[House Hearing, 113 Congress]
[From the U.S. Government Publishing Office]



 
              HONORING THE COMMITMENT: OVERCOMING 
               BARRIERS TO QUALITY MENTAL HEALTH CARE 
               FOR VETERANS

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

                                HEARING

                               before the

                     COMMITTEE ON VETERANS' AFFAIRS

                     U.S. HOUSE OF REPRESENTATIVES

                    ONE HUNDRED THIRTEENTH CONGRESS

                             FIRST SESSION

                               __________

                      WEDNESDAY, FEBRUARY 13, 2013

                               __________

                            Serial No. 113-3

                               __________

       Printed for the use of the Committee on Veterans' Affairs





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                     COMMITTEE ON VETERANS' AFFAIRS

                     JEFF MILLER, Florida, Chairman

DOUG LAMBORN, Colorado               MICHAEL H. MICHAUD, Maine, Ranking
GUS M. BILIRAKIS, Florida            CORRINE BROWN, Florida
DAVID P. ROE, Tennessee              MARK TAKANO, California
BILL FLORES, Texas                   JULIA BROWNLEY, California
JEFF DENHAM, California              DINA TITUS, Nevada
JON RUNYAN, New Jersey               ANN KIRKPATRICK, Arizona
DAN BENISHEK, Michigan               RAUL RUIZ, California
TIM HUELSKAMP, Kansas                GLORIA NEGRETE MCLEOD, California
MARK E. AMODEI, Nevada               ANN M. KUSTER, New Hampshire
MIKE COFFMAN, Colorado               BETO O'ROURKE, Texas
BRAD R. WENSTRUP, Ohio               TIMOTHY J. WALZ, Minnesota
PAUL COOK, California
JACKIE WALORSKI, Indiana

            Helen W. Tolar, Staff Director and Chief Counsel

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


                            C O N T E N T S

                               __________

                           February 13, 2013

                                                                   Page

Honoring The Commitment: Overcoming Barriers To Quality Mental 
  Health Care For Veterans.......................................     1

                           OPENING STATEMENTS

Hon. Jeff Miller, Chairman, Full Committee.......................     1
    Prepared Statement of Chairman Miller........................    35
Hon. Michael Michaud, Ranking Minority Member, Full Committee....     3
    Prepared Statement of Hon. Michaud...........................    36
Hon. Jackie Walorski, Prepared Statement only....................    37
Hon. Raul Ruiz, Prepared Statement only..........................    37

                               WITNESSES

M. David Rudd, Ph.D. ABPP, Dean, College of Social and Behavioral 
  Sciences, Co-Founder and Scientific Director, National Center 
  for Veteran Studies, University of Utah........................     5
    Prepared Statement of Dr. Rudd...............................    37
Linda Spoonster Schwartz, RN, Dr.PH, FAAN, Commissioner of 
  Veterans Affairs, State of Connecticut.........................     7
    Prepared Statement of Dr. Schwartz...........................    39
Joy J. Ilem, Deputy National Legislative Director, Disabled 
  American Veterans..............................................     9
    Prepared Statement of Ms. Ilem...............................    45
Ralph Ibson, National Policy Director, Wounded Warrior Project...    11
    Prepared Statement of Mr. Ibson..............................    51
Robert A. Petzel, M.D., Under Secretary for Health, Veterans 
  Health Administration, U.S. Department of Veterans Affairs.....    22
    Prepared Statement of Robert A. Petzel.......................    56
    Accompanied by:

      Dr. Mary Schohn, Director, Office of Mental Health 
          Operations, Office of Patient Care Services, Veterans 
          Health Administration, U.S. Department of Veterans 
          Affairs
      Dr. Sonja Batten, Deputy Chief Consultant for Specialty 
          Mental Health, Office of Patient Care Services, 
          Veterans Health Administration, U.S. Department of 
          Veterans Affairs
      Dr. Janet Kemp, Director, Suicide Prevention and Community 
          Engagement, National Mental Health Program, Office of 
          Patient Care Services, Veterans Health Administration, 
          U.S. Department of Veterans Affairs

                        STATEMENT FOR THE RECORD

The Department of Veterans Affairs Office of the Inspector 
  General........................................................    65
The Government Accountability Office.............................    67
The American Counseling Association..............................    71
The American Legion..............................................    73
Iraq and Afghanistan Veterans of America.........................    79
National Guard Association of the United States, (NGAUS).........    84
National Military Family Association.............................    88
Paralyzed Veterans of America....................................    92
Vietnam Veterans of America......................................    94

                        QUESTIONS FOR THE RECORD

Letter From: Hon. Jeff Miller, Chairman, To: Hon. Robert A. 
  Petzel, M.D., Under Secretary for Health, Department of 
  Veterans Affairs...............................................    97
Questions From: Hon. Jeff Miller, Chairman, Congressman Jeff 
  Denhan, and Congresswoman Jackie Walorski To: Department of 
  Veterans Affairs...............................................    98
Responses From: Department of Veterans Affairs, To: Hon. Jeff 
  Miller, Chairman, Congressman Jeff Denhan, and Congresswoamn 
  Jackie Walorski................................................   100
Questions From: Hon. Michael Michaud, Ranking Minority Member, 
  To: Department of Veterans Affairs.............................   129
Questions From: Congresswoman Julia Brownley, Ranking Minority 
  Member, Subcommittee on Health, Veterans Affairs, and 
  Congressman Waxman, To: Veterans Affairs.......................   131


 HONORING THE COMMITMENT: OVERCOMING BARRIERS TO QUALITY MENTAL HEALTH 
                           CARE FOR VETERANS

                      Wednesday, February 13, 2013

                     U.S. House of Representatives,
                            Committee on Veterans' Affairs,
                                                   Washington, D.C.
    The Committee met, pursuant to notice, at 10:04 a.m., in 
Room 334, Cannon House Office Building, Hon. Jeff Miller 
[Chairman of the Committee] presiding.
    Present: Representatives Miller, Bilirakis, Flores, Denham, 
Runyan, Benishek, Huelskamp, Amodei, Coffman, Michaud, Takano, 
Brownley, Kirkpatrick, Ruiz, Negrete McLeod, Kuster, and Walz.

              OPENING STATEMENT OF CHAIRMAN MILLER

    The Chairman. The Committee will come to order. We are 
awaiting some of our witnesses that were caught up in traffic 
this morning, and also in security outside of the building. 
They will be here momentarily. Before we begin our hearing this 
morning, I would like to recognize Mr. Takano to talk about the 
impact of recent events in California last night. Mr. Takano?
    Mr. Takano. Thank you, Mr. Chairman. My district, the 41st 
District, is based in Riverside County, and the largest city 
within my district is the City of Riverside. And I would like 
to offer a moment of silence for Officer Michael Crain of the 
Riverside Police Department, who was shot and killed last 
Thursday by former LAPD Officer Christopher Dorner; and for the 
other, three other victims of Dorner's violence.
    Prior to his service with the Riverside Police Department, 
Officer Crain served in the United States Marine Corps, and was 
deployed for two tours in Kuwait as a rifleman. He was awarded 
multiple honors for his bravery. So I would ask the Committee 
to take a moment of silence to honor the memory of Officer 
Crain, and the three other victims, three others whose lives 
were needlessly taken, and their families.
    The Chairman. Without objection, the Committee will pause 
for a moment of silence.
    [Moment of silence]
    The Chairman. Thank you, Mr. Takano. Our thoughts and 
prayers are with you and your constituents, and their families.
    Mr. Takano. Thank you, Mr. Chairman.
    The Chairman. Thank you very much. Thank you, everybody, 
for joining us this morning for the first Full Committee 
hearing of the 113th Congress, Honoring the Commitment: 
Overcoming Barriers to Quality Mental Health Care for Veterans.
    It is only fitting that we would start with this hearing 
today, as we begin our oversight by addressing what I think is 
one of the most pressing and fundamental issues facing our 
servicemembers, veterans, and their families. That is, the 
ability to provide timely and effective mental health care to 
veterans who need it, when they need it. This issue is not a 
new one, but I think everybody will agree that it is a growing.
    In the last six years there has been a 39 percent increase 
in VA's mental health care budget, and a 41 percent increase in 
VA's mental health care staff. Unfortunately these significant 
increases have not resulted in equally significant performance 
and outcomes. Less than a year ago the VA Inspector General 
released a review of veterans mental health care access that 
painted a disturbing picture, showing that the majority of 
veterans who seek mental health care through VA wait 50 days on 
average for an evaluation. That figure amounts to thousands of 
veterans in need. Veterans who have recognized that they need 
help, and who have taken the hard step of asking for that help, 
being told by the Federal bureaucracy tasked with caring for 
them that they must wait in line because VA cannot provide them 
with the timely access to the care that they need to begin 
their healing process. And it only gets worse.
    Earlier this month, VA released its 2012 Suicide Data 
Report. The report shows, among many alarming findings that the 
suicide rate among our veterans has remained steady for the 
past 12 years, with 18 to 22 veteran deaths per day since 1999. 
As that report so clearly illustrates, when a veteran is in 
need of care, the difference of a day or a week or a month can 
be the difference between life and death.
    This morning the department is going to testify that 
progress is being made to increase access to mental health care 
services and reduce veteran suicide. I think they are going to 
proclaim that they have hired just over 3,200 additional mental 
health care personnel. However, despite our request, VA has yet 
to provide evidence to verify its efforts.
    While I am and will remain supportive of the improvements 
that the department is attempting to make, it has become 
painfully clear to me that VA is focused more on its process 
and not on its outcomes. The true measure of success with 
respect to mental health care is not how many people have been 
hired, but how many people have been helped.
    Since 1999 their mental health care programs, their budget, 
and staff have increased exponentially and the number of 
veterans seeking care has grown. Yet the number of veterans 
tragically taking their own lives is still the same. What is 
more, the Suicide Data Report that I mentioned earlier shows 
that the demographic characteristics of veterans who die by 
suicide is similar among those veterans who access VA care and 
those veterans who do not access VA care. Something somewhere 
is clearly missing.
    Now on our first panel this morning we will hear from 
representatives from our veterans service organizations, an 
established veterans mental health researcher, and a state 
commissioner of veterans affairs. Three of them are veterans 
themselves, and all of them will testify that the provisions of 
mental health care services through VA is seriously challenged 
and that what is needed to fix is decidedly not more of the 
very same thing.
    Last night the President announced that a year from now 
34,000 of our servicemembers currently serving in Afghanistan 
are going to be back home. The one-size-fits-all path that the 
department is on, leaves our returning veterans with no 
assurance that current issues will abate and fails to recognize 
that adequately addressing the mental health needs of our 
veterans is a task that VA cannot handle by themselves.
    In order to be effective, VA must embrace an integrated 
care delivery model that does not wait for veterans to come to 
them, but instead meets them where they are. VA must stand 
ready to treat our veterans where and how our veterans want to 
be treated, not just where and how VA wants to treat them. I 
can tell you this morning that our veterans are in towns and 
cities and communities all across this great land, and the care 
that they want is care that recognizes and respects their own 
unique circumstances, their preferences, and their hopes. I 
earnestly appreciate all of you being here today and I yield to 
our Ranking Member Mr. Michaud for his opening statement.

    [The prepared statement of Chairman Miller appears in the 
Appendix]

               OPENING STATEMENT OF HON. MICHAUD

    Mr. Michaud. Thank you very much, Mr. Chairman, for 
continuing to keep the issue of access, quality, and timely 
mental health services provided to our veterans at the 
forefront of this Committee. And thank you to all of our 
witnesses today for coming and talking with us about the 
critical issues of veterans mental health access. I would also 
like to thank all of you in the audience who are here today for 
your continued support for our veterans population.
    We as a Nation have a responsibility, a sacred trust to 
care for those whom we send into harm's way. When we send our 
citizens into battle around the world, we must be leading the 
charge here at home, within our government, to make them whole 
again upon their return by ensuring that adequate resources and 
proper programs are in place to address their needs.
    Oversight of the VA's mental health programs have been a 
focus of this Committee for some time now. Over the years we 
have held numerous hearings, increased funding, and passed 
legislation in an effort to address the challenges of our 
veterans from all eras. VA spent $6.2 billion on mental health 
programs in fiscal year 2012. I hope to see some positive 
progress that this funding has been applied to the goals and 
outcomes for which it was intended and the programs are really 
working. We all know that mental health is a significant 
problem that the Nation is facing now, not only in the VA, but 
throughout our population. And the broader challenge is an 
opportunity for the VA to look outside of their walls to solve 
some of the challenges that they face rather than operate in a 
vacuum as they sometimes have done in the past.
    One of the most pressing mental health problems we face is 
the issue of suicide and how to best prevent it. Fiscal year 
2012 tragically saw an increase in military suicides for the 
third time in four years. The number of suicides surpassed the 
number of combat deaths. Couple that with the number of 
suicides in the veteran population of 18 to 22 per day and the 
picture becomes even more alarming.
    I believe VA is heading in the right direction. I believe 
that they have made a true effort to get a true picture of the 
suicide issue that surrounds veterans. But I believe a lot more 
can and must be done. I will be interested to hear from our 
panelists about the national mental health picture and helping 
this Committee put the veterans suicide rate in context, as 
well as what is happening nationally in treating mental 
illness.
    Today's hearing will examine the progress VA has made in a 
variety of areas concerning mental health and providing timely 
access and quality care. I'm hopeful that this will be a good 
discussion on ways to provide the care, such as more partnering 
with the public and private sector, increasing the pool of 
providers, and other creative ways to address mental health 
issues.
    And finally, I would be remiss if I did not acknowledge the 
dedication of the VA employees for providing quality mental 
health care to our veterans everyday. The directors, nurses, 
doctors, hospital workers are a team. And I want to thank them 
for all what they are doing. But we have to do a lot more. As 
you heard the Chairman talk about the President's speech last 
night, about our soldiers who are going to be coming back from 
Afghanistan. I do not know how many of those soldiers are going 
to be Guard and Reservists that will be going back to rural 
areas. Access and quality and the timeliness of care that our 
veterans will need to address these mental health issues should 
be readily available. And we definitely do have to think 
outside the box to make sure that they do get the help that 
they need when they need it.
    So with that, Mr. Chairman, once again I want to thank you 
for your dedication, your commitment, and your willingness to 
keep this issue before the Full Committee so we can make sure 
that our veterans get the help when they need it. Thank you, 
and I yield back.

    [The prepared statement of Hon. Michaud appears in the 
Appendix]

    The Chairman. Thank you very much to the Ranking Member. If 
I could invite the first panel to the witness table. And as you 
are making your way forward, I would like to introduce the 
witnesses to the Members of the Committee. First, Dr. David 
Rudd, Dean of the College of Social and Behavioral Sciences, 
and Co-Founder and Scientific Director of the National Center 
for Veterans Studies at the University of Utah. We also have 
Dr. Linda Schwartz, Commissioner of the Connecticut Department 
of Veterans' Affairs. Dr. Schwartz is a Vietnam Veteran having 
served on active duty as a Reservist for the United States Air 
Force. Dr. Schwartz, thank you for your service. They are 
joined by Joy Ilem, the Deputy Director of Legislative Affairs 
for the Department of Disabled Veterans of America. Ralph 
Ibson, the National Policy Director for the Wounded Warrior 
Project. Ms. Ilem and Mr. Ibson are both veterans of the United 
States Army. Thank you both for your service.
    I want to again say thank you to all of our witnesses for 
agreeing to appear this morning. This Committee is uniquely 
interested in what is going on. I would say that there are 
numerous members that are doubled up right now in an Armed 
Services Committee hearing as well that deals with the 
continuing resolution and sequestration. So their absence here 
does not affect the fact that they are very interested in this 
issue and they will be coming in and out as the hearing 
progresses. So with that, Dr. Rudd, please proceed with your 
testimony, sir.

   STATEMENTS OF M. DAVID RUDD, PH.D. ABPP, DEAN, COLLEGE OF 
   SOCIAL AND BEHAVIORAL SCIENCES, CO-FOUNDER AND SCIENTIFIC 
 DIRECTOR, NATIONAL CENTER FOR VETERAN STUDIES, UNIVERSITY OF 
 UTAH; LINDA SPOONSTER SCHWARTZ, RN, DR.PH, FAAN, COMMISSIONER 
OF VETERANS' AFFAIRS, STATE OF CONNECTICUT; JOY J. ILEM, DEPUTY 
NATIONAL LEGISLATIVE DIRECTOR, DISABLED AMERICAN VETERANS; AND 
 RALPH IBSON, NATIONAL POLICY DIRECTOR, WOUNDED WARRIOR PROJECT

                   STATEMENT OF M. DAVID RUDD

    Mr. Rudd. Mr. Chairman, Mr. Ranking Member, Members of the 
Committee, I want to thank you for the opportunity to speak 
with you here today. You have my written testimony. I'm not 
going to read that testimony other than just comment and 
emphasize a number of points that are embedded within the 
testimony.
    If we look at this problem over the course of the past 
decade, I think it is critical that we put it in context, that 
we understand it in context. And I think a starting point for 
understanding the trajectory of this problem over the course of 
the last ten to 11 years is to recognize that prior to Iraq and 
Afghanistan, service in the military was a protective variable 
to suicide. That the suicide rates for young men and women of 
comparable ages were about half that of the general population. 
So prior to these wars things were different. Things have 
changed. There are many of us that would speculate about what 
that is. I would tell you it probably is related to pre-
enlistment screening, how we handle screening. It's probably 
related to issues of unit cohesion. That ten to 11 years of war 
impact and affect unit cohesion in very profound ways. I have 
talked with many soldiers and service people about that very 
issue. The influence of purpose that ten to 11 years of war 
affects your sense of purpose, and ultimately the sense of 
warrior identity that we find in soldiers today which is 
profound and I will talk with you a little bit more about 
later.
    As a starting point, also let me applaud the transparency 
and the thoroughness of the VA Suicide Data Report. Dr. Kemp is 
with us and I would tell you that the effort is genuinely 
historic. This is something that we should have done decades 
ago to fully understand, be able to track, and monitor the 
problem. We have to have a system in place to genuinely 
understand the problem. This is a first effort to genuinely 
understand the nature of the problem, have accurate data that 
can actually inform policy and inform decisions. I think it is 
simply an exceptional move on the part of the VA and I am very 
glad to see that.
    Now when I say that, I think it is critical that we put 
these rates in context. When you look over the course of the 
last 12 years specifically, that if we look at the death rates 
by suicide for veterans, if you look at those death rates of 
VHA service users, those rates are triple the rates for the 
general population. They are double for the male population. 
And although that comparison is a little bit clouded given the 
nature of the two populations, if you look at the age specific 
data for the VA, I think it is important to understand that the 
18 to 34 year age group, that the rates are double that of 
comparable young males in the general population. That that 
risk endures. And I would suggest that in very specific ways 
that it is probably linked to active duty risk over the course 
of the last ten to 11 years. And it is a significant problem 
that we need to think about. Starting to conceptualize this as 
a continuum from active duty risk, to transition to veteran 
status and the endurance of that risk for the first decade to 
decade and a half of veteran status is an important thing for 
us to look at.
    As a result of the persistence of risk over the course of 
the last ten to 12 years, and the better the data we have, it 
seems more clear that the risk endures, I would very much agree 
with you, Mr. Chairman. It is time for us not to do the same 
thing. That more of the same simply is not working. That when 
these rates endure at the high levels that they are, that 
funding more of the same is not the route to go.
    A couple of other points I would like to make about the 
report. I think it is a significant move in terms of 
establishing, maintaining, and monitoring the crisis line. I 
find that a wonderful addition. I would encourage you, though, 
that we may not be reaching the right population. That the drop 
from 40 percent to 30 percent of the callers in terms of 
individuals that identify themselves as suicidal may mean we 
are not reaching the right group. We have got to think about 
different ways of reaching those individuals.
    And finally, I want to share briefly with you a story that 
I think is probably symptomatic of the problem. I have included 
it in my testimony. I am not sure that this is a clinical 
problem. I think it is a management, I think it is a systemic 
problem in terms of how we handle individuals that are at risk. 
And I have included in my testimony the tragic suicide of 
Russell Shirley. I spoke with Russell's mother over the course 
of the last month. I have spoken with one of his dear friends. 
And I think Russell is probably typical of the problem, the 
tragic problem which will occur over the coming years.
    Russell was a son, a husband, a father. He was a soldier. 
He served his country proudly and bravely in Afghanistan. He 
survived combat. He came home struggling with PTSD and 
Traumatic Brain Injury. With a marriage in crisis and 
escalating symptoms he turned to alcohol. He received a DUI. 
And after ten years of dedicated service he was discharged. And 
part of the rationale for the discharge was the increasing 
pressure to reduce the size of the force. I think we are going 
to see more and more of that over the coming years. After the 
loss of his family, the loss of his career, and the loss of his 
identify, Russell shot himself in front of his mother.
    Having spoken with Russell I would tell you, or having 
spoken with Russell's mother, I would tell you that a part of 
the tragedy is, we knew that Russell was at risk prior to his 
death. We recognized, identified him as an at risk soldier 
prior to his discharge. But yet there are not adequate 
transitional services in place that allow a clean connection 
from an individual to an individual. And I think those are the 
sorts of things that we need to start talking about, we need to 
start thinking about. How do we connect at risk soldiers, once 
we identify them and they are being discharged, particularly if 
they are being discharged against their wishes, into the VA 
system? And how do we connect them with an individual and not 
just a system? How do we help them connect in a relationship 
that can potentially save a life?
    I have included a picture of Russell with his two children 
at the end of my testimony and the reason I've done that is, I 
think it is important for all of us, when I read the Suicide 
Data Report, the one thing that is missing in this Suicide Data 
Report are the names of the individuals, the names of the 
families, the names of the loved ones that are affected and 
impacted by these tragic deaths. And I think it is important 
for all of us to remember that.
    Thank you very much.

    [The prepared statement of M. David Rudd appears in the 
Appendix]

    The Chairman. Thank you. Dr. Schwartz?

             STATEMENT OF LINDA SPOONSTER SCHWARTZ

    Ms. Schwartz. Good morning, Mr. Chairman, and good morning, 
Congressman Michaud. I'm Linda Schwartz. I'm the Commissioner 
of Veterans' Affairs for the State of Connecticut. As the 
Commissioner, I've been the Commissioner for ten years, I am 
serving my third governor, I am responsible for 277,000 
veterans in our state. I have a 75-bed substance abuse 
treatment recovery program. I have a chronic disease hospital. 
I have the second largest domicile in America which has today 
380 veterans in resident. I have three cemeteries and five 
district offices.
    I am here to kind of echo what was said by Dr. Rudd. 
Because let me just say this, when you talk about the suicide 
let us be clear. Let us be clear that no death index is going 
to have accurate information. In my experience, we were looking 
at suicides because it was a very important thing. Because I 
started, because I have three cemeteries, I look and see what 
are the causes of death? And many of these deaths are not 
declared suicide out of respect for the religions beliefs of 
the individual, for the family, or because no one wants to make 
that call.
    The reason it is so shocking is because it is secret. And 
many of the things that are going on with our Reserves and our 
Guard are not talked about openly. So I applaud the VA for at 
least making an attempt to quantify.
    But I also would like to move to the State of Connecticut, 
where for the past 25 years our Department of Mental Health and 
Addiction Services has been asking, ``Have you ever served in 
the military?'' They have been asking, ``Are you a veteran?''
    Interestingly, we did not quantify this until the late 
nineties. I was a public health nurse at the time so I was 
checking off those boxes. We had 5,000 veterans on the rolls of 
our State Department of Mental Health and Addiction Services. 
And even though we have had the opening of community-based 
outpatient clinics, and Vet Centers in the State of 
Connecticut, those numbers have not changed significantly. We 
still have about 5,000 veterans receiving their care from the 
state. I have referred to the reasons why, most of it, in my 
testimony. But the proximity, access to care is a lot more than 
being eligible for your VA benefits. It means that if your 
closest VA hospital is 65 miles away, and you are having a 
crisis, you want somebody in your community. You want somebody 
who is going to listen. Additionally, VA provides wonderful 
services, but you do not have access to your care provider 24/7 
like somebody in private practice.
    My masters is in psychiatric nursing, so I have had the 
experience of working with mental health patients. But I would 
just like to say that I am just going to skip, the President's 
message night, that we are going to have all of these people 
coming down, he mentioned a very important part. Some of these 
people joined, you have an all volunteer force who has joined. 
They intended to make this their career and now you have a draw 
down. And that is a loss of identity. As a disabled veteran, I 
had to leave military service and I had a long time finding a 
new identity.
    But I want to go quickly to what Connecticut is doing today 
because I believe it addresses some of the issues that others 
will raise. In 2005 we set aside money in our budget and the 
Legislature enacted legislation that we would set up a program 
for veterans, mostly at that time Guard and Reservist, who 
would not be covered by VA services. We trained medical 
professionals who were living in the community. We used a model 
that came out of 9/11 that Connecticut was tasked with a lot of 
mental health needs, so doing some training with people that 
are already in practice, already have their credentials, 
already have their professional requirements. We gave them 16 
hours of what we called Military 101. We have a 24/7 hotline. 
Anybody in the State of Connecticut, whether they are the 
military member, the spouse, the children, the parents, the 
significant other, are eligible for this program. If you call 
that number right now, and you say, ``I live in Pawtucket, 
Connecticut and my husband is going sailing every morning with 
Captain Morgan. What should I do?'' They will tell me who in my 
geographic area has gone through this training and is part of 
that network. And to part of that network the professional has 
to agree that they will contact that individual who makes that 
call, the client from the Military Support Program, they must 
contact them within 48 hours.
    This is open because many of the providers do not charge. 
However, the State of Connecticut has authorized 15 sessions 
within a calendar year for all of these family members. I did 
cite in my testimony that in Maine they did a study where they 
found out that many military members are more likely to go to 
treatment with their family because it does reduce the stigma. 
The military member can say, ``I'm doing this for my family.'' 
And everybody will say, ``That's a really great thing you are 
doing.'' And we hope, and we know, that they are also receiving 
their care and some help, too.
    I realize my time is almost out, but I want to say 
something very important to all of you. The states, each one of 
your states has someone like me, a director, responsible to the 
governor and the people of your state to take care of your 
people. States collectively put $6 billion on the table every 
year to take care of veterans. The VA is a vast system which 
cannot really meet the demands of our, the way we are doing 
more with our Reservists and our Guards today. So the most 
important thing that we are looking for is a little help from 
the Federal benefits and grants. Too much emphasis is put on 
having people go for health care where you have eligibility 
requirements. We have to look to the veterans benefits side of 
this, for outreach, for training for those individuals who will 
be the service officers that develop these claims. And although 
the VHA has a very robust and very good grant system, you need 
to look at having the Veterans Benefits Administration also be 
able to provide grants to support this. Can you imagine, I give 
high marks to Secretary Shinseki and Hickey, because they have 
done a lot to electronically do the records. But when it gets 
down to the real, where the rubber meets the road, it's the 
person who is taking the claims, it is the person that's 
pressing the button. I have ten service officers. Some of them 
are Vietnam veterans and they still feel that if they have to 
touch the computer they will become electrocuted. So this is a 
knowledge gap that is very, very essential.
    I thank you so much, really, for giving me a little extra 
time. But if you don't remember anything else I said today, VA 
cannot do this by themselves. You have many good people in each 
one of your states that wants to do a good job for your 
veterans, all veterans. It's time to really look about 
formalizing the partnership between your states and the Federal 
VA. Thank you so much.

    [The prepared statement of Linda Spoonster Schwartz appears 
in the Appendix]

    The Chairman. Thank you very much, doctor. We appreciate 
all of our states and our territories for doing what they do in 
partnership for our veterans. We appreciate your testimony. 
Next, Joy Ilem from the DAV. You are recognized. Thank you.

                    STATEMENT OF JOY J. ILEM

    Ms. Ilem. Thank you, Chairman Miller, and Members of the 
Committee. I am pleased to present the DAV's views on access to 
VA mental health services. Like the Committee, DAV is committed 
to fulfilling our promises to the men and women who served. And 
one of those promises is to ensure that veterans receive an 
opportunity to fully recover from physical and psychological 
wounds that occur as a consequence of their military service.
    Given the diligent oversight by this Committee and the 
significant level of new resources that have been authorized to 
address the existing deficits and to improve VA mental health 
services, the current question posed by the Committee chair is 
a valid one. Is VA's complex system of mental health care and 
suicide prevention services improving the health and wellness 
of our heroes in need? Over the past five years, VA's Office of 
Mental Health Services has made significant progress and placed 
special emphasis on suicide prevention efforts, launched an 
aggressive anti-stigma outreach and advertising campaign, 
increased peer to peer services, mental health consumer 
councils, and family and couples counseling and therapy 
services. Yet despite the noted progress, in our opinion there 
are several core issues that are likely responsible for the 
continued mental health access issues that are plaguing VA.
    These issues have been the topic of numerous congressional 
and government oversight reports and include problems with VA's 
outdated patient scheduling system, reliability of waiting time 
data, proper staffing levels, and a mental health staffing 
model that accounts for shifting trends and demand for specific 
types of services. Many of these issues were addressed at the 
May, 2012 hearing you held and VA noted work was underway on 
several fronts and specifically that a prototype staffing model 
was being tested in three VA networks. Like the Committee, we 
are anxious to learn whether VA can deploy this prototype 
throughout its system, and whether it works well for mental 
health in particular. Likewise, we are eager to learn about the 
progress on the variety of other issues addressed in the 
various reports.
    Mr. Chairman, another topic you asked that we address was 
effectively partnering with non-VA resources to address gaps 
that create more patient-centered network of care focused on 
wellness based outcomes. In this regard you addressed a VA 
TRICARE outsourcing alliance to serve the mental health needs 
of some newer veterans that VA is admittedly struggling to meet 
today. We urge VA to work with the Committee to ensure that if 
mental health care is expanded using the existing TRICARE 
network or some other outside network, veterans receive direct 
assistance by VA in coordinating such services and that the 
care veterans receive will reflect the integrated and holistic 
nature of VA care.
    When a veteran acknowledges the need for mental health 
services and agrees to engage in treatment, it is important for 
VA to determine the kind of mental health services that are 
needed and whether the most appropriate care should come from a 
VA provider or a community-based source. This type of triage is 
absolutely critical because high quality, effective mental 
health treatment is dependent on a consistent continuous care 
relationship developed between the veteran and the provider. 
Once a trusting therapeutic relationship is established, that 
connection should not be disrupted if possible.
    Mr. Chairman, DAV previously testified that in our opinion 
our newer veterans can particularly benefit from VA's expertise 
in treating coexisting PTSD, substance use disorders, traumatic 
brain injury, and other post-deployment transition issues. To 
that end, it is essential that VHA address and resolve the 
barriers that obstruct consistent timely access to care at VA 
facilities nationwide. However, if a veteran is referred by VA 
to a community resource, we urge that care be coordinated by 
VA. A critical component of care coordination is health 
information sharing. The absence of obtaining health 
information poses a barrier to implement good patient care 
strategies, such a chronic disease management, prevention, and 
use of safe care protocols within VA.
    These are some of the principal flaws we see in VA's 
current approach in fee-basis and contract care. We believe the 
policy changes made by VA's Office of Mental Health Services 
over the past decade are positive and ultimately equate to 
better patient care and improved mental health outcomes. But 
significant challenges are clearly evident and need continued 
attention. Unfortunately the root causes for these existing 
barriers in VA's mental health delivery system are complex, 
system based, and long standing, and cannot be resolved by any 
single reform. Therefore, we urge the Committee's continued 
oversight of VA's progress in correcting not only the internal 
processes and resolving the existing barriers that prevent some 
veterans from receiving the timely services they need to fully 
readjust and integrate following military service.
    I just wanted to say I really think what Dr. Rudd said 
really is a poignant point. That we really need for veterans 
that are at risk, they need to be put together with an 
individual, a person, someone they connect to and not just a 
system. So with that, I am willing to answer any questions the 
Committee may have. Thank you.

    [The prepared statement of Joy J. Ilem appears in the 
Appendix]

    The Chairman. Thank you very much. I'd ask the panelists' 
indulgence for just a moment while we recess the hearing and 
enter into a quick business meeting. And with that, I recognize 
Mr. Michaud for a motion.
    Mr. Michaud. Thank you very much, Mr. Chairman. I would 
like to offer a resolution adding Timothy J. Walz of Minnesota 
as a Democratic Member of the Subcommittee on Oversight and 
Investigations.
    The Chairman. Thank you for that motion. Since we do now 
have a quorum, all in favor will say aye.
    Opposed, no.
    The motion carries. Welcome, Mr. Walz, to the O&I 
Subcommittee. And thank you, Mr. Michaud, for your motion. Our 
business meeting is now adjourned. And we will take up the 
hearing again. Mr. Ibson, you are recognized.

                    STATEMENT OF RALPH IBSON

    Mr. Ibson. Thank you, Mr. Chairman. Chairman Miller, 
Ranking Member Michaud, Members of the Committee, let me also 
congratulate Mr. Walz, for Wounded Warrior Project and those we 
serve, the issues raised this morning, and the challenges it 
poses, are profound. We greatly appreciate your scheduling this 
hearing and greatly appreciate your powerful opening 
statements.
    My organization's mission is to honor and empower those 
wounded since 9/11. And let me give you some context for the 
concerns we have. In a large survey of our wounded warriors 
last year, 69 percent of respondents screened positive for 
PTSD, 69 percent. Sixty-two percent indicated they were 
currently experiencing symptoms of major depression. More than 
two-thirds of those surveyed indicated that emotional problems 
had interfered with work or regular activities during the 
previous four weeks. Some acknowledged getting help from VA 
therapists, but more than one in three reported difficulties in 
accessing effective mental health care. The feedback in essence 
was that VA is overwhelmed.
    I do want to acknowledge the hard work done by VA's central 
office mental health leadership, as well as the step VA took 
last year to increase mental health staffing. That step, 
though, is not a comprehensive solution. There is no single 
silver bullet out there in our view, because the system faces a 
range of different problems. One of the leading researchers in 
the field, Dr. Charles Hogue, has, I think captured the scope 
of VA's challenge as follows. ``Veterans remain reluctant to 
seek care, with half of those in need not utilizing mental 
health services. Among veterans who begin PTSD treatment with 
psychotherapy or medication, a high percentage drop out. With 
only 50 percent of veterans seeking care, and a 40 percent 
recovery rate, current strategies will effectively reach no 
more than 20 percent of all veterans needing PTSD treatment.''
    So the issue is not simply improving access. One has to 
ask, for example, access to what? Mental health care also has 
to be effective. At a minimum, that requires building a 
trusting relationship between provider and patient. And that 
trust can be quickly broken when a veteran, for example, who 
needs one on one therapy is simply offered medication. Or when 
that same veteran is put into group therapy prematurely, or is 
only offered therapy that requires reliving the painful trauma 
of war when he or she is not ready for that level of intensity.
    Many of our warriors become frustrated and drop out of VA 
treatment. But many VA clinicians as well are also frustrated. 
Why? Because the VA system too often bars them from exercising 
their best clinical judgment. Instead, VA performance 
requirements dictate clinical practice. As one psychiatrist 
told me recently, ``The number of required clinical reminders I 
get keeps growing. I have a patient who is homeless and whose 
wife has recently died. But I have to take time away from 
treatment to administer a depression screening test, even 
though I know the individual is depressed.'' Similarly, ``I 
need to be able to spend enough time addressing the veteran's 
wife's recent death rather than being required to urge him to 
stop smoking.''
    Sadly, a clinician who bucks the performance requirements 
in the name of exercising good clinical judgment can incur 
financial repercussions as a result. As one described it, ``The 
reality is that the VA is a top down organization that wants 
strict obedience.''
    At best, these performance requirements measure processes, 
as you indicated Mr. Chairman, rather than determining whether 
the patient is getting better. And as prior hearings have 
documented, these requirements are often circumvented or gamed.
    VA has acknowledged a need to improve mental health care 
deliver. But what seems to be missing in some instances is 
transparency. We wonder, for example, why after conducting 
mental health site visits at 150 VA medical centers last year, 
VA has not provided this Committee a detailed report of those 
findings. Last year to its credit, VA conducted a survey of its 
mental health staff. Why have we not heard about the findings?
    Let us be clear. There are things that are working well in 
this system. The Vet Center program is one. Providing peer 
outreach and peer support, as VA has begun to do, and is called 
for in the President's Executive Order, would be another one if 
it were launched in full and accomplished as intended. And 
again, let me emphasize that there are many well intentioned, 
highly dedicated mental health staff at VA centers and clinics 
who are committed to providing good treatment.
    But more must be done, in our view, to close gaps in the VA 
system. Close gaps between its promise and its on the ground 
reality. Between policy and practice. Congressional oversight 
has been a critical catalyst in identifying the need for system 
improvement.
    I think there are also opportunities to break down what can 
be an adversarial relationship between a Committee and a 
department, for greater partnership, for greater dialogue. I 
think as you suggested in your opening statements, there are 
different directions to be taken. There are opportunities, as 
Linda indicated, for greater partnerships between VA and 
states, and between VA and communities. These are all steps 
that ought to be pursued. Vigilant oversight, again, must 
continue. And we stand ready to support in that effort. I would 
be pleased to answer any questions you might have. Thank you.

    [The prepared statement of Ralph Ibson appears in the 
Appendix]

    The Chairman. Thank you very much, Mr. Ibson. And thank you 
for what the Wounded Warrior Project does as well. We 
appreciate, again, the testimony of our panelists, and all of 
your complete written statements will be entered into the 
record without objection. I recognize myself for five minutes 
for questions.
    Dr. Rudd, I was struck by your comment that we need to 
connect veterans in need not just with the system, but with 
people within the system. I think everybody here has said 
something very similar to that. I think it is important for us 
from a clinical standpoint to understand the need to connect 
personally and the personal efficacy and the importance of 
choice within the mental health care field. So can you talk a 
little bit about why it is so critical to connect on the 
personal level?
    Mr. Rudd. Oh, absolutely. If you look at, let us take for 
example the recent active duty numbers for this past year. So 
if we look at this, if we look at the recent active duty 
numbers from this past year, half of those individuals who died 
by suicide either were in treatment or had received care of 
some sort, either inpatient or outpatient care. If you look at 
the VA numbers from the report, you will see that 80 percent of 
those individuals had had a nonfatal event. In other words, 
made a suicide attempt. Were in treatment four weeks prior to 
the event.
    What I would tell you that both of those numbers reveal is 
the nature of how they are connected to care. That the problem, 
if we took the active duty numbers and took those, half of 
those individuals that tragically died, they remained in care 
and were effectively treated, the problem would no longer 
exist. We would be back to numbers that we had seen prior to 
Iraq. Those rates would have dropped dramatically. And so it is 
the nature of those connections that really is the critical 
thing.
    If you look at the work that we do in terms of studying 
effective treatment for suicidality, so we have got two 
clinical trials currently underway at Fort Carson in Colorado, 
it is the nature of the relationships that are established and 
maintained. Do we have mechanisms in place to maintain those 
relationships in an effective fashion? The question that I ask 
when I look at that Suicide Data Report data on, they had a 
contact a month prior, the question that I ask is how long was 
it until the next appointment? So when they had that contact, 
was the next appointment scheduled six weeks out? Was that the 
problem? Or was the next appointment scheduled a week out, and 
they did not keep the appointment?
    My concern is that from the individuals that we talk with 
that we treat, from the individuals that I know, the families, 
surviving family members of those that have died, oftentimes it 
is an issue of the system getting in the way of being able to 
keep an appointment, get an appointment, or get to an 
appointment. That those individuals that are connected need to 
be connected to people. They need to be connected to the same 
people. They need to be continued frequently in treatment. They 
do not need to receive care every six weeks. They are going to 
need more frequent care. It is those kinds of questions that I 
think we need to be asking, is how do we connect? How do we 
keep them there? Not necessarily are we getting them there. I 
think we are doing a good job of getting people there. I think 
the Army data, the military data reveals that. I think that the 
VA data reveals that. But ultimately the question is, how do we 
keep them engaged? How do we keep them involved? Have we made 
the system accessible so that they can, they can continue to be 
a part of the treatment cycle? That really is my core concern.
    The Chairman. Anybody got anything they would like to add 
to that? Doctor?
    Ms. Schwartz. I would. I would say it would be very 
interesting, and I did not read the report, it would be very 
interesting to see how many of these people were, had done 
multiple deployments and multiple tours. In my testimony, I 
wrote of a situation which I hope everyone will take a look at. 
The fact that people, veterans of the Guard and Reserve who 
have come to our state, who are already rated service-connected 
at 70 percent or 80 percent for mental health issues have been 
told, and they do, sign a waiver to stop their disability 
checks, and then sign up for another deployment. I have had 
some very difficult times for these people who already are 
rated, which is not an easy thing to do, and yet they sign away 
their checks. Someone, and it is well known because there is 
already a form for it. So they are deployed back to the combat 
zones, thinking that when they return they are going to get 
their disability checks are just going to smooth, and they will 
have their disability rating. They do not realize what they 
jeopardize. Nor do the people at the National Guard and Reserve 
levels understand what this is all about.
    But when you take someone who has been deployed multiple 
times, and in our state it varies from services. I myself am an 
Air Force veteran, so many deployments by the Air Force are not 
a whole year long. But the issue is, they come home. They just 
get reacquainted with their family or the community, and then 
they are gone again. And there is really no time for a 
decompression kind of experience where they can learn to be 
back in the community again before they have to gear up. And I 
do feel that some of this is they never gear down. They are 
always, as if the adrenaline is as if they are in the combat 
zones. And many families are at a loss. They think they are 
going to welcome them home and they find that the individual is 
not, that is now where it is at for them.
    So these multiple deployments, using people that already 
have disabilities to redeploy to the combat zones, that has to 
stop. It's just incomprehensible to me. I mean, as a military 
member when I had to leave my squadron it was probably the 
saddest day of my life. That was me. I wanted to go back. And 
somebody did offer me a chance to go back, and I could have 
signed my life away and gone back. Gone back. But I knew that I 
couldn't do the work. So you have a group of people right now 
who will do, some of them will do anything to get back. Because 
of the jobs, because of the feelings that this is a very 
important job that they are doing. So this is, this is not a VA 
thing. But we are left, all of us in the veteran community are 
left to deal with these situations.
    The Chairman. Thank you very much. Mr. Michaud?
    Mr. Michaud. Thank you, Mr. Chairman. Dr. Schwartz, first 
of all thank you for your continued service to our veterans and 
their families. I really appreciate it. You stated in your 
testimony that serving veterans is a shared responsibility with 
state and the Federal government. And I agree with you, and I 
also believe that the community needs to be involved as well.
    Can you elaborate a little bit more on the barriers that 
you have encountered while seeking to partner with the 
Department of Veterans Affairs? As well as, have you sought out 
other Federal agencies? And if you had, how has that 
relationship been?
    Ms. Schwartz. I think the VA has been operating on the 
notion that they have to do it all. And with the new 
hostilities and the heavy use of our Guard and Reserves, the 
real true citizen soldiers. So they have developed programs 
which, their counterparts in the states, or did not even know 
about. There is very little dialogue about, for example, I will 
just give you, you know, they create a program where they are 
working with the homeless. Well I have 380 homeless people. I 
have the most homeless people in the State of Connecticut. 
Second only in the Nation to California. But the issue is, the 
kind of dialogue we have, especially over some of the programs, 
the kind of dialogue, if they are going to start a new program 
to assist veterans, I do believe that VA has to at least talk 
to the state. If they are building a facility for assisted 
living in the State of Connecticut, and they really have not, 
the Commissioner and Mental Health and Addiction Services and I 
had no idea. It is being built on the premises of Newington VA. 
We had no idea that this was going on. However, it does affect 
that state. And I think that is one way.
    But the other thing, and let me be very clear, there are 
some really good models of how it works. For example, my 
substance abuse treatment program has 75 beds. The VA at 
Newington has a 21-day program. So all of my initial people in 
the program go to the 21-day program at Newington. They stay in 
a residential mode with us. And after they, because we think 
maybe you need a little more than 21 days, especially with some 
of our veterans, then they work with my clinical staff. And 
they can stay up to six months because what we do is as we work 
with them on their sobriety, we also work with them in getting 
back into the community. I am very proud to say that yes, we 
have a lot of people. But last year over 150 veterans left my 
facility with a job and a place to live. So some of them, and I 
would also say we have over 500 veterans of Iraq and 
Afghanistan have gone to this program in my time. That is ten 
years.
    But the issue here is there is so much more that needs to 
be done besides calling or giving, you need to have that 
interaction. Perfect hand-off. I talked about the military 
support program. It, we have expanded that program in the State 
of Connecticut to all veterans and all veteran families because 
of our concern about suicide. So that if somebody can call even 
in the middle of the night and get a friendly voice, we also 
have veteran workers standing by as crisis intervention. And I 
am not, we are not the only state. Massachusetts and other 
states are doing wonderful work along these lines. But it is a 
beginning. It is not, just as was mentioned, you want somebody 
there that they can trust and talk to. The therapeutic alliance 
does not necessarily happen with the VA because in the middle 
of the night you cannot call your VA clinician. You cannot talk 
to them. Families sometimes cannot even talk to them because of 
the HIPAA laws. So if any of our clinicians in the community 
find that this is a little over their head, they will make the 
referral to the appropriate place. And many of them are. Many 
of the veterans are referred to the VA. But at least, it is 
almost like a triage at the local level. And the hand-off that 
they get is a little personalized because it is not like you 
are calling an 800 number.
    And I would also add that some of the suicides that we have 
seen, do not think it is just men. I think some of the saddest 
things for me is that women are killing themselves, too. Women 
with children. And that really brought it to the forefront in 
our state. So the VA has to, in my testimony I do say that 
Secretary Shinseki has acknowledged this. The problem is, the 
problem is, as was noted in other testimony, that has not, that 
mind set has not filtered down to the people at the 
administrative local levels. I have a wonderful relation with 
my homeless outreach people at the VA level because we touch 
people. We are not shuffling papers. I know, I had to learn how 
to do that, too. But the point is, the people that touch people 
are deeply, deeply ingrained in making it happen. So as a, we 
have a new challenge here. And we have to challenge the status 
quo and begin to create new models. Because we are not going 
backwards. This is the way America is going to do war in the 
future. And these are, the Guard and the Reserve are going to 
be your clients, my clients.
    Mr. Bilirakis. [Presiding] Thank you very much. And I will 
recognize myself for five minutes. The first question is for 
Mr. Rudd. You mention in your testimony that in order to reduce 
wait times and increase access to mental health care, the VA 
may need to explore partnerships with private community 
providers. What do you believe is the biggest obstacle 
preventing the VA from doing this?
    Mr. Rudd. You know, I am really not sure what the biggest 
obstacle is outside of the simple fact that it has not been 
done, that it is a non-traditional approach. That the way that 
we have done this, I think, over the years, particular since 
the start of these wars, is that we have made the VA larger. I 
think the evidence would suggest that the VA does not need to 
continue to get larger. That I was not overly encouraged when I 
read the response that they have hired 1,000 individuals and 
some of these numbers. I do not see that as a solution. I think 
the solution is that we look at partnerships like TRICARE 
partnering, which is a wonderful partner approach. Primarily 
because those providers are already in those small communities. 
Those providers are available, accessible in those small 
communities. But what that means is shifting funding, shifting 
money to a non-traditional model. And I think that is 
personally the way to go. I think that is how you connect 
people to people at a local level so that individuals do not 
have to travel great distances.
    Mr. Bilirakis. Very good. Anyone else wish to comment on 
this subject matter?
    Ms. Ilem. I would just comment, I think from DAV's 
perspective we have a little bit of a different thought on 
that. We are definitely invested in wanting to make sure that 
the VA receives the proper funding and what they need to do 
their job. I mean, they are the primary source of government 
response to this issue, you know, to when veterans are coming 
home and need assistance. They are going to be there for the 
long term. And I think VA's long term relationships with its 
patients are extremely important in providing really high 
quality care. And not to say that VA does not have to partner 
with the community, and in these cases we have certainly found, 
you know, there has just been continued issues with access. And 
but at the same time, I think we really want to see VA resolve 
some of the issues that we know have been identified by the 
GAO, by the Office of the Inspector General, and VA itself. So 
what is the problem? Where is the logjam that they cannot 
overcome those obstacles within the system to be more efficient 
and spend the money which has been provided and authorized by 
this Committee, and by Congress, in significant amounts to 
really care for these people with the specialized treatment and 
services that they have, you know, really, they are second to 
none. And especially with these coexisting disorders. But they 
do, I think, need to look outside the box given the issues that 
we're, you know, they continue to experience with access. So 
but I would like to see VA really step up to the plate. I know 
that there are a lot of people that are trying hard. But you 
know, the time has come where it is just absolutely critical 
given all of these reports with, you know, the suicide and 
various issues we continue to hear about.
    Mr. Bilirakis. Thank you very much. Dr. Schwartz, in your 
testimony you make a valuable point that the Federal, State, 
and local initiatives should be coordinated. I agree with you, 
and I am a proponent of the one stop shop models. How do you 
believe that this integration can be best facilitated?
    Ms. Schwartz. I think there are models in the Federal 
government. And I know I did not respond to the question 
adequately. You know, with the public health, HHS gives grants. 
They have local level coordination across states of certain 
programs that are funded. I see that VA will always be, in 
reference to Joy Ilem's statement, VA will always be the crown 
jewel. But the needs of the veterans today are much different.
    For example, when I was in the military, and I am going to 
age myself, I was not allowed to be married. Then they allowed 
us to be married, and when you had a child, you had to leave 
the military. Now, almost 83 percent of the people on active 
duty have families, and 58 percent of the Guard and Reserve all 
of them, the family, especially with this generation, and was 
referred to the camaraderie, the sense of camaraderie, the need 
to be with each other. But the family, the family unit is more 
important now than it is ever. And VA is not authorized, across 
the board, to help these families. So that is why other 
programs have evolved.
    So the most important thing with these models is I would 
say, I am not telling you to just be dropping money everywhere, 
but that we would have grants to do the outreach to connect 
people. VA has a large grant per diem program for state homes. 
I have one. There is quality assurance that is built into that 
program, that could be built into the mental health program.
    But you are not going--as long as we rely on the Guard and 
Reserve, it is too long for someone to drive. And we did a 
survey of our veterans that they had to drive more than 30 
minutes to a source for anything, it was too far. I would have 
to drive. It is 65 miles from my home to the VA hospital. And 
if you had to take public transportation in the State of 
Connecticut, it would take you two days on public 
transportation.
    So accessibility is much more than eligibility. 
Accessibility is having someone, someone, a private clinician 
that, that is not the model of the VA, but that is a model that 
can be built using clinicians. This worked very well for the 
State of Connecticut after 9/11. I did not mention this, but we 
have had over 3,500--since this program had, we have had over 
3,500 clients, I would say a third of them have been referred 
to VA for care. But most of them are in treatment in the homes 
and the towns where they live, and the reimbursement if it's 
not coming from the--any other third party reimbursement, the 
State of Connecticut pays these therapists.
    Many of them do, actually I have to say do this pro bono 
because they want to help. But this is an excellent example of 
how it can go to where it needs to be. Thank you.
    Mr. Brownley. Thank you very much. I yield back, Mr. 
Chairman.
    Mr. Chairman. Thank you very much, Ms. Brownley.
    Ms. Brownley. Thank you, Mr. Chair, I appreciate this. I 
had a question actually for Dr. Rudd. And in your testimony you 
mentioned, you mentioned about access to service, but also 
transition services for people transitioning out of the 
military. And I recently, when I was assigned to the Committee, 
I decided to visit all of the veteran facilities in my 
district. And I visited the transition center at Naval Base 
Ventura County. And I was actually very, very impressed by what 
they are doing there, and their focused attention, and program 
that is very comprehensive that goes on for a pretty long 
period of time to prepare them for this kind of transition.
    And so I am really wondering, you know, how we can capture 
these best practices when we see a good facility like this 
doing good work, how we can create new models and best 
practices to replicate better than we are doing throughout the 
country.
    Mr. Rudd. Well, I agree with you. I think there's some very 
nice models out there. I think a part of the problem is that 
you can--you see one side or the other doing a nice effort, but 
not both simultaneously. So if you look at the death of Russell 
Shirley as an example. He was, because of the DUI, he was 
referred for treatment, substance abuse treatment on the active 
Army side, which when his discharge was processing, was 
discontinued, is a part of the--as a part of the discharge 
process.
    It is those little things that make the big difference. It 
is whether or not somebody actually gets into the service, gets 
connected with a provider in these critical moments. And so 
often times, those are non-clinical kinds of issues. Those are 
issues with commanders, those are issues with administrators, 
not with the clinical staff. And when I referenced, and I do 
not believe this is a clinical problem, I really do not believe 
this a clinical problem, I believe it is how we shepherd people 
through the system, they are at high risk with non-clinical 
procedures.
    Ms. Brownley. Uh-huh.
    Mr. Rudd. I think it is how we end up connecting them and 
then maintaining them there that is the problem. So I think 
part of the difficulty in Russell Shirley's death was the fact 
that the company commander disconnected him from treatment, did 
not connect him to transition services. Those are the kind of 
things that we need to find policies and implement, that can be 
maintained and monitored so we can effectively manage these 
people, as we move them through the system. I think more 
attention has to be focused there, not at the transition 
center. But how do you get somebody in the door? And then how 
do you monitor and make sure that they stay there, and they 
stay all the way through? And if they disengage, what are the 
procedures for re-engaging them if they disengage? Those are 
the kind of things that I think ultimately will save lives.
    Ms. Brownley. And are we doing anything vis-a-vis 
accountability to look at these transition centers and others 
to see--identifying people who are in trouble after transition, 
and looking specifically at the transition, the transitioning 
that they have or have not received.
    Mr. Rudd. Well, I think that we started the process. I 
mean, I think one of the tragedies of this, is that it has 
taken 10, 11 years of war, many deaths, and many tragic 
suicides for this to happen, that we are now putting systems in 
place to be able to look at this effectively. And I think the 
work that Dr. Kemp does genuinely is historic, but it should 
have happened decades ago. We should have had a system in place 
so we can monitor, manage and understand how many people are 
dying by suicide, and we can accurately the number of events. 
And we're still only at 21 states that have accurate data with 
the two largest states without accurate data at this point.
    And so I think we are just building the system. That's a 
wonderful contribution, but it really is just a foundation. So 
I think that when we get the foundation set, a part of what we 
have to layer in is some general patients with the idea that we 
do not have the infrastructure in place to do the very things 
you are asking. And I think that we need to ask that question 
repeatedly to get the infrastructure in place. We have got some 
of that on the suicide front, but it has to happen in so many 
different layers. And that is very much a non-clinical problem. 
I mean that very much is a management problem.
    And that is where I think making the VA bigger creates 
bigger challenges, because the management of big systems is 
tough. And so I think that is where we need to think a little 
bit creatively about how to do this.
    Ms. Brownley. Thank you, sir.
    The Chairman. Thank you. Dr. Benishek?
    Mr. Benishek. Thank you, Mr. Chairman. Dr. Schwartz, you 
said a couple of things earlier that sort of intrigued me. I 
want to ask you about them a little bit more.
    You said that, you know, there was a need for the private 
sector mental health care, because calling the VA, there is no 
access to people at the VA at night.
    Ms. Schwartz. Right.
    Mr. Benishek. So the Veteran Affairs Mental Health does not 
have any on-call person to take a call?
    Ms. Schwartz. Well, they do have an on-call person, but in 
the sense of mental health care, it is very essential that they 
find somebody that is responsive, not just somebody in the 
emergency room.
    Mr. Benishek. Right, right, right.
    Ms. Schwartz. And in large states, they may not even know 
this person. So the accessibility of trying to contact your 
mental health provider in the evening is not standard. We have 
had via the populations of veterans that I have also use VA, 
trying to get ahold of the person that is their primary treater 
for mental health, we do not have access to the primary care 
provider.
    Mr. Benishek. But you are saying in the private sector----
    Ms. Schwartz. We do.
    Mr. Benishek. --you do.
    Ms. Schwartz. I mean, I--just for example, I--my masters is 
in psychiatric nursing, and so a lot of clinical nurse 
specialists are in private practice, and they, when they are 
not available, any psychiatrist, they always have someone or 
psychologist, always have coverage. They--you have-- you can 
call into your provider, get ahold of them if it is a crisis, 
and if they are on vacation, you will get somebody that they 
have told you will be covering for them.
    Mr. Benishek. Right, right, right. Well, yeah.
    Ms. Schwartz. So it is there. It is there. It is somebody 
that you can really talk to.
    Mr. Benishek. Well, I am just sort of amazed by the fact 
that the VA does not have that same sort of a system. And I'm 
disappointed to hear that frankly.
    Ms. Schwartz. It is a large, large system, and was very 
well described, the larger the system gets, there is another 
thing, and I bring this in my testimony, the soldiers of today 
expect their treaters to be competent, to understand them, to 
respect them, and they expect the same kind of care they would 
if they were going to a private provider.
    Which means, if I am having trouble right now, if I want to 
call my psychiatrist, I want to call the office.
    Mr. Benishek. Right.
    Ms. Schwartz. And I want to talk to them, or maybe I need 
to go somewhere. This is not available----
    Mr. Benishek. Right.
    Ms. Schwartz. --on an individual basis. The large system 
may respond, but if I have somebody in crisis, and I get 
somebody at the VA that does not know this patient----
    Mr. Benishek. Right.
    Ms. Schwartz. --they're not going to be as helpful as----
    Mr. Benishek. Right, right. No, I completely understand. 
Mr. Ibson?
    Mr. Ibson. I think it--you know, I think the concept of 
partnership was discussed earlier, and I think we have to 
recognize that there is a national shortage of mental health 
providers. What I think--you know, what I think Linda had 
indicated earlier, and I hope VA is moving away from, is the 
sense that we own this issue alone. I think the opportunity is 
there for community and VA to work closely together. And I hope 
that is a direction we will see.
    Mr. Benishek. Right, right. Dr. Schwartz, you said one 
other thing, and that is, people waive their mental health 
disability to return to deployment.
    Ms. Schwartz. Yes.
    Mr. Benishek. How often does that happen?
    Ms. Schwartz. In a very small state, but I know at least 
five cases of this happening, because what happens is when they 
come back, they expect those checks to just keep rolling, and 
then they come to me because I have service officers, and we 
have to tell them the sad truth that you just signed away--when 
you signed--when you said you are good to go, you signed--
stopped your check, it says I am fit for duty.
    Mr. Benishek. Right, right, right.
    Ms. Schwartz. So if they are deployed, and they come back 
and they think they are going to get that, they have not been 
really--they were not well informed that they are signing away 
something that is very important. But at the same time, it is 
incomprehensible to me, I served 16 years in the United States 
Air Force, it is incomprehensible to me that they would ask 
someone who is already compromised----
    Mr. Benishek. Right, right.
    Ms. Schwartz. --to--at any rate, unless it was like 
somebody really, really unique, but these people are choosing 
to go back into the military because it is a job, and they feel 
as if they belong there. So you put that knowledge into the 
fact that we are going to have a drawn down of tens of 
thousands of people who feel that is where they belong.
    Mr. Benishek. Well, no, it just worries me that we are 
taking people that have, you know----
    Ms. Schwartz. Yes, it worries me too. They can----
    Mr. Benishek. --relating to mental illness to deployment 
are there----
    Ms. Schwartz. --get themselves into a lot of trouble.
    Mr. Benishek. I do not even know that we should be allowing 
that to occur.
    Ms. Schwartz. I would hope that this Committee would really 
look at that, and work with people to stop that.
    Mr. Benishek. Thank you for your comments, a lot of time.
    The Chairman. Thank you, Doctor. Ms. Negrete McLeod? Mr. 
Runyan? Mr. Coffman?
    Mr. Coffman. No questions.
    The Chairman. Mr. Michaud, have you got anymore questions?
    Okay. Thank you very much for being here. We do have some 
additional questions we would like to present to you for the 
record. Thank you so much for what you do. I look forward to a 
continued relationship with each of you on this very important 
issue and you are now excused.
    I'd like to invite our second panel to the witness table. 
Joining us from the Department is the Honorable Dr. Robert 
Petzel. Dr. Petzel, thank you for making your way through 
traffic and all kinds of security issues to be here. Dr. Petzel 
is the Under Secretary for Health for the Department of 
Veterans Affairs. He's accompanied today by Mary Schohn, 
Director of the Office of Mental Health Operations, Dr. Sonja 
Batten, Deputy Chief Consultant for Specialty Mental Health, 
and Dr. Janet Kemp, Director of Suicide Prevention and 
Community Engagement for the National Mental Health Program. We 
thank you all for joining us today, and Dr. Petzel, you are 
recognized to proceed with your testimony.

   STATEMENT OF HONORABLE DR. ROBERT A. PETZEL, M.D., UNDER 
  SECRETARY FOR HEALTH, VETERANS HEALTH ADMINISTRATION, U.S. 
   DEPARTMENT OF VETERANS AFFAIRS, ACCOMPANIED BY: DR. MARY 
SCHOHN, DIRECTOR, OFFICE OF MENTAL HEALTH OPERATIONS, OFFICE OF 
  PATIENT CARE SERVICES, VETERANS HEALTH ADMINISTRATION, U.S. 
DEPARTMENT OF VETERANS AFFAIRS; DR. SONJA BATTEN, DEPUTY CHIEF 
CONSULTANT FOR SPECIALTY MENTAL HEALTH, OFFICE OF PATIENT CARE 
 SERVICES, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF 
    VETERANS AFFAIRS; AND DR. JANET KEMP, DIRECTOR, SUICIDE 
  PREVENTION AND COMMUNITY ENGAGEMENT, NATIONAL MENTAL HEALTH 
   PROGRAM, OFFICE OF PATIENT CARE SERVICES, VETERANS HEALTH 
      ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS

              STATEMENT OF ROBERT A. PETZEL, M.D.

    Mr. Petzel. Good morning, Chairman Miller, Ranking Member 
Michaud, and the Committee Members. I appreciate the 
opportunity to come here to discuss VA's comprehensive mental 
health care and services for our Nation's veterans. I am 
accompanied today as the Chairman indicated by Dr. Mary Schohn, 
Dr. Sonja Batten, and Dr. Janet Kemp.
    Since early 2009, VA has been transforming and expanding 
its mental health care delivery system. We have improved our 
services for veterans, but we know that there is much more work 
to be done. My written testimony has more detailed information, 
and I would submit that for the record.
    Mr. Chairman. Without objection.
    Mr. Petzel. This morning, I will summarize these remarks, 
and update you on our major accomplishments. As the President 
stated last night, we will keep faith with our veterans 
investing in world class care, including mental health care for 
our wounded warriors, supporting our military families, and 
giving our veterans the benefits, education, and job 
opportunities that they have earned.
    We are progressively increasing veterans' access to mental 
health care by working closely with our Federal partners to 
implement the President's Executive Order, to improve access to 
mental health services for veterans, servicemembers and 
military families, as well as implementing the 2013 National 
Defense Authorization Act.
    We know these changes require investment. Last year VA 
announced an ambitious goal to hire 1,600 new mental health 
care clinical providers, and 300 administrative support staff. 
As of January 29, 2013, VA has hired 1,058 clinical providers, 
and 223 of the administrative staff. We are on track to meet 
the requirements of the Executive Order, and have these 
positions filled by June 30th of 2013.
    VA has many entry points for care, including 152 medical 
centers, 821 community-based out-patient clinics, 300 vet 
centers, 70 vet center vans, and the VA's crisis line, to name 
but a few.
    We have also expanded access to care by leveraging 
technology, Telehealth, phone calls, secure messaging, online 
tools, mobile applications, and outreach efforts, mental health 
integration into primary care, community partnerships and 
academic affiliations.
    Out-patient visits have increased by over--to over 17 
million in 2012. The number of veterans receiving specialized 
mental health treatment rose to 1.3 million in 2012 from 
927,000 to 2006.
    In part, this is because our primary care physicians 
proactively screen veterans for depression, PTSD, problem 
drinking, and military sexual trauma to help these veterans 
actually receive the treatment that they need.
    We are also refining how we measure access to ensure we 
accurately reflect the timeliness of the care we provide. VA is 
updating scheduling practices, strengthening its performance 
measures, and changing timeliness measures to best track new 
and existing patient access times.
    We will continue to measure performance, and hold employees 
and leadership accountable to ensure that the resources are 
devoted where they are needed for the benefit of America's 
veterans.
    VA has been working with partners to address access and 
care delivery gaps. In response to the Executive Order, VA is 
collaborating with health and human services to establish 15 
pilots using community-based health clinics and mental health 
clinics.
    VA is also partnering with DoD to advance a coordinated 
public health model to improve access, quality, and 
effectiveness of our mental health services through an 
integrated mental health strategy.
    VA is committed to ensuring the safety of our veterans, 
even one, even one veteran suicide is one too many. July 25th, 
2012 marked five years since the establishment of the veteran 
crisis hotline. This offers 24/7 emergency assistance. Last 
year this crisis hotline received more than 193,000 calls 
resulting in over 6,400 rescues, people rescued from harming 
themselves or someone else.
    Earlier this month, VA released a suicide report, developed 
collaboratively with the states. This report includes data on 
prevalence and characteristics of suicide amongst veterans, 
including those veterans that are not treated within the VA.
    The report provides us with valuable information as we 
eluded to earlier, to identify populations that need targeted 
inventions, such as women and Vietnam veterans. Moreover, it 
identifies opportunities to train providers who care for 
veterans in non-mental health settings.
    The report makes clear that although there is more work to 
be done, we are making a difference. There is a decrease in 
suicide attempts by veterans getting care within the VA, calls 
to the crisis hotline are becoming less acute, also 
demonstrating that the VA's early intervention appears to be 
working.
    Mr. Chairman, we know our work to improve the delivery of 
mental health services to veterans will never be done, and 
there is much more, much more to do. We appreciate your 
support, and encouragement in identifying and resolving 
challenges as we find new ways to care for this Nation's 
veterans.
    My colleagues and I are prepared to respond to any 
questions you may have.

    [The prepared statement of Robert A. Petzel appears in the 
Appendix]

    The Chairman. Thank you very much. At the end, and I did 
not have a chance to run back to your statement, but--one of 
your last comments was that the number of calls coming in to 
the crisis line were decreasing.
    Mr. Petzel. No, actually, sir, not the number of calls were 
decreasing, the intensity of the calls. The patients that are 
calling now are less acute than they were when we first 
entered, first developed the crisis line indicating----
    The Chairman. Well, and again, so you say that's a success?
    Mr. Petzel. I'm saying that that's an indication of the 
fact that we are having some impact.
    The Chairman. Could they be going somewhere else other than 
your crisis line?
    Mr. Petzel. We do not think so. The calls are, if anything, 
increasing. We are seeing the volume, we are not seeing the 
acuity.
    The Chairman. Because we had testimony from the Connecticut 
State Director about having 5,000 veterans on their rolls, 
could they be going to their mental health providers or 
somewhere else?
    Mr. Petzel. Let me ask Jan Kemp who runs that hotline to 
comment, Dr. Kemp.
    Ms. Kemp. Yeah, we looked extensively at the number of 
people who are calling the crisis line, and what they look 
like, and where they are coming from. Our volumes continue to 
increase. We think our messaging is out there, we are reaching 
people. We are making an increased number of referrals, so when 
those people call the crisis line, we are able to refer them 
primarily to VA mental health providers through their suicide 
prevention coordinators, but we do also have partnerships with 
other organizations for those veterans who do not want to go to 
the VA, such as Wounded Warriors, and given our--and Vets for 
Vets, so we have lots of options to give veterans referrals to, 
and we are proud of those.
    What is going down, however, is the number of rescues that 
we are having to call. So people hopefully, and we believe are 
calling earlier in their sort of crisis trajectory process, 
that we are able to get them help sooner before it comes to the 
point where they have already taken pills, or they are holding 
a gun to their head.
    That was our intent. That was one of the reasons why we 
sort of changed our messaging campaign halfway through the 
stream. We changed the name of it. We want to get people 
sooner. We think we are doing that.
    Mr. Chairman. Dr. Petzel, you said in your opening 
statement and I agree with this, that ``our ultimate desired 
outcome is a healthy veteran.'' The problem is after you said 
that, the focus, I think of the majority of your testimony was 
processes, number of people hired, numbers, numbers, numbers, 
and I think the most important number is how many veterans are 
getting healthy or healthier or helped.
    And so I think this Committee would like to know how you 
quantify whether or not a veteran is getting better--it is easy 
to quantify the number of people hired, but how do you quantify 
whether a veteran is being helped or is getting healthy.
    Mr. Petzel. Well, Mr. Chairman, we would agree with you, 
that the important data is how have we helped veterans. And we 
mentioned in the opening statement, and we will elaborate on 
that several instances. Number one is the crisis line data. No 
question about the fact that that indicates that there is some 
impact on veterans with mental health problems of the programs 
that we are involved in.
    Number two is the suicide data. The suicide data is going 
to become an important part of us evaluating how well we are 
doing. And there is an indication in that suicide data that 
indeed we are having an impact that people are being treated in 
the VA.
    The third thing is----
    Mr. Chairman. And--there is a difference, though, and I 
apologize, but being treated is one thing. How many of them are 
becoming healthy again?
    Mr. Petzel. Well, if the suicide rate is declining, if 
there are fewer suicide attempts, if there is a decreased need 
to rescue, that tells me that those people are getting better.
    Mr. Chairman. But not every person who has a mental health 
issue is--subject to a suicide attempt, or an actual suicide. 
They may continue with mental health and depression issues for 
a long time, so basing everything off of the crisis line, and 
the suicide numbers supposedly remaining stable--again, how do 
you quantify that a veteran suffering from depression or PTSD 
is getting better?
    Mr. Petzel. Let us take an example, Mr. Chairman, of PTSD. 
We can evaluate the symptoms in a patient when they initially 
present with PTSD, and they may go through cognitive behavior 
and therapy or another evidence based therapy. And subsequently 
they are evaluated for the presence of the symptoms related to 
PTSD. And we have good evidence in the literature that people 
that go through that program do indeed have less symptomatology 
associated with their PTSD, and are better adjusted to living 
in society.
    There are many instances of the treatment protocols that we 
have, where we can demonstrate the direct impact on those 
individuals that have been through that therapy.
    Mr. Chairman. Is there a disincentive for a veteran who has 
been rated for PTSD to show improvement?
    Mr. Petzel. I do not believe that there is. I believe that 
people that are suffering from PTSD do want to have that PTSD 
treated, and do want to go through therapy, and do want to make 
a better adjustment to their living circumstances, no.
    Mr. Chairman. Okay. Thank you. Mr. Michaud.
    Mr. Michaud. Thank you, Mr. Chairman. Thank you, Under 
Secretary for being here today.
    Mr. Ibson mentioned in his testimony about central office 
doing a survey of clinicians as far as the best clinical 
judgment. Is that survey completed, and could you share with 
the Committee? And my other question is, you mentioned the 
President's Executive Order, and that it is going to establish 
15 pilot sites. We heard earlier testimony today that when you 
look at the huge influx of soldiers that are going to be coming 
back, and 40 percent are in rural areas, how were the locations 
of those pilot sites determined, and did you take into 
consideration the problems we are facing in rural areas?
    Mr. Petzel. Thank you, Congressman Michaud. I am going to 
have to talk with Ralph Ibson about the survey that he referred 
to. I am not quite sure which one he meant. I know that more 
than a year ago, what really touched off the eventual feeling 
that we had to hire additional mental health workers, was a 
survey of our mental health providers, as to whether or not 
there was adequate staffing. And they may be what he is 
referring to, but I will talk with him after we finish----
    Mr. Michaud. Okay.
    Mr. Petzel. --with the hearing, and then we will then get 
back to you.
    In terms of the pilots, the--15 sites were selected, they 
were selected based upon the desire of the local network, our 
hospital to participate, and a need is identified often by how 
rural the areas were. There is one urban center where we are 
doing this in Atlanta, to get a feeling for what that might be 
like, because there are many, many community mental health 
clinics in the Atlanta area.
    I want to mention just tangentially to the pilots, that we 
have been participating with community and mental health 
centers in certain parts of the country prior to the pilots. In 
Montana, there is a network of community mental health centers 
that are providing care to veterans in that phenomenally remote 
state where we are not able to provide mental health providers 
in each one of the communities.
    We think that this is a--this is going to be a viable 
alternative in the future to us cooperating in the community 
with providing care in these again remote rural areas.
    Mr. Michaud. Okay. On the suicides, I understand the VA now 
has a memorandum of understanding with all 50 states to report 
the suicide data. We heard earlier this morning that the two 
largest states, I think it is Texas and California have not 
submitted that information. Are there any other states that 
have not submitted that information?
    Because my concern is when you look at the increase in 
suicide rates, it went from 18 to 22, and that is--to me that 
is the low number, because there is a lot more suicides, I 
believe out there that are not being reported. So are there any 
other states out there that have not reported?
    Mr. Petzel. I would ask Dr. Kemp who runs the suicide 
program to comment on that. I do not know the answer.
    Ms. Kemp. We now have agreements with all states that they 
will. We have gotten data from both Texas and California since 
the report came out. There is a couple of states that we are 
still working with over privacy issues and how we are going to 
share the data, and I am confident that we will get those soon.
    Mr. Michaud. Thank you. Earlier today we also heard, I 
think it was actually Mr. Ibson I believe, talked about the 
clinicians within the VA, that they have to meet certain 
performance requirements set out by central office.
    Last year, I think it was last year, we also heard from the 
former VA employee who worked in the facility, I believe it was 
New Hampshire, pretty much said the same thing, that they have 
a certain performance criteria they have to deal with, that 
they do not feel that they can provide the services to our 
veterans the way they should be providing it, because it is 
trying to just get them through the system, and that is a 
concern that I have. Can you talk about other performance 
requirements for the clinicians?
    Mr. Michaud. Thank you, Congressman Michaud. Yes, there 
are, and there is attention and a balance between having the 
time available and the need to provide direct clinical care, 
and on the other hand, the need to document what has been done. 
And the need to provide information in terms of performance 
measures, sometimes for us to be able to answer the Chairman's 
question about are we having an impact on patients. And often 
times, the performance measures, particularly outside of mental 
health in the medical health system are a very important part 
of our being able to say yes, we have had an impact. We have 
helped this patient to avoid cardiac disease or whatever.
    So it is important to have performance measures, and I 
think it is incumbent on us as the leaders to make sure that 
there is the proper balance between time available to do 
clinical care, and the necessity of meeting performance 
measures.
    And just an example, one of them would be, a reminder will 
pop up, you need to immunize this patient for influenza, and 
that is a reminder that has got to be satisfied, and there are 
a number of other kinds of reminders that need to be satisfied 
to do those things.
    Mr. Michaud. Would you provide the Committee with those 
performance standards that they have to meet?
    Mr. Petzel. Yes, we can. It is a--okay, we can. Yes, sir.
    Mr. Michaud. I take it by your delay, that it is probably a 
lengthy----
    Mr. Petzel. Congressman, it is not so much it is lengthy, 
it varies from the kind of clinical setting that one is in, but 
we can do this, yes.
    The Chairman. How does reminding a provider that somebody 
needs an immunization help them get better mentally? I mean 
that is what we are focused on at this point, providing mental 
health to the veteran. Clinically, I guess I understand if he 
or she needs a flu shot, but that is not what they are there 
for.
    Mr. Petzel. I'm sorry, Mr. Chairman. I was trying to give 
an example to the Congressman of the things that we hear 
clinicians complaining about in terms of performance measures 
and clinical reminders. There are clinical reminders that are 
related to mental health, such as----
    Mr. Chairman. No, I understand that. Just a question. I 
apologize. Mr. Runyan.
    Mr. Runyan. Thank you, Chairman. Some of my questions I am 
not even sure you can answer, because as Chairman Miller said, 
there is not a lot of data on what is happening day-to-day. My 
one question, Dr. Petzel, I do have, there seems a lot of 
things we do specifically in the mental health field, 
especially in the VA, and I think nationally, too, because I do 
not know if we are there yet as a medical field.
    The balance of being reactive to being proactive a lot of 
times is way out of balance. And have you had any movement on 
trying to figure out how we can get in? Obviously, a lot of the 
PTSD that a lot of our veterans have is triggered at some 
point. It is there, maybe we could have proactively got in 
front of that. Is there anything you've been discussing or have 
on the horizon that we can say that we are going to move in 
that direction, so we do not have to wait till the last minute, 
till there is a crisis?
    Mr. Petzel. That is an excellent question, Congressman 
Runyan, and I want to harken back to what Dr. Rudd said in 
terms of transition.
    Identifying--all the patients that we see come out of the 
Department of Defense, they are soldiers, sailors, Air Force 
members, airmen, Marines, and we need the opportunity to 
interact with these people before they leave the service. The 
new mandated transition assistance program I think is going to 
give us that opportunity to both present and interview the 
individuals before they leave the service to identify those 
people who are at risk, who might have a previous problem, who 
might have a problem in transition, so that we can do, what was 
referred to earlier as a hot transfer. A warm transfer between 
the Department of Defense, the Army, whatever it might be, and 
our VA health care system, so that these people do not fall 
through the cracks, so that we do get them into our system.
    We can do, we can do a very good job, once we can get 
people into the system, and I think a major issue is providing 
for the right kind of transition. And that involves our being 
able to get at these individuals in this mandated transition 
assistance program.
    The second thing that I would like to talk about in 
relationship to your question is another issue that came up, 
and that is establishing the kind of relationship with a 
patient, so that they will tell you their story.
    I mean, there are certain--in our age population, 50 and 
over, particularly, there are certain things that are 
associated with suicide, antecedent so to speak. Substance 
misuse, pain, depression, maybe PTSD, life stressors, we need 
to have a relationship with that patient such that they will 
tell us about those. They will tell us their story if you will, 
as opposed to the usual, is anything bothering you; no, nothing 
is bothering me. I think you have heard the interactions many, 
many times where it tends to be superficial and you don't 
really get the story.
    So getting at patients early through transition, and 
developing the relationships where they will tell us where 
there are things that may be antecedents to suicide that are 
bothering them, that we can act on again before there is a 
crisis.
    Mr. Runyan. Well, I think, and this is more of a statement 
than anything else. I think the bigger question is, it is human 
nature to be secluded and not do that. But how statistically 
can we deal with DoD data, kind of figure out people that are 
in the same unit, or that have been exposed to things like 
that, how can we proactively prod them, if you will, do you 
know, give us that information?
    Mr. Petzel. Well, certainly if we have access to the 
medical record with this integrated health record that is being 
developed, we will be able to see those people that have had 
difficulty meeting their mortgages, that have a difficulty with 
substance misuse, that have had behavioral problems, et cetera. 
Those things are all triggers that would indicate to us this 
person needs to be evaluated, this person needs to be looked at 
closely.
    It is getting the information, and the contact with the 
individual before they have the difficulty as you have pointed 
out is the problem.
    Mr. Runyan. Thank you, Chairman. I yield back.
    Mr. Chairman. Dr. Petzel, you may not be able to answer 
this today, but going back to testimony that was received two 
years ago, about a study published in the Journal of Traumatic 
Stress on the treatment utilization rates of veterans of Iraq 
and Afghanistan which found that less than ten percent of those 
newly diagnosed with PTSD received the recommended number and 
intensity of VA evidence based treatment sessions within the 
first year of their diagnosis.
    Can you comment on that? Has that gotten better?
    Mr. Petzel. I think you are right, Mr. Chairman. We are 
going to have to get back to the Committee. I am not familiar 
with the study, and I am not able to cite any specific evidence 
if that situation is different than what is in the study. So if 
we could, we would appreciate the opportunity to come back to 
you.
    Mr. Chairman. It was Dr. Karen Seal who testified, in mid-
June of 2011, but we will get you the information. I would like 
to measure this year against last year.
    Mr. Petzel. I would also. Thank you.
    Mr. Chairman. Okay. Yes, sir. Ms. Brownley.
    Ms. Brownley. Thank you, Mr. Chair. Before I ask a 
question, I would like to ask you, I mentioned earlier that I 
recently visited some VA facilities or most of the VA 
facilities in my district, the Oxnard, CBOC, the Ventura Vet 
Center, and West Los Angeles Medical Center, which serves both 
Ventura vets as well as Los Angeles County vets. And as you 
know, it is the VA, the West LA Medical Center is the largest 
medical center in the country.
    And I would just like to ask consent to include some 
written questions into the record for--as a result, I have 
questions from those visits that I had in Ventura County, as 
well as the West LA Medical Center, if I could submit those to 
the record on behalf of myself and Congressman Waxman, who also 
represents specifically the West LA Medical Center?
    Mr. Chairman. Without objection, and let the record show it 
is at the request of all Members of this Committee.
    Ms. Brownley. Thank you, Mr. Chair. And I just wanted to go 
back to, I think, you know, listening to the testimony of the 
first panel, I think my sort of biggest take away from that 
testimony is looking at our models of delivery, noting that 
personalization, trust, are essential components. Some of the 
testimony talked about looking, comparing our delivery of vet 
services to private practice, meaning having contact with one 
individual, with one therapist who you can call, you know, 24/7 
if needed.
    And so--and I know that they are--and your testimony that 
you talked about a lot of different programs which I believe 
are beneficial and are improving services, but it still is a 
concern to me if the personalization and trust is still built 
in to all of those programs. If you have to move from one 
program to the next program to the next program, I mean, that 
is one thing when you are having heart trouble, and you are 
going to get an X-ray and moving from one situation to the 
next. But for mental health care services, vets I believe, are 
different.
    So in the spirit, I guess, of--in any operation, in the 
spirit of sort of continuous improvement, are we looking down 
the road to sort of other models of delivery that would improve 
and enhance and bring our delivery of services perhaps closer 
to a private practice model?
    Mr. Petzel. The answer short is yes, Congresswoman 
Brownley. But I mean, in a moment, I am going to ask the other 
witnesses to comment on the remarks that Dr. Schwartz made, 
which are not the case. I cannot speak specifically what is 
going on in Connecticut, but our providers give their cell 
phone numbers, develop safety plans, et cetera to individual 
patients, and they are available 24/7, in addition to the 
emergency room services that we have available in all of our 
medical centers, and some of our larger clinics. That is just 
the way the system works.
    But as I said earlier, this developing of a relationship 
and such that people will talk to you about what is going on, I 
think is a very important fundamental part. And we have a newly 
organized task force that Dr. Kemp is chairing, that is going 
to look at how we can develop a different paradigm, if you 
will, for the way we deliver care to people that have chronic 
pain, sleep disorders, depression, et cetera. The thing that 
have the greatest impact on suicide.
    The other care model that is growing rapidly in our system 
is the embedding of mental health providers into the primary 
care clinic, or the PACT team. We now have, I believe 593 
places where that is actually happening, both in our medical 
centers, in our primary care clinics.
    And there you would have a nurse practitioner in mental 
health, perhaps a psychologist, or a psychiatric social worker 
who works with that primary care team, and has a relationship 
back to the primary mental health group, a psychiatrist, et 
cetera. And that individual is able to manage the mental health 
issues in that panel of primary care patients. Therefore, that 
individual with mental health difficulties does not have to 
leave that clinic. All those services are available in that 
same arena.
    I think that is going to become a rapidly developing 
phenomena. The VA is a pioneer in that, but I think this is 
something you are going to see in other integrated delivery 
systems in the private sector.
    And then the last thing is telemental health, which is 
growing very rapidly, and is the way that we are reaching, one 
of the ways that we are reaching into the rural parts of this 
country to provide the specialized mental health services.
    Ms. Brownley. And following up, there was also a comment 
about--part of the testimony saying that the larger the VA 
becomes, there is the possibility, I guess I should say of the 
quality and effectiveness of programs going down. And the 
notion of combining--partnering VA services with state services 
and I think community services to, again, I think to attract 
the right models of personalization and consistency and 
effectiveness, so.
    And what you were just suggesting and looking ahead to, are 
you also looking at greater community partnerships for our 
veterans?
    Mr. Petzel. Yes, we are, Congressman. That is what the 15 
pilots are all about. That is what the network that we already 
have established in Montana is all about. And I think that 
there is going to be fruitful work to be done, particularly 
with the community mental health systems, which is another 
federally funded system around the country.
    You know, the difficulty in the private sector is, they 
have got the same problems with shortages as everybody else 
does. When you look at a map of this country, there are 33 
states where more than 25 percent of the population is under 
served in terms of mental health, going all the way down the 
inter-mountain country, there are 18 states in that area that 
have a shortage of mental health providers. There is not a lot 
out there for us to contact within these community mental 
health clinics, are one of the resources that we know, you 
know, is there. And we intend to exploit that.
    Ms. Brownley. And what about pipeline issues? I read, I 
think, in your testimony or in another report that for example, 
psychiatrists, there is a shortage of psychiatrists, and I hear 
your concern about the limited amount of talent that is out 
there, that we need to secure. And so are we looking towards 
that sort of pipeline issue to make sure that we do, that we do 
indeed--am I over my time, Mr. Chair?
    The Chairman. Yes. There is a clock right in front of you.
    Ms. Brownley. Oh, I was looking at my clock here, and it 
says three minutes. I apologize.
    The Chairman. Yes, the little red light, the little red 
light, three minutes means you are three minutes over time.
    Ms. Brownley. Oh, I apologize.
    Mr. Petzel. May I take a moment, Mr. Chairman, to respond?
    Mr. Chairman. Please.
    Mr. Petzel. In terms of the pipeline, very important 
question. VA is the largest health--trainer of health care 
professionals in the country. We devote 6,400 trainee 
physicians a year to mental health programs. 1,900 psychology 
training positions, mostly internships, the finishing year for 
a psychologist, 3,400 psychiatry residency physicians, again 
the largest trainer of psychiatrists in the country; and then 
1,100 psychiatric social worker positions.
    We added last year 220 positions to that, all of them in 
these new concept team care organizations, training physicians 
in the PACT mental health embedded program, et cetera.
    So we are a big trainer. Seventy percent of the people we 
recruited in psychiatry and psychology trained within the VA. 
It is a very important recruitment tool for us. But I think the 
Committee must recognize the fact there is a shortage of 
psychiatrists in this country. There are not enough training 
positions for psychiatric residencies.
    The Chairman. Thank you very much. Mr. Coffman?
    Mr. Coffman. Thank you, Mr. Chairman. Dr. Petzel, in your 
testimony you state that as of March 2012, the VA was said to 
have 18,587 mental health providers, and by using an approved 
accounting methodology, the VA currently has 19,743, but on 
April 19th, 2012, the VA indicated it was adding 1,900 staff, 
``to an existing workforce of 20,590.'' Now, I'm not a 
mathematician, but the numbers show that VA is losing mental 
health professionals. So in what kind of fuzzy math is your 
current level of 19,743 a ``net increase'' over the past level 
of 20,590?
    Mr. Petzel. Well, Congressman Coffman, it is not fuzzy 
math. We had a process for assessing how many people we had on 
board in March that I would describe as incomplete. We took one 
database, and applied it across the country, and came up with a 
number that approximated 20,500 if I remember correctly.
    Over the summer, we have refined the way we count our on 
board strength, and what we have discovered is that there were 
people not doing clinical work, that were included in that 
20,500. They were hired to do clinical work and research, and 
we were counting them a hundred percent clinical. They were 
hired to do clinical work and education, and we were counting 
them as a hundred percent clinical work.
    When we went back and used two separate databases and 
refined these educational and research components and 
administrative components out of that, we came back with an on 
board strength in March of 18,587. Using that same methodology 
in November, we came on--we came to an on board strength of 
19,743. Thus, an increase of 1,156. Very clear, it is not 
fuzzy, it is not playing with the numbers, that is the fact.
    Mr. Coffman. I think that--it is odd that you--that VA 
would not know exactly how many people when asked are providing 
work to help our veterans. And so the--Dr. Petzel, has VA done 
anything to find out what your own mental health providers are 
saying about the work being done?
    Mr. Petzel. Yes. That is an excellent question. When we, 
this spring have got implemented our performance criteria for 
timeliness, the intention is to go out and do three things. 
One, look at the measures. Two, survey veterans as to whether 
or not they were--had timely access as well as other 
satisfaction related questions. And three, to survey the staff. 
Are they able to provide timely access for their patients, are 
they adequately staffed, do they have enough people to do the 
work that they are being required.
    So, yes, we are going to do it. And we will be doing that 
on a regular basis. That is part of evaluating whether or not 
we are accomplishing what we said we would accomplish in terms 
of access.
    Mr. Coffman. Great. Could you please provide a copy of the 
unadulterated results to the Committee by the end of the day?
    Mr. Petzel. Well, this is something we are going to be 
doing this spring, Congressman.
    Mr. Coffman. But there was a recent survey done, was there 
not? Could you provide to the Committee any recent surveys done 
in the last 12 month period on your providers, in terms of what 
we just talked about?
    Mr. Petzel. Yes, we will.
    Mr. Coffman. Thank you very much. Mr. Chairman, I yield 
back.
    The Chairman. Thank you very much. Mr. Michaud, anymore 
questions?
    Dr. Petzel, thank you and the folks that have joined you 
for what you do. We all want to work together to resolve this 
issue. My last question I guess to you is, what recommendations 
do you have for this Committee that we can do to aid you in 
your quest to provide quality and timely mental health services 
to our veterans?
    Mr. Petzel. That is an excellent question, thank you. One 
is facilitating our interactions with the community health 
centers. I cannot be specific, but I think that is an important 
part of the future.
    Two, is helping us work with the private sector, provide a 
community where it is available to provide services in areas 
where we are not able to do that.
    And then three, I would add as I mentioned earlier, I do 
not know how this Committee can influence it, but there is a 
real shortage of psychiatrists in this country, and mental 
health training positions. And whatever can be done to help 
improve that, I think would benefit the veteran community.
    The Chairman. I do find it quite interesting that you have 
mentioned the shortage of providers several times in your 
testimony, yet you are almost exceeding your goals for hiring. 
What do you do that the private sector cannot do that helps you 
fill those slots so quickly?
    Mr. Petzel. Thank you, that is also a very good question. 
Number one, our salaries are very competitive for nurses, for 
psychologists, and for social workers. Number two, is a good 
place to have a career. It is a large organization, and can 
work in many different parts of the country, and you do many 
different kinds of jobs.
    We do have, however, difficulty in the psychiatry. I mean, 
I do not want to brush over that. Of all of the professionals 
in mental health, the most difficult problem we are having is 
recruiting psychiatrists, and we have barely been able to 
recruit half of the new ones that we said we wanted to do, and 
that it is in spite of raising the salary quite substantially, 
providing incentives for recruitment bonuses, et cetera.
    The Chairman. Okay. Thank you very much. I would ask 
unanimous consent that all Members would have five legislative 
days to revise and extend their remarks, or add any extraneous 
material for the record. Without objection, so ordered.
    Thank you everybody for being here today. Thank you to both 
panels. This hearing is adjourned.

    [Whereupon, at 12:02 p.m., the Committee was adjourned.]



                            A P P E N D I X

                              ----------                              

            Prepared Statement of Hon. Jeff Miller, Chairman
    The Committee will come to order.
    Good morning, and welcome to today's Full Committee hearing, 
``Honoring The Commitment: Overcoming Barriers To Quality Mental Health 
Care for veterans.''
    Today's hearing is our first Full Committee hearing of the 113th 
Congress and it is only fitting that we begin our oversight by 
addressing one of the most pressing and fundamental issues facing our 
servicemembers, veterans, and their families--our ability to provide 
timely and effective mental health care to veterans in need.
    This issue is not a new one, but it is a growing one.
    In the last six years, there has been a thirty-nine percent 
increase in VA's mental health care budget and a forty-one percent 
increase in VA's mental health care staff.
    Unfortunately, those significant increases have not resulted in 
equally significant performance and outcomes.
    Less than a year ago, the VA Inspector General released a review of 
veterans mental health care access that painted a disturbing picture, 
showing that the majority of veterans who seek mental health care 
through VA wait fifty days, on average, for an evaluation.
    That figure amounts to thousands of veterans in need--veterans who 
have recognized they need help and who have taken the hard step of 
asking for it--being told by the Federal bureaucracy tasked with caring 
for them that they have to wait in line because VA cannot provide them 
with the timely access to care they need to begin healing.
    And it gets worse.
    Earlier this month, VA released its 2012 Suicide Data Report.
    That report shows, among many alarming findings, that the suicide 
rate among our veterans has remained steady for the past twelve years, 
with eighteen to twenty-two veteran suicide deaths per day since 1999.
    As that report so clearly illustrates, when a veteran is in need of 
care, the difference of a day or a week or a month can be the 
difference between life and death.
    This morning, the department is going to testify that progress is 
being made to increase access to mental health care services and reduce 
veteran suicide.
    They will proclaim that they have hired just over thirty-two 
hundred additional mental health care personnel.
    However, despite our requests, VA has not provided evidence to 
verify its efforts.
    And while I am and will remain supportive of the improvements the 
department is attempting to undertake internally, it has become 
painfully clear to me that VA is focused more on its process and not 
its outcomes.
    The true measure of success with respect to mental health care is 
not how many people are hired, it is how many people are helped.
    Since 1999, VA's mental health care programs, budget, and staff 
have increased exponentially and the number of veterans seeking care 
has grown, yet the number of veterans tragically taking their own lives 
has remained the same.
    What's more, the Suicide Data Report I mentioned earlier, shows 
that the demographic characteristics of veterans who die by suicide is 
similar among those veterans who access VA and those veterans who 
don't.
    Something is clearly missing.
    On our first panel this morning we will hear from representatives 
from our veterans service organizations, an established veterans mental 
health researcher, and a state commissioner of veterans affairs.
    Three of them are veterans themselves, and all of them will testify 
that the provision of mental health care services through VA is 
seriously challenged and that what is needed to fix it is decidedly not 
more of the same.
    Last night, the President announced that a year from now thirty 
four thousand of our servicemembers currently serving in Afghanistan 
will be home.
    The one size fits all path the department is on leaves our 
returning veterans with no assurance that current issues will abate and 
fails to recognize that adequately addressing the mental health needs 
of our veterans is a task that VA cannot handle alone.
    In order to be effective, VA must embrace an integrated care 
delivery model that does not wait for veterans to come to them, but 
instead meets them where they are.
    VA must stand ready to treat our veterans where and how our 
veterans want, not just where and how VA wants.
    I can tell you this morning that our veterans are in towns and 
cities and communities all across this country, and the care they want 
is care that recognizes and respects their own unique circumstances, 
preferences, and hopes.
    Thank you all for being here today.

                                 
               Prepared Statement of Hon. Michael Michaud
    Thank you, Mr. Chairman, for continuing to keep the issue of 
access, quality, and timely mental health services provided to our 
veterans at the forefront of this Committee.
    Thank you to all of our witnesses today for coming and talking with 
us about the critical issue of veteran mental health access. I would 
also like to thank all of you in the audience who are here today in 
support of veterans.
    We, as a Nation, have a responsibility - a sacred trust - to care 
for those whom we send into harm's way. When we send our citizens into 
battle around the world, we must be leading the charge here at home, 
within our government, to make them whole again upon their return by 
ensuring that adequate resources and proper programs are in place to 
address their needs.
    Oversight of VA's mental health programs has been a focus of this 
Committee for some time now. Over the years we have held numerous 
hearings, increased funding and passed legislation in an effort to 
address the challenges veterans from all eras face.
    VA spent $6.2 billion dollars on mental health programs in Fiscal 
Year 2012. I hope to see some positive progress that this funding has 
been applied to the goals and outcomes for which it was intended, and 
the programs are working.
    We all know that mental health is a significant problem that the 
Nation is facing, not just veterans or the VA. In this broader 
challenge is an opportunity for the VA to look outside their own walls 
to solve some of the challenges they face, rather than operate in a 
vacuum as they sometimes have done in the past.
    One of the most pressing mental health problems we face is the 
issue of suicide and how best to prevent it.
    Fiscal Year 2012 tragically saw an increase in military suicides 
and for the third time in four years, the number of suicides surpassed 
the number of combat deaths. Couple that with the number of suicides in 
the veteran population of 18 to 22 per day and the picture becomes even 
more alarming.
    I believe VA is headed in the right direction. I believe that they 
have made a true effort to get a good picture of the suicide issues 
that surround veterans. I believe more can and must be done.
    I will be interested to hear from our panelists about the national 
mental health picture and helping this Committee put the veteran 
suicide rates in context, as well as what is happening nationally in 
treating mental illness.
    Today's hearing will examine the progress VA has made in a variety 
of areas concerning mental health and providing timely access and 
quality care.
    I am hopeful that this will be a good discussion on ways to provide 
that care such as more partnering with the public and private sector, 
increasing the pool of providers, and other creative ways to address 
mental health.
    Finally, I would be remiss if I did not acknowledge the dedication 
of the VA employees who provide quality mental health care to our 
veterans every day. The directors, doctors, nurses and hospital workers 
are a team that when it comes together in a collaborative and 
synergistic way delivers on the Nation's responsibility and sacred 
trust to care for those who have sacrificed.
    With that Mr. Chairman, I yield back.

                                 
               Prepared Statement of Hon. Jackie Walorski
    Mr. Chairman, it's an honor to serve on this Committee.
    I thank you for holding this hearing on such an important issue 
facing our Nation's veterans.
    I must first express my sincere gratitude to the 50,000 veterans 
and their families back in Indiana's Second Congressional District. \1\ 
I am indebted to these men and women for their sacrifice in protecting 
this great Nation.
---------------------------------------------------------------------------
    \1\ There are an estimated 53,318 veterans in IN-02. This data was 
compiled on 09/30/2012, based on the district lines from the 112th 
Congress. http://www.va.gov/vetdata/Veteran--Population.asp
---------------------------------------------------------------------------
    While I am proud of these veterans, I am appalled and saddened by 
the progress that has been made in providing them with timely and 
appropriate mental health care. It is obvious that we must work to 
significantly improve the procedures and systems used in providing 
mental health care to current veterans as well as those servicemembers 
soon transitioning to civilian life.
    I look forward to working with my colleagues and our panelists to 
ensure our veterans are provided with the best access to mental health 
care.
    Thank you.

                                 
                  Prepared Statement of Hon. Raul Ruiz
    Thank you Mr. Chairman for holding today's hearing on mental health 
care services for our veterans. Oversight of VA's mental health 
programs has long been a focus of this Committee. And while much has 
been accomplished, we still have a long way to go in providing our 
veterans with quality, efficient mental health care.
    I am always discouraged when I hear stories of struggling veterans 
facing delay and denial of much needed care here at home when they 
sacrificed so much abroad. Our health care system is not only dated, 
but also strained to capacity. We need to begin modernizing and 
streamlining the process so veterans who need care can get care 
quickly.
    In this spirit, I am encouraged by a recent announcement last April 
of the addition of 1,600 mental health clinicians and 300 support staff 
to the VA's existing workforce. While this is a start, the VA needs to 
continue to focus on the many other cracks in the system including its 
inaccurate reporting of timely patient care.
    These issues are extremely important to veterans in my district 
considering the location of VA's Palm Desert clinic which provides 
primary care services for veterans in the Coachella Valley, including 
mental health care services.
    Thank you, Mr. Chairman, and I yield back my time.

                                 
                  Prepared Statement of M. David Rudd
    Mr. Chairman and members of the committee, I appreciate the 
opportunity to speak on the issue of barriers to quality mental health 
care for Veterans. As revealed in the Department of Veterans Affairs 
2012 Suicide Data Report, Veterans continue to die by suicide at 
tragically high rates, with an estimate of 22 deaths per day. However, 
the true scope of the problem is only realized by coupling VA and 
active-duty data. As has been widely reported, there were 349 suicides 
among active-duty service members in 2012, with that total exceeding 
combat deaths (and the rate doubling since 2004). Prior to Iraq and 
Afghanistan, military service was actually protective, with military 
suicide rates noticeably lower than general population rates likely 
secondary to pre-enlistment screening, unit cohesion, the influence of 
a remarkable sense of purpose, and a warrior identity. A decade of war 
has changed many things. It is important to recognize that Veteran 
suicides may actually be underreported, with reliable data only 
available in 21 states and data from two of our largest states (Texas 
and California) not included in the report. I have serious concerns 
that these numbers will continue to grow in the coming months and 
years, primarily a function of converging forces that can both be 
anticipated and managed more effectively.
    Although I applaud the transparency and thoroughness of the VA 
Suicide Data Report and progress made to date, I believe it critical 
for the committee to put the data into context. It is correct that 
suicide rates among Veterans (VHA users) have been relatively stable 
over the course of the past 12 years, with an overall rate of 35.9/
100,000 in 2009 (and a male suicide rate of 38.3). It is critical to 
recognize, though, that the rate is three times the national rate of 
12.0 in 2009 and double the male suicide rate (19.2) for the general 
population. It is also reported that although the suicide rate among 
Veterans rose 22 percent over the past decade the general population 
rate rose 31 percent. Please understand, though, that the Veteran 
suicide rate is already so high that the rate of growth should 
naturally slow. Similarly, the drop in the percentage of our nation's 
suicides accounted for by Veterans is important (from 25 percent to 21 
percent), but that means that one in five suicide deaths in the general 
population is by a Veteran despite the lowest military service rates in 
U.S. history. Perhaps most worrisome among findings is that younger 
Veterans appear to be dying by suicide at disproportionate rates (when 
compared to the percent of Veterans in the contributing states), with 
rates more comparable in older age groups. This data might reflect a 
persistence of problems from activity-duty to Veteran status for Iraq 
and Afghanistan Veterans in particular. My concern is that the data 
need to be accepted for what they represent, a very serious and 
significant health problem among Veterans. Contrast and comparisons to 
the general population, although limited, help us recognize the 
magnitude and persistence of the problem. These data should challenge 
us to do better not reassure us the problem is under control. These 
data should challenge us to think about doing things differently, not 
simply funding ``more of the same''. These data can be added to almost 
a decade worth of findings that indicate what we have been doing has 
not been particularly effective.
    As indicated in the report, since 2009 approximately 30 percent of 
callers to the national crisis line have endorsed thoughts of suicide, 
down from 40 percent. Although the drop could suggest progress, it is 
more likely that the crisis line is not actually attracting the highest 
risk callers. Are we reaching those at greatest risk for suicide? The 
persistence of high suicide rates would suggest the VA might need to 
explore other options for identifying and reaching those at greatest 
risk. The fact that 80 percent of those with non-fatal events were seen 
4 weeks prior to the event suggests the need to target the continuity 
and intensity of care, along with raising the question of whether or 
not heightened risk is readily recognized by clinicians. If it is, we 
need to improve access, the frequency, and continuity of care. We know 
the VA provides high quality care. Access to predictable, frequent 
follow-up care is an issue to target. Similarly, the fact that 90 
percent were seen in an outpatient setting suggests the need to target 
primary care and outpatient mental health as the focal points. The fact 
that the greatest risk is among Veterans over age 50 speaks to the 
chronicity of many of these mental health problems and the importance 
of not just crisis care, but ongoing long-term treatment. In order to 
reduce wait times and provide accessible, predictable, long-term care 
the VA will need to explore partnerships with private community 
providers. Continued centralization within VA healthcare needs to be 
challenged.
    I am convinced that the bulk of the problem is not a clinical one. 
We have to do a better job of managing those at risk, providing easy 
and frequent access to care, and convincing Veterans to stay in care. 
The more difficult we make it to get or stay in care, the more Veterans 
will die by suicide. I believe that among the most significant barriers 
to care for Veterans is the lack of meaningful transitional services 
for those evidencing heightened risk while on active duty, only to be 
discharged and left alone to navigate the maze of government services. 
The tragic suicide of Russell Shirley demonstrates the problem. I 
recently spoke with Russell's mother and one of his close friends. His 
mother consented to me sharing his story. Russell was a son, a husband, 
a father and a soldier. He served his country proudly and bravely in 
Afghanistan. Although he survived combat, he came home struggling with 
post-trauma symptoms and traumatic brain injury. With a marriage in 
crisis and escalating symptoms, Russell turned to alcohol, with the net 
outcome a DUI and eventual discharge. Russell lost his family, his 
career, his identity, and eventually put a gun to his temple and pulled 
the trigger in the presence of his mother. His mother now struggles 
with her own brand of PTSD. Russell's high risk status was easily 
recognized. In order to help struggling soldiers like Russell, we need 
to connect them not just the VA system, but people in the system. The 
DoD and the VA need to work hand in hand to improve transitional 
services for high-risk service members being discharged or voluntarily 
separating. With significant budget cuts likely, these numbers will 
only grow. The VA needs to experiment with partnerships in local 
communities that allow Veterans to receive accessible and long-term 
care near home rather than having to travel great distances. Instead of 
building an even bigger and less flexible and responsive healthcare 
bureaucracy, now is the time to experiment with new and creative 
alternatives.
    For the first time in history, we have conducted clinical trials 
with active-duty service members struggling with PTSD, depression and 
suicidality. Early results are promising. Can we find a way to provide 
treatment prior to designating a Veteran as ``disabled'', as we know 
that once someone is identified as disabled it is unlikely that status 
will ever change? This also speaks to the chronic nature of the 
problems revealed in the VA report, i.e. the highest suicide rates 
among those over age fifty. As the drawdown in Afghanistan continues 
and the DoD grapples with smaller budgets and force reductions there 
will be more tragedies like that experienced by the family of Russell 
Shirley unless we find ways to ease the transition from activity duty 
to VA services, improve access, retain Veterans in treatment, and 
experiment with alternatives to permanent disability status.
    It is important to recognize that behind every statistic quoted 
above there is a large collection of friends and loved ones. I have 
included a photo of Russell with his children at the end of this 
document so you and I can remember the Americans touched by this 
problem.
    M. David Rudd, Dean, College of Social & Behavioral Science, 
University of Utah
    Co-Founder and Scientific Director, National Center for Veterans 
Studies

                                 
             Prepared Statement of Linda Spoonster Schwartz
    Good morning Mr. Chairman and Members of the Committee, my name is 
Linda Schwartz and I have the honor to be Commissioner of Veterans' 
Affairs for the State of Connecticut. I am medically retired from the 
United States Air Force Nurse Corps and hold a Doctorate in Public 
Health from the Yale School of Medicine. I also serve as North East 
Vice-President and Chairman of Health Care for the National Association 
of State Directors of Veteran Affairs. I want to thank you for holding 
this hearing and for being concerned about overcoming barriers to 
quality mental health care for veterans.
    I served 16 years in the United States Air Force both on Active 
Duty and as a Reservist (1967-1986), since that time, a great deal has 
changed in the composition and needs of America's military and the 
Nation's expectations for the quality of life and support for the men 
and women of our Armed Forces. Now women comprise approximately 20 % of 
the military force, a stark contrast to the fact that before the advent 
of the all volunteer force, women were limited by law to only 2% of the 
Active Duty force. Another striking feature of our military force today 
is the heavily reliance on the ``citizen soldiers'' of our Reserve and 
National Guard and the increasing number of military men and women on 
Active Duty who are married with children. The Department of Defense 
reports that 93% of career military are married and the number of 
married military personnel not considered career is more than 58% 
today. Because military families of our Reserve and National Guard 
units are no longer housed on military instillations, they do not have 
the support systems and sense of community enjoyed by previous 
generations of military members.
    As America has continued to task Reserve and National Guard units 
with greater responsibilities in combat areas the realities of multiple 
deployments, loosely configured support systems and traditional 
military chain of command mentalities are challenging mental health 
delivery systems. Transitioning in and out of family life is not only 
difficult for the military member, the family, spouse, children, 
mother, father, sister, brothers and/or significant others are also 
traumatized as well. This is not happening on a remote site or military 
base, this time we read about our neighbor next door, the young woman 
who teaches kindergarten, our friend from school or church.
    As Connecticut's Commissioner of Veteran Affairs since 2003, I have 
a unique position and responsibility to be sure that we do not repeat 
the mistakes of the past. As a veteran of the Vietnam War and a nurse 
who has dedicated over 20 years to advocacy for veterans, I am acutely 
aware of the fact that the veterans returning home now are very 
different than the veterans of my generation or my fathers World War II 
generation. While they are not encumbered with validating the 
legitimacy of Post Traumatic Stress, they have brought the issues of 
blast concussions, Traumatic Brain Injuries, suicides and the 
importance of families to mission readiness to the forefront. Perhaps 
it is because they may have trained with a unit for years and 
experienced the intensity of living in the danger of a war zone with 
their unit, that they feel isolated in their own homes. During 
deployments, they longed for family and friends with visions of a 
celebrated homecoming only to find upon their return home that crowds 
and daily responsibilities are both overwhelming and frightening. After 
living on the edge of danger for the prolonged deployment periods, life 
in America seem boring and mundane. Although they care deeply about 
their families, they are ``different'' and ill at ease in their 
everyday existence and can't seem to find their way ``HOME Along with 
the ``Send Off'' ceremonies and the ``Welcome Homes'', observers began 
to realize that families left behind experienced difficulties and 
stress every day of the deployment. Along with readjusting to the 
absence of the military member and the great unknown of what they would 
be encountering during their tour of duty, those of us tasked with 
working with these families came to the realization that there were 
serious gaps in the system. In addition to the day to day concerns of 
home repairs, young spouses managing additional duties in the home, 
environment and financial constraints, families were having 
difficulties that indicated a need for professional counseling and 
treatment to cope with the demands and strains they encountered.
    State of Connecticut Mental Health Services and Programs for 
Veterans For more than 25 years, the State of Connecticut Department of 
Mental Health and Addiction Services (DMHAS) has documented the veteran 
status of their clients. As a Public Health Nurse working with 
psychiatric patients in the community, I was impressed that the 
question was included in the application for services. However it was 
not until the late 1990's that someone thought to quantify this 
population and found that over 5,000 Connecticut Veterans were 
receiving their Mental Health Service from the State. Over time that 
number has fluctuated but remains steady at the 5,000 mark. In that 
time VA has increased their outreach to veterans across our small State 
and established six Community Based Outpatient Clinics (CBOCS) in 
addition to 5 Vet Centers. I believe our experience with these services 
and the veterans in our State illustrate some of the ``barriers'' you 
are discussing today.
    As the wars in Iraq and Afghanistan have continued, the needs of 
veterans of those hostilities as well as veterans from previous periods 
of service, who need mental health services, have challenged the VA 
systems of care on several fronts. The deployment of Connecticut's 
largest National Guard Unit to Iraq brought to light the question of 
how this utilization of the true ``citizen soldiers'' would be assessed 
and addressed and what did we need to do to assure they received the 
help they earned when they came home. With over 1,000 members each town 
and city in our town had someone deployed to an active combat zone. As 
the State agency tasked by Statute with providing services and assuring 
the quality of services for those who ``are and have served in the 
Armed Forces of the United States''. I realized that our State needed 
to decisively address the issues of this new generation of soldiers and 
begin to plan for their return and programs that would be effective, 
timely and appropriate.
    Thus, Connecticut embarked on three major efforts: a) Survey of 
Recently Returned Veterans conducted in conjunction with the Center for 
Policy Research at Central Connecticut University; b) Summit for 
Recently Returned Veterans; c) Military Support Program spearheaded by 
the Department of Mental Health and Addiction Services. All of these 
efforts were implemented in 2007. I will refer to these programs and 
will be happy to provide details on how we accomplished and implemented 
the Summit and Survey. Most important and a strength of what we have 
learned is that these findings came from our veterans and have been 
preserved in their own words. I use them to illustrate my points but 
wish to stress that Connecticut Governors, Congressional and State 
Legislators, Commissioners and Directors of State Departments of Mental 
Health, Public Health, Labor, and Education were and have remained 
deeply committed and engaged in this effort.
                  Survey of Recently Returned Veterans
    With the reality that troops being deployed to Iraq, Afghanistan 
represented a striking departure from the mobilization of American 
troops in previous wars, the pro forma conventional methods and 
remedies relied on in the past seemed inadequate for addressing the 
emerging needs of military and veterans in the 21st Century. Thus, we 
embarked on a survey of returning veterans to ``take the pulse'' of 
their thinking, needs and expectations. To assess the growing 
population of returning ``Warriors'' and ``Heroes'' and specific 
problems they were encountering, as well as their expectations for 
services and the goals, we embarked on a series of surveys (2005 and 
2010) in collaboration with Central Connecticut State University's 
O'Neil Center for Public Policy. More than 650 veterans, a mix of 
Active Duty, Reserve and National Guard, with the majority being 
veterans of Iraq and Afghanistan and married (63%) who identified their 
major concerns as problems with spouses (41%), trouble connecting 
emotionally with others (24%), connecting emotionally with family (11%) 
and looking for help with these problems (10%). Using the ``Post 
Traumatic Stress Checklist - Military scale developed by VA National 
Center for PTSD which indicated that the responses of more than a 
quarter of the respondents reported symptoms which exceeded the 
diagnostic threshold for Post-Traumatic Stress Disorder.

    Common Barriers we have observed are:

    1. Proximity to VA - Most veterans today do not want to travel 
distances for care. We tend to think of access to care as being a 
question of eligibility for VA care. However we need to broaden the 
context of access to include transportation, hours of operation, 
qualifications of the provider, consistency in health care provider and 
availability to contact the primary care provider. Most mental health 
providers are available at the local level, have coverage after hours 
and are available to talk with their patients at any time of the day or 
night. This access to primary mental health providers is not standard 
operating procedures for most VA mental health providers. Additionally 
it is a common practice, that many providers in the VA System are not 
Board Certified or professionally credentialed. However these 
expectations are not unreasonable given the requirements for providers 
in the private sector. It is important to remember that veterans in 
today's society are very informed and often have acquired an 
expectation of competency, understanding and support that a health care 
provider especially a mental health provider should have. It is not 
uncommon for veterans to drop out of treatment because they are 
disappointed with the wait times for appointments. Many veterans are 
unwilling to devote and entire day to coming to the VA for care. 
Additionally they expect and deserve clinicians that have an 
understanding and respect for them. Clinicians, who do not meet the 
veteran where they are both with the symptoms they are experiencing and 
understanding and appreciation for the military service, will fail to 
engender a sense of trust that is essential to a therapeutic 
relationship.
    2. Treatment of Family Members - As mentioned earlier families, 
more than any other time, in the history of the Armed Forces are an 
essential consideration when considering the well being and mission 
readiness of our military today. While VA publications actually 
acknowledge that with the return of the veterans from deployments, the 
entire family will go through a period of transition. Along with many 
suggested activities, there is specific reference for a need for 
opportunities to reacquaint families with one another. Part of the 
transition is expected to be a process or restoring trust, support and 
integrity to the family circle. While there is an expectation that 
``Things have changed'' there is also the daunting task of beginning 
the difficult work of transition from soldier to citizen and 
reestablishing their identity in the family, work environment and 
community. Although the publication does a fine job of identifying the 
circumstances and the perils, the directions are not for family but how 
family can assist the veterans. Because services are focused on the 
military member and/or veteran the options for family members is 
limited. VA advises ``Families may receive treatment for war related 
problems from a number of qualified sources: chaplain services, mental 
or behavioral health assistance programs.'' In other words, as a rule, 
most VA Mental Health Programs do not treat family members or include 
them in the treatment of veterans or military members. While some VA 
facilities and individual programs have loosened the restrictions for 
providing services to family members either on an individual, couples 
or family therapy, serious consideration must be given to include these 
vital members of the veterans' support system. Vet Centers have been 
providing this care on a regular basis for decades, this is a model of 
how a system can adapt to the needs of veterans without compromising 
quality of care and managing existing resources. An example from our 
Summit for Recently Returned veterans illustrates the disparity this 
creates. A young Veteran recounted that he felt that treatment at the 
VA was preventing him from getting on with his life which he implied 
really meant VA was doing the exact opposite of what it should be doing 
for veterans and their loved ones. He said that for him, not attending 
the VA meetings ``was not about stigma, it's just that the VA is 
unhelpful.'' When he did go to the VA for help, his wife went with him, 
and they (VA) expressed surprise that she and her husband had come in 
as a couple. The wife was told to stay out of it, that it was ``his 
problem'' and not hers. She felt cut off. This spurred a more 
generalized discussion about how families have no idea how to interact 
with their veterans and feel lost. The conclusion was ``What little the 
VA does for veterans, it does even less for their families''.
                           Domestic Violence
    When addressing the issue of mental health treatment for families, 
I would be remiss if I did not reference the increase body of evidence 
which links combat veterans, Post Traumatic Stress with violent and 
abusive traumatic events in the home. Domestic Violence has always been 
a factor in military life. It is not new. What is new is the fact that 
victims are no longer silent and someone is listening. The American 
public is not as tolerant as it was decades ago to the litany of brutal 
deaths suffered in military communities or at the hands of a military 
member of veteran. While the Pentagon has made efforts to address these 
issues and offer support and education to military families, the 
present hostilities heavy reliance on citizen soldiers of the Reserve 
and National Guard Components accentuate the stressors on everyone 
involved and bring these volatile scenarios to every town and city in 
our Country.
    Additionally over 1 million children in America have had one of 
both of their parents deployed since 9/11. The long separations and 
multiple deployments which have become the standard for todays' 
military can create a sense of isolation, confusion, anxiety which can 
create higher levels of stress and more difficulties within the family. 
The total impact this environment has for members of these families has 
far reaching effects we have yet to know. The high rates of divorce 
within the military community verify that these dynamics are 
disruptions in family life which creates erosions of trust, instability 
that deeply wounds and destroys families.
    3. Women Veterans - The rising number of women serving in the 
military is a well known fact. They are pushing the envelope, serving 
as never before in the combat areas and rising to new leadership roles. 
As a woman veteran, I want to say that along with these achievements 
and advancements, women have come to expect equal respect for their 
contributions to the military mission and defense of this Nation. In 
fairness, we must acknowledge that VA has come a long way with their 
programs for women veterans with programs that have evolved to options 
we only dreamed of in the past.. However when we look at cause and 
effect, we see that reports of Military Sexual Trauma perpetrated on 
women in the military by other military members is both astonishing and 
unacceptable.
    In our States, we see women reluctant to seek treatment because of 
the experiences and victimizations they have had in the military. When 
the Department of Defense acknowledges that 23% of the women in combat 
areas report being victims of sexual assaults . . . not to mention the 
harassment which is not reported, there has not been an adequate 
response to deter these violent acts from reoccurring. Congress and the 
Department of Defense must take more stringent steps to ending the 
decades of this injustice for the women who wear our Nations uniform. 
What would happen if there was a report that 23% of the women working 
at IBM had been assaulted by their coworkers? Where is the demand for a 
``Congressional Investigation''? Why do these reports go unanswered? 
Why would a woman veteran victimized by their own Government look of 
help at the VA? Until Congress, deems this an unacceptable statistic, 
it will continue and these veterans and military members will continue 
to be second class citizens.
    4. Concerns About Confidentiality - With the perfusion of social 
and electronic technology and breaches of confidentiality, there is a 
great deal of concern on the part of military members, private 
providers and veterans about preserving the confidentiality of their 
health care, especially mental health care. Veterans, of deployments 
who are still in the military services as Reservists and National 
Guardsmen have a great deal of anxiety about seeking treatment at the 
VA and how that will affect their military careers and promotion 
potential. Additionally how those records are handled when they are 
transported or used to substantiate a Service Connected Disability are 
deeply troubling and do influence where these veterans receive their 
care. VA is a large system and there is a lack of clarity about what 
access DOD has to these records and where the information will travel.
    The issue of stigma associated with individuals who receive 
professional treatment for mental health problems is a big deterrent 
for veterans in need of this care. In our two surveys of Connecticut 
Veterans the most frequent reason cited for not seeking treatment was 
stigma. Veterans indicated their reluctance because:
    ``I would be seen as weak''; ``Commanders would not trust me''; 
``My Unit would have less confidence in me''; ``Leaders would blame me 
for problems''; and ``It would harm my career''. Interestingly 
respondents to the surveys with the most symptoms suggestive of Post-
Traumatic Stress were also the participants who most often reported 
that ``stigma'' was the greatest barrier to treatment.
    5. Understanding the Military/Veteran Culture - Failure of the 
treatment providers to understand key aspects of the military/veteran 
culture can influence both the willingness to seek treatment and 
continue in treatment. Effective communications is key to any encounter 
but more so when we are dealing with populations that have the shared 
experiences and values of serving in the Armed Forces. In the current 
veteran population, the sense of community that comes from training and 
being deployed in Units strengthens the sense of solidarity, friendship 
and acceptance. Increased emphasis to orienting VA providers that care 
for veterans is essential for success in treatment and trust to stay in 
treatment. It is important that VA acknowledge and support educational 
experiences with include an introduction to the military and veterans 
culture. We realized the importance of this from the surveys we did and 
``Focus Groups'' we convened.
    Most interesting we learned:

    a) Being in combat in Iraq of Afghanistan is profoundly life-
altering

    b) Importance of camaraderie with fellow military or veterans

    c) A sense of isolation from the community and not being understood

    d) Communication difficulties with everyone except fellow military

    e) The experiences of women were not the same as men

    6. Multiple Deployments - It is no secret that a common strategy 
during the wars in Iraq and Afghanistan has been the multiple 
deployments of Active Duty, Reserve and National Guard Units. The 
cycles of these deployments is another consideration which needs to be 
addressed when discussing the quality of mental health services. 
America is yet to know the real consequences of this process. However 
there is a particularly disturbing aspect of this process which bears 
heavily on the individual military member, the quality of their mental 
health services and the defense of our Nation. We have become aware 
that Iraq and Afghan veterans who have received VA Service Connected 
Disability Ratings, some as great as 80-100% are being redeployed. Some 
of these veterans have been rated for mental health disabilities but 
have signed paperwork to stop their disability compensation so that 
they can qualify for mobilizations and redeployments. You cannot 
imagine what kind of difficulties they face after multiple tours, many 
of them expect that their VA checks and Disability Ratings will be 
reinstated upon their return home. Not only are the realities of the 
system a shock, when they learn this does not happen, many face the 
disability rating process all over again. It is incomprehensible to me 
that this practice is permitted and known by the military.
    7. Coordination of Services and Resources - Although Congress, DOD 
and the VA may identify a problem, and derive solutions to these needs, 
the process of enacting legislation and implementing programs is years 
in the making. In the age of text messaging, the response time is 
considered by many to be out of touch and negligent compared to what 
returning ``Wounded Warriors'' or ``Heroes'', their families and most 
importantly the Public have come to expect in exchange for their 
service to the Country. Because our National Guard, comes under the 
authority of Governor's and State Legislatures, there is much more 
demand for accountability at the State and Local Levels that has not 
been experienced by DOD or VA in the past. Active Duty and Reservists, 
who return to their homes as individuals are also of concern because 
their immediate problems and needs arise where they live far from 
Federal Systems. This group is especially vulnerable because, for the 
most part they have retained or received little or no information about 
what is available to them or where to go for help. Many of these 
veterans have undiagnosed injuries or disabling conditions and 
cognitive difficulties which further complicates their ability to 
articulate their needs for help. Currently there exist within large 
public services agencies, including VA, many layers and silos of the 
administration and delivery of services but little emphasis on 
oversight activities and accountability directly effecting veterans at 
the grassroots levels.
                        A Shared Responsibility
    The task of serving veterans is a shared responsibility with States 
and the Federal Government. There is a need to move away from the idea 
that all services and programs must and should be provided by the 
Federal Government. Collectively State Governments spend more than $6 
Billion a year to support their veterans. In order to develop the best 
seamless transition, maximize existing resources and improve the 
accountability for these services t dedicated to the care and support 
of veterans and their families, we must challenge the status quo. Just 
as our military has changed, we must accept the realities that vast 
system changes in support of the military and their families are in 
order. Too often VA on the National and State level do not coordinate 
or even communicate with the State Departments and agencies tasked with 
caring and providing services for our veterans. State based programs 
are augmented by thousands of private-sector, community volunteers and 
faith based initiatives that attempt to help disabled and injured 
service members and their families meet housing, transportation, 
childcare, employment, mental health and short-term financial aid. We 
are not lacking in people wanting to help, we are lacing in a 
coordinated effort, accountability and creative approaches to solving 
problems in the local communities Just as all politics are local, the 
care and welfare of each military member, veterans and their families 
is not only a priority for State Governments, there are local programs, 
services and resources that have been developed to meet the needs of 
veterans where they live and work. State Legislators are as vitally 
engaged in the needs of veterans and also creating new programs and 
services as are Members of Congress.
    A true partnership of Federal and State resources can only improve 
the opportunities for our veterans, especially the troops returning 
today, and their families. My Governor and the citizens of Connecticut 
expect the best for our veterans and know that holding VA accountable 
is often an exercise in futility. While I am heartened that Secretary 
Shinseki has acknowledged States as partners in providing for our 
Nations veterans and has brought this relationship to new prominence, 
it is disappointing that individual administrators and staffs do no 
share his opinion or vision. This is not the continuum of service and 
care that veterans have earned and deserve.
    Several times, Congress has considered legislation which would 
authorize funding to States agencies to support service programs of 
outreach to veterans. Challenge grants, matching funds and program 
grant opportunities are vehicles which must be considered to meet the 
unique needs of veterans and further the work of VA. Consider how much 
time and money has been expended on addressing the backlog for 
processing disability claims and compensation. While the ``Big VA'' has 
made many efforts to streamline the process, consider the possibilities 
of improving the quality of the claim at the start of that process. 
Grants to support, educate and initiate quality assurance at the State 
Veteran Service Officer level from the initial intake, development of 
the claim and final submission has the potential to create fully 
developed claims from the beginning which will facilitate the entire 
rating process.
                 Connecticut's Military Support Program
    In 2004 the Connecticut General Assembly enacted legislation 
authorizing the Department of Mental Health and Addiction Services 
(DMHAS) to provide ``behavioral health services, on a transitional 
basis, for the dependents and any member of any reserve component of 
the armed forces of the United States who has been called to active 
service in the armed forces of this state or the United States for 
Operation Enduring Freedom or Operation Iraqi Freedom. Such 
transitional services are to be provided when no Department of Defense 
coverage for such services was available or such member was not 
eligible for such services through the Department of Defense or until 
an approved application is received from the federal Department of 
Veterans' Affairs and coverage is available to such member and such 
member's dependents.'' (CGS 27-103).
    From the beginning, this initative was a collaborative effort 
between Connecticut's Departments of Mental Health and Addiction 
Services (DMHAS), Veteran Affairs (CTVA), National Guard (CTNG) 
Department of Families and Children (DCF) and the Family Readiness 
Group. Building on the experience DMHAS had gained in assisting 
families in the aftermath of 9/11, the concept of working with mental 
health professionals in the community was ideally suited for the broad 
context of the legislation and the geographical distribution of 
potential clients.
    Also taking from previous ``lessons learned'', the scope of the 
program was created not only to include military members, their spouses 
and children but immediate family members (parents, siblings) and 
significant others were also eligible for care. With the assistance of 
the Connecticut and Federal Departments of Veteran Affairs and the 
Adjutant General, sixteen hours of training in Military 101, dynamics 
of deployments and post traumatic stress including panel discussions by 
OIF/OEF veterans and their families was provided to 400 volunteer 
mental health professionals licensed in Connecticut. Only clinicians, 
completing the training were eligible to participate in the program.
    The Military Support Program (MSP) was designed to streamline the 
process of access to care with an emphasis on confidential services 
throughout the state. The goal of delivering quality, appropriate, 
timely and convenient services was further enhanced by a 24/7 manned 
toll free center, veteran outreach workers and State reimbursement for 
clinical services when there was no other funding available.
    Typically, anyone eligible for the program can call the 24/7 
number. In this day and age, it is important that a real person answers 
the call. If the nature of the call does not involve a mental health 
issue, the caller is directed to an individual at the appropriate 
agency. Should the nature of the call be a request for help with a 
problem best handled by a mental health professional, the caller is 
given the names of clinicians in their immediate geographical area, who 
have completed the training and are registered with DMHAS.
    Another very attractive aspect of this approach is the fact that 
families including the military member can have the opportunity to work 
out their issues together. Due to the limitations of VA Health Care, 
families are often excluded from the therapeutic process which can be 
counterproductive in the long run. Family therapy is less threatening 
to a military member who may not seek treatment because of the stigma 
associated with mental health problems. A 2005 study of Iraq Veterans 
assigned to the Maine National Guard indicated that 30% of those in the 
study expressed a likelihood of participating in ``confidential 
services in the community''. Responses to the question of who they 
would be most likely to participate in support groups included ``with 
other veterans (32%), couples' communication skills training (28%) and 
couples/marital counseling (26%). (Wheeler, 2005) lends credence to the 
concepts we have implemented.
                                Suicides
    Although there is no exact method to determine the actual numbers 
of suicides, even matches with the Death Index would be under reported 
because of concern for the family, religious beliefs or unanswered 
questions. Even the press has no idea of the true numbers of suicides 
in the military or veteran communities because the ``secret'' is also 
part of the shock. However the increased awareness and concern for the 
number of these events and the great hope that these could be prevented 
with better systems, Connecticut Governor Malloy, in consultation with 
the Departments of Mental Health and Veteran Affairs, authorized the 
expansion of the Military Support Program in 2012 for all military, 
veterans and their families.
    Since the Connecticut Military Support Program (MSP) has been in 
operation, they have responded to over 3,500 calls. A particularly 
important aspect of this program is the fact that there is an immediate 
response to a caller with an offer to help. Part of the responsibility 
of a Clinician in the network is to respond within 48hrs of being 
contacted by the MSP client. Many veterans and their families can be 
treated in the communities where they live. While some may require more 
intense care or services offered by the US Department of Veteran 
Affairs the immediate need, assessment, crisis intervention and if need 
be referral to VA provides appropriate, timely and professional 
responses that the situations require.
    Connecticut has been caring for veterans since 1863. From that time 
to this, each generation of Americans, who have shouldered the 
responsibility of serving in our Armed Forces, has influenced the 
development of the collective service systems provided by Federal, 
State and Local governments. Just as the business of conducting war and 
defending the Nation has changed dramatically, America and this 
Committee need to rethink the delivery system and the care we extend to 
those who have borne the battle. The old adage that ``if the military 
wanted you to have a spouse they would have issued you one'' has been 
outstripped by the number of married military members we rely on to 
protect our freedoms. In this day and age, the expectation of caring 
for our military must include tending to the health of their families.
    Mr. Chairman this concludes by testimony, I will be happy to answer 
any questions you may have.

                                 
                   Prepared Statement of Joy J. Ilem
    Chairman Miller, Ranking Member Michaud and Members of the 
Committee:
    On behalf of Disabled American Veterans (DAV) and our 1.2 million 
members, all of whom are wartime wounded, injured or ill veterans, 
along with 200,000 Auxiliary members, I am pleased to present our views 
on addressing the barriers veterans face when trying to gain access to 
mental health services from the Department of Veterans Affairs Veterans 
(VA). DAV is committed to fulfilling our promises to the men and women 
who served, and one of those promises is to ensure that veterans 
receive a full and lasting opportunity to recover from physical, 
emotional and psychological wounds that occur as a consequence of their 
military service experience.
    We appreciate your determination, Mr. Chairman and Members of this 
Committee, for continued concentration on this important and pressing 
issue, as well as the opportunity to offer DAV's views on the 
challenges confronting the Veterans Health Administration (VHA) in 
meeting the critical mental health needs of our nation's veterans. 
DAV's statement focuses on the Committee's concerns about the status of 
VA's progress on growing mental health professional staffing levels; 
mandates outlined in the President's recent Executive Order to improve 
access to mental health services for veterans, service members and 
their families; addressing the recommendations in the 2012 Office of 
Inspector General (OIG) report on waiting times for mental health 
services; improving data collection related to access measures; 
scheduling processes and procedures; and partnering with non-VA mental 
health providers to address gaps in VA care.
    Since the wars in Iraq and Afghanistan began over a decade ago, 
more than 2.4 million individuals were deployed to overseas combat 
theaters; many have deployed several times. Of this group of brave men 
and women, 1.5 million have been honorably discharged and are now 
eligible for VA health care. VA's most recent cumulative data shows 
that 834,467 of them have obtained VA health care and that 53 percent, 
or 444,551 veterans, have been diagnosed with a mental disorder.
    Additionally, there were a record 349 military suicides in 2012, 
exceeding the 310 combat deaths reported during that period.
    More than eleven years of war have clearly taken a toll on the 
mental and physical health of American military forces and the veterans 
among them who have returned to civilian life. Research shows that post 
deployment mental health readjustment challenges and post-traumatic 
stress disorder (PTSD) are prevalent in many returning service members 
and veterans. We believe that everyone returning from contingency 
operations overseas should be empowered to achieve maximal opportunity 
to recover and successfully readjust to civilian life. But to do so, as 
warranted by their circumstances, they must be able to gain ``user-
friendly'' and easy access to Department of Defense (DoD) and VA mental 
health services--services that have been validated by research evidence 
to ensure their best opportunities for full recovery and reintegration 
with their families, jobs and private life.
    Over the past five years, the post-deployment health status of our 
servicemen and women and veterans, suicide prevention, and timely 
access to appropriate mental health services, have been topics of 
numerous Congressional hearings, government reports and regular media 
scrutiny. Collectively, the hearing findings, reports and coverage cast 
a negative impression related to appropriate and timely access to 
services, often highlighting barriers to care and systemic flaws in an 
overly ``medicalized,'' bureaucratic health care system. Given the 
diligent oversight by the Veterans' Committees in both Chambers, and 
the significant level of new resources that were authorized to address 
the existing deficits and to improve VA mental health services and 
other care for veterans, the current question posed by the Committee 
Chair is a valid one: ``Is the VA's complex system of mental health 
[care] and suicide prevention services improving the health and 
wellness of our heroes in need?''
    Mr. Chairman, although flaws unquestionably can be found in the 
system, and must be addressed, DAV would be remiss in failing to 
recognize and applaud VA's efforts to date to improve these programs. 
Tens of thousands of dedicated mental health practitioners and 
Readjustment Counseling Service Vet Center counselors work day-in and 
day-out, to help veterans who are struggling in their post-deployment 
readjustments.
    Over the past five years, VA's Office of Mental Health Services 
(OMHS) has developed and disseminated a comprehensive array of mental 
health services throughout the VA health care system, while 
accommodating a 35 percent increase in the number of veterans receiving 
mental health services and managing a 41 percent increase in mental 
health staff. At DAV, despite all the problems reported, we believe 
this is remarkable progress. In 2011 (most recent data), VA provided 
specialty, recovery focused mental health services to 1.3 million 
veterans, at very high levels of satisfaction. These services were both 
patient-centered and integrated into the basic care of the patients 
using VA services. Today, mental health is a prominent component of VA 
primary care - a long sought goal of DAV, other veterans' advocates and 
the mental health research community.
    VA offers veterans a wide range of mental health services, from 
treatment of the milder forms of depression and anxiety in primary care 
settings themselves, to intensive case management of veterans with 
serious, chronic mental challenges such as schizophrenia, schizo-
affective disorder, and bi-polar disorder. VA also offers specialized 
programs and treatments for veterans struggling with substance-use 
disorders and post-deployment readjustment difficulties, including 
providing evidence-based treatments for PTSD for combat veterans and 
for those who endured and survived military sexual trauma.
    For at least the past five years, while under intense external 
pressure, VA has placed special emphasis on suicide prevention efforts, 
launched an aggressive anti-stigma, outreach and advertising campaign, 
and provided services for veterans involved in the criminal justice 
system, including direct VA participation in the veterans treatment 
courts initiative, to support both pre-release and jail-diversion 
programs in a rising number of states and cities. Peer-to-peer 
services, mental health consumer councils, and family and couples 
counseling and therapy services have also been evolving and spreading 
throughout the VA health care system. We at DAV are encouraged by these 
developments, we believe they are humane approaches, and are saving 
lives.
    Yet despite noted progress, the Institute of Medicine (IOM) 
released a report, entitled Treatment for Posttraumatic Stress Disorder 
in Military and Veteran Populations, in July 2012, that addresses some 
of the Chairman's concerns--specifically, whether the readjustment 
services available to veterans improving the health and wellness of our 
nation's transitioning service members. In the report, after a 
comprehensive review of government programs for the treatment of PTSD, 
the IOM found a lack of coordination, assessment and monitoring by both 
DoD and VA. The IOM concluded treatment is not reaching everyone who 
may need it, and that the Departments are not tracking which treatments 
are being used, or evaluating whether and how well they work over the 
long term.
    DAV concurs with recommendations made by the IOM that VA and DoD 
should invest in targeted research to fully evaluate the effectiveness 
and health outcomes of existing PTSD treatment and rehabilitation 
programs and services. Likewise, VA and DoD should support research 
that investigates new and emerging technologies and web-based 
approaches to overcome barriers to accessing mental health care, and 
adhering as well to more comprehensive and long-term evidence-based 
treatments. The report noted that the IOM committee's analysis of 
innovative or complementary and alternative medicine treatments such as 
yoga, acupuncture and animal-assisted therapy was limited since these 
types of treatments lacked empirical evidence of their effectiveness. 
Given that these alternative treatments have become more popular and 
requested by many veterans, DAV urges that both DoD and VA carefully 
study and evaluate these treatments to judge their efficacy versus 
other approaches.
OFFICE OF INSPECTOR GENERAL 2012 RECOMMENDATIONS, AND PRIOR EXTERNAL 
        REVIEWS
    Based on a request from both Committees on Veterans Affairs, in 
April 2012, the VA OIG reported on the level of accuracy the Veterans 
Health Administration (VHA) documents in waiting times for mental 
health services for new and established patients, and whether the data 
VA collects is a true depiction of veterans' ability to gain and keep 
access to needed services. The OIG found that VHA's mental health 
performance data is inaccurate and unreliable and that VHA's data 
reporting of first-time access to full mental health evaluation was not 
a meaningful measure of waiting.
    Since the OIG had found a similar practice in previous audits 
nearly seven years earlier, and given that VHA had not addressed the 
longstanding problem, OIG urged VHA to reassess its training, 
competency and oversight methods, and to develop appropriate controls 
to collect more reliable and accurate appointment data for mental 
health patients. The OIG concluded that the VHA `` . . . patient 
scheduling system is broken, the appointment data is inaccurate and 
schedulers implement inconsistent practices capturing appointment 
information.'' These deficiencies in VHA's patient-appointment 
scheduling system have been documented in numerous reports.
STAFFING ISSUES
    The OIG also recommended in the 2012 report that VHA conduct a 
comprehensive analysis of staffing to determine if mental health 
provider vacancies were systemic and impeding VA's ability to meet its 
published mental health timeliness standards.
    The DAV shares the Committee's concerns about how VA plans to 
resolve its mental health staffing deficits to meet rising demand for 
critical mental health services. In April 2012, the Secretary announced 
VA would add approximately 1,600 mental health clinicians and 300 
support staff to VA's existing mental health staff of 20,590, in an 
effort to help VA facilities meet burgeoning demand. In his testimony 
before this Committee on May 8, 2012, Secretary Shinseki testified that 
he estimated six months would be required for VA to hire most of these 
new mental health personnel. DAV awaits VA's report on the number of 
new providers who have been hired, and are now providing care to 
veterans. As we have noted in prior testimony, the bureaucratic and 
cumbersome human resources process in VA, especially in credentialing 
new VA professional providers, continues to hamper VA's ability to 
quickly put newly-hired individuals on the front lines caring for 
patients. For more insight on these challenges, please review our 
discussion of VA human resources concerns in the Fiscal Year 2014 
Independent Budget, at www.independentbudget.org.
    VHA's timely access goal is simply to treat a veteran patient in 
clinic within 14 days from the desired date of care. One method VA uses 
to monitor access to health care including mental health services is to 
calculate a patient's waiting time by measuring the number of days 
between the desired date of care to the date of the treatment 
appointment. Appointment schedulers at VA facilities must enter the 
correct desired date(s) of care in the automated scheduling system to 
ensure the accuracy of this measurement.
    Data generated to measure a veteran patient's timely access to care 
continues to remain unreliable. There continues to be weaknesses in 
VA's policy and implementation of scheduling medical appointments based 
on several reports spanning more than a decade from VA's OIG and the 
U.S. Government Accountability Office. \1\ The weaknesses reported 
include VA's definition of the ``desired date'' of the medical 
appointment contained in policy, \2\ and VHA's training and oversight 
program to address the problems in measuring waiting times. We urge VA 
OIG to report on the status of those recommendations from its 2007 
review, which indicated that five out of eight recommendations were 
either not implemented or were only partially implemented.
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    \1\ HEHS-00-90, VA Needs Better Data on Extent and Causes of 
Waiting Times, May 31, 2000; GAO-01-953, More National Action Needed to 
Reduce Waiting Times, but Some Clinics Have Made Progress, Aug 31, 
2001; GAO-12-12, Number of Veterans Receiving Care, Barriers Faced, and 
Efforts to Increase Access, Oct 14, 2011; VA OIG Report No. 02-02129-
95, Audit of Veterans Health Administration's Reported Medical Care 
Waiting Lists, May 14, 2003; VA OIG Report No. 04-02887-169, Audit of 
the Veterans Health Administration's Outpatient Scheduling Procedures, 
July 8, 2005; VA OIG Report No. 07-00616-199, Audit of the Veterans 
Health Administration's Outpatient Waiting Times, September 10, 2007, 
and; VA OIG Report No. 12-00900-168, Veterans Health Administration 
Review of Veterans' Access to Mental Health Care, April 23, 2012.
    \2\ VHA Directive 2010-027
---------------------------------------------------------------------------
    Without reliable data, VA will remain challenged in conducting 
meaningful analysis and decision-making that directly impact the 
quality, patient-centeredness and timely delivery of needed care, 
including mental health care.
    After more than a decade of effort, VA's Office of Information and 
Technology has remarkably still not completed development of a 
replacement for VHA's antiquated, 25-plus year-old scheduling system, 
and one that can effectively manage the scheduling process, provide 
accurate workload data capture and reporting technology, and be 
responsive to the needs of VA's mental health patients and providers.
    As noted in OIG's most recent report on veterans' access to mental 
health care, VA's ``scheduling software is 25 years old and the 
software interface is not ``user-friendly.'' This automated scheduling 
application has been an essential component of the Veterans Health 
Information Systems and Technology Architecture (VistA) electronic 
health record, and performs multiple, interrelated functions. VistA 
captures and assembles utilization data, which is intended to enable VA 
to measure, manage and improve access, quality and efficiency of care, 
and evaluate the operating and capital resources used.
    GAO reported in 2010 on VA management deficiencies, principally 
VA's second effort at developing a replacement scheduling system for 
the aging VistA. \3\ Since that time, VA has abandoned this project, 
and on December 21, 2012, VA issued a request for information in 
Federal Business Opportunities to update and rebuild the application, 
with responses due from industry by January 31, 2013. VA plans the new 
scheduling system to be standards-based, extensible and scalable and 
interoperable with the version of VistA held by the Open Source 
Electronic Health Record Agent (OSEHRA). According to VA, the new 
health scheduling system will rely on web- and mobile-device 
capabilities for quick and secure communications with veterans, and 
support for resource allocation decisions based on truer data, with 
more opportunity to adjust capacity dynamically to meet changing needs.
---------------------------------------------------------------------------
    \3\ GAO-10-579, Management Improvements Are Essential to VA's 
Second Effort to Replace Its Outpatient Scheduling System, May 27 2010.
---------------------------------------------------------------------------
    Because of current weaknesses in measuring veteran patients' access 
to care, it is unclear to DAV at this time if VA's new direction will 
correct lengthy VA waiting times, yield accurate access measures, or 
result in less cumbersome scheduling processes and procedures. DAV 
recommends the Committee conduct further oversight on VA's plans and 
intentions with respect to the replacement of VistA. This challenge has 
become much more acute based on VA's and DoD's joint announcement last 
week of their decision to abandon their long sought joint electronic 
health record project that would have served both the veteran and 
military populations, to proceed in separate directions, but to rely on 
a Janis GUI interface technique to translate data from one system to 
the other. In this case, VA scheduling software and its ongoing 
problems are a major weakness that must be addressed. Most importantly, 
the OIG report noted that meaningful analysis and decision making 
required reliable data, not only related to veterans' access to care, 
but also on shifting trends in demand for services, the range of 
treatment availability and mix of staffing, provider productivity and 
treatment capacity of the facilities. From this study, the OIG made 
four major recommendations to VHA. Similar to previous external 
reviews, the VA Under Secretary for Health concurred with all 
recommendations and replied that a number of responsive actions were 
underway. Again, in this instance we are anxious to determine from VHA 
the progress made thus far on the above-referenced recommendations.
    In August of 2012, the President issued an Executive Order (EO) to 
improve access to mental health services for veterans, service members, 
and military families. It was noted that based on the wars in Iraq and 
Afghanistan, the need for mental health services will only increase in 
the coming years as the nation deals with the effects of more than a 
decade of conflict. We concur and agree that coordination between the 
DoD and VA during service members' transitions to civilian life is 
essential to achieving the goal of timely access to the provision of 
high quality mental health treatment for those who need it.
    The EO focused on six areas including: suicide prevention; enhanced 
partnerships between VA and community mental health providers; expanded 
VA mental health services staffing; improved mental health research, 
and appointment of a military and veterans mental health interagency 
task force. Specific mandates in the EO included: expanding the 1-800-
273-TALK ``Veterans Crisis Line'' capacity by 50 percent; developing 
and implementing a joint VA-DoD national suicide prevention campaign; 
establishing no fewer than 15 pilot programs and formal agreements with 
community-based mental health providers; hiring and training at least 
800 new VA peer counselors by December 31, 2013; hiring 1,600 VA new 
mental health professionals by June 30, 2013; establishing a ``National 
Research Action Plan'' within eight months of the EO; developing in the 
DoD and Department of Health and Human Services (HHS) a comprehensive 
longitudinal mental health study with an emphasis on PTSD and TBI, 
including enrollment of at least 100,000 service members by December 
31, 2012; and, development of an Interagency Task Force of VA, DoD and 
HHS to identify reforms and take actions that facilitate implementation 
of the strategies outlined in the EO.
    This is clearly an ambitious plan, and we look forward to VA's 
report of progress on the outlined initiatives to improve access to 
mental health services for veterans, service members, and military 
families.
PARTNERING WITH NON-VA RESOURCES TO EXTEND ACCESS FOR VETERANS WITH 
        MENTAL HEALTH CHALLENGES
    Mr. Chairman, you recently endorsed a VA-TRICARE outsourcing 
alliance to serve the mental health needs of newer veterans that VA is, 
admittedly, struggling to meet today. Having offered little to bolster 
the confidence of DAV's members and millions of other veterans and 
their families that mental health services are, in fact, being 
effectively provided by VA where and when a newer veteran might need 
such care, we urge VA to work with the Committee to ensure that, if 
mental health care is expanded using the existing TRICARE network or 
some other outside network, veterans must receive direct assistance by 
VA in coordinating such services, and the care veterans receive must 
reflect the integrated and holistic nature of VA mental health care.
    In working with Congress on this issue, the primary question is 
whether VA should partner with community mental health resources to 
provide this care when local waiting times exceed VA's own policies. 
When a veteran acknowledges the need for mental health services and 
agrees to engage in treatment, it is important for VA to determine the 
kind of mental health services needed and whether the most appropriate 
care would come from a VA provider or a community-based source. This 
type of triage is critical, because effective mental health treatment 
is dependent upon a consistent, continuous-care relationship with a 
provider. Once a trusting therapeutic relationship is established 
between a veteran and a provider, that connection should not be 
disrupted because of a lack of VA resources, a local parochial 
decision, or for the convenience of the government.
    Moreover, it is imperative that if a veteran is referred by VA to a 
community resource we would insist the care be coordinated with VA. 
According to the IOM study cited earlier, care coordination is at the 
center of integration, and has been identified as a key component of 
high-quality health care. We agree. A critical component of care 
coordination is health information sharing between VA and non-VA 
providers. Information flow increases the availability of patient 
utilization and quality of care data, and improves communication among 
providers inside and outside of VA. The absence of obtaining this kind 
of health information poses a barrier to implement patient care 
strategies such as care coordination, disease management, prevention, 
and use of care protocols. These are some of the principal flaws of 
VA's current approach in fee-basis and contract care.
    Today, as an evidence-based, data-driven and integrated health care 
system, VA has little meaningful information about how the care the 
Department currently purchases from outside communities affects 
clinical outcomes and health status of the veteran patient population 
receiving those services.
    DAV's desire is to avoid this situation for veterans who may be 
referred by VA to receive mental health care from community sources, 
whether in TRICARE networks or community mental health centers. VA 
commissioned the RAND Corporation and the Altarum Institute to conduct 
an independent evaluation of the quality of the VA's mental health care 
system; they released a technical report in October 2011 titled, 
Veterans Health Administration Mental Health Program Evaluation. This 
report found a high degree to which veterans diagnosed with at least 
one of five mental health conditions also have difficulties with 
physical functioning and general health. That is, these veterans, while 
representing only 15 percent of the VHA patient population in 2007, 
accounted for one-third of all VHA health care costs because of their 
high levels of medical care consumption.
    Because of the likelihood these veterans will need more than only 
mental health services, VA must be able to coordinate outside care with 
the services it is able to directly provide, and do so in an integrated 
manner. Integrated health care means the delivery of comprehensive 
services that are well-coordinated, with effective communication and 
health information sharing among providers, whether they are inside or 
outside of VA. Patients become informed and involved in their 
treatment, and when properly integrated, the care is high-quality and 
cost effective.
    DAV believes VA's current authority to purchase by contract health 
care in the community ensures a continuum of medical care; however, 
this authority to date has been specifically intended by Congress to be 
a supportive (and restrictive) tool, to strengthen the VA health care 
system and improve the quality of health care provided to veterans, 
while ensuring no diminution of services that VA provides directly to 
veterans.
    Mr. Chairman, in accordance with DAV Resolution No. 212, adopted by 
our members at our most recent National Convention in 2012, we urge VA 
to establish a purchased-care coordination program that complements the 
capabilities and capacities of each VA medical facility. Furthermore, 
we urge Congress and the Administration to conduct strong oversight of 
VA's purchased-care program to ensure service-connected disabled 
veterans are not encumbered in receiving non-VA care at VA's expense.
DAV RECOMMENDATIONS
    DAV has recommended that VA develop a proper triage, and a better 
mental health staffing model, to help VA clinicians manage their 
patient workloads to address the unique treatment needs of each 
veteran, and to tailor treatment approaches to those needs. At your May 
2012 hearing, VA also noted work was underway on a prototype staffing 
model that was being tested in three Veterans Integrated Service 
Networks (VISN). We are anxious to learn of the progress of the 
determination on whether VA can deploy this prototype throughout its 
nationwide system, and whether it works well for mental health in 
particular.
    We have urged VA to be flexible and creative in its approach to 
solving this pressing issue of mental health and readjustment needs of 
younger veterans, including the use of treatment options ranging from 
non-traditional alternative and complementary care, peer- and non-
medical counseling, to traditional evidence-based therapies, depending 
on the needs of individuals. We look forward to hearing about VA's 
progress in making these adjustments.
CLOSING
    Despite obvious improvements, it is clear to us that much progress 
still needs to be accomplished by VHA to fulfill the nation's 
obligations to veterans who are challenged by serious and, in some 
cases, chronic mental illness, and particularly for younger veterans 
who are impacted by post-deployment mental health, repatriation, and 
transition challenges. Currently, we see the pressing need for more 
timely mental health services for many of our returning wartime 
wounded, injured and ill veterans, particularly in early intervention 
services for veterans with substance-use disorders, and for evidence-
based treatments for those with PTSD, suicidal ideation, depression and 
other consequences of combat exposure. If these symptoms are not 
readily addressed at onset, they can easily compound and become chronic 
and lifelong. The costs mount in personal, family, emotional, medical, 
financial and social damage to those who have honorably served their 
nation, and to society in general. Delays or failures in addressing 
these problems can result in self-destructive acts, job and family 
disintegration, incarceration, homelessness, and even suicide.
    Mr. Chairman, DAV has previously testified, that in our considered 
opinion, sending these veterans out of the system en masse is not the 
answer--this group particularly can benefit from VA's expertise in 
treating post-traumatic stress, PTSD, substance-use disorders, TBI and 
other post-deployment transition challenges. To that end, it is 
essential that VHA address and resolve the barriers that obstruct 
mental health and substance abuse care and prevent consistent, timely 
access to care at VA facilities nationwide.
    Unfortunately, the problems in VA's mental health programs are 
complex, and cannot be resolved by any single reform. The root causes 
for existing barriers to care are multiple, systems-based, 
longstanding, and complex. DAV urges VA to address these deficits by 
addressing the root causes, not solely managing symptoms of the 
problem.
    We believe the policy changes made by VA's Office of Mental Health 
Services over the past decade are positive and will ultimately equate 
to better patient care and improved mental health outcomes--but 
significant challenges are evident and need continued attention, 
intensity, resources and oversight--and the development of sound and 
workable solutions to ease the pressure while meeting veterans' needs. 
In our opinion, VHA must develop a number of short- and long-range 
goals to resolve existing problems identified by the OIG, GAO, Congress 
and the veterans' service organization (VSO) community. VHA must 
develop reliable data systems; fix the flaws in its appointment and 
scheduling system with effective policies and IT systems that fill the 
current gaps and are responsive to mental health needs; develop an 
accurate mental health staffing model that accounts for both primary 
and a multitude of complex specialty mental health capacity demands; 
revolutionize its hiring practices and eliminate the barriers that 
obstruct timely hiring of mental health providers and support staff; 
adjust its practices to address the complexities of co-occurring 
general health, mental health and psychosocial problems of veterans, in 
a truly patient-centered manner, and re-establish trust with the 
veterans that VA is charged to serve.
    The DAV appreciates the efforts made by VA to improve the safety, 
consistency, and effectiveness of mental health care programs for all 
veterans. We also appreciate that Congress is continuing to provide 
increased funding in pursuit of a comprehensive set of services to meet 
the mental health needs of veterans, in particular veterans with 
wartime service who present post-deployment readjustment needs. We urge 
the Committee's continued oversight of VA's progress in fully 
implementing its Mental Health Strategic Plan and resolving the 
existing barriers that prevent some veterans from receiving the 
services they need to fully readjust and reintegrate following military 
service.
    Chairman Miller and Members of the Committee, this concludes my 
prepared statement. DAV appreciates the opportunity to provide this 
testimony for the record of this important hearing.

                                 
                   Prepared Statement of Ralph Ibson
    Chairman Miller, Ranking Member Michaud and members of the 
Committee:
    We are grateful to you for conducting this hearing and for your 
continued oversight on the important issue of Veterans' Mental Health 
Care. Thank you for inviting Wounded Warrior Project (WWP) to offer our 
perspective.
    With WWP's mission to honor and empower wounded warriors, our 
vision is to foster the most successful, well-adjusted generation of 
veterans in our nation's history. The mental health of our returning 
warriors is clearly a critical element. As has been well documented, 
PTSD and other invisible wounds can affect a warrior's readjustment in 
many ways - impairing health and well-being, compounding the challenges 
of obtaining employment, and limiting earning capacity. VA does provide 
benefits and services that are helping some of our warriors overcome 
such problems, but there is much more to do.
    With the drawdown of forces in Afghanistan, more and more 
servicemembers will be transitioning to veteran status and the issues 
of engaging veterans and providing effective mental health care will 
continue to grow. We applaud the oversight and focus your Committee has 
provided, particularly regarding access to timely treatment, and we 
welcome such initial steps as VA hiring additional mental health 
providers. But increased staffing alone will not close all the gaps we 
see in VA's mental health system.
Engagement in Treatment as a First Step
    The scope of the problem is not limited to timely access. We see 
evidence suggesting that veterans at many VA facilities may not be 
getting the kind of mental health care they need or the appropriate 
intensity of care. In a recent survey of over 13,000 WWP alumni, over a 
third of respondents reported difficulties in accessing effective 
mental health care. The identified reasons for not getting needed care 
were inconsistent treatment (eg. canceled appointments, having to 
switch providers, lapses in between sessions, etc.) and not being 
comfortable with existing resources at the VA. \1\ Some report that the 
VA is quick to provide medications, \2\ and others identify the limited 
types of treatment available as potential barriers. VA is pressing 
clinicians to employ exposure-based therapies that - without adequate 
support--are too intense for some veterans, with the result that many 
drop out of treatment altogether. VA is also not reaching large numbers 
of returning veterans. As described by one of the leading mental health 
researchers on the mental health toll of the conflict in Afghanistan 
and Iraq, Dr. Charles W. Hoge,

    \1\ Franklin, et al, 2012 Wounded Warrior Project Survey Report, ii 
(June 2012). WWP surveyed more than 13,300 warriors, and received 
responses from more than 5,600. (Hereinafter ``WWP Survey'').
    \2\ Id. at 105. Studies document widespread off-label VA use of 
antipsychotic drugs to treat symptoms of PTSD, and the finding that one 
such medication is no more effective than a placebo in reducing PTSD 
symptoms. D. Leslie, S. Mohamed, and R. Rosenheck, ``Off-Label Use of 
Antipsychotic Medications in the Department of Veterans' Affairs Health 
Care System'' 60(9) Psychiatric Services, 1175-1181 (2009); John 
Krystal, et al., ``Adjunctive Risperidone Treatment for Antidepressant-
Resistant Symptoms of Chronic Military Service-Related PTSD: A 
Randomized Trial,'' 306(5) JAMA 493-502 (2011).
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    `` . . . veterans remain reluctant to seek care, with half of those 
in need not utilizing mental health services. Among veterans who begin 
PTSD treatment with psychotherapy or medication, a high percentage drop 
out...With only 50% of veterans seeking care and a 40% recovery rate, 
current strategies will effectively reach no more than 20% of all 
veterans needing PTSD treatment. \3\

    \3\ Charles W. Hoge, MD, ``Interventions for War-Related 
Posttraumatic Stress Disorder: Meeting Veterans Where They Are,'' JAMA, 
306(5): (August 3, 2011) 548.
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    Without access or adequate care, one apparent consequence of only 1 
out of 5 warriors getting sufficient treatment is a disturbing rise in 
the number of suicides. Recent data have only begun to describe the 
issue. Past research has shown that veterans were at an increased risk 
of suicide during the 5 years after leaving active duty. \4\ There is 
an urgent need for intervention and an ongoing issue of identifying and 
tracking the scope of the problem. While access to care is the first 
step in preventing suicide, identifying the factors that lead warriors 
to drop out of therapy is a critical factor in reversing this troubling 
trend.
---------------------------------------------------------------------------
    \4\ http://articles.washingtonpost.com/2013-02-01/national/
36669331--1--afghanistan-war-veterans-suicide-rate-suicide-risk
---------------------------------------------------------------------------
    Another area of needed engagement is on mental health treatment for 
victims of military sexual trauma (MST). Victims' reluctance to report 
these traumatic incidents is well documented, but many also delay 
seeking treatment for conditions relating to that experience. \5\ The 
VA reports that some 1 in 5 women and 1 in 100 men seen in its medical 
system responded ``yes'' when screened for MST. \6\ While researchers 
cite the importance of screening for MST and associated referral for 
mental health care, many victims do not currently seek VA care. Indeed, 
researchers have noted frequent lack of knowledge on the part of women 
veterans regarding eligibility for and access to VA care, with many 
mistakenly believing eligibility is linked to establishing service-
connection for a condition. \7\ In-service sexual assaults have long-
term health implications, including PTSD, increased suicide risk, major 
depression and alcohol or drug abuse and without outreach to engage 
victims of MST on needed care, the long-term impact may be intensified. 
\8\
---------------------------------------------------------------------------
    \5\ Rachel Kimerling, et al., ``Military-Related Sexual Trauma 
Among Veterans Health Administration Patients Returning From 
Afghanistan and Iraq,'' 100(8) Am. J. Public Health, 1409-1412 (2010).
    \6\ U.S. Dept. of Veterans' Affairs and the National Center for 
PTSD Fact Sheet, ``Military Sexual Trauma,'' available at http://
www.ptsd.va.gov/public/pages/military-sexual-trauma-general.asp.
    \7\ See Donna Washington, et al., ``Women Veterans' Perceptions and 
Decision-Making about Veterans Affairs Health Care,'' 172(8) Military 
Medicine 812-817 (2007).
    \8\ M. Murdoch, et al., ``Women and War: What Physicians Should 
Know,'' 21(S3) J. of Gen. Internal Medicine S5-S10 (2006).
---------------------------------------------------------------------------
    With projections of only 1 in 5 veterans receiving adequate 
treatment, the importance of early intervention and consequences of 
delaying mental health care, and the rising rates of suicide and MST, 
we must heed growing evidence that a majority of soldiers deployed to 
Afghanistan or Iraq are not seeking needed mental health care. \9\ 
While stigma and organizational barriers to care are cited as 
explanations for why only a small proportion of soldiers with 
psychological problems seek professional help, soldiers' negative 
perceptions about the utility of mental health care may be even 
stronger deterrents. \10\ To reach these warriors, we see merit in a 
strategy of expanding the reach of treatment, to include greater 
engagement, understanding the reasons for negative perceptions of 
mental health care, and ``meeting veterans where they are.'' \11\
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    \9\ Paul Kim, et al. ``Stigma, Negative Attitudes about Treatment, 
and Utilization of Mental Health Care Among Soldiers,'' 23 Military 
Psychology 66 (2011).
    \10\ Id. at 78.
    \11\ Hoge, supra note 14.
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    Importantly, current law requires VA medical facilities to employ 
and train warriors to conduct outreach to engage peers in behavioral 
health care. \12\ Underscoring the benefit of warriors reaching out to 
other warriors, our recent survey found that nearly 30 percent 
identified talking with another Operation Enduring Freedom (OEF)/
Operation Iraqi Freedom (OIF) veteran as the most effective resource in 
coping with stress. \13\ Many of our warriors benefit greatly from the 
counseling and peer-support provided at Vet Centers, but VA leaders are 
failing other warriors when they resist implementing a nearly two-year-
old law that requires VA to provide peer-support to OEF/OIF veterans at 
VA medical facilities as well. \14\
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    \12\ National Defense Authorization Act for Fiscal Year 2013, 
Public Law 112-239, Sec. 730, (Jan. 2, 2013). Additionally, the 
President issued an Executive Order in August 2012 which included among 
new steps to improve warriors' access to mental health services, a 
commitment that VA would employ 800 peer-specialists to support the 
provision of mental health care. Exec. Order No. 13625 ``Improving 
Access to Mental Health for Veterans, Service Members, and Military 
Families'' (Aug. 31, 2012)
    \13\ WWP Survey, at 54.
    \14\ Sec. 304, Public Law 111-163.
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    While high percentages of OEF/OIF veterans are not engaging or 
dropping out of mental health programs, peer support has been 
identified as a critical element in reversing that trend. Last August's 
Executive Order on Improving Access to Mental Health Services for 
Veterans, Servicemembers, and Military Families was clear on improving 
care for the mental health needs of those who served in Iraq and 
Afghanistan. We applaud its directive that VA hire and train 800 peer 
counselors by the end of this calendar year. We are concerned, however, 
that VA's approach to the peer-support initiative in the Order is not 
focused or targeted to OEF/OIF veterans.
    In addition to peer outreach, enlisting family members in mental 
health care helps foster recovery and facilitates warrior engagement. 
VA has lagged in addressing family issues and involving caregivers in 
mental health treatment. \15\ Given the impact of family support and 
strain on warriors' resilience and recovery, more must be done to 
implement provisions of law to provide needed mental health care to 
veterans' family members.
---------------------------------------------------------------------------
    \15\ Khaylis, A., et al. ``Posttraumatic Stress, Family Adjustment, 
and Treatment Preferences Among National Guard Soldiers Deployed to 
OEF/OIF,''176 Military Medicine 126-131(2011).
---------------------------------------------------------------------------
    The VA has certainly taken significant steps over the years to 
improve veterans' access to mental health care. But for all the 
positive action taken, too many warriors still have not received 
timely, effective treatment. In short, and as WWP has testified, \16\ 
wide gaps remain between well-intentioned policies and on-the-ground 
practices.
---------------------------------------------------------------------------
    \16\ VA Mental Health Care Staffing: Ensuring Quality and Quantity: 
Hearing Before the Subcomm. on Health of the H. Comm. on Veterans' 
Affairs, 112th Cong. (May 8, 2012) (Testimony of Ralph Ibson, National 
Policy Director, Wounded Warrior Project).
---------------------------------------------------------------------------
Need for Outcome Measurements
    Against the backdrop of a series of congressional hearings 
highlighting long delays in scheduling veterans for mental health 
treatment, the VA last April released plans to hire an additional 1900 
mental health staff. \17\ While appreciative of VA's course-reversal, 
WWP has urged that other related critical problems also be remedied. It 
is not clear that VA medical facilities are sufficiently flexible in 
accommodating warriors. Access remains a problem, particularly for 
those living at a distance from VA facilities and for those whose work 
or school requirements make it difficult to meet current clinic 
schedules. Mental health care must also be effective, of course. As one 
provider explained,
---------------------------------------------------------------------------
    \17\ Dept. of Veterans' Affairs Press Release, ``VA to Increase 
Mental Health Staff by 1,900,'' (Apr. 19, 2012), available at: http://
www.va.gov/opa/pressrel/pressrelease.cfm?id=2302.

    ``Getting someone in quickly for an initial appointment is 
worthless if there is no treatment available following that 
appointment.'' \18\
---------------------------------------------------------------------------
    \18\ Id.
---------------------------------------------------------------------------
    Providing effective care requires building a relationship of trust 
between provider and patient - a bond that is not necessarily instantly 
established. \19\ Accordingly, congressional testimony highlighting 
that many VA medical centers routinely place patients in group-therapy 
settings rather than provide needed individual therapy merits further 
scrutiny. \20\ We have also urged more focus on the soundness and 
effectiveness of the VA's mental health performance measures; these 
track adherence to process requirements, but fail to assess whether 
veterans are actually improving. \21\
---------------------------------------------------------------------------
    \19\ VA Mental Health Care Staffing: Ensuring Quality and Quantity: 
Hearing Before the Subcomm, on Health of the H. Comm. on Veterans' 
Affairs, 112th Cong. (May 8, 2012) (Testimony of Nicole Sawyer, PsyD, 
Licensed Clinical Psychologist).
    \20\ VA Mental Health Care: Evaluating Access and Assessing Care: 
Hearing Before the S. Comm. on Veterans' Affairs, 112th Cong. (Apr. 25, 
2012) (Testimony of Nicholas Tolentino, OIF Veteran and former VA 
medical center administrative officer).
    \21\ VA Mental Health Care Staffing: Ensuring Quality and Quantity: 
Hearing Before the Subcommittee on Health of the H. Comm. on Veterans' 
Affairs, 112th Cong. (2012) (Testimony of Ralph Ibson), supra note 21.
---------------------------------------------------------------------------
    Unfortunately, the imperative of meeting performance requirements 
can create perverse incentives, at odds with good clinical care. As one 
provider explained, ``Veterans face many obstacles to care that are 
designed to meet `measures' rather than good clinical care, i.e. having 
to wait hours to be seen in walk-in clinic as the only point of access, 
being forced to attend groups, etc.'' \22\ Prior hearings also 
documented instances of such measures being ``gamed.'' \23\
---------------------------------------------------------------------------
    \22\ WWP Survey of VA Mental Health Staff (2011).
    \23\ As one WWP-survey respondent explained in describing practices 
at a VA facility, ``Unreasonable barriers have been created to limit 
access into Mental Health treatment, especially therapy. Vets must go 
to walk-in clinic so they are never given a scheduled initial 
appointment. Walk-in only provided medication management, but Vets who 
just want therapy must still go to walk-in. After initial intake, Vets 
are required to attend a group session, typically a month out. After 
completing the group session, Vets can be scheduled for individual 
therapy, typically another month out. Performance measures are gamed. 
When a consult is received, the Veteran is called and told to go to 
walk-in. The telephone call is not documented directly (that would 
activate a performance measure) . . . Then the consult is completed 
without any services being provided to the Veteran. Vets often slip 
through the cracks since there is no follow-up to see if they actually 
went to walk-in. Focus of the Mental Health [sic] is to make it appear 
as if access is meeting measures. There is no measure for follow-up, so 
even if Vets get into the system in a reasonable time, the actual 
treatment is significantly delayed. Trauma work is almost impossible to 
do since appointments tend to be 6-8 weeks apart.''
---------------------------------------------------------------------------
    WWP has been encouraged by the VA's willingness to dedicate 
research resources and additional mental health providers to addressing 
gaps in veterans' mental health care. But it's not necessarily just 
about reaching particular funding or staffing levels. It's about 
outcomes--ultimately honoring and empowering warriors, and, in our 
view, about making this the most successful generation of veterans. 
It's not enough for VA administrators to set performance metrics for 
timeliness or other process-measures (especially when those metrics may 
not adequately reflect the true situation), they must establish 
performance measures that recognize and reward successful treatment 
outcomes.
    Recent reports from VA Inspector General and Government 
Accountability Offices have highlighted the need for more effective 
measures to aid oversight. \24\    \25\ WWP shares concerns about 
scheduling and wait times and urges VA to implement a reliable, 
accurate way to measure how long veterans are waiting for appointments 
in order to resolve problems effectively. Waiting too long during a 
time of intense need undermines a veteran's trust in the system.
---------------------------------------------------------------------------
    \24\ U.S. General Accountability Office, ``Reliability and Reported 
Outpatient Medical Appointment Wait Times and Scheduling Oversight Need 
Improvement,'' GAO-13-130 (Dec 2012).
    \25\ VA Office of Inspector General, ``Review of Veterans' Access 
to Mental Health Care''' (Apr 2012).
---------------------------------------------------------------------------
    The reports underscore concerns that VA is unable to measure a 
range of pertinent mental health matters, including timely access, 
patient outcomes, staffing needs, numbers needing or provided 
treatment, provider productivity, and treatment capacity. Greater VA 
transparency and continued oversight into VA's mental health care 
operations are starting points for closing those gaps.
Need for Continued Congressional Oversight
    WWP welcomes the Department's acknowledgment of a ``need [for] 
improvement'' in its mental health system. \26\ While there has been 
movement in response to recent critical congressional oversight, the 
VA's actions have often lacked needed transparency. To illustrate, the 
VA testified to having conducted a ``comprehensive first-hand 
assessment of the mental health program at every VA medical center,'' 
\27\ but it would not afford advocates the opportunity to participate 
in such visits (despite a request to do so) and has not disclosed its 
site-visit findings, the expectations for each such facility, or 
facility remediation plans. The VA also cited its adoption, on a pilot 
basis, of a prototype mental health staffing model, without meaningful 
explanation of the foundation or reliability of its model. VA Central 
Office recently also surveyed mental health field staff; but while its 
survey effort could represent a healthy step, officials have neither 
disclosed the survey findings nor indicated how the data might be used, 
if at all.
---------------------------------------------------------------------------
    \26\ VA Mental Health Care Staffing: Ensuring Quality and Quantity: 
Hearing Before the Subcomm. on Health of the H. Comm. on Veterans' 
Affairs, 112th Cong. (May 8, 2012) (Testimony of Eric Shinseki, 
Secretary of the Dept. of Veterans' Affairs).
    \27\ Id.
---------------------------------------------------------------------------
    It bears emphasizing that PTSD and other war-related mental health 
conditions can be successfully treated - and in many cases, VA 
clinicians and Vet Center counselors are helping veterans recover and 
thrive. But these problems have their origin in service, and more can 
and must be done both to prevent and to treat behavioral health 
problems at the earliest point - during, rather than after, service. 
That will require not only overcoming negative perceptions among 
servicemembers about mental health care, but affording them assurance 
of confidentiality. \28\ Vet Centers - long a source of confidential, 
trusted care--can and should be a greater resource. Provisions of the 
National Defense Authorization Act for 2013 (NDAA) direct both DoD and 
the VA, respectively, to close critical gaps in their mental health 
systems, targeting particularly the importance of suicide prevention in 
the armed forces and the VA's need to provide wounded warriors timely, 
effective mental health care. \29\ Among its provisions, the NDAA 
requires the VA - in consultation with an expert study committee under 
the auspices of the National Academy of Sciences (NAS)- to establish 
and implement both mental health staffing guidelines and comprehensive 
measures to assess the timeliness and effectiveness of its mental 
health care. \30\ WWP urges VA to give high priority to entering into a 
contract with NAS as soon as possible - and bring some ``sunshine'' and 
outside expertise into what should be an important step toward 
improving VA behavioral health care.
---------------------------------------------------------------------------
    \28\ See Lt. Col. Paul Dean and Lt. Col. Jeffrey McNeil, ``Breaking 
the Stigma of Behavioral Healthcare,'' U.S. Army John F. Kennedy 
Special Warfare Center and School, 25(2) Special Warfare (2012), 
available at: http://www.soc.mil/swcS/SWmag/archive/SW2502/
SW2502BreakingTheStigmaOfBehavioralHealthcare.html.
    \29\ National Defense Authorization Act for Fiscal Year 2013, supra 
note 18, at Sec. Sec.  580-583 and 723-730.
    \30\ Id. at Sec.  726.
---------------------------------------------------------------------------
    Finally, as we suggested in testimony before the Health 
Subcommittee last May, it is important to consider the ``culture'' 
within which VA mental health care is provided. As one clinician 
described it succinctly in responding to a WWP survey,

    ``The reality is that the VA is a top-down organization that wants 
strict obedience and does not want to hear about problems.''

    Mental health staff at some VA facilities have described a 
leadership climate that employs a command and control model that 
imposes administrative requirements which too often compromise 
providers' exercise of their own clinical judgment, and thus frustrate 
effective treatment.
    Without answers to what Central Office has learned through its site 
visits or surveys about the extent to which clinicians have needed 
latitude to exercise their best clinical judgment, we are left to 
question whether morale or other problems compromise effective mental 
health care and whether remedial steps are being taken. We cannot 
answer such questions without greater VA transparency.
    In the recent past, congressional oversight has been a critical 
catalyst in identifying the need for major system improvements in the 
provision of mental health care for wounded warriors and in effecting 
necessary reforms. Such vigilant oversight must continue in order to 
close remaining gaps in VA's mental health system. Among these, we urge 
that congressional oversight include focusing on the following:

    I  Given new statutory requirements to work with the NAS to 
establish new staffing guidelines and measures to assess timeliness and 
effectiveness of mental health care, the VA must give high priority to 
expeditiously contract with NAS to conduct the necessary assessments 
and establish the framework for reforms required by law;
    I  DoD and the VA must work collaboratively, not simply to improve 
access to mental health care, but to identify and further research the 
reasons for--and solutions to - warriors' resistance to seeking such 
care;
    I  As provided for in law and Executive Order, the VA in 2013 must 
carry out large-scale training and employment of at least 800 returning 
warriors (who have themselves experienced combat stress) to provide 
peer-outreach and peer-support services as part of VA's provision of 
mental health care to wounded warriors, and DoD must support that 
initiative by referring servicemembers to be considered for such 
employment;
    I  The VA should partner with and assist community entities or 
collaborative community programs in providing needed mental health 
services to wounded warriors, to include providing training to 
clinicians on military culture and the combat experience;
    I  The VA must implement provisions of law that require it to 
provide needed mental health services to immediate family members of 
veterans whose own war-related mental health issues may diminish their 
capacity to support those warriors;
    I  The VA should improve coordination between its medical 
facilities and Vet Centers, and increase both Vet Center staffing and 
the number of Vet Center sites, with emphasis on locating new ones near 
military facilities; and
    I  The VA should provide for Vet Center staff to participate in 
VSO-operated recreational programs that are designed to encourage 
veterans' readjustment, as provided for by law.
    Thank you for consideration of WWP's views on this most important 
subject.

                                 
                 Prepared Statement of Robert A. Petzel
    Good morning, Chairman Miller, Ranking Member Michaud and Members 
of the Committee. Thank you for the opportunity to discuss VA's 
delivery of comprehensive mental health care and services to the 
Nation's Veterans and their families. I am accompanied today by Dr. 
Mary Schohn, Director, Office of Mental Health Operations; Dr. Sonja 
Batten, Deputy Chief Consultant for Specialty Mental Health; and Dr. 
Janet Kemp, National Mental Health Program Director, Suicide Prevention 
and Community Engagement, all from the Veterans Health Administration 
(VHA)'s Office of Patient Care Services, Mental Health Services.
    Since September 11, 2001, more than two million Servicemembers have 
deployed to Iraq or Afghanistan with unprecedented duration and 
frequency. Long deployments and intense combat conditions require 
optimal support for the emotional and mental health needs of our 
Veterans and their families. VA continues to develop and expand its 
mental health delivery system. Since 2009, VA has learned a great deal 
about both the strengths of our mental health care system, as well as 
areas that need improvement. VA constantly strives to enhance the 
services provided to our Veterans and will use any data and assessments 
to achieve that goal.
    VA is working closely with our Federal partners to implement 
President Barack Obama's Executive Order 13625, ``Improve Access to 
Mental Health Services for Veterans, Service Members, and Military 
Families,'' signed on August 31, 2012. The executive order reaffirmed 
the President's commitment to preventing suicide, increasing access to 
mental health services, and supporting innovative research on relevant 
mental health conditions. The executive order strengthens suicide 
prevention efforts by increasing capacity at the Veterans/Military 
Crisis Line and through supporting the implementation of a national 
suicide prevention campaign. The executive order supports recovery-
oriented mental health services for Veterans by directing the hiring of 
800 peer specialists, to bring this expertise to our mental health 
teams. It also supports VA in using a variety of recruitment strategies 
to hire 1,600 new mental health clinicians and 300 administrative 
personnel in support of the mental health programs. Furthermore, it 
strengthens building partnerships between VA and community providers by 
directing VA to work with the Department of Health and Human Services 
(HHS), to establish 15 pilot agreements with HHS-funded community 
clinics to improve access to mental health services in pilot 
communities, and to develop partnerships in hiring providers in rural 
areas. Finally, it promotes mental health research and development of 
more effective treatment methodologies in collaboration between VA, 
Department of Defense (DOD), HHS, and Department of Education.
    VHA has begun work on implementation of Fiscal Year 2013 National 
Defense Authorization Act (P.L. 112-239) (NDAA), signed on January 2, 
2013, including developing measures to assess mental health care 
timeliness, patient satisfaction, capacity and availability of 
evidence-based therapies, as well as developing staffing guidelines for 
specialty and general mental health. In addition, VA is formulating a 
contract with the National Academy of Sciences to consult on the 
development and implementation of measures and guidelines, and to 
assess the quality of mental health care. VA is also expanding efforts 
to recruit mental health providers without compensation to support 
delivery of mental health services.
    My written statement will describe how VA delivers quality mental 
health care and engages in ongoing research in such specialty areas as 
post-traumatic stress disorder (PTSD), military sexual trauma, and 
suicide prevention. It will then cover how we are refining mental 
health access, and finally examine VA's recent enhancement of mental 
health staffing.
I. Mental Health Care
    VA operates one of the highest-quality care systems. VA is a 
pioneer in mental health research, discovering and utilizing effective, 
high-quality, evidence-based treatments. It has made deployment of 
evidence-based therapies a critical element of its approach to mental 
health care. State-of-the-art treatment, including both psychotherapies 
and biomedical treatments, are available for the full range of mental 
health problems, such as PTSD, consequences of military sexual trauma, 
substance use disorders, and suicidality. While VA is primarily focused 
on evidence-based treatments, we are also monitoring and assessing 
those complementary and alternative treatment methodologies that need 
further research, such as meditation in the care of PTSD. Our ultimate 
desired outcome is a healthy Veteran.
    VHA provides a continuum of recovery-oriented, patient-centered 
services across outpatient, residential, and inpatient settings. VA has 
trained over 4,700 VA mental health professionals to provide two of the 
most effective evidence-based psychotherapies for PTSD: Cognitive 
Processing Therapy and Prolonged Exposure Therapy. The Institute of 
Medicine (IOM) report and the VA/DOD Clinical Practice Guideline have 
consistently affirmed the efficacy of these treatment approaches. 
Furthermore, VA operates the National Center for PTSD, which guides a 
national PTSD Mentoring program, working with every specialty PTSD 
program across the country to improve care. The Center has also begun 
to operate a PTSD Consultation Program open to any VA practitioner 
(including primary care practitioners and Homeless Program 
coordinators) who requests expert consultation regarding a Veteran in 
treatment with PTSD. So far, 500 VA practitioners have utilized this 
service. The Center further supports clinicians by sending subscribers 
updates on the latest clinically relevant trauma and PTSD research, 
including the Clinician's Trauma Update Online, PTSD Research 
Quarterly, and the PTSD Monthly Update. As IOM observed in its recent 
report, ``Spurred by the return of large numbers of veterans from 
[Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn 
(OEF/OIF/OND)], the VA has substantially increased the number of 
services for veterans who have PTSD and worked to improve the 
consistency of access to such services. Every medical center and at 
least the largest community-based outpatient clinics are expected to 
have specialized PTSD services available onsite. Mental health staff 
members devoted to the treatment of OIF and OEF veterans have also been 
deployed throughout the system.'' \1\
---------------------------------------------------------------------------
    \1\ Institute of Medicine of the National Academies. Treatment for 
Posttraumatic Stress Disorder in Military and Veteran Populations 
Initial Assessment. July 13, 2012.
---------------------------------------------------------------------------
    Specialized care is available for Veterans who experienced military 
sexual trauma (MST) while serving on active duty or active duty for 
training. All sexual trauma-related care and counseling is provided 
free of charge to all Veterans, even if they are not eligible for other 
VA care. In FY 2012, every VHA facility provided MST related outpatient 
care to both women and men and over 725,000 outpatient MST-related 
mental health clinical visits were provided to 64,161 Veterans with a 
positive MST screen. This is a 13.3 percent increase from the previous 
year (FY 2011). Additionally, in FY 2012, of those who received care in 
a VA medical center or clinic, over 500,000 Veterans with a Substance 
Use Disorder (SUD) diagnosis received treatment for this problem. VA 
developed and disseminated clinical guidance to newly hired SUD-PTSD 
specialists who are promoting integrated care for these co-occurring 
conditions, and provided direct services to over 18,000 of these 
Veterans in FY 2012.
    Use of complementary and alternative medicine (CAM) for treating 
mental health problems is widespread in VA. A 2011 survey of all VA 
facilities by VA's Healthcare Information and Analysis Group found that 
89 percent of VA facilities offered CAM. VA's Office of Research and 
Development (ORD) recently undertook a dedicated effort to evaluate CAM 
in the treatment of PTSD with the solicitation of research applications 
examining the efficacy of meditative approaches to PTSD treatment. The 
result was three new clinical trials; all are currently underway, 
recruiting participants with PTSD. VA has also begun pilot testing a 
mechanism for conducting multi-site clinical CAM demonstration projects 
within mental health that will provide a roadmap for identifying 
innovative treatment methods, measuring their efficacy and 
effectiveness, and generating recommendations for system-wide 
implementation as warranted by the data. Nine medical facilities with 
meditation programs were selected for participation in the clinical 
demonstration projects. A team of subject matter experts in mind-body 
medicine from the University of Rochester has been asked to provide an 
objective, external evaluation. The majority of the clinical 
demonstration projects are expected to be completed by March 2013, and 
the aggregate final report by the outside evaluation team is due later 
in 2013.
Veteran Suicide
    Even one Veteran suicide is too many. VA is absolutely committed to 
ensuring the safety of our Veterans, especially when they are in 
crisis. Our suicide prevention program is based on the principle that 
in order to decrease rates of suicide, we must provide enhanced access 
to high quality mental health care and develop programs specifically 
designed to help prevent suicide. In partnership with the Substance 
Abuse and Mental Health Services Administration's National Suicide 
Prevention Lifeline, the Veterans Crisis Line (VCL) connects Veterans 
in crisis and their families and friends with qualified, caring 
Department of Veterans Affairs responders through a confidential toll-
free hotline that offers 24/7 emergency assistance. VCL has recently 
expanded to include a chat option and texting option for contacting the 
Crisis Line. Since its establishment five years ago, the VCL has made 
approximately 26,000 rescues of actively suicidal Veterans. The program 
continues to save lives and link Veterans with effective ongoing mental 
health services on a daily basis. In FY 2012, VCL received 193,507 
calls, resulting in 6,462 rescues, any one of which may have been life-
saving. In accordance with the President's August 31, 2012, Executive 
Order, VA has completed hiring and training of additional staff to 
increase the capacity of the Veterans Crisis Line by 50 percent. 
However, VCL is only one component of the VA overarching suicide 
prevention program that is based on the premise that ready access to 
high quality care can prevent suicide.
    VA has placed Suicide Prevention Teams at each facility. The 
leaders of these teams, the Suicide Prevention Coordinators, are 
specifically devoted to preventing suicide among Veterans, and the 
implementation of the program at their facilities. The coordinators 
play a key role in VA's work to prevent suicide both in individual 
patients and in the entire Veteran population. Among many other 
functions, coordinators ensure that referrals from all sources, 
including the Crisis Line, e-mail, and word of mouth referrals are 
appropriately responded to in a timely manner. Coordinators educate 
their colleagues, Veterans and families about risks for suicide, 
coordinate staff education programs about suicide prevention, and 
verify that clinical providers are trained. They provide enhanced 
treatment monitoring for veterans at risk. They assure continued care 
and treatment by verifying that each ``high risk'' Veteran has a 
medical record notification entered; that they receive a suicide-
specific enhanced care package, and any missed appointments are 
followed up on. The coordinators track and monitor all suicide-related 
events in an internal data collection system. This allows VA to 
determine trends and common risk factors, and provides information on 
where and how best to address concerns.
    VA has developed two hubs of expertise, one at the Canandaigua 
Center of Excellence for Suicide Prevention (Canandaigua, NY), and 
another at the VISN 19 Mental Illness Research Education and Clinical 
Center (Denver, CO), to conduct research regarding intervention, 
treatments and messaging approaches and has developed a Suicide 
Consultation Program for practitioners that opened in 2013 and is 
already in use.
    On February 1, 2013, VA released a report on Veteran suicides, a 
result of the most comprehensive review of Veteran suicide rates ever 
undertaken by the VA. The report shows current interventions and 
programs have been able to maintain relatively stable rates despite 
increasing rates of suicide in like populations in America. With 
assistance from state partners providing real-time data, VA is now 
better able to assess the effectiveness of its suicide prevention 
programs and identify specific populations that need targeted 
interventions. This new information will assist VA to identify where at 
risk Veterans may be located and improve the Department's ability to 
target specific suicide interventions and outreach activities in order 
to reach Veterans early and proactively. The data will also help VA 
continue to examine the effectiveness of suicide prevention programs 
being implemented in specific geographic locations (e.g., rural areas), 
as well as care settings, such as primary care in order to replicate 
effective programs in other areas.
II. Mental Health Care Access
    At VA, we have the opportunity, and the responsibility, to 
anticipate the needs of returning Veterans. Mental health care at VA is 
an unparalleled system of comprehensive treatments and services to meet 
the individual mental health needs of Veterans. We have many entry 
points for VHA mental health care: through our 152 medical centers, 821 
community-based outpatient clinics, 300 Vet Centers that provide 
readjustment counseling, the Veterans Crisis Line, VA staff on college 
and university campuses and other outreach efforts.
    Since FY 2006, the number of Veterans receiving specialized mental 
health treatment has risen each year, from 927,052 to more than 1.3 
million in FY 2012, partly due to proactive screening to identify 
Veterans who may have symptoms of depression, PTSD, problematic use of 
alcohol, or who have experienced MST. Outpatient visits have increased 
from 14 million in FY 2009 to over 17 million in FY 2012. Vet Centers 
are another avenue for access, providing services to 193,665 Veterans 
and their families in FY 2012. The Vet Center Combat Call Center, an 
around-the-clock confidential call center where combat Veterans and 
their families can talk with staff, comprised of fellow combat Veterans 
from several eras, has handled over 37,300 calls in FY 2012. The Vet 
Center Combat Call Center is a peer support line, providing a 
complementary resource to the Veterans Crisis Line, which provides 24/7 
crisis intervention services. This represents a nearly 470 percent 
increase from FY 2011.
    In response to increased demand over the last four 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. VA believes that mental health care must 
constantly evolve and improve as new research knowledge becomes 
available. As more Veterans access our services, we recognize their 
unique needs and needs of their families--many of whom have been 
affected by multiple, lengthy deployments. In addition, proactive 
screening and an enhanced sensitivity to issues being raised by 
Veterans have identified areas for improvement.
    For example, in August 2011, VA conducted an informal survey of 
line-level staff at several facilities, and learned of concerns that 
Veterans' ability to schedule timely appointments may not match data 
gathered by VA's performance management system. These providers 
articulated 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 finding, VA took three major actions. First, VA 
developed a comprehensive action plan aimed at overcoming barriers to 
access, and addressing the concerns raised by its staff in the survey 
as well as concerns raised by Veterans and Veterans groups. Second, VA 
conducted focus groups with Veterans and VA staff, conducted through a 
contract with Altarum, to better understand the issues raised by front-
line providers. Third, VA conducted a comprehensive first-hand 
assessment of the mental health program at every VA medical center and 
is working within its facilities and Veterans Integrated Service 
Networks (VISNs) to improve mental health programs and share best 
practices.
    Ensuring access to appropriate care is essential to helping 
Veterans recover from the injuries or illnesses they incurred during 
their military service. Access can be realized in many ways and through 
many modalities, including:

      through face-to-face visits;
      telehealth;
      phone calls;
      online systems;
      mobile apps and technology;
      readjustment counseling;
      outreach;
      community partnerships; and
      academic affiliations.
Face-to-Face Visits
    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. As the recent IOM report 
on Treatment for Posttraumatic Stress Disorder in Military and Veteran 
Populations noted, it is VA policy to screen every patient seen in 
primary care in VA medical settings for PTSD, MST, depression, and 
problem drinking. \2\ The screening takes place during a patient's 
first appointment, and screenings for depression and problem drinking 
are repeated annually for as long as the Veteran uses VA services. 
Furthermore, PTSD screening is repeated annually for the first 5 years 
after the most recent separation from service and every 5 years 
thereafter. Systematic screening of Veterans for conditions such as 
depression, PTSD, problem drinking, and MST has helped VA identify more 
Veterans at risk for these conditions and provided opportunities to 
refer them to specially trained experts. The PTSD screening tool used 
by VA has been shown to have high levels of sensitivity and 
specificity.
---------------------------------------------------------------------------
    \2\ Institute of Medicine of the National Academies. Treatment for 
Posttraumatic Stress Disorder in Military and Veteran Populations 
Initial Assessment. July 13, 2012.
---------------------------------------------------------------------------
    Since the start of FY 2008, VA has provided more than 2.5 million 
Primary Care-Mental Health Integration (PC-MHI) clinical visits to more 
than 700,000 unique Veterans. This improves both access by bringing 
care closer to where the Veteran can most easily receive these 
services, and quality of care by increasing the coordination of all 
aspects of care, both physical and mental. Among primary care patients 
with positive screens for depression, those who receive same-day PC-MHI 
services are more than twice as likely to receive depression treatment 
than those who did not. Treatment works and there is hope for recovery 
for Veterans who need mental health care. These are important advances, 
particularly given the rising numbers of Veterans seeking mental health 
care.
Telehealth
    VA offers expanded access to mental health services with longer 
clinic hours, telemental health capability to deliver services, and 
standards that mandate rapid access to mental health services. 
Telemental health allows VA to leverage technology to provide Veterans 
quicker and more efficient access to mental health care by reducing the 
distance they have to travel, increasing the flexibility of the system 
they use, and improving their overall quality of life. This technology 
improves access to general and specialty services in geographically 
remote areas where it can be difficult to recruit mental health 
professionals. Currently, the clinic-based telehealth program involves 
the more than 580 VA community-based outpatient clinics (CBOCs) where 
many Veterans receive primary care. In areas where the CBOCs do not 
have a mental health care provider available, VA is implementing a new 
program to use secure video teleconferencing technology to connect the 
Veteran to a provider within VA's nationwide system of care. Further, 
the program is expanding directly into the home of the Veteran with 
VA's goal to connect approximately 2,000 patients by the end of FY2013 
using Internet Protocol (IP) video on Veterans' personal computers.
Mobile Apps and Technology
    VA has made massive strides towards providing all of those in need 
with evidence-based treatments, and we are now working to optimize the 
delivery of these tools by using novel technologies. From delivery of 
the treatments to rural Veterans in their homes, to supporting 
treatment protocols with mobile apps, VA's objective is to consistently 
deliver the highest quality mental health care to Veterans wherever 
they are. The multi-award winning PTSD Coach, co-developed with the 
DOD, has been downloaded nearly 100,000 times in 74 countries since 
mid-2011. It is being adapted by government agencies and non-profit 
organizations in 7 other countries including Canada and Australia. This 
app is notable as it aims to assist Veterans with recognizing and 
managing PTSD symptoms, whether or not they are comfortable engaging 
with VA mental health care.
    For those who are kept from needed care because of logistics or 
fear of stigma, PTSD Coach provides an opportunity to better understand 
and manage the symptoms associated with PTSD as a first step toward 
recovery. For those who are working with VA providers, whether in 
specialty clinics or primary care, this app provides evidence-informed 
tools for self-management and symptom tracking between sessions. VA is 
planning to shortly roll out a version of this app that is connected to 
the electronic health record for active VA patients.
    A wide array of mobile applications to support the evidence-based 
mental and behavioral health care of Veterans will be rolled out over 
the course of 2013. These apps are intended to be used in the context 
of clinical care with trained professionals and are based on gold-
standard protocols for addressing smoking cessation, PTSD and 
suicidality.
    Apps for self-management of the consequences of traumatic brain 
injury and crisis management, some of the more challenging issues 
facing Veterans and our healthcare system, will follow later in the 
year. Mobile apps can help Veterans build resilience and manage day-to-
day challenges even in the absence of mental health disorders. Working 
with DOD, VA will release mobile apps for problem-solving and parenting 
in 2013 to help Veterans navigate common post-deployment challenges. 
Because we understand that healthy families are at the center of a 
healthy life, we are creating tools for families and caregivers of 
Veterans as well, including the PTSD Family Coach, a mobile app geared 
towards friends and families that is expected to be rolled out in mid-
2013.
    Technology allows us to extend our reach, not just beyond the 
clinic walls but to those who need help but have not yet sought our 
services, and to those who care for them and support their personal and 
professional missions. In November 2012, VA and DoD launched 
www.startmovingforward.org, interactive Web-based educational life-
coaching program based on the principles of Problem Solving Therapy. It 
allows for anonymous, self-paced, 24-hour-a-day access that can be used 
independently or in conjunction with mental health treatment.
Readjustment Counseling - Vet Centers
    In addition to integrating mental health care with primary care, VA 
provides a full range of face-to-face readjustment counseling services 
through the network of 300 community-based Vet Centers located in all 
50 states, the District of Columbia, American Samoa, Guam, Puerto Rico, 
and the U.S. Virgin Islands. In FY 2012, the Vet Centers experienced 
over 1.5 million visits from Veterans and their families, a 9 percent 
increase in visits from FY 2011. The Vet Center program has 
cumulatively provided services to 458,795 OEF/OIF/OND Veterans and 
their families. This represents over 30 percent of the OEF/OIF/OND 
Veterans that have left active duty.
    The Vet Centers provide targeted outreach to returning combat 
Veterans through a fleet of 70 Mobile Vet Centers that can provide 
confidential counseling and outreach to Veterans who live 
geographically distant from VA facilities, ensuring availability of 
access to mental health care for Veterans, no matter where they may 
live. In 2010, Public Law 111-163 expanded eligibility of Vet Center 
services to members of the Armed Forces (and their family members), 
including members of the National Guard or Reserve, who served on 
active duty in the Armed Forces in OEF/OIF/OND. VA and DOD are working 
together to implement this expansion of services.
    The recently passed FY 2013 NDAA also includes provisions that 
expand the peer support counseling program to members of the Armed 
Forces and expand the Vet Center program to include counseling to 
certain members of the Armed Forces and their family members. One 
cornerstone of the Vet Center program's success is the added level of 
confidentiality for Veterans and their families. Vet Centers maintain a 
separate system of record which affords the confidentiality vital to 
serving a combat-exposed warrior population. Without the Veteran's 
voluntary signed authorization, the Vet Centers will not disclose 
Veteran client information unless required by law. Early access to 
readjustment counseling in a safe and confidential setting goes a long 
way to reducing the risk of suicide and promotes the recovery of 
Servicemembers returning from combat. Furthermore, more than 72 percent 
of all Vet Center staff are Veterans themselves. This allows the Vet 
Center staff to make an early empathic connection with Veterans who 
might not otherwise seek services even if they are much needed.
Outreach
    In November 2011, VA launched an award-winning, national public 
awareness campaign, Make the Connection, aimed at reducing the stigma 
associated with seeking mental health care and informing Veterans, 
their families, friends, and members of their communities about VA 
resources (www.maketheconnection.net). The candid Veteran videos on the 
Web site have been viewed over 4 million times, and over 1.5 million 
individuals have ``liked'' the Facebook page for the campaign 
(www.facebook.com/VeteransMTC). AboutFace, launched in May 2012, is a 
complementary public awareness campaign created by the National Center 
for PTSD (www.ptsd.va.gov/public/about--face.html). This initiative 
aims to help Veterans recognize whether the problems they are dealing 
with may be PTSD related and to make them aware that effective 
treatment can help them ``turn their lives around.'' The National 
Center for PTSD has been using social media to reach out to Veterans 
utilizing both Facebook and Twitter. In FY 2012, there were 18,000 
Facebook ``fans'' (up from 1,800 in 2011), making 16 posts per month 
and almost 7,000 Twitter followers (up from 1,700 in 2011) with 20 
``tweets'' per month. The PTSD Web site, www.ptsd.va.gov, received 2.3 
million visits during FY2012.
    VA, in collaboration with DOD, continues to focus on suicide 
prevention though its year-long public awareness campaign, ``Stand By 
Them,'' which encourages family members and friends of Veterans to know 
the signs of crisis and encourage Veterans to seek help, or to reach 
out themselves on behalf of the Veteran using online services on 
www.veteranscrisisline.net. VA's current suicide awareness and 
education Public Service Announcement titled ``Common Journey'' has 
been running in the top one percent of the PSA Nielsen ratings since 
before the holidays. It is now being replaced with a PSA designed 
specifically to augment the Stand By Them Campaign titled ``Side By 
Side,'' which was launched nationally in January 2013.
    In order to further serve family members who are concerned about a 
Veteran, VA has expanded the ``Coaching Into Care'' call line 
nationally after a successful pilot in two VISNs. Since the inception 
of the service January 2010 through November 2012, ``Coaching Into 
Care'' has logged 5,154 total calls and contacts. Seventy percent of 
the callers are female, and most callers are spouses or family members. 
On 49 percent of the calls, the target is a Veteran of OEF/OIF/OND 
conflicts; Vietnam or immediately post-Vietnam era Veterans comprises 
the next highest portion (27 percent).
Community Partnerships
    VA recently developed and released a ``Community Provider Toolkit'' 
which is an on-line resource for community mental health providers to 
learn more about mental health needs and treatments for Veterans. The 
Veterans Crisis Line has approximately 50 Memoranda of Agreement with 
community and internal VA organizations to refer callers, accept calls, 
and provide and receive services for callers. Furthermore, suicide 
Prevention Coordinators at each VA facility are required to provide a 
minimum of 5 outreach activities a month to their communities to 
increase awareness of suicide and promote community involvement in the 
area of Veteran suicide prevention.
    VA has been working closely with outside resources to address gaps 
and create a more patient-centric network of care focused on wellness-
based outcomes. In response to the Executive Order, VA is working 
closely with HHS to establish 15 pilot projects with community-based 
providers, such as community mental health clinics, community health 
centers, substance abuse treatment facilities, and rural health 
clinics, to test the effectiveness of community partnerships in helping 
to meet the mental health needs of Veterans in a timely way. These are 
being established in areas where there are access issues or staffing 
concerns.
    VHA will continue to work closely with DOD to educate 
Servicemembers, VA staff, Veterans and their families, public 
officials, Veterans Service Organizations, and other stakeholders about 
all mental health resources that are available in VA and with other 
community partners. VA has partnered with DOD to develop the VA/DOD 
Integrated Mental Health Strategy (IMHS) to advance a coordinated 
public health model to improve access, quality, effectiveness and 
efficiency of mental health services for Servicemembers, National Guard 
and Reserve, Veterans, and their families.
Academic Affiliations and Training
    VA is strategically working with universities, colleges and health 
professional training institutions across the country to expand their 
curricula to address the new science related to meeting the mental and 
behavioral needs of our Nation's Veterans, Servicemembers, Wounded 
Warriors, and their family members. In addition to ongoing job 
placement and outreach efforts through VetSuccess, VA has implemented a 
new outreach program, ``Veterans Integration to Academic Leadership,'' 
that places VA mental health staff at 21 colleges and universities to 
work with Veterans attending school on the GI Bill.
    VA's Office of Academic Affiliations trains roughly 6,400 trainees 
in mental health occupations per year (including 3,400 in psychiatry, 
1,900 in psychology, and 1,100 in social work, plus clinical pastoral 
education positions). Currently, VA has one of only two accredited 
psychology internship programs in the entire state of Alaska. VA is 
committed to expanding training opportunities in mental health 
professions in order to build a pipeline of future VA health care 
providers. VA continues to expand mental health training opportunities 
in Nursing, Pharmacy, Psychiatry, Psychology, and Social Work. For 
example, over 202 positions were approved to begin in academic year 
2013-2014 at 43 VHA facilities focused on the expansion of existing 
accredited programs in integrated care settings such as General 
Outpatient Mental Health Clinics or Patient Aligned Care Teams (PACT). 
These include over 86 training positions for Outpatient Mental Health 
Interprofessional Teams and 116 training positions for PACTs with 
Mental Health Integration, specifically 12 positions in Nursing, 43 in 
Pharmacy, over 34 in Psychiatry, 62 in Psychology, and 51 in Social 
Work. The Office of Academic Affiliations is scheduled to release the 
Phase II Mental Health Training Expansion Request for Proposals in 
Spring 2013 which will further assist with VA future workforce needs.
III. Mental Health Care Staffing and Hiring
    VA is committed to hiring and utilizing more mental health 
professionals to improve access to mental health care for Veterans. To 
serve the growing number of Veterans seeking mental health care, VA has 
deployed significant resources and is increasing the number of staff in 
support of mental health services. VA has taken aggressive action to 
recruit, hire, and retain mental health professionals to improve 
Veterans' access to mental health care. The department has also used 
many tools to hire the mental health workforce, including pay-setting 
authorities, loan repayment, scholarship programs and partnerships with 
health care workforce training programs to recruit and retain one of 
the largest mental health care workforces in the Nation. As a result, 
VA is able to serve Veterans better by providing enhanced services, 
expanded access, longer clinic hours, and increased telemental health 
capability to deliver services.
Mental Health Staffing
    VHA 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 soon separate from active duty status as they return from 
Afghanistan.
    Since there are no industry standards defining accurate mental 
health staffing ratios, VHA is setting the standard, as we have for 
other dimensions of mental health care. VHA has developed a prototype 
staffing model for general mental health delivery and is expanding the 
model to include specialty mental health care. VHA developed and 
implemented an aggressive recruitment and marketing effort to fill 
existing vacancies in mental health care occupations. To support 
implementation of the guidance, VHA announced the hiring of 1,600 new 
mental health professionals and 300 support staff in April 2012. Key 
initiatives include targeted advertising and outreach, aggressive 
recruitment from a pipeline of qualified trainees/residents to leverage 
against mission critical mental health vacancies, and providing 
consultative services to VISN and VA stakeholders. Despite the national 
challenges with recruitment of mental health care professionals, VHA 
continues to make significant improvements in its recruitment and 
retention efforts. Focused efforts are underway to expand the pool of 
applicants for those professions and sites where hiring is most 
difficult, such as creating expanded mental health training programs in 
rural areas and through recruitment and retention incentives.
    As part of our ongoing comprehensive review of mental health 
operations, VHA has considered a number of factors to determine 
additional staffing levels distributed across the system, including:

      Veteran population in the service area;
      The mental health needs of Veterans in that population; 
and
      Range and complexity of mental health services provided 
in the service area.

    Specialty mental health care occupations, such as psychologists, 
psychiatrists, and others, are difficult to fill and will require a 
very aggressive recruitment and marketing effort. VHA has developed a 
strategy for this effort focusing on the following key factors:

      Implementing a highly visible, multi-faceted, and 
sustained marketing and outreach campaign targeted to mental health 
care providers;
      Engaging VHA's National Health Care Recruiters for the 
most difficult to recruit positions;
      Recruiting from an active pipeline of qualified 
candidates to leverage against vacancies; and
      Ensuring complete involvement and support from VA 
leadership.
Mental Health Hiring
    In April 2012, VA announced a goal to hire an additional 1,600 
clinical providers and 300 administrative support staff. As of January 
29, 2013, VA has hired 1,058 clinical providers and 223 administrative 
staff in support of this specific goal. President Obama's August 31, 
2012, executive order requires the positions to be filled by June 30, 
2013.
    In order to provide greater access to mental health services, VHA 
knew that it would have to set aggressive goals to fill these new 
positions as well as existing mental health staff vacancies. Like any 
large health care system, VHA is constantly managing changes within its 
existing mental health workforce levels (e.g., retirements, transfers, 
promotions and resignations) to ensure providers are available to 
deliver care. Therefore, VHA set a hiring target of 5,000 mental health 
providers and administrative support staff to: 1) hire for new 
positions; 2) fill existing vacancies; and 3) replenish naturally 
occurring turnover. This ensures a robust flow into the workforce as we 
anticipate and respond to the needs of both workforce staffing and our 
Veterans. VHA has made significant progress to this end, by hiring a 
total of 3,262 clinical and administrative support staff to directly 
serve Veterans since May 2012. This progress has improved the 
Department's ability to provide timely, quality mental health care for 
Veterans.
    In March 2012, VHA reported a core mental health workforce of 
20,590. This calculation was based upon data from VHA's Allocation 
Resource Center (ARC), which reports monthly updates of Full Time 
Equivalent Employees (FTEE) based on departmental accounting of 
accumulated mental health clinical and administrative workload costs. 
Using this methodology demonstrates a core mental health workforce of 
21,502, an increase of 912, as of November 30, 2012.
    In our continued efforts to ensure we are providing effective 
direct care to our Veterans, VHA re-evaluated this methodology and 
concluded that the inpatient mental health care data in ARC was 
adequate - it measured what it was designed to measure. However, FTEE 
is not a head count of the workforce, and the data for outpatient 
mental health care included some non-clinical activities such as 
workload associated with mental health education, research, and 
administration. Additionally, a small amount of mental health clinical 
workload which is provided outside of core mental health was not 
included in the original workforce calculation. The ARC data also uses 
year-to-date methodology, which essentially prorates gains made over 
the year and does not adequately reflect hiring in real time. For these 
reasons, VHA developed an improved methodology for capturing mental 
health on-board strength. This methodology permits provider-level 
detail - including comparisons of staffing over time - to ensure 
accurate reporting of the direct care clinical workforce providing 
mental health services.
    This improved methodology required VA to develop a new system of 
accountability by combining information from three existing databases, 
which enhances our accuracy and allows VHA to:

    1) Ensure better visibility of mental health clinical outpatient 
data to the provider-level;

    2) Ensure that non-clinical workload is properly accounted for and 
not included in direct care calculations; and

    3) Obtain consistency in the application of the current 
comprehensive definition of mental health providers across VA.

    Using this improved accounting methodology, VA determined the 
mental health workforce providing direct patient care to be 18,587 as 
of March 2012. Applying this accounting methodology to the November 
2012 data provides a more accurate picture of the on board strength, 
which has increased from 18,587 to 19,743 mental health FTEE, for a 
total, net increase of 1,156 providing direct care to our Veterans. 
Regardless of accounting methodology used, the data reflects a net 
increase in the number of mental health professionals providing 
clinical health services thus increasing the access to quality mental 
health care for our Nation's Veterans. We always strive to improve our 
data collection to better serve Veterans, and to ensure that our 
methods are transparent.
Peer Support
    There are many Veterans who are willing to seek treatment and to 
share their experiences with mental health issues when they share a 
common bond of duty, honor, and service with the provider. While 
providing evidence-based psychotherapies is critical, VA understands 
Veterans benefit from supportive services other Veterans can provide. 
To meet this need in accordance with the Executive Order and 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 has hired over 
100 Peer Specialists in recent months, and is hiring and training 
nearly 700 more. Additionally, VA has awarded a contract to the 
Depression and Bipolar Support Alliance to provide certification 
training for Peer Specialists. This peer staff is expected to be hired 
by December 31, 2013, and will work as members of mental health teams. 
Simultaneously, VA is providing additional resources to expand peer 
support services across the Nation to support full-time, paid peer 
support technicians.
Performance Measures
    VA is reengineering its performance measurement methodologies to 
evaluate and revamp its programs. Performance measurement and 
accountability will remain the cornerstones of our program to ensure 
that resources are being devoted where they need to go and are being 
used to the benefit of Veterans. Our priority is leading the Nation in 
patient satisfaction regarding the quality, effectiveness of care and 
timeliness of their appointments.
    Recognizing the benefit that would come from improving Veteran 
access, VA is modifying the current appointment performance measurement 
system to include a combination of measures that better captures each 
Veteran's needs. VA will ensure this approach is structured around a 
thoughtful, individualized treatment plan developed for each Veteran to 
inform the timing of appointments.
    In April 2012, VA's Office of Inspector General (OIG) report on 
VA's mental health programs gave four recommendations: 1) a need for 
improvement in our wait time measurements, 2) improvement in patient 
experience metrics, 3) development of a staffing model, and 4) 
provision of data to improve clinic management. Further, in January 
2013, the U.S. Government Accountability Office reviewed VA's 
healthcare outpatient medical appointment scheduling and appointment 
notification processes, specifically focusing on Veterans wait times, 
local VA Medical Center implementation of national scheduling policies 
and processes as well as VHA initiatives to improve Veterans' access to 
medical appointments.
    In direct response, VA is using OIG and GAO results along with our 
internal reviews to implement important enhancements to VA mental 
health care. Based on OIG and GAO findings, VA is updating scheduling 
practices, and strengthening performance measures to ensure 
accountability. VA has examined how best to measure Veterans' wait time 
experiences and how to improve scheduling processes to define how our 
facilities should respond to Veterans' needs and commissioned a study 
to measure timely appointment access and resulting patient 
satisfaction. Based on the results of this study, VA is changing its 
timeliness measures to best track different populations (new vs. 
established patients) using the approach which best predicts patient 
satisfaction and clinical care outcomes. In addition, VA is developing 
measures based on timeliness after referral to mental health services, 
patient perceptions of barriers to care, and measures of clinic 
capacity. By taking these steps, we are confident that we will be able 
to deliver accessible, high quality mental health care to Veterans.
    The development of improved performance metrics, more reliable 
reporting tools, and an initial mental health staffing model, will 
enable VHA to better track wait times, assess productivity, and 
determine capacity for mental health services. All of these tools will 
continue to be evaluated and improved with experience in their use.
Conclusion
    Mr. Chairman, we know our work to improve the delivery of mental 
health care to Veterans will never be truly finished. However, we are 
confident that 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. We appreciate your support and 
encouragement in identifying and resolving challenges as we find new 
ways to care for Veterans. VA is committed to providing the high 
quality of care that our Veterans have earned and deserve, and we 
continue to take every available action to improve access to mental 
health care services. We appreciate the opportunity to appear before 
you today, and my colleagues and I are prepared to respond to any 
questions you may have.

                                 
                       Statements For The Record

                      Office of Inspector General
    Mr. Chairman, Ranking Member Michaud, and members of the Committee, 
thank you for the opportunity to provide information to the Committee 
on the work of the Office of Inspector General (OIG) regarding the 
delivery and efficacy of mental health care by the Department of 
Veterans Affairs (VA).
    VA provides medical care to eligible veterans throughout the United 
States through VA medical centers, VA community based outpatient 
clinics, and private providers in the community under the Non-VA Fee 
Care Program (``Fee Basis''). The activation of National Guard and 
Reserve units from across the country and the duration of the conflicts 
in Iraq and Afghanistan, combined with the increased utilization of VA 
mental health services by prior service-era veterans have stressed the 
ability of VA to provide ready and reliable access to necessary mental 
health care for returning veterans. The OIG has continued to report on 
the challenges that VA faces in delivering health care to address 
complex mental health issues including preventing suicides among 
returning veterans, addressing post traumatic stress and related 
clinical issues that result from prolonged combat, assisting female 
veterans to overcome the issues related to military sexual trauma, and 
providing appropriate treatment for substance use disorders while 
treating chronic pain conditions. Attached is a list of selected OIG 
reports dealing with these issues, which can be found on our website, 
www.va.gov/oig.

    The Committee requested the OIG comment on five areas:

      Fulfilling the promise to hire additional mental health 
personnel and fill the large number of existing vacancies - In April 
2012, VA announced a hiring initiative for mental health providers. As 
of December 26, 2012, which is the most recent information that VA 
provided to the OIG, less than half of the desired psychiatrists (260 
of 558) have been hired and less than 70 percent of the desired 
psychologists (507 of 854), social workers (686 of 981) and mental 
health nurses (688 of 1032) have been hired. The goals identified in 
VA's plan are very ambitious given the limited number of mental health 
professionals trained each year and the increased competition for 
qualified mental health providers as economic and related conditions 
increase the non-governmental need for mental health professionals.
    VA has exceeded the hiring goal for non-clinical support staff (341 
against a goal of 300). However, hiring more non-clinical staff than 
required does not compensate for the lack of clinical staff and may not 
improve efficiency.
      Implementing the Executive Order on ``Improving Access to 
Mental Health Services for Veterans, Service Members, and Military 
Families'' - The OIG has not reviewed VA's actions related to the 
requirements in the Executive Order.
      Addressing the recommendations of the recent VA Inspector 
General and Government Accountability Office reports - As of today, all 
four recommendations from the OIG report, Veterans Health 
Administration - Review of Veterans' Access to Mental Health Care 
(April 23, 2012) remain open. The recommendations relate to improving 
the metrics used by VA to measure appointment wait times and the 
utilization of related metrics designed to effectively reflect the 
patient experience of access to mental health care and to improve 
management oversight of these clinical activities. In addition, VA 
committed to performing a staffing analysis to determine the personnel 
needs to provide the required mental health services. VA indicates that 
progress has been made toward accomplishing these goals but VA has not 
provided evidence of those efforts to the OIG to verify.
      Correcting lengthy wait times, misleading access 
measures, and cumbersome scheduling processes and procedures - As the 
OIG reports have indicated, VA mental health access times are not 
accurately reported and may not be the most useful measures to monitor 
clinical performance. While workgroups have been established and move 
ahead, changes to these metrics have not been finalized and/or 
implemented.
    The OIG has reported on the inefficiencies of the current patient 
appointment system for many years. The business rules of the current 
system also limit the usefulness of management data derived from the 
system. The installation of a new patient appointment system will take 
many months if not years to occur.
      Effectively partnering with non-VA resources to address 
gaps and create a more patient-centric network of care focused on 
wellness-based outcomes - VA has an inconsistent record of contracting 
effectively with non-VA providers to obtain health care for veterans. 
At present, the procurement of specialty medical services through Fee 
Basis does not provide a seamless compliment to in-house VA medical 
care. The use of the current Fee Basis business rules is cumbersome for 
VA facilities, and in practice, the business rules do not create 
certainty in the minds of veterans or Fee Basis providers that the goal 
of timely, appropriate health care will be delivered and paid for.
    The OIG has consistently reported on contracting issues with both 
in-patient and out-patient fee care. Weaknesses include reviewing bills 
to ensure the proper payment is made and ensuring clinical data is 
easily incorporated within the VA medical record. OIG has reported on 
instances of improper payment and/or inadequate integration of the 
treatment through purchased care into the veteran's medical records.
    With the return of servicemen and servicewomen from our ongoing 
conflicts and the aging veteran population, VA faces a number of 
critical challenges in order to improve current performance and 
increasingly and consistently meet the complex mental health needs of 
veterans. The OIG will continue to review and report on VA actions at 
this critical time. Our veterans deserve no less.
                          SELECTED OIG REPORTS
    Healthcare Inspection - Appointment Scheduling and Access Patient 
Call Center, VA San Diego Healthcare System, San Diego, California - 1/
28/2013
    Healthcare Inspection - Inpatient and Residential Programs for 
Female Veterans with Mental Health Conditions Related to Military 
Sexual Trauma- 12/5/2012
    Healthcare Inspection - Alleged Clinical and Administrative Issues, 
VA Loma Linda Healthcare System, Loma Linda, California - 11/19/2012
    Healthcare Inspection - Delays for Outpatient Specialty Procedures, 
VA North Texas Health Care System, Dallas, Texas - 10/23/2012
    Healthcare Inspection - Delay in Treatment, Louis Stokes VA Medical 
Center, Cleveland, Ohio - 10/12/2012
    Healthcare Inspection - Consultation Mismanagement and Care Delays, 
Spokane VA Medical Center, Spokane, Washington - 9/25/2012
    Healthcare Inspection - Alleged Staffing and Quality of Care 
Issues, VA Black Hills Health Care System, Hot Springs, South Dakota - 
9/11/2012
    Healthcare Inspection - Access and Coordination of Care at 
Harlingen Community Based Outpatient Clinic, VA Texas Valley Coastal 
Bend Health Care System, Harlingen, Texas - 8/22/2012
    Healthcare Inspection - Management of Chronic Opioid Therapy at a 
VA Maine Healthcare System Community Based Outpatient Clinic, Calais, 
Maine - 8/21/2012
    Healthcare Inspection - Service Delivery and Follow-up After a 
Patient's Suicide Attempt, Minneapolis VA Health Care System, 
Minneapolis, Minnesota -7/19/2012
    Homeless Incidence and Risk Factors for Becoming Homeless in 
Veterans - 5/4/2012
    Healthcare Inspection - Suicide of a Veteran Enrolled in VA 
Supported Housing, Bay Pines VA Healthcare System, Bay Pines, FL - 4/
18/2012
    Healthcare Inspection - Alleged Mental Health Access and Treatment 
Issues at a VA Medical Center - 3/21/2012
    Healthcare Inspection - Select Patient Care Delays and Reusable 
Medical Equipment Review Central Texas Veterans Health Care System 
Temple, Texas - 1/6/2012
    Healthcare Inspection - Clinical and Administrative Issues in the 
Suicide Prevention Program Alexandria VA Medical Center Pineville, 
Louisiana - 8/30/2011
    Healthcare Inspection - Attempted Suicide During Treatment West 
Palm Beach VA Medical Center, West Palm Beach, Florida - 7/25/2011
    Healthcare Inspection - Electronic Waiting List Management for 
Mental Health Clinics Atlanta VA Medical Center Atlanta, Georgia - 7/
12/2011
    Healthcare Inspection - A Follow-Up Review of VHA Mental Health 
Residential Rehabilitation Treatment Programs (MH RRTP) - 6/22/2011
    Healthcare Inspection - Prescribing Practices in the Pain 
Management Clinic, John D. Dingell VA Medical Center, Detroit, Michigan 
- 6/15/2011
    Healthcare Inspection - Post Traumatic Stress Disorder Counseling 
Services at Vet Centers - 5/17/2011
    Review of Combat Stress in Women Veterans Receiving VA Health Care 
and Disability Benefits - 12/16/2010

                                 
                    Government Accountability Office
    Chairman Miller, Ranking Member Michaud, and Members of the 
Committee:
    I am pleased to have the opportunity to comment on overcoming 
barriers for quality mental health care for veterans--particularly 
those who are returning from deployment. In 2011, we reported that the 
number of veterans receiving mental health care had increased each year 
from fiscal year 2006 to 2010, and veterans who served in Afghanistan 
and Iraq accounted for an increasing proportion of veterans receiving 
mental health care during this period. \1\ We also reported on the key 
barriers that may hinder veterans from accessing mental health care 
from the Department of Veterans Affairs (VA), which included difficulty 
scheduling appointments. \2\ More recently, in December 2012, we 
reported on problems with VA's oversight of outpatient medical 
appointment scheduling processes and measurement of outpatient medical 
appointment wait times. \3\
---------------------------------------------------------------------------
    \1\ GAO, VA Mental Health: Number of Veterans Receiving Care, 
Barriers Faced, and Efforts to Increase Access, GAO-12-12 (Washington, 
D.C.: Oct. 14, 2011).
    \2\ We identified key barriers from the literature, and 
corroborated the barriers through interviews with VA officials.
    \3\ GAO, VA Health Care: Reliability of Reported Outpatient Medical 
Appointment Wait Times and Scheduling Oversight Need Improvement, GAO-
13-130 (Washington, D.C.: Dec. 21, 2012).
---------------------------------------------------------------------------
    In fiscal year 2011, there were more than 8 million veterans 
enrolled in VA's health system, which is operated by the Veterans 
Health Administration (VHA). VHA provided nearly 80 million outpatient 
medical appointments to veterans through its primary and specialty care 
clinics. \4\ Although access to timely medical appointments is critical 
to ensuring that veterans obtain needed medical care, long wait times 
and inadequate scheduling processes at VA medical centers (VAMC) have 
been long-standing problems that persist today. For example, in 2001, 
we reported on the timeliness of medical appointments and found that 
two-thirds of the specialty care clinics visited had wait times longer 
than 30 days, although some clinics had made progress in reducing wait 
times, primarily by improving their scheduling processes and making 
better use of their staff. \5\ Later, in 2007, the VA Office of 
Inspector General (OIG) reported that VHA facilities did not always 
follow VHA's scheduling policies and processes and that the accuracy of 
VHA's reported wait times for medical appointments was unreliable. \6\ 
Most recently, in 2012, the VA OIG reported that VHA was not providing 
all new veterans with timely access to full mental health evaluations, 
and had overstated its success in providing veterans with timely new 
and follow-up appointments for mental health treatment. \7\ Although 
VHA has reported continued improvements in measuring and achieving 
timely access to medical appointments, patient complaints and media 
reports about long wait times have persisted, prompting renewed 
concerns about excessive medical appointment wait times.
---------------------------------------------------------------------------
    \4\ Outpatient clinics offer services to patients that do not 
require a hospital stay. Primary care addresses patients' routine 
health needs and specialty care is focused on a specific specialty 
service such as orthopedics, dermatology, or psychiatry. Throughout 
this statement we will use the term ``medical appointments'' to refer 
to outpatient medical appointments.
    \5\ GAO, VA Health Care: More National Action Needed to Reduce 
Waiting Times, but Some Clinics Have Made Progress, GAO-01-953 
(Washington, D.C.: Aug. 31, 2001).
    \6\ Department of Veterans Affairs, Office of Inspector General, 
Audit of the Veterans Health Administration's Outpatient Waiting Times, 
Report No. 07-00616-199, (Washington, D.C.: Sept. 10, 2007).
    \7\ Department of Veterans Affairs, Office of Inspector General, 
Veterans Health Administration: Review of Veterans' Access to Mental 
Health Care, Report No. 12-00900-168, (Washington, D.C.: Apr. 23, 
2012).
---------------------------------------------------------------------------
    VHA has a scheduling policy intended to help its VAMCs meet its 
commitment to scheduling medical appointments with no undue waits or 
delays. \8\ The policy establishes processes and procedures for 
scheduling medical appointments and ensuring the competency of staff 
directly or indirectly involved in the scheduling process. It includes 
several requirements that affect timely appointment scheduling, as well 
as accurate wait time measurement. \9\ For example, the policy requires 
schedulers to record appointments in VHA's Veterans Health Information 
Systems and Technology Architecture (VistA) medical appointment 
scheduling system, including the date on which the patient or provider 
wants the patient to be seen--known as the desired date. \10\
---------------------------------------------------------------------------
    \8\ VHA medical appointment scheduling policy is documented in VHA 
Directive 2010-027, VHA Outpatient Scheduling Processes and Procedures 
(June 9, 2010). We refer to the directive as ``VHA's scheduling 
policy'' from this point forward.
    \9\ VHA has a separate directive that establishes policy on the 
provision of telephone service related to clinical care, including 
facilitating telephone access for medical appointment management. VHA 
Directive 2007-033, Telephone Service for Clinical Care (Oct. 11, 
2007).
    \10\ VistA is the single integrated health information system used 
throughout VHA in all of its health care settings. There are many 
different VistA applications for clinical, administrative, and 
financial functions, including the scheduling system.
---------------------------------------------------------------------------
    At the time of our review, VHA measured medical appointment wait 
times as the number of days elapsed from the patient's or provider's 
desired date, as recorded in the VistA scheduling system by VAMCs' 
schedulers. According to VHA central office officials, VHA measures 
wait times based on desired date in order to capture the patient's 
experience waiting and to reflect the patient's or provider's wishes. 
In fiscal year 2012, VHA had a goal of completing primary care 
appointments within 7 days of the desired date, and scheduling 
specialty care appointments within 14 days of the desired date. \11\ 
VHA established these goals based on its performance reported in 
previous years. \12\ To help facilitate accountability for achieving 
its wait time goals, VHA includes wait time measures--referred to as 
performance measures--in its Veterans Integrated Service Network (VISN) 
directors' and VAMC directors' performance contracts, \13\ and VA 
includes measures in its budget submissions and performance reports to 
Congress and stakeholders. \14\
---------------------------------------------------------------------------
    \11\ In 2012, VA also had several additional goals related to 
measuring access to mental health appointments specifically, such as 
screening eligible patients for depression, post-traumatic stress 
disorder, and alcohol misuse at required intervals; and documenting 
that all first-time patients referred for or requesting mental health 
services receive a full mental health evaluation within 14 days of 
their initial encounter. As noted earlier, in its Report No. 12-00900-
168, the VA OIG found that some of the mental health performance data 
were not reliable. VA is dropping several of these mental health 
measures in 2013.
    \12\ In 1995, VHA established a goal of scheduling primary and 
specialty care medical appointments within 30 days to ensure veterans' 
timely access to care. In fiscal year 2011, VHA shortened the wait time 
goal to 14 days for both primary and specialty care medical 
appointments. In fiscal year 2012, VHA added a goal of completing 
primary care medical appointments within 7 days of the desired date.
    \13\ Each of VA's 21 VISNs is responsible for managing and 
overseeing medical facilities within a defined geographic area. VISN 
and VAMC directors' performance contracts include measures against 
which directors are rated at the end of the fiscal year, which 
determine their performance pay.
    \14\ VA prepares a congressional budget justification that provides 
details supporting the policy and funding decisions in the President's 
budget request submitted to Congress prior to the beginning of each 
fiscal year. The budget justification articulates what VA plans to 
achieve with the resources requested; it includes performance measures 
by program area. VA also publishes an annual performance report--the 
performance and accountability report-- which contains performance 
targets and results achieved compared with those targets in the 
previous year.
---------------------------------------------------------------------------
    This statement highlights key findings from our December 2012 
report that describes needed improvements in the reliability of VHA's 
reported medical appointment wait times, scheduling oversight, and VHA 
initiatives to improve access to timely medical appointments. \15\ For 
that report, we reviewed VHA's scheduling policy and methods for 
measuring medical appointment wait times and interviewed VHA central 
office officials responsible for developing them. We did not include 
mental health appointments in the scope of our work, because this issue 
was already being reviewed by VA's Office of Inspector General. We also 
visited 23 high-volume outpatient clinics at four VAMCs selected for 
variation in size, complexity, and location; these four VAMCs were 
located in Dayton, Ohio; Fort Harrison, Montana; Los Angeles, 
California; and Washington, D.C. At each VAMC we interviewed leadership 
and other officials about how they manage and improve medical 
appointment timeliness, their oversight to ensure accuracy of 
scheduling data and compliance with scheduling policy, and problems 
staff experience in scheduling timely medical appointments. We examined 
each VAMC's and clinic's implementation of elements of VHA's scheduling 
policy and obtained documentation of scheduler training completion. In 
addition, we interviewed schedulers from 19 of the 23 clinics visited, 
and also reviewed patient complaints about telephone responsiveness, 
which is integral to timely medical appointment scheduling. We 
interviewed the directors and relevant staff of the four VISNs for the 
sites we visited. We also interviewed VHA central office officials and 
officials at the VAMCs we visited about selected initiatives to improve 
veterans' access to timely medical appointments. We performed this work 
from February 2012 through December 2012 in accordance with generally 
accepted government auditing standards.
---------------------------------------------------------------------------
    \15\ GAO-13-130.
---------------------------------------------------------------------------
    In brief, we found that (1) VHA's reported outpatient medical 
appointment wait times are unreliable, (2) there was inconsistent 
implementation of certain elements of VHA's scheduling policy that 
could result in increased wait times or delays in scheduling timely 
medical appointments, and
    (3) VHA is implementing or piloting a number of initiatives to 
improve veterans' access to medical appointments. Specifically, VHA's 
reported outpatient medical appointment wait times are unreliable 
because of problems with correctly recording the appointment desired 
date--the date on which the patient or provider would like the 
appointment to be scheduled--in the VistA scheduling system. Since, at 
the time of our review, VHA measured medical appointment wait times as 
the number of days elapsed from the desired date, the reliability of 
reported wait time performance is dependent on the consistency with 
which VAMC schedulers record the desired date in the VistA scheduling 
system. However, aspects of VHA's scheduling policy and related 
training documents on how to determine and record the desired date are 
unclear and do not ensure replicable and reliable recording of the 
desired date by the large number of staff across VHA who can schedule 
medical appointments, which at the time of our review was estimated to 
be more than 50,000. During our site visits, we found that at least one 
scheduler at each VAMC did not record the desired date correctly, 
which, in certain cases, would have resulted in a reported wait time 
that was shorter than the patient actually experienced for that 
appointment. Moreover, staff at some clinics told us they change 
medical appointment desired dates to show clinic wait times within 
VHA's performance goals. Although VHA officials acknowledged 
limitations of measuring wait times based on desired date, and told us 
that they use additional information, such as patient satisfaction 
survey results, to monitor veterans' access to medical appointments, 
reliable measurement of how long veterans wait for appointments is 
essential for identifying and mitigating problems that contribute to 
wait times.
    At the VAMCs we visited, we also found inconsistent implementation 
of VHA's scheduling policy, which can result in increased wait times or 
delays in scheduling timely medical appointments. For example, four 
clinics across three VAMCs did not use the electronic wait list to 
track new patients that needed medical appointments as required by 
VHA's scheduling policy, putting these clinics at risk for losing track 
of these patients. Furthermore, VAMCs' oversight of compliance with 
VHA's scheduling policy was inconsistent across the facilities we 
visited. Specifically, certain VAMCs did not ensure the completion of 
scheduler training by all staff required to complete it even though 
officials stressed the importance of the training for ensuring correct 
implementation of VHA's scheduling policy. VAMCs also described other 
problems that impede the timely scheduling of medical appointments, 
including VA's outdated and inefficient VistA scheduling system, gaps 
in scheduler staffing, and issues with telephone access. The current 
VistA scheduling system is more than 25 years old, and VAMC officials 
reported that using the system is cumbersome and can lead to errors. 
\16\ In addition, shortages or turnover of scheduling staff, identified 
as a problem by all of the VAMCs we visited, can result in appointment 
scheduling delays and incorrect scheduling practices. Officials at all 
VAMCs we visited also reported that high call volumes and a lack of 
staff dedicated to answering the telephones impede the scheduling of 
timely medical appointments. Although we did not specifically review 
mental health clinic wait times, some of the problems we identified 
were pervasive, and may also affect clinics other than those we 
visited.
---------------------------------------------------------------------------
    \16\ In October 2012, VA announced a contest seeking proposals for 
a new medical appointment scheduling system from commercial software 
developers.
---------------------------------------------------------------------------
    VHA is implementing or piloting a number of initiatives to improve 
veterans' access to medical appointments that focus on more patient-
centered care; using technology to provide care, through means such as 
telehealth and secure messaging between patients and their health care 
providers; and using care outside of VHA to reduce travel and wait 
times for veterans who are unable to receive certain types of 
outpatient care in a timely way through local VHA facilities. For 
example, VHA is piloting a new initiative to provide health care 
services through contracts with community providers that aims to reduce 
travel and wait times for veterans who are unable to receive certain 
types of care from VHA in a timely way. Although VHA collects 
information on wait times for medical appointments provided through 
this initiative, these wait times may not accurately reflect how long 
patients are waiting for appointments because they are counted from the 
time the contracted provider receives an authorization from VA, rather 
than from the time the patient or provider first requests an 
appointment from VHA.
    In conclusion, VHA officials have expressed an ongoing commitment 
to providing veterans with timely access to medical appointments and 
have reported continued improvements in achieving this goal. However, 
unreliable wait time measurement has resulted in a discrepancy between 
the positive wait time performance VA has reported and veterans' actual 
experiences. More consistent adherence to VHA's scheduling policy and 
oversight of the scheduling process, allocation of staff resources to 
match clinics' scheduling demands, and resolution of problems with 
telephone access would potentially reduce medical appointment wait 
times. VHA's ability to ensure and accurately monitor access to timely 
medical appointments is critical to ensuring quality health care to 
veterans, who may have medical conditions that worsen if access is 
delayed.
    To ensure reliable measurement of how long veterans are waiting for 
appointments and improve timely medical appointment scheduling, we 
recommended that the Secretary of VA direct the Under Secretary for 
Health to take actions to (1) improve the reliability of its medical 
appointment wait time measures, (2) ensure VAMCs consistently implement 
VHA's scheduling policy, (3) require VAMCs to routinely assess 
scheduling needs for purposes of allocation of staffing resources, and 
(4) ensure that VAMCs provide oversight of telephone access and 
implement best practices to improve telephone access for clinical care. 
VA concurred with our recommendations and identified actions planned or 
underway to address them.
    This concludes my statement for the record.
GAO Contacts and Staff Acknowledgments
    For questions about this statement, please contact Debra A. Draper 
at (202) 512-7114 or [email protected]. Contact points for our Offices of 
Congressional Relations and Public Affairs may be found on the last 
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statement include Bonnie Anderson, Assistant Director; Rebecca Abela; 
Jennie Apter; Lisa Motley; Sara Rudow; and Ann Tynan.

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                  The American Counseling Association
    Chairman Miller, Ranking Member Michaud and Members of the 
Committee, I want to thank you for inviting me to submit testimony to 
the Committee today. It is an honor and a privilege to speak on behalf 
of the American Counseling Association and we appreciate the 
opportunity to contribute to this very important discussion. We share 
the concerns of this committee regarding the well-being of our service 
members, and we consider it a national tragedy that on average, one of 
our veterans commits suicide every 80 minutes. I can think of no more 
pressing concern for this committee than stopping this terrible toll.
    The American Counseling Association is the country's largest and 
oldest professional association representing the counseling profession, 
with over 52,000 members across the United States and overseas. Our 
members have diverse backgrounds and many of them specialize in 
treating substance abuse disorders, mental health issues, trauma, 
family issues and depression among others.
    There are more than 120,000 licensed professional counselors 
(LPC's) nationwide, authorized under licensure laws enacted in all 50 
states and other U.S. jurisdictions to practice independently. As with 
the profession of social work, states use slightly differing titles for 
those licensed as professional mental health counselors, the most 
commonly used title being ``licensed professional counselor.'' LPCs 
meet education, training, and examination requirements similar to--and 
in many states, more stringent than--those of marriage and family 
therapists and clinical social workers. Licensed professional 
counselors have to have a master's degree in counseling or a related 
field, pass a national exam (in some cases two exams), and accumulate 
thousands of hours of post-degree supervised experience. As with other 
health care professionals, counselors must adhere to a code of ethics, 
are required to practice within the scope of their expertise, and 
practice subject to the oversight and approval of their state's 
licensure board. Counselors provide outpatient psychotherapy 
independently under private sector health plans nationwide, as 
authorized by state licensure laws, and form a significant part of the 
nation's mental health workforce.
    Licensed professional counselors can make a valuable contribution 
to treating the mental health concerns of service members, and as the 
committee knows, psychological and cognitive injuries and their 
consequences are the signature wounds of the Iraq and Afghanistan 
conflicts. Policymakers both inside and outside the Department of 
Veterans Affairs have repeatedly said that there aren't enough mental 
health providers available to meet veterans' treatment needs. From our 
perspective this problem is to a large extent a self-inflicted wound, 
because despite a past press release to the contrary, the VA has 
effectively decided not to utilize LPCs as part of its mental health 
workforce. The VA's rules and policies have kept far too many 
counselors from operating under either of those two areas at a time 
when we need them most. And these rules could be changed by the 
Administration in a fairly simple and quick manner so that we can begin 
to deliver the care and treatment that our troops need right now.
    As I mentioned, there are more than 120,000 licensed professional 
counselors across the country, all meeting stringent education, 
training, experience, examination, and ethical standards. In all of 
2012, a grand total of 58 LPMHC (``licensed professional mental health 
counselor'') VA positions were posted on USAJobs.com. In comparison, 
1,527 clinical social worker positions were posted. In terms of the 
number of licensees at the highest level of licensure, the ratio for 
the two professions nationwide isn't 26 to 1; it's roughly 1.7 to 1.
    While we understand that the local needs of VA Medical Centers and 
Community-Based Outpatient Clinics are varied and that the local staff 
or those facilities are positioned to identify and meet those needs, it 
is clear to us that LPCs are an overlooked solution to the staffing 
problem. Also, in many cases, both VAMCs and CBOCs are unable to 
integrate LPCs into their staff due to the fact that there are barriers 
that have been created by the VA itself. To cite one important example, 
the VA's Office of Academic Affiliations each year establishes paid 
traineeship positions for both psychologists and clinical social 
workers counselors, which serve as a pathway to service in the VA 
health care system. The Office of Academic Affiliations has denied our 
request that they establish paid traineeship positions for professional 
counselors. The most recent justification given for this denial is the 
unsubstantiated, false claim that there is a different ``community 
standard'' regarding paid internships within the mental health 
counseling profession than exists for the clinical social work and 
psychology professions. Less than a year ago, the justification given 
was that there was ``not a need'' for professional mental health 
counselors at VA facilities.
    Despite the current crisis in veterans' mental health care, the VA 
is using overly restrictive eligibility criteria for LPMHC positions, 
which includes graduation from counseling programs that are 
specifically named. ACA supports the highest standards of 
accreditation. In fact, organizations such as the Council on 
Accreditation of Counseling and Related Educational Programs (CACREP) 
is one that our organization helped to create. However, while we 
understand the VA's interest in relying on national accreditation to 
ensure provider quality, large numbers of highly qualified, experienced 
LPCs will be denied the ability to provide critical mental health 
services of our returning wounded warriors. We believe this is 
unconscionable.
    By mandating such a strict accreditation requirement, the VA is 
shutting out many highly-trained mental health counselors--many of them 
veterans themselves--at a time when veterans are literally dying for 
want of help. We have asked the VA to increase job listings for LPCs 
and adopt grand parenting standards to allow an alternative route to 
eligibility for LPMHC positions for the tens of thousands of fully-
licensed counselors who right now can't apply, but the VA has said they 
are not interested. The result is that our members are being told that 
they should go back to school and obtain another degree if they wish to 
work in a VA facility, if and when the VA decides to begin hiring 
LPMHCs in large numbers.
    ACA recommends that the VA expand the eligibility criteria for 
LPMHC positions to include mental health counselors who:

    1) Holds at least a master's degree in counseling from a regionally 
accredited program;

    2) Is licensed as a professional counselor in a U.S. jurisdiction 
at the highest level of licensure offered; and

    3) Passes the National Clinical Mental Health Counseling (NCMHCE) 
Exam.

    ACA believes that by adopting grandfathering provisions such as 
these, at least during this time of severe need for more clinicians, 
the VA can recruit more LPCs without sacrificing the quality of care to 
our veterans. It could also allow many veterans who are counselors to 
serve their country and their compatriots.
    In addition to adopting these grandfathering provisions, ACA has 
several other specific policy recommendations that we have recommended 
to the VA and would like to share with the committee. And while these 
recommendations may seem like small steps that the VA could take, they 
would be huge strides for the LPC community and would go a long way 
toward opening the door to members of our profession who want to care 
for our veterans:

      The VA's Office of Academic Affiliations should include 
counselors in its paid trainee program. These positions are a well-trod 
pathway to careers within the VA, and counselors are being unfairly and 
arbitrarily discriminated against by being excluded from the program.
      That the VA collaborate with ACA and other groups to help 
fill vacancies in the VA. ACA has a national network and an office of 
professional affairs that can help find applicants for these positions.
      That the VA appoint a liaison to work with the counseling 
community toward hiring more LPCs in the VA.
      VA Secretary Eric Shinseki should issue a public notice 
to the entire VA healthcare system (Specifically to VISN Directors, 
VMAC Directors and HR Directors) reminding them that they are empowered 
to hire counselors, and asking them not to shut-out an entire 
profession that can provide desperately needed help to our vets.

    All of these recommendations could be undertaken by the VA 
immediately, and without the need for congressional authorization. They 
could be acted upon today and thus hasten the ability for the VA to 
expand the opportunities for our service members to receive quality 
mental healthcare.
    I hope that by sharing these recommendations with you, we can work 
together toward implementing these recommendations and get more LPCs 
into the VA. More LPCs in the system would mean that we are increasing 
the availability of mental health clinicians to our veterans and their 
family members. In the end, improving the quality and accessibility of 
mental health services for our veterans and their families should be 
what we are all focused on.

                                 
                          The American Legion
    Chairman Miller, Ranking Member Michaud and distinguished Members 
of the Committee:
    The United States of America lost 22 veterans to suicide every day 
in 2010 according to the Department of Veterans Affairs (VA) study 
released earlier this month. According to the report's estimations, a 
veteran took his or her own life every 66 minutes \1\. With veteran 
suicide at an all time high, naturally we must question whether VA's 
mental health care system is equipped to meet the demands of the 
veteran population it was created to serve. The VA may offer veterans 
the best mental health care option available, but if we face difficult 
barriers to access that care, then veterans are not really being 
served.
---------------------------------------------------------------------------
    \1\ ``Suicide Data Report, 2012'' Department of Veterans Affairs 
Mental Health Services Suicide Prevention Program, p 15
---------------------------------------------------------------------------
    On behalf of Commander James Koutz and the 2.4 million veterans of 
The American Legion, we would like to thank you for this opportunity to 
provide testimony for the record in order to highlight issues with 
overcoming barriers to quality mental health care provided by VA.
    Specifically, we will address the following five issues:

    1) Fulfilling the promise to hire additional mental health 
personnel and fill the large number of vacancies

    2) Implementation of the E.O to improve access to mental health 
care for veterans and their families

    3) Addressing the recommendations in the IG and GAO report

    4) Correcting lengthy wait times and misleading access measures, 
and cumbersome scheduling processes, and

    5) Effective partnering with non-VA resources to address gaps and 
create a more patient-centric network of care focused on wellness-based 
outcomes
The Large Number of Existing Vacancies
    During the past half decade, VA has nearly doubled their mental 
health care staff, jumping from just over 13,500 providers in 2005 to 
over 20,000 providers in 2011. However, during that time there has been 
a massive influx of veterans into the system, with a growing need for 
psychiatric services. With over 1.5 million veterans separating from 
service in the past decade, 690,844 have not utilized VA for treatment 
or evaluation. The American Legion is deeply concerned about nearly 
700,000 veterans who are slipping through the cracks unable to access 
the health care system they have earned through their service.
    On June 11th, 2012, a VA Press Release outlined an aggressive 
recruitment effort to hire 1,600 mental health professionals and 300 
support staff. The release stated that all of the positions would be 
filled by the 2nd Quarter of FY2013. Unfortunately, despite repeated 
requests for updates on the progress of the hiring, The American Legion 
had not received any numbers or date until a belated, eleventh hour 
press release from VA that was released just hours before this hearing.
    In order to instill confidence in the veterans' mental health care 
stakeholders, VA must improve the transparency of their process and 
work to foster meaningful two-way communication. The veteran community 
wants to work with VA to ensure the needs of our veterans are being 
met, yet effective communication is impossible without open access to 
the information we need to discuss. The American Legion urges VA to 
provide more information on the status of hiring for these positions, 
throughout the entire process. If the concerned veterans' community 
only learns of unfilled positions after a deadline is missed, it will 
be too late for stakeholders and partners to work together to achieve 
meaningful solutions.
Implementing the Executive Order on Improving Access to Mental Health 
        Services for Veterans, Servicemembers and Military Families
    The Executive Order on Improving Access to Mental Health Services 
for Veterans, Servicemembers and Military Families dealt with suicide 
prevention, enhancing partnerships between the VA and community 
providers, expanding VA mental health services staffing, improved 
research & development, and the creation of a Military and Veterans 
Mental Health Interagency Task Force.
    After reviewing the Executive Order and examining the 
implementation, The American Legion has identified certain gaps that 
may need to be considered in the future development and implementation 
of this Executive Order.
    The Executive Order Section 1: Policy order states that ``as part 
of our ongoing efforts to improve all facets of military mental health, 
this order directs the Secretary of Defense, Health and Human Services, 
Education, Veterans Affairs, and Homeland Security to expand suicide 
prevention strategies and take steps to meet the current and future 
demand for mental health and substance abuse treatment services for 
veterans, service members and their families.''
    However, The American Legion is gravely concerned about the 
February 5, 2012 decision by VA and DOD to abandon efforts to create a 
single medical records system. Rather than supporting the vision of the 
Executive Order to work with multiple agencies, this decision can only 
lead to greater distance and fragmentation. With veterans waiting on 
average 374 days for Medical Evaluation Board (MEB)/Physical Evaluation 
Board (PEB) claims and 257 days for a traditional VA claim, veterans 
need faster processing which will only come from a smooth transition of 
records. These records are needed for decisions and the lack of a 
shareable record is hurting veterans.
Suicide Prevention
    According the Executive Order, the Veterans Crisis Line was to be 
increased by 50%, which The American Legion applauds because it 
increases the capacity to serve veterans in a timely manner. It also 
called for the creation of a 12 month national suicide prevention 
campaign, and on bringing down the negative stigma associated with 
mental health needs for the veteran, but the American Legion is 
concerned this campaign does not adequately target families and 
community members. Because PTSD is comparable to other societal issues 
such as substance abuse, where the victim may not recognize their own 
problem, reaching out to the existing support structures around those 
victims is all the more critical. Veterans may have a lack of 
understanding or awareness of mental health care, and may not 
understand their conditions or may feel that their mental health 
conditions are not severe enough to warrant asking for help. Family and 
community members can help increase awareness and encourage the veteran 
to seek help \2\.
---------------------------------------------------------------------------
    \2\ GAO Report 13-130, December 2012
---------------------------------------------------------------------------
    One of the impediments VA has faced has been with the collecting 
and tracking of accurate suicide data. In the Suicide report, it found 
that ``as of November 2012, data had only been received from 34 states 
and data use agreements have been approved by an additional eight 
states.'' However, agreements are still under approval or development 
by other states which impacts VA's ability to accurately calculate the 
total number of veteran suicides. In order to improve the collection 
and reporting of suicide data, Congress should urge the states to share 
this information with VA. Without accurate suicide prevention and 
mortality data, the estimates that 18 to 21 veterans commit suicide are 
not truly accurate and these estimates in reality in all actuality 
could be much higher or lower.
Enhanced Partnerships Between the VA and Community Providers
    VA and Health & Human Services (HHS) were asked to establish at 
least 15 pilot programs with community providers in order to ensure 
that the needs of veterans are being met, by providing access to mental 
health services within 14 days of the patient's requested date.
    While DOD has led the effort in utilizing pro-bono community 
provider programs to treat service members for mental health 
conditions, including PTSD; Senate testimony from a November 30th, 2011 
Veterans Affairs Committee hearing \3\ made it clear that VA was not 
working with non-profit organizations to minimize patient wait times 
for appointments, thus exacerbating the problem of the veterans ability 
to receive care in a timely manner.
---------------------------------------------------------------------------
    \3\ Testimony of Dr. Van Dahlen - 11/30/11 Senate Veterans Affairs 
Committee
---------------------------------------------------------------------------
    In a congressional hearing, VA Fee Basis Care: Examining Solutions 
to a Flawed System, on September 14, 2012 The American Legion found 
many problems with VA's non-VA purchased care programs such as:

      need for VA to develop and implement fee-basis policies 
and procedures with a patient-centered strategy that takes veterans' 
interest and travel distance into account;
      lack of training and education programs for non-VA 
providers; lack of integration of VA's computer patient record system 
with non-VA providers which creates delay in contractors submitting 
appointment documentation;
      VA does not have a process to ensure all VA and non-VA 
purchased care contracts are inputted into a tracking system to ensure 
they do not lapse.

    Without these VA reforms and improvements, VA cannot adequately 
leverage non-VA and community partnerships.
    The American Legion demands that veterans have access to quality 
and timely mental health care, which should be based in an adequately 
funded budget for mental health. However, the VA should be leveraging 
community resources to help alleviate the issue associated with wait 
times whenever possible. In addition, it is crucial that the VA ensure 
that the community providers performing this important work are trained 
to provide the quality of care equal to what is delivered by VA 
providers. Ultimately, given the experience in dealing with military 
matters such as the unique complexities of PTSD, VA and DOD providers 
are, and should be, the gold standard of care, and VA planning should 
have the ultimate goal of fulfilling the needs of veterans within the 
VA system. While working to achieve that goal VA should ensure that no 
veterans slip through the cracks by leveraging all available community 
resources until the care can be completely met by VA resources.
    It should be noted that the VA is working with community providers 
through the five-site, 3-year pilot program, Project Access Received 
Closer to Home (ARCH), which is administered through the Office of 
Rural Health. This program utilizes contracting and a fee-basis payment 
system to help meet the needs of rural veterans. The American Legion 
notes that processing the authorizations for certain services were 
concerns that were brought up in April 2012 during the evaluation of 
the Montana Project ARCH program. The 2012 System Worth Saving Task 
Force Report on Rural Health recognized that the ARCH project was a 
three year pilot, yet concerns existed regarding effective utilization 
of budget for patient care, a lack of outreach guidelines and 
communication and the difference in structures between VA care and non-
VA care.
    While Community providers are an option, The American Legion is 
concerned that a main issue associated with using community providers 
lies in the continuity of care. To address this concern, the VA is 
implementing a program that will address the lack of providers, while 
increasing the continuity of care, called; VA Specialty Care Access 
Networks - Extension for Community Healthcare Outcomes (SCAN-ECHO). 
This unique program utilizes primary care physicians to provide 
specialty care to veterans who choose to enroll in the program. The 
primary care physician presents the veteran's case to a panel of 
medical professionals, including specialists, who discuss diagnoses and 
treatments. By incorporating the primary care physician in the 
treatment, there is an increased level of continuity of care. Primary 
care physicians bring in a more holistic approach of the veteran that 
The American Legion believes will benefit the veteran patient.
Expanding VA Mental Health Services Staffing
    The Executive Order also calls for the addition of 800 peer-to-peer 
counselors by December 2013, while providing hiring incentives and 
evaluating reporting requirements to reduce paperwork requirements to 
bring on new staff.
    Peer-to-peer counseling has been used as an effective treatment to 
help veterans in the rehabilitation process, which is clearly 
exemplified by the Vet Center program implemented across the nation. 
The American Legion advocates expanding the program of peer-to-peer 
support networks, and believe this would be very instrumental in moving 
from a treatment based model to a recovery model.
    The American Legion continues to encourage the Secretary of 
Veterans Affairs to utilize returning service members for positions as 
peer support specialists in the effort to provide treatment, support 
services and readjustment counseling for those veterans requiring these 
services. If appropriately skilled unemployed veterans can receive 
training to fulfill staffing needs in the mental health care system, VA 
will be solving multiple problems with a single, forward thinking 
solution. Robust recruitment and vocational training in this area 
should be a priority and The American feels so strongly about this 
issue that we passed a resolution during our National Convention last 
year specifically to call upon VA to institute a peer to peer outreach 
program \4\.
---------------------------------------------------------------------------
    \4\ American Legion Resolution No. 136: The Department of Veterans 
Affairs to Develop Outreach and Peer to Peer Programs for 
Rehabilitation
---------------------------------------------------------------------------
    Hiring incentives may entice providers to apply to work for the VA 
over the private sector, and reducing the cumbersome process of 
credentialing and privileging to bring providers on board more quickly 
could help meet VA's needs, provided it is done in a manner that does 
not sacrifice quality and competency of care. VHA needs to conduct a 
staffing analysis to determine if psychiatrists or other mental health 
provider vacancies are systemic issues impending VHA's ability to meet 
mental health timeliness goals \5\. Many facilities visited through The 
American Legion's System Worth Saving program have demonstrated 
difficulties competing with the private sector, and complained that the 
Credentialing & Privileging process for physicians is too lengthy.
---------------------------------------------------------------------------
    \5\ OIG Report 12-00900-168, April 23, 2012
---------------------------------------------------------------------------
Improved Research & Development
    The Executive Order called for the creation of a National Research 
Action Plan to be developed within 8 months by DOD, VA, HHS, and the 
Office of Science & Technology Policy (OSTP). This plan was supposed to 
develop better prevention, diagnosis, and treatment for PTSD, other 
mental health conditions, and Traumatic Brain Injury (TBI). 
Additionally it calls for DOD and HHS to engage in a comprehensive 
longitudinal health study on PTSD, TBI, and related injuries with 
minimum enrollment of 100,000 service members.
    The American Legion applauds this effort, because it is inclusive 
of TBI which has a high level of co-morbidity with PTSD. It also looks 
at long term effects of TBI, PTSD, and other mental health conditions, 
while focusing on the whole process of prevention, diagnosis, and 
treatment. The American Legion has long supported research efforts that 
address the signature wounds of the Iraq and Afghanistan conflicts and 
supports these efforts through a series of membership based resolutions 
that were passed during our National Convention last summer \6\.
---------------------------------------------------------------------------
    \6\ Resolution No. 108: Request Congress Provide the Department of 
Veterans Affairs Adequate Funding for Medical and Prosthetic Research, 
Resolution No. 285: Traumatic Brain Injury and Post Traumatic Stress 
Disorder Programs
---------------------------------------------------------------------------
    In addition to traditional treatment measures currently in use 
through the VA and DOD health care systems, The American Legion urges 
Congress to provide oversight and funding to the DOD and VA for 
innovative TBI and PTSD research currently used in the private sector, 
such as Hyperbaric Oxygen Therapy and Virtual Reality Exposure Therapy, 
as well as other non-pharmacological treatments. The American Legion 
also recommends the creation of a joint office for DOD & VA research in 
order to increase agency collaboration and communication. Finally, The 
American Legion finds it troubling that DOD and VA are not designated 
as the lead agencies for this effort, with HHS and OSTP providing 
advisory roles.
Military and Veterans Mental Health Interagency Task Force
    The creation of a taskforce, which is designed to implement the 
Executive Order, met with all the stakeholders in January. The American 
Legion encourages the Task Force to continue to involve VSOs at all 
stages of their work.
Addressing the recommendations in recent VA Inspector General (OIG) and 
        Government Accountability Office (GAO) reports
    Since 2005, multiple reports from the OIG have stated that the 
schedulers were entering incorrect desired appointment dates for 
veterans who were requesting mental health appointments. 
Recommendations have repeatedly directed VA to reassess their training, 
competency, and oversight methods to ensure reliable and accurate 
appointment data is captured.
    The American Legion is extremely concerned that an overall lack of 
accountability will make this goal difficult to achieve. Much like the 
school system, the VA medical centers are trying to meet a standard 
they are mandated to achieve, and as in the case of the school systems, 
tests can be modified by the states to show success that is not 
occurring. The American Legion is further concerned that VHA statistics 
and data are being manipulated in order to show the desired results, 
and that this data is not accurately depicting the situation. Policies 
and measurements are created in order to monitor the information, but 
if individuals feel that their performance is based upon this measure, 
then the predilection to alter the data becomes problematic.
    The American Legion also notes that the measurements are not always 
the issue. Staffing, technology, and veteran perceptions & 
circumstances also can play a big role in delaying treatment provided 
to veterans.
    The VHA system has multiple issues with scheduling that could be 
alleviated with more funding \7\. Chief among these concerns are an 
outdated VistA Scheduling System, problems with scheduler turnover, and 
the ongoing provider staffing gaps. As the primary scheduling system, 
the outdated VistA can cause difficulties in scheduling due to a lack 
of multitasking ability inherent to the software. A more modern system 
could alleviate this, and will require funding to develop and 
implement. Consistency with staffing, not only of providers but also 
with schedulers, will ensure more consistency delivering appointments.
---------------------------------------------------------------------------
    \7\ GAO Report13-130, December 2012
---------------------------------------------------------------------------
    Although not mentioned in the report, the centralization of 
Informational Technology (IT) has created a shared pot where the 
different VA entities are now competing for the same technology storage 
space and resources. This creates and issue with updating programs such 
as the VistA Scheduling System or other IT solutions for scheduling. 
Facilities need to have flexibility in meeting their IT needs.
    The more recent GAO report focuses on barriers faced and efforts to 
increase access \8\. The report mainly addresses the negative stigma, 
lack of understanding of mental health, logistical challenges, and 
concerns about the VA that may hinder veterans from accessing care.
---------------------------------------------------------------------------
    \8\ Ibid
---------------------------------------------------------------------------
    Most notable in this report was the information regarding the 
values and priorities that veterans may have. For example, due to 
family, work, or schooling commitments, many veterans have concerns 
about scheduling VA appointments during traditional hours of operation.
    VA attempted to address this issue with a Directive issued on 
September 5th, 2012 developed by the VHA \9\, however, the directive 
was rescinded less than a week later on September 11th, 2012 through 
VHA Notice 2012-13, and the changes never took place. On January 9, 
2013, VHA Directive 2013-001 was sent to the field to extend hours 
access for veterans requiring primary care, including women's health 
and mental health services. Unfortunately, the implementation of this 
regular is expected by July 31, 2013 and they are only required to have 
one weekend shift that is limited to only two hours. In addition, 
extended hours are only required in VA Medical Centers and Community 
Based Outpatient Clinics with 10,000 unique patients or greater. The 
American Legion is concerned about the impact of this on veterans, 
particularly in rural areas.
---------------------------------------------------------------------------
    \9\ Directive 2012-023, ``Extended Hours Access for Veterans 
Requiring Primary Care Including Women's Health and Mental Health 
Services at Department of Veterans Affairs Medical Centers and Selected 
Community Based Outpatient Clinics''
---------------------------------------------------------------------------
Correcting lengthy wait times, misleading access measures, and 
        cumbersome scheduling processes and procedures.
    Thus far, VA is taking a multi pronged approach to address the 
scheduling issue, by looking at the issues associated with technology, 
access measures, training, and funding.
Technology
    The VA announced in the Federal Register in October of 2012 the 
opportunity for companies to provide adjustments to the open-source 
VistA electronic health system, and all submissions are due by June 
2013. By creating the Medical Appointment Scheduling System (MASS) 
contest, the VA appears to be moving ahead on this issue.
    Additionally, the GAO has determined that the VA telephone system 
is outdated \10\. The VHA directed all VISN directors to provide plans 
to assess their current phone system needs, and develop strategic 
improvements plans with a target completion of March 30th, 2013, 6 
weeks from now.
---------------------------------------------------------------------------
    \10\ GAO Report13-130, December 2012
---------------------------------------------------------------------------
    Because the correction of the substandard VistA system and phone 
systems is vital to helping alleviate some of the associated 
difficulties with access to mental health care, The American Legion 
urges Congress to ensure VA's budget receives adequate funding to 
address these issues.
Access Measures and Training
    The VA is scheduled to have both the new measurements and the 
training package for schedulers by November 1st, 2013. The American 
Legion would like the VA to be more transparent regarding the updates 
associated with any progress associated with scheduling procedures. 
Furthermore, as VA develops these methods, The American Legion 
encourages strong cooperation with veterans' groups and other 
stakeholders throughout the entire process.
Funding
    In FY 2012 H.R. 2646 authorized the VA sufficient appropriations to 
continue to fund and operate leased facility projects that support our 
veterans all across the country. In November of 2012 the FY 2013 
appropriations for the same facilities was eliminated from 
appropriations due to a ``scoring change'' initiated by the 
Congressional Budget Office (CBO). While the locations, projects, 
leases, and funding requirements did not change - the way in which CBO 
scored the projects did, which resulted in the appearance that the 
project would cost more than 10 times the actual needed revenue. 
According to VA, CBO refuses to share their evaluation process and will 
only issue the final score. As a result of CBO's adjustment in scoring 
review, Congress refused to introduce the FY 2013 appropriations bill 
needed to keep these community based centers open. As these leases now 
become due, there are 15 major medical facilities that will be forced 
to close unless Congress acts quickly to provide the appropriate 
funding to these centers.
    If these centers are allowed to close due to insufficient funding, 
the impact on our veterans, and the VA would be devastating. Not only 
would the center employees have to either relocate within the VA or be 
terminated, the VA could be subject to legal action for prematurely 
defaulting on their leases. The veterans currently being served by 
these facilities would then have to either travel long distances to the 
nearest VA facility, or would have to find care at local hospital that 
the VA would be required to pay for, at a fee-for-services basis. This 
would ultimately cost the VA an estimated 4 times what the original 
appropriations would have cost for these shuttered facilities. The 
facilities currently in jeopardy are located in; Albuquerque, New 
Mexico, Brick, New Jersey, Charleston, South Carolina, Cobb County, 
Georgia, Honolulu, Hawaii, Lafayette, Louisiana, Lake Charles, 
Louisiana, New Port Richey, Florida, Ponce, Puerto Rico, San Antonio, 
Texas, West Haven, Connecticut, Worchester, Massachusetts, Johnson 
County, Kansas, San Diego, California, and Tyler, Texas.
    The American Legion implores Congress to fund these centers as 
originally planned. The funds that these centers need has already been 
obligated, and refusal to fund these centers will cause a false 
perception of excess monies to exist within the federal budget, which 
The American Legion is afraid will be falsely reported as a money 
saving initiative.
Effectively partnering with non-VA resources to address gaps and create 
        a more patient-centric network of care focused on wellness-
        based outcomes
    The Department of veteran Affairs has not engaged The American 
Legion in the development of any of the 15 pilot programs that VA is 
engaging in, pursuant to the Presidential Executive Order. As such, we 
have concerns regarding the quality and viability of the non-VA 
resources. The American Legion has made clear that they would prefer to 
be one of the VA's primary resources for dealing with mental health 
care for veterans, for a variety of reasons which should be obvious.
    The VA health care program is a holistic program as it takes into 
account all of the patient's doctors, to develop an approach that 
recognizes the interconnectivity of multiple or complicated disorders. 
Doctors in the VA system have access to all of a patient's records, 
which is helpful and relevant when dealing with disorders having co-
morbid symptoms such as PTSD and TBI. Furthermore, VA mental health 
care providers are perhaps the most uniquely qualified practitioners 
available to address military related PTSD and other related emotional 
conditions. Civilian providers may lack the requisite experience and 
finite training to deal with these issues.
    Because outside providers lack the sharing of information and 
military experience inherent to the VA system, the ideal solution is to 
ensure that veterans receive their care in the VA system. They have 
earned access to this system through their service, and deserve to be 
able to benefit from the VA's healthcare system, sans scheduling 
difficulties or unreasonable and potentially deadly delays. However, 
when that system proves unable to cope with the demand, outside help 
may be needed until the VA system can be adjusted to once again handle 
the scope and scale of the influx of veterans who need mental health 
care assistance.
    The American public has expressed a tremendous outpouring of 
support for those who serve and there is a vast and growing assortment 
of community based groups who are eager to provide help to veterans who 
are suffering. Given this level of community support veterans should be 
able to find the help they need within their communities. Understanding 
that the VA health care system is uniquely qualified to meet the needs 
of the veterans, and the ultimate goal should be to ensure that the 
system has the capacity to serve all veterans; local resources can and 
should be used to fill in the gaps until a suitable system is in place.
Conclusion
    In conclusion, The American Legion is deeply concerned about the 
issues associated with the barriers to access, the timeliness, and 
quality of care available to our veterans, many of whom are suffering. 
The Legion urges VA to work with stakeholders, the Veterans Service 
Organizations, and Congress to develop a plan to increase transparency 
and address existing barriers to quality healthcare so we can all work 
together to ensure that veterans receive the timely and quality mental 
health services they deserve - especially for those veterans located in 
remote rural areas.
    The American Legion recognizes that the VA is working hard to 
fulfill its mission; however they will only be successful if they are 
able to enjoy the full support of Congress, the VSOs, and the 
community.

                                 
                Iraq and Afghanistan Veterans of America
    Chairman Miller, Ranking Member Michaud and distinguished members 
of the committee, on behalf of Iraq and Afghanistan Veterans of America 
(IAVA) I would like to extend our gratitude for being given the 
opportunity to share with you our views and recommendations regarding 
Honoring the Commitment: Overcoming Barriers to Quality Mental Health 
Care for Veterans. IAVA applauds the committee's continued dedication 
in addressing the critical issues surrounding mental health care and 
IAVA looks forward to working closely with the committee in addressing 
these and other issues throughout the 113th congressional session.
    IAVA is the country's first and largest nonprofit, nonpartisan 
organization for veterans of the wars in Iraq and Afghanistan and has 
more than 200,000 member veterans and supporters nationwide. Founded in 
2004, our mission is to improve the lives of Iraq and Afghanistan 
veterans and their families. Through assistance, awareness and 
advocacy, we strive to create a country which honors and supports 
veterans of all generations.
    The veteran suicide rate is a national crisis. According to a 
recent VA report approximately 22 veterans a day are taking their own 
lives. Unfortunately, IAVA fears that these numbers may actually still 
be lower than the true number of veterans we lose to suicide, as some 
states don't report veteran suicide and are not included in VA's 2013 
report. Regardless of the exact number, IAVA strongly believes that 
even one veteran or servicemember life lost to suicide is one too many.
    Since 2008, nearly 1.5 million servicemembers of Operation Iraqi 
Freedom (OIF), Operation Enduring Freedom (OEF) and Operation New Dawn 
(OND) have transitioned back into the civilian population. According to 
multiple studies performed by the National Institute of Health, 
Department of Veterans Affairs (VA) and Department of Defense (DoD), 
upwards of 43 percent of veterans who served in OIF/OEF/OND will have 
experienced traumatic events causing Post Traumatic Stress Disorder 
(PTSD) or other psychological disorders such as depression. Left 
untreated, these invisible wounds can have a devastating impact on the 
lives of those veterans and servicemembers who suffer in silence.
    As the suicide numbers show and as the prevalence of these 
invisible injuries demonstrate, our country must start better 
addressing the psychological wounds of war. Up to this point, VA and 
DoD have taken a very reactionary approach to addressing the 
psychological wounds of war. IAVA believes that it is time to start 
addressing these wounds in a proactive way. While our country has made 
significant strides in improving the care for veterans, there is still 
a long way to go.
    There are two main approaches to providing treatment for the 
psychological wounds of war and the prevention of suicide. The first 
approach is treating psychological wounds and suicide as a public 
health issue and approaching it as any other public health issues, such 
as an influenza outbreak or HIV. This approach requires public outreach 
educating all sectors of the public, involving the public in solutions 
to the problem and ensuring that services are widely available 
throughout the community. The second approach is the clinical, or 
medical, approach. This approach focuses on intensive clinical care, 
prescribing medications and regular appointments with psychiatrists and 
psychologists. Unfortunately though, we often focus on one rather than 
the other. Together, both approaches provide the best quality of care 
and successful outcomes. The public health approach helps veterans and 
servicemembers understand the resources that are available to them and 
how to easily access the care they may need. The clinical approach 
ensures they receive proper treatment once there. If we are to 
successfully address the mental health care shortfalls and prevent 
suicide in our nation, it will require both approaches.
    The partnering of the two approaches is also particularly 
important, because suicide is a tragic conclusion of the failure to 
address the spectrum of challenges returning veterans face. These 
challenges are not just mental health injuries; they include finding 
employment, reintegrating to family and community life, dealing with 
health care and benefits bureaucracy and many others. Fighting suicide 
is not just about preventing the act of suicide, it is about providing 
a ``soft and productive landing'' for our veterans when they return 
home. The bottom line is we must treat and offer resources to the 
entire veteran, including their community and families, and move away 
from treating individual symptoms, as if they are somehow mutually 
exclusive of one another.
    Stigma is a significant barrier to veterans and servicemembers 
seeking mental health care. Unfortunately, even though there has been 
an effort to remove the stigma associated with psychological wounds in 
recent years by VA and DoD leadership, their message has failed to 
reach all ranks of servicemembers and the entire veteran population. 
Despite these efforts, the stigma still seems to be ever so present, 
and seeking mental health care is often viewed as a sign of weakness or 
lack of resiliency among those who have been trained to be strong and 
fearless.
    Multiple studies confirm that veterans and servicemembers are 
concerned about how seeking care could impact their careers, both in 
and out of the military. Concerns include the effect on their ability 
to get security clearances and how co-workers and supervisors would 
perceive them. It is critical that we continue to work to reduce this 
stigma. We must step up our efforts in removing stigmas and immediately 
develop and implement newer, more confidential ways of offering 
assistance to those who need it most if we wish to end the cycle of 
preventable suicides plaguing today's veteran and military communities.
    To combat the stigma, IAVA recommends that VA and DoD partner with 
experts in the private and nonprofit sector to develop a robust and 
aggressive outreach campaign. This campaign should focus on directing 
veterans to services such as Vet Centers, as well as local community 
and state based services. It should be integrated into local campaigns 
such as San Francisco's veterans 311 campaign. This campaign should be 
well-funded and reflect the best practices and expertise of experts in 
both the mental health and advertising fields. For our part, IAVA has 
partnered with the Ad Council to launch a public service awareness 
campaign that is focused on the mental health and invisible injuries 
facing veterans of Iraq and Afghanistan. Part of this campaign focuses 
on reducing the stigma of seeking mental health care. This is only one 
example of the multiple programs and resources IAVA has established to 
help combat the stigma associated with seeking care for invisible 
wounds.
    Community partnerships will play a key role in providing quality 
mental health care to veterans throughout the country. Nationwide, we 
have private sector and non-profit organizations that are already 
providing mental health care and resources to the members of their 
individual communities. These organizations are easily accessible and 
have staff who are trained to address most of the unique and common 
mental health needs within their communities. Establishing partnerships 
with those organizations will ensure that veterans, servicemembers and 
their families receive quality care in their communities, regardless if 
they start seeking care at their local VA or with one of these 
providers.
    Another critical aspect to preventing suicide, and where VA is 
still falling short, is ensuring timely access to care and having 
properly trained staff at every VA facility. This is often the 
difference between life and death for many veterans. According to VHA's 
Strategic Plan, VHA requires suicide prevention training for all VHA 
staff who interact with veterans, plus additional training for health 
care providers. However, while this may be a policy, IAVA has doubts as 
to whether or not it is actually be enforced at every VA facility. The 
importance and need in ensuring timely care and proper training of all 
staff is clearly illustrated by the experience of Army veteran Jacob 
Manning in early 2012. Here is Jacob's story, as told in part by Leo 
Shane of Stars and Stripes:

    Jacob Manning waited until his wife and teenage son had left the 
house, then walked into his garage to kill himself. The former soldier 
had been distraught for weeks, frustrated by family problems, 
unemployment and his lingering service injuries. He was long ago 
diagnosed with traumatic brain injury, caused by a military training 
accident, and post-traumatic stress disorder stemming from the 
aftermath. He had battled depression before, but never an episode this 
bad.
    He tossed one end of an extension cord over the rafters above and 
then fashioned a noose. The cord snapped. It couldn't handle his 
weight.
    He called Christina Roof, a friend and national veterans policy 
adviser who helped him years before, and rambled about trying again 
with a bigger cord or a gun. She urged him to calm down sand tried to 
get him to call the veterans crisis line. Ms. Roof sent a message to 
Manning's wife, Charity, telling her to rush home. The two of them 
tried for more than a day to persuade him to get professional help. Ms. 
Roof eventually got Manning to agree to call the veterans hospital in 
Columbia, Mo., near his home, after telling him that he had two 
choices: ``Either call VA or I have no choice but to call the police,'' 
Roof said.
    When a VA staffer at the mental health clinic answered the phone, 
Manning explained what he had done, and asked if he could be taken into 
care. The VA staffer asked if Manning was still suicidal. He wavered, 
saying he wasn't trying to kill himself right then. The hospital 
employee told him the office was closing in an hour, and asked if 
Manning could wait until the next day to deal with the problem. Ms. 
Roof told Manning she didn't care what this VA staffer told him and 
that she was sending a car within the hour to pick him up and bring him 
to the VA Medical Center. She told him to pack a bag.

    Mr. Manning made it safely to the emergency room and was checked in 
upon his arrival. Nevertheless, this one experience raises so many 
other questions as to what other problems veterans in crisis are 
experiencing when they reach out for help.
    Sadly, Manning's story is all too familiar. In April 2012, VA's 
Office of the Inspector General (OIG) found VA officials had been 
inflating the success rates for providing timely mental health services 
to veterans. VA had repeatedly reported to Congress that 95 percent of 
new patients seeking mental health treatment received full evaluations 
for care within the department's required window of 14 days. However, 
VA OIG found that just 49 percent were seen within that period, and the 
average wait time for most veterans seeking any type of mental health 
care was over 50 days. IAVA strongly believes that VA must be ready and 
equipped with the proper care models, policies and personnel to address 
the huge influx of veterans they will care for in the coming years.
    According to the American Psychological Association, there are 
``significant barriers to receiving mental health care in the 
Department of Defense (DOD) and Veterans Affairs (VA) system.'' Mental 
health professionals are often unavailable to servicemembers, 
especially those in theatre, and to veterans, particularly those in 
rural areas. Even veterans in urban areas encounter lengthy wait times 
when seeking mental health care.
    VA must ensure that every employee is trained to respond to a 
veteran in crisis. VA employees across the administration interact with 
veterans, and each employee must be aware of the signs of a veteran in 
crisis and be aware of all of the resources available to support a 
veteran in crisis. All VA employees must also be trained to provide 
quality customer service to every veteran they encounter. For a 
veteran, like Mr. Manning, to have the strength and resilience to 
actually seek help, only to be met by a dismissive attitude at the one 
place he should always be able to count on, is in itself a tragedy.
    IAVA has to wonder, and so too should our nation, how many other 
veterans in crisis are being turned away and how many other veterans 
have not received the care they needed due to an encounter with an 
untrained VA staff member?
    Additionally, IAVA has real concerns as to how many veterans have 
we may have lost due to inadequate training and procedures within the 
VA mental health care system? For a veteran, like Mr. Manning, to have 
the strength and resilience to actually seek help, only to be met with 
a dismissive attitude by a staff member at the one place he should 
always be able to turn to is a tragedy. IAVA believes it is critical 
for VA to ensure that all of their staff be properly trained to respond 
to a veteran in crisis and that every veteran in crisis has immediate 
access to emergency mental health services.
    Specifically within VA, there needs to be numerous changes and 
corrections in the policies and procedures within the Veterans Health 
Administration (VHA) and the Veterans benefit Administration (VBA). In 
an effort to address VA's and DoD's issues, on August 31, 2012, 
President Obama signed an Executive Order (EO) entitled ``Improving 
Access to Mental Health Services for Veterans, Service Members, and 
Military Families.'' While IAVA applauds the President's actions and 
believes that it was a good first step to implementing solid solutions 
that stand to make a significant difference in the mental health care 
available to veterans across the country, we believe the real test will 
be its impact within the veteran and military communities. However, 
IAVA also notes that the Executive Order's success will also be 
determined by how effectively and timely it is implemented. As of this 
hearing, there are lingering questions on the status of the 
implementation of several key parts of the Executive Order.
    For example, the August 2012 Executive Order includes some previous 
VA initiatives, notably the expansion of mental health care providers 
and their plan to hire 1,600 new mental health clinicians and 300 
mental health support staff. While this is definitely a step in the 
right direction, IAVA has serious concerns about VA's ability to meet 
this mandate given the problems they have encountered in the past, both 
in finding and keeping qualified mental health care providers. 
Moreover, IAVA respectfully asks for clarification on VA's recent press 
release stating they have hired an additional 1,000 mental health care 
providers. IAVA respectfully asks if these new employees were put 
through an expedited hiring process given the quickness of their 
hiring? Further, we respectfully ask if these 1,000 new mental health 
providers were hired to fill the current mental health care provider 
vacancies VA has had many years filling or if these 1,000 new providers 
are intended to be a part of the 1,600 new providers mandated by the 
Executive Order?
    The Executive Order also requires the VA and DoD to establish a 
national suicide prevention campaign. The order reads, that ``No later 
than September 1, 2012, the Departments of Defense and Veterans Affairs 
shall jointly develop and implement a 12 month national suicide 
prevention campaign, focused on connecting veterans and service members 
to mental health services.'' However, IAVA has been left to wonder as 
to whether or not this deadline was met. By all accounts, we have yet 
to see any solid evidence that this campaign was rolled out.
    Another part of the Executive Order that has had a deadline pass, 
states: ``By December 31, 2012, the Department of Veterans Affairs, in 
continued collaboration with the Department of Health and Human 
Services, shall expand the capacity of the Veterans Crisis Line by 50 
percent to ensure that veterans have timely access, including by 
telephone, text, or online chat, to qualified, caring responders who 
can help address immediate crises and direct veterans to appropriate 
care. Further, the Department of Veterans Affairs shall ensure that any 
veteran identifying him or herself as being in crisis connects with a 
mental health professional or trained mental health worker within 24 
hours. The Department of Veterans Affairs also shall expand the number 
of mental health professionals who are available to see veterans beyond 
traditional business hours.'' IAVA has yet to receive a response from 
VA as to whether or not this goal was met. We look to this committee to 
ensure that this part of the Executive Order was met, and if it was 
not, we are also interested to learn about what plans are in place to 
ensure its completion.
    These lingering questions underscore the critical importance of 
strong Congressional oversight of the implementation of this Executive 
Order. This committee has the authority to ensure VA, DoD and the other 
agencies tasked with improving mental health care for our veterans and 
military communities are held accountable to doing so. IAVA cannot 
stress enough the importance of strict Congressional oversight in 
ensuring all programs and policies mandated by the 2012 mental health 
executive order are fully developed, implemented, and that all of the 
agencies involved are held accountable to meeting the mandated time 
lines.
    For our part, IAVA will continue to be a critical partner in 
holding VA and DoD accountable for the goals outlined in the Executive 
Order, but we look to the members of the 113th Congress to stand up for 
our veterans, servicemembers and their families through real actions in 
bringing about change to the health care services, resources and 
benefits they depend on.
    Finally, given the wide array of issues the Committee requested we 
address in this testimony IAVA makes the following recommendations on 
ways we can improve the mental health care system:

    1. VA and DoD must immediately establish a new employee education 
and mentoring program to overcome the practical problems new staff and 
longtime staff have in establishing and implementing new programs and 
policies related to mental health care, especially when they are 
unfamiliar with VA or federal procedures. We believe the current 
policies and procedures being used have proved ineffective in the 
establishment of uniformed mental health care.

    2. Involve the families in a veterans or servicemembers mental 
health care plan. Despite progress, the current level of effort and 
provision of services remains inadequate in making treatment planning a 
true partnership between the veteran, family members, and provider.

    3. Establish national partnerships to roll out a nationwide 
education and public service announcement campaign focusing on reducing 
the stigmas attached to seeking mental health care and addressing the 
psychological wounds of war. All wounds sustained in war are equally 
important and need treatment, be they visible or invisible. We need to 
ensure this is done through clear and concise messaging. For example, 
if you had a physical injury, you would certainly seek medical care to 
address it. So why would you hesitate to do the same with a 
physiological injury?

    4. Integrate mental health care screenings and resources into all 
aspects of a veterans and servicemember's primary health care.

    5. Implement uniformed evidence-based care in all VHA facilities 
and CBOCs. Veterans should have equal access to high quality mental 
health care regardless of where they live.

    6. Conduct a thorough review of VHA Handbook 1160.01, to ensure 
every VA facility is in compliance. This includes ensuring that every 
VA facility has a trained mental health care provider on staff at all 
times or is readily available to care for a veteran in crisis via a 
page or phone call.

    7. Provide easily accessible mental health care or support programs 
for family members who have a loved one undergoing mental health care 
or treatment.

    8. Increase awareness efforts at the local level to educate all 
members of the community on the signs associated with suicidal 
behaviors or tendencies.

    9. Conduct robust public outreach campaigns to educate the general 
public or the realities of the invisible wounds of war by removing all 
of the misinformation and myths the general public has been exposed to 
through inaccurate media portrayals' of veterans.

    10. Expand the peer-to-peer counseling program and immediately 
train more veterans to be peer support counselors.

    11. Expand upon VA's Community Toolkit Provider program by further 
developing and actively promoting a nationally recognized certification 
program which would train mental health professionals in military 
culture and the unique challenges faced by service members, veterans 
and their families. This should include best practices in providing 
care to this community and the nuances of military culture.

    12. Integrate robust mental health awareness and suicide prevention 
training into DoD's enlisted education system, as well as VA's current 
employee continuing education system.

    In closing, caring for the men and women who defend our freedom is 
a solemn responsibility that belongs to lawmakers, business leaders, 
and every citizen alike. Despite numerous successes, veterans' and 
servicemembers' mental health programs and care options are still not 
where they should be. We must remain ever vigilant and continue to show 
the men and women who volunteer to serve their country that we have 
their backs, through swift actions in correcting the gaps and 
shortfalls in mental health care. IAVA looks forward to working closely 
with this committee, VA, DoD and communities across our nation in a 
combined effort to finally close the gaps in our mental health care 
system. IAVA will also continue to work tirelessly to ensure that no 
veteran, servicemember or their family ever have to suffer in silence 
while carrying the burdens of our nation's 11 years of war.

                                 
        National Guard Association of the United States (NGAUS)
    Thank you for all you have done for our veterans since 9/11 and for 
this opportunity to present this statement for the record.
Background - Unique Citizen Service Member/Veteran
    The National Guard is unique among components of the Department of 
Defense (DoD) in that it has the dual state and federal missions. While 
serving operationally on Title 10 active duty status in Operation Iraqi 
Freedom (OIF) or Operation Enduring Freedom (OEF), National Guard units 
are under the command and control of the President. However, upon 
release from active duty, members of the National Guard return as 
veterans to the far reaches of their states, where most continuing to 
serve in over 3,000 armories across the country under the command and 
control of their governors. As a special branch of the Selected 
Reserves they train not just for their federal missions, but for their 
potential state active duty missions such as fire fighting, flood 
control, and providing assistance to civil authorities in a variety of 
possible disaster scenarios.
    Since 9/11, nearly a half a million National Guard members have 
deployed in contingency operations to gain veteran status. When they 
return from deployment, they are not located within the closed 
structure of a 24/7 supported active military installation, but rather 
reside in their home town communities where they rely heavily on the 
medical support of the Veterans Administration (VA) when they can 
overcome time and distance barriers to obtain it.
    Using the National Guard as an operational force will require a 
more accessible mental health program for members and their families 
post-deployment in order both to provide the care they deserve as 
veterans and to maintain the necessary medical readiness required by 
deployment cycles. It cannot be a simple post-deployment send off by 
the active military of ``Good job. See you in five years.'' To create a 
seamless medical transition from active duty to the VA, an improved 
medical screening of our members before they are released from active 
duty is essential to identify the medical issues that will be passed to 
the VA. The Department of Defense must also recognize its 
responsibility of sharing the burden with the VA in funding mental 
health care for our National Guard members between deployments, which 
remains an unmet readiness need.
    The Department of Defense must also be called to task for the 
mishandling and disappearance of National Guard medical records in the 
OIF/OEF theaters and the shoddy administration of Guard and Reserve 
demobilization. Statistics published last year by the VA show that the 
VA denies National Guard and Reserve disability benefit compensation 
claims at four times the rate of those filed by active duty veterans. 
Lacking clear records to establish the service connection for their 
injuries, our Guard members face failure when they later file their VA 
disability claims for undocumented physical and behavioral injuries. 
This is a blot on the integrity of our federal government in its 
treatment of our veterans. This Committee must seriously and separately 
in another hearing consider legislation to establish a presumption of 
service connection for certain war common injuries of National Guard 
and Reserve veterans who later file disability benefit compensation 
claims based upon those injuries.
    Military service in the National Guard is uniquely community based. 
The culture of the National Guard remains little understood outside of 
its own circles. When the Department of Defense testifies before 
Congress stating its programmatic needs, it will likely recognize the 
indispensable role of the more cost efficient National Guard as a vital 
operational force, but it will say little about, and seek less to, 
redress the benefit disparities, training challenges, and unmet medical 
readiness issues for National Guard members and their families at the 
state level before, during, and after deployment. We continue to ask 
Congress to give the Guard a fresh look with the best interests of the 
National Guard members, their families, and the defense of the homeland 
in mind.
FULLY LEVERAGE THE VET CENTER MODEL
    For behavioral support, Guard veterans often look to the stellar 
Vet Centers located throughout the country where they and their 
families can obtain confidential peer to peer counseling as well as 
behavioral treatment from on site clinicians; telehealth programs; or 
from referrals to fee based clinicians paid for and pre approved by the 
Vet Centers.
    Confidentiality is vital in bringing our veterans still serving in 
the Guard to treatment in order to assuage real concerns about the 
sharing of medical records with the Department of Defense which VA 
Medical Centers are authorized to do. The fee basing of referred care 
by the Vet Center to community providers establishes a model for this 
Committee to consider expanding to close the treatment gaps in our 
rural communities. A voucher program administered by the Vet Centers 
authorizing paid for treatment to qualified community providers would 
maximize scheduling flexibility and plug direct access gaps to care for 
our Guard veterans.
IMPLEMENT A VOUCHER PROGRAM FOR VETERAN COMMUNITY BASED MENTAL HEALTH 
        CARE
    The issues of veterans' unemployment and mental health maintenance 
cannot be separated. Before veterans can maintain gainful employment in 
a challenging job environment, they must be able to maintain a healthy 
mental status and establish supportive social networks.
    In 2007, the Rand Corporation published a study titled, ``The 
Invisible wounds of War.'' It found that at the time 300,000 veterans 
of Operation Iraqi Freedom and Operation enduring Freedom suffered from 
either PTSD or major depression. This number can only have grown after 
five more years of war. The harmful effects of these untreated 
invisible wounds on our veterans hinder their ability to reintegrate 
with their families and communities, work productively, and to live 
independently and peacefully.
    Rand recommended that a network of local, state, and federal 
resources centered at the community level be available to deliver 
evidence-based care to veterans whenever and wherever they are located. 
Veterans must have the ability to utilize trained and certified 
services in their communities. In addition to training providers, the 
VA must educate veterans and their families on how to recognize the 
signs of behavioral illness and how and where to obtain treatment.
    VA and Vet Center facilities are often located hundreds of miles 
from our National Guard veterans living in rural areas. Requiring a 
veteran, once employed, to drive hundreds of miles to obtain care at a 
VA facility necessitates the veteran taking time off from work for 
reasons likely difficult to explain to an employer. Most employees can 
ill afford to miss work, particularly after an extended absence from 
deployment in the case of our Guard veterans. The VA needs to leverage 
community resources to proactively engage veterans in caring for their 
mental health needs in a confidential and convenient manner that does 
not require long distance travel or delayed appointments.
    To facilitate the leveraging of mental health care providers in our 
communities, the VA through its Office of Mental Health Services or 
through its highly effective Vet Centers can actively exercise its 
authority to contract with private entities in local communities, or 
creatively implement a voucher program that would allow our veterans to 
seek fee-based treatment locally with certified providers outside the 
brick and mortar of the Veterans Administration facilities and even the 
Vet Centers.
    The Vet Center in Spokane for example serves an area as big as the 
state of Pennsylvania. It is not practical for veterans in this 
catchment area to drive hundreds of miles to seek counseling or 
behavioral clinical care. That Vet Center pre screens fee based 
providers to whom it will refer veterans for confidential treatment in 
its management area. It also monitors the process to make sure the 
veteran is actually receiving care paid for by the Vet Center. This 
system already works. However, a voucher process would improve 
efficiencies by relieving the Vet Center of its scheduling burden by 
allowing the veteran to directly make his or her own appointment with 
providers as needed.
    The VA and Vet Centers also need to fully leverage existing state 
administrative mental health and veteran networks. Working with the 
state mental health care provider licensing authorities, community 
providers certified by the VA or Vet Center to treat veterans could be 
identified at the state agency level with vouchers to pay for treatment 
by those providers administered by the state department of veterans 
affairs who likely may have an even greater list of veterans in the 
state than the VA or Vet Center.
    Several of our veterans have fallen through the cracks of the VA 
health care system, and will continue to do so. According to the 
Vietnam Veterans of America, last year only 30% of our veteran 
population had enrolled in VA medical programs. Many veterans end up in 
the care of state social service programs in cooperation with state and 
national veteran organizations. The VA has the authority to assist in 
maintaining this safety net of care for veterans in a stressful 
economic climate for our states with a voucher program or expanded 
contracting with private entities. It needs to act.
HIPPA CONFIDENTIALITY MUST BE OBSERVED WITH MENTAL HEALTH CARE
    Most of our National Guard veterans of OIF/OEF eligible for VA care 
post-deployment are still serving with their units and subject to 
redeployment. Given the evolving electronic medical records 
interoperability between the VA and the Department of Defense (DoD), a 
confidentiality issue exists relative to mental health treatment 
records for these veterans who remain in the military who do not want 
their records shared by the VA with their military commanders for fear 
of career reprisals.
    It is essential that HIPPA confidentiality be maintained by the VA 
for the mental health treatment records of these veterans to encourage 
their treatment with VA providers. Our Vet Centers already operate with 
full confidentiality which makes them the service center of choice for 
Guard members who want to maintain confidentiality of their mental 
health counseling records relative to protect against perceived 
negative repercussions in their units. HIPPA rules observe 
confidentiality but draw the line with patients who are dangers to 
themselves or their communities whose cases must be reported. Prevent.
    It is critical that confidentiality this be established as soon as 
possible legislatively with the VA much the same as it is currently 
observed in Vet Centers. We believe that the VA is operating under 
advice from its legal staff that all VA medical records can be 
transferred to DoD. Lack of confidentiality will chill the treatment 
process and is likely contributed to the under utilization of VA 
medical care by our veterans.
REQUIRE THE VA TO FULLY IMPLEMENT SECTION 304 OF THE CAREGIVERS AND 
        VETERANS OMNIBUS HEALTH SERVICES ACT 0F 2009, PUBLIC LAW 111-
        163, TO PROVIDE MENTAL HEALTH SERVICES TO VETERAN AND 
        THEIIMMEDIATE FAMILY MEMBERS OF OIF/OEF VETERANS USING PRIVATE 
        ENTITIES
    Post-deployment, our National Guard members and their families 
heavily rely on the VA for mental health care. Congress recognized as 
much in passing The Caregivers and Veterans Omnibus Health Services Act 
of 2009, Public Law 111-163, enacted May 6, 2010, now requires the VA 
to reach out not just to veterans but to their immediate families as 
well to assist in the reintegration process.
    The law also authorized the VA Secretary the Secretary to contract 
with community mental health centers and other qualified entities to 
provide the subject services only in areas the Secretary determines are 
not adequately served by other health care facilities or vet centers of 
the Department of Veterans Affairs. It is not clear how thoroughly the 
VA has fully taken advantage of this authority to contract with private 
entities to deliver community based mental health services.
    Section 304 of the Family Caregiver Act (reproduced in the 
Appendix) required the VA to make full mental health services available 
also to the immediate family members of OIF/OEF veteran for three years 
post-deployment. However, the VA delayed for at least two years in 
making the full range of its Office of Mental Health Services (OMHS) 
programs available to immediate to families as required by Section 304. 
It is not clear today that the program has been fully implemented.
    Section 304 was enacted on May 6, 2010. For many, the three year 
post-deployment period will begin to lapse in 2013. The VA OMHS needed 
to fully comply with Section 304 in a timely manner. Because the VA's 
unreasonably delayed implementation of this important program, this 
Committee needs to consider extending the subject three year post 
deployment limitation period another three years to allow family 
members to access their care.
    It also needs to lean harder on the VA to fully utilize its 
contracting to better leverage private entities and to use a voucher 
system described above to make community based treatment more 
accessible and convenient. Our veterans and their immediate families 
may be a small subset, but they are worth it.
THE DEPARTMENT OF DEFENSE MUST COOPERATIVELY WORK WITH THE VA IN 
        SCREENING BEHAVIORAL HEALTH CARE NEEDS OF OUR MEMBERS BEFORE 
        THEY ARE RELEASED FROM ACTIVE DUTY
    At all stages of PTSD and depression, treatment is time sensitive. 
However, this is particularly important after onset, as the illness 
could persist for a lifetime if not promptly and adequately treated, 
and could render the member permanently disabled. The effects of this 
permanent disability on the member's entire family can be devastating. 
It is absolutely imperative that members returning from deployment be 
screened with full confidentiality at the home station while still on 
active duty by trained and qualified mental health care providers from 
VA staff and/or qualified health care providers from the civilian 
community. These providers could include primary care physicians, 
physician assistants, and nurse practitioners who have training in 
assessing psychological health presentations. Prompt diagnosis and 
treatment will help to mitigate the lasting effects of mental illness. 
This examination process must be managed by the VA in coordination with 
the National Guard Director of Psychological Health for the respective 
state, and the state's Department of Mental Health to allow transition 
for follow up treatment by the full VA and civilian network of 
providers within the state.
    As an American Legion staffer at Walter Reed once stated, the main 
problem for Reserve Component injured service members is that they are 
``rushed out of the system'' before their service connected injuries 
and disability claims have been resolved. Our injured members should 
not be given the ``bum's rush'' and released from active duty until a 
copy of their complete military medical file, including any field 
treatment notes, has been transferred to the VA, their discoverable 
service connected military medical issues have been identified, any 
service connected VA disability physicals have been performed similar 
to what is provided to the active forces before they are released from 
active duty, and the initial determination of any service connected VA 
disability claim has been rendered. Unless medically not feasible, our 
members should be retained on active duty in their home state for 
treatment to discourage them from reporting injures out of fear of 
being retained at a distant demobilization site.
    It is absolutely necessary to allow home station screening for all 
returning members by trained health care professionals who can screen, 
observe, and ask relevant questions with the skill necessary to elicit 
medical issues either unknown to the self-reporting member, or 
unreported for fear of being retained at a far removed demobilization 
site. In performing their due diligence before the issuance of an 
insurance policy, insurance companies do not allow individuals to self 
assess their health. Neither should the military. If geographical 
separation from families is causing some to underreport, or not report, 
physical or psychological combat injuries on the PDHA, then continuing 
this process at the home station for those in need would likely produce 
a better yield at a critical time when this information needs to be 
captured in order for prompt and effective treatment to be 
administered.
    Please see the copy of a November 5, 2008 electronic message to 
NGAUS from Dr. Dana Headapohl set forth in the Appendix that still 
pertains. Dr. Headapohl strongly recommended a surveillance program for 
our members before they are released from active duty. Dr. Headapohl 
opines the obvious in stating that inadequate medical screening of our 
members before they are released from active duty is ``unacceptable to 
a group that has been asked to sacrifice for our country.'' (emphasis 
added)
Conclusion
    Thank you for that you have done for our veterans since 9/11. 
Please view our efforts as part of a customer feedback process to 
refine and improve the ongoing vital and enormous undertaking of the 
VA. Our National Guard veterans, both still serving and separated, will 
remain one of your largest base of customers who will continue to 
require your attention. Thank you for this opportunity to testify.
E-mail from Dana Headapohl, MD, to NGAUS
    Colonel Duffy - I am sending links to articles about the importance 
of providing medical surveillance examinations for workers in jobs with 
specific hazardous exposures. I believe this approach could be modified 
to evaluate National Guard members returning from Iraq and Afghanistan 
for PTSD, TBIs and depression.
    The OSHA medical surveillance model includes the following basic 
elements:

    1. Identification of potential hazardous exposures (chemical, 
physical, biologic).

    2. Screening workers for appropriateness of placement into a 
specific work environment with such exposures. For example, individuals 
with compromised liver functions should not be placed in environments 
with unprotected exposures to hepatotoxins.

    3. Monitoring workers after unprotected exposure incidents. 
Examples- monitoring pulmonary function in a worker exposed to a 
chlorine gas spill, or following hepatitis and HIV markers in a nurse 
after a needle stick injury.

    4. Conducting exit examinations at the end of an assignment with 
hazardous exposures, to ensure that workers have not suffered adverse 
health effects from those exposures.

    (including concussive explosions or other traumatic events).
    Surveillance exams of all types (OSHA mandated surveillance 
programs, population health screening for chronic disease risk factors) 
have been a part of my practice of Occupational and Preventive Medicine 
in Montana for the past 22 years. Early diagnosis and treatment is 
especially essential for potential medical problems facing military 
members serving in Iraq and Afghanistan - post traumatic stress 
disorder (PTSD), traumatic brain injury (TBI) and depression. Timely 
diagnosis and aggressive treatment is essential especially for these 
problems, to maximize treatment success and functioning and to mitigate 
suffering.
    There are a number of organizations that design and implement 
medical surveillance programs. There is no reason the same approach 
could not be applied to the specific exposures and potential medical 
problems facing National Guard troops in Iraq and Afghanistan. With 
proper program design and local provider training, this program would 
not need to be costly. In my clinical experience, male patients 
especially are more likely to report symptoms of PTSD, TBI, or 
depression in the context of an examination rather than questionnaire. 
Findings can present subtly, but if untreated can have devastating 
effects on the individual, family and work place.
    In my practice, I have seen a number of Vietnam veterans, and more 
recently National Guard members who have returned from deployment in 
Iraq or Afghanistan, who have been inadequately screened and/or are 
suffering unnecessarily because of geographical barriers to adequate 
treatment. This is unacceptable treatment of group that has been asked 
to sacrifice for our country. They deserve better.
    I applaud your organization's efforts to lobby for better post 
deployment screening and treatment of the National Guard members 
returning from Iraq and Afghanistan.
    Dana Headapohl MD
    http://www.aafp.org/afp/20000501/2785.html
    https://www.desc.dla.mil/DCM/Files/QSRHealth%20Medical%20Exam--
1.pdf This is about military surveillance exams.
    http://www.lohp.org/graphics/pdf/hw24en06.pdf
    http://www.cdc.gov/niosh/sbw/management/wald.html
    http://www.ushealthworks.com/Page.aspx?Name=Services--MedSur

                                 
                  National Military Family Association
    The National Military Family Association is the leading nonprofit 
organization committed to strengthening and protecting military 
families. Our over 40 years of accomplishments have made us a trusted 
resource for families and the Nation's leaders. We have been at the 
vanguard of promoting an appropriate quality of life for active duty, 
National Guard, Reserve, retired service members, their families and 
survivors from the seven uniformed services: Army, Navy, Air Force, 
Marine Corps, Coast Guard, and the Commissioned Corps of the Public 
Health Service and the National Oceanic and Atmospheric Administration.
    Association Volunteers in military communities worldwide provide a 
direct link between military families and the Association staff in the 
Nation's capital. These volunteers are our ``eyes and ears,'' bringing 
shared local concerns to national attention.
    The Association does not have or receive federal grants or 
contracts.
    Our website is: www.MilitaryFamily.org.
    Chairman Jeff Miller, Ranking Member Michael Michaud, and 
Distinguished Members of the Veterans' Affairs Committee, the National 
Military Family Association thanks you for the opportunity to submit 
testimony for the record on ``Honoring the Commitment: Overcoming 
Barriers to Quality Mental Health Care for Veterans.'' After 11 years 
of war, we continue to see the impact of repeated deployments and 
separations on our service members, veterans, and their families. We 
appreciate your recognition of the service and sacrifice of these 
families, as well as the unique mental health challenges facing them. 
Our Association will take the opportunity to discuss the mental health 
challenges and needs of our veterans and their families.
Behavioral Health Care
    Our Nation must help veterans, transitioning service members, 
National Guard and Reserve members, and their families cope with the 
aftermath of over a decade of war. Frequent and lengthy deployments 
have created a sharp need in behavioral health services. The Department 
of Veterans Affairs (VA), Department of Defense (DoD), and State 
agencies must partner in order to address behavioral health issues 
early in the process and provide transitional mental health programs, 
especially when leaving active duty and entering veteran status 
(voluntary or involuntary). Partnering will also capture the National 
Guard and Reserve member population and their families, who often 
straddle these agencies' health care systems.
    There are barriers to access for some in our population. Many 
already live in rural areas, such as our National Guard and Reserve 
members, or they will choose to relocate to rural areas lacking 
available mental health providers. We need to address the distance 
issues families face in finding mental health resources and obtaining 
appropriate care. Isolated service members, National Guard and Reserve 
members, veterans, and their families do not have the benefit of the 
safety net of services and programs provided by the VA facilities, 
Community-Based Outpatient Centers, and Vet Centers, or DoD's network 
of care.
    The VA should examine DoD's alternative methods of mental health 
services as possible solutions to their access issues. DoD discovered 
embedding mental health providers in medical home modeled clinics 
allows for easier access for mental health services. DoD has created a 
flexible pool of mental health providers that can increase or decrease 
rapidly in numbers depending on demand on the Military Health System 
side. Currently, Military Family Life Consultants and Military 
OneSource non-medical counseling are providing this type of 
preventative and entry-level service. DoD has been offering another 
vehicle for service members, National Guard and Reserve members, and 
their families through a web-based (Skype) medical and non-medical 
mental health counseling. This works extremely well especially for 
those who live far from counselors. Veterans and their families need 
this flexibility of support.
    The VA, along with the DoD, should examine the possibility of 
adopting the United Kingdom's model of community involvement in 
providing mental health services and programs to their military, 
veterans, and their families. This model of care identifies local 
resources and creates buy-in by the community to help their own. The 
model creates a direct reporting line from the community to Parliament 
and back to the community.
Families Impacted from Stresses of War
    In the research they conducted for us, RAND found military children 
reported higher anxiety signs and symptoms than their civilian 
counterparts. A study by Gorman, et. al (2010), Wartime Military 
Deployment and Increased Pediatric Mental and Behavioral Health 
Complaints, found an 11 percent increase in outpatient mental health 
and behavioral health visits for children from the ages of 3-8 during 
2006-2007. Researchers found an 18 percent increase in pediatric 
behavioral health visits and a 19 percent increase in stress disorders 
when a parent was deployed. Additional research has found an increase 
in mental health services by non-deployed spouses during deployment. A 
study of TRICARE claims data from 2003-2006 published last year by the 
New England Journal of Medicine showed an increase in mental health 
diagnoses among Army spouses, especially for those whose service 
members had deployed for more than one year. The VA needs to be aware 
of the mental health needs of veterans' children when allowing access 
to service and implementing support programs.
    Our Association's research also found the mental health of the 
caregiver directly affects the overall well-being of the children. 
Therefore, we need to treat the family as a unit as well as 
individuals. Communication is key in maintaining family unit balance. 
Our study also found a direct correlation between decreased 
communication and an increase in child and/or caregiver issues during 
deployment. Research is beginning to validate the high level of stress 
and mental strain our military families are experiencing. This stress 
is carried over with them when they enter veteran status. The answer is 
making sure our families have access to behavioral health providers 
with the VA's system of care, as well.
    Successful reintegration programs will require strong partnership 
at all levels between the various mental health arms of the VA, DoD, 
and State agencies. Opportunities for the entire family and for the 
couple to reconnect and bond again must also be provided. Our 
Association has recognized this need and established family retreats 
under our Operation Purple  program in the National Parks, 
promoting families the opportunity to reintegrate and readjust 
following the stresses of war and deployment. The VA should provide 
similar types of venues for veterans and families to reintegrate.
Wounded Veterans have Wounded Families
    Our Association asserts that behind every wounded service member 
and veteran is a wounded family. It is our belief the government, 
especially DoD and VA, must take a more inclusive view of military and 
veterans' families. Those who have the responsibility to care for the 
wounded, ill, or injured service member or veteran must also consider 
the needs of the spouse, children, parents of single service members/
veterans, and their siblings, and their caregivers. The VA and DoD need 
to think proactively as a team and one system, rather than separately, 
and address problems and implementing initiatives upstream while the 
service member and their family is still on active duty status.
    Reintegration programs become a key ingredient in the wounded 
service members, veterans, and their family's success. For the past 
three years, we have held our Operation Purple  Healing 
Adventures camp to help wounded, ill, or injured service members and 
their families learn to play again as a family. We hear from the 
families who participate in this camp that many issues still create 
difficulties for them well into the recovery period. Families find 
themselves having to redefine their roles following the injury of the 
service member. They must learn how to parent and become a spouse/lover 
with an injury/illness. Each member needs to understand the unique 
aspects the injury/illness brings to the family unit. Parenting from a 
wheelchair brings a whole new challenge, especially when dealing with 
teenagers. Parents need opportunities to get together with other 
parents who are in similar situations and share their experiences and 
successful coping methods. Our Association believes everyone must focus 
on treating the whole family, with VA and DoD offering mental health 
counseling and skill based training programs for coping, intervention, 
resiliency, and overcoming adversities. Injury interrupts the normal 
cycle of the reintegration process causing readjustment issues. The VA, 
DoD, and non-governmental organizations must provide opportunities for 
the entire family and for the couple to reconnect and bond, especially 
during the rehabilitation and recovery phases.
    The VA and DoD must do more to work together both during the 
treatment phase and the wounded service member's transition to ease the 
family's burden. They must continue to break down regulatory barriers 
to care and expand support when appropriate through the Vet Centers, 
the VA medical centers, and the community-based outpatient clinics 
(CBOCs), along with DoD's system of care. We recommend the VA allow 
veteran families access to mental health services throughout the VA's 
entire network of care. Before expanding support services to families, 
however, VA facilities must establish a holistic, family-centered 
approach to care when providing mental health counseling and programs 
to the wounded, ill, or injured service member or veteran. Family 
members are a key component to a veteran's psychological well-being. 
They must be included in mental health counseling and treatment 
programs for veterans.
Caregivers of the Wounded
    Caregivers need to be recognized for the important role they play 
in the care of their loved one. Without them, the quality of life of 
the wounded service members and veterans, such as physical, psycho-
social, and mental health, would be significantly compromised. They are 
viewed as an invaluable resource to VA and DoD health care providers 
because they tend to the needs of the service members and the veterans 
on a regular basis. Their daily involvement saves VA, DoD, and State 
agency health care dollars in the long run. However, their long-term 
psychological care needs must be addressed. Caregivers of the severely 
wounded, ill, or injured service members, who are now veterans, have a 
long road ahead of them. In order to perform their job well, they will 
require access to robust network of mental health services.
    We have observed from our own Healing Adventure Camps the lack of 
support and assistance to the spouse/caregiver of our wounded, ill, or 
injured. Many feel frustrated with not being considered part of the 
care team and not included in long-term care decisions. The level of 
frustration displayed by the spouses/caregivers at our recent Healing 
Adventure Camp at Ft. Campbell about lack of information and support 
was disturbing. Even the Congressionally mandated Recovering Warrior 
Task Force (RWTF) discovered the same level of frustration during their 
site visit to Ft. Carson and raised their concerns to the Military 
Treatment Facility (MTF) and Warrior Transition Unit (WTU) Commanders. 
The VA and DoD need to make sure the spouse/caregiver and the family 
are also cared for and provided them the support they need to perform 
their role as a caregiver and provide them with the tools to care for 
themselves as well. The VA and DoD need to establish spouse/caregiver 
support groups and mentoring opportunities. Spouses/caregivers need a 
platform where they can voice their concerns without the fear of 
retribution.
    The VA has made a strong effort in supporting veterans' caregivers. 
Our Association still has several concerns with the VA's interpretation 
of P.L.111-163. The VA's eligibility definition does not include 
illness, which means it does not align with DoD's Special Compensation 
for Service. This means the benefit ends once the ill service member 
transfers to veteran status. We believe the VA is waiting too long to 
provide valuable resources to caregivers of our wounded, ill, or 
injured service members and veterans who served in Operation Iraqi 
Freedom/Operation Enduring Freedom/Operation New Dawn (OIF/OEF/OND). 
The intent of the law was to allow caregivers to receive value-added 
benefits, such as mental health counseling, in a timely manner in order 
to improve the caregiver's overall quality of life.
Educating Those Who Care for Veterans and their Families
    The families of veterans must be educated about the effects of 
Post-Traumatic Stress Disorder (PTSD), and suicide in order to help 
accurately diagnose and treat the veteran's condition. These families 
are at the ``pointy end of the spear'' and are more likely to pick up 
on changes attributed to either condition and relay this information to 
their health care providers. Programs are being developed by the VA and 
each Branch of Service. However, DoD's are narrow in focus, targeting 
line leaders and health care providers, but not broad enough to capture 
our military family members and the communities they live in. The VA's 
message is broader, but still lacks the direct outreach needed to 
educate veterans' families.
    There are many resources for veterans and their families provided 
by DoD, VA, State agencies, and non-government agencies. However, there 
is often difficulty navigating this sea of good will and knowing which 
resource to access when. We recommend an extended outreach program to 
veterans and their families of these available mental health resources.
    Health care and behavioral health providers must also be educated 
about our military culture. We recommend a course on military culture 
be required in all health care and behavioral health care college 
curriculums and to offer a standardized VA and DoD approved military 
culture Continuing Education Unit (CEU) for providers who have already 
graduated. Providers should be incentivized to take these courses. VA 
providers must be educated about stigma among veteran families, who are 
experiencing secondary PTSD. These families, often caregivers, are 
afraid to tell someone they too have PTSD. Veterans' families must be 
told it is okay to seek help for themselves.
    Families want to be able to access care with a mental health 
provider who understands or is sympathetic to the issues they face. We 
appreciate the VA allowing family member access to Vet Centers. 
However, families need to have access without gaining permission from 
the veteran first. Once the service members become veterans, families 
have fewer access points for mental health services. Barriers, such as 
the requirement for families to first obtain the veteran's permission, 
only further prevent access to timely mental health care. Treatment 
through the VA should include access to medication along with therapy. 
Currently, the VA is only allowing therapy for families and caregivers. 
We also encourage the VA to develop more family-oriented programs and 
offer web-based Skype group meetings.
    The VA must also look beyond its own resources to increase mental 
health access by working with other government agencies. We appreciate 
President Obama's recent Executive Order allowing the VA to partner 
with the Substance Abuse and Mental Health Services Administration 
(SAMHSA). However, we encourage the VA to include SAMHSA's Military 
Families Strategic Initiative and Service member, veteran, and family 
Policy Academy States and Territories in their partnership. SAMHSA's 
initiative encourages State agencies to provide already established 
services and programs to service members, veterans, and family members. 
Our Association has been actively working with SAMHSA providing 
valuable input on military families and military culture. We encourage 
committee members to ask fellow Members of Congress and the 
Administration to fund SAMHSA's initiative so they may educate the 
remaining States and Territories about the unique needs of the 
military, veterans, and their families.
Survivors
    The VA must work together to ensure surviving spouses and their 
children can receive the mental health services they need through all 
of VA's venues
    Recommend the VA examine DoD's alternative methods of mental health 
services and possibly adopt the United Kingdom's model of community 
involvement as possible solutions to their access issues.
    Recommend the VA be aware of the mental health needs of veterans' 
children and families when allowing access to service and implementing 
support programs.
    Recommend the VA and DoD think proactively as one team and one 
system, in order to successfully address problems and implement 
initiatives upstream while the service member and their family is still 
on active duty status.
    Recommend the VA establish a holistic, family-centered approach to 
care.
    Recommend the VA and DoD establish spouse/caregiver support groups 
and mentoring opportunities.
    Recommend the VA educate family members of veterans about the 
effects of Post-Traumatic Stress Disorder (PTSD) and suicide.
    Recommend the VA create outreach programs to veterans and their 
families about all of the available VA, DoD, State agencies, and non-
government agencies behavioral health resources.
    Recommend the VA and DoD educate health care and behavioral health 
providers about our military culture and stigma among veterans' 
families.
    Recommend committee members ask fellow Members of Congress and the 
Administration to fund SAMHSA's initiative so they may educate the 
remaining States and Territories about the unique needs of the 
military, veterans, and their families.
    Recommend the VA ensure surviving spouses and their children 
receive the behavioral health services they need through all of VA's 
venues.
Military Families - Our Nation's Families
    The National Military Family Association would like to thank you 
again for the opportunity to submit testimony on overcoming barriers to 
quality mental health care for veterans and their families. Veteran 
families have supported the Nation's military mission. The least their 
country can do is make sure they have consistent access to high quality 
behavioral health care. Wounded service members and veterans have 
wounded families. The VA and DoD systems of care should work together 
in providing quality behavioral health services. We ask this Committee 
to assist in meeting that responsibility. We look forward to working 
with you to improve the quality of life for service members, veterans, 
their families and caregivers, and survivors.

                                 
                     Paralyzed Veterans of America
    Chairman Miller, Ranking Member Michaud, and members of the 
Committee, thank you for allowing Paralyzed Veterans of America (PVA) 
to submit a statement for the record concerning the Department of 
Veterans Affairs' (VA) mental health services. Overcoming barriers to 
quality mental health care for veterans is extremely important as the 
number of veterans enrolled in the VA health care system continues to 
grow, and the newest generation of veterans and their families 
acclimate to civilian life after war. PVA thanks the Committee for 
their continued oversight and hard work on this important health care 
issue.
    The increased demand for VA mental health services has put greater 
emphasis on the areas in which VA can improve upon its delivery and 
approach to providing quality mental health care. In the past year, 
both the VA Office of Inspector General and the Government 
Accountability Office have released reports identifying issues that 
preclude veterans from receiving timely, quality VA mental health care. 
Such issues include inadequate staffing of VA mental health 
professionals, unreasonable wait times for appointments, and inaccurate 
reporting of mental health metrics and program outcomes.
    In August 2012, the President issued an Executive Order #13625, 
``Improving Access to Mental Health Services for Veterans, Service 
Members, and Military Families.'' The Executive Order focuses on 
suicide prevention, mental health research and development, VA mental 
health staffing, and partnerships between the VA and mental health 
community providers. PVA believes that the aforementioned report 
findings, and the Executive Order substantiate the need for Congress, 
the Administration, VA leadership, and the veteran community to work 
together to develop innovative approaches for providing VA mental 
health care that meets the evolving needs of all veterans.
    As we work to improve VA mental health care, PVA believes that it 
is important to recognize that VA is the best health care provider for 
veterans. Providing primary care and specialized health services is an 
integral component of VA's core mission and responsibility to veterans. 
In the area of mental health it is vital that veterans receive care 
that is tailored to their unique experiences and needs as veterans. The 
VA has made tremendous strides in the quality of care and variety of 
``veteran specific'' mental health services. These improvements include 
incorporating mental health into VA's primary care delivery model, 
increasing the number of Vet Centers, launching mental health public 
awareness campaigns, and creating call centers that are available to 
veterans 24 hours a day, 7 days a week. While these improvements were 
much needed and have helped many veterans, we agree with this Committee 
that more must be done.
    The VA must focus on recruiting and retaining qualified mental 
health professionals to meet the growing mental health care demand. 
Last year, the VA announced its plan to increase the mental health 
workforce by an additional 1,900 mental health professionals. In 
response to this hiring goal, PVA recommends that the VA conduct a 
comprehensive analysis of the mental health care needs of veterans, and 
create a mental health strategic plan for staffing to accurately assess 
current staffing needs and appropriately place newly hired employees.
    In addition to increased staffing, PVA recommends that the VA work 
to improve and expand current mental health services that have proven 
beneficial to veterans such as peer to peer support programs. As 
recommended in the FY 2014 Independent Budget, VA medical centers 
should work to hire veterans as peer counselors to provide individual 
counseling, as well as reach out to veterans to promote the importance 
of mental health, and help veterans currently receiving VA mental 
health services sustain treatment. Additionally, as the VA works to 
improve and increase access to mental health care, it must identify and 
adapt to the varying needs of the different generations of veterans. 
The VA must work to address the mental health needs of veterans 
returning from the most recent conflicts, as well as the larger 
population of disabled veterans who are dealing with severe illnesses 
and catastrophic injuries.
    To meet the varying mental health needs of veterans, the VA must 
work with veterans, veteran service organizations, and stakeholders in 
the community to create innovative ways to provide quality mental 
health services. In fact, the President's Executive Order mandates 
enhanced partnerships between the VA and community mental health 
providers to ensure that veterans are able to receive care in a timely 
manner. Specifically, it states that the VA and the Department of 
Health and Human Services shall establish pilot projects to contract 
with community based providers to help meet veterans' mental health 
care needs in a timely manner. While PVA understands the urgent nature 
of providing veterans with timely mental health care, we believe that 
the quality of that care is equally important.
    As it relates to contracted care, mental health services are unique 
in that it is difficult to move from one provider to another after 
trust and a rapport have been established. It is important to consider 
that when veterans are referred to providers outside of the VA for 
mental health care, they may not return to the VA for those services, 
and ensuring that veterans seek additional mental health services 
through the VA may become more difficult. When developing community 
partnerships with non-VA providers there must be a balance that allows 
VA to provide contracted services for mental health care without 
discouraging veterans from utilizing other VA mental health services, 
or VA's primary care and specialized services that are readily 
available to them. Therefore, PVA strongly recommends that the first 
phase of implementation of the Executive Order should require VA to 
work closely with veteran service organizations to determine the 
guidelines and policies under which the VA may provide a veteran with 
mental health care in the community setting. Specifically, PVA believes 
that before the VA provides veterans with care through contracted 
services, mechanisms must be in place to ensure care coordination, and 
allow VA to monitor the quality of care provided. The VA must also make 
certain that the professionals providing the care meet VA standards and 
are familiar with cultural norms of military service and experiences of 
veterans.
    While PVA believes that the greatest need is still for qualified VA 
mental health professionals to provide veterans with the care they 
need, veterans should not have to wait for such essential care. The VA 
must work to hire and officially assign mental health staff, improve 
administrative processes that lead to lengthy wait times, and develop 
ways to increase access to VA mental health services while maintaining 
VA's high quality of care and providing care that is centered on the 
unique needs of veterans. When veterans have timely access to quality 
mental health care services they in turn have the opportunity to 
establish productive personal and professional lives.
    PVA would like to once again thank this Committee for the 
opportunity to provide a statement for the record, and we look forward 
to working with you to improve VA mental health services for our 
veterans.
Information Required by Rule XI 2(g)(4) of the House of Representatives
    Pursuant to Rule XI 2(g)(4) of the House of Representatives, the 
following information is provided regarding federal grants and 
contracts.
                            Fiscal Year 2013
    No federal grants or contracts received.
                            Fiscal Year 2012
    No federal grants or contracts received.
                            Fiscal Year 2011
    Court of Appeals for Veterans Claims, administered by the Legal 
Services Corporation--National Veterans Legal Services Program-- 
$262,787.

                                 
                      Vietnam Veterans of America
    Chairman Miller, Ranking Member Michaud, and Distinguished Members 
of the House Veterans Affairs Committee, Vietnam Veterans of America 
(VVA) thanks you for the opportunity to present our statement for the 
record on ``Honoring the Commitment: Overcoming Barriers to Quality 
Mental Health Care for Veterans''.
    First, VVA recognizes that the Veterans Health Administration (VHA) 
has made some significant progress in its efforts to improve the 
quality of mental health care for America's veterans. For example, 
although not all mental health clinical staff has yet been trained, VA 
should be commended for its system-wide adoption (finally) of evidence-
based cognitive behavioral treatment modalities for PTSD. In addition, 
the development of various web-based program applications and social 
media mental health outreach campaigns reflect a much better effort to 
reach America's veterans. While these efforts are laudable, VVA 
continues to believe they have not gone far enough.
    VVA remains very concerned about three related mental health areas: 
suicides, especially among the older veterans' cohort; recruitment, 
hiring, and retention of VA mental health staff; and timely access to 
VA mental health clinical facilities and programs, especially for our 
rural veterans.
    To be fair, since media reports of suicide deaths and suicide 
attempts began to surface back in 2003, the VA has developed a number 
of strategies to reduce suicides and suicide behaviors which include: 
the development of the Veterans Crisis Hotline and Chatline (in 
partnership with the Substance Abuse and Mental Health Administration) 
and a social media campaign emphasizing VA crisis support services; the 
creation of suicide prevention coordinator (SPCs) positions at all VA 
medical facilities whose duties include education, training, and 
clinical quality improvement for VHA staff members; and the hiring and 
training of additional staff to increase the capacity of the Veterans 
Crisis Line by 50 percent.
    However, the VA's report of February 1, 2013 on veterans who die by 
suicide paints a shocking portrait of what's happening among our older 
vets (see chart below).


                          Percentage of suicides by age and veteran status among males
----------------------------------------------------------------------------------------------------------------
                          Age group                                  Non-veteran                 Veteran
----------------------------------------------------------------------------------------------------------------
29 and younger                                                                  24.4%                      5.8%
----------------------------------------------------------------------------------------------------------------
30-39                                                                            20.0                       8.9
----------------------------------------------------------------------------------------------------------------
40-49                                                                            23.5                      15.0
----------------------------------------------------------------------------------------------------------------
50-59                                                                            16.9                      20.0
----------------------------------------------------------------------------------------------------------------
60-69                                                                             7.4                      16.8
----------------------------------------------------------------------------------------------------------------
70-79                                                                             4.2                      19.0
----------------------------------------------------------------------------------------------------------------
80 and older                                                                      3.6                      14.5
----------------------------------------------------------------------------------------------------------------

    Over two-thirds of veterans who commit suicide are age 50 or older. 
Among the report's other findings:

      The average age of veterans who die of suicide is just 
short of 60; for nonveterans, it's 43.
      Female veterans who commit suicide generally do so at 
younger ages than males. Two-thirds of women who killed themselves were 
under 50 years of age; one-third were under 40 and 13 percent were 
under 30. For men, the comparable figures were 30 percent, 15 percent 
and 6 percent.
      About 15 percent of veterans who attempt suicide, but 
don't succeed, try again within 12 months.
VVA asks why?
    VVA understands that it is very challenging to determine an exact 
number of suicides. Some troops who return from deployment become 
stronger from having survived their experiences. Too many others are 
wracked by memories of what they have experienced. This translates into 
extreme issues and risk-taking behaviors when they return home, which 
is one of the reasons why veteran suicides have attracted so much 
attention in the media. Many times, suicides are not reported, and it 
can be very difficult to determine whether or not a particular 
individual's death was intentional. For a suicide to be recognized, 
examiners must be able to say that the deceased meant to die. Other 
factors that contribute to the difficulty are differences among states 
as to who is mandated to report a death, as well as changes over time 
in the coding of mortality data. In fact, previously published data on 
veterans who died by suicide were only available for those who had 
sought VA health care services. But for the first time, the February 
1st report also includes some limited state data for veterans who had 
not received health care services from VA.
    Nevertheless, according to the American Foundation for Suicide 
Prevention, in more than 120 studies of a series of completed suicides, 
at least 90 percent of the individuals involved were suffering from a 
mental illness at the time of their death. The most important 
interventions are recognizing and treating these underlying illnesses, 
such as depression, alcohol and substance abuse, post-traumatic stress 
and traumatic brain injury. Many veterans (and active duty military) 
resist seeking help because of the stigma associated with mental 
illness, or they are unaware of the warning signs and treatment 
options. These barriers must be identified and overcome.
    VVA has long believed in a link between PTSD and suicide, and in 
fact, studies suggest that suicide risk is higher in persons with PTSD. 
For example, research has found that trauma survivors with PTSD have a 
significantly higher risk of suicide than trauma survivors diagnosed 
with other psychiatric illness or with no mental pathology (1). There 
is also strong evidence that among veterans who experienced combat 
trauma, the highest relative suicide risk is observed in those who were 
wounded multiple times and/or hospitalized for a wound (2). This 
suggests that the intensity of the combat trauma, and the number of 
times it occurred, may indeed influence suicide risk in veterans, 
although this study assessed only combat trauma, not a diagnosis of 
PTSD, as a factor in the suicidal behavior.
    Considerable debate exists about the reason for the heightened risk 
of suicide in trauma survivors. Whereas some studies suggest that 
suicide risk is higher due to the symptoms of PTSD (3,4,5), others 
claim that suicide risk is higher in these individuals because of 
related psychiatric conditions (6,7). However, a study analyzing data 
from the National Co-morbidity Survey, a nationally representative 
sample, showed that PTSD alone out of six anxiety diagnoses was 
significantly associated with suicidal ideation or attempts (8). While 
the study also found an association between suicidal behaviors and both 
mood disorders and antisocial personality disorder, the findings 
pointed to a robust relationship between PTSD and suicide after 
controlling for co-morbid disorders. A later study using the Canadian 
Community Health Survey data also found that respondents with PTSD were 
at higher risk for suicide attempts after controlling for physical 
illness and other mental disorders (9).
    Some studies that point to PTSD as the cause of suicide suggest 
that high levels of intrusive memories can predict the relative risk of 
suicide (3). Anger and impulsivity have also been shown to predict 
suicide risk in those with PTSD (10). Further, some cognitive styles of 
coping such as using suppression to deal with stress may be 
additionally predictive of suicide risk in individuals with PTSD (3).
    Other research looking specifically at combat-related PTSD suggests 
that the most significant predictor of both suicide attempts and 
preoccupation with suicide is combat-related guilt, especially amongst 
Vietnam veterans (11). Many veterans experience highly intrusive 
thoughts and extreme guilt about acts committed during times of war, 
and these thoughts can often overpower the emotional coping capacities 
of veterans.
    Researchers have also examined exposure to suicide as a traumatic 
event. Studies show that trauma from exposure to suicide can contribute 
to PTSD. In particular, adults and adolescents are more likely to 
develop PTSD as a result of exposure to suicide if one or more of the 
following conditions are true: if they witness the suicide, if they are 
very connected with the person who dies, or if they have a history of 
psychiatric illness (12,13,14). Studies also show that traumatic grief 
is more likely to arise after exposure to traumatic death such as 
suicide (15,16). Traumatic grief refers to a syndrome in which 
individuals experience functional impairment, a decline in physical 
health, and suicidal ideation. These symptoms occur independent of 
other conditions such as depression and anxiety.
    VVA strongly suggests that until VA mental health services develops 
a nationwide strategy to address the problem of suicides among our 
older veterans--particularly Vietnam-era veterans--it immediately adopt 
and utilize the appropriate suicide risk and prevention factors for 
veterans found in the ``National Strategy for Suicide Prevention 2012: 
Goals and Objectives for Action: A Report of the U.S. Surgeon General 
and of the National Action Alliance for Suicide Prevention'' that's 
available on-line at the web sites for both the Surgeon General's 
Office and SAMHSA.
    The second item with which VVA has grave concerns is the 
recruitment, hiring, and retention of VA mental health staff. In its 
February 1st report, the VA claims to be ``currently engaged in an 
aggressive hiring campaign to expand access to mental health services 
with 1,600 new clinical staff, 300 new administrative staff, and is in 
the process of hiring and training 800 peer-to-peer specialists, who 
will work as members of mental health teams''. Nice words, but VVA 
asks: Of these 1,600 clinical positions, do they represent new 
additional staff, or replacements for those who've retired or left VA 
employ? What mental health clinical job categories do these hires 
represent? And what is the VA's staffing plan for these hires? In other 
words how many staff is VA hiring, in what positions, and how many do 
they currently have? It appears that we need a scorecard to determine 
what is going on . . .
    And last, but certainly not least, VVA remains concerned about 
timely access to VA mental health services and programs, especially 
since the 2012 Inspector General's report illustrated in incredible 
clarity how top VA facility and VISN administrators ``game the system'' 
to make wait times appear shorter for the veterans they serve. The 
I.G.'s report said that, rather than starting the clock from the moment 
a vet asks for mental health care, the VA has been counting from 
whenever the first appointment became available, adding weeks or months 
to the wait time. So while the VA was saying 95 percent of vets were 
seen as quickly as they were supposed to be, nearly 100,000 patients 
had to wait much longer. At the VA Medical Center in Salisbury, N.C., 
for example, the average wait was three months.
    Once again, on behalf of VVA's National Officers, Board, and 
general membership, thank you for your leadership in holding this 
important hearing on a topic that is literally of vital interest to so 
many veterans, and should be of keen interest to all Americans who care 
about our nation's veterans.
References
    1. Knox, K.L. (2008). Epidemiology of the relationship between 
traumatic experience and suicidal behaviors. PTSD Research Quarterly, 
19(4).

    2. Bullman, T. A., & Kang, H. K. (1995). A study of suicide among 
Vietnam veterans. Federal Practitioner, 12(3), 9-13.

    3. Amir, M., Kaplan, Z., Efroni, R., & Kotler, M. (1999). Suicide 
risk and coping styles in posttraumatic stress disorder patients. 
Psychotherapy and Psychosomatics, 68(2), 76-81.

    4. Ben-Yaacov, Y., & Amir, M. (2004). Posttraumatic symptoms and 
suicide risk. Personality and Individual Differences, 36, 1257-1264.

    5. Thompson, M. E., Kaslow, N. J., Kingree, J. B., Puett, R., 
Thompson, N. J., & Meadows, L. (1999). Partner abuse and posttraumatic 
stress disorder as risk factors for suicide attempts in a sample of 
low-income, inner-city women. Journal of Traumatic Stress, 12(1), 59-
72.

    6. Fontana, A., & Rosenheck, R. (1995). Attempted suicide among 
Vietnam veterans: A model of etiology in a community sample. American 
Journal of Psychiatry, 152(1), 102-109.

    7. Robison, B. K. (2002). Suicide risk in Vietnam veterans with 
posttraumatic stress disorder. Unpublished Doctoral Dissertation, 
Pepperdine University.

    8. Sareen, J., Houlahan, T., Cox, B., & Asmundson, G. J. G. (2005). 
Anxiety Disorders Associated With Suicidal Ideation and Suicide 
Attempts in the National Comorbidity Survey. Journal of Nervous and 
Mental Disease. 193(7), 450-454.

    9. Sareen, J., Cox, B.J., Stein, M.B., Afifi, T.O., Fleet, C., & 
Asmundson, G.J.G. (2007). Physical and mental comorbidity, disability, 
and suicidal behavior associated with posttraumatic stress disorder in 
a large community sample. Psychosomatic Medicine. 69, 242-248.

    10. Kotler, M., Iancu, I., Efroni, R., & Amir, M. (2001). Anger, 
impulsivity, social support, and suicide risk in patients with 
posttraumatic stress disorder. Journal of Nervous & Mental Disease, 
189(3), 162-167.

    11. Hendin, H., & Haas, A. P. (1991). Suicide and guilt as 
manifestations of PTSD in Vietnam combat veterans. American Journal of 
Psychiatry, 148(5), 586-591.

    12. Andress, V. R., & Corey, D. M. (1978). Survivor-victims: Who 
discovers or witnesses suicide? Psychological Reports, 42(3, Pt 1), 
759-764.

    13. Brent, D. A., Perper, J. A., Moritz, G., Friend, A., Schweers, 
J., Allman, C., McQuiston, L., Boylan, M. B., Roth, C., & Balach, L. 
(1993b). Adolescent witnesses to a peer suicide. Journal of the 
American Academy of Child and Adolescent Psychiatry, 32(6), 1184-1188.

    14. Brent, D. A., Perper, J. A., Moritz, G., Liotus, L., 
Richardson, D., Canobbio, R., Schweers, J., & Roth, C. (1995). 
Posttraumatic stress disorder in peers of adolescent suicide victims: 
Predisposing factors and phenomenology. Journal of the American Academy 
of Child and Adolescent Psychiatry, 34(2), 209-215.

    15. Melhem, N. M., Day, N., Shear, M. K., Day, R., Reynolds, C. F., 
& Brent, D. A. (2004). Traumatic grief among adolescents exposed to a 
peer's suicide. American Journal of Psychiatry, 161(8), 1411-1416.

    16. Prigerson, H. G., Shear, M. K., Jacobs, S. C., Reynolds, C. F. 
I., Maciejewsk, P. K., Davidson, J. R., Rosenheck, R., Pilkonis, P. A., 
Wortman, C. B., Williams, J. B., Widiger, T. A., Frank, E., Kupfer, D. 
J., & Zisook, S. (1999). Consensus criteria for traumatic grief: A 
preliminary empirical test. British Journal of Psychiatry, 174, 67-73.

    17. Posttraumatic Stress Disorder: Diagnosis and Assessment 
Subcomittee on Posttraumatic Stress Disorder of the Committee on Gulf 
War and Health: Physiologic, Psychologic, and Psychosocial Effects of 
Deployment-Related Stress. Institutes of Medicine. National Academies 
Press. 2006.
                      VIETNAM VETERANS OF AMERICA
                           Funding Statement
                            February 8, 2013
    The national organization Vietnam Veterans of America (VVA) is a 
non-profit veterans' membership organization registered as a 501(c) 
(19) with the Internal Revenue Service. VVA is also appropriately 
registered with the Secretary of the Senate and the Clerk of the House 
of Representatives in compliance with the Lobbying Disclosure Act of 
1995.
    VVA is not currently in receipt of any federal grant or contract, 
other than the routine allocation of office space and associated 
resources in VA Regional Offices for outreach and direct services 
through its Veterans Benefits Program (Service Representatives). This 
is also true of the previous two fiscal years.
    For Further Information, Contact: Executive Director for Policy and 
Government Affairs, Vietnam Veterans of America, (301) 585-4000, 
extension 127

                                 
                        Questions For The Record

Letter From: Hon. Jeff Miller, Chairman, To: Hon. Robert A. Petzel, 
        M.D., Under Secretary for Health, Department of Veterans 
        Affairs

    March 1, 2013

    The Honorable Robert A. Petzel, M.D.
    Under Secretary for Health
    U.S. Department of Veterans Affairs
    810 Vermont Avenue, NW
    Washington, DC 20420

    Dear Dr. Petzel:

    On Wednesday, February 13, 2013, you testified before the Committee 
during an oversight hearing entitled, ``Honoring the Commitment: 
Overcoming Barriers to Quality Mental Health Care for Veterans.'' As a 
follow-up to the hearing, I request that you respond to the attached 
questions and provide the requested materials in-full by no later than 
close of business on Friday, April 1, 2013.
    If you have any questions, please contact Dolores Dunn, Staff 
Director for the Subcommittee on Health, at [email protected] 
or by calling (202) 225-9154.
    Your timely response to this matter and your commitment to our 
nation's veterans and their families are both very much appreciated.
    With warm personal regards,

    Sincerely,

    JEFF MILLER
    Chairman

    CJM/dd/sg

 Questions From: Hon. Jeff Miller, Chairman, Congressman Jeff Denhan, 
  and Congresswoman Jackie Walorski To: Department of Veterans Affairs
    1. In a Full Committee hearing on June 14, 2011, entitled, ``Mental 
Health: Bridging the Gap Between Care and Compensation for Veterans,'' 
Dr. Karen Seal of the San Francisco Department of Veterans Affairs (VA) 
Medical Center testified regarding a study she had recently published 
in the Journal of Traumatic Stress regarding mental health services 
utilization rate for veterans of Operations Enduring Freedom and Iraqi 
Freedom (OEF/OIF) using VA healthcare from 2002-2008. Dr. Seal 
testified that less than 10% of those newly diagnosed with post-
traumatic stress disorder (PTSD) received the recommended number and 
intensity of VA evidence-based treatment sessions within the first year 
of their diagnosis. She also testified that only about a quarter of 
veterans received VA's recommended PTSD treatment protocol of nine or 
more sessions, and only about 10% attended such sessions within VA's 
recommended timeframe of fifteen weeks following their initial 
diagnosis.
    - Please provide, for each fiscal year (FY) 2008 through 2012, the 
number of OEF/OIF veterans using VA healthcare who have: (1) been 
diagnosed with PTSD, (2) received the recommended PTSD treatment 
protocol of nine of more sessions following their initial diagnosis; 
and, (3) attended such sessions within fifteen weeks of their initial 
diagnosis.
    2. Of the approximately 3,262 mental health professionals VA 
alleges to have hired as of January 29, 2013, please provide the 
following:
    - the number of such providers broken down by occupation and status 
(i.e., on-board, firm or tentative job offer, awaiting credentialing 
and privileging, pending interview, etc.);
    - the number of such providers broken down by Veterans Integrated 
Service Network and VA medical center or clinic;
    - the number of such providers who perform disability evaluations, 
either full-time or part-time;
    -the average length of time it takes the Department to credential 
and privilege each such provider;
    - the number of such providers who were transferred from other VA 
facilities.
    3. During the hearing, in response to my question about how VA 
evaluates patient outcomes with regard to mental health care, you 
stated that, `` . . . we have good evidence in literature that people 
that go through [VA treatment programs] do indeed have less 
symptomatology associated with their PTSD and are better adjusted to 
living in society. There are many instances of the treatment protocols 
that we have, where we can demonstrate the direct impact on those 
individuals that have been through that therapy.''
    - Please provide a copy of any and all of the ``literature'' that 
you referred to in the above statement.
    - Please describe each incident referenced in your above statement 
where VA is able to demonstrate ``the direct impact'' of the mental 
health care VA provides on the subsequent mental health of the veterans 
who access that care.
    4. In response to my question regarding how the Committee can 
assist VA in providing quality and timely mental health care services 
to veteran patients, you stated that the Committee may help in: (1) 
facilitating interactions between VA and community health centers; (2) 
helping VA interact better with private sector providers; and, (3) 
addressing the shortage of psychiatrists.
    - Please expand on how you believe the Committee could be of 
assistance to the Department in each of the three areas listed above.
    5. In response to my question regarding how VA has been able to 
hire increased numbers of mental health providers, you stated that, 
``[o]f all of the professionals in mental health, the most difficult 
problem we are having is recruiting psychiatrists, and we have barely 
been able to recruit half of the new ones that we said we wanted to do, 
and that it is in spite of raising the salary quite substantially, 
providing incentives for recruitment, bonuses, etc.''
    - Please provide further details on the salary raises, recruitment 
incentives, bonuses, and any and all other actions VA has taken in an 
effort to recruit and retain psychiatrists.
    - Please describe any and all actions beyond the ones referenced 
above that VA has taken or is considering taking to alleviate the the 
difficulties VA has experienced recruiting psychiatrists (i.e. 
undertaking additional recruitment and retention incentives, increasing 
partnerships with non-VA resources, recruiting increased numbers of 
other mental health professionals, etc.).
    6. In response to a question from Ranking Member Michaud regarding 
Section 3 of the Executive Order on Improving Access to Mental Health 
Servicemembers, Veterans, and Their Families, you stated that, `` . . . 
15 pilots sites were selected . . . based upon the desire of the local 
network to participate, our hospital to participate, and a need . . . 
identified often by how rural the areas were. There is one urban center 
where we are doing this in Atlanta to get a feel for what they might be 
like, because there are many, many community mental health clinics in 
the Atlanta area.'' You further stated that, ``[w]e think that this is 
. . . going to be a viable alternative in the future to us cooperating 
in the community with providing care in these again remote rural 
areas.''
    - Please name the location of each of the 15 selected pilot sites.
    - Please describe, in detail, the criteria the Department used to 
choose each of the sites named above.
    - Please expand on your statement above that enhanced partnerships 
between VA and community partners is going to be a ``viable 
alternative'' to ``cooperating in the community,'' to include what you 
see these partnerships as an alternative to and whether or not you see 
them as an asset in rural areas only or, potentially, in urban 
communities as well and why.
    7. In response to a question from Ranking Member Michaud regarding 
veteran suicide data, Dr. Janet Kemp, the Director of VA's Suicide 
Prevention and Community Engagement Program, stated that, ``[t]here 
[are] a couple of states that we are still working with over privacy 
issues and how we are going to share data and I am confident that we 
will get those soon.''
    - Please name the states referenced above.
    - Please describe any and all barriers, including privacy issues, 
to the states referenced above providing VA with the requested data on 
veteran suicide rates.
    - When does the Department expect that complete veteran suicide 
rate data will be received from all 50 states?
    8. In response to a question from Ranking Member Michaud regarding 
performance requirements for VA mental health providers, you stated 
that, `` . . . .it is important to have performance measures, and I 
think it is incumbent upon us as the leaders to make sure that there is 
the proper balance between time available to do clinical care, and the 
necessity of meeting performance measures.''
    - Please name each of the current performance measures (including 
any and all clinical reminders) currently in place for VA mental health 
care providers, to include the justification for using each measure and 
how long it has been in place.
    - Please describe how you, as the Under Secretary for Health, 
ensure a ``proper balance'' between measuring provider performance and 
ensuring sufficient clinical care.
    9. In response to a question from Representative Runyan regarding 
the need to be proactive in addressing veterans' mental health needs, 
you discussed the need to develop close, trusting relationships between 
veteran patients and VA mental health providers. You stated that VA 
needed to focus on, `` . . . developing the relationships where 
[veteran patients] will tell us where there are things that may be 
antecedents to suicide that are bothering them,'' and, ``[i]t is 
getting the information, and the contact with the individual before 
they have the difficulty as you have pointed is the problem.'' In 
response to a similar question from Representative Brownley, you stated 
that,'' . . . we have a newly organized task force that Dr. Kemp is 
chairing that is going to look at how we can develop a different 
paradigm if you will for the way we deliver care to people that have 
chronic pain, sleep disorders, depression, etc., the things that have 
the greatest impact on suicide.''
    - How does VA foster such relationships between VA providers and 
veteran patients?
    - What different paradigms is the taskforce referenced above 
looking at regarding the delivery of mental health care and when is 
that work expected to be complete?
    10. In response to a question from Representative Coffman regarding 
VA mental health care providers, you stated that, `` . . . this spring 
[we have] implemented our performance criteria for timeliness, the 
intention is to go out and do three things. One, look at the measures. 
Two, survey veterans as to whether or not they were - had timely access 
as well as other satisfaction related questions. And three, to survey 
the staff. Are they able to provide timely access for their patients, 
are they adequately staffed, do they have enough people to do the work 
that they are being required. So, yes, we are going to do it. And we 
will be doing that on a regular basis''
    - Please provide the timeliness performance criteria referenced 
above.
    - Please provide information regarding the survey of veteran 
patients referenced above, to include the number of veteran patients 
expected to be surveyed, the questions expected to be included on the 
survey, the method expected to be used to conduct the survey (i.e., in 
person, electronic, via telephone, etc.), the expected survey results, 
the expected total cost of the survey, and any and all follow-up 
actions expected to result from the survey.
    - Please provide information regarding the survey of VA mental 
health care providers referenced above, to include the number of VA 
mental health providers expected to be surveyed, the questions expected 
to be included on the survey, the method expected to be used to conduct 
the survey (i.e., in person, electronic, via telephone, etc.), the 
expected survey results, the expected total cost of the survey, and any 
and all follow-up actions expected to result from the survey.
    - When does the Department expect all three of the above actions to 
be completed?
    - How often does the Department expect to conduct follow-up surveys 
of veteran patients accessing VA mental health care?
    - How often does VA expect to conduct follow-up surveys of VA 
mental health providers?
Questions for the Record from Congressman Jeff Denham
    1. As we have heard the hearing, the conflicts in Afghanistan and 
Iraq have created extraordinary demands for care as veterans return 
from theater. For those with PTSD or other mental health issues, long 
waits for treatment can put them at risk for suicide or other 
behavioral problems.
    - Has VA considered short-term solutions to address the immediate 
mental health need while it recruits and hires the staff it needs long 
term?
    2. I understand that VA has been conducting pilot programs designed 
to provide veterans with access to community-based mental health 
services in several rural communities like mine. For veterans that are 
able to get into one of these programs, they provide needed care closer 
to the veteran's home. However, I understand that use of these pilots 
by VA facilities has been very low.
    - What are you doing to encourage use of these programs in rural 
communities?
    - Are there any plans to expand these rural pilot programs, to 
other rural communities across the country?
Questions for the Record from Congresswoman Jackie Walorski
    1. During the hearing, we heard how veterans are discouraged with 
long wait times in-between appointments and consequently drop out of 
treatment.
    - What is VA doing to improve mental health wait times for veteran 
patients accessing VA mental health care?
    - How is VA working to better accommodate veterans who have 
transitioned into the civilian world and all the new responsibilities 
they must deal with while trying to seek the health care they need?

                                 
         Responses From the U.S. Department of Veterans Affairs
    1. In a Full Committee hearing on June 14, 2011, entitled, ``Mental 
Health: Bridging the Gap Between Care and Compensation for Veterans,'' 
???Dr. Karen Seal of the San Francisco Department of Veterans Affairs 
(VA) Medical Center testified regarding a study she had recently 
published in the Journal of Traumatic Stress regarding mental health 
services utilization rate for veterans of Operations Enduring Freedom 
and Iraqi Freedom (OEF/OIF) using VA healthcare from 2002-2008. Dr. 
Seal testified that less than 10% of those newly diagnosed with post-
traumatic stress disorder (PTSD) received the recommended number and 
intensity of VA evidence-based treatment sessions within the first year 
of their diagnosis. She also testified that only about a quarter of 
veterans received VA 's recommended PTSD treatment protocol of nine or 
more sessions, and only about 10% attended such sessions within VA's 
recommended timeframe of fifteen weeks following their initial 
diagnosis.
    Please provide, for each fiscal year (FY) 2008 through 2012, the 
number of OEF/OIF veterans using VA healthcare who have: (1) been 
diagnosed with PTSD, (2) received the recommended PTSD treatment 
protocol of nine of more sessions following their initial diagnosis; 
and, (3) attended such sessions within fifteen weeks of their initial 
diagnosis.
VA Response:
    We identified all Operation Enduring Freedom/Operation Iraqi 
Freedom (OEF/OIF) Veterans who have enrolled in VA care and received 
any outpatient VA services between the date of their separation from 
military service (for regular Armed Forces), or the end date of their 
last deployment (for Reserve and National Guard), and the end of fiscal 
year (FY) 2011. \1\ The Veterans Health Administration (VHA) has 
treated 728,705 of these Veterans.
---------------------------------------------------------------------------
    \1\ The FY12 data are not included because the outcomes measures 
(any care in one year, any psychotherapy in one year, and 9 visits in 
15 weeks at any time within one year of diagnosis) required at least 
one year in which to examine. Therefore, we included all Veterans 
through the end of FY11 and examined their utilization through the end 
of FY12.
---------------------------------------------------------------------------
    Table 1 indicates the numbers that were diagnosed with Post-
traumatic Stress Disorder (PTSD) in the same time frame. Those 
diagnosed with PTSD are those who had at least two outpatient visits, 
or one inpatient or residential bed day, where a diagnosis of PTSD was 
present. This methodology for counting those with a diagnosis of PTSD 
differs from Dr. Seal's methodology, but is consistent with how Mental 
Health Service and Office of Mental Health Operations report numbers on 
PTSD. Over all of the years, a cumulative total of 166,604 (22.9 
percent) OEF/OIF Veterans treated by VHA were diagnosed with PTSD.


                  Table 1. Number of OEF/OIF Veterans diagnosed with PTSD, by year of diagnosis
----------------------------------------------------------------------------------------------------------------
                                                                                            % of all OEF/OIF
                            Year                                  Number with PTSD         Veterans with PTSD
----------------------------------------------------------------------------------------------------------------
2002                                                                               10                      0.01
2003                                                                               94                      0.06
2004                                                                             2216                      1.33
2005                                                                             8054                      4.83
2006                                                                            12369                      7.42
2007                                                                            19154                      11.5
2008                                                                            26674                     16.01
2009                                                                            30537                     18.33
2010                                                                            32582                     19.56
2011                                                                            34914                     20.96
----------------------------------------------------------------------------------------------------------------

    Next, we calculated the proportion of those who received a 
diagnosis of PTSD who also had at least nine outpatient mental health 
visits in the year after their initial diagnosis. That data is 
presented in Table 2. Note that while Dr. Seal's analysis included only 
mental health visits to sub-specialty PTSD, mood disorder, or substance 
use clinics, and visits to mental health clinicians embedded in primary 
care, she did not include a number of settings where evidence-based 
PTSD treatment can be delivered, such as psychology and psychiatry 
individual visits and general mental health clinics. We included these 
locations in our analysis of mental health care utilization.

 Table 2. Number and proportion of OEF/OIF Veterans diagnosed with PTSD who received at least nine visits in the
                                          year after initial diagnosis
----------------------------------------------------------------------------------------------------------------
                                                                  Number of OEF/OIF         % of all OEF/OIF
                            Year                               Veterans with PTSD who     Veterans with PTSD in
                                                               had 9 visits in a year           the year
----------------------------------------------------------------------------------------------------------------
2002                                                                                4                     40.00
2003                                                                               46                     48.94
2004                                                                              817                     36.87
2005                                                                             2374                     29.48
2006                                                                             3530                     28.54
2007                                                                             5551                     28.98
2008                                                                             7654                     28.69
2009                                                                             9196                     30.11
2010                                                                             9711                     29.80
2011                                                                             9905                     28.37
----------------------------------------------------------------------------------------------------------------

    Finally, we calculated the proportion of those diagnosed with PTSD 
who received nine visits within a 15 week period during the year after 
their initial diagnosis. We used the same list of possible locations of 
care as in Table 2. This data is in Table 3.

 Table 3. Number and proportion of OEF/OIF Veterans diagnosed with PTSD who received at least nine visits within
                              a 15 week period in the year after initial diagnosis
----------------------------------------------------------------------------------------------------------------
                                                                                         % of all Veterans with
                            Year                              Number with PTSD who had   initial PTSD diagnosis
                                                                9 visits in 15 weeks           in the year
----------------------------------------------------------------------------------------------------------------
2002                                                                                2                     20.00
2003                                                                               28                     29.79
2004                                                                              501                     22.61
2005                                                                             1403                     17.42
2006                                                                             2082                     16.83
2007                                                                             3222                     16.82
2008                                                                             4396                     16.48
2009                                                                             5512                     18.05
2010                                                                             5957                     18.28
2011                                                                             6156                     17.63
----------------------------------------------------------------------------------------------------------------

    2. Of the approximately 3,262 mental health professionals VA 
alleges to have hired as of January 29, 2013, please provide the 
following:
    The number of such providers broken down by occupation and status 
(i.e., on-board, firm or tentative job offer, awaiting credentialing 
and privileging, pending interview, etc.);
VA Response:
    All of the 4,308 mental health professionals hired as of June 30, 
2013, reported by VA were brought are on-board to provide services to 
our Veterans.
    a) The break out of the occupations is as follows:



--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                                   Social      Other       Non-    Grand
                         Occupations                          LMFT \1\  LPMHC \2\  Nurse  Physician  Psychologist  Worker  clinical \3\  clinical  Total
--------------------------------------------------------------------------------------------------------------------------------------------------------
Number                                                            31        40      986      403          757        990        626         475    4,308
--------------------------------------------------------------------------------------------------------------------------------------------------------

    TABLE 1: Mental Health Professionals Hired as of January 29, 2013
     \1\ Licensed Marriage and Family Therapist.
     \2\ Licensed Professional Mental Health Counselors.
     \3\ Other Mental Health Professions include: Addiction Therapists, 
Health Technicians, Health Science Specialists, Nurse Assistants, 
Pharmacists, Occupational Therapists, Physician Assistants, 
Recreational Therapists, and Vocational Rehabilitation Therapists.

    b) Tentative job offer as of January 29, 2013: Already on board

    c) Firm job offer as of January 29, 2013: Already on board

    d) Pending interview as of January 29, 2013: Already on board

    e) Awaiting credentialing and privileging: Already on board

    The number of such providers broken down by Veterans Integrated 
Service Network and VA medical center or clinic;
VA Response:


------------------------------------------------------------------------
                     VISN                                 Hired
------------------------------------------------------------------------
1                                                                   128
------------------------------------------------------------------------
2                                                                    55
------------------------------------------------------------------------
3                                                                   144
------------------------------------------------------------------------
4                                                                   326
------------------------------------------------------------------------
5                                                                    59
------------------------------------------------------------------------
6                                                                   166
------------------------------------------------------------------------
7                                                                   345
------------------------------------------------------------------------
8                                                                   394
------------------------------------------------------------------------
9                                                                   280
------------------------------------------------------------------------
10                                                                  121
------------------------------------------------------------------------
11                                                                  167
------------------------------------------------------------------------
12                                                                  188
------------------------------------------------------------------------
15                                                                  132
------------------------------------------------------------------------
16                                                                  375
------------------------------------------------------------------------
17                                                                  243
------------------------------------------------------------------------
18                                                                  167
------------------------------------------------------------------------
19                                                                  127
------------------------------------------------------------------------
20                                                                  199
------------------------------------------------------------------------
21                                                                  176
------------------------------------------------------------------------
22                                                                  232
------------------------------------------------------------------------
23                                                                  176
------------------------------------------------------------------------
VCL \1\                                                             108
------------------------------------------------------------------------
Total                                                             4,308
------------------------------------------------------------------------

     \1\ Veterans Crisis Line
    TABLE 2: Number of Mental Health Providers Hired by the VA
    the number of such providers who perform disability evaluations, 
either full-time or part-time;
VA Response:
    That number is unknown, as the number of providers who perform 
disability evaluations is only tracked locally.
    the average length of time it takes the Department to credential 
and privilege each such provider;
VA Response:


----------------------------------------------------------------------------------------------------------------
                                                                  Average Days from         Average Days from
                          Category                            enrollment in VetPro* to  Submission in VetPro* to
                                                                     Submission           Complete Verification
----------------------------------------------------------------------------------------------------------------
All provider                                                                       10                        35
----------------------------------------------------------------------------------------------------------------
Licensed independent provider (Physician)                                          20                        48
----------------------------------------------------------------------------------------------------------------
Psychologist (licensed)                                                            13                        31
----------------------------------------------------------------------------------------------------------------
Psychologist (unlicensed)                                                          10                        32
----------------------------------------------------------------------------------------------------------------
Licensed Professional Mental Health Counselor                                       3                        20
----------------------------------------------------------------------------------------------------------------
Marriage and Family Therapist                                                       5                        26
----------------------------------------------------------------------------------------------------------------
Social Worker (licensed)                                                            5                        27
----------------------------------------------------------------------------------------------------------------
Social Worker (other)                                                               4                        27
----------------------------------------------------------------------------------------------------------------

    *VetPro is used in VA to credential and privilege VA providers
    TABLE 3: Length of Time to Credential and Privilege VA Providers
    the number of such providers who were transferred from other VA 
facilities.
VA Response:
    Of note, VA is tracking the backfills of these positions. If a 
current VA provider transfers from one facility to a different VA 
facility, VA does not count the transfer itself as a new hire. As 
stated above in condition 3, a new hire is counted only when the 
original position is backfilled with an external hire. In no instance 
has VHA counted current VHA employees who vacated a mental health 
position to fill a different mental health position as this would not 
meet the intent of VHA's drive towards the initiative.
    3. During the hearing, in response to my question about how VA 
evaluates patient outcomes with regard to mental health care, you 
stated that, ``...we have good evidence in literature that people that 
go through [VA treatment programs] do indeed have less symptomatology 
associated with their PTSD and are better adjusted to living in 
society. There are many instances of the treatment protocols that we 
have, where we can demonstrate the direct impact on those individuals 
that have been through that therapy.''
    Please provide a copy of any and all of the ``literature'' that you 
referred to in the above statement.
VA Response:
    The following is an annotated bibliography of research literature 
supporting the efficacy of PTSD treatments provided at VA. Published 
International Literature on Traumatic Stress (PILOTS) ID numbers noted 
at the end of each reference are unique identifiers that can be used to 
locate the reference within the National Center for PTSD's PILOTS 
database.
Cognitive Processing Therapy (CPT)
    1.Alvarez, J., McLean, C., Harris, A. H. S., Rosen, C. S., Ruzek, 
J. I., and Kimerling, R. E. (2011). The comparative effectiveness of 
cognitive processing therapy for male Veterans treated in a VHA 
posttraumatic stress disorder residential rehabilitation program. 
Journal of Consulting and Clinical Psychology, 79, 590-599. 
doi:10.1037/a0024466 PILOTS ID: 37362
    This was one of the first studies to demonstrate that CPT is more 
effective than a usual care treatment within a VA clinical setting. The 
104 Veterans treated with group CPT in a VA PTSD Residential 
Rehabilitation Program had greater improvement in PTSD, depression, and 
psychological quality of life, and were more likely to lose their PTSD 
diagnosis than 93 Veterans treated with trauma-focused group therapy, 
the usual treatment being delivered prior to CPT's implementation.

    2.Chard, K. M., Schumm, J. A., Owens, G. P. and Cottingham, S. M. 
(2010). A comparison of OEF and OIF Veterans and Vietnam Veterans 
receiving cognitive processing therapy. Journal of Traumatic Stress, 
23, 25-32. doi:10.1002/jts.20500 PILOTS ID: 83687
    This study addressed the important question of whether OEF/OIF 
Veterans respond differently to outpatient PTSD treatment than Vietnam 
Veterans. The investigators found that compared with 50 Vietnam 
Veterans, 51 OEF/OIF Veterans had lower PTSD severity after CPT, yet 
attended fewer treatment sessions. The study suggests that the chronic 
nature of PTSD among the Vietnam cohort may be more difficult to treat 
and requires a longer course of therapy.

    3.Chard, K. M., Schumm, J. A., McIlvain, S. M., Bailey, G. W., and 
Parkinson, R. B. (2011). Exploring the efficacy of a residential 
treatment program incorporating cognitive processing therapy-cognitive 
for Veterans with PTSD and traumatic brain injury. Journal of Traumatic 
Stress, 24, 347-351. doi:10.1002/jts.20644 PILOTS ID: 85169
    To better understand how TBI affects response to PTSD-focused 
treatment, this study of 42 Veterans examined outcomes from a 
residential VA PTSD-TBI treatment program that incorporates CPT. 
Results showed that the treatment led to better outcomes for Veterans 
with mild TBI and Veterans with moderate/severe TBI, with no 
differences between the TBI groups. This is the first study to show 
that Veterans with PTSD and TBI experience decreased PTSD and 
depression following participation in a residential trauma-focused 
treatment program.

    4.Chard, K. M., Ricksecker, E. G., Healy, E. T., Karlin, B. E., and 
Resick, P. A. (2012). Dissemination and experience with cognitive 
processing therapy. Journal of Rehabilitation Research & Development, 
49, 667-678. doi:10.1682/JRRD.2011.10.0198 PILOTS ID: 86801
    The study is a program evaluation of VA's national training rollout 
of CPT. Outcome data from 374 Veterans who received CPT from therapists 
trained via the program indicated statistically significant and 
clinically meaningful improvements in PTSD. Veterans from Vietnam, OEF/
OIF, and the Persian Gulf War benefited equally from CPT.

    5.Monson, C. M., Schnurr, P. P., Resick, P. A., Friedman, M. J., 
Young-Xu, Y.,and Stevens, S. P. (2006). Cognitive processing therapy 
for Veterans with military-related posttraumatic stress disorder. 
Journal of Consulting and Clinical Psychology,74, 898-907. doi:10.1037/
0022-006X.74.5.898 PILOTS ID: 28862
    The study is the first randomized controlled trial of CPT for 
Veterans with PTSD. In the sample of 60 Veterans, CPT led to 
significantly greater improvements in PTSD, depression, and social 
adjustment, among other outcomes, compared to a wait-list control 
group. Importantly, Veterans with PTSD-related disability improved just 
as much as Veterans without PTSD-related disability.

    6.Suris, A., Link-Malcolm, J., Chard, K., Ahn, C., and North, C. 
(2013). A randomized clinical trial of cognitive processing therapy for 
Veterans with PTSD related to military sexual trauma. Journal of 
Traumatic Stress, 26, 28-37. doi:10.1002/jts.21765 PILOTS ID: TBD
    This is the first randomized controlled trial of CPT for PTSD-
related to military sexual trauma (MST). This study found CPT to be 
more effective than Present-Centered Therapy, a non-trauma-focused PTSD 
treatment, in reducing self-reported PTSD symptoms in a sample of 86 
Veterans (73 female, 13 male).
Prolonged Exposure (PE) and other Exposure Therapies
    1. Rauch, S. A., Defever, E., Favorite, T., Duroe, A., Garrity, C., 
Martis, B., and Liberzon, I. (2009). Prolonged exposure for PTSD in a 
Veterans Health Administration PTSD clinic. Journal of Traumatic 
Stress, 22, 60-64. doi:10.1002/jts.20380 PILOTS ID: 82589
    This pilot study showed that PE was effective in reducing PTSD and 
depression in a small sample of 10 men and women Veterans from various 
war eras seen in a VA PTSD clinic. Half the patients were seen by 
therapists participating in the national VA training program in PE. 
Outcomes for these patients were just as positive as those for patients 
seen by clinicians experienced with PE.

    2. Schnurr, P. P., Friedman, M. J., Engel, C. C., Foa, E. B., Shea, 
M. T., Chow, B. K., . . . Bernardy, N. C. (2007). Cognitive behavioral 
therapy for posttraumatic stress disorder in women: A randomized 
controlled trial. Journal of the American Medical Association, 297, 
820-830. doi:10.1001/jama.297.8.820 PILOTS ID: 29137
    This study is one of the largest clinical treatment trials 
conducted, with a sample of 284 female Veterans and active duty 
personnel, and the first of PTSD in female Servicemembers. Women who 
received PE had greater improvements in PTSD, depression, anxiety, and 
quality of life than women who received Present-Centered Therapy, a 
non-trauma-focused PTSD treatment.

    3.Strachan, M., Gros, D. F., Ruggiero, K. J., Lejuez, C.W., and 
Acierno, R. E. (2011). An integrated approach to delivering exposure-
based treatment for symptoms of PTSD and depression in OIF/OEF 
Veterans: Preliminary findings. Behavior Therapy, 43, 560-569. 
doi:10.1016/j.beth.2011.03.003 PILOTS ID: 37822
    This study presents preliminary data from an ongoing clinical trial 
and indicates that a brief behavioral treatment incorporating exposure 
was effective in significantly improving PTSD, depression, and anxiety 
among 31 OEF/OIF Veterans, whether delivered using home-based 
telehealth or in-person. The findings suggest that exposure treatment 
can be effectively administered using telehealth technology, which may 
expand the reach of this evidence-based approach.

    4.Thorp, S. R., Stein, M. B., Jeste, D. V., Patterson, T. L., and 
Wetherell, J. L. (2012). PE therapy for older Veterans with 
posttraumatic stress disorder: A pilot study. American Journal of 
Geriatric Psychiatry, 20, 276-280. doi:10.1097/JGP.0b013e3182435ee9 
PILOTS ID: 38445
    This preliminary study begins to fill the gap in research on PTSD 
treatment in older Veterans. Findings indicated that PE was well 
received by a small sample of 10 Veterans age 56 to 78 and effective in 
improving PTSD symptoms to a significant and large degree. Dropout was 
similar to that seen in other PTSD treatment studies. Improvement in 
PTSD was larger in the PE group than in a nonrandomized comparison 
sample of older Veterans receiving usual treatment (medication 
appointments or case management) in the same clinic.

    5.Tuerk, P. W.; Yoder, M.; Grubaugh, A. L.; Myrick, H.; Hamner, M. 
B.; and Acierno, R. E. (2011). Prolonged exposure therapy for combat-
related posttraumatic stress disorder: An examination of treatment 
effectiveness for Veterans of the wars in Afghanistan and Iraq. Journal 
of Anxiety Disorders, 25, 397-403. doi:10.1016/j.janxdis.2010.11.002 
PILOTS ID: 35452
    This is one of the few studies of real-world treatment 
effectiveness exclusively focused on OEF/OIF Veterans. The trial found 
that a sample of 65 OEF/OIF Veterans treated with PE by VA PTSD 
Clinical Teams (PCT) had significant improvements in PTSD that were 
similar in size to those found in randomized controlled trials of PE in 
civilians. Importantly, PTSD improved irrespective of service 
connection disability status.

    6.Tuerk, P. W., Yoder, M., Ruggiero, K. J., Gros, D. F., and 
Acierno, R. E. (2010). A pilot study of prolonged exposure therapy for 
posttraumatic stress disorder delivered via telehealth technology. 
Journal of Traumatic Stress, 23, 116-123. doi:10.1002/jts.20494 PILOTS 
ID: 83699
    This is the first trial of PE delivered via telehealth technology. 
Results indicated that 12 Veterans who received PE via telehealth at 
their local VA Community-Based Outreach Clinic experienced large 
reductions in PTSD and depression. These improvements were generally 
similar to those experienced by a group of 35 Veterans who received the 
treatment in-person at the main VA Medical Center (VAMC). PE via 
telehealth was safe and feasible, with acceptable, albeit slightly 
higher than in-person, rates of treatment completion.

    7.Wolf, G. K., Strom, T. Q., Kehle, S. M., and Eftekhari, A. 
(2012). A preliminary examination of prolonged exposure therapy with 
Iraq and Afghanistan Veterans with a diagnosis of posttraumatic stress 
disorder and mild to moderate traumatic brain injury. Journal of Head 
Trauma Rehabilitation, 27, 26-32. doi:10.1097/HTR.0b013e31823cd01f 
PILOTS ID: 37922
    This small study demonstrated that prolonged exposure with minimal 
procedural enhancements was feasible and effective for treating PTSD 
and depression in OEF/OIF Veterans with traumatic brain injury. 
Improvements were large and 9 out of the 10 Veterans no longer meeting 
criteria for PTSD based on a self-report measure.

    8.Yoder, M., Tuerk, P. W., Price, M., Grubaugh, A. L., Strachan, 
M., Myrick, H., and Acierno, R. E. (2012). Prolonged exposure therapy 
for combat-related posttraumatic stress disorder: Comparing outcomes 
for Veterans of different wars. Psychological Services, 9, 16-25. 
doi:10.1037/a0026279 PILOTS ID: 37575
    This study added to the literature examining whether there is 
variability in PTSD treatment response across different cohorts of 
Veterans. The investigators examined archival data from 112 Veterans 
treated with PE by a PCT. The treatment was very effective at reducing 
PTSD and depression for the overall sample, although Gulf War Veterans 
experienced less improvement compared with Vietnam or OEF/OIF Veterans 
and also had a slower rate of improvement. The factors that may account 
for this differential effectiveness have yet to be explored.
Other Cognitive-Behavioral Treatments
    1.Beidel, D. C., Frueh, B. C., Uhde, T. W., Wong, N., and 
Mentrikoski, J. M. (2011). Multicomponent behavioral treatment for 
chronic combat-related posttraumatic stress disorder: A randomized 
controlled trial. Journal of Anxiety Disorders, 25, 224-231. 
doi:10.1016/j.janxdis.2010.09.006 PILOTS ID: 35248
    The randomized clinical trial compared a multicomponent cognitive-
behavioral therapy, Trauma Management Therapy. This therapy combines 
exposure therapy and social emotional rehabilitation, to exposure 
therapy only in a group of 35 male combat Veterans with chronic PTSD. 
Veterans in both conditions had moderate improvements in PTSD, with no 
difference between groups. The Trauma Management Therapy group had 
greater decreases in social impairment after receiving the treatment 
component that focuses on social functioning.

    2.Frueh, B. C., Monnier, J., Yim, E., Grubaugh, A. L., Hamner, M. 
B., and Knapp, R. G. (2007). A randomized trial of telepsychiatry for 
post-traumatic stress disorder. Journal of Telemedicine and Telecare, 
13, 142-147. doi:10.1258/135763307780677604 PILOTS ID: 29644
    This randomized clinical noninferiority trial of group therapy 
compared video teleconferencing with in-person format in a sample of 38 
male Veterans with PTSD. Change in self-reported PTSD from before to 
after treatment was small in both groups and did not differ between 
groups, who also did not differ in session attendance and treatment 
satisfaction. However, the same-room group was more likely to complete 
assigned homework and reported greater comfort when talking with their 
therapist.

    3.Jakupcak, M., Roberts, L. J., Martell, C., Mulick, P. S., 
Michael, S. T., Reed, R., McFall, M. E. (2006). A pilot study of 
behavioral activation for Veterans with posttraumatic stress disorder. 
Journal of Traumatic Stress, 19, 387-391. doi:10.1002/jts.20125 PILOTS 
ID: 80064
    This pilot study evaluated the feasibility and effectiveness of 
behavioral activation for treating PTSD in 11 Veterans who received 16-
weekly individual sessions of treatment, 9 of whom completed the 
protocol. There were moderate pre-post improvements in PTSD, but no 
improvement in depression and quality of life.

    4.Morland, L. A., Greene, C. J., Rosen, C. S., Foy, D. W., Reilly, 
P. M., Shore, J. H., . . . Frueh, B. C. (2010). Telemedicine for anger 
management therapy in a rural population of combat Veterans with 
posttraumatic stress disorder: A randomized noninferiority trial. 
Journal of Clinical Psychiatry, 71, 855-863. doi:10.4088/
JCP.09m05604blu PILOTS ID: 33947
    This randomized clinical noninferiority trial of anger management 
therapy for 125 Veterans with PTSD found that those who received 
treatment by video teleconferencing had comparable symptom improvements 
to those who received in-person therapy. There were no differences in 
attrition, adherence, satisfaction, or treatment expectancy, although 
Veterans in the in-person condition reported higher therapeutic 
alliance.

    5.Monson, C. M., Fredman, S. J., Macdonald, A., Pukay-Martin, N. 
D., Resick, P. A., and Schnurr, P. P. (2012). Effect of cognitive-
behavioral couple therapy for PTSD: A randomized controlled trial. 
Journal of the American Medical Association, 308, 700-709. doi: 
10.1001/jama.2012.9307 PILOTS ID: 39124
    Forty couples in which one partner had PTSD (including 9 couples in 
which the PTSD partner was a Veteran) were randomized to receive couple 
therapy or to a waitlist. Couple therapy resulted in greater decreases 
in PTSD and other symptoms and increased relationship satisfaction in 
the PTSD partners, but no differential improvement in relationship 
satisfaction in the non-PTSD partners.

    6.Rotunda, R.J., O'Farrell, T.J., Murphy, M., and Babey, S.H. 
(2008). Behavioral couples therapy for comorbid substance use disorders 
and combat-related posttraumatic stress disorder among male Veterans: 
An initial evaluation. Addictive Behaviors, 33, 180-187. doi:10.1016/
j.addbeh.2007.06.001 PILOTS ID 30123
    This randomized controlled trial compared outcomes of behavioral 
couples therapy in 38 Veterans who had comorbid PTSD and alcohol use 
disorder or alcohol use disorder only. There were similar improvements 
in both groups in relationship satisfaction, alcohol consumption, 
negative consequences of drinking male-to-female violence, and 
psychological distress.
Supported Employment
    1.Davis, L. L., Leon, A. C., Toscano, R., Drebing, C. E., Ward, L. 
C., Parker, P. E., . . . Drake, R. E. (2012). A randomized controlled 
trial of supported employment among Veterans with posttraumatic stress 
disorder. Psychiatric Services,63,464-470. doi:10.1176/
appi.ps.201100340 PILOTS ID: 38033
    A randomized clinical trial of 85 Veterans who were randomized to 
receive either individual placement and support (IPS) or standard VHA 
vocational rehabilitation found that found that Veterans who received 
IPS were much more likely to gain competitive employment (approximately 
76 percent in IPS vs. 28 percent in vocational rehabilitation). 
Veterans who received IPS also spent more time in competitive 
employment and had greater income.
Eye Movement Desensitization and Reprocessing (EMDR)
    1.Carlson, J. G., Chemtob, C. M., Rusnak, K., Hedlund, N. L., and 
Muraoka, M. Y. (1998). Eye movement desensitization and reprocessing 
(EMDR) treatment for combat-related posttraumatic stress disorder. 
Journal of Traumatic Stress, 11, 3-24. doi:10.1023/A:1024448814268 
PILOTS ID: 13921
    In this randomized clinical trial (RCT), 47 male combat Veterans 
with PTSD were assigned to receive either EMDR, relaxation, or a wait 
list. The authors reported greater improvements in PTSD and other 
outcomes for the 35 Veterans who completed the trial; Intention-to-
Treat analysis was not reported.

    2.Rogers, S., Silver, S. M., Goss, J., Obenchain, J. V., Willis, 
A., and Whitney, R. L. (1999). A single session, group study of 
exposure and eye movement desensitization and reprocessing in treating 
posttraumatic stress disorder among Vietnam War Veterans: Preliminary 
data. Journal of Anxiety Disorders, 13, 119-130. doi:10.1016/S0887-
6185(98)00043-7 PILOTS ID: 14686
    In this small RCT, 12 Vietnam War Veterans with PTSD were either a 
single session of exposure therapy or EMDR. Both groups showed 
improvement in self-reported overall PTSD symptom severity but groups 
did not differ. EMDR treatment resulted in greater positive changes in 
within-session subjective units of discomfort levels and on self-
reported intrusive symptoms.

    3.Silver, S. M., Brooks, A., and Obenchain, J. V. (1995). Treatment 
of Vietnam War Veterans with PTSD: A comparison of eye movement 
desensitization and reprocessing, biofeedback, and relaxation training. 
Journal of Traumatic Stress, 8, 337-342. doi:10.1007/BF02109568 PILOTS 
ID: 12519
    Program evaluation of 100 Veterans treated in a VA specialized 
inpatient program showed that those who received EMDR had greater 
improvements than those who received relaxation or biofeedback in PTSD 
and other symptoms.
Complementary and Alternative Medicine
    1.Bormann, J. E., Thorp, S. R., Wetherell, J. L., Golshan, S., and 
Lang, A. J. (2012, March 12). Meditation-based mantram intervention for 
Veterans with posttraumatic stress disorder: A randomized trial. 
Psychological Trauma: Theory, Research, Practice, and Policy. Advance 
online publication. doi:10.1037/a0027522 PILOTS ID: 38465
    In this RCT, 146 outpatient Veterans with PTSD were assigned to 
receive usual care (medication and case management alone) or usual care 
plus a mantram repetition program. Participants who received mantram 
repetition had greater improvements in self-reported and clinician-
rated PTSD symptoms and in depression, mental health status, and 
existential spiritual well-being.

    2.Niles, B. L., Klunk-Gillis, J., Ryngala, D. J., Silberbogen, A. 
K., Paysnick, A., and Wolf, E. J. (2012) November 14). Comparing 
mindfulness and psychoeducation treatments for combat-related PTSD 
using a telehealth approach. Psychological Trauma: Theory, Research, 
Practice, and Policy, 4, 538-547. doi:10.1037/a0026161 PILOTS ID: 37920
    In this RCT, 33 male combat Veterans with PTSD were assigned to one 
of two telehealth treatment conditions: mindfulness or psychoeducation. 
In the 24 participants who completed all assessments, participation in 
the mindfulness intervention was associated with a temporary reduction 
in PTSD symptoms. The authors concluded that a brief mindfulness 
treatment may not be of adequate intensity to sustain effects on PTSD 
symptoms.
Integrated Care
    1.Cigrang, J. A., Rauch, S. A. M., Avila, L. L., Bryan, C. J., 
Goodie, J. L., Hryshko-Mullen, A., . . . STRONG, S. C. (2011). 
Treatment of active-duty military with PTSD in primary care: Early 
findings. Psychological Services, 8, 104-113. doi:10.1037/a0022740 
PILOTS ID: 36597
    This pilot study evaluated a brief cognitive behavioral therapy 
protocol that included elements of PE and Cognitive Processing Therapy 
for treating PTSD in 15 Veterans in a primary care setting. There were 
large decreases in self-reported and clinician-rated PTSD but symptoms 
still remained high after treatment.

    2.Jakupcak, M., Wagner, A. W., Paulson, A., Varra, A. A., and 
McFall, M. E. (2010). Behavioral activation as a primary care-based 
treatment for PTSD and depression among returning Veterans. Journal of 
Traumatic Stress, 23, 491-495. doi:10.1002/jts.20543 PILOTS ID: 80064
    This pilot study of 8 OEF/OIF Veterans who received Behavioral 
Activation as a primary care-based treatment for PTSD found that there 
improvements in PTSD following treatment that were maintained at 3-
month follow up. The majority of Veterans demonstrated meaningful 
improvements on depression and quality of life and reported high 
treatment satisfaction.

    3.McFall, M., Saxon, A. J., Malte, C. A., Chow, B., Bailey, S., 
Baker, D. G., Beckham, J. C., Boardman, K. D., et al., for the CSP 519 
Study Team. (2010). Integrating tobacco cessation into mental health 
care for posttraumatic stress disorder: A randomized controlled trial. 
Journal of the American Medical Association, 304, 2485-2493. 
doi:10.1001/jama.2010.1769 PILOTS ID: 35450
    This randomized clinical of integrated smoking cessation for 943 
smokers with military-related PTSD, recruited from outpatient PTSD 
clinics at 10 VAMCs found that Veterans who were referred to integrated 
smoking cessation treatment had better smoking outcomes relative to 
Veterans who were referred to usual care VA smoking cessation clinics. 
There was no worsening of PTSD symptoms in either group. Both groups 
had small (10 percent) reductions in clinician-rated PTSD.

    - Please describe each incident referenced in your above statement 
where VA is able to demonstrate ``the direct impact'' of the mental 
health care VA provides on the subsequent mental health of the veterans 
who access that care.
VA Response:
    As part of its strong commitment toward providing high quality 
mental health care, VHA has been working to nationally disseminate and 
implement specific evidence-based psychotherapies (EBP) for PTSD and 
other mental and behavioral health conditions. As part of this effort 
to make these treatments widely available to Veterans, VHA has 
implemented competency-based staff training programs in PE therapy and 
CPT for PTSD, as well as training programs in EBPs for other 
conditions. Both PE and CPT are recommended in the VA/Department of 
Defense Clinical Practice Guideline for PTSD at the highest level, 
indicating ``a strong recommendation that the intervention is always 
indicated and acceptable.'' As of March 1, 2013, VHA had provided 
training in PE and/or CPT to more than 4,700 staff. Program evaluation 
results indicate that the implementation of PE and CPT by newly-trained 
staff has resulted in significant positive patient outcomes, with 
average reductions of approximately 20 points on the PTSD checklist 
(Chard, Ricksecker, Healy, Karlin, & Resick, 2012; Eftekhari, Ruzek, 
Crowley, Rosen, Greenbaum, and Karlin, 2012). Program evaluation 
results associated with the implementation of EBPs for other 
conditions, including Cognitive Behavioral Therapy and Acceptance and 
Commitment Therapy for depression and Cognitive Behavioral Therapy for 
insomnia, indicate large overall reductions in symptoms and 
improvements in quality of life among Veterans (Karlin et al., 2012, in 
press; Karlin, Trockel, Taylor, Gimeno, and Manber, in press).
                               References
    Chard, K. M., Ricksecker, E. G., Healy, E., Karlin, B. E., and 
Resick, P. A. (2012). Dissemination and experience with Cognitive 
Processing Therapy. Journal of Rehabilitation Research and Development, 
49, 667-678.

    Eftekhari, A., Ruzek, J. I., Crowley, J., Rosen, C., Greenbaum, M. 
A., and Karlin, B. E. (2012). Effectiveness of national implementation 
of Prolonged Exposure Therapy in VA care. Manuscript submitted for 
publication.

    Karlin, B. E., Brown, G. B., Trockel, M., Cunning, D., Zeiss, A. 
M., and Taylor, C. B. (2012). National dissemination of Cognitive 
Behavioral Therapy for depression in the Department of Veterans Affairs 
health care system: Therapist and patient-level outcomes. Journal of 
Consulting and Clinical Psychology, 80, 707-718.

    Karlin, B. E., Trockel, M. Taylor, C. B., Gimeno, J., and Manber, 
R. (in press). National dissemination of Cognitive Behavioral Therapy 
for insomnia in Veterans: Clinician and patient-level outcomes. Journal 
of Consulting and Clinical Psychology.

    Karlin, B. E., Walser, R. D., Yesavage, J., Zhang, A., Trockel, M., 
and Taylor, C. B. (in press). Effectiveness of Acceptance and 
Commitment Therapy for depression: Comparison among older and younger 
veterans. Aging and Mental Health.

    4. In response to my question regarding how the Committee can 
assist VA in providing quality and timely mental health care services 
to veteran patients, you stated that the Committee may help in: (1) 
facilitating interactions between VA and community health centers; (2) 
helping VA interact better with private sector providers; and, (3) 
addressing the shortage of psychiatrists.
    Please expand on how you believe the Committee could be of 
assistance to the Department in each of the three areas listed above.
VA Response:
    VA appreciates the on-going support of the Committee for its 
mission of providing quality and timely mental health care to Veterans. 
Regarding interactions between VA and community health centers and 
interactions between VA and private sector providers, expanding 
opportunities in both areas would benefit from improved information 
technology (IT) capabilities. On-going support for graduate medical 
education and training in psychiatry is important to continue.
    5. In response to my question regarding how VA has been able to 
hire increased numbers of mental health providers, you stated that, 
``[o]f all of the professionals in mental health, the most difficult 
problem we are having is recruiting psychiatrists, and we have barely 
been able to recruit half of the new ones that we said we wanted to do, 
and that it is in spite of raising the salary quite substantially, 
providing incentives for recruitment, bonuses, etc.''
    Please provide further details on the salary raises, recruitment 
incentives, bonuses, and any and all other actions VA has taken in an 
effort to recruit and retain psychiatrists.
    Please describe any and all actions beyond the ones referenced 
above that VA has taken or is considering taking to alleviate the 
difficulties VA has experienced recruiting psychiatrists (i.e. 
undertaking additional recruitment and retention incentives, increasing 
partnerships with non-VA resources, recruiting increased numbers of 
other mental health professionals, etc.).
VA Response:
    VHA diligently uses the 3Rs (Recruitment, Relocation, Retention) to 
recruit and retain psychiatrists, as well as providing competitive 
salaries.
    These are salary data for the psychiatrist (occupational series = 
602 and assignment code = 31) at 5 points in time, presented as the 
mean, minimum, and maximum at the end of each calendar year plus March 
2012:


----------------------------------------------------------------------------------------------------------------
              PSYCHIATRIST SALARY                 12/31/2009   12/31/2010   12/31/2011   3/31/2012    12/31/2012
----------------------------------------------------------------------------------------------------------------
MEAN                                                 175000       180487       182436       182991       186884
----------------------------------------------------------------------------------------------------------------
MIN                                                  119000       124123       128117       129000       117589
----------------------------------------------------------------------------------------------------------------
MAX                                                  277721       292987       250107       286848       286848
----------------------------------------------------------------------------------------------------------------

    From 2009 to 2012 the psychiatrist average salary increased by 
$11,884 or
    6.3 percent, the minimum salary dropped by $1,411 or 1.2 percent, 
and the maximum salary increased by $9,127 or 3.2 percent.
    From March 31, 2012 to December 31, 2012, the psychiatrists' 
average salary increased by $3,893 or 2 percent, the minimum salary 
dropped by $11,411 or 9.7 percent, and the maximum salary stayed 
steady.
    These are the incentives the psychiatrist (occupational series = 
602 and assignment code = 31) from the nature of action file (codes = 
815, 816 and 827) for the 3Rs:


----------------------------------------------------------------------------------------------------------------
                                                                                                     Grand Total
       Time Period of Incentives Paid to Psychiatrists        Recruitment   Relocation   Retention       3Rs
----------------------------------------------------------------------------------------------------------------
March 2012 - December 2012                                    $1,677,722     $503,674   $1,219,001   $3,400,397
----------------------------------------------------------------------------------------------------------------
CY 2011                                                       $1,240,674     $332,752   $1,581,375   $3,154,801
----------------------------------------------------------------------------------------------------------------
CY 2012                                                       $1,963,484     $543,174   $1,667,961   $4,174,619
----------------------------------------------------------------------------------------------------------------

    From March 2012 to December 2012, VHA paid $3,400,397 in 3R 
incentives to psychiatrists. In Calendar Year (CY) 2011, VHA paid 
$3,154,801 in 3R incentives. In CY 2012, VHA paid $4,174,619 in 3R 
incentives. This is an increase of $1,019,818 in 3R incentives, over a 
single calendar year for this occupation.
    VHA has implemented a robust and aggressive recruitment and 
marketing strategy creating national awareness for the mental health 
hiring initiative. Our practice opportunities were highlighted at 11 
national and regional clinical conferences specifically targeting 
psychiatrists and other mental health professionals. VHA requested that 
its national recruiters recruit 170 psychiatrists for critical mental 
health positions. They successfully recruited 166 psychiatrists against 
that initial tasking. As a result of this success, VHA National 
Recruiters have expanded their efforts with medical centers to 
aggressively recruit the remaining psychiatrist vacancies. From March 
2012 through June 2013, VHA has hired 403 psychiatrists.
    Significant marketing milestones include national TV recruitment 
commercials and public service announcements, 16 online campaigns, 15 
direct mail campaigns (to include e-newsletters), 11 print advertising 
campaigns, and an integrated social media plan on Facebook and Twitter. 
We have established committed non-VA partnerships with 85 mental health 
associations including American Psychological Association, 25 
universities, and the National Rural Recruitment and Retention Network; 
while continuing ongoing collaborative engagement with Veterans Service 
Integrated Networks (VISN), program offices, and field public affairs 
offices. Finally, we continue to adapt our strategy as needed, most 
recently by implementing a Web form application feature on 
www.vacareers.va.gov/mental-health/. Since finalizing the form on 
February 26, 2013, we have processed over 1,000 online inquiries--
highlighting the tremendous interest from mental health practitioners.
Detailed Milestones in Effort to Hire Mental Health Professions:
      VHA National Recruiters staffed booths at multiple mental 
health professional association meetings nationwide from May to 
November 2012 to collect contact information for candidates interested 
in VHA mental health careers. Events included: American Psychiatric 
Association, American Psychiatric Nurses Association, US Public Health 
Service Scientific Symposium, VA for Veterans, Greil Mental Health 
Hospital job fair, Career MD (multiple regions), NC Psychiatric 
Association, International Association for Traumatic Stress Study, and 
US Psychiatric and Mental Health Congress.
      Print marketing templates targeted to Mental Health 
available to facilities on May 30, 2012.
      VISN, Program Office, and field Public Affairs Officers 
were all briefed on the Mental Health Initiative.
      VA Careers website updated to spotlight Mental Health 
positions launched on May 18, 2012. Refresh of Mental Health banner on 
VAcareers.va.gov.
      Revised VHA Mental Health Hiring Initiative Poster 
approved in collaboration with Office of Mental Health and uploaded on 
AdCreator in VHA Recruiter Toolkit online for use in various sizes that 
can be easily customized for local recruitment events to support the 
initiative.
      Mental Health Public Service Announcement featuring VA 
Employee/ Olympic medalist Natalie Dell on VA YouTube. Distribution of 
video nationally with hard copies to 200 media stations and digital 
copies to 800 media outlets on October 1, 2012. Airings began on 
October 10, 2012. Promotion on www.VAcareers.va.gov also went live 
October 10, 2012. Reported as showing over 3800 times for a value 
exceeding $1 million in free television advertising. This is currently 
11 times the return on investment.
      Mental Health Marketing Campaign has launched with 
updates to www.VAcareers.va.gov making contact more readily accessible. 
These efforts have already yielded more than 200 new leads in February 
and March 2013. We are now targeting our efforts to the hard-to-fill 
psychiatrists and PhD psychologists with leads assigned to VISN 
Recruiters for follow-up. Enhanced Mental Health social media plan has 
begun on Facebook and Twitter with record reach to over 68,000 
prospects. Twitter #WorkatVA Launch: A twitter chat occurred on March 
21, 2013, targeting Mental Health providers. VHA has promoted the event 
as well.
      VHA remains an ongoing partner with National Rural 
Recruitment and Retention Network.
      TV Recruitment Commercial has been awarded. Kickoff 
meeting was conducted February 11, 2013. Existing content was aired 
beginning the second week of March. Additional recruitment commercials 
and public services announcements targeting health care providers will 
be aired beginning in July to increase hiring and to increase hiring 
awareness for VA hard-to-fill occupations nationwide.
      Website Updates: We are developing a mockup of a material 
download center that we will include on the VA Careers mental health 
site. We feel that a designated download center on the mental health 
hiring page will be the best way to ensure that our materials are 
readily available to our target audience.
      VHA's Workforce Management & Consulting Office (WMC) has 
been actively working with the Office of Human Resource Management 
(OHRM) to develop clear objectives for a Healthcare Recruitment 
contract with a private sector search firm. OHRM has contacts with the 
Office of Personnel Management (OPM) and the capability to establish 
task orders against OPM contracts. Discussion with OPM regarding VA's 
use of OPM contracts is ongoing. Since March 2012, the VHA National 
Recruiters have successfully recruited 205 psychiatrists including the 
initial 170 positions described above. Recruiters continue to actively 
pursue candidates nationwide. When combined with the efforts of HR 
staff nationwide, VHA has hired 403 psychiatrists since March 2012.
      WMC continues to collaborate with the VHA Office of 
Mental Health to market to relevant mental health provider associations 
and recruitment events in FY 2013 as part of the Mental Health 
marketing contract with partners Reingold and TMP Government.
Targeted Paid Media:
      Psych News - quarter page, full-color print ad in the 
June 15, 2012 issue (40,000+ circulation)
      Psychiatric Times - quarter page, full-color print ad in 
the June 2012 issue (40,000+ circulation)
      Targeted email blast to 23,241 Psychiatry members of the 
American Medical Association launched June 13, 2012
      Psychiatric Times Career Opportunities eNewsletter 
sponsorship reaching 65,000 Psychiatry opt-in subscribers - June 2012 
issue
      American Journal of Psychiatry eToc sponsorship reaching 
30,000+ APA members - June 2012 issue
      American Psychological Association (APA) also published 
the following at no cost for VA:
    -A lead news story in APA Access, APA's all member e-newsletter
    -Placed the provided VA banner ad in APA Access
    -Published a lead news story in PracticeUpdate, the e-newsletter of 
the APA Practice Organization
Targeted Online Banner Advertising:
      USAJobs Spotlight (received over 65,000 click-throughs to 
VACareers)
      AMHCA (American Mental Health Counselors Association)
      NASW (National Association of Social Workers) through 
June 2012
      SocialWorkToday.com
      American Psychiatric Association
      American Counseling Association
      Negotiated free 4-week banner run with HealtheCareers on 
their Mental Health Specialty site
      VA was November's featured Employer on National Rural 
Recruitment and Retention Network (tie-in to Veterans Day)
      Eleven website banner advertisements through Joining 
Forces partnership across their networks

    6. In response to a question from Ranking Member Michaud regarding 
Section 3 of the Executive Order on Improving Access to Mental Health 
Servicemembers, Veterans, and Their Families, you stated that, ``...15 
pilots sites were selected ...based upon the desire of the local 
network to participate, our hospital to participate, and a need 
...identified often by how rural the areas were. There is one urban 
center where we are doing this in Atlanta to get a feel for what they 
might be like, because there are many, many community mental health 
clinics in the Atlanta area.'' You further stated that, ``[w]e think 
that this is...going to be a viable alternative in the future to us 
cooperating in the community with providing care in these again remote 
rural areas.''
    Please name the location of each of the 15 selected pilot sites.
VA Response:
    As of May 31, 2013, the Department of Veterans Affairs (VA) has 
established pilot projects with 24 community-based mental health and 
substance abuse providers across nine states and seven Veterans 
Integrated Service Networks (VISNs). The twenty-four pilots have been 
established across Georgia, Tennessee, Wisconsin, Mississippi, Alaska, 
South Dakota, Nebraska, Indiana and Iowa. Pilot projects are varied and 
may include provisions for inpatient, residential, and outpatient 
mental health and substance abuse services. Sites may include 
capabilities for tele-mental health, staff sharing, and space 
utilization arrangements to allow VA providers to provide services 
directly in communities that are distant from a VA facility. The pilot 
project sites were established based upon community provider available 
capacity and wait times, community treatment methodologies available, 
Veteran acceptance of external care, location of care with respect to 
the Veteran population, and mental health needs in specific areas.

                           MAY 31 PILOTS FOR VA COLLABORATION WITH COMMUNITY PROVIDERS
----------------------------------------------------------------------------------------------------------------
                       Geographic Location          VISN                VAMC               Community Provider
----------------------------------------------------------------------------------------------------------------
           1             Griffin, Georgia              7               Atlanta VAMC          McIntosh Trail Community
                                                                                             Service Board (CSB)
----------------------------------------------------------------------------------------------------------------
           2        Flowery Branch, Georgia            7               Atlanta VAMC                   Avita Community Partners
----------------------------------------------------------------------------------------------------------------
           3             Atlanta, Georgia              7               Atlanta VAMC     Peachford Behavioral
                                                                                               Health System
----------------------------------------------------------------------------------------------------------------
           4             Atlanta, Georgia              7               Atlanta VAMC                  DeKalb Community Service
                                                                                                     Board (CSB)
----------------------------------------------------------------------------------------------------------------
           5              Canton, Georgia              7               Atlanta VAMC          Highland Rivers
                                                                                                            Community Service Board
                                                                                                           (CSB)
----------------------------------------------------------------------------------------------------------------
           6                             Lawrenceville,7Georgia        Atlanta VAMC        View Point Health
----------------------------------------------------------------------------------------------------------------
           7           Newport, Tennessee              9      James H. Quillen VAMC,                        Cherokee Health Systems
                                                                 Mountain Home, TN
----------------------------------------------------------------------------------------------------------------
           8        Mountain City, Tennessee           9      James H. Quillen VAMC,         Frontier Health
                                                                 Mountain Home, TN
----------------------------------------------------------------------------------------------------------------
           9             Bedford, Indiana             11      Richard L. Roudebush        Affiliated Service
                                                                               VAMC, IndProviders of Indiana,
                                                                                                Inc. (ASPIN)
----------------------------------------------------------------------------------------------------------------
          10            Columbus, Indiana             11      Richard L. Roudebush        Affiliated Service
                                                                               VAMC, IndProviders of Indiana,
                                                                                                Inc. (ASPIN)
----------------------------------------------------------------------------------------------------------------
          11              Kokomo, Indiana             11      Richard L. Roudebush        Affiliated Service
                                                                               VAMC, IndProviders of Indiana,
                                                                                                Inc. (ASPIN)
----------------------------------------------------------------------------------------------------------------
          12           Cashton, Wisconsin             12                 Tomah VAMC     Scenic Bluffs Health
                                                                                                            Center
----------------------------------------------------------------------------------------------------------------
          13              Bolivar County,             16      G. V. (Sonny) Montgomery                Delta Community Mental
                              Mississippi                                      VAMC, JacksHealth Services (DCMHS)
----------------------------------------------------------------------------------------------------------------
          14            Gulfport/ Coastal             16                  VA Gulf Coast Veterans       Gulf Coast Community
                              Mississippi                                  Health Care System,Mental Health Clinic
                                                                        Biloxi, MS
----------------------------------------------------------------------------------------------------------------
          15             Wrangall, Alaska             20      Alaska VA Healthcare            Alaska Island Community
                                                                            System              Services (AICS)
----------------------------------------------------------------------------------------------------------------
          16          Southeastern Alaska             20      Alaska VA Healthcare         South East Alaska
                                                                            System           Regional Health
                                                                                                            Consortium (SEARHC)
                                                                                           Behavioral Health
                                                                                                  Department
----------------------------------------------------------------------------------------------------------------
          17          Huron, South Dakota             23      Sioux Falls VA Health                         Community Counseling
                                                                                  Care System       Services
----------------------------------------------------------------------------------------------------------------
          18        Sioux Falls, South Dakota         23      Sioux Falls VA Health     Southeastern Behavioral
                                                                                  Care System        Health Care
----------------------------------------------------------------------------------------------------------------
          19        Mitchell, South Dakota            23      Sioux Falls VA Health                  Dakota Counseling
                                                                                  Care System      Institute
----------------------------------------------------------------------------------------------------------------
          20           Cedar Rapids, Iowa             23                     Iowa City VA Health Care  Abbe Center for
                                                                            System                          Community Mental Health
----------------------------------------------------------------------------------------------------------------
          21             Des Moines, Iowa             23                          Central Iowa VEyerly Ball Community
                                                                                  Care System Mental Health Center
----------------------------------------------------------------------------------------------------------------
          22              Iowa City, Iowa             23                     Iowa City VA Health Care       Community Mental Health
                                                                            System                          Center for Mid-Eastern
                                                                                                        Iowa
----------------------------------------------------------------------------------------------------------------
          23              Omaha, Nebraska             23      VA Nebraska-Western Iowa            One World Community
                                                                           Health Care System        Health Center
----------------------------------------------------------------------------------------------------------------
          24              Omaha, Nebraska             23      VA Nebraska-Western Iowa                      Charles Drew Health
                                                                           Health Care System               Center
----------------------------------------------------------------------------------------------------------------

    Please describe, in detail, the criteria the Department used to 
choose each of the sites named above.
VA Response:
    To determine our top priorities for collaboration, VA assessed 
recruitment success and difficulties as well as access to care issues 
(performance measure information), such as wait times for appointments 
and geographic distances to medical centers and/or Community-Based 
Outpatient Clinics (CBOC). These factors were used as VA developed its 
first round of pilot programs for community partnerships. Challenges in 
recruitment vary across VHA due to the differences among VHA 
facilities, patient need, and the local availability of mental health 
professionals. Additionally, when developing the pilot programs VHA 
considered not only community provider available capacity and wait 
times, but treatment methodologies, Veteran acceptance of external 
care, location of care with respect to the Veteran population, and 
mental health needs in specific areas.
    -Please expand on your statement above that enhanced partnerships 
between VA and community partners is going to be a ``viable 
alternative'' to ``cooperating in the community,'' to include what you 
see these partnerships as an alternative to and whether or not you see 
them as an asset in rural areas only or, potentially, in urban 
communities as well and why.
VA Response:
    These partnerships are being explored as an alternative to 
traditional care defined as administered solely in a VA medical 
facility setting. By utilizing the community partners, not only will 
care be delivered closer to Veterans but potentially in a more familiar 
and comfortable setting within the Veteran's own community. Bringing 
care to a closer, familiar setting has been a successful model rolled 
out in other areas of VA including: campus outreach Vet Centers, and 
previous mental health programs partnership in particular the North 
Shore-Long Island Jewish Health System. Additional care modalities are 
also being explored through these pilot programs to determine their 
feasibility as alternative methods of delivering care. Telemental 
health will be evaluated at a number of sites and in various 
representations through the pilots. Some pilots will include video 
equipment being placed in community centers, with primary mental health 
care provided by a clinician at the supporting VAMC. The community 
provider will assist with administrative and crisis support. This will 
be a closely monitored collaborative approach to the Veterans' 
recovery.
    Pilot programs are being explored in both rural and urban 
communities. A shortage of providers is not limited to rural areas, and 
returning Veterans will go back to all geographic areas. It is 
important to determine the validity of community partnerships in both 
settings to give all Veterans the opportunity for the quality care in 
the setting they desire. Urban pilots may face their own set of 
challenges. For example, urban pilots may be located in larger, busier, 
louder areas that may require a different model of collaboration and 
oversight. In one urban pilot, VA is placing liaisons in the community 
centers to assist in Veteran-centric issues and follow up.

    7. In response to a question from Ranking Member Michaud regarding 
veteran suicide data, Dr. Janet Kemp, the Director of VA's Suicide 
Prevention and Community Engagement Program, stated that, ``[t)here 
[are] a couple of states that we are still working with over privacy 
issues and how we are going to share data and I run confident that we 
will get those soon.''

    Please name the states referenced above.

    Please describe any and all barriers, including privacy issues, to 
the states referenced above providing VA with the requested data on 
veteran suicide rates.

    When does the Department expect that complete veteran suicide rate 
data will be received from all 50 states?
VA Response:
    We are continuing to receive information from the states. We have 
attached the latest worksheet we are using to collect this information. 
There are concerns expressed from the states concerning how we will use 
the information, how we will protect the privacy of the people listed 
in their data bases, and if the information can legally be sent to us. 
Over time, VA has been able to resolve these issues with each State. 
See the attached sheet with the information as of March 7th, which is 
the latest available. The States with ``R'' - requested but not 
received are the States we are currently still working with. South 
Carolina has refused the initial request but is currently processing a 
second request which we anticipate will also be denied.


                                    Updated State Data Availability (March 7)
----------------------------------------------------------------------------------------------------------------
 State/
  Area     1999    2000    2001    2002    2003    2004    2005    2006    2007    2008    2009    2010    2011
----------------------------------------------------------------------------------------------------------------
Alabama     I       I       I       I       I       I       I       I       I       I       I       I       P
----------------------------------------------------------------------------------------------------------------
Alaska      I       I       I       I       I       I       I       I       I       I       I       I       P
----------------------------------------------------------------------------------------------------------------
American    R       R       R       R       R       R       R       R       R       R       R       R       R
 Samoa
----------------------------------------------------------------------------------------------------------------
Arizona     R       R       R       R       R       R       R       R       R       R       R       R       R
----------------------------------------------------------------------------------------------------------------
Arkansas    A       A       A       A       A       A       A       A       A       A       A       A       A
----------------------------------------------------------------------------------------------------------------
Californ    P       P       P       P       P       P       P       P       P       P       P       P       P
    ia
----------------------------------------------------------------------------------------------------------------
Commonwe    R       R       R       R       R       R       R       R       R       R       R       R       R
 alth N.
 Mariana
 Islands
----------------------------------------------------------------------------------------------------------------
Colorado    A       A       A       A       A       A       A       A       A       A       A       A       P
----------------------------------------------------------------------------------------------------------------
Connecti    R       R       A       A       A       A       A       A       A       A       A       R       R
   cut
----------------------------------------------------------------------------------------------------------------
Delaware    P       P       P       P       P       P       P       P       P       P       P       P       P
----------------------------------------------------------------------------------------------------------------
Florida     I       I       I       I       I       I       I       I       I       I       I       I       I
----------------------------------------------------------------------------------------------------------------
Georgia     P       P       P       P       P       I       I       I       I       I       I       P       P
----------------------------------------------------------------------------------------------------------------
 Guam       R       R       R       R       R       R       R       R       R       R       R       R       R
----------------------------------------------------------------------------------------------------------------
Hawaii      A       A       A       A       A       A       A       A       A       A       A       A       P
----------------------------------------------------------------------------------------------------------------
Idaho       I       I       I       I       I       I       I       I       I       I       I       I       A
----------------------------------------------------------------------------------------------------------------
Illinois    R       R       R       R       R       R       R       R       R       R       R       R       R
----------------------------------------------------------------------------------------------------------------
Indiana     R       R       R       R       R       R       R       R       R       R       R       R       R
----------------------------------------------------------------------------------------------------------------
 Iowa       A       A       A       A       A       A       A       A       A       A       A       A       A
----------------------------------------------------------------------------------------------------------------
Kansas      I       I       I       I       I       I       I       I       I       I       I       I       P
----------------------------------------------------------------------------------------------------------------
Kentucky    R       R       R       R       R       R       R       R       R       R       R       R       R
----------------------------------------------------------------------------------------------------------------
Louisian    A       A       A       A       A       A       A       A       A       A       A       A       P
     a
----------------------------------------------------------------------------------------------------------------
Maine       I       I       I       I       I       I       I       I       I       I       I       P       P
----------------------------------------------------------------------------------------------------------------
Maryland    R       R       R       R       R       R       R       R       R       R       R       R       R
----------------------------------------------------------------------------------------------------------------
Massachu    I       I       I       I       I       I       I       I       I       I       I       P       P
 setts
----------------------------------------------------------------------------------------------------------------
Michigan    I       I       I       I       I       I       I       I       I       I       I       I       P
----------------------------------------------------------------------------------------------------------------
Minnesot    I       I       I       I       I       I       I       I       I       I       I       I       P
     a
----------------------------------------------------------------------------------------------------------------
Mississi    P       P       P       P       P       P       P       P       P       P       P       P       P
   ppi
----------------------------------------------------------------------------------------------------------------
Missouri    I       I       I       I       I       I       I       I       I       I       I       P       P
----------------------------------------------------------------------------------------------------------------
Montana     A       A       A       A       A       A       A       A       A       A       A       A       P
----------------------------------------------------------------------------------------------------------------
Nebraska    I       I       I       I       I       I       I       I       I       I       I       I       P
----------------------------------------------------------------------------------------------------------------
Nevada      I       I       I       I       I       I       I       I       I       I       I       I       P
----------------------------------------------------------------------------------------------------------------
  New       A       A       A       A       A       A       A       A       A       A       A       A       A
 Hampshi
    re
----------------------------------------------------------------------------------------------------------------
  New       I       I       I       I       I       I       I       I       I       I       I       I       P
 Jersey
----------------------------------------------------------------------------------------------------------------
  New       P       P       P       P       P       P       P       P       P       P       P       P       P
 Mexico
----------------------------------------------------------------------------------------------------------------
New York    I       I       I       I       I       I       I       I       I       I       I       I       P
----------------------------------------------------------------------------------------------------------------
New York    I       I       I       I       I       I       I       I       I       I       I       I       P
  City
----------------------------------------------------------------------------------------------------------------
North       I       I       I       I       I       I       I       I       I       I       I       I       I
 Carolin
     a
----------------------------------------------------------------------------------------------------------------
North       A       A       A       A       A       A       A       A       A       A       A       A       A
 Dakota
----------------------------------------------------------------------------------------------------------------
 Ohio       A       A       A       A       A       A       A       A       A       A       A       A       A
----------------------------------------------------------------------------------------------------------------
Oklahoma    I       I       I       I       I       I       I       I       I       I       I       A       P
----------------------------------------------------------------------------------------------------------------
Oregon      A       A       A       A       A       A       A       A       A       A       A       A       P
----------------------------------------------------------------------------------------------------------------
Pennsylv    A       A       A       A       A       A       A       A       A       A       A       A       P
  ania
----------------------------------------------------------------------------------------------------------------
Philippi    R       R       R       R       R       R       R       R       R       R       R       R       R
   nes
----------------------------------------------------------------------------------------------------------------
Puerto      R       R       R       R       R       R       R       R       R       R       R       R       R
  Rico
----------------------------------------------------------------------------------------------------------------
Rhode       A       A       A       A       A       A       A       A       A       A       A       A       A
 Island
----------------------------------------------------------------------------------------------------------------
South        C       C       C       C       C       C       C       C       C       C       C       C       C
 Carolin
     a
----------------------------------------------------------------------------------------------------------------
South       P       P       P       P       P       P       P       P       P       P       P       P       P
 Dakota
----------------------------------------------------------------------------------------------------------------
State       R       R       R       R       R       R       R       R       R       R       R       R       R
 Departm
   ent
----------------------------------------------------------------------------------------------------------------
Tennesse    A       A       A       A       A       A       A       A       A       A       A       A       A
     e
----------------------------------------------------------------------------------------------------------------
Texas       A       A       A       A       A       A       A       A       A       A       A       A       A
----------------------------------------------------------------------------------------------------------------
 Utah       A       A       A       A       A       A       A       A       A       A       A       A       A
----------------------------------------------------------------------------------------------------------------
Vermont     I       I       I       I       I       I       I       I       I       I       I       P       P
----------------------------------------------------------------------------------------------------------------
Virgin      R       R       R       R       R       R       R       R       R       R       R       R       R
 Islands
----------------------------------------------------------------------------------------------------------------
Virginia    I       I       I       I       I       I       I       I       I       I       I       I       I
----------------------------------------------------------------------------------------------------------------
Washingt    I       I       I       I       I       I       I       I       I       I       I       I       I
    on
----------------------------------------------------------------------------------------------------------------
Washingt    P       P       P       P       P       P       P       P       P       P       P       P       P
 on D.C.
----------------------------------------------------------------------------------------------------------------
 West       I       I       I       I       I       I       I       I       I       I       I       I       P
 Virgini
     a
----------------------------------------------------------------------------------------------------------------
Wisconsi    A       A       A       A       A       A       A       A       A       A       A       A       P
     n
----------------------------------------------------------------------------------------------------------------
Wyoming     A       A       A       A       A       A       A       A       A       A       A       A       A
----------------------------------------------------------------------------------------------------------------
I = data included in initial report,
A = available for future analysis,
P = pending state approval/processing,
R = requested but not received,
C = being processed

    8. In response to a question from Ranking Member Michaud regarding 
performance requirements for VA mental health providers, you stated 
that, ``....it is important to have performance measures, and I think 
it is incumbent upon us as the leaders to make sure that there is the 
proper balance between time available to do clinical care, and the 
necessity of meeting performance measures.''

    Please name each of the current performance measures (including any 
and all clinical reminders) currently in place for VA mental health 
care providers, to include the justification for using each measure and 
how long it has been in place.
VA Response:
    There are 4 mental health performance measures in VHA's FY 2013 
Performance Plan:

      Percent of new mental health appointments completed 
within 14 days of the create date for the appointment - New as a 
performance measure in FY 2013.
      Percent of established mental health patients with a 
scheduled appointment within 14 days of the desired date for the 
appointment - New as a performance measure in FY 2013.
      Percent of patients discharged from an inpatient mental 
health unit who receive outpatient mental health follow-up within seven 
days of discharge - Started in FY 2009.
      Percent of targeted population of OEF/OIF/OND Veterans 
with a primary diagnosis of PTSD who receive a minimum of eight 
psychotherapy sessions within a 14-week period - Started in FY 2012.

    Clinical reminders are not considered performance measures. The 
clinical reminder system helps providers deliver higher quality care to 
patients for both preventive health care and management of chronic 
conditions, and helps ensure that timely clinical interventions are 
initiated. Reminders assist clinical decision-making and also improve 
documentation and follow up, by allowing providers to easily view when 
certain tests or evaluations were performed and to track and document 
when care has been delivered. They can direct providers to perform 
certain tests or other evaluations that will enhance the quality of 
care for specific conditions. The clinicians can then respond to the 
reminders by placing relevant orders or recording clinical activities 
on patients' progress notes.
    Clinical reminders may be used for both clinical and administrative 
purposes. However, the primary goal is to provide relevant information 
to providers at the point of care, for improving care for Veterans. 
Clinical reminders support clinicians by providing pertinent data for 
clinical decision-making, reducing duplicate documenting activities, 
assisting in targeting patients with particular diagnoses and 
procedures or site-defined criteria, and assisting in compliance with 
VHA performance measures and with health promotion and disease 
prevention guidelines.
    While some clinical reminders are national, facilities/VISNs also 
develop clinical specific reminders to support quality improvement 
efforts. Responsibility for completing clinical reminders is also left 
to the discretion of facilities/ VISNs.
    The national mental health clinical reminders, deployed throughout 
the system, include:

    Primary care screens: Primary care providers complete most of these 
reminders but are supported by mental health. These reminders are 
conducted annually to ensure all primary care patients are assessed for 
common mental health diagnoses. If the screen is positive for the first 
three measures below, additional follow up is required. The Military 
Sexual Trauma (MST) screen is completed one time to assess for a 
history of MST during military service. All Veterans who respond 
positively to the screen are offered a referral for mental health 
services. VA medical centers are expected to refer the Veteran to 
appropriate services in the event the Veteran tests positive from the 
homeless screener. If homelessness screen is positive for actual 
homelessness, the Veteran is immediately referred to the local VA 
facility homeless services team and if the homelessness screen is 
positive for being at risk for homelessness, the Veteran is referred to 
social work services.

      Alcohol Use Screen
      I  Alcohol Use Positive follow-up evaluation
      Depression Screen
      I  Depression Positive follow-up evaluation
      PTSD Screen
      I  PTSD Positive follow-up evaluation
      Military Sexual Trauma (MST) Screening
      Homelessness Screening

Specialty mental health reminders:
      PTSD Reassessment - to support administration of the PTSD 
checklist for patients receiving treatment for PTSD
      Mental health high risk no show follow up - to support 
tracking high risk patients that have missed an appointment

    Please describe how you, as the Under Secretary for Health, ensure 
a ``proper balance'' between measuring provider performance and 
ensuring sufficient clinical care.
VA Response:
    VHA's performance measurement system was developed to improve 
quality of care and to support strategic planning. The key aspects of 
the Performance Measurement Program are to:

      Demonstrate an integrated health system consistently 
using the best scientific evidence in clinical practice to reliably and 
efficiently achieve the highest quality health outcomes
      Set national benchmarks for the quality of preventive and 
therapeutic healthcare services that exceed private sector performance
      Facilitate provision of care to a larger Veteran 
population without increasing health care expenditures
      Align resources to support strategic initiatives

    While strategic directions are codified by VHA leadership, 
performance measures typically require review and input from front line 
providers, subject matter experts, external stakeholders, health care 
policy experts, regulators, and others as they are developed and 
implemented. In the past, these measures frequently were also used as 
part of employee performance plans to support implementation. In the 
last few years, VHA has been reducing its use of the performance 
measurement system in reviewing individual performance and has sought 
to achieve system compliance with the measures without inclusion in 
performance plans.

    9. In response to a question from Representative Runyan regarding 
the need to be proactive in addressing veterans' mental health needs, 
you discussed the need to develop close, trusting relationships between 
veteran patients and VA mental health providers. You stated that VA 
needed to focus on, ``...developing the relationships where [veteran 
patients] will tell us where there are things that may be antecedents 
to suicide that are bothering them,'' and, ``[i]t is getting the 
information, and the contact with the individual before they have the 
difficulty as you have pointed is the problem.'' In response to a 
similar question from Representative Brownley, you stated that,'' ...we 
have a newly organized task force that Dr. Kemp is chairing that is 
going to look at how we can develop a different paradigm if you will 
for the way we deliver care to people that have chronic pain, sleep 
disorders, depression, etc., the things that have the greatest impact 
on suicide.''
    How does VA foster such relationships between VA providers and 
veteran patients?
VA Response:
    Establishment of healing relationships between providers and 
Veterans is fundamental to care. This includes not only the individual 
provider but the healthcare team as a whole. Mental health providers 
are trained to reach out to Veterans and develop relationships based 
upon trust, including the ethical principles of respect for autonomy, 
beneficence, non-malfeasance, justice, and integrity. VA providers and 
Veterans jointly develop goals for treatment (VHA Strategic Plan, FY 
2013) based on Veteran preferences. The VA mental health provider is 
charged with providing a full breadth of information about mental 
health services available to assist the Veteran in collaboratively 
establishing the plan of care and ensuring that the Veteran receives 
any needed care. In VA, mental health providers are embedded in 
multiple settings including the Patient Aligned Care Team (PACT), 
Geriatric and Extended Care settings, as well as in specialty mental 
health to support both individualized outreach and coordination of 
care. The VHA Strategic Plan emphasizes personalized, proactive, 
patient-driven healthcare with the sub-goals of effective communication 
and convenient access to information, advice and support.
    What different paradigms is the taskforce referenced above looking 
at regarding the delivery of mental health care and when is that work 
expected to be complete?
VA Response:
    The VA's Mental Health Innovations Task Force is embarking on a 
groundbreaking proactive, population-based approach that is designed to 
address antecedents to suicidal behavior, by creating strategies to 
reach Veterans before they are in crisis and establishing a sustained 
relationship that connects all aspects of their life with an emphasis 
on mental health and wellbeing. This holistic approach to addressing 
suicide prevention will build on our understanding of diagnoses known 
to increase risk and effective evidence-based treatments and will 
expand our approaches to proactive strategies which are often not a 
part of our current treatment plans, moving beyond simple 
identification and treatment of specific diseases. Our goal is to focus 
on the Veteran (whole person), the community where he or she lives, and 
the inclusion of proactive health strategies and approaches to optimize 
mental health and wellbeing. This will require a culture change, which 
takes time in any organization along with a communications strategy and 
the development of tools providers can use to assist them in creating 
this climate of personalized care. The initial strategic plan for the 
taskforce includes a series of action steps with delivery dates that 
began in February 2013 and extend into 2014, and beyond that there will 
be an on-going process of implementing the lessons learned through this 
initiative.
    10) In response to a question from Representative Coffman regarding 
VA mental health care providers, you stated that, ``...this spring [we 
have] implemented our performance criteria for timeliness, the 
intention is to go out and do three things. One, look at the measures. 
Two, survey veterans as to whether or not they were- had timely access 
as well as other satisfaction related questions. And three, to survey 
the staff. Are they able to provide timely access for their patients, 
are they adequately staffed, do they have enough people to do the work 
that they are being required. So, yes, we are going to do it. And we 
will be doing that on a regular basis''
    Please provide the timeliness performance criteria referenced 
above.
VA Response:
    VHA has two measure of timeliness for mental health:

      Percent of new mental health appointments completed 
within 14 days of the create date for the appointment - new as a 
performance measure in FY 2013.
      Percent of established mental health patients with a 
scheduled appointment within 14 days of the desired date for the 
appointment - new as a performance measure in FY 2013.

    Please provide information regarding the survey of veteran patients 
referenced above, to include the number of veteran patients expected to 
be surveyed, the questions expected to be included on the survey, the 
method expected to be used to conduct the survey (i.e., in person, 
electronic, via telephone, etc.), the expected survey results, the 
expected total cost of the survey, and any and all follow-up actions 
expected to result from the survey.
VA Response:
    The Veteran survey is attached below, and VHA plans to distribute 
the survey to 10,000 Veterans. VHA is still developing the method of 
distribution; cost of distribution will be related to the actual method 
used. VHA will use the information in two ways: 1) as an overall 
measure of Veteran perceptions of care that can be trended over time; 
2) as feedback to assist individual facilities in developing action 
plans to address barriers to access perceived by Veterans at their 
sites.
          OFFICE OF MENTAL HEALTH VETERAN SATISFACTION SURVEY
    The Paperwork Reduction Act of 1995 requires us to notify you that 
this information collection is in accordance with the clearance 
requirements of section 3507 of this Act. Accordingly, we may not 
conduct or sponsor and you are not required to respond to a collection 
of information unless it displays a valid OMB number. We anticipate 
that the time expended by all individuals who complete this survey will 
average 15 minutes. This includes the time it will take to read 
information provided and gather the necessary facts to fill out the 
form. Submission of this form is voluntary and failure to respond will 
have no impact on benefits to which you may be entitled. Responses to 
the survey will be reported in aggregate form and will be anonymous.


For each item identified below, circle the number to the right that best
   fits your judgment of its occurence at your facility. Use the scale
                  above to select the frequency number
------------------------------------------------------------------------
                                   Neither
 Survey    Strongly    Disagree    Disagree   Agree   Strongly    NA or
  Item     Disagree                or Agree            Agree     Unknown
------------------------------------------------------------------------
1. I get      1           2           3        4         5        NA
 appoint
 ments
 with my
 mental
 health
 provide
  r on
 the day
 that I
 want or
 within
   two
 weeks
 of the
   day
 that I
  want
------------------------------------------------------------------------
2. I can      1           2           3        4         5        NA
 see my
 mental
 health
 provide
 r who
 prescri
 bes my
 medicat
 ions as
 frequen
 tly as
 needed
------------------------------------------------------------------------
3. If I       1           2           3        4         5        NA
 have a
 questio
 n about
    my
 psychia
  tric
 medicat
 ions, I
 can get
    in
 touch
 with a
 mental
 health
 provide
  r or
 pharmac
 ist by
 phone
 to get
    my
 questio
     n
 answere
     d
------------------------------------------------------------------------
 4. I         1           2           3        4         5        NA
 talk to
   the
 person
   who
 prescri
 bes my
 mental
 health
 medicat
 ion by
 Telemen
   tal
 health
 (V-Tel)
------------------------------------------------------------------------
 5. I         1           2           3        4         5        NA
 talk to
    my
 counsel
   or/
 therapi
 st by
 Telemen
   tal
 health
 (V-Tel)
------------------------------------------------------------------------
6. There      1           2           3        4         5        NA
   are
 problem
     s
 getting
   the
 Telemen
   tal
 health
 (V-Tel)
 equipme
 nt to
  work
------------------------------------------------------------------------
   7.         1           2           3        4         5        NA
 Mental
 health
 treatme
 nt has
  been
 helpful
 in my
  life
------------------------------------------------------------------------
8. I was      1           2           3        4         5        NA
 able to
 choose
 which
 of the
 psychot
 herapie
   s I
 wanted
 to try
 after
  good
 discuss
   ion
 with my
 mental
 health
 provide
 r about
   the
 options
------------------------------------------------------------------------
 9. I         1           2           3        4         5        NA
 believe
 it is
 necessa
 ry for
 me to
 stay in
 mental
 health
 treatme
 nt to
 keep my
 service
 connect
    ed
 disabil
   ity
------------------------------------------------------------------------
10. I         1           2           3        4         5        NA
 would
 like to
 schedul
     e
 mental
 health
 appoint
 ments
 during
 extende
 d hours
 (early
 morning
    s,
 evening
 s, or
    on
 weekend
    s)
------------------------------------------------------------------------
11. It        1           2           3        4         5        NA
 is hard
 to get
 to my
 mental
 health
 appoint
 ments
 because
    of
 transpo
 rtation
 problem
     s
------------------------------------------------------------------------
  12.         1           2           3        4         5        NA
 Parking
  is a
 problem
 at my
 facilit
     y
------------------------------------------------------------------------
13. My        1           2           3        4         5        NA
 mental
 health
 appoint
 ments
   are
 schedul
 ed by
    VA
 without
   any
 input
 from me
------------------------------------------------------------------------
14. I         1           2           3        4         5        NA
 get a
 reminde
 r call
    or
 letter
 about
    my
 mental
 health
 appoint
 ments
------------------------------------------------------------------------
15. I         1           2           3        4         5        NA
 attend
 group
 mental
 health
 treatme
 nt, and
   the
  room
 comfort
  ably
  fits
 all the
 group
 partici
 pants
------------------------------------------------------------------------
16. When      1           2           3        4         5        NA
 I have
    an
 individ
   ual
 mental
 health
 session
 with my
 provide
 r, we
 meet in
 a room
 that is
 private
------------------------------------------------------------------------
17. I         1           2           3        4         5        NA
  know
 that I
  will
 get a
  call
 back if
 I leave
     a
 message
 for my
 mental
 health
 provide
     r
------------------------------------------------------------------------
18. My        1           2           3        4         5        NA
 mental
 health
 provide
 r and I
 agree
 on how
 often I
 should
  have
 appoint
 ments
------------------------------------------------------------------------
19. I         1           2           3        4         5        NA
 can't
 see my
 mental
 health
 provide
  r as
 much as
     I
 should
 because
   the
 provide
 r does
   not
  have
 time to
 see me
------------------------------------------------------------------------
20. I am      1           2           3        4         5        NA
 comfort
 able in
   the
 waiting
  area
   for
 mental
 healthc
   are
------------------------------------------------------------------------
21. The       1           2           3        4         5        NA
 staff
 is open
 to my
 suggest
  ions
 regardi
    ng
 improve
 ments
    to
 mental
 health
 service
     s
------------------------------------------------------------------------
22. I am      1           2           3        4         5        NA
 treated
  with
 respect
   and
 kindnes
  s at
   the
 mental
 health
 program
     s
------------------------------------------------------------------------
  23.         1           2           3        4         5        NA
 During
   our
 appoint
 ments,
    my
 mental
 health
 provide
     r
 focuses
 on the
 compute
     r
 rather
  than
 engagin
 g with
 me in
 face-to-
  face
   eye
 contact
------------------------------------------------------------------------
24. I         1           2           3        4         5        NA
  know
  that
 there
   are
 mental
 health
 provide
    rs
 availab
    le
 right
    in
 Primary
  Care
------------------------------------------------------------------------
25. My        1           2           3        4         5        NA
 primary
  care
 provide
     r
 prescri
 bes my
 psychia
  tric
 medicat
 ions,
 such as
 medicin
  e to
  help
  with
 depress
 ion or
 nervous
  ness
------------------------------------------------------------------------
26. My        1           2           3        4         5        NA
 family
   has
  been
 involve
  d in
 mental
 health
 treatme
 nt with
 me as
 much as
 I would
  like
 them to
    be
 involve
     d
------------------------------------------------------------------------

WRITE IN SECTION:
    27. My Mental Health Treatment Coordinator is:

    28. The biggest problem or concern I have about Mental Health 
Treatment is:

    29. The biggest compliment or positive I have about Mental Health 
Treatment is:

    If you wish to discuss your experience, please feel free to contact 
your Mental Health Treatment Coordinator, facility Mental Health Chief, 
Local Recovery Coordinator, or other Mental Health staff.

    Please provide information regarding the survey of VA mental health 
care providers referenced above, to include the number of VA mental 
health providers expected to be surveyed, the questions expected to be 
included on the survey, the method expected to be used to conduct the 
survey (i.e., in person, electronic, via telephone, etc.), the expected 
survey results, the expected total cost of the survey, and any and all 
follow-up actions expected to result from the survey.
    When does the Department expect all three of the above actions to 
be completed?
VA Response:
    VA has completed the implementation of the new performance measures 
although we will be rolling out new processes to support the 
implementation of these measures throughout FY 2013, notably the use of 
the ``Agreed upon Date'' for documenting the desired date. VA has 
administered the Mental Health Provider Survey in September 2012 to 
collect baseline data, although additional data was collected from non-
responding facilities in January 2013. VHA will re-administer this 
survey in September 2013. VHA will implement the Veteran Survey in the 
summer 2013.
    How often does the Department expect to conduct follow-up surveys 
of veteran patients accessing VA mental health care?
VA Response:
    Annually.
    How often does VA expect to conduct follow-up surveys of VA mental 
health providers?
VA Response:
    Annually.
Department of Veterans Affairs Responses to Questions from Congressman 
                              Jeff Denham
    1. As we have heard the hearing, the conflicts in Afghanistan and 
Iraq have created extraordinary demands for care as veterans return 
from theater. For those with PTSD or other mental health issues, long 
waits for treatment can put them at risk for suicide or other 
behavioral problems.
    Has VA considered short-term solutions to address the immediate 
mental health need while it recruits and hires the staff it needs long 
term?
VA Response:
    VA has been expanding the use of technology to improve access to 
care especially in rural areas or areas where it is difficult to hire 
staff. VA has increased the use of telemental health to allow VA to use 
provider resources from areas with capacity to deliver services to 
areas that have limited provider resources. VA has expanded this 
service to begin implementation of telemental health home based care 
ensuring further improvements in accessibility. In addition, VA 
continues to develop Mobile Applications such as the PTSD Coach to 
support clinical service delivery.
    VA recognizes that not all access issues can be resolved through 
staffing. In some instances, access issues may be the result of 
inefficient care delivery processes or difficulties in implementation 
of specialty programs. VA has been conducting site visits at all of its 
health care systems to review mental health program implementation and 
to provide consultation on areas needing improvement.
    Also, VA is utilizing community providers to provide mental health 
services through the Non-VA Medical Care Program. Also, as part of the 
President's Executive Order, VA has established 15 pilot programs to 
support improving access to care. In addition, VA will continue to 
monitor access and wait times to ensure continual improvement in access 
going forward.
    2. I understand that VA has been conducting pilot programs designed 
to provide veterans with access to community-based mental health 
services in several rural communities like mine. For veterans that are 
able to get into one of these programs, they provide needed care closer 
to the veteran's home. However, I understand that use of these pilots 
by VA facilities has been very low.
    What are you doing to encourage use of these programs in rural 
communities?
VA Response:
    The first pilots, initiated under the direction of the Executive 
Order, were brought on line during the last week of February 2013. 
These pilots include a number of rural community sites. There has been 
a positive response not only from the medical center staff and the 
community partners but among the Veterans. VA management, from the 
Under Secretary of Health to network directors to center directors, has 
made this a priority to implement and oversee these pilots. By early 
inclusion of both sides of the partnership and allowing the sites the 
leeway to define their programs based on local needs, we have achieved 
early buy in from facilities and staff. To preserve the initial 
enthusiasm about these pilots regular calls are conducted not only with 
each local site but with the nationwide group to encourage information 
sharing and lessons learned. Veterans are encouraged to participate in 
a number of ways. The sites are using email and local announcements to 
ensure staff are aware of the pilot program and the potential for 
inclusion of Veterans the pilot. Veteran case files must be reviewed 
for Veterans that match the treatment types and locations being offered 
through the pilot. VA staff contact the Veteran and explain the program 
and offer the opportunity to participate. One key to working towards a 
successful outcome and continued participation by all parties will be 
continued communication and coordination between the VA, the community 
partner, and the Veteran. Community partners are also reviewing their 
case files for Veterans that may not be enrolled with the VA, and 
working with their pilot contacts at the medical centers to contact and 
enroll these Veterans.
    Are there any plans to expand these rural pilot programs, to other 
rural communities across the country?
VA Response:
    Although only 15 pilots were required in the Executive Order, as of 
May 31, 2013, the Department of Veterans Affairs (VA) has established 
pilot projects with 24 community-based mental health and substance 
abuse providers across nine states and seven Veterans Integrated 
Service Networks (VISNs). The twenty-four pilots have been established 
across Georgia, Tennessee, Wisconsin, Mississippi, Alaska, South 
Dakota, Nebraska, Indiana and Iowa. VA plans to allow these pilots to 
move forward for one year and then evaluate whether further expansion 
is recommended.
      Department of Veterans Affairs Responses to Questions from 
                     Congresswoman Jackie Walorski
    1. During the hearing, we heard how veterans are discouraged with 
long wait times in-between appointments and consequently drop out of 
treatment.
    What is VA doing to improve mental health wait times for veteran 
patients accessing VA mental health care?
VA Response:
    VA has the responsibility to meet and anticipate the needs of 
returning Veterans. VA has a multipronged strategy for improving mental 
health wait times for Veterans accessing VA mental health including:

      Hiring and staffing initiatives;
      Expansion of the use of technology;
      Quality improvement initiatives; and
      Development of community contracts.

    In FY 2012, VA began the development and implementation of a 
general outpatient mental health staffing model to provide guidance to 
VA facilities and VISNs to ensure a consistent level of mental 
staffing. To support the implementation of the model, VA initiated an 
aggressive hiring plan to hire 1,600 mental health clinicians and 300 
clerical support staff, as well as to ensure that vacancies are filled 
in a timely fashion. VA is also enhancing the training programs for 
mental health professionals over the next few years to increase the 
number of psychiatrists, psychologists, nurses, social workers, and 
pharmacists. In addition, as part of the President's Executive Order, 
VA is hiring 800 peer specialists to provide additional coverage for 
mental health treatment teams.
    VA has been expanding the use of technology to improve access to 
care especially in rural areas or areas where it is difficult to hire 
staff. VA has increased the use of telemental health to allow VA to use 
provider resources from areas with capacity to deliver services to 
areas that have limited provider resources. VA has expanded this 
service to begin implementation of telemental health home-based care 
ensuring further improvements in accessibility. In addition, VA 
continues to develop mobile applications such as the PTSD Coach to 
support clinical service delivery.
    VA recognizes that not all access issues can be resolved through 
staffing. In some instances, access issues may be the result of 
inefficient care delivery processes or difficulties in implementation 
of specialty programs. VA has been conducting site visits at all of its 
health care systems to review mental health program implementation and 
to provide consultation on areas needing improvement.
    Also, VA is utilizing community providers to provide mental health 
services through the non-VA Medical Care Program. As part of the 
President's Executive Order, VA is in the process of establishing 15 
pilot programs to support improving access to care. In addition, VA 
will continue to monitor access and wait times to ensure continual 
improvement in access going forward.

    2. How is VA working to better accommodate veterans who have 
transitioned into the civilian world and all the new responsibilities 
they must deal with while trying to seek the health care?
VA Response:
    In order to expand the number of providers available beyond 
traditional business hours, VHA released a directive on January 9, 
2013, on ``Extended Hours Access for Veterans Requiring Primary Care 
Including Women's Health and Mental Health Services at Department of 
Veterans Affairs (VA) Medical Centers and Selected Community-Based 
Outpatient Clinics.'' This increases VA's commitment to offering 
appointments during evenings or weekends. Benchmarks are currently 
being set to ensure implementation of this directive across the VA 
system.
    Integrating mental health care into primary care settings is a 
critical element of increasing the availability of mental health care 
for Veterans. VA's Primary Care-Mental Health Integration programs 
combine co-located collaborative care and care management (often by 
telephone) to support primary care providers in treating common mental 
health conditions within the primary care setting. Through the first 
quarter of FY 2013, 88 percent of VA medical centers and COBCs 
classified as large and very large have integrated behavioral health 
programs, and 6.3 percent of all primary care patients at these sites 
were directly served by these programs.
    As part of the Department of Defense (DoD)/VA Integrated Mental 
Health Strategy, VA and DoD are collaborating on the development of 
Web-based self-help resources for common issues experienced by Veterans 
after they have transitioned into the civilian world. These programs 
allow for 24-hour, anonymous, self-paced access and can be used by 
Veterans on their own or in conjunction with mental health treatment. 
In November 2012, the Moving Forward program was launched online 
(www.startmovingforward.org). Moving Forward is an educational, life-
coaching program for individuals who are having problems, but are not 
yet in need of or willing to engage in mental health treatment. The 
program is based on the principles of Problem Solving Therapy, an 
evidenced-based cognitive behavioral treatment for depression and other 
distress. The Moving Forward Web course uses highly interactive, multi-
media presentations to teach problem-solving skills through text, 
videos, exercises and games. The second course, Parenting for 
Servicemembers and Veterans, is in the final stages of development and 
will be launched in FY 2013. It is a free online course that will 
provide Military and Veteran parents with tools to help them reconnect 
with their families and build closer relationships with their children. 
Using stories from real Veteran and Military families, videos, 
interactive activities, and original curriculum developed by leading 
experts, this Web-based course is intended to help parents learn how to 
address both everyday parenting problems and family issues unique to 
their military experience.
    In addition to innovative Web-based approaches, VA and DoD are 
collaborating on mobile applications for smartphones and tablet 
computers to enhance access to mental health information and care for 
Veterans and Servicemembers. For example, VA and DoD jointly launched 
the PTSD Coach smartphone application in April 2011. As of March 1, 
2013, the PTSD Coach application has been downloaded more than 100,000 
times in 74 countries. PTSD Coach helps users track their PTSD 
symptoms, links them with public and personalized sources of support, 
provides accurate information about PTSD, and teaches helpful 
strategies for managing PTSD symptoms. PE Coach, another joint VA/DoD 
mobile application, guides and facilitates evidence-based PE treatment 
for PTSD. The application is designed to be installed onto a patient's 
personal phone, brought into therapy sessions, and used during and 
between treatment sessions. The application includes the ability to 
audio record the therapy session (as required by the treatment 
protocol) directly onto the patient's phone, removing the typical 
logistical challenges associated with audio recording in the past. The 
application also delivers text-based psychoeducational handouts as 
multi-media experiences; provides all patient homework in a digital 
format; utilizes an interactive breathing retraining tool to improve 
learning and rehearsal of the PE relaxation skill; provides clinicians 
with the ability to review compliance with PE protocol homework based 
on patient's actual use of the various components of the PE Coach 
application; integrates phone calendar functionality with the PE Coach 
application to increase the likelihood of patient recall and attendance 
of PE therapy sessions; tracks a patient's self-reported symptoms and 
subjective distress over time; and, display outcomes for convenient 
review of progress. These technological approaches are designed to 
ensure availability of mental health information and facilitate 
meaningful participation in mental health interventions in ways that 
are more convenient and accessible to the Veteran.

                                 
  Questions From: Hon. Michael Michaud, Ranking Minority Member, To: 
                     Department of Veterans Affairs
    1. As you heard in my opening statement, mental health is a 
significant problem that faces the nation, not just veterans or the VA. 
We have been told that shortages in mental health clinicians are 
affecting health care systems across the nation. I imagine that 
difficulty in finding qualified providers is most acute in the rural 
and highly rural areas.

    a. What have you done to work on a more collaborative basis with 
other Federal agencies to implement programs that will grow the numbers 
of qualified mental health providers?

    2. The President's Executive Order required VA and HHS to work 
together to establish 15 pilot projects with community based providers, 
such as community mental health clinics, health centers, substance 
abuse treatment facilities and rural health clinics.

    a. Have these pilot sites been established?

    b. Where are they located?

    c. How were the locations of the pilot sites determined?

    3. The President's Executive Order required VA to hire and train 
800 peer to peer counselors by December 31, 2013.

    a. Please provide us with an update on how many you have hired, 
where they have been placed, and a brief description of the training 
that VA will be providing to these new counselors.

    4. Considerable concern has been voiced about the lack of 
transitional services between the Department of Defense and VA, 
especially as it relates to mental health and those on active duty who 
are evidencing heightened risk of mental health issues. In testimony, 
Dr. Rudd from the first panel stated that he is convinced that the bulk 
of the problem is not a clinical one. He said we have to do a better 
job of managing those at risk, providing easy and frequent access to 
care, and convincing veterans to stay in care.

    a. What are VA and DoD doing to work together to ensure that those 
transitioning with mental health issues are not falling through the 
cracks? Are we getting communities involved early in the process?

    b. Is there something similar to a ``warm handoff'' that 
servicemembers who are severely disabled experience?

    c. If not, are we working toward that goal?

    5. It is my understanding that VA now has Memorandums of 
Understanding with all 50 States to share suicide data and that the 
Suicide Data Report recently released by VA now includes State veteran 
data which is a big step forward. However in this report many States 
are not included, which limits the report somewhat. Could you please 
tell the Committee:

    a. What States are not included in the data?

    b. What are the barriers or reasons why some States did not 
participate?

    c. Has VA reached out and made a good faith effort to get these 
States to participate?

    d. Moving forward how is VA planning to improve data collection?

    6. I understand that since March VA has an additional 1150 mental 
health clinical providers on board. I also understand that in addition 
to the new hires of 1600 clinical and 300 administrative, VA continues 
to fill existing and projected mental health vacancies within the VA 
system.

    a. What is VA's combined goal of new and existing vacancy hires?

    b. Do you have a projected number of mental health clinicians that 
will be on board and providng services to veterans?

    c. Please provide an update on the total number of additional 
mental health staff hired to-date, broken down by occupation, status 
(whether full-time, part-time, clinical, administrative, other, or a 
combination), Veterans Integrated Service Network (VISN) and veteran 
status.

    7. VA has reported that they need to substantially increase the 
number of mental health trainees exposed to VA in their training years 
by increasing the number of clinical training positions in mental 
health to include nursing, pharmacy, psychology, psychiatry, and social 
work for the 2013-14 academic year.

    a. How is VA progressing with this increase in training positions?

    b. What are the difficulties VA encounters when trying to recruit 
residents who have not been exposed to VA?

    c. Please provide a breakdown by discipline and number of positions 
of the increase.

    d. Have these positions been allocated throughout the VA health 
care system?

    8. There is concern in the community that veterans may not be 
getting the kind of mental health care they need or the appropriate 
intensity of care. Wounded Warrior Project conducted a survey of over 
13,000 alumni, over a third of respondents reported difficulties in 
accessing effective mental health care. Reasons given were inconsistent 
treatments (e.g. canceled appointments, switch of providers, lapses in 
between sessions, etc..) and not being comfortable with existing 
resources.

    a. Please provide a copy of the survey.

    9. 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 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.

    a. Can you tell us what percentage of first-time patients are 
actually identified as needing urgent care or hospitalization?

    10. Please provide a copy of the mental health performance 
requirements for all mental health settings.

                                 
Questions From: Congresswoman Julia Brownley, Ranking Minority Member, 
 Subcommittee on Health, Veterans Affairs, and Congressman Waxman, To: 
                   the Department of Veterans Affairs
    1. Mental Health Staffing

    a. How many full-time mental health professionals have been hired 
at each of the following facilities since January 1, 2012: the Oxnard 
CBOC, Ventura Vet Center, and West LA VA?

    b. How many part-time mental health professionals have been hired 
at the Oxnard CBOC, Ventura Vet Center, and West LA VA over that time 
period?

    c. Please identify the program to which each full time and part 
time mental health professional has been assigned.

    2. Mental Health Funding

    a. Please identify the funding levels for mental health services at 
the Oxnard CBOC, Ventura Vet Center, and West LA VA for FY12 and FY 13.

    b. Please include a detailed description of how those funds are 
allocated across the Oxnard CBOC, Ventura Vet Center, and West LA VA 
programs.

    3. Social Worker Staffing

    a. How many social workers have been hired at the Oxnard CBOC, 
Ventura Vet Center, and West LA VA HUD-VASH programs since January 1, 
2012?

    b. Has the VA met its set goal for the ratio between social workers 
and veterans?

    c. How many additional social workers need to be hired to meet the 
ratio the VA set as a goal?

    4. Waiting Times

    a. What is the current average waiting time for veterans to receive 
mental health screenings and services at the Oxnard CBOC, Ventura Vet 
Center, and West LA VA?

    b. What is the average waiting time over the past 6 months?

    c. What the median waiting time over that period?

    d. What is the range of waiting times over that period?

    e. If the Oxnard CBOC, Ventura Vet Center, and West LA VA do not 
track this data on waiting times please provide an explanation of why 
they do not.

    5. What changes in the treatment of mental health does the VA plan 
to implement at the Oxnard CBOC, Ventura Vet Center, and West LA VA 
during FY13?

    6. What transportation options are available for veterans traveling 
from Ventura County, and outlying areas of LA County, to the West LA VA 
for medical treatment?

    a. Does the VA provide door-to-door bus or vanpool service for 
veterans?

    b. Are veterans expected to find their own means of transportation?

    c. If so, does the VA reimburse veterans for the cost of private or 
public transportation?

    7. Does the Department of Veterans Affairs have in place a pipeline 
system for identifying and recruiting qualified mental health 
professionals from colleges and universities across the country?

    a. How does the VA conduct outreach to mental health professionals 
for recruiting purposes?

                                 
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