that were
accepted by the USH on July 1, 2012. These recommendations are in the
process of being implemented.
Question 3. In the discussion on metrics, VHA mentioned that the
work group recommended they return to using the ``create date'' metric
to help give a better picture of veterans' waiting times.
(a) When the use of this was metric abandoned?
Response. VHA still collects the data on Create Date (CD), but
stopped using it as a performance measure in 2010.
(b) Why did VHA stop using it?
Response. VHA stopped using it because field facilities indicated
there were multiple case of patients who wanted to make appointments
earlier than 14 or 30 days from the time they wanted the appointment to
occur. It was an attempt to make the waiting time measure more patient-
centric.
Question 4. In light of Sec. Shinseki's announcement of the
addition of 1600 mental health clinicians and 300 support positions,
how will these positions be distributed amongst the VISNs?
(a) How did VHA determine the numbers of needed clinicians and
support staff?
Response. VHA is piloting a staffing model to ensure consistent
staffing patterns for outpatient mental health services based on
numbers of patients served, the range of services available at a
facility, characteristics of the facility, and complexity of services.
A projection for national implementation of the model showed that many
sites would need additional staff. This need was also suggested by data
from site visits, providers and Veterans. The initial projection was
then modified in conjunction with VISNs/facilities to correct for local
practices such as the use of tele-mental health or contracting.
(b) Is this number an appropriate reflection of the need for mental
health providers throughout the VA system?
Response. VHA is piloting the staffing model, which is based on
Veteran population in the service area, mental health needs of Veterans
in that population, and range and complexity of mental health services
provided in the service area. VHA will be assessing the adequacy of the
model based on access, Veteran and provider satisfaction, use of
evidence-based psychotherapy among other therapies, and will continue
to adjust staffing as needed to meet the mental health needs of
Veterans.
(c) What will VHA do in the interim to help veterans receive timely
mental health services?
Response. As part of the site visit process, VHA is working with
facilities to reduce barriers to access as they are identified. In FY
2012, VHA provided $12 million in funding to expand the use of tele-
mental health for PTSD and is continuing to work with sites to identify
opportunities to use this technology to provide expanded services. VHA
is also expanding the implementation of mental health in primary care
which allows Veterans to have access to mental health services within
the primary care setting. Sites are also able to use fee and/or
contract services to provide timely services.
Question 5. The VHA Action Plan states that the work group will
provide the Under Secretary for Health with an action plan to create
new metrics no later than July 1, 2012.
(a) How long will the review process take?
Response. The review process began with the July action plan
deadline and will continue, with expected refinements, and initial
piloting of the new metrics by the first quarter of FY 2013.
(b) What is the timeframe for implementation of the work group's
action plan?
Response. It is anticipated that the action plan will be
implemented by December 31, 2012.
______
Response to Posthearing Questions Submitted by Hon. Roger F. Wicker to
William Schoenhard, Deputy Under Secretary for Health for Operations
and Management, Veterans Health Administration, U.S. Department of
Veterans Affairs
post-traumatic stress disorder
Over the years, the public has seen an increase in Veterans who
suffer from PTSD. With the recent withdrawal of U.S. combat forces from
Iraq and the administrations announcement to end combat operations in
2014 in Afghanistan, I expect that there will be an increasing number
of veterans that will be diagnosed with PTSD. I am concerned about the
process to determine how benefits are given to those who suffer from
PTSD amid this backlog.
Question 1. My office has received complaints about doctors at VA
hospitals in Mississippi who are skeptical of accepted science
regarding PTSD. What actions will be taken to ensure that certain
doctors, who receive a large number of complaints, over an extended
period of time, will be properly vetted by the VA and that appropriate
action will be taken?
Response. VHA is invested in ensuring that Veterans receive
evidence-based care for PTSD and appreciates being informed when
concerns are identified about PTSD treatment. Complaints about any
provider that are reported to the patient advocates locally are
recorded in a complaint tracking file. Supervisors are notified when a
complaint is made and the supervisor follows up with the concern at
that time. Additionally, all VA credentialed and privileged providers
are required to be reviewed on a variety of performance standards twice
a year through the Ongoing Professional Practice Evaluation (OPPE).
Quality monitors are reviewed with providers by their supervisor. If
there is a continued pattern of complaints regarding a provider, this
would be reviewed at that time as well as with the mid-year performance
and end-of-year performance evaluations. If improvements are not made,
the supervisor may pursue disciplinary actions and/or dismissal if no
progress is made on written goals.
Question 2. What is the number of denials for PTSD claims at the
Jackson Regional Office based on the doctor's recommendations?
Additionally, what is the number of claims which were initially denied,
but later reversed on appeal?
Response. VBA does not track claims by physician. In FY 2011,
service-connection for PTSD was granted on approximately 11,500 appeals
nationally. Of these, 1,573 were granted by the Board of Veterans'
Appeals.
Question 3. Can you please provide the statistical data on the
denial rate at the Jackson VA Regional Office in comparison to other VA
Regional Offices?
Response. In FY 2011, the average percentage of claims denied
nationwide was 23.2 percent for claims for PTSD, to include original
claims, claims for increase, and claims that were previously denied.
The Jackson Regional Office's (RO) denial rate was 33.4 percent.
In 2006 and 2009, the Institute for Defense Analyses (IDA)
conducted studies to determine factors that contribute to differences
in disability compensation awards. One factor they found was that
claims approval rates vary significantly based on the population
served. For example, ROs processing high volumes of pre-discharge
claims and claims from recently separated Servicemembers have higher
grant rates. Pre-discharge claims and claims from recently separated
Servicemembers usually have service treatment records readily available
and up-to-date medical information and have a higher number of issues
claimed. IDA also found that other factors that contribute to the
differences include median family income, percentage of the general
population with a mental disability, length of service, and population
density (urban, rural, and highly rural). In areas experiencing
difficult economic conditions, Veterans are more likely to submit
first-time claims, claims for an increase in benefits, and to resubmit
claims that were previously denied, also impacting grant and denial
percentages.
Question 4. Why is the VA Form 9 processed at Regional Offices
before they reach the Board of Veteran Appeals?
Response. VA Form 9s are processed at ROs prior to going to the BVA
because it provides additional opportunities to resolve the appeal at
the lowest possible level. ROs must ensure the following actions take
place after a VA Form 9 is filed:
Determine if the VA Form 9 was timely filed
Obtain clarification of appealed issues if VA Form 9 is incomplete
Consider additional evidence submitted by the appellant
Accommodate appellant requests for a local hearing at the RO
Consider any new issues raised by the appellant
These prerequisite steps to certifying an appeal are in place to
ensure ROs have done everything possible to resolve the appeal prior to
sending the claim to the Board of Veterans' Appeals.
Question 5. Describe how the VA conducts quality control of PTSD,
C&P Exam Results, and C&P Examiner Performances?
Response. The Systematic Technical Accuracy Review (STAR) program
assesses the accuracy of disability benefit determinations and is
administered by VBA's Compensation Service. It utilizes employees well-
versed in the claims adjudication process to review and analyze claims
data nationwide. Although there is no special review for PTSD claims, a
percentage of them are reviewed along with other categories of claims.
The STAR reviews focus on nationwide rating consistency by reviewing RO
rating decision variance across frequently rated medical diagnostic
codes, including those for PTSD and other mental disorders. In
addition, earlier this year VBA implemented the Quality Review Team's
transformation initiative that will result in improvements in the
service VBA provides. Dedicated teams of quality review specialists at
each RO evaluate decision accuracy at both the RO and individual
employee level, and perform in-process review to eliminate errors at
the earliest possible stage in the claims process. The teams are
comprised of personnel trained by our national quality assurance review
staff to assure local reviews are consistently conducted according to
national standards.
VHA's Office of Disability and Medical Assessment (DMA) conducts
quality reviews of VA Compensation and Pension (C&P) examination
requests made by VBA and examinations completed by VHA clinicians. The
Quality Management section, an integral component of DMA's quality and
timeliness mission, is responsible for the collection and evaluation of
VA disability examination data to support recommendations for
improvement throughout the VHA and VBA examination process. The quality
review program incorporates a three-dimensional approach consisting of
an audit review process to assess medical-legal completeness,
performance measures, and a review process to assess clinical
examination reporting competence.
A mix of staff knowledgeable in both the clinical protocol/
practices of the C&P examination process and staff with VBA rating
experience perform the reviews. This monthly random sample can include
all potential exam types. This quality review process started in
October 2011, replacing the former C&P Examination Program that was
discontinued in October 2010. Ongoing enhancements to data collection
will provide VBA and VHA with detail data to support process
improvement.
DMA is charged with improving the disability examination process by
monitoring the quality of examinations conducted. Quality is monitored
monthly using an audit review tool and the results are reported on a
quarterly basis. This intense audit is conducted on all types of
disability examinations, assessing consistency between the medical
evidence and the examination report.
DMA monitors disability examiner registration and certification and
designs and conducts continuous education and training. DMA, in
conjunction with the Employee Education System, oversees the program
for mandatory registration and certification as outlined by VHA
Directive 2008-05, ``Certification of Clinicians Performing
Compensation and Pension Examinations,'' (below). This program provides
all compensation and pension (C&P) clinicians with a common resource of
essential knowledge about the C&P process and ensures that all
Veterans' disability examinations are performed by clinicians who are
specially trained to conduct C&P examinations.
Chairman Murray. Thank you very much.
Ms. Halliday?
STATEMENT OF LINDA HALLIDAY, ASSISTANT INSPECTOR GENERAL FOR
AUDITS AND EVALUATIONS, OFFICE OF INSPECTOR GENERAL, U.S.
DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY LARRY
REINKEMEYER, DIRECTOR, KANSAS CITY OFFICE OF AUDITS AND
EVALUATIONS
Ms. Halliday. Madam Chairman, Members of the Committee,
thank you for the opportunity to discuss the results of our
recent report on veterans access to mental health care services
in VA facilities. We conducted the review at the request of the
Committee, the VA Secretary, and the House of Veterans' Affairs
Committee.
Today I will discuss our efforts to determine how
accurately the VHA reports wait times in mental health services
to both new and established patient appointments. Dr. Daigh,
the assistant Inspector General for the Office of Healthcare
Inspections, will address whether the wait times data VHA
collects is an accurate depiction of the veterans' ability to
access those services.
We are accompanied today by Dr. Michael Shepherd, a senior
physician in the Office of Healthcare Inspections, and Mr.
Larry Reinkemeyer, the Director of the Kansas City Office of
Audits.
Our review found that inaccuracies in data and inconsistent
scheduling practices diminished the usability of information
needed to fully assess current capacity, resource distribution,
and productivity across the VA system. In VA's Fiscal Year
2011, in the performance accountability report, VHA reported 95
percent of first time patients received a full mental health
evaluation within 14 days. However, we concluded that that 14-
day reported measure has no real value as an access to care
measure because VHA measured how long it took to conduct the
mental health evaluation, not how long the patient waited to
receive that evaluation.
We calculated the number of days between the first time
patient's initial contact with mental health and the completion
of their evaluation. We projected that VHA provided only 49
percent or approximately 184,000 of these evaluations, within
14 days of either the veterans' request or referral for mental
health care. On average, it took VHA about 50 days to provide
the remaining patients their full evaluation.
Once VHA provides the patient with their evaluation, VHA
schedules the patient for an appointment to begin treatment. In
Fiscal Year 2011, we determined that VHA completed
approximately 168,000 or 64 percent new patient appointments
for treatment within 14 days of their desired date. Thus,
approximately 94,000 or 36 percent of the appointments
nationwide exceeded 14 days.
In comparison, VHA data showed that 95 percent received
timely care. We also projected that VHA completed approximately
8.8 million or 88 percent of the follow up appointments for
treatment in 14 days. Thus, approximately 1.2 million or 12
percent of the appointments nationwide exceeded 14 days. In
contrast, VHA reported 98 percent received timely care for
treatment.
We based our analysis on the dates documented in VHA's
medical records. However, we have concerns regarding the
integrity of the date information because providers told us
they used the desired date of care based on their schedule
availability.
I want to point out that we reported concerns with VHA's
calculated wait time data in our audits of outpatient
scheduling procedures in 2005 and outpatient wait times in
2007. During both audits, we found schedulers were entering an
incorrect desired date, and our current review show these
practices continue. For new patient appointments, the
schedulers frequently stated they used the next available
appointment slot as the desired date of appointment for new
patients. This practice greatly distorts the actual waiting
time for appointments.
To illustrate, VHA showed 81 percent or approximately
211,000 new patients received their appointments on their
desired appointment date. We found the veteran could still have
waited two to 3 months for an appointment, and VHA's data would
show a zero day wait time.
Based on discussions with medical center staff and our
review of the data, we contend it is not plausible to have that
many appointments scheduled on the exact day the patients'
desired.
I offer the rest of my time to Dr. Daigh, who will provide
the overall OIG conclusion.
[The prepared joint statement of Ms. Halliday and Dr. Daigh
follows:]
Prepared Statement of the Office of Inspector General,
U.S. Department of Veterans Affairs
introduction
Madam Chairman and Members of the Committee, thank you for the
opportunity to discuss the results of a recent Office of Inspector
General (OIG) report, Veterans Health Administration--Review of
Veterans' Access to Mental Health Care, on veteran access to mental
health care services at VA facilities. We conducted the review at the
request of the Committee, the VA Secretary, and the House Veterans'
Affairs Committee. The OIG is represented by Ms. Linda A. Halliday,
Assistant Inspector General for Audits and Evaluations; Dr. John D.
Daigh, Jr., Assistant Inspector General for Healthcare Inspections; Dr.
Michael Shepherd, Senior Physician in the OIG's Office of Healthcare
Inspections; and Mr. Larry Reinkemeyer, Director of the OIG's Kansas
City Office of Audits and Evaluations.
background
Based on concerns that veterans may not be able to access the
mental health care they need in a timely manner, the OIG was asked to
determine how accurately the Veterans Health Administration (VHA)
records wait times for mental health services for both initial (new
patients) and follow-up (established patients) visits and if the wait
time data VA collects is an accurate depiction of veterans' ability to
access those services.
VHA policy requires all first-time patients referred to or
requesting mental health services receive an initial evaluation within
24 hours and a more comprehensive mental health diagnostic and
treatment planning evaluation within 14 days. The primary goal of the
initial 24-hour evaluation is to identify patients with urgent care
needs and to trigger hospitalization or the immediate initiation of
outpatient care when needed. Primary care providers, mental health
providers, other referring licensed independent providers, or licensed
independent mental health providers can conduct the initial 24-hour
evaluation.
VHA uses two principal measures to monitor access to mental health
care. One measure looks at the percentage of comprehensive patient
evaluations completed within 14 days of an initial encounter for
patients new to mental health services. Another method VHA uses is to
calculate patient waiting times by measuring the elapsed days from the
desired dates\1\ of care to the dates of the treatment appointments.
Medical facility schedulers must enter the correct desired dates of
care in the system to ensure the accuracy of this measurement. VHA's
goal is to see patients within 14 days of the desired dates of care.
---------------------------------------------------------------------------
\1\ The desired date of care is defined as the earliest date that
the patient or clinician specifies the patient needs to be seen.
---------------------------------------------------------------------------
review results
Our review focused on how accurately VHA records wait times for
mental health services for initial and follow-up visits and if the wait
time data VA collects is an accurate depiction of the veterans' ability
to access those services. We found:
VHA's mental health performance data is not accurate or reliable.
VHA's measures do not adequately reflect critical dimensions of
mental health care access.
Although VHA collects and reports mental health staffing and
productivity data, the inaccuracies in some of the data sources
presently hinder the usability of information by VHA decisionmakers to
fully assess current capacity, determine optimal resource distribution,
evaluate productivity across the system, and establish mental health
staffing and productivity standards.
VHA's Performance Data Is Not Accurate or Reliable
In VA's fiscal year (FY) 2011 Performance and Accountability Report
(PAR), VHA reported 95 percent of first-time patients received a full
mental health evaluation within 14 days. However, the 14-day measure
has no real value as VHA measured how long it took VHA to conduct the
evaluation, not how long the patient waited to receive an evaluation.
VHA's measurement differed from the measure's objective that veterans
should have further evaluation and initiation of mental health care in
14 days of a trigger encounter. VHA defined the trigger encounter as
the veteran's contact with the mental health clinic or the veteran's
referral to the mental health service from another provider.
Using the same data VHA used to calculate the 95 percent success
rate shown in the FY 2011 PAR, we conducted an independent assessment
to identify the exact date of the trigger encounter (the date the
patient initially contacted mental health seeking services, or when
another provider referred the patient to mental health). We then
determined when the full evaluation containing a patient history,
diagnosis, and treatment plan was completed. Based on our analysis of
that information, we calculated the number of days between a first-time
patient's initial contact in mental health and their full mental health
evaluation. Our analysis projected that VHA provided only 49 percent
(approximately 184,000) of first-time patients their evaluation within
14 days.
VHA does not consider the full mental health evaluation as an
appointment for treatment, but rather the evaluation is the
prerequisite for VHA to develop a patient-appropriate treatment plan.
Once VHA provides the patient with a full mental health evaluation, VHA
schedules the patient for an appointment to begin treatment. We found
that VHA did not always provide both new and established patients their
treatment appointments within 14 days of the patients' desired date. We
reviewed patient records to identify the desired date (generally
located in the physician's note as the date the patient needed to
return to the clinic or shown as a referral from another provider) and
calculated the elapsed days to the date of the patient's completed
treatment appointment date.
We projected nationwide that in FY 2011, VHA:
Completed approximately 168,000 (64 percent) new patient
appointments for treatment within 14 days of their desired date; thus,
approximately 94,000 (36 percent) appointments nationwide exceeded 14
days. VHA data reported in the PAR showed that 95 percent received
timely care.
Completed approximately 8.8 million (88 percent) follow-up
appointments for treatment within 14 days of the desired date; thus,
approximately 1.2 million (12 percent) appointments nationwide exceeded
14 days. VHA data reported in the PAR showed that 98 percent received
timely care for treatment. Although we based our analysis on dates
documented in VHA's medical records, we have less confidence in the
integrity of this date information because providers at three of the
four medical centers we visited told us they requested a desired date
of care based on their schedule availability.
Scheduling Process
Generally, VHA schedulers were not following procedures outlined in
VHA directives and, as a result, data was not accurate or reliable. For
new patients, the scheduling clerks frequently stated they used the
next available appointment slot as the desired appointment date for new
patients. Even though a consult referral, or contact from the veteran
requesting care, may have been submitted weeks or months earlier than
the patient's appointment date, the desired appointment date was
determined by and recorded as the next available appointment date. For
established patients, medical providers told us they frequently
scheduled the return to clinic date based on their known availability
rather than the patient's clinical need. Providers may not have
availability for 2-3 months, so they specify their availability as the
return to clinic timeframe.
OIG first reported concerns with VHA's calculated wait time data in
our Audit of VHA's Outpatient Scheduling Procedures (July 8, 2005) and
Audit of VHA's Outpatient Wait Times (September 10, 2007). During both
audits, OIG found that schedulers were entering an incorrect desired
date. Nearly 7 years later, we still find that the patient scheduling
system is broken, the appointment data is inaccurate, and schedulers
implement inconsistent practices capturing appointment information.
Workload and Staffing
According to VHA, from 2005 to 2010, mental health services
increased their staff by 46 percent and treated 39 percent more
patients. Despite the increase in mental health care providers, VHA's
mental health care service staff still do not believe they have enough
staff to handle the increased workload and to consistently see patients
within 14 days of the desired dates. In July 2011, the Senate Committee
on Veterans' Affairs requested VA to conduct a survey that among other
questions asked mental health professionals whether their medical
center had adequate mental health staff to meet current veteran demands
for care; 71 percent responded their medical center did not have
adequate numbers of mental health staff.
Based on our interviews at four VA medical centers (Denver,
Colorado; Spokane, Washington; Milwaukee, Wisconsin; and Salisbury,
North Carolina), staff in charge of mental health services reported
VHA's greatest challenge has been to hire and retain psychiatrists. We
analyzed access to psychiatrists at the four visited medical centers by
determining how long a patient would have to wait for the physician's
third next available appointment. Calculating the wait time to the
third next available appointment is a common practice for assessing a
provider's ability to see patients in a timely manner. On average at
the four VA medical centers we visited, a patient had to wait 41 days.
VHA's Measures Do Not Adequately Reflect Critical Dimensions of Mental
Health Care Access
The data and measures needed by decisionmakers for effective
planning and service provision may differ at the national, Veterans
Integrated Service Network, and facility level. No measure of access is
perfect or provides a complete picture. Meaningful analysis and
decisionmaking requires reliable data, on not only the timeliness of
access but also on trends in demand for mental health services,
treatments, and providers; the availability and mix of mental health
staffing; provider productivity; and treatment capacity. These demand
and supply variables in turn feed back upon a system's ability to
provide treatment that is patient centered and timely.
Decision makers need measures that:
Are derived from data that is reliable and has been consistently
determined system-wide.
Are based on reasonable assumptions and anchored by a reasonable
and consistent set of business rules.
Are measurable in practice given existing infrastructure.
Are clinically or administratively relevant.
Provide complementary or competing information to other measures
used by decisionmakers.
Measure what they intend to measure.
Measuring Access to VHA Mental Health Care
Included in the FY 2012 Network Director Performance Plan are the
following measures: the percentage of eligible patient evaluations
documented within 14 days of a new mental health patient initial
encounter; a metric requiring a follow-up encounter within 7 days of
discharge from inpatient hospitalization; a measure requiring four
follow-up encounters within 4 weeks of discharge from inpatient
treatment for high risk patients; and a measure of the percentage of
new Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF)
veterans receiving eight psychotherapy sessions within a 14-week period
during one year period.
VHA's 14-day measure calculates the percentage of comprehensive
patient evaluations documented within 14 days of an initial encounter
for patients new to mental health services. In practice, the 14-day
measure is usually not triggered until the veteran is actually seen in
a mental health clinic and a comprehensive mental health evaluation is
initiated. For example, a new-to-VHA veteran presents to a primary care
clinic, screens positive for depression, and the primary care provider
refers the veteran for further evaluation by a mental health provider.
The ``clock'' for the 14-day follow-up measure will start when the
veteran is actually seen in a mental health clinic and a comprehensive
mental health evaluation is initiated, not at the time of the primary
care appointment. Consequently, the data underlying this measure only
provides information about the timeliness within which comprehensive
new patient evaluations are completed but not necessarily the
timeliness between referral or consult to evaluation.
Veterans access VHA care through various routes, such as VA medical
center emergency departments, primary and specialty care clinics,
women's clinics, or mental health walk-in clinics. Alternatively, they
may seek services at community based outpatient clinics or Vet Centers
in their communities. They may also initiate mental health services
with private providers and later come to VA seeking more comprehensive
services. The 14-day measure does not apply to veterans who access
services through Vet Centers or non-VA-based fee basis providers.
A series of complementary and competing timeliness and treatment
engagement measures that better reflect the various dimensions of
access would provide decisionmakers with a more comprehensive view of
the ability with which new patients can access mental health treatment.
The timeframe immediately following inpatient discharge is a period
of high risk. The 7-day post-hospitalization and the four follow-up
appointments in 4 weeks for high-risk patient measures are clinically
relevant. The eight psychotherapy session in 14 weeks measure attempts
to be a proxy for whether OEF/OIF patients are receiving evidence-based
psychotherapy. The measure is clinically relevant but the utility is
presently marred by inaccurate data or unreliable methodology.
Beyond measures of timeliness (or delay) to mental health care,
user friendly measures that incorporate aspects of patient demand,
availability and mix of mental health clinical staffing, provider
productivity, and treatment capacity, anchored by a consistent set of
business rules, might provide VHA decisionmakers with more information
from which to assess and timely respond to changes in access
parameters.
Recommendations
Our report contained four recommendations for the Under Secretary
for Health:
Revise the current full mental health evaluation measurement to
ensure the measurement is calculated from the veterans contact with the
mental health clinic or the veteran's referral to the mental health
service from another provider to the completion of the evaluation.
Reevaluate alternative measures or combinations of measure that
could effectively and accurately reflect the patient experience of
access to mental health appointments.
Conduct a staffing analysis to determine if mental health staff
vacancies represent a systemic issue impeding the Veterans Health
Administration's ability to meet mental health timeliness goals, and if
so, develop an action plan to correct the impediments.
Ensure that data collection efforts related to mental health
access are aligned with the operational needs of relevant
decisionmakers throughout the organization.
The Under Secretary for Health concurred with our recommendations
and presented an action plan. We will follow-up as appropriate.
conclusion
VHA does not have a reliable and accurate method of determining
whether they are providing patients timely access to mental health care
services. VHA did not provide first-time patients with timely mental
health evaluations and existing patients often waited more than 14 days
past their desired date of care for their treatment appointment. As a
result, performance measures used to report patient's access to mental
health care do not depict the true picture of a patient's waiting time
to see a mental health provider.
While no measure will be complete, meaningful analysis and
decisionmaking requires reliable data. A series of paired timeliness
and treatment engagement measures might provide decisionmakers with a
more comprehensive view of the ability with which new patients can
access mental health treatment.
Madam Chairman, thank you for the opportunity to discuss our work.
We would be pleased to answer any questions that you or other Members
of the Committee may have.
______
Response to Posthearing Questions Submitted by Hon. Bernard Sanders to
the Office of Inspector General, U.S. Department of Veterans Affairs
Ms. Linda Halliday
Question 1. During your investigation, did you observe any obvious
trends, such as an influx of National Guard servicemembers recently
discharged from active-duty that helps explain why some veterans are
scheduled appointments within the performance standards while others
are not?
Response. We did not identify any trends specific to particular
groups of veterans. As part of our review, we interviewed key personnel
involved in the scheduling process at four VA medical centers located
in Spokane, Washington; Milwaukee, Wisconsin; Salisbury, North
Carolina; and Denver, Colorado. None of the personnel interviewed
stated that a recent influx of National Guard servicemembers recently
discharged from active-duty caused any of their access issues.
Question 2. Did any scheduler or scheduler's supervisor explain why
there was such a deviation from VA Directives with regards to mental
health appointments?
Response. The schedulers that we interviewed received the required
annual training that clearly shows how the appointments should be
scheduled. However, at two of the locations (Salisbury and Denver),
schedulers indicated that supervisors told them not to follow the
Directive. Instead, schedulers access the software to see when the next
appointment is available. The scheduler then backs out of the
scheduling package and goes back in to enter the date of the available
appointment as the desired date. An audit trail is not created in
Veterans Health Administration's (VHA) records that documents and
captures these actions.
Dr. John Daigh
Question 1. Would you consider group therapy for ``high risk''
mental health patients as ``clinically inappropriate'' if it is not, at
minimum, done in concert with individual therapy?
Response. ``High risk'' is a term that can have a variety of
meanings. Patients may over a short period of time transition from
``high risk'' to ``low risk'' and back to ``high risk.'' Mental health
providers need to consider all forms and combinations of therapy when
constructing a treatment plan. A more specific answer requires the
facts and circumstances of a specific patient.
Question 2. During your investigation, did you discover any group
therapy for ``high risk'' mental health patients who were not at the
same time receiving individual therapy? If so, how frequently was this
group therapy done in lieu of a more individuated or comprehensive plan
of therapy?
Response. The scope of our review did not include this issue.
______
Response to Posthearing Questions Submitted by Hon. Johnny Isakson to
Office of Inspector General, U.S. Department of Veterans Affairs
Question 1. The OIG has reported several times on inappropriate and
inconsistent scheduling practices in 2005, 2007, and now again in 2012.
VHA has taken steps to address these issues, however, the problem
persists.
A. Why does this continue to be an issue and what is contributing
to the inappropriate practices?
Response. The required management oversight is not effective.
Schedulers told us that supervisors focused their attention on the
appointments where schedulers were not able to schedule the patient
within 14 days of the desired date of care rather than the integrity/
accuracy of the appointments they were able to schedule within 14 days.
B. Is it simply a lack of training for schedulers? Are the
schedulers receiving the required annual trainings and taking the
annual tests to ensure they are properly carrying out VHA directives?
Response. We do not think it is lack of training, but more that the
oversight is not effective and the lack of focus on ensuring the data
integrity of the scheduling information. At the sites we visited, the
training and competency records were up to date and schedulers stated
they were receiving training on proper scheduling procedures.
Scheduling supervisors also stated they evaluated schedulers'
competency annually, as required. The training provided to schedulers
aligns with VA's Directives.
Question 2. According to the OIG, this is leading to skewed data
that is not helpful to key decisionmakers from the managerial level to
the administrative level to Congress.
A. Do these inconsistencies occur in all the Veterans Integrated
Service Networks (VISNs), or are some performing better than others?
Response. For our review, we visited four VA medical centers
located in four different VISNS, and confirmed inappropriate scheduling
practices occurred at three of the four centers. Our analysis did not
attempt to draw a conclusion between VISN performance so we cannot
offer an opinion in this area.
B. What is VHA doing to correct this problem?
Response. VHA has indicated they are changing the way new patient
appointment timeliness will be evaluated by using the ``appointment
create date'' instead of the ``desired date'' to evaluate appointment
timeliness. VHA agreed with our concerns that the ``desired date'' is
ambiguous and that a simpler methodology will improve the reliability
of scheduling data.
Chairman Murray. Dr. Daigh.
STATEMENT OF JOHN DAIGH, 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, OFFICE OF HEALTHCARE
INSPECTIONS
Dr. Daigh. Madam Chairman, Ranking Member, and Members of
the Committee, it is an honor to testify before you today. I
and my staff from the Office of Health Care Inspections on a
daily basis deal with clinical care issues in VA, and we know
that both the employees and leadership within VA strive to
provide the highest quality care. And despite the subject of
this meeting, I do believe VA provides very high quality health
care to its veterans. In fact, with respect to quality metrics,
I believe VA leads the Nation with respect to both the use of
data and the publication of that data on the Web site.
With respect to access to care metrics, I believe it is
quite a different story. I believe those metrics are flawed. I
believe, as our report indicates, Dr. Petzel has indicated that
he will put together a group to try to resolve the issue and
get the access to care metrics in line so that they do
accurately reflect the business processes that are ongoing at
VA.
I plan to talk about some of the access to care metrics in
the private sector, but I think what I would like to make are
two different statements after hearing your opening statement,
ma'am.
The first would be I think VA has a number of missions.
They have a mission to provide health care. They have a mission
to do research. They have a mission to train individuals who
will work in the United States and elsewhere in the health care
industry. They have a mission to be available in times of
national disaster. And I think as individuals out there in
hospitals they decide how they are going to spend their time,
those missions are generally accepted as being equal--there is
not a directive that says the primary mission is the delivery
of health care, and we will address those requirements first as
professionals schedule their time or allocate their time.
So, I think when we have a crisis like we have, that a
prioritization of mission, again, stated clearly from top to
bottom, would allow individuals across the system to rethink
how they are spending their time.
The second issue I think is important is to set a standard
of productivity. I realize that health care cannot be numbers
driven. I realize it is a personal interaction between a
patient and a provider. But at the same time, there has to be
some method to determine that you are getting enough work or
productivity from the people that are working for you.
So, I think although VA has worked on these issues for a
while, that there just has to be a clear, measurable, and in my
view, productivity standard that is easily relatable to the
work done in the private sector by a similar provider, so that
one can decide whether the money spent is actually being
effectively used. The other issues that are brought forward in
terms of the kind of access to care standards we could use, I
think that Mr. Schoenhard and others well understand those, and
I think we can work with them in order to improve the standards
that they currently have in place.
With that, I will end my comments and be happy to answer
any questions.
Chairman Murray. Thank you very much.
Mr. Tolentino.
STATEMENT OF NICHOLAS TOLENTINO, OIF VETERAN AND FORMER VA
MENTAL HEALTH OFFICER
Mr. Tolentino. Madam Chairman, Senator Brown, Members of
the Committee, as and OEF/OIF combat veteran, I am honored to
appear here today to share deep concerns about the
administration of VA's mental health care system.
My testimony is based on my experience as a VA mental
health administrative officer, as well as service on a VA
network executive committee, membership on several VA national
work groups, and a background in quality management that led to
an MBA degree. Deep concerns about the Manchester, NH, VA
medical center's failure to provide needed care ultimately led
to my resignation last December.
I want to commend this Committee for your vigilant
oversight of VA mental health care. Let me also acknowledge the
VA's recent announcement and plans to add positions to its
mental health workforce and address problems you have helped to
uncover. But I want to emphasize that additional staffing alone
will not remedy the systemic problems in the VA management of
mental health care.
Let me be clear. I do not wish to discredit the VA or its
mental health staff who work diligently to help veterans. But
for all it strives to do, the VA's mental health system is
deeply flawed. The system is too open to putting numerical
performance goals ahead of veterans' mental health care needs.
It is too susceptible to gaming practices and making the
facilities look good and too little focus on overseeing the
effectiveness of care it promises to provide. These systemic
problems compromise the work of a dedicated mental health staff
and fail our veterans.
Like many VA medical centers, the overriding objective at
our facility, from top management on down, was to meet our
numbers, meaning to meet our performance measures. The goal was
to see as many veterans as possible, but not necessarily to
provide them the treatment they needed. Performance measures
are well intended, but they are linked to executive pay and
bonuses, and as a result, create incentive to find loopholes
that allow the facility to meet its numbers without actually
providing the services. Far too often, the priority is to meet
a measure rather than meet the needs of the veteran.
Many factors, including understaffing, make it very
difficult to meet performance requirements. But administrators
do not feel that they can acknowledge that. Instead, as soon as
new performance management program manuals were published each
year, network and facility leadership began planning how to
meet those measures. That led to brainstorming, even with
colleagues of mine across the country, to find loopholes to
game requirements that could not be met.
While I have detailed multiple examples in my full
statement, I would like to share two of them now.
Several performance measures mandate that veterans in
mental health treatment be seen within certain timeframes. At
Manchester, where demand for mental health was great and
staffing very limited, the facility director demanded a plan to
get better and seen at any cost. We got the order: focus only
on the veteran's immediate problem. Treat it quickly in that
appointment, usually with medication, and do not ask further
questions about needs because, ``We don't want to know, or
we'll have to treat it.''
Another directive requires that a patient who is actively
suicidal or high risk for suicide should be seen at least once
per week for 4 weeks after an inpatient discharge. This is to
ensure the veteran's receiving the intensity of care needed to
reduce the risk of readmission and to increase the success of
treatment.
Instead of providing these high-risk patients individual
therapy, Manchester instead created a group for them, a step
that was both clinically inappropriate and contrary to the
directive's intent. Veterans who refuse to join the group were
often labeled resistant to treatment.
The idea that group therapy could be substituted for
individual psychotherapy spread throughout the network. In
fact, the network mental health executive committee actually
promoted this idea as a so called best practice. Even though it
was not at all good clinical practice, it was seen as a good
way to meet performance measures.
I believe that most VA facilities have an understaffed
mental health service because the VA lacks a methodology to
determine what mental health staffing is needed at an
individual facility. In a misguided attempt to justify more
mental health staff at Manchester, the head of our mental
health service stated that the priority needed to be quantity
rather than quality. She said, and I quote, ``Have contact with
as many veterans as we can, even if we aren't able to help
them.''
The outcome was that the facility continued to enroll a
growing number of veterans, far more than our mental health
clinicians could handle. And as a result, veterans fell through
the cracks. Tragically, there was no effective oversight, even
to detect those deep systemic problems we faced.
For example, every year, the medical center would complete
a mandatory central office survey to assess facility compliance
with the VA's mandate to provide uniform mental health
services, but each year our network told us we were never to
answer that services were not provided. Many of our answers
were actually changed to say that required services were being
provided when they in fact were not.
During my years at Manchester, other members of the mental
health staff and I repeatedly raised concerns with both
facility and network leadership regarding practices we believed
were unethical or violated VA policy. Those concerns largely
fell on deaf ears. Our staff also repeatedly brought the
concerns to our facility's ethics committee. And to our great
frustration, however, the ethics committee consistently
declined to take up these issues because they felt they were
clinical matters.
For me, the final straw was the medical center's failure to
take meaningful action upon discovery that a mental health
clinician was visibly intoxicated while providing care to our
veterans. Ultimately, I could not continue to work at a
facility where veterans' well being seemed secondary to making
the numbers look good.
I very much hope the VA will make real changes to address
the systemic problems I have described. I believe that there
are steps the VA can take beyond adding staff. I humbly offer
these suggestions.
First, the VA should stop monetarily rewarding leadership
for meeting numerical and process requirements that are not
real measures of effective mental health care.
Second, the VA should institute a much more extensive
oversight into how care is actually being provided and how
program funding is deployed to ensure the funds actually go to
the programs they are intended to supplement.
Finally, I would urge this Committee to press the VA to
develop and implement a very long overdue empirically supported
mental health methodology so that it is no longer necessary to
guess whether 1,900 more mental health staff will be enough.
In closing, I am honored to have had the opportunity to
share both my experience and assessment of problems that I hope
you can help to resolve. I would be very pleased to answer any
questions you may have. Thank you.
[The prepared statement of Mr. Tolentino follows:]
Prepared Statement of Nicholas Tolentino, OIF Veteran and Former VA
Mental Health Administrative Officer
Chairman Murray, Ranking Member Burr and Members of the Committee:
I am honored to appear before you today to share my experience,
perspective and resultant concerns about the delivery of timely,
effective mental health care in the VA system. I want to begin by
sharing with you that I am myself an OIF/OEF combat veteran, medically
retired after nearly 14 years of service in the United States Navy.
In April 2009 I took a position as the Mental Health Administrative
Officer of the Mental Health Service Line at the Manchester VA Medical
Center (VAMC) in Manchester, NH. While working in the Navy as an
Independent Duty Hospital Corpsman, I earned my MBA and developed a
deep interest in the quality-management of medical facilities. An
opportunity to support VA efforts to aid my brothers and sisters, was
for me, an ideal transition into civilian work and service. As the
Mental Health Administrative Officer I was responsible for a vast
number of the administrative functions of the Mental Health Service
Line. In addition to those duties and responsibilities, I served as a
member of the VISN 1 Mental Health Executive Committee which worked to
address network-wide mental health service issues, and also as chairman
of the Manchester VAMC Mental Health Systems Redesign Team, which
worked to address local issues specific to the function and design of
our mental health services. Deep concerns about needed care we were NOT
providing at Manchester ultimately led me to resign last December.
additional mental health staffing alone is no panacea
As a combat veteran, I want to commend this Committee for your
vigilant oversight into VA mental health care. Let me also acknowledge
Secretary Shinseki's announcement of plans for additional staff to
supplement VA's over-stretched mental-health work force and address the
problems your oversight helped uncover. But additional staffing alone
will not remedy fundamental national problems in VA's administration
and management of mental health care. The problems I will highlight in
this testimony--problems I have seen at the medical center, VISN level,
and on multiple national work groups--are significant enough to derail
and undermine the Secretary's well-intentioned effort.
how vaco mental-health performance measures distort care delivery
It is important for me to make clear that in sharing these
concerns, I do not intend to discredit the VA, an organization with a
critical role. I know from experience that many VA mental health
staff--clinical and administrative--work tirelessly to help the
veterans they serve. But I also know from experience that that system
is deeply flawed. The system is too open to putting numerical
performance goals ahead of veterans' mental health care needs--too
susceptible to ``gaming'' practices to make facilities ``look good''--
and too little focused on overseeing the effectiveness of the mental
health care it promises to provide. I have seen just how easily these
systemic problems can compromise the important work of dedicated VA
mental health staff, and fail our veterans.
By way of context, the Manchester VAMC serves some 12,000 veterans
in the state of New Hampshire. We are the only VA in New Hampshire and
we are a small facility with no inpatient services. The mental health
service line staffing has itself grown exponentially over the past five
years with increased national attention and funding for mental health,
and is now comparable in size to many of the other services provided on
site; however demand for mental health care has grown faster.
Historically, but even more so during the almost four years that I
worked at Manchester, the overriding medical center objective--from top
management on down was to ``meet our numbers,'' that is, to meet
performance measures and to see as many veterans as possible.
Performance measures play a significant but troubling role in VA mental
health care. While it is not unreasonable to expect a facility to want
to meet numerical performance objectives and provide needed care to as
many veterans as possible, VA Central Office's well-intentioned
performance requirements often prove antithetical to providing
appropriate care.
First and foremost, the achievement of performance measures is
linked to pay and bonuses for Executive Career Field (ECF) employees,
most commonly, upper management (myself included). The financial
incentive to meet these measures too easily creates a perverse
administrative incentive to find and exploit loopholes in the measures
that will allow the facility to meet its numbers without actually
providing the services or meeting the expectation the measure dictates.
The upshot of these all too widespread practices is that meeting a
performance target, rather than meeting the needs of the veteran,
becomes the overriding priority in providing care.
You might ask: Why not provide the services the way the measure
dictates and simply ``make the numbers'' in that way, why employ
loopholes? While most performance measures are intended to ensure that
care is provided in ways that are effective (based on empirical
research), timely, and relevant to the needs of the population, they do
not necessarily take the following operational realities into account:
1. Staffing: Most facilities' mental health services are
understaffed, and mine was no exception. Without solid means to measure
the relative needs of each facility, given its size, population served,
etc., staffing levels are haphazard. (For example, White River Junction
VAMC in Vermont, our neighboring facility, serves half the number of
veterans in their mental health service, but has double the staff).
Performance measures, rightfully, are not flexible as they relate to VA
facility capabilities, as a veteran does not deserve lesser treatment
because his local facility is small. However, the expectations
reflected in VA's performance measures often far exceed the
capabilities of the staff that must meet them. In my experience, it was
a routine matter for facility and VISN administrators to find and use
loopholes to ``meet their numbers'' whenever they were confronted with
a gap between a performance requirement and a facility's limited
capabilities that had adverse implications for their paychecks.
Tragically, though, this kind of ``gaming'' of the system meant that
veterans too often weren't getting needed mental health services.
2. Mandated services are not always relevant to a facility: By way
of example, in a well-intentioned effort to improve rural veterans'
access to mental health care, VA Central Office set mandates, and
accompanying performance requirements, that called for providing
certain percentages of veterans with telehealth services. However, not
all facilities have this need. While our facility in particular, did
not have much demand for this service, the requirement led us to place
many veterans in telehealth treatment whether they wanted it or not,
and in circumstances where it was not clinically relevant or of any use
to the veteran. Additionally, group therapy and other services not
otherwise needed or indicated for such technology were forced to adapt
their treatments to fit this new initiative. The upshot was that
precious staff time was devoted to a mode of treatment that veterans
neither needed nor wanted.
One might think that administrators whose facilities are truly
incapable of meeting a performance requirement would simply acknowledge
that they cannot meet a target and request additional staff or other
needed support. Unfortunately the system does not encourage that
behavior, and facility administrators generally don't wish to ``look
bad.'' Moreover ``failing to meet'' a performance measure has adverse
implications:
1. The first and most obvious is that failing to meet a performance
measure has a direct impact on administrators' personal paychecks.
2. When a facility fails a measure, it must take on a significant
amount of administrative work. Action reports must be generated and
submitted to the VISN, data must be tracked and analyzed and a
tremendous amount of attention is brought onto the administration. No
one likes that. (The irony is that there are loopholes around even this
administrative requirement.)
3. And finally, unlike the VA Primary Care Service Lines, for
example, that have a well-defined staffing methodology, VA lacks a good
method for establishing individual facility mental health staffing
needs. While on paper a facility can appear ``fully staffed'' based on
VACO's determination for that region, in reality the veteran workload
and needs far exceed the man hours available to serve them. In my
experience, when a service line manager does submit a request for
additional staff, often the request doesn't make it past the facility
director because he or she will want data to support the need before
taking it higher up the chain. Gathering data takes a great deal of
work, and the data gathered rarely depicts the demand in a way that
translates into man hours needed. This takes us back to why even VACO
has difficulty establishing a good method for establishing staffing
needs for individual facilities.
Manchester offers a troubling case in point. Failure to meet a
performance measure has not historically resulted in staffing needs
being addressed. Instead, failure has resulted in more work for an
already stretched staff, and a leadership response that has insisted
that ``we are already fully staffed,'' and therefore any failure to
meet measures must be an indication of inefficient use of resources,
not a lack of resources. The mental health service line manager
translated the call for ``improved efficiency'' to mean ``find more
loopholes.''
gaming the system
I know from my experience on the VISN 1 Executive Committee and on
various national VA workgroups that these problems are not unique to
Manchester VAMC. Unfortunately, most VA facilities struggle to fit into
the highly uniform expectations of VA performance measures. While the
goal of expecting all facilities to provide uniform quality care is
laudatory, the rigid one-size-fits-all approach contributes to systemic
problems.
As soon as the new ECF Performance Management Program manual and
performance measure technical manuals are published each year, even in
draft form, planning among VISN leaders, facility leaders, Quality
Management staff, and Service Line staff begins regarding how to meet
the measures for that year. Staff analyze those measures that are
determined not likely to be met by a facility due to either low demand,
lack of resources, etc., and the group brainstorms to find loopholes
that can be exploited to game the requirement. The group will also ask
other facilities in the region and nationally for their ``solutions''
to similar problems. Let me offer some examples:
Desired Date of Appointment: VACO's performance measures
include a requirement that a veteran treated by the mental
health service is to be scheduled for a mental health
appointment within 14 days of his or her ``desired date'' for
service.
At Manchester, despite the fact that effective treatment
requires a level of intensity and frequency determined by the
veteran's symptoms, limited staffing (and other problems) made
it impossible to offer veterans the frequency of psychotherapy
appointments to meet their clinical needs. While a veteran and
his or her clinician might agree that the veteran should return
next week to continue his progress, the appointment
availability was simply not there. Nevertheless our service
``met'' this measure by simply eliminating the opportunity for
the veteran to give us a desired appointment date. Instead, the
veteran was told when the next appointment with his provider
was available and that appointment (often weeks, even months
away) was entered as his ``desired'' date, thus ``meeting'' the
measure.
(Veterans who are unable to be scheduled for their actual
desired date should be placed on an Electronic Wait List (EWL)
developed for this purpose and meant to track the demand versus
the availability of services. (But facility leadership
``unofficially ordered'' that the EWL was NOT to be used under
any circumstances.)
Meeting frequency measures for clinical contact: Several
different performance measures mandate that veterans in mental
health treatment be seen within certain timeframes and
frequencies based on such classifications as whether the
veteran was new to treatment, a high risk for suicide, etc. At
Manchester, where demand for mental health care was great and
the resources were very limited, the facility director pressed
the mental health service line manager to develop a plan to
``get the veterans seen'' at any cost. The plan that was
ultimately developed ``gamed'' the system so that the facility
``met'' performance requirements but utterly failed our
veterans. Specifically, instead of conducting an assessment of
veterans' mental health needs and scheduling and providing the
appropriate intensity and frequency of services, the plan
called for providing only the most limited mental health
services (such as medication management or a mental health
check-in from time to time) through the facility's primary
mental health clinic. The service line manager's order was to
focus only on the immediate problem with which the veteran
presented in that moment, treat that quickly in that
appointment (this meant only medication) and not to ask further
questions about needs because, ``we don't want to know or we'll
have to treat it.''
This perverse approach reduced the need to schedule
appointments in an already backlogged scheduling system. (When
appointments aren't scheduled there is no evidence that the
facility is NOT getting the veterans in for appointments in a
timely way that meets the measures. Thus, the facility succeeds
in appearing to meet the measure.) Veterans were encouraged and
often required to make use of the walk-in service, despite
clinical contraindications. This fundamentally unethical
approach meant that veterans who needed much more intense care
made no progress toward symptom remission and achieving
treatment goals.
High Risk Patients: By VHA directive, a patient who is
actively suicidal or identified to be at high risk for
completing suicide should be seen, at minimum, on a once-weekly
basis for four weeks after being discharged from an inpatient
unit. This is to ensure the veteran is receiving the intensity
of care necessary to reduce the likelihood of readmission to
the inpatient ward and to increase the success of the treatment
provided. Manchester's response to this requirement was to
create a group for these high-risk veterans to attend, instead
of providing individual therapy. Not only was this clinically
inappropriate and in direct conflict with the intent of the
directive, but if a veteran refused to be in a group, that
veteran was often labeled ``resistant to treatment.''
Group therapy to meet intense-therapy requirement: Another
performance requirement mandates that a certain percentage of
OEF/OIF veterans who have a primary diagnosis of PTSD are to
receive a minimum of 8 psychotherapy sessions within a 14-week
period. While the clear intent of that measure is based on
research that emphasized immediate, intense individual
psychotherapy as the best clinical approach to combating PTSD,
the technical wording of the measure did not effectively
restrict the nature of appointments to the clinically indicated
individual psychotherapy. Manchester took advantage of that
lack of ``guidance'' in the technical wording and once again
used group therapy sessions as a means to meet the measure. And
once again, veterans who refused to attend group therapy were
labeled as non-compliant with treatment. So while the facility
looked ``on paper'' as though it had met this VA performance
measure, the vast majority of the patients in fact were not
getting the intensity of care that the measure intended.
Group therapy as ``best practice:'' Despite clinical
contraindications, the idea that group therapy could be
substituted for individual psychotherapy spread throughout the
VISN. Manchester was certainly not the first facility to use
this strategy. In fact, the VISN Mental Health Executive
Committee, which met annually to discuss how individual
facilities were meeting performance measures, actually fostered
this idea as a so-called ``best practice.'' While the idea of
substituting group therapy for individual therapy for any and
all patients is not at all good clinical practice, it was
looked on as a good way to meet requirements. The VISN actually
brought that so-called ``best practice'' to a national level,
promoting this practice at a national VA mental health
conference.
(While I am not a clinician, I am aware of the various
methodologies for treating many mental health disorders and
symptoms relevant to the veteran population. Group therapy is a
very effective and important aspect of mental health service.
The problem with its use in these instances is the lack of
choice and intensity in the treatment. Group therapy is by its
nature a less intense form of psychotherapy, generally
speaking. In addition, the veterans were given no choice over
whether they would receive individual therapy or group therapy.
Instead, at many facilities they are directed into a mode of
care many do not want, need, or with which they are
uncomfortable, because the facilities' need to meet the
associated performance measure is the overriding priority.)
Targeted populations: Some performance measures identify
target populations, and result in assigning certain classes of
patients' priority and access to preferred treatment
modalities. The obvious result is that veterans of other eras
or demographics may receive less than desirable or not-so-
clinically indicated treatments to create space for the
preferred population. Under these circumstances the
individual's clinical needs are not considered. A Vietnam
veteran in crisis with significant symptoms would be passed
over for that all-too-rare appointment spot with a
psychotherapist, if an OIF veteran also seeks that appointment.
The fact that the OIF veteran may not be in urgent need for
services is not considered. He would get the appointment
because a performance measure dictates that he get a more
timely appointment than all others. While the intent of
fostering early intervention is a good one, the drive to meet
the measure impedes exercise of good clinical judgment.
budget gaming confounds provision of good mental health care
I'm well aware that this Committee has been instrumental in
increasing VA mental health care funding over the years. But
``disconnects'' between VA Central Office and VA medical facilities
have in some instances stood in the way of special funding (to enhance
mental health services) actually reaching the veterans. (Such ``special
funding'' was intended to support the implementation of the Uniform
Mental Health Services policy in VA medical centers and Clinics (VHA
Handbook 116.01), which aims to ensure that a uniform set of mental
health services would be accessible to veterans across the country.)
Despite a clear directive, Manchester did not actually use special
funding as intended or fully implement the Uniform Services Package
(the ``USP'').
On numerous occasions, VA Central Office would establish a new
initiative related to the USP, and provide special funding for a
particular mental health staff position to carry out that initiative.
Most times a VHA or VACO Memorandum would be sent out to the facilities
stating that the posting and hiring of the position was mandated and to
be done ``ASAP.'' However, Manchester's leadership would mandate that
the position go through various administrative approval boards (despite
the Memorandum having specifically stated that the position is not to
be subjected to such processes). This process would greatly increase
the amount of time taken to post and hire for the position. During this
time--often 3-6 months in duration--the position would be caught up in
meetings awaiting ``approval'' and the salary dollars received by the
facility would go unspent, creating a substantial excess (often
referred to as lag funds). At the end of the fiscal year, these lag
funds would be converted to cover salary expenses of regular staff or
converted into facility General Purpose (GP) funds to reduce overall
facility debt accrued over the course of the year. I can recall many
instances, across several fiscal years, where Manchester acquired
hundreds of thousands of dollars of special mental health funding
without fulfilling the actual intent of the funding.
In FY 2011, for example, approximately $500 thousand in mental
health funds were converted to general operating funds. As a result, we
were not able to hire the specialty mental health staff we needed or
provide the initiative-programs with the tools required to perform
effectively. But because VA Central Office directed all medical centers
to carry out a number of new initiatives, including expansion of
Geriatric Psychiatry services, substance abuse services and expansion
of homeless programs, for example, clinicians at the facility were
forced to take those titles on as a collateral duty, or the services
were simply not offered. While concerns over the situation were raised
at both the facility and VISN level, they received only minimal
attention for a short time, without resultant change.
(By assigning collateral duties to clinicians who already held
important titles and functions, Manchester was able to appear fully
staffed without having to hire additional clinicians. On paper we were
able to say that we had an ``Military Sexual Trauma (MST)
Coordinator,'' for example, despite the fact that that clinician was
also carrying other mandated titles and responsibilities. This
gamesmanship impacted appointment availability and further stretched
limited resources. Moreover, most titled positions come with many
administrative duties (weekly or monthly conference calls, data
tracking, etc.). So when a clinician carries several titles, much of
his or her time is consumed by those administrative tasks, resulting in
less appointment availability for veterans).
Good mental health care, of course, requires that we provide
veterans privacy, and the necessary office space to make that possible.
We had a need for additional mental-health-service space at Manchester,
and a project was submitted to VACO to remodel a storage area so that
we could co-locate multiple mental health offices with primary care.
VACO provided us mental health special funds to perform the work. But
after the work was completed, the facility leadership decided that the
space would not in fact be used for mental health offices, but would
instead be used to expand Primary Care. Mental health received no
additional space and was informed that the facility priority was now
Primary Care, given the identification of the upcoming Primary Care
expansion. This scenario was repeated with the submission of a project
to add an additional wing to the medical center specifically for the
expansion of mental health. After the project received initial VACO
approval, the facility leadership once again chose to use it for
Primary Care, though not altering the project-intent statements to
reflect this fact.
mental health budget: distortions in providing care
Manchester's Mental Health Service Line Manager's response to our
staffing dilemma was made clear to us in a meeting in which she
emphasized that the service line priority needed to be ``quantity''
rather than ``quality.'' By that she meant to ``have contact with as
many veterans as we can, even if we aren't able to help them.'' The
strategy was an attempt to show workload numbers as a way to justify
requests for adequate resources. The upshot, though, was that the
facility was enrolling growing numbers of veterans with very real
mental health needs, but the mental health clinicians were reporting
``we already have more patients than we can handle.'' As a result,
veterans began to fall through the cracks.
Under such circumstances where demand for needed treatment far
exceeds the services available, VHA's Uniform Mental Health Services
Handbook dictates that mental health services ``must be made accessible
when clinically needed'' either in-house or under contract
arrangements. But despite that mandatory language, the VISN's Mental
Health Service Line Manager took the position that ``these are more
guidelines than rules.'' There was, in theory, a process through which
to get fee-basis care authorized--that required going through the
service-line manager to get approval from the chief of staff--but I was
told requests for approving fee-basis mental health care were very
rarely approved. And even if they were approved, the facility lacked
any effective means to case-manage these patients, as required under
the directives regarding fee-services. Similarly, it was often a battle
to even send a patient to another facility for needed care.
Let me share just one horrific example to illustrate how the
mindset at Manchester turned good patient care on its head. A
psychiatrist assigned to the Substance Abuse Treatment Team, on more
than one occasion was faced with a veteran seeking treatment to end his
opioid addiction. Because the psychiatrist believed that he didn't have
time to assist the patient, he prescribed the very opioids to which the
veteran was addicted. He tried to justify this by stating that he
needed to ``hold the patient over,'' and went on to schedule him an
appointment to return sometime in the future. The psychiatrist said
``they are going to get the drugs from somewhere so we might as well
just go ahead and give them to them.''
lack of effective oversight
It is heartbreaking to reflect on the many, many barriers staff
encountered to getting patients the mental health care they needed and
deserved. While patients truly fell through the cracks, there was no
effective oversight to detect that and to address the deep systemic
problems we faced. Every year our medical center took part in a Central
Office survey to assess medical facilities' compliance with the Uniform
Mental Health Services Handbook; as part of that surveying we were
asked to delineate the services we provided. Each year, however, the
VISN Mental Health Office gave the facilities the guidance that we were
never to answer that services were not provided. Many of the answers
were changed to say that specific (required) services WERE being
provided when they weren't. Specifically, we were instructed that the
``fallback'' answer was that the services were provided by fee-service,
although this was never actually the case.
During my years at Manchester, other members of the mental health
staff and I repeatedly raised concerns with facility leadership as well
as at the VISN level regarding practices and decisions which were
either frankly unethical or violated VA policy. Those concerns largely
fell on deaf ears.
Internally, our medical center has an ethics committee, and staff
often brought concerns regarding the compromises to mental health care
to that committee. To our great frustration, however, the ethics
committee consistently declined to take up these issues on the basis
that they were ``clinical matters'' beyond its purview.
Manchester is located in relatively close proximity to the National
Center for PTSD headquartered at the VA Medical Center in White River
Junction, Vermont. The National Center is not an oversight body, but
its director, Dr. Matt Friedman, did visit Manchester on one occasion
during my tenure and advised on various requirements the facility
needed to meet. He was simply told, ``we don't have the staff'' to meet
those requirements, and was not invited back.
unethical practices: the last straw
I could detail other instances of unethical practice at the
Manchester VAMC that contributed to my decision to resign, but the
final straw occurred when the medical center failed to take meaningful
action in response to the discovery that a VA clinical
psychopharmacologist was intoxicated while providing patient care. On
October 31st, 2011 the Mental Health Service Line Manager discovered
that a psychopharmacologist at our facility was noticeably intoxicated
and slurring his speech. The Service Line Manager became aware of this
situation when a veteran reported that the clinician had failed to
appear for an appointment. Looking into the matter, I discovered that
he had written numerous prescriptions during that day, presumably
during the period of his intoxication. The very next day, while the
clinician was again treating patients, a water bottle was found hidden
in that clinician's personal office refrigerator that was filled with a
brown fluid clearly smelling of alcohol. An internal panel was
convened, but the panel seemed to be more of a formality than an actual
investigatory board. I was disturbed to learn that the incident did not
lead to the clinician's removal, and instead he was simply transferred
to work in the pharmacy. To make matters worse, the service line
manager's response to my protest regarding the lack of action was to
imply that, as a combat veteran, I was likely also vulnerable to
substance-abuse. That implication, notwithstanding my impeccable
employment history, was not only personally insulting, but unfathomable
coming from a psychiatrist responsible for the facility's mental health
service. A similar attempt to imply that my combat veteran status is a
personal liability was made after my resignation, when I provided
voluntary testimony to an internal investigative board. The board
attempted to discredit my testimony by stating that my responses to
incidents I'd reported were simply magnified by my combat experiences
and resulting emotional instability.
recommendations
Ultimately, I could not continue to work at a facility where the
well-being of our patients seemed secondary to making the numbers look
good. I do care deeply that the VA health care system not only makes
our veterans' mental health a real priority, but that it institutes the
kinds of changes needed to make VA mental health care timely and
effective. I believe there are steps that can be taken--beyond adding
additional staff--to make this happen. Let me offer three
recommendations:
1. VA must stop measuring and monetarily rewarding administrators
for meeting numerical and process requirements that are simply not
sound proxies for effective mental health care.
2. VA must institute much more extensive oversight into how care is
actually provided and how program funding is deployed to ensure the
funds actually go to the programs that they are intended to supplement.
3. Finally, I would urge that this Committee press the VA to
develop and implement a very long overdue mental health staffing
methodology, so that it is no longer necessary to guess whether, for
example, 1900 more mental health staff will be enough.
In closing, I'm honored to have had the opportunity to share with
you my ``on the ground'' experience and assessment of problems that I
hope you can help resolve. I'd be pleased to answer any questions you
may have.
Chairman Murray. Thank you very much.
Major General Jones.
STATEMENT OF T.S. JONES, MAJGEN, USMC (RET.), FOUNDER AND
EXECUTIVE DIRECTOR, OUTDOOR ODYSSEY YOUTH DEVELOPMENT AND
LEADERSHIP ACADEMY
General Jones. I am Tom Jones, retired Marine, founder and
director of Outdoor Odyssey, which is a camp for at-risk youth.
I do not have any expertise in mental health. I have a lot of
experience dealing with those who have mental health issues.
I have been visiting Walter Reed in Bethesda every week
since the start of the war in Afghanistan in 2001. I have met
thousands of folks. I have been privileged to be on the board
of the Semper Fi Fund, started by wives, run by wives, that
deals with families of the wounded.
I also started Semper Fi Odyssey as an outgrowth of Outdoor
Odyssey. While it started as a normal transition course, I met
a Marine Corps captain in Bethesda who was grievously wounded,
visited him many times over the next year. And while he is in
therapy, he asked me to help him to start a 501(c)(3), since I
had already done so, a nonprofit.
We originally started as a normal transition course,
however, it was patently obvious after a while that the mental
health issues were such that we really got into the whole issue
of dealing with mental health. Because of my medical
background, I was able to bring a lot of folks in from the
outside. I noted Navy psychiatrist, Dr. Bill Nash. And he was
so moved by the experience that he had me be involved in a
number of gatherings of mental health professionals. From that,
I was able to--because I am an adjunct at the Institute for
Defense Analysis here in D.C., I was able to start a project
looking at best practices on mental health.
What we have done, we have run 30 sessions now, week long
sessions, of Outdoor Odyssey. I chiefly used Outdoor Odyssey
because I had the facilities. What we have done is build on a
volunteer strategy with team leaders. And almost all the people
involved are in voluntary category.
What has transpired is this whole issue of trust, cohesion
and bonding, which works in the military when you are dealing
with veterans. Of our cohort, 30 sessions, 35 or so, we attend
each time. Just had one last week. So we have dealt with over a
thousand not only veterans but those soon to be discharged from
the military.
We work in conjunction with the Wounded Warrior Regiment,
so it gives us a pretty good index not only of the problems we
are having in the military, but also, most strikingly, the
problems we are having in the veteran community. And what we
have found is that many, if not most, of the people who are
undergoing clinician's care have not divulged even the source
of the main stressor that has created the problem.
I agree with several of the panelists here. I do not think
the numbers of additional mental health coordinators is solely
going to solve the problem. I think the mental health
coordinator has to have a better understanding of what the
demands are of the individual warrior. I think the one thing
that we have learned through our experience with bringing
mental health professionals to these experiences is that many
of them can get a better perspective of what these individuals
are facing through interaction with them.
So I would encourage other folks here, even my panel
members, if we are so inclined to be involved, I think the
insights and the site picture provided to you is absolutely
illuminating. What we have learned--I call them salient
outcomes. We can see the same things you get in a normal
transition course, and we are getting breakthroughs where
people are actually coming forward and talking about demons
that they heretofore have never talked about before. We build a
network of trust that is lasting, not just a network in the
sense of a transition course, but a network that will follow
them after they leave the experience.
Most importantly what we have learned is the fact that a
large percentage and a growing percentage of folks are having
mental health issues. And I would say--it is an opinion, but I
think it is a pretty well-founded opinion--that the numbers are
going to be growing in the future. I would think that we need
experiences where folks that do deal in the setting of a
clinician have a better understanding of what the issues are
that they are dealing with.
I am very honored to be here. I thank you very much. I will
answer any questions, and I will certainly encourage any
members of your staff to visit. We have got plenty of chow and
a place to put you down. Thank you very much.
[The prepared statement of General Jones follows:]
Prepared Statement of T.S. Jones, MajGen, USMC (Ret.), Founder/
Executive Director, Outdoor Odyssey Youth Development and Leadership
Academy
Dear Chairman Murray and Members of the Senate Committee on
Veterans' Affairs: Good morning. My name is Tom Jones, and I serve as
the Executive Director of Outdoor Odyssey as well as an Adjunct Staff
Member of the Institute for Defense Analyses (IDA). In 1998, I founded
Outdoor Odyssey and have served as its Executive Director in a
voluntary capacity since that time. I am very pleased to have the
opportunity to appear before the Committee this morning on this very
critical subject. Although, unlike other speakers this morning, I have
no certified expertise in mental health, I have been privileged to gain
a great deal of experience in dealing with servicemembers who continue
to struggle with mental health issues and have witnessed countless
examples of success, attributed in no small measure to the power of the
team, cohesion and one-on-one genuine concern. My experiences are the
by-product of my involvement with wounded warriors as an active-duty
officer, reinforced after my retirement through my role as a Board
Member of the Semper Fi Fund and the fact that I founded and oversee
the activities of Outdoor Odyssey. I will briefly outline my
perspectives on the issue at hand in the following sections:
Background; Semper Fi Odyssey; Cadre of Support; Salient Outcome,
Lessons Learned and Opinions.
background
Although I have visited wounded Marines and Sailors weekly since
the initiation of combat action soon after 9/11, and have certainly
gained key perspectives from those same visits, my insights have been
honed in large measure by the approximately thirty (30) weeklong
sessions I have hosted at Outdoor Odyssey designed to assist wounded
warriors make the transition from the military to the civilian sector.
These sessions, now known as Semper Fi Odyssey, represent the
collaborative efforts of two nonprofits, working with the Wounded
Warrior Regiment of the United States Marine Corps.
As mentioned above, I founded Outdoor Odyssey in 1998, geared to
identify and impact at-risk youth; at-risk in this context are those
elementary-age youth identified by educators as those who face
significant challenges to successful achievement in school. The focus
of Outdoor Odyssey identifies strong, potential leaders among high
school juniors and seniors and prepares these youth through a
Leadership Academy to engage, bond with and then provide follow-on care
to at-risk youth from their own community through an aggressive
mentoring program. These high school mentors are themselves mentored by
community leaders, serving as Umbrella Mentors. Leveraging the success
of this program with 38 school districts in western Pennsylvania,
programs have been created over the past 14 years to engage countless
other educational institutions to provide leadership development and
team building opportunities. At the risk of appearing arrogant, I have
been blessed at Outdoor Odyssey, as the success of these programs has
allowed Outdoor Odyssey to expand both facilities and programs to
become a high adventure leadership academy rivaled by few and surpassed
by no other similar organization that I have had the opportunity to
visit. I offer this information, as programs incorporated at Outdoor
Odyssey associated with mentoring, bonding, goal setting, etc.,
represent the by-products of my lengthy Marine Corps experience and set
the stage for development of the Semper Fi Odyssey experience.
Due to my involvement with Outdoor Odyssey, I was able to assist a
wounded Marine Corps' Captain pursue his dream of building a transition
program for wounded warriors who could not remain in the military. I
met this young man during my visits to what was then known as Bethesda
Naval Hospital and discussed his dream with him on numerous follow-on
visits. Due to my experience with starting a 501(c)3 nonprofit, I
helped him create a nonprofit and agreed to host the first session at
Outdoor Odyssey and later assisted him by traveling to other sites in
the United States to hold follow-on sessions. The original concept was
to have quarterly sessions in different regions of the country; follow-
on sessions were held in Vail, Colorado; Tampa, Florida and New York
City. While the plan was conceptually sound, it precluded development
of continuity of effort and the creation of a cadre of volunteer
support; moreover, it soon became apparent that the costs associated
with such a concept were staggering and, therefore, prohibitive to
success. Due to the potential that I saw in the program and the obvious
and compelling need of the wounded warriors, I went to my fellow board
members of the Semper Fi Fund to assist with certain of the financial
requirements. In an effort to significantly reduce financial demands, I
offered to host the next four sessions at Outdoor Odyssey. The initial
weeklong program, then known as COMPASS, gained immediate traction with
those who oversaw the Wounded Warrior Regiment and visiting mental
health professionals. I was able to recruit significant help from
associates within the Washington, DC, and Pittsburgh regions, and the
weeklong programs evolved from one solely oriented on transition from
the military into one providing the participant bona fide skill sets in
all aspects of his/her life. Most important, the sessions became a
vehicle to identify and deal with a growing number who were struggling
with mental health issues. A noted Psychiatrist, Dr. William Nash,
along other mental health professionals, visited the sessions regularly
and requested my support in sharing the power of these sessions with
others at major mental health gatherings; the aforesaid led to my
involvement in a major project sponsored by OSD (P&R) and connected to
the Institute for Defense Analyses (IDA).
Unfortunately, the nonprofit inspired by the young Marine Corps
Captain did not survive for a variety of his (Captain) professional and
personal reasons. Key lessons acquired during the weeklong sessions,
however, provided ample evidence of significant success, and the Semper
Fi Fund and Outdoor Odyssey collaborated to form Semper Fi Odyssey,
with approximately thirty (30) sessions now having been held. To remove
even a hint of any conflict of interest, I stepped down from the Board
of Directors of the Semper Fi Fund and am now on the Board of Advisors
of the Fund and maintain an Emeritus Status on the Board of Directors.
semper fi odyssey
As mentioned above, Outdoor Odyssey and the Semper Fi Fund, have
collaborated to develop Semper Fi Odyssey, working in conjunction with
the Wounded Warrior Regiment for the identification of the majority of
the participants. The vast majority of the participants are combat
wounded, with a few struggling with illnesses such as cancer or
undergoing recovery from injuries sustained in activities other than
combat. With the exception of staff members of the Wounded Warrior
Regiment who routinely participate, all of the participants will soon
be medically discharged from the Marine Corps. Additionally, a growing
number of veterans have been identified for involvement by case workers
of the Semper Fi Fund; this cohort is exclusively comprised of those
struggling to overcome mental health issues. Most of this later group
have been clinically diagnosed with PTSD and/or TBI, and almost ALL
diagnosed with PTSD are currently under a clinician's care. Moreover,
and of significance, many of the participants who have been diagnosed
with PTSD have not shared with the clinician the source of the stressor
that ultimately led to the PTSD. For a variety of reasons, many
struggling with PTSD have a very difficult time of developing a
covenant of trust with the mental health provider.
Albeit it's virtually impossible to briefly describe Semper Fi
Odyssey, suffice it to say that the weeklong session is a holistic
approach to engage the Marine and through a covenant of trust help him/
her build a realistic plan for the future. Rest assured, my use of
holistic approach does NOT connote esoteric pabulum laced with lofty
phrases but one-on-one, eye-ball level leadership, inspiring the
participant to come to grips with the mental, emotional, physical and
spiritual aspects of his/her life. Participants form teams and are led
by very successful, volunteer veterans who are assisted by active-duty
officers and senior noncommissioned officers who themselves have fought
alongside the participants in Iraq and/or Afghanistan. The imperative
to include the active-duty component became patently obvious as the
evidence of operational stress grew in significance. All of the
veterans who serve as Team Leaders have made a successful transition
into the civilian sector, with the majority of this cohort having
entered the business world; moreover, a sizable percentage of these
veterans have experienced combat.
While the syllabus of Semper Fi Odyssey ranks as taxing and quite
challenging, the underlying objective is the development of both
professional and personal goals, supported by definitive,
understandable and usable tools to reach these goals. Participants are
LED to examine themselves VERY closely and are invariably inspired to
share innermost thoughts and ``demons.'' In general, participants
arrive skeptical and somewhat tentative; however, the genuine concern
of the Team Leader invariably ``breaks the ice,'' leading to team
cohesion and trust among team members.
While the course includes the obvious pieces of any typical
transition course, the focus of effort is to provide the participant
the ability to know and talk about himself/herself, without falling
victim to the commonly-known habit of building a resume that doesn't
reflect in ANY manner the individual described. Without question, by
the final day of the Semper Fi Odyssey session, the participant has
grown immeasurably in his/her ability to understand and share insights
about his/her strengths, while being armed with the ability and
assistance to tackle weaknesses and challenges. More important, the
participant leaves the experience with the skills to build and follow a
plan to succeed, reinforced by the knowledge that he/she now has a
cadre of supporters (read network) for the future.
I simply couldn't adequately outline all of the elements of the
week's experience but will now offer but one vignette from our most
recent weeklong event which concluded this past Saturday, the 21st of
April 2012. We reinforce the classroom work and Team Leader time with
physical activities to the degree possible, based on the physical
challenges of the participants. As noted above, Outdoor Odyssey offers
a wide variety of high adventure activities and facilities that enable
sessions in activities such as yoga and physical fitness, using
equipment usable to those with physical challenges. The participants
thrive on events such as the zip line, high ropes course and climbing,
obviously tempered by physical limitations. This past week, two
Marines, having but one leg between them, executed the long staircase
of our indoor facility, with the Marine with an artificial leg carrying
the Marine with NO legs up to the high ropes course on his back. These
two Marines then negotiated a VERY tough and rigorous ropes course in
tandem; there was not ONE dry eye in the building. A Senior Staff Non-
commissioned Officer, deathly afraid of heights and heretofore
declining to undertake the high ropes course, was SO inspired by the
experience that he scaled the stairs and negotiated the course. Without
exaggeration or any sort of hyperbole, the Marine without legs felt
ten-feet tall and bullet proof upon completion of the experience.
Everyone (and I mean everyone) saw a stark example of the power of the
mind--regardless of the body. This particular event will impact not
only those involved last week but many others as well in the days
ahead, as it was chronicled by camera in the form of pictures and film.
The final, collective event of the week is the visit to the crash
site of Flight 93 that came down in a western Pennsylvania farm field,
roughly a 20-minute drive from Outdoor Odyssey. Without question, the
emotional release ranks as palpable; Marines, most for the first time,
are able to come face-to-face with the reality of 9/11. As the VAST
majority of these young folks joined the military in large part due to
the events of that fateful day, the experience reinforces key messages
shared relative to survivor's guilt and other stressors associated with
the trauma of combat.
cadre of supporters
It would be virtually impossible to accurately chronicle all of the
volunteer support that goes into the weeklong Semper Fi Odyssey
session. However, it is critical to note that the word volunteer ranks
as KEY to any and all success of the sessions held thus far at Outdoor
Odyssey. Folks routinely arrive skeptical of the worth of the
experience, as many, if not MOST, have listened to many folks offer
assistance that has eventually fallen short of advertised pedigree.
Without question, though, the power of the week rests on the two most
important words in leadership: genuine concern. The one-on-one sessions
and interpersonal dynamics with those who freely give of themselves and
their time set the experience aside from all others the participant has
encountered. Moreover, and critical from my perspective, the nature of
the volunteer, able to convey genuine concern, truly sets the stage for
the covenant of trust that is developed; this can NOT be
overemphasized!! To provide an illustration of the utility of the
volunteer, I will use the most recent Semper Fi Odyssey as an example;
this event was conducted last week, concluding this past Saturday, the
21st of April. While not all-inclusive, I'll show certain positions
that played integral roles in the weeklong session, coupled with
examples of the various backgrounds of those filling the respective
roles:
Team Leader: clearly the key to the success of Semper Fi Odyssey;
most Team Leaders (TLs) volunteer for the entire week, with a small
percentage sharing the responsibility, changing at midweek; eleven
teams were used during the recent session, with TLs coming from such
locations as Oregon, Wyoming, New York, Virginia and, of course,
Pennsylvania. The TLs from Oregon, Wyoming and New York were all
Vietnam veterans; the gent from Oregon was an infantry officer in the
USMC, followed by a stint as a F-4 pilot in the Corps; he is now CEO of
his own company; he has traveled to Outdoor Odyssey six times to serve
as a Team Leader; his brother was a company commander killed in Viet
Nam in an epic battle experienced by one of our local Team Leaders from
Pittsburgh who has now served in that capacity for 20 weeklong
sessions. The gent from Wyoming is an Orthopedic Surgeon, who served in
Vietnam as a Battalion Surgeon of the same battalion as the brother of
the gent from Oregon and the aforementioned TL from Pittsburgh. Several
of the Team Leaders hail from Pennsylvania--all former Marine Officers
and/or Senior Non-commissioned Officers and serving in leadership
positions in various businesses. Additionally, two retired Colonels
from the DC area served as TLs during this recent session: both retired
Colonels and CEOs of their own companies (one from the Air Force and
one female retired from the Army--both having served multiple times as
TLs). During this recent session, we were blessed with the support of
several active-duty Marines to serve as TL or Assistant TL: two Majors,
two Captains and two Gunnery Sergeants--all with multiple combat
deployments to Iraq and Afghanistan. Previous sessions have seen TLs
from Texas (Professor at Texas A&M and former Marine), Alabama (former
enlisted squad leader in Viet Nam and successful businessman) and
Florida (former Navy SEAL and financial advisor). Team Leaders coming
from the Washington D.C. area are simply too numerous to list, with the
vast majority being retired Colonels, LtCols and Senior Non-
commissioned Officers--most with combat experience.
Mental Health Professional: During this session, we were supported
by a psychiatrist (retired Navy Captain) who had served as the 1st
Marine Division Psychiatrist in Iraq and, upon his retirement, played a
key role in the development of the Marine Corps' program of record for
dealing with mental health injuries known as OSCAR (Operational Stress
Control and Readiness). We vigorously follow the tenets of OSCAR,
working hard to identify those struggling to overcome stress injuries,
while working to support the mental health professional for those
clinically diagnosed to be struggling with illnesses. This particular
psychiatrist has been with us many times and strongly endorses our
work, while providing significant reinforcement to the Team Leader.
During this recent session, we were also supported by a psychologist
from a prominent university, located in Pittsburgh; this gent had
learned of Semper Fi Odyssey from a fellow mental health professional
and actively sought the opportunity to partake and assist. I am
confident that we will benefit from his services for many sessions in
the days ahead.
Representatives from the University of Pittsburgh and Penn State:
One of the most popular, and I would state most successful,
presentations of the week has routinely been one oriented on dealing
with stress management. Clearly, the sessions at Semper Fi Odyssey have
identified that day-to-day stressors significantly exacerbate the
incidence of operational stress or post-traumatic stress that many, if
not most, servicemembers face after a combat deployment. We have been
blessed for approximately twenty (20) sessions with a representative
from the University of Pittsburgh who provides a striking and most
stimulating presentation that includes tools that can be immediately
implemented to address stress levels and improve sleep habits. Many
participants have offered compelling testimony relative to the power of
this two-hour block of instruction. Additionally, during this most
recent weeklong session, we had seven representatives from Penn State
and the University of Pittsburgh form a panel to address any and all
questions posed by the participants, focusing on post-secondary
education, veteran benefits, Vocational Rehab and any area related to
education and training sought and/or required following departure from
the military. This group consisted of college professors, specialists
in veterans programs and benefits, department heads and overseers of
various programs associated with the matriculation to higher learning.
As many of the participants face some level of physical challenge upon
departure from the military, this session has proved to be MOST
beneficial, providing insights into learning aids available to the
veteran. The session takes approximately two hours, with panel members
but rarely unable to answer the specific questions proffered by the
participants; however, for those queries that stymy the group, an
answer is invariably provided by one of the representatives later in
the week.
Yoga Instruction: Semper Fi Odyssey has been supported by the
nonprofit Exalted Warrior for approximately the last twenty (20)
sessions. The key instructor hails from Tampa, Florida, and routinely
spends the entire week at Outdoor Odyssey. Sessions are incorporated
into the daily routine during at least four days of the weeklong
schedule, with voluntary sessions held each evening after completion of
scheduled events. This recent session was supported by two instructors,
one of whom a Navy Admiral (retired career SEAL) who was instrumental
in the founding of the Exalted Warrior nonprofit organization.
Instruction is modulated according to the physical capabilities of the
participants, and MANY extol the virtues of these sessions to assist in
relaxation and meditation, while helping to address problems with
sleep.
Fitness Instruction: For the last three plus years, we have been
supported by the Fitness Anywhere Corporation via the involvement of a
former Navy SEAL who is an exercise physiologist, chiropractor and bona
fide fitness expert of the first order. Instruction orients on the use
of a device known as the TRX, and, simply put, it can be used by
virtually anyone regardless of physical challenge. The addition of
several periods of this instruction into the weeklong syllabus has been
HUGELY popular, with every session having one or more participant
opining that use of the TRX was the first time the participant felt
like a warrior since being wounded. The Fitness Anywhere Corporation,
founded by a retired Navy SEAL, offers a TRX free to every participant,
based on the recommendation of those overseeing the Semper Fi Odyssey.
Professional Assessment: A company owned by the father of a
wounded Marine Captain offers his company's service during each session
of Semper Fi Odyssey to conduct a computerized assessment of each
participant in the manner of the Meyers Briggs personality assessment.
The evaluation provides the participant insight into his/her personal
makeup, principally focused on elements of the individual's
personality, strengths and orientation relative to occupational fields.
Fortunately, during this recent session, the Marine Corps' Captain, an
above-the-knee amputee from combat in Iraq and a recent returnee from
Afghanistan where he served as a company commander, represented his
father for the presentation of the assessment results.
Numerous Instructors: Quite a variety of other professionals, too
numerous to list, visit Semper Fi Odyssey during the weeklong session
to provide various periods of instruction. Many of these individuals
are former military; however, we work hard to recruit, train and
incorporate talent without military experience, as it serves to better
educate the populace of the staggering sacrifices borne by today's
servicemember. Moreover, involvement by those without military
experience provides the participant the opportunity to learn more from
those he/she will likely encounter after departure from the military.
Many of the instructors utilized for the weeklong sessions, be they
former military or not, have been responsible for the creation of
actual job opportunities for a number of the participants. An example
of the periods of instruction provided by these instructors are as
follows: goal setting; operational planning skills; resume building;
interview skills and techniques; opportunities in the Federal
Government; business 101 perspectives; STAR techniques for articulating
accomplishments, etc. Of additional note, EVERY weeklong session has
included presentations oriented on bona fide job opportunities; several
sessions have had participants linked to his/her future employer.
Interviewers: Our most seasoned Team Leader, a former Marine Corps
Infantry Officer with considerable combat experience, hails from
Pittsburgh. This gent trains the new Team Leaders and plays an integral
role in virtually anything and everything that goes on at Semper Fi
Odyssey. He owned his own computer company for over three decades in
Pittsburgh and knows virtually everyone in the city. He has built an
inventory of over seventy potential interviewers, and personally
coordinates the involvement for approximately 15-20 interviewers for
the final day of instruction for each session of Semper Fi Odyssey.
Each interviewer ranks as a leader in his/her field, and the variety of
fields represented covers virtually any occupation one could pursue.
The interview session provides each participant the opportunity to
undergo at least three or more mock interviewers by folks they have
never met, instilling a level of stress and offering an opportunity to
evaluate the participant's ability to talk about his/her skills,
experiences and passion to serve. A number of the interviewers are
military veterans; many, if not most, routinely hold interviews for
actual positions within their respective organizations. Without
question, those interviewers recruited for this experience are
passionate about the unique opportunity that they themselves have in
helping the participant transition into the civilian sector. It is NOT
uncommon for an interviewer to become a mentor for one of the
participants he/she has had the privilege of interviewing. This
particular session ranks as one of the most, if not the most, popular
of the week, greatly instilling confidence in virtually every
participant. The following is a snapshot of the interviewers from the
most recent session: former Vietnam Army Officer and former CEO of
largest Electrical Construction Company in US; President of
manufacturing firm; Human Resource Manager of major bank; Senior
Franklin Covey Facilitator; West Point Grad and Vietnam Infantry
Officer and President and CEO of major construction company; President
of Performance Consulting; President of company that provides host of
services to small businesses; Director of Systems Engineering of KEYW
Corporation; lawyer and owner of Law Office; former Marine Sergeant in
Vietnam and owner of nine restaurants in Pittsburgh; President and CEO
of prominent technology company in Pittsburgh; Superintendent of one of
Pittsburgh's School Districts; former Marine enlisted infantryman in
Vietnam and high level labor negotiator; Director of three assisted
living homes; former infantry Sergeant with experience in Iraq who owns
a major construction company; former Army Engineer with service in
Vietnam who is now a TV and radio talk show host in Pittsburgh;
Orthopedic Surgeon in Pittsburgh who served as a battalion surgeon
supporting Marines in Vietnam; Assistant VP of Federal Reserve Bank in
Cleveland; Manager of Recruitment at the University of Pittsburgh
Medical Center.
Salient Outcomes, Lessons Learned, and Opinions: As I pen this
written testimony, we have now been privileged to engage approximately
30-35 participants for 30 weeklong sessions. Without any exaggeration,
trust, cohesion and team building represent the major by-products of
the Semper Fi Odyssey experience, helping the participant share, learn
and grow during the week while setting the stage for future success.
Participants build relationships that are lasting and depart with the
assurance that they are armed with connecting files to people who will
indeed follow up with them in the days ahead. Obviously, those who
choose to break contact can; however, those who elect to remain
connected and gain follow-on support have a vehicle to do so.
FORTUNATELY, the vast majority of past participants remain connected. I
offer the following insights from the Semper Fi Odyssey experiences:
Salient Outcomes:
Conduct self assessment and built definitive plan for improvement
Gain bona fide skills in application of life-planning tools
Identify and connect to people in their lives that they can count
on and trust
Build a honest network of support among fellow participants and
volunteer support
Make commitments that lead to accountability and likelihood of
noble pursuits
Experience trust and cohesion, inspiring participants to share
``demons''
Made significant breakthroughs relative to mental health issues
that pave the way to improve follow-on care
Develop SMART (specific; measurable; attainable; realistic; time
bound) Goals
Hone interview skills and STAR techniques that reinforce a TRUE
resume
Build a tentative network of support in the eventual geographical
location of residence
Enjoy being treated as a warrior and inspired by useful, workable
skills
Learn that others with similar experiences have grown and
prospered greatly
Lessons Learned:
Vast majority of wounded warriors require some level of assistance
in preparation for transition
A growing % of wounded warriors struggle with operational stress
issues, and a growing number are being diagnosed with PTSD and/or TBI
Trust, team building and cohesion pay REMARKABLE dividends in
preparing Marines for eventual departure
Many, many programs, based on sound concepts and procedures,
simply DO NOT connect to the individual warrior, lacking one-on-one,
eye-ball level leadership and understanding
Many diagnosed and under a clinician's care do NOT disclose
stressor at root of the problem
Team building and cohesion led to significant number of
breakthroughs among those diagnosed with PTSD but heretofore unable to
disclose nature of stressor
Experiences at Semper Fi Odyssey paid huge dividends in project
sponsored by OSD designed to identify best practices; OSCAR is truly a
winner if presented correctly
Individuals who care and possess genuine concern for the wounded
warrior are essential
Key personnel within OSD are working to provide a grant that would
enable support to be provided to members of any branch of the service
Opinions:
Any cohort of combat veterans who have served in Iraq and/or
Afghanistan would provide indications of stress levels roughly
equivalent to those observed in wounded Marines
A very large percentage of mental health professionals DO NOT
remotely connect to combat vets and are presently unable to establish
the necessary covenant of trust
Semper Fi Odyssey could easily serve as a prototype for programs
within the active-duty services
Many, many veterans will be identified to be struggling with
combat stress issues in the near future--and for many, many months to
follow
There exist too many disparate programs that DO NOT connect to the
individual servicemember
The Semper Fi Odyssey model stands to greatly assist mental health
professionals engage veterans with mental health issues
We need to build a mechanism of support that would permit the
inclusion of members from any branch of the service
Very Warm Regards and Semper Fi.
Chairman Murray. Thank you very much.
Mr. Schoenhard, first let me say that I am very happy to
hear that the VA is finally acknowledging there is a problem.
When the Department is saying there is near perfect compliance,
but every other indication is that there are major problems, I
think it is an incredible failure of leadership that no one was
looking into this. In fact, when you sit at that table before
this Committee, we expect you to take seriously the issues that
are raised here. It should not take multiple hearings, and
surveys, and letters, and ultimately an IG investigation to get
you to act.
I also would like to suggest that if the reality on the
ground could be so far off from what Central Office thought was
happening as it relates to mental health, then you better take
a very hard look at some of the other areas of care for similar
disconnects.
Now, what we have heard from the IG is very, very
troubling. For months now, we have been questioning whether
Central Office had a full understanding of the situation out in
the field, and I believe the IG report has very clearly shown
you do not. So I want to start by asking you today, after
hearing from this Committee, from veterans, from providers, and
from outside experts, why you were not proactive about this
problem months ago?
Mr. Schoenhard. Chairman Murray, we have been looking at
mental health for many years. As you know, with the support of
the Congress, we increased our capacity and hired about 8,000
new providers between 2007 and 2011. We relied primarily on a
uniform mental health handbook that would be the source of the
way in which we would deliver care to our Nation's veterans.
That has been the focus of the Department, to ensure that we
are getting evidence based therapies and a staffing model that
was largely based on the handbook put out in 2009.
I think what we have learned in this journey, and we have
been wanting to work very closely with our providers, is a
number of things. As I mentioned in my opening statement, the
way in which we measure these performance measures is not a
good measure of wait time. We want to work very closely with
the IG and with any other resources that are available to
assist us in ensuring that we provide Vet Centered performance
measures going forward.
Chairman Murray. Mr. Schoenhard, with all due respect, I
think back in 2005, the IG said this information was there. So
that is a long time with a lot of veterans in between. So my
question is, how are you going to address that growing gap that
we have seen, what Central Office believes, and what is
actually happening in the field?
Mr. Schoenhard. As Dr. Daigh described in our response to
the IG report, we have a number of things going on. One is
first we have a working group that will report this summer on a
new set of performance measures that includes providers on the
ground assisting us with ensuring that we have developed
measures in conjunction with support from the IG that are
really Vet Centered, that are centered on the veterans'
individual condition, and one in which we can revamp and go
forward.
We fully embrace that our performance measurement system
needs to be revised, and we will be doing that with the work of
people on the front lines to assist us. We have the benefit of
these mental health site visits that are assisting us. We are
learning as we go on other issues having to do with scheduling.
And all of this effort is assisting us in not just having
people at Central Office develop proposed solutions, but to
engage the field in a way that we need to in order to ensure we
are Vet Centered and we are able to support our providers in
delivering this care.
Chairman Murray. I appreciate that, but it is very
troubling to me that this did not happen five, 10 years ago;
that we are just now--after months of this, years of this, that
that disconnect is there. But we will go back to that, because
I want to ask Mr. Tolentino--and I really appreciate your
willingness to come forward today. And I believe your testimony
is going to be very helpful to addressing many of the changes
that are needed in a timely fashion.
In your testimony, you suggested that VA institute more
extensive oversight into how mental health care is actually
delivered and funds are spent. Given how adept many of the
facility administrators are getting around the current system
without being caught, how do you think the VA can most
effectively perform that oversight?
Mr. Tolentino. Madam Chairman, to be perfectly honest, I do
not have a very good answer for you because of the fact that
the gaming is so prevalent. As soon as something in put out, it
is torn apart to look to see what the work around is.
I feel that the reporting that is done is--it is very
redundant reporting that feels like it goes nowhere. There is
no feedback loop. One way we are telling you exactly what you
in most times want to hear that we did at the facilities and
even at the network, but there is no coming back and
rechecking, or coming back and feedback to say, well, you said
you spent this money on these services, but there is no
workload to verify it. There is nothing concrete to be able to
speak to what you say you have done.
In the short time that I worked there, many times we got
vast amounts of financial monies for different programs, but
very, very seldom did we ever get requests to verify what we
have done with workload, with any kind of feedback reports, or
anything like that. So I think opening the lines of
communication and a very transparent feedback loop at that.
Chairman Murray. Mr. Schoenhard, my time is out. I want to
turn it over to Senator Brown, but I do want to address a very
important issue here.
The Department has announced 1,600 new mental health care
providers, and I appreciate that step. I think it is really
needed. But I am concerned that VA hospitals all across the
country are going to run into the same hurdles that Spokane VA
has been in not being able to hire health staff. And I hope
that medical centers are doing everything, including using all
available hiring incentives to fill those vacancies. By the
way, I assure you that is the next question this Committee is
going to look at.
But I want to ask you specifically how are you going to
make sure that 1,600 new mental health care providers that you
announced do not remain 1,600 new vacancies?
Mr. Schoenhard. Chairman Murray, that is a very important
question. And we have stood up in our human resources group in
VHA workforce two task forces to assist us with this. One is
the recruitment and retention of mental health providers with a
particular focus on psychiatry. That is where our greatest need
and problem is in retaining and recruiting mental health
providers.
The second task force is a hiring task force; that is, what
can we be doing to expedite and make sure that we are having
the process of recruitment as speedy as possible. The group has
put together a number of good recommendations that we will be
implementing.
Part of what Dr. Daigh spoke of earlier in terms of our
four part mission, one of the great assets, having been in the
private sector for many years before coming to VA, is that many
mental health providers, including hundreds of trainees,
currently today get part of their training in VA and have the
opportunity to experience this going forward. We need to better
link with these trainees and ensure that we have a warm hand
off for employment when they finish this.
Chairman Murray. OK. That is one issue. But then how you
arrived at your staffing plan is really unclear to me.
Mr. Schoenhard. Oh, I am sorry.
Chairman Murray. The new 1,600 mental health providers that
you allocated and the information that we got from the
Department yesterday on where that was going to go is not
supported by any concrete facts or evidence. In fact, yesterday
the VISN 20 director told Senator Begich and me that she
learned about the new positions only a couple days ago, did not
know if it was sufficient, and did not know how the Department
even reached those numbers.
So I want to ask you, how did you arrive at that number of
1,600, and what makes you confident that it is going to be
effectively placed across the country? What is the plan,
staffing plan you used to do that?
Mr. Schoenhard. Thank you. I am sorry. I misunderstood the
question. I am going to ask Dr. Schohn if she may want to speak
on this. But we used a model that looks at the volume of
services. We are piloting this in three VISNs, and I would be
happy to answer further.
Ms. Schohn. Thank you. Yes. As part of our response to the
Committee in November, we plan to develop a staffing model. The
staffing model----
Chairman Murray. I am sorry. You plan to develop a staffing
plan that is not yet in place?
Ms. Schohn. No, no. We did develop a staffing model, but we
submitted to you that that was part of our action plan in
November. We developed a staffing model, and we are in the
process of implementing it in VISNs 1, 4 and 22, to understand
how to implement it. So we do not want to just simply say here
is the number of staff without actually a plan for how this
rolls out, issues the right number of staff, to really evaluate
how well and how effective this methodology is.
Our plan, however, also is not to wait until we get a full
evaluation of this plan, but basically to staff up so that we
will be fully ready to implement this plan throughout the
country by the end of the fiscal year. So we will have--we are
planning--the plan itself is based on identification of
existing staff at facilities, the veteran population, the range
of services offered, and the demand for services. And our plan
is to be able to use this to project the need so that we will
have a standard model in the future that is empirically
validated, that we all know how many staff we need.
Chairman Murray. My time is up. I do want to come back to
this because it is critically important. But I will let Senator
Brown and Senator Tester first speak.
Senator Brown. Thank you.
So, Mr. Secretary, you announced last week that the VA will
hire 1,900 additional mental health staff, 1,600 mental health
providers and then 300 support staff. Yet in response to a
question for the record submitted by Senator Burr, a poll of
your facilities in December 2011 revealed that there were 1,500
open mental health positions.
So I guess my question is, are these 1,900 positions
announced last week by the VA in addition to those already
identified to Senator Burr as open?
Mr. Schoenhard. Senator, the 1,900 additional positions are
based on what we believe are the needed complement----
Senator Brown. I know. But is it in addition to the 1,500?
Mr. Schoenhard. It is in addition--these are additional
positions, in addition to those that we are searching to
recruit for, that are currently open.
Senator Brown. So is it 3,400 positions you are going to be
filling?
Mr. Schoenhard. No, sir. These are additional positions on
top of what we are currently recruiting in terms----
Senator Brown. You said in 2011, there are 1,500 open
positions. And now you are saying you have 1,900----
Mr. Schoenhard. Fifteen hundred vacancies. And Dr. Schohn,
you may want to comment to this. But I think it is important
for this----
Senator Brown. Who is in charge? Is it you or her, or what?
Mr. Schoenhard. Well, for the Committee, let me just
clarify. These are not related to the number of vacancies.
These are related to the number of positions that are needed in
our facilities. And so we will be adding 1,900 positions, 1,600
in clerical and provider support, in addition to those that we
are currently recruiting for.
Senator Brown. All right. So how long do you think it will
take to fill these positions?
Mr. Schoenhard. Well, it depends on the level of provider
that we are searching for. But----
Senator Brown. Give me an idea. Is it a week? Is it a
month, a year?
Mr. Schoenhard. It can take four or 5 months, sir.
Senator Brown. Four or 5 months. OK. And how do you
determine the number of additional staff and which type of
clinicians are actually needed? How do you make that
determination?
Mr. Schoenhard. We are allocating the FTEE to the VISN for
its distribution to the facilities. We will be working with the
facilities in the VISNs. Part of what we have not described
here that is in place now is a robust system by which Dr.
Schohn is working with the mental health leads in the VISNs.
And with a new management information system that we have in
place, we have greater visibility to VISN management of this
open and going forward.
Senator Brown. So this is four to 5 months, then, still,
that we are talking about?
Mr. Schoenhard. Sir, we are planning by mid May to have
identified where the specific positions go.
Senator Brown. But in the interim----
Mr. Schoenhard. But we want to do that in conjunction with
the VISN leadership.
Senator Brown. Thank you. But in the interim, you have
soldiers that are killing themselves and people who are hurting
and need services. I know that the Uniform Mental Health
Services Handbook also says that you can actually--on a fee
basis, you can actually refer out people who need help.
Mr. Schoenhard. Yes.
Senator Brown. So I am curious as to--you read about these
things. And if there is such an overload and there is such a
breakdown, why is only 2 percent per year of the total unique
patient population in mental health sent out for non-VA care.
Why is it only 2 percent, yet the handbook says that you should
and could do it?
Mr. Schoenhard. Yes. We do that where we can. Often where
we have shortages, the community has shortages.
Senator Brown. Well, it seems like there are--I mean, based
on what we have heard and the testimony we have been receiving,
there is clearly a shortage. So in the interim, before you work
and upload these 1,900 people, why don't you get these people
out the door and get them care and coverage right away?
Mr. Schoenhard. Sir, first let me clarify, for those who
need urgent care, we are emphatic that we ensure that those who
are at risk are well treated. And it is referred to as suicide
prevention coordinator for immediate treatment.
Senator Brown. Well, Jack Manning needed care and coverage,
and he did not get it. And he killed himself. I mean, there are
others like that. So what is the definition of critical care
and immediate care? I mean, to me it means immediate, like the
guy calls; he gets help right then and there.
Mr. Schoenhard. Absolutely. Anyone who presents with any at
risk factors should be seen and treated right away----
Senator Brown. But they are not.
Mr. Schoenhard [continuing]. Within the 24-hour triage.
Senator Brown. But they are not.
Mr. Schoenhard. They should be.
Senator Brown. But they are not.
Mr. Schoenhard. Well----
Senator Brown. Is that right? They are not.
Mr. Schoenhard [continuing]. We have an obligation to
ensure that they are.
Senator Brown. But they are not. Correct? So if they are
not--I mean, I know the answer. So you can certainly just say
that, yes, they are not. We have had some people slip through
the cracks. If that is the case, then, we need to actually
outsource and use these resources that we have, these other
folks that are out there, who want to try to help.
We should be doing that. Do you agree or disagree?
Mr. Schoenhard. Sir----
Senator Brown. Sir, do you agree or disagree?
Mr. Schoenhard. I think we should take them on in our
system because we can best serve their urgent needs by----
Senator Brown. Sir, with all due respect, that is not
happening. OK? That is why we are here. That is why the IG
report said that there is a breakdown with you meeting
performance standards and actually not handling the individual
needs of the individual soldiers who are killing themselves. So
it is clearly not working.
So my question is, do you think we should be sending out
more people or not--yes or no--to the fee based--outside the VA
system?
Mr. Schoenhard. We should sent out where we do not have the
capacity, but we should--for those who are most at risk that
need urgent care, we should ensure that they receive treatment
within the VA.
Senator Brown. But you are not. Correct?
Mr. Schoenhard. Well----
Senator Brown. I am not saying every time, but there are
instances where there has been a problem.
Is that a fair statement?
Mr. Schoenhard. And where we do that, we need to ensure
that we have----
Senator Brown. Sir, listen. It is pretty simple. Are there
instances in which we, the VA, collectively, everybody here, we
have let somebody fall through the cracks.
Yes or no?
Mr. Schoenhard. There are instances where veterans----
Senator Brown. OK. All right. We are not perfect. So in
those instances, though, should we then be making sure that we
do not do that again. And if there is a problem, that we refer
them to the appropriate open agencies that can help right away.
Is that a fair statement?
Mr. Schoenhard. Yes, but----
Senator Brown. We are only doing 2 percent. Only 2 percent
of those folks actually are referred out. And it is clear that
there may be some sectors, some VA sectors, where there is a
problem. Not everybody. And these are not for the people who
are out there working their tails off each and every day. I get
it. They are overloaded. They are overworked. If that is the
case, let us refer them out and get them care and coverage.
Mr. Schoenhard. Dr. Schohn or Dr. Zeiss may want to
comment.
Senator Brown. I will. I will get to them.
I just want to say, Nick, if you could just comment on the
testimony you have heard, and comment on the fact that, based
on your experiences in Manchester, do you see--or what do you
think of the testimony from the Secretary, first of all? Number
1.
Number 2, am I missing something? Is there an appropriate
way to refer people out like that? And is it being done? And if
it is not, why not, and should it be done?
Mr. Tolentino. Senator, listening to the testimony so far,
there are a couple of things I would like to comment on. One is
the hiring practices, saying it is hard to recruit and fill
these positions.
There are barriers that are on the front lines that are not
being heard at this level up here, such as when these special
purpose funds come in, they are for X number of years--1 or 2
years, whatever it may be. And a lot of facilities, many
facilities--not just Manchester--those positions were then
being listed as not to exceed 2 years, or not to exceed 1 year,
to be able to go along with the special funding, so that they
did not have to worry about their budget in the future, and
instead gave them the option to opt out.
So if I am a psychiatrist or a mental health clinician,
why, especially in this economy, am I going to leave a full
time position to go to work for the VA if it is not even
guaranteed that I am going to be there in 2 years, or that
position is going to be there in 2 years? That is the reality.
That is just one of many examples that the front lines are
encountering in trying to get people in there.
Second, when you are talking about the fee service, it
felt, where I was at--let me qualify that. It felt where I was
at that the fee service was saying that our system was not
adequate. So we are not going to send people out if we cannot
deliver this care that we are so very proud of, that we offer.
And when they were fee'd out, the problem that--in the Uniform
Mental Health Handbook, it says that the VA is then responsible
for ensuring the care management of those people out in the
community. And that was not even evident either, because we did
not have even the personnel to do that.
Senator Brown. Thanks for your answer.
I also want to----
[Pause.]
Senator Brown. I will stay all day, Madam Chair. I mean,
this is an important issue.
I want to talk about the bonus program, to the fact that
you have people who are getting salary, and then they are
getting bonuses on performance. I would like to talk about that
in the next round of questioning because I think it is
important to note that if somebody is getting a salary to do
their job, and they are just hitting numbers to get a bonus, I
find that a little bit surprising. So I would like to talk
about that, and I will refer to the next round.
Chairman Murray. OK. Absolutely. And we will have as many
rounds as we need, I assure you.
Senator Tester.
STATEMENT OF HON. JON TESTER,
U.S. SENATOR FROM MONTANA
Senator Tester. Thank you, Madam Chair, and thank you for
holding this hearing. I want to thank everybody who has
testified today.
Just from a rural perspective, I will tell you that one of
the reasons the VA cannot contract out in a rural State like
Montana is because the private sector does not have any more
mental health professionals than the VA has. And I just want to
point that out because mental health professionals, whether it
is in the private sector or in the VA, getting this to these
folks is a big problem.
I very much appreciate Mr. Tolentino's--about nobody is
going to go to work for a year or 2 years in the VA when in
fact in the private sector, they have much more predictability
in their jobs. And we need to take that into consideration when
we start allocating dollars for the VA, to make sure that they
have the advantage to be able to compete. I very much
appreciate that perspective.
Along those same lines, I just want to ask--Senator Brown
was right in the area of 1,500 positions opened and an
additional 1,900. So there are about 3,400 positions. They may
not all be psychiatrists, and they may not all be clinicians.
But how you are going to fill those in an area where the
private sector is sucking folks up? Because it is a big issue
there, too. And the VA--it is interesting to me.
Do you have an allocation by a VISN of these 1,600 folks?
Do you?
Mr. Schoenhard. Yes, sir.
Senator Tester. Could we get a list of those? How they are
they going to be allocated?
Mr. Schoenhard. Yes, sir.
Senator Tester. I know you talked about metrics, number of
veterans and that kind of stuff. Could you give me a list of
metrics on why the numbers are there, how many are going to be
psychiatrists, how many are going to be nurses, clinicians?
Are any of them going to be psychologists?
Mr. Schoenhard. Sir, we are leading to the VISN and in
discussion with the facilities, it could be psychologists. It
could be family--it could be a variety of different mental
health providers.
Senator Tester. Thank you. And when it comes to contracting
out, do you guys typically only use psychiatrists, or can you
use psychologists, too?
Mr. Schoenhard. No. We can contract with others.
Senator Tester. Oh, super. That is good, because there are
some accessibility of those folks in a place like Montana.
I want to put two things that Mr. Tolentino said along with
Major General Jones. And, Major General Jones, I want to thank
you for what you are doing. I very much appreciate it.
Mr. Tolentino said when he was there, it was clearly common
if somebody came in with a problem, do not ask if there is
another issue. There are all sorts of correlations here that
are wrong. But I just want to tell you that--OK. So if that is
done--and I believe he is probably right because that then
became a problem. But if you combine that with what Major Jones
said, that the folks that he is working with, the major
stressor is unknown, we have a problem in our system here.
Because the only way you are going to find out how to get to
the real root of the problem when it comes to mental health--
and I am not a mental health professional--is you have got to
find out what that stressor is. You have got to find out what
created that problem.
Does that kind of--well, let me just ask you. If you had a
VA professional in one of the CBOCs or at one of the hospitals
tell their people do not ask any questions because we do not
want to know, I am hoping the hell that does not come from your
end. And why would do they do that?
Mr. Schoenhard. Sir, if that is being done, that is totally
unacceptable. And we will review the situation we had to review
going on in Manchester. And we will continue to follow up any
time that that occurs because----
Senator Tester. I am going to tell you, I think you ought
to do it in every VISN you have. That is just my opinion
because that is totally unacceptable. We are not going to get
our arms around this. You guys have been dealt this hand with
multiple deployments. So the mental health issue is a big
issue. And it is an issue that, quite honestly, if we do not
get our arms around it, there are going to be more and more
people who slip through the cracks, whether we want them to or
not. That is the way it is.
Our use in the private sector is important. Our
partnerships we develop are important. Nobody wants to
dismantle the VA, but when it comes to mental health issues, I
think it is all hands on deck. I just think it is all hands on
deck.
Last, I just--and I have a bunch of questions here. They
were written out. The metrics that are used--and I know the
access to care metrics were the ones that one of you said--and
it might have been you, Dr. Daigh, about those being flawed.
I do not know if this is the same thing or not, but the
report I read means that they were kind of jimmying the numbers
to look like people were getting treatment in a timely manner
when they were not.
Dr. Daigh. I think that the problem is that the schedulers
were not consistently operating by a business rule that said
you should schedule the appointment according to the date that
was desired. And the desired date, what is the desired date?
The desired date the patient wants, the doctor wants?
So in the to and fro of scheduling, I think VA created
metrics which are not supportable in a systematic way. Then you
look at the dataset. It is not usable from my point of view. So
I think that is, in large measure, part of the problem with the
access measures across the system.
We also hear reports of gaming and people trying to game
the system. But I do not have evidence that I can give to you
of gaming, but I certainly can say that from the dataset, we do
not think it accurately reflects access as it is in the VA.
Senator Tester. OK. Well, one last thing, and this will be
the last one. There is a stigma in this country, and probably
in the world, but definitely in America, the United States,
attached to mental health issues, injuries. I have multiple
stories about folks who will not go get treatment because they
are afraid it will be on their record, afraid they will not be
able to get a job, afraid it might impact the job they do have,
perception by family, friends, colleagues.
Does the VA have an active education program to try to
reach out to those folks to let them know that this is part
of--as Major General Jones says, it is increasing, it is
present, and it is growing. And it is not uncommon, and it is
OK.
Is there some kind of educational outreach going on?
Mr. Schoenhard. Yes, Senator. There is Make the Connection
initiative that has just been undertaken. I think it gets back
to the primary care integration of mental health, where we are
able to screen for PTSD.
The other aspect of care that we have not mentioned today
is the Vet Centers, which are also ways in which veterans can
approach for help, for whatever reasons they would be reluctant
to access a traditional system.
Senator Tester. I agree. And before I go--and I want to
thank the Chairman for the length--I just want to say thank you
for all you do. Look, I put myself on the line for the VA every
day because you guys have got a big job to do. But you have got
to make sure that what is going on up here, things that the
chairman says and other people on this Committee, that it
actually gets to the ground, because we are hearing that things
are not going so well in some areas. We are hearing things are
going fine in others. And mental health is a huge challenge,
and it is not easy. And please do make sure that it gets to the
ground.
If there is stuff like Mr. Tolentino said about temporary
dollars, temporary money, hell, I would not take a job like
that if I was in demand. So let's figure out how to fix that,
figure out how to make it work. And let's figure out also--by
the way, because we have Healing Waters in my State that does a
great job, and there are some others. Let's figure out how we
can dovetail onto things like what Major Jones is doing because
that can be an incredible paradox--I mean, you know, whether
you are fishing or riding a horse, or whatever, I do not care.
Those can be incredible programs to get people back on their
feet.
Thank you very much, Madam Chair.
Chairman Murray. Thank you.
Senator Moran?
STATEMENT OF HON. JERRY MORAN,
U.S. SENATOR FROM KANSAS
Senator Moran. Thank you, Chairman, Chairwoman.
Secretary Schoenhard, I was pleased to hear the VA announce
its plan to hire 1,900 mental health workers. And then I was
additionally pleased with the announcement yesterday about the
family therapist and the licensed professional mental health
counselors. My discouragement is how long it took for the VA to
implement.
I have a history with particularly those two professions,
that in 2006, Congress passed the Veterans Benefits Health Care
and Information Technology Act. And part of that act was a
piece of legislation that I introduced to encourage, authorize,
and insist that you hire those two professionals within the VA.
And now five and a half years later, it is occurring.
So while I think I will stay on the positive note, I am
discouraged by how long it took, but I am very pleased at this
point in time to see that you moved in that direction. I
encourage you to hire those people and put them to work as
rapidly as possible.
Part of my interest in this topic is coming from a State as
rural as Kansas, in which our access to mental health
professionals is perhaps even more limited than more urban and
suburban States. And we need to take advantage of the wide
array of professional services that are available at every
opportunity. And so I am here to encourage you, now that you
have made this announcement, let's bring it to fruition. And
thank you for reaching the conclusion and getting us to this
point.
I want to direct my question to General Jones. I thank you
very much for your Semper Fi Odyssey efforts. I had a Kansan
visit with me within the last month who has organized a
program--I do not know that it is modeled after what you are
doing, but the same kind of focus and effort. And it is
somewhat related to the conversation or the questions of
Senator Tester about kind of the stigma or lack of willingness
to admit that one needs help; lack of perhaps knowledge about
what programs are available; how to connect the veteran with
what is there.
I wanted to give you the opportunity to educate me and
perhaps others on what it is that you have been able to do to
bring that veteran, who is not likely to know the existence of
your program or programs like yours. And second, what can be
done to overcome the reluctance of military men and women and
veterans to access what is available, such as your program.
General Jones. Thank you, sir. Well, first off, I think
that the Semper Fi Fund that I have been a board member of
provides the ability for these veterans to come. Admittedly,
most of the veterans that come back to their case workers of
the Semper Fi Fund have some problems, or they would not be
there, and they have had a difficult time making a transition.
So when they arrive in Western Pennsylvania for one of the
week long sessions, they arrive with a major degree of
skepticism and very tentative. And we try to restore them to
the strength of their experience in the Marine Corps, the team,
the cohesion, team building, and basically restoring their
trust. I would say trust in the system and trust in others.
I think that my work through the Semper Fi Odyssey, because
of the mental health professionals that have come in and really
bought in to the program, and have really advertised the
program and allowed me to speak to other groups, led to a
project I am doing with the Institute of Defense Analysis,
sponsored by OSD, that looks at best practices.
So for a long time, we never talked much about mental
health issues until recently. As a Vietnam platoon commander,
we never talked about it. But now there are programs in the
Marine Corps, and I would say the Army, too, Comprehensive
Soldiers Fitness, in the Army. The Marine Corps' program is
Operational Stress Control and Readiness.
It is a great program, but it is not easy to overcome the
stigma. And the program really rests on the strength of the
NCO. No major general is going to ride into a link, or squad,
or platoon, or company, and build immediate trust. It is going
to come from the NCO.
So overcoming that skepticism, overcoming that chasm of
trust is difficult, but it is happening, especially those units
that have deployed four and five times; young NCOs, young
officers, who are seeing the power of what a squad leader or
platoon commander can do to identify problems when they are
still in the category of combat stress injuries and have not
migrated to combat stress illnesses.
I think that is the strength of the Marine Corps' program.
I think the problem with--mind you, this is only my opinion
now--the Army program is that it is very well built. The
application is not focused on the young NCO as is the Marine
Corps' program. I am not saying this because I am a Marine, but
I just sense the NCO identifying in Iraq or Afghanistan if
there is a problem.
You can start the dialog right there. You can start the
reconciliation process right there. You do not have to wait 6
months after he returns and he has got this problem in his
metal wall locker he pulls out then, when he is by himself.
So we try to restore, and very successfully restore,
because all these veterans come in and actually volunteer their
services. This past week, we did 35 Marines. We had an
individual travel all the way from Oregon six times. His
brother was killed in Vietnam as a company commander. He
himself was a Marine Corps officer. He is a CEO of a very
successful business, but he is giving up a week of his time.
We had an orthopedic surgeon come in as a team leader from
Wyoming. Well, it does not take a Phi Beta Kappa very long to
tell that, hey, these people are giving themselves for me, so
that chasm of trust is taken care of pretty quickly. I would
say by Wednesday of a 7-day program, these people start
realizing these people care about me. Then you are on the road
to identification. That is when the demons start coming out.
That is when you find out that a guy, when the company
commander was killed, feels guilty--irrationally but true--and
he has never shared that with a clinician. That is when you
find out a guy has been behind curtains of his own apartment in
Racine, Wisconsin, for 2\1/2\ years, and the only person he has
talked to is his clinician. He has never divulged to his
clinician that he killed a Marine accidentally because their
sectors aligned with each other.
So I think we have no full-proof system, but I think the
power of the Corps and the power of the Army clearly has team,
clearly has cohesion, clearly has trust. And if you can restore
that to what degree you can restore that, then you are on the
road to a good program.
There is no shortage of people that come and chronicle
their experience with a clinician. And they are not damning the
clinician at all, but the clinician simply does not understand
the individual adequately enough to build that bond of trust.
Senator Moran. General, thank you, for your service to our
country and to the veterans. And thank you all for your
interest and well being of our Nation's service men and women.
Thank you, Chairman.
Chairman Murray. Thank you very much.
Dr. Daigh, let me turn to you. As you well know, it is hard
enough to get veterans into the VA system to receive mental
health care. Once a veteran does take a step to reach out for
help, we need to knock down every potential barrier to care.
Clearly, the report your team produced shows a huge gap between
the time that the VA says it takes to get veterans' mental
health care and the reality of how long it actually takes them
to get seen at facilities across our country.
Now, VA has concurred with all of your recommendations, but
I think it is clear we all have some real concerns because some
of these issues have been problems for years. So can you
address a question of what you think it would take to get the
VA to get this right this time?
Dr. Daigh. I think, to begin with, the veteran population
is dispersed across the country, and the VA is not evenly
dispersed across the country. So those veterans that go to
fixed facilities to receive their care, the VA, I am guessing,
probably is trying to address in this current plan for 1,600
people. I have not seen the details of the plan, so I do not
know.
So I think the first issue is to realize that you have a
problem where you have facilities and where you do not have
facilities. And I think the second problem is that, as has been
stated here, there simply are not enough mental health
providers to hire off the street in a timely fashion, I
believe.
I mean, we looked at the other day--I think there is
something like 1,200 psychiatry graduates a year in this
country, from our medical schools. So there is a limited pool,
and there is a great deal of demand for mental health
providers. In our discussions with private sector, they said
that because of the downturn in the economy and other facts,
that the non VA, non military demand had also gone up, in their
experience, 10, 20 percent the last couple of years.
We were asked several years ago to look at access to mental
health care in Montana. And it was a very interesting review
for me, in that Montana VA had linked up with the community
mental health centers in Montana.
I believe that--I may be out of date by a couple years
since we did it a couple of years ago--but there was an
organization of community mental health centers. And by
allowing veterans to go to those mental health centers, which
are usually staffed by psychologists and social workers and
usually not by physicians, they were able to dramatically
improve the access time to get folks to talk to competent
people in their neighborhood, in their city, to get some care.
I think in order to make that care cohesive, as Mr.
Tolentino said, you have got to be able to get medical records
back and forth so that there is a coordination of care.
So I think the all hands on deck idea is one that I wholly
endorse and one where, if I look at some of the cases--tragic
cases we have looked at in the past--it was not infrequent for
veterans to show up at a community mental health center in
their town. And because they were veterans, they were then sent
to the VA, and there was not a link. They were not accepted, or
there was no payment mechanism, or there was no authority. So I
think that would be a useful step.
Second, I think you really do have to sit down--and as bad
as metrics are, I think you just do have to sit down and model
what you are going to do, and figure out what demand is, and
try to lay out a business case for what you are doing.
Chairman Murray. Is that in place at the VA today?
Dr. Daigh. I do not believe that they have for mental
health the level of business plan that I think they should
have, nor do I think they have it for most medical specialties.
Chairman Murray. Ms. Halliday, do you want to comment on
that?
Ms. Halliday. No. However, I would like to say, though, to
your original question, where you said what is needed to fix
this, I really believe VA needs to focus on the data integrity
of the information they are collecting, along with the new set
of metrics. And I think they need to hold the medical facility
directors accountable to ensure that data integrity.
We have seen scheduling practices that resulted in gaming
the system to make performance metrics look better at the end
of the day, over the past 7 years, they need a culture change.
To get that culture change, I think they really need to hold
the facility directors accountable for how well the data is
actually being captured.
The auditors that actually did the work in the field at the
sites for this review had general observations, that the focus
was always on the outliers, who was not getting care outside
of, say, the 14-day window, but there really was very limited
focus on how well the schedulers were capturing that
information.
That is the information that starts to identify demand. It
starts to tell you what type of services you are going to need
and whether you need to address emergent care; or to
strategically address care over the long term, you have to have
reliable information. So coupled with I think a positive step
to increase the staffing, that is clearly very important.
Chairman Murray. OK. Thank you very much.
Senator Brown?
Senator Brown. Thank you very much.
So, Mr. Secretary, I want to get back to, obviously, the
bonus issue. This year's budget for 2012 is $5.9 billion; next
year, 2013, $6.2 billion, an obvious increase. And the VA gave
out in 2011 $194 million to senior executive service employees.
Do you think that is appropriate?
Mr. Schoenhard. Well, sir, we have--at VA, under Secretary
Shinseki's leadership--run an extensive review of performance
bonuses and have reduced those in both the number of
outstanding ratings and the dollar amount that has actually
been implemented.
Senator Brown. So the number was actually higher at one
point than----
Mr. Schoenhard. It was, sir.
Senator Brown [continuing]. $100 million?
Mr. Schoenhard. Yes. We have taken this very much to heart.
So let me just offer that the integrity of our performance
measures, and the integrity of our scheduling system, and the
fidelity with which we implement these and adhere to them that
are veteran centric is extremely important to the Department.
So we take very seriously the comments that have been made by
the IG, and we will be rigorously following up.
We have been emphasizing the integrity of the system. And
it is obvious that some of what we have put in, in my opinion,
in performance measures, particularly as it relates to desired
date, may get us into a discussion where it leads to this kind
of confusion. Because what sometimes happens is that a
scheduler will say I want to schedule you for when you want to
next come in. And the veteran might say, ``When are you next
available? I will be happy to take whatever is there.'' And
that is a trick bag we need to get out of, by going back, in
our view----
Senator Brown. Sir, listen. I understand that. But my
question is really focusing on bonuses now. I understand that
there are holes and we need to fix them. The Chairwoman brought
up that this has been an issue since the mid 2000s, 2005, 2008,
whatever, and it is something you are going to continue to
obviously work on. And I get that. It is not perfect. I
understand that as well.
But I am a little curious. What is the average salary for
these people that are actually getting these bonuses?
Mr. Schoenhard. Sir, can we take that for the record?
Senator Brown. Yes. I would like to--I am going to get you
some--what is the salary? What are the bonuses based on? How do
you justify $194 million of the tax dollars to go to pay for
bonuses? This should be part of their job. I just want to make
sure I understand it. And maybe if not, then I will stand
corrected.
Nick, what do you think about the opinion of tying these
bonuses to quality rather than quantity? What do you think
about that possibility?
Mr. Tolentino. Senator, my opinion with the bonuses is that
I think he already mentioned it. It is bonuses for doing your
job. So if you are doing your job up to par, you are rewarded
for that. And what I was always taught from my 14 years in the
military is your bonus is your reward for going above and
beyond. And clearly, I am not seeing that, in the treatment of
veterans and the care that they need.
So my opinion is, I truly do not agree.
Senator Brown. Do you think that money could be used
somewhere better?
Mr. Tolentino. Beg your pardon?
Senator Brown. Do you think that $194 million could be used
somewhere better?
Mr. Tolentino. I do.
Senator Brown. Thank you.
Mr. Tolentino. I do, Senator.
Senator Brown. First of all, thank you once again. I
enjoyed the testimony from Senator Moran.
Why do you think the veterans are reluctant to share their
experiences with a clinician and that you are finding that
during your situation in Semper Fi Odyssey and during that
week, you have found that so many folks have actually opened
up? Why do you think that--is it a trust issue? Is it just
being in the military? Or what is it?
General Jones. Yes, sir. It is clearly a trust issue. The
issue--the combat--obviously, there is operational stress.
There is----
Senator Brown. Can I just add one thing to that? And what
do you think the VA could do to establish that bond that
apparently you have?
General Jones. I think that the issue is a lot of--it is a
trust issue, the lack of trust. And it is a fact that, quite
honestly, many clinicians do not understand the nuances of
combat stress. In fact, some of the tools that are being built
now are much like a wreck on 95 in a traumatic event.
Combat stress is very different. It is very personal. And
it is something that people have a fear and then trust with
somebody else to share those experiences. And the longer the
person waits for the reconciliation process, the more difficult
the problem may be.
The answer to that, what I think they could do, is I think
that we need to provide more opportunities, like we are doing
at Semper Fi Odyssey, for some of these people in the mental
health community. As mentioned before, I do not think that
1,900 more people, or 3,400 more people, are going to solve the
problem unless you are hiring the person that really can, in
fact, connect to the individual that will inspire him or her to
share their perspective.
Senator Brown. Great. Thank you. Thank you all very much.
Chairman Murray. Dr. Schohn, at this Committee's November
mental health hearing, you said you were not aware of any
facilities that were gaming the system and not fully reporting
waiting times. You heard Mr. Tolentino's testimony about the
Manchester VA regularly using loopholes to artificially meet
their mental health performance measures, often at the direct
expense of veteran care.
So now that you have read the IG report and performed your
own audit of mental health practices at various VA facilities,
and you have listened to his testimony, I want to ask you the
same question today that I asked you in November.
Do you believe that VA facilities are gaming the system and
now fully reporting wait times?
Mr. Schoenhard. Senator, I would say that we have zero
tolerance for that. We are going to continue our audits and
reviews to ensure, with additional training of scheduling
practices, that this is not occurring. This is certainly not a
practice that can be condoned.
Chairman Murray. Well, you heard Mr. Tolentino. He talked
about the Manchester VA increasing their mental health workload
numbers in order to get additional resources, despite not
having enough staff to support that growth; the quantity over
quality, I believe that you stated. And the result is veterans
not getting the care that they need. I am really shocked that
the VA allowed providers to be put in that kind of dilemma,
where they have to choose between following directions from the
leadership and following the ethics of their profession.
So let me ask you, what are you going to do to ensure that
the quality of care is not being sacrificed as you continue to
meet these timeliness standards?
Mr. Schoenhard. I think it is a multifold approach going
forward, that we are underway and have been implementing here.
First, we need to ensure a staffing model that we will continue
to perfect, that we have sufficient staffing on board to serve
the veterans' needs. We also need to look, as Dr. Daigh said
earlier, at the productivity of that. And there is a
productivity directive that is being developed to ensure that
care is being rendered in a productive way.
Second, we need to make sure that we have the measures in
place to ensure that the veterans are receiving timely care in
accordance with their condition.
If I might just go back to an earlier discussion with
Senator Brown. As we were discussing those veterans who are
most critically at need, who are urgently in need of crisis, I
feel so strongly that we should be sure to respond to those.
But certainly in the case where we would not have, say, an
inpatient psychiatric bed available, we would fee that out to
the private community. And that is something that should happen
in order to ensure the veteran is cared for. But it is
fundamentally important that we get visibility for this.
In the conversation with Senator Brown, what I was trying
to emphasize is that we must have visibility, and we must
respond to those who are most in crisis. And if that requires
that we fee out because we do not have a bed available or
something, we would do that. We do do that. But we would only
do that after making sure we do not have the capacity because,
candidly, part of the risk is the handoff to the private
sector. And it is important we get visibility, we bring those
veterans in, and we take care of them.
Chairman Murray. Let me go back to the scheduling issue
because that is a critically important piece of all this. Back
in 2005 and again in 2007, the IG released reports that
highlighted problems with the patient scheduling, including the
calculation of wait times, inconsistence practices by
schedulers, all that. And despite having heard about this for 7
years now, here we are today.
So why is it so difficult to address these problems, and
should we be more optimistic it is going to happen this time?
Mr. Schoenhard. Well, VHA has established needs, Madam
Chairman, for scheduling, including a vision of a modern
scheduling package that would, among other things, provide
patients the ability to make their own appointments.
Chairman Murray. And the implementation date?
Mr. Schoenhard. We published an RFI in December 2001. We
would like to take, for the record, when we will be
implementing because we are underway in this new initiative.
Chairman Murray. Dr. Daigh, do you believe that is going to
happen?
Dr. Daigh. I do not have enough information to comment,
ma'am. I would have to check and see where they are with this.
I would just say this has been an issue for a number of years,
and it has not been solved. So I am not aware of the specifics
of what they are talking about.
Chairman Murray. OK. I have several other questions I am
going to submit for the record.
But I do want to say, I want to thank all of you for being
here today and sharing your views. Critically, access to VA
health care in a timely fashion is absolutely essential,
especially as we have a growing number of men and women who are
returning from the war, where this is a signature wound that we
are very cognizant of, and we need to be prepared. And this
Committee is focused on this, wants answers and follow up, and
not just this to be another hearing, but wants real action
taken.
So, Mr. Schoenhard, I appreciate the VA stepping up to this
today. I appreciate them accepting the IG report. I really
appreciate the IG for all the work you did in a short amount of
time. A large number of your resources were focused on this.
Of course, to our other witnesses, thank you very much for
being here today.
I want to make it very clear: this is not something we are
going to have a hearing on, and leave, and go do something else
tomorrow. This has to be taken care of. We owe it to these men
and women. I do not want to continue to hear that anybody is
gaming the system. I want to know that the action plan is being
put in place to make sure that the hiring you have announced is
actually taking place. If there are barriers to that, we want
to know about it.
And I want to know how you decided which VISNs are going to
get the practitioners that you plan to recruit. I want VA to
know that this is not just another hearing here in Washington,
DC.
So this is very critical. I think we have made some
progress, but, boy, do we have a lot of work ahead of us. And I
think the Nation expects that of us. I intend to stand up to
it, and I expect all of you to stand up to it as well.
I do want to just take a second and congratulate Ms.
Halliday on her recent promotion to Assistant Inspector
General. We do look forward to working with you.
With that, this hearing is adjourned. Thank you.
[Whereupon, at 11:12 a.m., the Committee was adjourned.]
A P P E N D I X
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Prepared Statement of Claire Haaga Altman, Executive Vice President/
Chief Operating Officer, HealthCare Chaplaincy
Madam Chairwoman and Committee Members: Thank you for this
opportunity to present the testimony of HealthCare Chaplaincy, Inc. My
name is Claire H. Altman and I represent HealthCare Chaplaincy, a New
York City based nonprofit organization founded in 1961, whose mission
is to improve the effectiveness and efficiency of health care through
the innovative ways chaplains promote and advance palliative care
research, education, and practice. Fully understanding that the
distress in a health care setting involves the mind, the body and the
spirit, board-certified multi-faith chaplains serve as the spiritual
care expert on medical teams. Our chaplains, employed in clinical
settings alongside doctors, nurses and other health care professionals,
work closely with patients and families, religious or otherwise, to
help find comfort in difficult times.
With minor exceptions, every veteran who enters the VA has seen
active duty in military, naval or air service. During their tours, they
have worked side by side with chaplains. Chaplains in a military
setting provide care to the spirit to servicemembers of any faith or no
faith. Chaplaincy is a well-established and trusted institution in the
Armed Forces. When a servicemember wants to have a confidential
conversation about crisis of meaning and purpose, he or she is often
more comfortable approaching the chaplain who has been in the trenches
with them, as opposed to the social worker or psychologist. Off the
battlefield, this attitude carries into civilian life. Chaplains are an
understood and trusted presence.
Many veterans suffer from serious spiritual and mental distress;
22% of N.Y. Afghanistan and Iraq war veterans have probable diagnoses
of Post Traumatic Stress Disorder (PTSD) and/or depression. It is
difficult for them to discuss their issues with their families and
friends, often exacerbating their distress and isolation. This distress
can manifest itself in a number of ways--suicide, substance abuse,
strained familial ties, difficulty finding or retaining a job, and the
list goes on. As we are also seeing now, PTSD and/or depression are
reemerging as older veterans confront age-related illness and loss.
Unfortunately, many veterans fear utilizing the more standard
support services due to a potential stigmatization and loss of
confidentiality, as well as not wanting to be perceived as ``weak.''
However, veterans generally trust chaplains and speaking with them is
not perceived as a sign of weakness. In addition, the confidential
nature of the chaplain visit will not affect future deployment or
career considerations.
Another barrier to service delivery is that veterans and their
families who are experiencing crises of meaning and purpose often go
unrecognized in civilian hospitals where otherwise chaplains and other
health care professionals would be available to help them. We know of
no civilian hospitals that ask patients or their family about their
affiliation with military service.
HealthCare Chaplaincy recommends two actions: 1) include chaplaincy
services in VA funded outposts/clinics to provide services that
servicemembers know and trust; and 2) ensure that civilian hospital
systems across the country include admissions questions asking if a
patient is a veteran, has seen military combat or is a family member of
a veteran.
We applaud the work of this Committee and are encouraged that these
hearings are taking place to shine a much needed light on the critical
needs of our servicemembers.
______
Prepared Statement of American Society for the Advancement of
Pharmacotherapy