[Senate Hearing 113-41]
[From the U.S. Government Publishing Office]
S. Hrg. 113-41
VA MENTAL HEALTH CARE: ENSURING TIMELY ACCESS TO HIGH-QUALITY CARE
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HEARING
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES SENATE
ONE HUNDRED THIRTEENTH CONGRESS
FIRST SESSION
__________
MARCH 20, 2013
__________
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COMMITTEE ON VETERANS' AFFAIRS
Bernard Sanders, (I) Vermont, Chairman
John D. Rockefeller IV, West Richard Burr, North Carolina,
Virginia Ranking Member
Patty Murray, Washington Johnny Isakson, Georgia
Sherrod Brown, Ohio Mike Johanns, Nebraska
Jon Tester, Montana Jerry Moran, Kansas
Mark Begich, Alaska John Boozman, Arkansas
Richard Blumenthal, Connecticut Dean Heller, Nevada
Mazie Hirono, Hawaii
Steve Robertson, Staff Director
Lupe Wissel, Republican Staff Director
C O N T E N T S
----------
March 20, 2013
SENATORS
Page
Sanders, Hon. Bernard, Chairman, U.S. Senator from Vermont....... 1
Burr, Hon. Richard, Ranking Member, U.S. Senator from North
Carolina....................................................... 4
Tester, Hon. Jon, U.S. Senator from Montana...................... 6
Johanns, Hon. Mike, U.S. Senator from Nebraska................... 6
Isakson, Hon. Johnny, U.S. Senator from Georgia.................. 6
Murray, Hon. Patty, Chairman, U.S. Senator from Washington....... 41
Boozman, Hon. John, U.S. Senator from Arkansas................... 49
Blumenthal, Hon. Richard, U.S. Senator from Connecticut.......... 128
WITNESSES
Wood, Jacob, President and Co-Founder, Team Rubicon.............. 7
Prepared statement........................................... 9
Wing, Andre, Team Leader, Vermont Veterans Outreach Program...... 11
Prepared statement........................................... 13
Ruocco, Kim, Director, Tragedy Assistance Program for Survivors.. 14
Prepared statement........................................... 16
Allred, Kenny, LTC, US Army (Ret.), Chair, Veterans and Military
Council, National Alliance on Mental Illness................... 23
Prepared statement........................................... 25
Response to posthearing questions submitted by Hon. Richard
Blumenthal................................................. 30
Van Dahlen, Barbara, Ph.D., Founder and President, Give an Hour.. 31
Prepared statement........................................... 33
Petzel, Robert, M.D., Under Secretary for Health, Veterans Health
Administration, U.S. Department of Veterans Affairs;
accompanied by Janet Kemp, RN, Ph.D., Director of Suicide
Prevention and Community Engagement, National Mental Health
Program, Office of Patient Care Services; Sonja Batten, Ph.D.,
Deputy Chief Consultant, Specialty Mental Health Program,
Office of Patient Care Services; and William Busby, Ph.D.,
Acting Director, Readjustment Counseling Service and Regional
Manager for the Northwest Region............................... 52
Prepared statement........................................... 54
Response to posthearing questions submitted by:
Hon. Bernard Sanders....................................... 65
Hon. Richard Burr.......................................... 72
Hon. John D. Rockefeller IV................................ 106
Hon. Mark Begich........................................... 107
Hon. Mazie Hirono.......................................... 109
Porter, Col. Rebecca, Chief, Behavioral Health Division, Office
of the Surgeon General, U.S. Army.............................. 111
Prepared statement........................................... 112
Response to posthearing questions submitted by:
Hon. Bernard Sanders....................................... 114
Hon. John D. Rockefeller IV................................ 115
Hon. Mazie Hirono.......................................... 116
APPENDIX
Rockefeller, John D., IV, U.S. Senator from West Virginia;
prepared statement............................................. 131
The American Legion, Veterans Affairs and Rehabilitation
Commission; prepared statement................................. 131
Ilem, Joy J., Deputy National Legislative Director, DAV;
prepared statement............................................. 137
Wounded Warrior Project; prepared statement...................... 145
VA MENTAL HEALTH CARE: ENSURING TIMELY ACCESS TO HIGH-QUALITY CARE
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WEDNESDAY, MARCH 20, 2013
U.S. Senate,
Committee on Veterans' Affairs,
Washington, DC.
The Committee met, pursuant to notice, at 10 a.m., in room
418, Russell Senate Office Building, Hon. Bernard Sanders,
Chairman of the Committee, presiding.
Present: Senators Sanders, Murray, Tester, Blumenthal,
Burr, Isakson, Johanns, and Boozman.
OPENING STATEMENT OF HON. BERNARD SANDERS,
CHAIRMAN, U.S. SENATOR FROM VERMONT
Chairman Sanders. This hearing of the Senate Veterans'
Committee is beginning and I want to start by thanking all of
our wonderful panelists who have years of experience in the
area, the very important areas that we are going to be delving
into today. I want to thank them very much for coming here
today and I want to thank VA for being here as well.
As I think we all know, it is now 10 years since the United
States went to war in Iraq and we went to war in Afghanistan
before that. What we have learned--in a variety of ways--is
that the costs of those wars has been very, very high.
The costs have been high not just in the loss, the tragic
loss, of life that we have experienced; not just in terms of
those who come home without arms, legs, eyesight or hearing
problems; but also in terms of the invisible wounds of war,
wounds which are quite as real as any other kind.
Those wounds include Post Traumatic Stress Disorder (PTSD),
Traumatic Brain Injury (TBI), and all of the symptoms
associated with those very serious illnesses.
Further, and tragically, it includes the serious problem of
suicide. We are losing about 22 veterans every single day as a
result of suicide. That is more than 8,000 veterans every year.
And, while suicide is a major problem in the United States
as a whole for our civilian population, it is a terrible,
terrible tragedy for the veterans' community and is something
that must be addressed.
Let me preface my remarks by saying what I think everybody
understands. The issues that we are dealing with today are
very, very tough issues; and if anyone had any magic solution
to the problems of mental illness in general, trust me, we
would have heard about them a long, long time ago.
So, this is a tough issue and we are going to do our best
today to figure out where we are in terms of meeting the needs
of our veterans and where we go from here.
I think everyone is in agreement that ensuring timely
access to high-quality mental health care is critical not only
for our veterans but for their loved ones as well. What we are
going to hear today from our panel is that mental health issues
impact not only the soldier or the veteran but the wife, the
husband, the children as well.
As a Nation, our goal must be to ensure that veterans get
the best mental health care possible, and that they get it in a
timely, non-bureaucratic way. How that health care is delivered
is of enormous consequence.
I want to commend VA for its work in this area. The
department has made important strides in providing mental
health services to our veterans. In fact, in many ways, VA is
leading the Nation in PTSD research.
But clearly, with all of the accomplishments, much, much
more must be done because this is an area that is impacting
tens of thousands of veterans and we must find the best
solutions that we can.
We know that our veterans who need mental health services
need them quickly. Today, all first-time patients referred to
or requesting mental health care services are required to
receive an initial evaluation within 24 hours and a
comprehensive evaluation within 14 days.
In April of last year, the Office of the Inspector General
found that VHA was not meeting these benchmarks. Some veterans
were waiting as long as 60 days for an evaluation. In the real
world, if somebody is struggling, if somebody is hurting,
drinking too much or doing drugs, clearly waiting 60 days is
not acceptable. Therefore, this was a deeply troubling finding.
A year after those negative findings, it appears that VA
has made progress in implementing recommendations from the IG
report and in many ways people are now, as I understand it,
getting their evaluations within 24 hours. That is an issue we
are going to explore this morning with VA.
The point here is that if people are hurting, we need to
get them in the door. We need to have them see somebody. We
need to get them into the system, and waiting 2 months is
absolutely unacceptable.
One issue that I remain very concerned about, both as
Chairman of this Committee and as a Member of the Health and
Education Committee, is the shortage that we have of mental
health providers. This is not just a veterans' issue, it is an
issue for our entire Nation.
The long wait times that I mentioned are partially caused
by staffing shortages. I am pleased that Secretary Shinseki has
implemented the executive order to hire 1600 mental health
clinicians.
I understand that as of March 13, VA has hired more than
3,000 mental health professionals and administrative support
including more than 1,100 of these new mental health
conditions. This is good progress toward teaching VA's goal.
However, let me emphasize this point, I am very concerned
that VA has hired only 47 clinicians in the last 2 months. I
think we all understand the challenge here. You do not want to
run out on the street and pick up the first clinician you can.
You want to make sure that the people you are hiring are well
trained and that they are of the quality our veterans deserve.
But clearly, VA must step up the pace of hiring if it
intends to meet its goal of 1600 new clinicians by the end of
June of this year. In order to meet this goal, VA will need to
hire almost 500 clinicians in the next 2 months. Frankly, I do
not see how that is possible and I want to talk to VA about how
they are moving forward in this area.
So, the goal is not just rushing out, bringing people into
the system. We must make sure they are of good quality so we
can get people into the system as rapidly as we can.
It is clear that we all want our veterans to be seen by
properly trained mental health counselors who can provide the
high quality care that our veterans deserve. VA has made some
important steps forward in this area.
VA clinicians are now trained in evidence-based therapies
such as cognitive behavioral therapy and prolonged exposure
therapy. While VA clinicians are trained in these therapies, VA
must do a better job tracking utilization so we may ensure that
these clinicians are doing what they are trained to do and that
these therapies are being put into practice all across the
country.
Access to timely and high-quality care only matter if the
care is delivered to veterans in the appropriate way. VA must
continue to provide care in a variety of settings to meet the
needs of each veteran.
Medical centers, community-based outpatient clinics
(CBOCs), Vet Centers, and telehealth services each play
important roles in appropriate care delivery.
VA medical centers are equipped to treat the most severe
cases of mental health diagnoses, such as PTSD. They are also
critical in addressing the mental health care needs of patients
admitted to the hospital for physical injuries.
I am a great supporter of Vet Centers, and I am not sure
that we utilize them as much as we should. Vet Centers provide
a safe, welcoming, home-like environment for veterans to
receive care both on a one-on-one counseling and in group
settings. Veterans often feel very comfortable in that
nonbureaucratic environment.
Additionally, CBOCs offer mental health care services that
are often closer to veterans' homes. In certain situations,
CBOCs use telemedicine to link veterans to clinicians at VA
medical centers. VA has done an excellent job, by the way, with
telehealth in general.
It is critical that VA provides these various options of
care. We must ensure not only that these options remain
available but veterans know about them. In fact, the next
hearing we are going to have deals with outreach in general.
You can have the best care in the world. If a veteran does not
know about that care, it doesn't do anyone any good at all.
While VA has made significant strides in improving mental
health care to our veterans, we must do more to ensure better
prevention for today's servicemembers, the veterans of
tomorrow.
I think we are all aware of the frightening level of
suicides among members of the Armed Services today,
approximately one a day. The Army has to help us address this
issue.
Based in large part on the efforts of this Committee, the
Army task force on behavioral health recently completed a
comprehensive review of behavioral health care and the report
provided multiple recommendations for improving mental health
counseling.
In other words, what we are beginning to understand, one
which this Committee will deal with, is that a soldier is a
soldier from the first day of enlistment to his or her last day
on earth. When that veteran is in the VA, that continuity of
care is extremely important.
While we often think of the military and VA as providers of
mental health care for our servicemembers and veterans,
community organizations like the ones that will testify here
today play a key role in helping veterans access the care they
need.
These organizations can partner with VA to identify
veterans in need of care, work with veterans to help them
prepare for care and provide direct care to veterans. We are
going to hear from these wonderful organizations, and again I
want to thank you all very, very much for the work you do and
thank you so much for being with us today. I will be
introducing you in a few minutes when you testify.
These organizations do not shy away from the worst
consequence of serious mental illness, including suicide. In my
homestate of Vermont, the Vermont Veterans Outreach Program,
operated by the Vermont National Guard, has intervened to
prevent suicides from occurring; and that is certainly true
with all of the organizations that are here today.
So, let me just conclude by saying that the issue that we
are dealing with today is a very difficult one. It is an issue
of enormous consequence. It is an issue that impacts the lives
of tens and tens of thousands of men and women who put their
lives on the line to defend this country. Whether it is PTSD,
Traumatic Brain Injury, or suicide, these are issues that we
must delve into and we must succeed in improving our outcomes.
So, thank you again very much for being here and I would
like to give the mic over to Senator Burr.
STATEMENT OF HON. RICHARD BURR, RANKING MEMBER,
U.S. SENATOR FROM NORTH CAROLINA
Senator Burr. Thank you, Mr. Chairman. Thank you for
calling this hearing. I welcome our witnesses today and look
forward to the insight that you can provide to us.
Kim and Jake, I want to especially thank you two for
sharing your experiences with us. I know some of it will be
painful to recount but we are grateful for the insight that you
can give Members of this Committee.
It is important that we hear first-hand from veterans,
their families, and friends about the experience in seeking
mental health services. So, it is absolutely vital to us.
As you know, this hearing follows three mental health
hearings we held last Congress. At those hearings, we heard
from veterans and providers about the barriers veterans faced
in receiving mental health care in the VA facilities.
After the first mental health hearing, VA, at the request
of Senator Murray, conducted a poll of its mental health care
providers which painted a stark picture of VA's mental health
program and its ability to provide the care our veterans need
and deserve.
Following the second hearing, the Committee requested the
Inspector General audit the VA mental health program. The IG
found that VHA's schedulers were not following directives for
scheduling appointments and providers frequently scheduled
patients for follow-up appointments based upon their
availability, not on the clinical needs of patients. In my
mind, this revealed a complete breakdown in VA's mental health
program.
In response to the IG report, VA announced the hiring of
1600 additional mental health providers. While I am glad VA has
finally admitted to having a problem, I still have questions
regarding that initiative. For instance, did VA conduct any
staffing analysis to determine the type and how many mental
health providers were needed; and when 70 percent of VA
providers indicated in a survey that there was not enough space
in mental health clinics, I cannot help but wonder where
additional staff will be placed.
I believe this problem could be larger than just providing
mental health services to a current generation of veterans. VA
is seeing an increase in demand not only from veterans of Iraq
and Afghanistan, VA is seeing an increase in demand from
Vietnam vets and other generations as well.
Vet Centers have already noticed an increase in the number
of Vietnam-era veterans returning for counseling. As Vietnam-
era veterans retire and seek services, I fear we are going to
find ourselves back here again trying to fix the same problem.
While VA has the authority to improve access to mental
health services by changing outcome measures, hiring more
staff, and fixing broken scheduling processes, the VA cannot
fix this problem alone.
VA needs to look outside the box for answers and engage the
private sector and charitable organizations for help in
treating veterans in need of mental health services. Without a
realistic plan that combines partnerships with outside
providers and charities, the outcomes of a staffing analysis,
and fixes to VA's internal problems, they will not see an
improvement in mental health services, especially with those
veterans who need it the most.
This is a problem that cannot be solved with one or two
changes. It needs a comprehensive approach that incorporates
solutions both from within and outside the VA system.
What does that all mean? It means I still think we are hung
up with process and not with outcomes. We are hung up with how
many people can we hire, how much space can we get, do we have
enough access versus are we fixing people who come in the front
door and fixing them when they go out the back door, confirming
that they are well.
Let me just say to my colleagues, if we allow mental health
to be treated like the disability claims backlog where we focus
only on how many people can we hire, I assure you we will get
the same outcomes--less productivity and a backlog that
continues to grow.
We have got to focus on fixing these kids. We have got to
get the talent that we need regardless of whether it is inside
or outside the VA to fix these kids, to make sure they are
better on the back-end. That is hopefully where the focus of
this Committee will be.
Finally, I want to take a minute to address my concerns
regarding the recent quality of care issues including the
single-use insulin pens at Buffalo and Salisbury VAMCs and the
ongoing issues at Jackson. I am even more frustrated by how
these issues were handled and how Congress was notified.
There is a broader discussion to be had on these issues,
Mr. Chairman, and this is not the venue for it, but it should
be the focus of the Committee with the appropriate folks from
the VA.
Mr. Chairman, I want to thank you. I want to encourage my
colleagues to pass on opening statements--if you would do it
today--and limit your questions, because we have got a vote and
we want to try to accommodate both panels before we go into
those votes.
Thank you.
Chairman Sanders. Senator Tester.
STATEMENT OF HON. JON TESTER,
U.S. SENATOR FROM MONTANA
Senator Tester. I have just got to say a few words, Ranking
Member Burr. First I want to thank the Chairman and you for
having this.
First of all, this is a signature injury coming out of Iraq
and Afghanistan now. This is not new news. It has been here
forever.
If we knew how to treat mental illness in a way that was
very, very effective in this country, this issue would not even
be on the radar; but we have run from it for decades.
We ran from it in Vietnam, and now we are trying to address
it. I just want to say that I think the folks that are working
at the VA need to think outside the box and we do need to get
more medical professionals on the ground, especially in rural
places like Montana, which I am a little bit biased about.
On the other side of the coin, I do not think this issue is
going to be solved tomorrow. It is going to take some time but
if we work at it and we work at it together and we do not call
for people's resignations but rather work with them, I think
that we can get a lot more done.
Thank you very much.
Chairman Sanders. Thank you, Senator Tester.
Senator Johanns.
STATEMENT OF HON. MIKE JOHANNS,
U.S. SENATOR FROM NEVADA
Senator Johanns. Thank you, Mr. chair. I am mindful of the
vote that is coming up, so I will pass on an opening statement.
If I have anything, I will submit it for the record.
Chairman Sanders. Thank you very much.
Senator Isakson.
STATEMENT OF HON. JOHNNY ISAKSON,
U.S. SENATOR FROM GEORGIA
Senator Isakson. I may submit a statement for the record.
Chairman Sanders. Thank you, Senator Isakson.
Let me introduce our wonderful panel. Again, we are very
appreciative that they are with us today. We are going to hear
first from Jacob Wood, who is the President and Co-Founder of
Team Rubicon. Next, we are going to hear from a fellow
Vermonter and the Team Leader, Vermont Veterans Outreach
Program, Andre Wing. Then, we are going to hear from the
Director of the Suicide Postvention Program at the Tragedy
Assistance Program for Survivors, Kim Ruocco.
Next, we will hear from retired U.S. Army Lieutenant
Colonel and Chair of the veterans and Military Counsel at the
National Alliance on Mental Health, Kenny Allred; and then we
will close out the panel with Dr. Barbara Van Dahlen, Founder
and President of Give an Hour.
So, I just thank you again for the work that you are doing
and for the testimony you are about to give us.
Jacob, let us begin with you.
STATEMENT OF JACOB WOOD, PRESIDENT AND CO-FOUNDER, TEAM RUBICON
Mr. Wood. If you please will bear with me while I read you
a few names. McShan, Jenson, Stewart, Ross, Rios, Markel,
Rocha, and Clay Hunt.
In 2008, my unit redeployed home to the U.S. after a long
and bloody tour in Helmond Valley, Afghanistan. In 7 months, we
lost 20 men, suffered nearly two dozen amputations, and took
over 150 casualties.
The names I just read, however, were not among those grim
statistics. No. The names I just read are the names of the men
we have lost in the last 4 years; names of the men we have lost
to suicide while pursuing peace.
That last name, Clay Hunt, belonged to my dear friend and
sniper partner. Clay was a good man, a great Marine, and an
incredible humanitarian. Clay helped me start an organization
called Team Rubicon, a nonprofit which uses the skills and
experiences of returning combat veterans for continued service
following natural disasters.
My cofounder and I launched Team Rubicon after the Haiti
earthquake in 2010. We arrived only a few days after the
devastating quakes struck, provided medical triage in the
hardest hit areas of Port au Prince; essentially using the
principles of Counter-Insurgency warfare to mitigate risk, move
quickly, gain the trust of an unstable populace, and render
critical aid.
It was in Clay's suicide, however, that we realized a
critical truth: Team Rubicon is more than a high-speed disaster
response organization. Rather, it is a veteran service
organization that is using natural disasters as an opportunity
for veterans to continue their service and regain what they
have lost since leaving the military.
Ladies and gentlemen, many will come testify here that jobs
or education or access to health care is what will keep our
Nation's warriors from killing themselves here at home. But as
a simple Marine Sergeant, I am going to argue that it is much
simpler.
You see, returning from a decade-long war that has suffered
from ambiguous political leadership, an unclear mission, and a
disengaged and disinterested public takes a heavy mental and
emotional toll on servicemen and women.
Picture for a moment an 18-year-old boy from Omaha, NE.
That 18-year-old boy graduates high school and joins the Army.
The Army sends him to boot camp and gives him a rifle, and
later he deploys to Iraq and is promoted to the rank of
Sergeant.
This young man spends 12 months and every day he leads his
men outside the wire to pacify a countryside and protect his
comrades from insurgent attacks. He has purpose. Every night,
back inside the wire, he checks on his men, ensuring that they
have what they need. They laugh together, they cry together. He
has a community.
Twelve months later his unit returns home. The young man
walks through the airport in his uniform and is slapped on the
back and thanked from all around. He has an identity. A few
short months later the man leaves the Army and returns home to
Omaha, NE. He gets a job and reconnects with old high school
friends.
Soon, however, he discovers a serious void. Things are not
the same. No job can replace the purpose he once felt. Distant
high school friends simply cannot understand or replace the
community he has left behind. And no mechanics' overalls or
pinstripe suit will ever give him the identity he once felt
while proudly wearing the uniform of his beloved Nation.
He is not whole; and now left to his own devices, he
questions his war because everyone around him questions it. He
now finds himself trying to justify the lives lost, the lives
taken, and the moral code that war inevitably compromises. For
some this is the most difficult part because the mission may no
longer feel noble and the threat no longer imminent.
We at Team Rubicon believe that the foundation to a healthy
transition lays in those three simple concepts: purpose,
community, and identity. By providing veterans with a new,
noble mission--helping those afflicted by disasters--veterans
not only help their neighbors, they help themselves.
Through disaster response, our veterans find a new method
of employing the skills that they learned for war. Combat
medics treat young children. Combat engineers build refugee
camps, and squad leaders bring order to ravaged communities.
They raise their right hand and let their neighbors know
that when disasters strike, they will once again lace up their
boots and answer the call. They look around themselves and
discover a new band of brothers, men and women with a similar
ethos and desire for community.
Last, they wear our T-shirt with pride, a pride of
belonging to something bigger than themselves. If done right,
we can make them feel whole again.
Earlier, I mentioned community and community can not be
undervalued. Today's servicemembers come together from
communities all across the country and the form tightknit
units. But when they leave the military, they go back to their
hometowns, losing that connection, that brotherhood that they
had when they were in the service.
To help build a 21st century veteran community, I have also
cofounded a technology company called POS REP or Position
Report. POS REP was also inspired by Clay Hunt, when, at his
funeral, I discovered that there were three Marines who lived
within 10 miles of him in Houston, TX, that we had served with
in Iraq. Clay had, in fact, not been alone.
Frustrated with the VA and the DOD's inability to connect
veterans with one another after they leave the service, we set
out to solve the problem using the most ubiquitous tool on the
planet, our smartphones.
Using the GPS capability of smartphones, we have created an
application exclusively for military veterans. It connects
veterans not only with the veterans they already know, but,
more importantly, it helps them discover and communicate with
veterans all around them.
It also serves as a unifying platform for veteran service
organizations, helping numerous nonprofits reach veterans in
order to provide critical transition services. In later
versions, we hope to help veterans connect with VA services
based on their proximity to those resources.
The app can serve as a hyper-local, veteran version of
Foursquare. However, to do so, requires cooperation with the
Federal and State government, which has proven to be
tremendously cumbersome for a young, underfunded startup like
POS REP.
In closing, it is my humble opinion that at the root of
this issue of transition lays three core tenets: purpose,
community, and identity. Team Rubicon is working to provide all
three through a new, exciting mission; and POS REP is trying to
create a new offline community through an innovative online
discovery tool.
Thank you for your time.
[The prepared statement of Mr. Wood follows:]
Prepared Statement of Jacob Wood, President and
Co-Founder, Team Rubicon
McShan, Jenson, Stewart, Ross, Rios, Markel, Rocha * * * Clay Hunt.
In 2008, my unit redeployed home to the U.S. after a long and
bloody tour in Helmand Valley, Afghanistan. In 7 months, we lost 20
Marines, suffered nearly two dozen amputations, and took over 150
casualties. The names I just read, however, weren't among those grim
statistics. No, the names I just read are the names of the men we've
lost in the last four years; names of the men we've lost to suicide
while pursuing peace.
That last name, Clay Hunt, belonged to my dear friend and sniper
partner. Clay was a good man, a great Marine, and an incredible
humanitarian. Clay helped me start an organization called Team
Rubicon--a nonprofit which uses the skills and experiences of returning
combat veterans for continued service following natural disasters.
My cofounder and I launched Team Rubicon after the Haiti earthquake
in 2010. We arrived only a few days after the devastating quake struck,
and provided medical triage in the hardest hit areas of Port au Prince;
essentially using the principles of Counter-Insurgency warfare to
mitigate risk, move quickly, gain the trust of an unstable populace,
and render critical medical aid.
It was after Clay's suicide, however, that we realized a critical
truth: Team Rubicon is more than a high-speed disaster response
organization. Rather, it is a veteran service organization that is
using disasters as an opportunity for veterans to regain what they've
lost since leaving the military. Ladies and gentlemen, many will come
and testify here today that jobs, or education, or access to healthcare
is what will keep our Nation's warriors from killing themselves here at
home. But, simple Marine Sergeant, I'm going to argue that it is much
simpler.
You see, returning from a decade long war that has suffered from
ambiguous political leadership, an unclear mission, and a disengaged
and disinterested public takes a heavy mental and emotional toll on our
servicemen and women.
Picture for a moment an 18 year old boy in Omaha, Nebraska. That 18
year old boy graduates high school and joins the Army. The Army sends
him to boot camp and gives him a rifle. Later he deploys to Iraq and is
promoted to the rank of sergeant. This young man spends twelve months
in Iraq, and every day he leads his men outside the wire on a mission
to pacify the countryside and protect his comrades from insurgent
attacks. He has purpose.
Every night, back inside the wire, he checks on his men, ensuring
they have what they need. They laugh together, and they cry together.
He has a community.
Twelve months later his unit returns home. The young boy, now a
man, walks through the airport in his uniform and is slapped on the
back and thanked by all those around. He has an identity.
A few short months later, that man leaves the Army and returns home
to Omaha, Nebraska. He gets a job and reconnects with old high school
friends. Soon, however, he discovers a serious void--things just aren't
the same. No job can replace the purpose he once felt. Distant high
school friends simply cannot understand or replace the community he has
left behind. And no mechanics' overalls or pinstripe suit will ever
give him the identity he once felt while proudly wearing the uniform of
his beloved Nation.
He is not whole. And now, left to his own devices, he questions his
war because everyone around him questions it. He now finds himself
trying to justify the lives lost, the lives taken, and the moral code
war inevitably compromises. For some this is the most difficult part
because the mission may no longer feel noble, the threat no longer
imminent.
We at Team Rubicon believe that the foundation to a healthy
transition lays in those three simple concepts: Purpose, Community, and
Identity. By providing veterans with a new and noble mission--helping
those afflicted by disasters--veterans not only help their neighbors,
they help themselves.
Through disaster response our veterans find a new method of
employing the skills they learned for war. Combat medics treat young
children; combat engineers build refugee camps; and squad leaders bring
order to ravaged communities. They raise their right hand and let their
neighbors know that when disasters strike they will, once again, lace
up their boots and answer the call. They look around themselves and
discover a new band of brothers; men and women with a similar ethos and
desire for community. Last, they wear our t-shirt with pride; a pride
of belonging to something bigger than themselves. If done right, we can
make them feel whole again.
Earlier I mentioned community, and community cannot be undervalued.
Today, servicemembers come together from communities all across the
country and form tight-knit units. But when they leave the military,
they go back to their home towns, losing that connection--that
brotherhood--they had when they were in the service.
To help build a 21st century veteran community, I have also
cofounded a technology company called POS REP, or Position Report. POS
REP was also inspired by Clay Hunt, when, at his funeral, I discovered
that Clay had lived within 10 miles of three Marines we'd served with
in Iraq--Clay, in fact, had not been alone. Frustrated with the VA and
DOD's inability to connect veterans with one another after they leave
the service, we set out to solve the problem using the most ubiquitous
tool on the planet--our smartphones.
Using the GPS capability of smartphones, we have created an
application exclusively for military veterans. It connects veterans not
only to the vets they already know, but more importantly it helps them
discover and communicate with the unseen network of veterans around
them, unlocking a peer support network that we all know is critical to
stemming the tide of veteran suicide. It also serves as a unifying
platform for veteran service organizations, helping numerous nonprofits
reach veterans in order to provide critical transition services. POS
REP is an innovative attempt to solve an age-old problem.
In later versions, we hope to help veterans connect with VA
services based on their proximity to those resources. The app can serve
as a hyper-local, veteran version of ``Foursquare,'' however, to do so
requires cooperation with the Federal and state government, which has
proven to be tremendously cumbersome for a young, underfunded startup,
such as POS REP.
In closing, it is my humble opinion that at the root of this issue
lays three core tenants: purpose, community and identity. Team Rubicon
is working to provide all three of those through a new, exciting
mission in disaster response, and POS REP is looking to create offline
communities through innovative online discovery tools. In order for us
to adequately address what has become a national epidemic--one in which
22 veterans a day are successfully killing themselves--we must have the
public and private sectors come together to propose and execute bold,
innovative solutions. At this stage inaction is not an option.
Thank you for your time, and I'd be happy to answer your questions.
Chairman Sanders. Thank you very much, Mr. Woods.
Andrew Wing is a Team Leader for the Vermont Veterans
Outreach Program. Andre.
STATEMENT OF ANDRE WING, TEAM LEADER, VERMONT VETERANS OUTREACH
PROGRAM
Mr. Wing. Chairman Sanders and Members of the Committee,
thank you for your invitation to discuss the Vermont Veterans
Outreach Program. I have been the Vermont Veterans Outreach
Team Leader since April 2010. Since 2007, my team has conducted
needs assessment surveys with over 4,300 veterans to discuss
their needs and the needs of their families.
The Vermont Veterans Outreach Program has evolved and
expanded beyond its original 2007 mandate of helping only OEF/
OIF veterans. We now also assist servicemembers from other war-
time conflicts.
One of the reasons the Vermont Veterans Outreach Program
has been so successful is our grassroots, ``sliding our feet
under their kitchen tables'' way of doing business. We are the
ones going to the veterans' homes and working with them to find
what they really need. The issues range from health care,
emotional support, disability benefits, homelessness,
employment, or financial assistance.
One of the most innovative components of our Veterans
Outreach Program is the Veterans' Administration Medical Center
liaison we established to help veterans navigate the VA system.
Our liaison is located at the White River Junction Welcome
Center which is the entry point into the VA system for Vermont.
Our outreach specialist will often use this resource to
establish a soft handoff to someone who understands how to
navigate the VA system effectively. The liaison also works with
many walk-ins which are typically active duty veterans who come
on their own not realizing how overwhelming the process could
be.
In addition, the liaison attends the VA Patient Centered
Care Committee meeting which discusses ways to improve
relationships with the veterans and how best to implement any
changes recommended.
Having the liaison attend these meetings helps our Veterans
Outreach team learn of new initiatives the VA is implementing,
as well as improved communication between the specialists out
in the field and the VA.
We have increased awareness of the Vermont Outreach Program
working through one of our community partners, Vermont 211, and
our own 24/7 phone service line. Calls will often come through
these two services and allows us to act upon each situation in
a very timely manner.
Our outreach specialists established relationships with our
Vermont State Police as well to go out with them to make
wellness calls to assess a situation with a veteran and call
upon professional services as needed.
I have established a strong rapport with the local OEF/OIF/
OND Program Manager. This relationship has helped my team
capture returning veterans that may have fallen through the
cracks.
An example of this would be that I received a call from a
mother in Florida that works for Cabot Cheese. Her son, an OIF
veteran, was struggling in Florida with substance abuse and
PTSD. She took the chance. She flew him to Vermont where my
team picked him up at the airport, brought him to the Veteran
Administration Medical Center in White River Junction, where he
was enrolled in the 6-week Intensive Outpatient Program. My
team also helped with a disability claim issue. The veteran
completed the program successfully and is now a contributing
member of his community, now living in Colorado.
Without this kind of partnership from the program manager
who facilitated care in Vermont, this veteran may not be here
today. As a matter of fact, the mother told me that my team
saved his life.
We are a very rural State that does not have any active
duty military installations nor do we have an established
public transportation infrastructure outside our largest
county, which is Chittenden County. For that reason, our
Outreach Specialists transports our veterans to the White River
Junction VA or the CBOCs throughout Vermont for their first
couple of visits.
While this windshield time reduces the time available to
contact other veterans, my team members have noted that this
drive time is, in reality, a short decompression period for the
servicemember. Faced with the decision between helping a
soldier right in front of them or those yet to be contacted,
the Outreach Specialist always tends to the more immediate
need.
The person-to-person time spent by our Outreach Specialists
with each individual servicemember and/or their family is an
extremely important component of the program. In the past many
veterans would miss appointments or did not bother enrolling
because they could not afford the travel or did not have
transportation and thereby jeopardizing their health or access
to benefits.
A critical piece of our success is our follow-up with the
servicemembers. Our outreach specialists often meet with CBOC
counselors and the servicemembers to go over the follow-up plan
needed for the veteran. It might be to make sure that they show
up for their follow up appointments with the VA or getting them
linked with a community partner such as Veterans, Inc., for
financial help, or with the Department of Labor or the employer
support of the Guard and Reserve for employment issues.
The bottom line is we established a relationship with these
veterans and their families. We have the resources. We have the
skills, and we have the tenacity needed to make sure our
veterans, from all combat conflicts, get the services they
deserve.
Our hope is to continue this work until every servicemember
and their family that needs help, gets help.
Thank you for this opportunity to discuss Vermont's
outreach program and I look forward to answering any questions
you may have.
[The prepared statement of Mr. Wing follows:]
Prepared Statement of Andre Wing, Team Leader, Vermont Veterans
Outreach Program
Chairman Sanders and Members of the Committee, Thank you for your
invitation to discuss the Vermont Veterans Outreach Program. My name is
Andre Wing, I have been the Vermont Veterans Outreach team leader since
April 2010. In that time, my team has conducted ``needs
asssement``surveys with over 4300 veterans to discuss their needs and
the needs of their families.
Before I begin, let me say that my testimony today reflects my
personal views and does not necessarily reflect the views of the Army,
the Department of Defense, or the Administration.
The Vermont Veterans Outreach Program has evolved and expanded
beyond its original 2007 mandate of helping OIF/OEF servicemembers. We
now also assist servicemembers from other war-time conflicts.
One of the reasons the Vermont Veterans Outreach program has been
so successful is our grassroots, ``sliding our feet under their kitchen
tables'' way of doing business. We are the ones going to the veterans'
home and working with them to find what they really need. The issues
range from health care, emotional support, disability benefits,
homelessness, employment, or financial assistance.
One of the most innovative components of our Veterans Outreach
program is the VAMC liaison we established to help veterans navigate
the VA system. Our liaison is located at the White River Junction
Welcome Center which is the entry point into the VA system for Vermont.
Our outreach specialists will often use this resource to establish a
``soft'' handoff to someone who understands how to navigate the VA
system effectively. The liaison also works with many ``walk-ins'' which
are typically active duty veterans who come on their own not realizing
how overwhelming the process could be.
In addition, the liaison attends the VA Patient Centered Care
Committee which discusses ways to improve relationships with the
veterans and how best to implement any changes recommended. Having the
liaison attend these meetings helps our Veterans Outreach team learn of
new initiatives the VA is implementing, as well as improve
communication between the specialists out in the field and the VA.
We have increased awareness of the Vermont Outreach Program working
through one of our community partners, VT 211, and our own 24/7 phone
service. Calls will often come through these two services and allows us
to act upon each situation in a very timely manner. Our outreach
specialists established relationships with our Vermont State Police to
go out with them to make ``wellness calls'' to assess a situation with
a veteran and call upon professional services as needed.
I have established a strong rapport with the local OEF/OIF/OND
Program Manager. This relationship has helped my team capture returning
veterans that may have fallen through the cracks. An example of this
would be that I received a call from a mother in Florida that works for
Cabot Cheese. Her son, an OIF veteran was struggling in Florida with
substance abuse and PTSD. She flew him to Vermont where we picked him
up at the airport, brought him to the VAMC in WRJ, where he was
enrolled in the 6 week Intensive Outpatient Program. My team also
helped with an issue with a disability claim. The veteran completed the
program successfully and is a contributing member of his community, now
in Colorado. Without this kind of partnership from the program manager,
who facilitated care in Vermont, this veteran may not be here today. As
a matter of fact, the mother told me that my team saved his life.
We are a very rural state that does not have any active duty
military installations. Nor do we have an established public
transportation infrastructure outside our largest county, Chittenden
County.
For that reason, our Outreach Specialists transports our veterans
to the White River Junction VA Medical Center, or the CBOCs throughout
Vermont for their first couple of visits. While this ``windshield
time'' reduced the time available to contact other veterans, Outreach
Team members have noted that this drive time is, in reality, a short
decompression period for the servicemember. Faced with the decision
between helping a soldier right in front of them and those yet to be
contacted, the Outreach Specialist always tends to the more immediate
need. The person-to-person time spent by our Outreach Specialists with
each individual servicemember and/or their family is a very important
component of the program. In the past many veterans would miss their
appointments or didn't bother enrolling because they could not afford
the travel and/or didn't have transportation and thereby jeopardizing
their health or access to benefits.
A critical piece of our success is our follow-up with the
servicemembers .Our outreach specialists often meet with CBOC
counselors and the servicemember to go over the follow-up plan needed
for the veteran. It might be to make sure they show up for their follow
up appointments at the VA, or getting them linked with a community
partner such as Veterans, Inc. for financial help or with ESGR/DOL for
employment issues. The bottom line is we establish a relationship with
these veterans and their families and we have the resources, skills and
tenacity needed to make sure our veterans, from all combat conflicts,
get the services they deserve.
Our hope is to continue this work until every servicemember and
their family that needs help, gets help. Thank you for this opportunity
to discuss Vermont's outreach program and I look forward to answering
any questions you may have.
Chairman Sanders. Thank you, Andre.
Kim Ruocco is the Director of the Suicide Postvention
Program at the Tragedy Assistance Program for Survivors.
Kim, thanks so much for being with us.
STATEMENT OF KIM RUOCCO, DIRECTOR, TRAGEDY ASSISTANCE PROGRAM
FOR SURVIVORS
Ms. Ruocco. Thank you for having me, Mr. Chairman. I am
honored to present this testimony on behalf of the Tragedy
Assistance Program for Survivors, also known as TAPS.
Last year, we sadly welcomed 931 people seeking help in
coping with a suicide loss of a loved one who was in the
military or had recently left the military and was
transitioning back to the community.
That is at least two people per day seeking help in coping
with a suicide, and these military families comprise at least
19 percent of our current caseload. These numbers are actually
a lot higher because once we get them into our caseload we
realized that they came in not admitting that it was a suicide
or had a different kind of cause of death listed.
We have built a supportive, comprehensive community of care
at TAPS for these families with more than 3,000 family members
grieving a death by suicide in our data bank as of today.
Our survivors receive multidimensional services including
connection to trauma support, emotional support, and risk
assessment and reduction among the survivors.
My name is Kim Ruocco, and I am also the surviving widow of
a Marine major John Ruocco, who died by suicide in 2005. He was
preparing for his second combat to tour to Iraq. He died soon
after his return home from the first one.
I am the Director of Suicide Postvention Programs and
Survivor Care at suicide support at TAPS and a clinical social
worker.
I am speaking today about the challenges facing our
returning veterans in getting quality mental health care. I
have submitted written testimony that presents many cases with
family members where they have shared information around this
issue. They have come to us seeking support in coping with the
suicide of a recent veteran. It is our hope that by sharing
this information, services for veterans can be improved and
lives can be saved.
Many common themes emerged while talking with survivors
grieving the death of a recent veteran of suicide, and one can
almost paint a picture or roadmap of a veteran who dies by
suicide.
After being discharged from the military, these veterans
struggle in multiple areas of their lives. They usually are not
discharged with a treatment plan or an appointment.
They attempt to go to college but have trouble accessing
G.I. Bill benefits and find their disability benefits delayed
or denied. They struggle to find employment; and if they do get
employment, they have concentration problems like insomnia,
anxiety, and other issues that prevent them from keeping that
job.
Physical injuries complicate the situation further. The
stress of all of this begins to adversely affect their
relationships, especially those significant relationships.
What I have gathered from my families is that these
servicemembers can become barriers to their own care because of
issues. People who are not in the right state of mind cannot
stand in line or in crowded waiting rooms to complete
complicated paperwork or wait 2 months for an appointment or
tolerate staff turnovers in counselors who are not staying or
who are frequently changing.
Sadly, the information we gather at TAPS from survivors
always ends in tragedy but it does not have to be that way.
Suicide is not inevitable. There are many good programs
addressing veterans mental health care at the VA and we have
seen treatment work among veterans if they can get into the
system and really get the kind of treatment plan and care that
they need.
What we really need is to focus on how we can reduce or
eliminate the barriers to getting to that treatment and getting
it to be comprehensive. ``It takes a warrior to ask for help,''
is the slogan used at the VA, but few know what help can look
like. They hear the terms ``seek treatment, seek help'' but
stigma prevents them from help seeking. Veterans do not know or
believe initially that treatment can work.
They do not really know what treatment is. They need to be
educated about how mental health care treatment can work. It is
vitally needed for this education.
Many of these veterans delay seeking care because of the
stigma about mental health care; and when they do finally go,
they are so sick that they can barely function and need
immediate care, which is not often available.
We need a campaign to get these veterans into care earlier
before they are in crisis and demonstrate what help looks like
and show them that treatment can work.
For those who are in crisis, a fast lane screening effort
for mental health needs would help them get past these
paperwork hurdles and get those in need of urgent care into
care more quickly.
Peer support can play a vital role in helping veterans
access their benefits and support in between appointments at
the VA. Improving connections between the VA and
nongovernmental agencies could help the VA more fully integrate
care-based support programs into these programs. These
improvements and care-based support could help save lives.
We have the following recommendations based on the
information that we have gathered:
Number 1, provide more funding for peer-based programs to
assist veterans through organizations such as Vets4Warriors and
VA Vet Centers.
Number 2, assign peer advocates at first contact to
navigate the system, support the veteran, and connect with
support systems.
Number 3, decrease the amount of paperwork and red tape
required before first appointments; and
Finally, create public awareness campaigns to describe what
mental health treatment is, emphasize that treatment can work,
and highlight the rewards of working with veterans in that it
is also serving your country to help a vet.
Thank you very much.
[The prepared statement of Ms. Ruocco follows:]
Prepared Statement of Kimberly Ruocco, Director of Suicide Postvention
& Survivor Support, Tragedy Assistance Program for Survivors (TAPS)
executive summary
I. Introduction
Because of its role in caring for thousands of surviving families
left behind by America's fallen military and recent veterans since
1994, the Tragedy Assistance Program for Survivors (TAPS) works
extensively with bereaved military families, including those grieving a
death by suicide. TAPS receives an average of at least two people per
day seeking help and support in coping with the death by suicide of a
servicemember, Guard member, activated Reserves member, or recent
veteran.
In this testimony, Marine Corps widow Kim Ruocco, an expert in
suicide postvention programs, shares critical information reported by
surviving families of a suicide loss to TAPS and offers insights on
improving the quality of mental health care within the VA system. The
testimony discusses insights and observations gained from surviving
families of recent veterans who died by suicide and examines the
following:
(1) how extensive wait times and paperwork for initial mental
health screenings, referrals to specialists, and complex disability
ratings interfere with the mental health and well-being of our
veterans;
(2) the value of peer-based support programs in filling gaps in
mental health care; and
(3) how national non-governmental organizations link veterans to
mental health services.
II. Recommendations for Improvement
(1) Provide continued funding for peer-based support programs to
assist veterans through organizations such as Vet4Warriors and through
the VA Vet Centers.
(2) Create incentive systems within the VA and the Vet Centers to
encourage peer-support program managers and counseling staff,
especially those who are veterans, to continue working at the VA and in
the Vet Center.
(3) Assign an advocate at first contact, preferably a peer, to
provide support to the veteran and help navigate the system while
waiting for the first appointment.
(4) Decrease the amount of paperwork and ``red tape'' involved in
getting veterans to their first mental health appointment.
(5) Create and implement a national public awareness campaign to
support VA and Vet Center mental health staff recruitment focused on
the rewards of working with veterans and issue a call to national
service for mental health workers.
(6) Create and implement a national public awareness campaign that
emphasizes the messages that veterans who are struggling can get help
and that treatment can work. Suicide is not inevitable.
______
Mr. Chairman and Members of the Committee: I am pleased to have the
opportunity to submit this testimony on behalf of the Tragedy
Assistance Program for Survivors (TAPS).
TAPS is the national organization providing compassionate care for
the families of America's fallen military heroes. TAPS provides peer-
based emotional support, grief and trauma resources, grief seminars and
retreats for adults, `Good Grief Camps' for children, case work
assistance, connections to community-based care, and a 24/7 resource
and information helpline for all who have been affected by a death in
the Armed Forces. Services are provided to families at no cost to them.
We do all of this without financial support from the Department of
Defense. TAPS is funded by the generosity of the American people.
TAPS was founded in 1994 by Bonnie Carroll following the death of
her husband in a military plane crash in Alaska in 1992. Since then,
TAPS has offered comfort and care to more than 40,000 bereaved
surviving family members. The journey through grief following a
military or veteran death can be isolating and the long-term impact of
grief is often not understood in our society today. On average, it
takes a person experiencing a traumatic loss five to seven years to
reach his or her ``new normal.''
TAPS has extensive contact with the surviving families of America's
fallen military servicemembers and recent veterans. TAPS receives an
average of 13 newly bereaved survivors per day through our protocols
with the Services' casualty officers and direct contact from those who
are grieving the death of someone who died while serving the Armed
Forces or in recent veteran status.
In 2012, 4,807 new survivors came to TAPS for comfort and care.
This means that TAPS received in 2012, 13 new people each day seeking
care and support in coping with the death of a servicemember or recent
veteran. It should be noted that on average, TAPS received 7 new
survivors on average per day in 2011. The number of grieving survivors
turning to TAPS in 2012 seeking help and support increased by 46% over
the previous year.
Thirty percent of the survivors coming to TAPS were grieving the
death of a loved one in combat or in hostile action. Twelve percent
were grieving the death of a loved one by sudden illness, and nine
percent lost a loved one in an auto accident. Six percent lost a loved
one in an accident and four percent were grieving someone who died in
an aviation accident (typically a military training accident). Three
percent were grieving the death of a loved one by homicide. One percent
were grieving a death in a non-hostile incident, 0.7 percent lost a
loved one in a noncombat incident, and 0.3 percent to friendly-fire.
Nineteen percent of the survivors coming to TAPS in 2012 were
grieving the death of a loved one who died by suicide or in a suspected
suicide under investigation. At least two new survivors per day on
average contact TAPS for support who are grieving the death by suicide
of a servicemember or recent veteran. Fifteen percent of survivors
reported a cause of death as ``unknown'' for their servicemember which
often means a death is under investigation. Many of these ``unknown''
deaths are later ruled suicides, so the true number of families coming
into TAPS grieving a death by suicide is actually closer to 30% or
about four per day.
In 2012, approximately sixty-two percent of the family members
coming to TAPS for support were grieving the death of a loved one who
had served in the Army. Sixteen percent of the families were grieving a
loved one who had served in the Marine Corps. Thirteen percent were
grieving a loved one who had served in the Navy, six percent were
grieving the death of someone who had served in the Air Force, and
three percent were grieving the death of someone who served in the
Coast Guard or another area.
TAPS also engages in suicide prevention programs for its survivors.
As the Wall Street Journal reported in December 2012 in a front-page
story, there have been a handful of suicides among surviving families
of the fallen where a family has lost one family member to war, and
then a second family member to suicide.
Nearly all of the bereaved who come to TAPS seeking care and
support are grieving the traumatic, unexpected, and often violent death
of a loved one who served in the military or recently left military
service. Many of these families grieving a suicide have experienced the
additional trauma of finding their loved ones body or being present
when they died.
Suicide risk also goes up for the families left behind by our
veterans and servicemembers who die by suicide. While it is important
to note that suicide is never inevitable, family members grieving a
suicide loss are two to five times more likely to die by suicide
themselves.
It's very important that organizations undertaking work with
traumatized populations like TAPS does have in place good suicide
prevention protocols that ensure safety and support help-seeking. On
average, our 24/7 resource and information helpline receives at least
one contact from a survivor in danger of imminent self-harm per week.
Our online peer based support groups run 24/7 and are monitored by peer
professionals in case a survivor posts something concerning. If a
survivor is in crisis and appears to be in danger of self-harm, a TAPS
staff member can immediately reach out to this survivor to assess risk
and connect with support.
Additionally, the TAPS helpline occasionally receives calls from
servicemembers or recent veterans who are struggling and need care. We
have built a comprehensive support network that we can warmly connect
these servicemembers and recent veterans to, including chaplains, Vet
Centers and the National Veterans crisis line (NVCL).
My name is Kimberly Ruocco. I am the national director of suicide
postvention and survivor support programs at TAPS. I am also the
surviving widow of U.S. Marine Corps Major John Ruocco. My husband was
a decorated Cobra helicopter pilot who proudly served his country in
the Marine Corps for fifteen years. He died by suicide in 2005 while
preparing for his second combat deployment to Iraq.
I first came to TAPS in 2005 with my 8 and 10-year-old boys, Billy
and Joey. I was seeking help and support for my children and myself, in
coping with the death of my husband. He was my best friend and we had
been together for 23 years. My family was devastated and I did not know
how to begin to heal. The challenges were overwhelming. How do you tell
two young boys that their Dad, their coach, their hero made it home
safely from combat and then took his own life? How would I keep my
husband's death from defining his entire life? How would I keep my
children from seeing suicide as an option? How would I keep my children
from thinking that their Dad had chosen to leave them? These and other
questions propelled me on a journey to heal my family and gather
information and skills to help others and prevent suicide.
I have a master's degree in clinical social work from Boston
University and I used my education and experience to come to help me
understand how this could happen to my family. I read whatever I could
find on the subject, I talked to experts in the field and spoke to
survivors of suicide attempts. I reflected on our lives and worked to
assemble a timeline of how my husband's struggles developed and what
could have been done to save his life.
I came to understand that my husband was suffering from untreated
post-traumatic stress injuries and depression. The military culture and
his sense of who he was and who he was supposed to be conflicted with
asking for help. On the day he died, he was having difficulty
functioning in all areas of his life and he felt that this was all his
fault. He had been resilient for years, fighting off his injuries and
illness by exercising, praying, and giving back to his country,
community and family. On the day he died, his resilience had been
exhausted and he felt hopeless and helpless. He may have thought of the
words he lived by, such as ``death before dishonor,'' ``you are only as
strong as your weakest link,'' and of course ``Semper Fidelis.'' He saw
himself as the weakest link and the problem. He was supposed to re-
deploy in just a month and due to his struggles he was no longer able
to fly his aircraft. He worried that he was letting everyone down, or
worse, that he would get someone killed. As a Marine, he was used to
making life and death decisions in a split second. He was a problem
solver. He was fiercely loyal and cared for his Marines more than
himself. I believe that in that moment of intense emotional pain and
cognitive constriction he killed himself thinking that the world would
be better off without him. How wrong he was.
With the support and assistance of TAPS and their trained mentors
at the Good Grief Camp, my children and I began to heal and create a
healthy new life. Over time, more families came to TAPS grieving deaths
by suicide. I began to work with TAPS to create a program specifically
focused on helping suicide survivors grieving the death of a
servicemember or a recent veteran. We applied the best practices in
peer-based emotional support and created a support program at TAPS to
address the specific needs of military and recent veteran families
grieving a death by suicide. By 2007, we were receiving two to three
suicide survivors per week. By 2009, we were receiving, on average, one
or two suicide survivors per day. Now, the average is more than two
people per day who are grieving the death of a loved one by suicide. It
should be noted that there may be multiple people grieving each death
as TAPS provides care to parents, siblings, spouses, children and all
others who are grieving a death in the Armed Forces, and multiple
family members often come to TAPS hand-in-hand seeking help.
In 2012, TAPS sadly welcomed 931 people seeking care and support
grieving the death by suicide of a loved one who served in the
military. However, the true number is actually closer to thirty percent
of our total caseload, or around 1,400 to 1,500 people, because so many
families coming to TAPS tell us the cause of death was ``unknown,''
either because they are in denial or feel shame to say that suicide is
suspected, or because the death is under investigation and they are
waiting for the outcome of that investigation. Many of these
``unknown'' deaths are later ruled suicides.
The war in Iraq is now over and the war in Afghanistan is drawing
down, but the number of families coming to TAPS for bereavement support
continues to increase. While these wars had some of the lowest casualty
rates in our country's military combat history, there is no official
count of the impact on families left. Nor is there an accurate
accounting of the impact that many years at a high state of readiness
has left on our troops. At TAPS we also see increasing numbers of
bereaved military families and the families of recent veterans, who are
grieving deaths by suicide or accidental deaths following high risk and
self-destructive behavior. These ``accidents'' include high-speed head
on vehicle or motorcycle collisions with no signs of braking. We are
also beginning to see more families grieving deaths from sudden
illnesses linked to toxic exposure while deployed.
Recently we have seen at TAPS increasing numbers of veterans who
die by suicide within a couple of months or years of being discharged
from active duty service in the military. It is this population that
gives insights into the struggles that our veterans encounter in trying
to reintegrate into their communities. It also highlights weaknesses
and gaps in our system. While there are many veterans who receive
outstanding care and thrive, TAPS sees those families who could not
navigate the complex challenges of reintegration and lost hope. These
families come to us heavily grieving and asking the question I asked
myself, why?
One of the ways some families grieving a suicide cope with their
loss is by sharing with each other what happened to their loved one. I
have heard many families recount their narratives of what happened to
their loved ones over the years. This desire and need to share is part
of grieving and is part of the processing that many survivors do to
cope with their grief. In many cases, I have seen surviving families
gather voluminous amounts of information, interview people who were
close to their loved ones, and work very hard to answer a simple
question, ``why?'' It's a very legitimate question for our families to
ask. They wonder how their loved ones reached the point of dying by
suicide. Answering that question can take families years. Many of them
do not really begin addressing their grief until after they have
completed this information-gathering and fact-finding process.
I wish to submit our testimony with information gathered by our
surviving families in the wake of a suicide as part of their search for
clues and inquiries made to understand what happened to their loved
one. Families who come to TAPS, are traumatically bereaved after a
death. Our testimony does not offer success stories of lives saved and
deaths by suicide prevented, although many exist. Our families speak
from a place of loss and often can point out lapses in care and areas
for improvement so future deaths can be prevented and lives saved. Our
testimony should be viewed with this perspective in mind.
The focus of this hearing is on timely access to high-quality
mental health care. We believe that the experiences of our surviving
families and the information that they have gathered about their loved
ones and their treatment prior to their tragic deaths, can inform the
Committee's discussions about prevention efforts.
In order to properly explain the challenges that these military
families and their loved one faced, it is important to first discuss
what this journey can look like for a veteran who dies by suicide.
There are many variations to this story but there are common threads we
hear within them. Many of the families who come to TAPS grieving the
death by suicide of a recent veteran describe a similar scenario of a
servicemember who is discharged with the hope of making it in civilian
life, but instead face obstacles and frustrations that leave them
feeling unappreciated and forgotten. They struggle to succeed in all
areas of their lives--finding difficulty getting jobs, going back to
school, connecting with civilian peers, and communicating with their
significant others. If they suffer from illness or injury related to
their service, then this complicates matters further. If they do manage
to get a job, often concentration problems, sleep deprivation and
anxiety can make it difficult to maintain employment. They may begin
school to try to better themselves, but the combination of fighting for
reimbursement for classes and struggling with emotional and physical
challenges interferes with their ability to succeed.
At some point, the veteran may decide to go to the VA because he or
she is struggling and needs help. Often this happens after a long
battle and the servicemember's life is already falling apart and he or
she is very sick. The servicemember then contacts the VA looking for
help with his or her symptoms, whether it is addiction, anxiety,
depression, uncontrollable outbursts of rage, etc. This is a critical
time for the veteran. He or she may have shame about asking for help.
He or she may feel disconnected from his or her unit and military
peers. He or she has lost a sense of purpose and identity. He or she
may have a relationship breakup and/or legal and financial issues due
to their struggles. Very often the veteran's suffering is complicated
with combinations of physical and emotional pain including issues like
Traumatic Brain Injury, post-traumatic stress, depression, moral
injury, and survivor guilt. These issues become the veteran's own
personal barriers to care. In this population we see avoidance, anxiety
and trouble concentrating. Symptoms like panic attacks, flashbacks and
hyper-vigilance among this population of veterans are often described
to us by our surviving families.
These symptoms run counterintuitive to navigating a complex system
of paperwork, crowded waiting rooms, extended wait times for
appointments, referrals and disability ratings. The veteran enters this
system tentatively with trepidation and some fear. The veteran is
barely holding on. The veteran may feel like people do not understand
him and that the public does not appreciate what he or she has
sacrificed for this country. He or she may feel that his or her service
did not matter or that they are now unprepared for the civilian world.
He or she may feel as though he or she is losing everything that he or
she has worked so hard for. When the veteran asks for help, he or she
is desperate, and may be thinking of killing himself or herself because
he or she is losing hope that things will get better. This is the
composite profile of the veteran who dies by suicide, who initially
approaches the VA for help.
At this point, the veteran and his or her family need immediate,
comprehensive and quality care. One widow said to me ``It was like
finally making it to the people with the water after walking for days
in the desert without it. I wanted them to wrap their arms around us
and say ``we've got you now'' and give us water and clothes and
instruction on how to proceed. Instead, while we could see them, we
couldn't get to them, and when we finally got to them, they said ``you
can get water in two months'' and turned us away to wonder in the
wilderness once again.
In my testimony I will discuss: (1) how extensive wait time and
bureaucracy for initial mental health screenings, referrals to
specialists and complex disability ratings interfere with the mental
health and well-being of our veterans; (2) discuss the value of peer
based support in filling gaps; (3) highlight how national non-
governmental organizations can link veterans to mental health services;
and (4) offer recommendations for improvement.
It is important to state that our families are in every state of
this country and therefore are seeking services in many different VA
settings. I encountered many issues that were specific to only one
clinic or location, but I attempted to gather those examples that
demonstrated a common issue or struggle. The following stories were
gathered for the purpose of understanding some of the contributing
factors to the death by suicide of our veterans. These families are
presently under the care of TAPS.
A young Marine was discharged from active duty eighteen months
before he died by suicide in August 2011. He did not want to leave the
Marine Corp but while deployed to Iraq he suffered from multiple
physical and emotional issues that were so severe that he was sent home
half-way through his deployment. Back in the states he continued to
struggle and was eventually ``medical boarded out.'' He had a young
family with a fiance and a little daughter. His fiance and his parents
tell us that he had a lot of difficulty ``making it'' when he got out.
He had dizzy spells and anxiety attacks. He had difficulty sleeping and
would wake up in a cold sweat with nightmares. His fiance states that
she tried to talk to him about his nightmares and all he would say is
``I've never seen so much blood.'' She asked ``in Iraq?'' and he said
``yes'' but he would not elaborate.
She encouraged him to go to counseling and he would say ``we don't
do that, I need to suck it up.'' He also expressed fear about what
would happen to him if he went for help. He worried, ``What would they
do?'' He questioned why he needed to go while his peers didn't seem to
need help and they had stayed for the whole deployment. He felt he was
weak and should be able to handle it. In the meantime he couldn't get a
job, his finances were suffering and his family was depending on him.
He went to his parents for financial help because he was six months
behind on his truck payment. He became more and more depressed and had
angry outbursts.
His fiance finally convinced him to call the VA. He called and
asked for an appointment stating that his life was falling apart and he
was depressed and anxious. The first appointment was two months away.
He got a mental health evaluation and a referral to a psychiatrist. His
fiance states that ``it took a long time to see him.'' He saw a
psychiatrist approximately two months before his death. He was put on
medications and according to his family was not offered counseling or
peer-based support and he also did not have a follow up appointment.
His fiance states that he did not improve on the medication he was
placed on. In fact, he complained a lot about how it made him feel. The
night before he killed himself he called his Dad and said that the VA
``put him on medications'' and he just ``felt worse.'' He stated that
he just wanted to talk to someone else who had been through the same
thing. His fiance was six weeks pregnant when he died. She has been
denied survivor benefits for his children because there is not enough
proof that his death was connected to his military service.
The parents of another Marine veteran came to us for support after
their son died by suicide in November 2012. Their son served eight
years in the Marine Corps and was honorably discharged. He had a one
year deployment as a diesel mechanic. According to his parents he had a
successful career in the Marines but had a lot of difficulty
transitioning in to the community. His parents state that he was
diagnosed with post-traumatic stress and Traumatic Brain Injury before
he was discharged from the military. He was given a number and told to
contact the VA. His Dad says that his son had a lot of trouble
``getting on his feet'' and said that his son had trouble
concentrating, experienced difficulty sleeping, and had a lot of
anxiety. He applied for a number of jobs but could not get one. He
enrolled in school but the paperwork for the tuition was daunting and
seemed impossible for him to complete. His classes were canceled due to
non-payment. His parents finally convinced him to go to the VA and ask
for help. He was given an appointment for the next month. At his
appointment he was given referrals for a specialist for the Traumatic
Brain Injury and depression but the specialist was located an hour and
a half from where he lived and it was months before the first
appointment could be scheduled. His parents feel that their son lost
hope and felt disconnected from his Marines. They state that they
wished they knew more about how to help him and could have been
involved in his treatment.
A wife of an Army veteran came to us for support after her husband
died by suicide in December 2012. She stated that her husband had a one
year deployment to Iraq and was ``completely different when he
returned.'' He separated from the Army in 2010 after the two of them
decided it would be better for their family. One week after his
discharge she went looking for him in the house and found him on their
deck with a gun and ``a crazy look in his eyes.'' She called his name
but he would not respond. She became extremely frightened and called
the police. The police responded and he was charged with ``felony
menacing.'' After meeting with the lawyer, the lawyer suggested that he
may have post-traumatic stress and should go to the VA. His wife stated
that they contacted the VA and were given an appointment for one month
out. She claims that days before the appointment the VA called and
rescheduled for another month away. She states that he attended the
appointment and was offered medication which he refused to take. After
several attempts, she was able to get him into counseling. She claims
that the time and paperwork it took to get to the counseling was
``overwhelming.'' For about a year her husband went to counseling and
he seemed to be getting better. She states that she wishes the
counseling were more often and included her and maybe a support group.
She claims that due to the wait for appointments and cancellations and
rescheduling he only went to five appointments in a year. Six months
before his death his counselor left the VA. His wife says that the
appointment was canceled with no follow up. His wife claims that they
were under a lot of stress at the time with financial, legal and
relationship issues. She was worried about him and feared that things
were going to get worse. She states that her husband was suffering with
anxiety and depression. She claims that in the first week of
December 2012 her husband called the VA and said he needed an
appointment. He was told the first available appointment was
January 18th. On December 29th this young widow says she and her
husband had a good evening. They talked about their future and he moved
the furniture out of the living room so that they could dance together.
After dancing he went to bed first and she went to join him about an
hour later. When she got into bed she saw that ``crazy look in his
eyes'' and noticed that he had a gun. Before she could react he shot
himself in the head and died instantly. This widow tells us that she
wishes that the care was more consistent and focused more on why he was
acting this way instead of treating his symptoms. She also wishes that
they could have worked on his problems together as a couple in a
consistent and comprehensive manner.
A surviving father who came to TAPS and was grieving the death of
his veteran son by suicide, who is himself a veteran, and he talked
with me about his and his son's experiences accessing care through the
VA. I think this case illustrates some of the challenges in providing
quality mental healthcare. The stressor of his son's suicide was so
severe, that the father's own service-connected post-traumatic stress
re-emerged. The father went to the VA seeking help and waited for four
months to get a mental health evaluation. After the evaluation, he saw
a counselor once a week and things seemed to stabilize for him. But
every few months, the counselor would change and he would have to start
all over again. The breaking of the bond with the counselor has
hampered his healing. He became depressed. He requested to see a VA
psychiatrist six months ago, and is still waiting for an appointment.
He tells TAPS that he feels abandoned. This father's son had been
medically discharged from the Army at Fort Hood after two combat
deployments overseas where he saw two of his friends blown up. All that
was left of one of his friends was his glove, which he photographed and
carried on a photo in his wallet. The young soldier attempted suicide
immediately after his discharge from the military. His veteran father
and his mother took him to the VA after the suicide attempt seeking
care and help. He received inpatient care and outpatient treatment but
there were wait times to get him appointments and into care. While the
care for the young soldier addressed some of his mental health needs,
his father felt the care never addressed the loss of his friends and
the grief and pain he was carrying over their deaths in combat. The
young veteran lost his job and a significant relationship, and then the
young veteran died by suicide fourteen months ago. His father began to
cry when he shared with us that he took in two neighborhood teens that
had lost their parents. He mentored them and convinced them to join the
military. One of them just returned to his home because he is getting
divorced and is suffering from depression and lost his job. He is
attempting to get him ``in at the VA.''
In the past five years, significant expansion of specific services
to benefit returning Veterans has occurred at the VA. These services
include: VA Vet Centers that are staffed by clinicians who are veterans
themselves and Suicide Prevention Coordinators as well as the peer
partners program and clinic specifically for issues such as post-
traumatic stress.
After talking to these families and many more, it became clear that
there are many promising programs and outstanding clinicians at the VA,
but we must do something to ensure that our veterans can get the kind
of comprehensive quality care they need in a timely fashion. We must
also look at the kind of care we are giving for the type of injuries
and illnesses they are suffering from. We must not only address the
symptoms but provide care that helps heal the cause of the symptoms. I
have spoken at many military bases to thousands of troops. I have never
left one of those presentations without a Soldier, Marine, Airman or
Sailor coming to me in tears and saying ``I just want to talk to
someone who has been there, who knows what this is like.''
We have found at TAPS that peer-to-peer support plays a key role in
helping traumatized families find healing and comfort. We also find
that peer-to-peer contact opens up lines of communication and helps
families better access the support and services they need. Similarly,
veterans also benefit from peer-to-peer connections.
We believe that peer-based support can help maintain an umbrella of
care for our veterans that is critically needed. We believe that peer-
based support can provide a needed safety net for veterans who may be
waiting for appointments or waiting on benefits.
VA Vet Center treatment can be successful when it is grounded in a
veteran-connection that gets established between a veteran clinician
and the veterans who use the service. TAPS is very familiar with the
services offered by the VA's Vet Centers. Many of our survivors are
eligible for bereavement counseling through the Vet Centers and find
these services have proven to be a helpful part of their journey toward
healing.
Peer support can play a powerful and transformative role when
coupled with treatment. The VA has begun to implement many peer-based
programs and veterans tell me that this has been invaluable in helping
them ``keep it together'' especially while waiting or in between
appointments. The ``peer partners program'' is one such program. I work
closely with one of these peers who has made it his life's work to
advocate and support veterans. He became a trained peer partner through
the VA and is available whenever a veteran is in need.
He recently told me about a young veteran who was discharged from
active duty and was suffering from severe post-traumatic stress and was
self-medicating with alcohol. His life was spiraling out of control, he
couldn't find a job, he lost his home, and his wife left him. His post-
traumatic stress symptoms kept him from going to the VA because of the
crowds and his avoidance and anxiety. He made one attempt to get care
and became overwhelmed with the paperwork and the wait. The peer
partner was called because another veteran thought this veteran was
suicidal. The peer partner was able to escort him to the VA, help him
fill out the paperwork and secure an appointment which was scheduled
for a date in three months. The peer partner then took him to a home
for homeless veterans and got him a room. While waiting for his VA
appointment, the peer partner was able to get the veteran into free
counseling at the Andrews center, a private mental health center that
got a grant from the State of Texas to provide free counseling to
veterans. This veteran now had weekly counseling appointments, peer-
based support groups and a place to live. Six months later this veteran
was enrolled in a specialized post-traumatic stress clinic at the VA
and was doing very well. What I love most about this story is the
healing and sense of purpose the peer partner found in helping another
vet.
There are limitations to the VA Vet Centers which can be addressed.
Their capacity is stretched for staffing, and there are not enough
centers, particularly in geographically challenging areas in the Mid-
West and West. I know of a surviving sibling who drives over one
hundred miles roundtrip to see her Vet Center counselor for bereavement
counseling support and across a state line because that is the closest
location to her home. In addition, the prioritization given to deployed
or combat veterans limits the support available at the Vet Centers for
the non-combat veterans in crisis who may also need access to care.
Unfortunately, staff turnovers at the Vet Centers have often
impacted peer-based support programs, like veteran support groups and
support groups for their families. A family of a veteran who died by
suicide shared with TAPS that the veteran was in despair after his
peer-based support group at the Vet Center stopped meeting because the
Vet Center did not have anyone on staff to run it. ``I miss going to my
group,'' is what the veteran said to his family. His family was also
missing the peer support they found at the Vet Center in a support
group that was structured for their needs. Sadly, the veteran died by
suicide.
Because peer support can play such an important role in helping
veterans we need to look at other ways it can be offered. Much synergy
and better service could be provided by VA Vet Centers if there was a
direct connection between the VA Vet Centers with a veteran peer
support line such as Vets4Warriors where Vets4Warriors could bridge the
gap in capacity (before and between appointments) and geographic
access.
Vets4Warriors, funded by the Department of Defense as a 24/7
Veteran peer support help line, has fielded more than 55,000 incoming
and outgoing calls, chats and emails since Dec 2011. The majority of
callers, more than 63%, are routine callers who are looking to connect
with another veteran and get information about VA benefits and
entitlements or employment/financial/legal/counseling resources. They
are not in crisis and can benefit from peer-based support. All callers
receive follow up calls if they give permission. Vets4Warrriors has
also made initial calls to the soldiers in the Individual Ready Reserve
(IRR) with great success (70% of those contacted wanted follow up).
Vets4Warriors has an established, formal referral relationship with
the National Veterans Crisis Line (NVCL) where warm transfers are made
for the small (less than 2%) number of callers in crisis. The
partnership between the NVCL and Vets4Warriors has yielded benefits for
the veterans utilizing both call lines in that the NVCL transfers all
non-crisis or non-emergent callers that just want to connect with a
veteran peer. Additionally, Vets4Warriors has a unique capability,
because of the follow up provided to callers to further support the
NVCL with follow up calls to those veterans who only called the NVCL
and were at risk.
Many other amazing non-profit organizations have also emerged to
fill these gaps in service. One such organization is ``Give an Hour.''
This organization, founded by Dr. Barbara Van Dahlan, provides free
mental health care services to US military personnel and families
affected by the current conflicts in Iraq and Afghanistan.
Thank you for the opportunity to submit this testimony on behalf of
the Tragedy Assistance Program for Survivors (TAPS).
Chairman Sanders. Ms. Ruocco, thank you very much for your
testimony.
Kenny Allred is a retired U.S. Army Lieutenant Colonel and
Chair of the Veterans and Military Council at the National
Alliance on Mental Illness.
Thank you very much for being with us.
STATEMENT OF KENNY ALLRED, LTC, USA (RET.), CHAIR, VETERANS AND
MILITARY COUNCIL, NATIONAL ALLIANCE ON MENTAL ILLNESS
Colonel Allred. Chairman Sanders, Ranking Member Burr, and
distinguished Members of the Committee, NAMI, The National
Alliance on Mental Illness, is grateful for the opportunity to
share our views and recommendations regarding the VA mental
health care ensuring timely access to high-quality care.
As my full statement is part of the record, I offer this
summary.
NAMI applauds the Committee's continued dedication in
addressing veterans' mental health care issues and looks
forward to working closely with the Committee.
NAMI is the largest grassroots mental health organization
in the Nation dedicated to building better lives for the
millions of Americans, including warriors, veterans, and their
families, affected by mental illness. I am proud to lead the
NAMI Veterans and Military Council.
I am a retired U.S. Army officer with service from 1970 to
1990 as an Army airborne Ranger infantry officer, Army aviator,
and military intelligence battalion commander of a mixed-gender
unit.
I am a member of The American Legion, Disabled American
Veterans, Military Officers, Association of America, and
AMVETS; and I have used the VA health care system for 23 years.
I offer the following key points. It is critical that our
scarce resources have full and transparent accountability. We
fully support VA adoption of the recommendations in the fiscal
year 2014 Independent Budget while keeping stakeholders fully
informed.
NAMI also urges increased funding for research to keep pace
with other areas of VA spending particularly with respect to
stigma reduction, readjustment, prevention, and treatment of
acute post traumatic stress and substance abuse and increased
funding and accountability for evidence-based treatment
programs.
Veteran unemployment is higher than civilian unemployment
and is especially high among our younger veterans. For our
National Guard and Reserve, many of them in remote and rural
areas, military service often is their only employment and many
are not eligible for VA benefits and health care. NAMI supports
hiring preferences for all who have served.
NAMI believes that the key to reducing stigma and
strengthening suicide prevention is a change in our approach.
It is absolutely unacceptable that veteran suicides have grown
from 18 to 22 a day in the last 10 years.
In 2012, suicide deaths among soldiers, many of whom who
had never deployed, were higher than combat deaths. We strongly
support parity, accountability, collaboration, and action to
end the stigma of seeking mental health treatment.
NAMI also believes that award of the Purple Heart for all
combat-induced wounds will encourage veterans to seek treatment
for mental wounds and reduce stigma and suicide.
Leaders at all levels must be held accountable on written
performance evaluations for eliminating stigma, hazing,
bullying, and suicide. VA providers in all health disciplines
must proactively encourage veterans to seek mental health
treatment.
Collaboration to end the stigma of seeking help for
invisible wounds of military service, including sexual trauma,
is essential. The NAMI-VHA memorandum of understanding for
training at VHA facilities should be expanded.
Finally, action is needed to energize those throughout the
VA system to improve and encourage mental health and expedite
claims processing. Technology to consolidate appointments and
reduce travel expense and risks, to deliver counseling via
distance means, increase the community providers to create a
hometown stake in veteran recovery, and build a sense of
ownership for the total cost of military service, diagnose
veterans within 14 days of their mental health complaints and
approve compensation and pension claims for veterans with a
diagnosed mental illness within 30 days, expand outreach to
underserved populations including women, student veterans,
older veterans, and other diverse populations.
Additional recommendations are in my written statement.
Mr. Chairman, in summary, barriers to veteran mental health
treatment can be eliminated and recovery is possible. We must
end the epidemic of veterans suicide that is now at the
horrific rate of almost one in each hour.
The long-term cost of unmet veterans' mental health needs
will be significant especially if the government does not act
now.
Thank you for this opportunity to offer National Alliance
on Mental Illness views to the Committee. We look forward to
working with you to improve the lives of all veterans and their
families living with mental illness.
[The prepared statement of Colonel Allred follows:]
Prepared Statement of LTC Kenny Allred, U.S. Army (Ret.), Chair,
Veterans and Military Council, The National Alliance on Mental Illness
(NAMI)
i. introduction
Chairman Sanders, Ranking Member Burr and distinguished Members of
the Committee, On behalf of NAMI (The National Alliance on Mental
Illness) I would like to extend our gratitude for being given the
opportunity to share with you our views and recommendations regarding
VA Mental Health Care: Ensuring Timely Access to High-Quality Care.
NAMI applauds the Committee's continued dedication in addressing the
critical issues surrounding mental health care and NAMI looks forward
to working closely with the Committee in addressing these and other
issues throughout the 113th congressional session.
NAMI, the National Alliance on Mental Illness, is the Nation's
largest grassroots mental health organization dedicated to building
better lives for the millions of Americans affected by mental illness.
NAMI advocates for access to services, treatment, support and research
and is steadfast in its commitment to raising awareness and building a
community of hope for all of those in need.
Historically, NAMI has recognized the psychological needs of
veterans and their families. In recent years NAMI has moved
aggressively to position itself to address the needs of our newest
veterans who require post-deployment services essential to maintaining
or restoring a state of mental well-being for themselves and their
families.
NAMI honors veterans and their service to our country and endorses
the Independent Budget and our Veteran Service Organization colleague's
efforts to independently identify and address legislative and policy
issues that affect the organizations' memberships and the broader
veteran's community.
NAMI's Veterans and Military Council (NVMC) is organized under the
authority of the NAMI Board of Directors to ensure that the requisite
attention is given to veterans' mental health issues and to advise the
Board on measures to improve the continuum of care for veterans and
their families. Members of the Council are from virtually every state--
including those which you represent, and work voluntarily in
cooperation with NAMI state and local leaders. Most of our Council
members are former military or family members and many conduct free
NAMI training programs--including our Family-to-Family twelve week
course offered at many VA centers around the Nation pursuant to a
Memorandum of Understanding between NAMI and the VA dating back to
2008. A description and status of that MOU is an appendix to this
testimony.
I am the nationally elected Chair of NAMI's Veterans and Military
Council. I am a retired U.S. Army Officer, with service from 1970 to
1990. I am a former classroom high school and college teacher. I am
trying to be a Tennessee farmer, but spending much of my time
volunteering as a mental health advocate focusing warriors, veterans
and their families. I have utilized the VA health-care and, until
recently, the dental care system for twenty-three years. I have the
honor to lead a team of volunteer veteran advocates, including Clare,
our Secretary from Vermont; MOJO, our first Vice President from
Missouri and Samuel, our Second Vice President from North Carolina. We
meet via a monthly conference call with our State Representative
members who send you greetings and appreciation from throughout the
Nation. Our volunteers are extremely dedicated--``Amy from Hawaii''
joins our monthly calls at 7:00 a.m. with a cheery ``Aloha'' when many
of us are starting our afternoon.
I am a former Army Airborne Ranger Infantry Officer, opposing force
commanding officer, Military Intelligence Battalion Commander of a
mixed-gender unit with service in the Middle East before Desert Storm.
I am also a former helicopter and fixed wing US Army aviator who flew
reconnaissance aircraft missions against both Cold War and combat
targets. I was awarded the Armed Services Expeditionary Medal and the
Joint Meritorious Unit Award for our team's significant classified
intelligence work.
I am a graduate of the Military Intelligence Officers' Advanced
Course, the Mohawk Aircraft surveillance and reconnaissance course,
Army Photo Interpretation School, U.S. Air Force Defense Sensor Course,
U.S. Army Command and General Staff College, Tennessee Tech University
(BA, Marketing) and Kansas University (MS, Middle East & Russian
History and Remote Sensing).
I served in Europe, Australia, Central America, Asia and the Middle
East and as a force integration staff officer and congressional
briefing writer at the Pentagon. I am published in both Military
Intelligence and in Military Review Magazines. I developed instruction
and taught for the Australian Schools of Military Intelligence and
Aviation, U.S. Army Intelligence Center and School, Roane State
Community College and University of Tennessee Medical Center in both
personal contact and interactive distance learning settings. After
military retirement, I taught leadership to young men and women high
school students for fourteen years in our Army Junior Reserve Officers
Training program at two rural Tennessee high schools.
I am a member of the American Legion, Disabled American Veterans,
Military Officers' Association of America, AMVETS and the League of
Women Voters. I served as Chair of the Tennessee Governor's Veterans'
Task Force and currently serve as a member of an Inter-agency
Behavioral Health Advisory Council and as a member of a Crisis
Intervention Team advisory group representing veterans' interests to
the law enforcement community. In 2009, I received the NAMI Tennessee
President's Award for my mental health advocacy efforts. I live and
farm in East Tennessee.
ii. more accountability in how the va spends mh dollars
It is critical that our very scarce resources have full and
transparent accountability. Every dollar spent is a reflection of the
total cost of military service. NAMI fully supports the Independent
Budget--the diligent effort of our collaborative Veteran Service
organizations, and agrees that Congress should require the VA to
develop performance measures and provide an assessment of resource
requirements, expenditures, and outcomes in its mental health programs,
as well as a firm completion date for full implementation of the
components of its reformed program and the full Uniformed Mental Health
Services package. NAMI also agrees that the VA should provide periodic
reports that include facility-level accounting of the use of mental
health enhancement funds, with an accounting of overall mental health
staffing, the filling of vacancies in core positions, and total mental
health expenditures, to Congressional staff, veterans service
organizations, and the VA Advisory Committee on the Care of Veterans
with Serious Mental Illness and its Consumer Liaison Council.
Particularly important is the need to increase research funding
which has not seen the increases in the same manner as other areas of
VA spending at a time when the VA budget has been fully funded and
beyond. The VA should conduct health services research on effective
stigma reduction, readjustment, prevention, and treatment of acute Post
Traumatic Stress Disorder and substance-use disorder in combat
veterans, and increase funding and accountability for evidence-based
treatment programs. VA should also conduct an assessment of the current
availability of evidence-based care, including services for PTSD;
identify shortfalls by sites of care; and allocate the resources
necessary to provide universal access to evidence-based care.
iii. veterans preferences in hiring
A key ingredient of psychological health is the feeling of self-
worth from productive employment. Sadly, veteran unemployment, which is
higher than civilian unemployment in all age groups across the Nation,
is especially high among our younger veterans. And among our National
Guard and Reserve, many in remote, rural areas, military service often
is their only employment. Unfortunately those National Guard and
Reservists are not eligible for Veteran health benefits unless they
have been activated for Federal service. They account for fully 25% of
the suicides of those in uniform.
NAMI advocates strongly for Veterans health benefits and for
psychological service providers as embedded advisors in all of our
National Guard and Reserve units. NAMI also advocates for hiring
preferences for veterans in the civilian workforce. On the bright side,
many civilian employers are now recognizing the value of employing
Veterans and are stepping up with preferential hiring and some are even
guaranteeing employment to any veteran. This is good for the hiring
companies, good for the economy and good for the veterans and their
families. The trail of unemployment is often financial and family
troubles are often followed by depression, withdrawal and isolation and
sometimes suicides.
Many of our Veterans have received top flight training to become
certified in occupational areas such as Medic or Mechanic, but the
military certification is often not recognized in the civilian
community. Thus, these Veterans must start anew at the beginning of
civilian training to qualify for state certification and land a job
immediately based on military certification. This exclusion and
discrimination should end and veteran skills, especially in technical
and technology areas. Military training should be put to immediate use
and veterans should be given preference in hiring and extra points on
government exams with a guaranteed interview for any local, state or
Federal job. Local, state and Federal Governmental entities that do not
recognize these preferences for veteran hiring, and who have any form
of Federal funding, should be strongly encouraged to change their
policies. Consideration should be given to having Federal funds
withheld until their hiring practices include preferential status for
veterans.
Veterans hiring preferences should include the spouses of deceased
and disabled veterans and special attention and help should be given to
the nearly three hundred thousand caregivers who are already working
full time in the home to care for r those they love. This is often done
at the sacrifice of their own jobs and income.
To be sure, I have seen many examples of caring that have helped
veterans in need. One example is a friend of mine, Joe, who had both of
his legs blown off by an improvised explosive device on his second tour
of duty in Iraq. Joe and his wife were overwhelmed and feeling hopeless
by his lack of job prospects upon his return I spoke with a VA manager,
Deb. Who took it upon herself to take instant action both to ramp up
Joe's care within the VA and to use her civilian job contacts to help
Joe find a job. Today, Joe, his wife and their two daughters are
enjoying family life near Nashville, TN. Thank you Deb for your
kindness!
iv. reduce stigma and strengthen suicide prevention
NAMI believes that the key to reducing stigma and strengthening
suicide prevention is a change in the way we approach these problems.
It is absolutely unacceptable to be applying the resources we have for
the last ten years and to see suicides grow at a rate of twenty-percent
among veterans from eighteen to twenty-two a day. Many of these
suicides are occurring among those who have never been in combat. In
2012, suicide deaths among soldiers were higher than combat deaths. We
strongly support parity, accountability, collaboration and action to
end the stigma of seeking mental health treatment both in our active
forces and among our Veterans and National Guard and Reserve as a means
to reduce stigma and suicide. NAMI's recently issued ``Parity for
Patriots'' report is enclosed for the record and contains a number of
recommendations for addressing stigma and strengthening suicide
prevention.
Parity must be given to all wounds, physical and mental, whether
from combat or other forms of trauma and injury. Sexual trauma and full
access to health services for all victimized by this crime is a
particular NAMI concern. As the former Battalion Commander of a mixed-
gender unit with males and females at the ``front line of troops'' I
know that all warriors will do their duty in a professional manner when
given opportunity and caring leaders, and it is unconscionable for any
to be distracted or victimized by the crime of sexual trauma. NAMI
applauds the work of the Committee to stop the crime of sexual trauma
and punish the perpetrators.
We also believe that award of the Purple Heart for combat induced
physical and mental wounds will legitimize the equality of the mental
or invisible wound and encourage veterans to seek treatment. Some
oppose this award on the basis that the mental wound cannot be seen,
but with the approval of the Purple Heart for combat induced Traumatic
Brain Injury the way is open for the next step toward de-stigmatizing
mental wounds of war. Rather than be associated by the regulations in
the same category as ``trench foot,'' Post-Traumatic Stress and other
mental wounds of war should be accorded the honor of being classified
as a legitimate combat wound. Congress, the President or the Department
of Defense have authority to make this change and should do so now to
achieve parity and equality of all combat induced wounds.
Accountability must be accepted by leaders at all levels for any
stigma, bullying, hazing, suicide or denial of mental health services.
Though many publically support the need for mental health, there is no
formal mechanism for holding leaders accountable in a standardized,
systemic manner, and there have been instances of leaders seeming to
ridicule those who showed the ``weakness'' of taking their own lives.
Performance evaluations should immediately and specifically include
measurements of how leaders are or are not ending stigma, bullying,
hazing and suicide.
Leaders focus on the areas that affect their careers and job
security, and they will find a way to reduce the epidemic of suicide if
held accountable on evaluation reports. In the system of VA care, there
are often ``silos'' especially in the specialty care areas that are
either derisive or dismissive of the reality of wounds such as Post
Traumatic Stress. This may be seen in the callous remarks of someone
who is not a provider of mental health services or in directives from a
VA Dental Chief to deny certain treatments to veterans with mental
health conditions. An example of one such communication to a community
fee basis provider from the VA is offered for the record as part of
this testimony. The impression of that provider of the deteriorating
relationship with VA affecting the care of patients is also enclosed
and is a courageous statement given the power of VA approval for
payment of community providers.
Collaboration in combatting the stigma of seeking help for
invisible wounds of military service is essential and is certainly
represented well by this Committee's invitation to testify today.
Another excellent example of collaboration is NAMI's partnership with
AMVETS to establish organizational relationships from local to national
level and bring veterans and mental health advocates together. We
expect this to be the first of many Veteran Service Organization
collaborations to bring the synergy of organizations with the common
interest of veterans, and particularly veteran's mental health,
together. An additional excellent and appreciated collaboration is the
VA Office of Mental Health Services quarterly stakeholder meeting to
gather information and discuss veterans mental health needs.
NAMI is also appreciative of a vigorous interaction with the mental
health providers of the Office of the Army Surgeon General. Whether in
combat or peacetime settings, our warriors, male and female and our
veterans deserve respect, honor and gender appropriate privacy when
seeking or receiving care. Unfortunately, many of those who wear or
have worn the uniform have been subjected to sexual trauma that has
been left untreated and has its own particular brand of debilitating
stigma. This is absolutely unacceptable and NAMI recognizes with
approval the efforts made by this Committee to hold accountable those
who perpetrate this unspeakable crime. I have had the honor of
commanding wonderful soldiers of both genders, and those who know this
crime will not be tolerated always perform well even in mixed units in
field settings.
Finally, action is needed to energize those throughout the VA
system to take charge in a positive manner to improve the health care
and claims processing that is deficient and slow creating tremendous
backlogs. VA employees should be empowered to say ``yes'' but not
``no'' at the lowest levels. ``No'' should only be the response of the
equivalent of a field-grade officer. A great deal of power is bestowed
on those making decisions about health care and veteran compensation
and pensions and progress has been made with the latest rulings on
documenting mental wounds, but more must be done to move claims faster.
Current technology can be leveraged to consolidate appointments and
reduce travel expense and risk and to deliver counseling via distance
means such as computers and telephones. Adding community based
providers as a major component of treatment offers hometown service
with a hometown stake in the recovery and builds a sense of ownership
for the total cost of military service. Relaxing barriers, possibly by
sharing phone numbers and first names for those who choose, and
encouraging more direct veteran communication and interaction could be
a helpful step short of professional counseling, group therapy or a
crisis line and allow shared experiences, sometimes across generations
of veterans to help with the mental healing process and reduce stigma.
Some believe that VA use of a veteran's former rank when providing care
would honor the service and sensitize providers to that veteran's
service.
A concern expressed by some veterans as a significant and possibly
growing barrier to seeking treatment by VA or identifying themselves as
having conditions such as Post Traumatic Stress, is the fear that they
will lose their right to own or possess a firearm solely due to
receiving mental health care. For example, there are reports that
veterans who have a fiduciary representative appointed are identified
by the VA as not being permitted to possess firearms. Were the VA to
publicize that this is not the case, it would help assuage the fears of
these veterans and encourage them to seek treatment. NAMI supports
access to mental health services for all without denial of any
constitutional rights only because of treatment for mental illness.
NAMI has long been and is proud of being an advocate for a diverse
population of veterans who, as conscripts or volunteers, have defended
America's freedom. We express our support for veterans of all ages--
some of whom have special language or cultural needs and who come from
a variety of ethnic groups and lifestyles. With older veterans having a
suicide rate twice that of younger veterans, it is particularly
important to find a way to mix and strengthen the entire veteran
population. VA help in this endeavor is requested. For the veteran
organizations to which I belong, it is common to attend meetings with
an aging group, dwindling in number and on a path to extinction unless
we find a creative way to ``pass the torch'' to those who follow us.
Finally, attached as an appendix is a summary of ``Talking Points''
delivered by NAMI's Veterans and Military Council at the White House
Interagency Task Force on Mental and Veterans Mental Health is
enclosed.
These recommendations include:
Holding military and civilian leaders accountable for
bullying, hazing and suicide by way of the performance rating system.
Current Combat Lifesaver Training should include training and a
qualification badge for Mental Health First Aid
Reviewing Personality Disorder and Adjustment Disorder
discharges with a view to establishing veterans' benefits for those who
do have or may have had legitimate mental illness, if properly
diagnosed at the time
Promoting coalition building and collaboration with
Federal, state and local government agencies, Veteran Service
Organizations, for profit organizations, non-profit organizations and
communities to enhance outreach to veterans and military families to
decrease the impact of psychological wounds of military service
Collaborating to improve access, training and utilization
of veteran families, peers, and housing. Consider use of Neurofeedback
treatment, and improve access to and certification of service animals
to avoid crises
v. address appointment wait times
We should provide broader and quicker care (within 14 days) for
veteran mental health complaints. Resolution of these complaints should
be fast-tracked (within 30 days) and decisionmaking and approval of
compensation and pension claims for veterans with a diagnosed mental
illness should be decentralized. Authority to deny claims should occur
only at the highest levels. Outreach to underserved populations,
including women and other diverse populations, should be expanded.
In Tennessee, I have seen promising models that fall outside the
traditional, expensive VA system of care. For example, telemedicine,
self-help groups, peer counselors and NAMI In Our Own Voice training to
share the journey of recovery and heal. Reaching veterans in rural
areas that may not have VA facilities is particularly a problem.
Providing VA resources to Community Mental Health Centers and other
non-VA mental health services could help to address this problem. Under
a Memorandum of Understanding (MOU) originating in 2008 with the
Veterans Health Administration (VHA), NAMI offers Family-to-Family
Education Program (FFEP) in select VHA facilities across the country.
The NAMI FFEP is a free 12-week course for family caregivers of
individuals with mental illness, taught by trained family member
volunteers, using a highly structured and scripted manual. In weekly 2
to 3 hour sessions, family caregivers receive information about mental
illness, treatment, medications, and recovery. There are many other
community agencies providing treatment and services to veterans with
Post-Traumatic Stress and other mental disorders that fall outside the
VA system.
Attention must also be given to addressing the health and mental
health care needs of National Guard and Reservists who are not
considered ``veterans'' despite their service. These individuals have
frequently experienced the same challenges and trauma as those in the
more traditional branches of the military.
Consider use of fee-based psychological services, including
telephone counseling, for psychologically homebound veterans and those
in rural and other remote areas--to include National Guard and Reserve
who have not been activated for Federal service and are not considered
veterans.
Recovery from PTSD and other mental illnesses requires more than
medical treatment. Housing, employment, substance abuse counseling, and
other psychosocial supports are also key to recovery. A national policy
giving special preference to veterans in interviewing and hiring for
jobs would be a significant step in the right direction. Veterans
should also be given preference and subsidies for appropriate housing
and landlords, particularly in rural areas should be encouraged to
provide housing at a reduced rate with preference for housing subsidy
priorities.
The national scourge of homeless veterans, many of them with mental
health issues, must end as promised by Secretary Shinseki.
Additionally, student veterans who often have difficulty fitting in
with the more traditional student population, and drop out of higher
education and training at a greater rate than non-veterans, must
continue to be provided with adequate and timely financial support and
counseling services.
Continue Federal programs which support veteran employment and
hiring preference, and encourage state and local governments to
continue and or adopt preferential hiring practices for veterans--to
include National Guard and Reserve who have not been activated for
Federal service and are not considered veterans.
vi. summary
Barriers to treatment of veteran mental health issues can be
overcome and recovery is possible. Some barriers can be resolved
easily, while others will take much time and effort to resolve. Some
barriers will likely never be completely resolved, but all of us must
keep trying to end the epidemic of veteran suicide that has taken more
lives than those killed in Vietnam and continues at the unacceptable
rate of almost one each hour.
NAMI will continue to play a vital role in increasing awareness of
the critical link between treatment, successful re-integration, and
living a productive life. We agree that the long-term societal costs of
unmet veterans' mental health needs will be significant--especially, if
the government does not act now.
The National Council for Behavioral Health's November 2011 Report
on Meeting the Behavioral Health Needs of Veterans of Operation
Enduring Freedom and Operation Iraqi Freedom summarizes best what
specific action needs to be taken and is enclosed:
To fulfill our national obligation, we need a mandate and the
funding to deliver proper outreach and assessment techniques
and evidence-based treatments for our veterans. This effort
must occur where veterans receive care--the behavioral health
care systems of the Department of Defense (DOD), Department of
Veterans Affairs (VA), and community-based care including the
Nation's system of Community Behavioral Health Centers.
Accomplishing this will save lives and money.
Thank you for affording me this opportunity to testify before you
today.
______
Response to Posthearing Questions Submitted by Hon. Richard Blumenthal
to Kenny Allred, LTC, USA (Ret.), Veterans and Military Council Chair,
National Alliance on Mental Illness (NAMI)
Question 1. Your testimony recommends including Mental Health First
Aid in current combat lifesaver training. Many of us on this Committee
are familiar with the immense benefits of this kind of training. As you
may know, I recently joined Senator Begich, Senator Ayotte, and a
bipartisan coalition of our colleagues (including Senator Tester, who
also sits on this Committee) in introducing the Mental Health First Aid
Act of 2013 in the wake of the Newtown tragedy. This legislation
provides resources for training programs to help people like school
officials, law enforcement professionals, and emergency personnel
identify, understand, and safely address crisis mental health
situations. Though this legislation is not necessarily directed at
programs for veterans, I believe it's an important step toward better
understanding and addressing mental illness in our greater communities.
Would you please expand on any current Mental Health First Aid efforts
that you are aware of in the veterans and military communities, and
explain the importance of this training for these groups?
Response. A large amount of training is occurring in the state of
Missouri where our NAMI Veterans and Military Council (NVMC) First Vice
President and Missouri State Representative--Lieutenant Commander
Michael O'Neil Jones, Ph.D. (Ret.) is a senior instructor for Mental
Health First Aid. Dr. Jones has taught more than 60 NAMI-facilitated
courses since 2008; and is a staunch advocate for utilizing Mental
Health First Aid training as a measure to improve continuum of care for
active duty military, National Guard and Reserve personnel, andveterans
and military families impacted by serious mental illness.
The Community Partnership of Southern Arizona (CPSA) adapted Mental
Health First Aid for use with servicemembers, veterans and their
families; and hosted a pilot training for a new, veteran/military-
focused version of Mental Health First Aid earlier this year.
Reportedly, the training was only the third of its kind ever offered in
the U.S. The partnership included the Western Interstate Commission for
Higher Education, the Arizona National Guard and its ``Be Resilient''
Program and the National Guard Bureau's Psychological Health Program.
NAMI Southern Arizona supported CPSA's initiative by promoting the
Mental Health First Aid training at NAMI signature programs such as
Family to Family and other educational programs.
The importance of Mental Health First Aid training for veterans and
military communities is very important. Mental Health First Aid covers
the symptoms and risk factors associated with mental health crises
situations--including suicidal thoughts and behaviors. Mental health
intervention strategies conveyed in Mental Health First Aid training
may help de-escalate crises and therefore stem the tide of the nearly
23 suicides per day that occur among veterans and active duty members.
Also, considering the fact that roughly 20 percent of soldiers
returning from Iraq and Afghanistan develop PTSD, and many do not seek
treatment for fear of being stigmatized, Mental Health First Aid
training can serve as an intervention effort to minimize barriers to
treatment for PTSD for OEF/OIF veterans. One of the training program's
main goals is to erase the stigma associated with mental health
illnesses. Furthermore, educating community members in Mental Health
First Aid creates a healthy community perspective that is responsive to
the needs of veterans and military families and supportive of their
recovery.
Finally, community collaboration is essential to achieving truly
integrated care. Given rising U.S. Department of Veterans Affairs (VA)
medical care and benefits compensation costs, as well as limited
states' resources for mental health services, Mental Health First Aid
training provides opportunities for collaboration and is a great
opportunity for the VA to engage community partners.
Chairman Sanders. Colonel Allred, thank you very much for
your testimony.
Dr. Barbara Van Dahlen is the Founder and President of Give
an Hour. Dr. Van Dahlen, thank you so much for being with us.
STATEMENT OF BARBARA VAN DAHLEN, Ph.D., FOUNDER
AND PRESIDENT, GIVE AN HOUR
Ms. Van Dahlen. Chairman Sanders, Ranking Member Burr, and
Members of the Committee, thank you for this opportunity to
provide testimony.
As a clinical psychologist who has spent the last 8 years
of my career devoted to this cause and as the daughter of a
World War II veteran, I am honored to appear before this
Committee, and I am proud to offer my assistance to those who
serve.
The Department of Veterans Affairs remains the principal
organization in our Nation's effort to ensure that all who wore
the uniform receive the mental health care they need. Clearly,
the VA has worked hard to keep up with the changing landscape
and the growing demands over the last 11 years of war.
And, as we have heard, the VA has increased the number of
mental health professionals providing services. It has
increased the number of Vet Centers across the country, and it
has added additional mobile Vet Centers in its efforts to serve
our rural communities.
Further, the VA has expanded its call centers and launched
the Veterans Crisis Line. Indeed, my organization, Give an
Hour, is pleased that we now have a memorandum of agreement
with the VA in coordination with the Veterans' Crisis Line.
Finally, the VA has become a National leader in integrating
mental health care into primary care settings. But as many of
us who come before this Committee are fond of saying, no
organization, agency, or department can provide all of the
education, support, and mental health treatment that every
veteran and his or her family needs.
It is actually more helpful to those who serve and their
families to see numerous endeavors coordinated on their behalf
so that they understand that our country--not just our
government--supports them and is committed to their health and
well-being.
Give an Hour is but one example of a community-based effort
designed to complement the important work of the VA. Give an
Hour providers provide free mental health care and support to
servicemembers, veterans, and their families in communities
across the country.
We have nearly 6,800 providers who have collectively given
over 82,000 hours of care. This translates into over $8.2
million worth of mental health care. If every one of our
providers was utilized on a weekly basis, we could provide over
$36 million of mental health care each year; and Gave an Hour
is able to do this all at a cost of about $17 an hour.
We are honored to do our part but we are eager to do more.
While we have been assured that sequestration will not directly
affect VA programs, the impact across government agencies will
certainly affect veterans.
So, we must think collaboratively, creatively, and
collectively about how best to knit together the array of
resources and services that every community has to offer.
Although progress has been made, we have yet to develop an
effective strategy for consistently delivering coordinated care
in communities where veterans and their families live and work.
To move toward our goal of ensuring timely access to high-
quality care, it is important to consider several important
points. One size does not fit all with respect to support and
treatment for our veterans nor is there a specific progression
of care and intervention that is appropriate for every
individual in need.
For example, some veterans want, need, and will benefit
from traditional psychological treatment that can be delivered
by the VA or by a community provider like those who volunteer
with Give an Hour.
In contrast, other veterans are not yet willing or able to
accept traditional care even though they are suffering. These
veterans might respond more favorably to alternative
opportunities and approaches that are available in their
communities. And perhaps an alternative approach is all a
veteran needs to move forward in life.
Or perhaps an alternative form of care might lead to a
willingness to seek more traditional treatment for the issues
that come home from war.
There are successful models currently being implemented
across the country to facilitate the coordination and
collaboration of community efforts.
Give an Hour's work in North Carolina and Virginia
regularly brings community organizations together to assess
gaps and develop solutions.
The Community Blueprint, an initiative now with the
organization Points of Light, has launched efforts in 42
communities. The focus of this initiative is to identify and
coordinate local efforts and to provide opportunities and
support for our military and veteran community.
Got Your 6, a campaign created by Service Nation, is
bringing the entertainment industry together with over two
dozen respected nonprofits. TAPS, Team Rubicon, Give an Hour,
and others are part of that effort.
These nonprofit organizations work together to further the
missions of each organization and to improve the reintegration
of veterans into our communities.
The VA has participated locally and nationally in
discussions and efforts associated with the two initiatives I
just talked about. Give an Hour has seen the positive impact
the coordination with VA can have in our work in Fayetteville
and in other communities, but we can and must create a more
systematic process to knit efforts together if we are to ensure
that all who are in need receive the proper care that they
deserve.
When I first developed the concept for Give an Hour, it was
with the perhaps idealistic notion that I would build a network
of mental health professionals who were prepared to serve and I
would give this resource to the VA and to DOD.
Although we have successfully built the network, giving
this service to these agencies has proven to be very
challenging and Give an Hour is but one of many organizations
that has much to offer veterans and their families.
So, how do we get there? The VA has tremendous potential to
function both as a catalyst and a convener, to engage and
encourage national nonprofits and local efforts in the service
of our veterans.
The VA can identify without necessarily endorsing
organizations doing important work to support those who serve.
It can bring these organizations together here in Washington
and in communities wherever there are VA facilities to explore
needs and develop specific strategies that result in actions
and outcomes.
And, if there are policies and regulations that prevent the
VA from functioning in this manner, then it is time to review
and adjust these policies. We can no longer be hampered by
restrictions that prevent us from leveraging all of the
resources and expertise available in our offices and in our
communities.
There is no doubt the greater coordination and
collaboration will improve well-being and save lives. There is
no doubt that we have the resources needed to attend to those
in need. The only doubt is whether we have the will and the
determination to meet the challenge together.
Thank you so much.
[The prepared statement of Ms. Van Dahlen follows:]
Prepared Statement of Barbara Van Dahlen, Ph.D., Founder and President,
Give an Hour
Thank you for this opportunity to provide this testimony. It is an
honor to appear before this Committee and I am proud to offer my
assistance to those who serve our country.
As a psychologist and the Founder and President of Give an
HourTM, a national nonprofit organization providing free
mental health services to returning troops, their families, and their
communities, I am well aware of the mental health issues that now
confront the men, women, and families within our military and veterans
community. As an American I share your commitment to ensure that all
veterans in need of mental health services receive the care and
treatment they deserve.
the impact of nearly twelve years of war
Since September 11, 2001, more than 2.6 million servicemembers have
deployed to Iraq or Afghanistan. This increased exposure to combat--and
the associated stress--has taken its toll on those who have served. In
addition, over a decade of war has put significant strain on our
military families. And as we know, the failure to provide effective
mental health education, support, and treatment to military personnel,
veterans, and their families will have dire consequences for
generations to come.
Traumatic Brain Injury (TBI) and Post Traumatic Stress Disorder (PTSD)
The Congressional Research Service released two reports in
February 2013 examining the number of military servicemembers diagnosed
with mental health problems while serving on active duty. These reports
included all servicemembers serving in Operation Enduring Freedom
(OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND).
From January 1, 2002, through August 20, 2012, 253,330 servicemembers
were diagnosed with TBI. From January 2002 through December 12, 2012,
131,341 servicemembers in OEF/OIF/OND were diagnosed with Traumatic
Brain Injury TBI.
The Department of Veterans Affairs examined the cumulative
prevalence of PTSD in all OEF/OIF/OND veterans utilizing healthcare
within its system. Among the 56% of OEF/OIF/OND veterans who utilize
health benefits through the Department of Veterans Affairs the
cumulative prevalence of PTSD was calculated to be 29%. This covered
the period from 1st Quarter FY 2002 through 4th Quarter FY 2012.
As the Congressional Research report states, ``From FY 2002 through
FY 2012, 1.6 million OEF/OIF veterans (including members of the Reserve
and National Guard) left active duty and became eligible for VA health
care; by the end of FY 2012, 56% of them had enrolled and obtained VA
health care.''
The National Center for PTSD reported in 2010 that studies
utilizing the ``gold standard'' in TBI diagnosis calculated the
prevalence of TBI among OEF/OIF post-deployers to be 22.8%. Other
studies using screening methods or other self-reporting methods such as
mailed surveys found a prevalence ranging from 12% to 20%. In studies
of OEF/OIF veterans, screening methods have yielded a prevalence of
20%.
Military Sexual Trauma (MST)
Military sexual trauma is sexual assault or repeated, threatening
sexual harassment that occurs in the military. It can happen to men and
women, and it can occur during peacetime, training, or war. According
to the Department of Veterans Affairs, about 1 in 5 women and 1 in 100
men seen in Veterans Health Administration facilities respond ``yes''
when screened for MST.
MST is an experience, not a diagnosis or a mental health condition
and as with other forms of trauma, there are a variety of reactions
that veterans can have in response to MST. The type, severity, and
duration of a veteran's difficulties vary based on factors such as
whether he/she has a prior history of trauma, the types of responses
from others he/she received at the time of the MST, and whether the MST
happened once or was repeated over time. Many who have experienced
sexual assault also develop PTSD, depression, and other mood disorders,
as well as substance abuse following the assault.
Homelessness
The ``Homeless Incidence and Risk Factors for Becoming Homeless in
Veterans'' study conducted by the VA reported the following factors
about homelessness among Veterans.
1. OEF/OIF and women veterans experienced higher homeless
incidences after military separation than their non--OEF/OIF and male
counterparts.
2. Veterans who experienced homelessness after military separation
were younger, enlisted with lower pay grades, and more likely to be
diagnosed with mental health issues and/or TBI at the time of
separation from active duty.
3. Homeless veterans who had served in OEF/OIF were more likely to
be diagnosed with mental health issues prior to their first homeless
episode than non--OEF/OIF homeless veterans.
4. In the majority of cases, newly homeless veterans diagnosed with
mental health disorders and substance-related disorders were diagnosed
before they became homeless.
5. Homeless veterans, especially women, received disproportionally
higher MST-related treatment than non-homeless veterans.
Effect of War on Children
We have ample evidence of the impact of prolonged deployment and
trauma-related stress on military families, particularly in spouses and
children. There are approximately 700,000 military spouses and an
additional 400,000 spouses of Reserve members. More than 700,000
children have experienced one or more parental deployment. Currently,
about 220,000 children have a parent deployed. The cumulative impact of
multiple deployments is associated with more emotional difficulties
among military children and more mental health diagnoses among spouses.
A 2010 study reports an 11% increase in outpatient visits for
behavioral health issues among a group of 3- to 8-year-old children of
military parents and an increase of 18% in behavioral disorders and 19%
in stress disorders when a parent was deployed. Children's reactions to
a parent's deployment vary by child and, more broadly, by a child's
developmental stage and age and the presence of any preexisting
psychological or behavioral problems. Very young children may exhibit
separation anxiety, temper tantrums, and changes in eating habits.
School-age children may experience a decline in academic performance
and have mood changes or physical complaints. Adolescents may present
as angry and may act out, withdraw, and show signs of apathy. The
mental health of the at-home parent is often a key factor affecting the
child's distress level. Parents reporting clinically significant stress
are more likely to have children identified as ``high risk'' for
psychological and behavioral problems.
the effects of sequestration
In addition to navigating the already challenging tasks associated
with reintegration, our military families and veterans must now
confront as a result of sequestration cuts to programs and services
that were once available to them.
The Federal sequestration order cancels $85 billion in resources
across the Federal Government for the remainder of FY 2013. Although
the Department of Veteran Affairs has been exempted from these budget
cuts, numerous other Federal programs supporting military
servicemembers, veterans, and their families will be negatively
affected by the sequester. Some of these consequences will be delayed;
others are already being felt.
The Department of Defense (DOD) recently advised the service
branches to suspend their distributions of the $560 million DOD tuition
assistance program. According to the Associated Press, the Army, Air
Force, Coast Guard, and Marine Corps have already suspended these
benefits for the duration of FY 2013. Any students utilizing tuition
assistance for the current semester will not lose these benefits for
any courses already in progress. However, these benefits will be
unavailable beginning next semester.
This cut interrupts and in some cases derails servicemembers'
pursuit of higher education. Thousands of our returning troops take
advantage of this tuition assistance program, which affords them up to
$4,500 in tuition assistance per year, allowing them to take college
courses that prepare them for jobs in the military or for positions as
they transition to the civilian workforce. The army's utilization of
this program in 2012 involved 201,000 soldiers, totaling $373 million
of assistance for tuition. These setbacks will produce difficulties for
a great many military families and veterans who cannot afford higher
education without tuition assistance.
Sequestration also requires cuts to the Veterans Employment and
Training Service (VETS), a Department of Labor job training program.
About 55,000 veterans and 44,000 servicemembers will not receive
employment and other transition assistance to help them enter the
civilian job market. This is the same program that has been implemented
to reduce the high unemployment rate among post-9/11 veterans (9.4%),
as the veteran rate remains higher than the overall unemployment rate
(7.7%).
In addition, the Pentagon plans to put most of its 800,000 civilian
employees on unpaid leave for 22 days, cut ship and aircraft
maintenance, and curtail training. Aside from the impact this may have
on our military's readiness to fight, such DOD budget cuts have real
effects on military families. Civilians make up 40% of the Defense
Department's medical providers at military hospitals and clinics. They
are all subject to furlough. As Jonathan Woodson, the Pentagon's
assistant secretary for health affairs, recently blogged, ``this may
mean a decrease in clinic appointment availability or longer wait times
to see providers.'' As a result, we will have military personnel--
future veterans--who are not receiving the care they need and deserve.
Sequestration cuts will increase the already lengthy, month-or-more
waiting time for burial at Arlington National Cemetery, with the number
of daily burials expected to drop from 31 to 24. The wait that grieving
family members and friends must endure before their loved one's
military burial will be prolonged. This specific cut will clearly
affect the emotional well-being of the families of our fallen
servicemembers and veterans.
And sequestration will affect the progress being made to end
homelessness among our veteran population. Housing and Urban
Development (HUD) vouchers for homeless veterans are credited with
reducing the number of homeless veterans by 17% since 2009. Although
these vouchers are exempt from the cuts, administrative funding will
certainly be affected. Consequently, the number of local housing
authorities willing to accept the vouchers are expected to decrease
because in order to use these vouchers, local housing authorities will
have to close the gap in funding created by the Federal cuts.
Sequestration will also have a negative effect on the Department of
Justice's ability to fund alternative sentencing programs for veterans.
The loss of grant funding for diversion programs will lead to
incarceration with little consideration of treatment for veterans with
mental health issues who are arrested for a crime. Diversion programs
have been found to be very successful when treatment is available as an
option. According to Dan Abreu, who oversees the Justice Department's
Jail Diversion Trauma Recovery Grant, there were over 1.1 million
arrests of veterans in 2007 (U.S. Department of Justice, Bureau of
Justice Statistics) and trauma history has been found to be present in
up to 73% of those arrested. Diversion programs have been established
to address the unique needs of these veterans, of which over 50% are
from OEF/OIF.
Finally, budget cuts are expected to have an impact on current
programs that encourage and support service-disabled veteran-owned
small businesses. As the U.S. Small Business Administration reports,
there were over 203,000 service-disabled veteran small-business owners
across America in 2007. More generally, veteran-owned firms represented
9% of all U.S. firms, employed 5.793 million employees, and amassed an
annual payroll of $210 billion in 2007.
the department of veterans affairs
The Department of Veterans Affairs remains the principal
organization in our Nation's effort to ensure that all who wore the
uniform receive the mental health care they need to lead healthy and
productive lives once they complete their service.
VA Structure, Sites, and Basic Services
The VA operates the Nation's largest integrated health care system,
with more than 1,700 hospitals, clinics, community living centers,
domiciliaries, readjustment counseling centers, and other facilities.
The VA serves over 8.3 million veterans each year. As of September 30,
2012, there were 821 VA Community-Based Outpatient Clinics, 300 Vet
Centers, 152 VA Hospitals, and 56 Veterans Benefits Administration
Regional Offices. In addition, the VA has the 70 Mobile Vet Centers
(MVCs), which are intended to increase access to readjustment
counseling services for veterans and their families in rural and
underserved communities across the country. In fiscal year 2011, MVCs
participated in more than 3,600 Federal, state, and locally sponsored
veteran-related events. VA sites are located in 23 regions or VISNs
(Veteran Integrated Service Networks) in the 50 states, Puerto Rico,
Virgin Islands, Guam, America Samoa, and the Philippines. The VA has
300 permanent Vet Centers across the country, which provide veterans
and their families with readjustment counseling and outreach services.
Depending on the location, Vet Centers can also provide the following
services:
Individual and group counseling for veterans and their
families
Family counseling for military-related issues
Bereavement counseling for families who experience an
active duty death
Military sexual trauma counseling and referral
Outreach and education
Substance abuse assessment and referral
Screening and referral for medical issues including
Traumatic Brain Injury and depression
PTSD programs
OEF/OIF Utilization Statistics
According to the latest Defense Manpower Data Center statistics on
the VA Web site (www.va.gov), as of September 30, 2008, there were
957,441 living OEF/OIF veterans, 89% male and 11% female. Of these
living OEF/OIF veterans, 498,737 (52%) received VA benefits and/or
services in FY 2008. In terms of program usage during FY 2008, 277,907
(56%) OEF/OIF veterans used only one VA program. Of these OEF/OIF
program users, 88% (246,000) were male, and 85% (235,000) were 44 years
old or younger. Also during FY 2008, 220,830 (44%) of OEF/OIF veterans
used multiple VA programs. Of these recipients, 87% (192,000) were
male, and 81% (180,000) were 44 years old or younger. As of FY 2008,
39% (84,000) of the OEF/OIF veterans receiving disability compensation
did not use VA health care.
The VA has worked hard to keep up with the changing landscape and
the growing demands over the last decade as a result of the wars in
Iraq and Afghanistan. The VA has increased the number of mental health
professionals providing services since 2006. It has also expanded its
call centers to help connect veterans in need with counseling services
and launched the Veterans Crisis Line, which allows veterans and their
families to call 24 hours a day, seven days a week for assistance.
Moreover, the VA has become the national leader in integrating mental
health care into its primary care settings.
But no organization, agency, or department can provide all of the
education, support, and mental health treatment that every veteran and
his or her family needs. Indeed, I would argue that it is more helpful
to those who serve and their families to see numerous endeavors
coordinated on their behalf so that they understand that our country--
not just our government--supports them and is committed to their health
and well-being. Give an Hour is one example of a community-based effort
to complement the good work of the Department of Veterans Affairs. We
are honored to do our part.
give an hour
I founded Give an Hour in 2005. As the daughter of a World War II
veteran, I became concerned about the stories coming home about those
who were serving. Although the Departments of Defense and Veterans
Affairs were doing more than ever before in their efforts to care for
the invisible injuries of war, servicemembers were clearly struggling
and their families were suffering. Early studies by Dr. Charles Hoge
and others indicated that significant numbers of servicemembers would
continue to come home with post-traumatic stress, Traumatic Brain
Injury, depression, anxiety, and other understandable consequences of
exposure to the brutality of war.
The idea behind Give an Hour is really quite simple: ask licensed
civilian mental health professionals across the country to provide an
hour a week of free mental health support to any post-9/11
servicemember, veteran, or loved one in need. Those looking for
services visit our Web site, at www.giveanhour.org, type in their zip
code, and get a list of providers located near them and eager to help.
Though not required, those who receive care through GAH are given the
opportunity to give back by volunteering in their own communities.
We have developed excellent relationships with all of the major
mental health associations, and we accept mental health professionals
from all of the major disciplines. Give an Hour providers offer a wide
range of options with respect to available appointment times to those
who seek services including evenings and weekends. In addition, they
bring a wealth of treatment options and areas of expertise to their
work. We know that one size does not fit all with respect to this
population or any. Flexibility and treatment based on individual needs
and preferences are critical elements if we are to reach and
successfully support the mental health needs of veterans and their
families. There is no limit to the number of sessions that
servicemembers receive, and all services are free.
Believing that collaborating with other organizations, agencies,
and communities is the key to successfully serving military families,
we and our providers also consult to schools, first responders,
employers, and community organizations. For example, we have enjoyed a
long-standing relationship with organizations such as TAPS (the Tragedy
Assistance Program for Survivors) and SVA (Student Veterans of
America), providing direct assistance with referrals and participating
in their events. We are also regularly asked to join Yellow Ribbon
events and similar community gatherings across country. Our staff
members present at conferences and are key members of advisory groups
addressing the needs of those in our Armed Forces.
We are proud that Give an Hour is successfully harnessing the
knowledge, wisdom, skill, and compassion of our civilian mental health
professionals and exemplifying a highly collaborative approach in
offering these resources to supplement the critical mental health
services provided by the Departments of Defense and Veterans Affairs in
our Nation's efforts to assist those who serve, our veterans, and their
families in communities across the country.
In fact, since it began providing services in 2008, Give an Hour
has:
Increased its volunteer provider network by 570% from
1,000 in February 2008 to 6,700 in January 2013
Increased volunteer hours given by mental health providers
from 1,415 in August 2008 to 82,000 hours in January 2013
Been selected one of five winners of the White House
Joining Forces Community Challenge, sponsored by First Lady Michelle
Obama and Dr. Jill Biden in April 2012
In addition, I was personally honored when named to the TIME 100 of
the Most Influential People in the World in 2012.
We are also proud that Give an Hour was chosen to lead the health
pillar of the Got Your 6 campaign, a nationwide initiative uniting the
entertainment industry and top-tier nonprofits to shine a spotlight on
veterans as civic assets and leaders. The campaign focuses on six
pillars of reintegration: jobs, housing, education, health, family, and
leadership, and offers pathways for the American public to connect and
engage with these issues and bridge the military-civilian divide.
the community blueprint and the power of collaboration
Got Your 6 is a prime example of applying a comprehensive approach
to meeting the needs of the men, women, and families who serve our
Nation. Similarly, to address these needs by leveraging the combined
experience and expertise of collaborating organizations, volunteers
from several leading nonprofits created an initiative and an online
tool called the Community Blueprint, which is already helping local
community leaders assess and improve their community's support for
veterans, servicemembers, and their families. The initiative is now
formally being administered by Points of Light and is being implemented
in several communities across the country.
Give an Hour and the Community Blueprint History
In January 2010 the ``America Joins Forces with Military Families''
retreat in White Oak, Florida, brought together representatives of 55
nonprofits, veterans and military family service organizations,
government agencies, faith-based groups, and senior DOD officials to
discuss the challenges facing America's military families and how our
Nation must come together to address them. I and other nonprofit
leaders concerned about these issues began to refine a concept that had
been percolating in the veterans support community for years--that of a
blueprint to assist communities in more effectively and strategically
supporting veterans and military families. Since then the Community
Blueprint has developed into a national initiative with multiple
Blueprint demonstration sites.
Give an Hour acted as the first nonprofit to implement the
Blueprint initiative on a large scale, thanks to a two-year grant from
the Bristol Myers Squibb Foundation to lead implementation of the
Blueprint in two demonstration sites--Fayetteville, North Carolina, and
Norfolk/Hampton Roads, Virginia. Since early 2011 Give an Hour has been
working with the local communities, and in late 2011 the nonprofit
organization Points of Light stepped up to serve as the national
Community Blueprint umbrella organization. Due to Give an Hour's
pioneering role in this initiative, Points of Light and various
communities consult and look to Give an Hour as thought-leaders and
subject matter experts on the Blueprint.
Definition of the Community Blueprint
The Community Blueprint is both an approach and a tool. The
approach provides a forum to enable local veteran-focused organizations
in the nonprofit, for-profit, and government sectors to communicate and
collaborate to address needs. The Blueprint founders identified eight
Blueprint focus areas: behavioral health, education, employment, family
strengths, financial/legal assistance, volunteerism, homelessness, and
reintegration. As a tool, the Blueprint catalogs ``promising
practices'' (defined as action steps, initiatives, and events) for
meeting needs and makes them available in a Web-based toolbox located
at www.the-communityblueprint.org.
Promising Practices and Accomplishments
Give an Hour has held numerous events covering the eight areas of
focus in the demonstration sites. The following examples highlight our
promising practices.
Behavioral Health
Give an Hour staff learned that Fayetteville is home to multiple
behavioral health groups. Through the Blueprint working group process,
staff contacted the various behavioral health groups and helped to form
one consolidated group, called the Behavioral Health Professional
Association (BHPA). The BHPA includes a cross-section of behavioral
health leaders from nonprofits, private practice, the VA, and Fort
Bragg.
Education
In Norfolk/Hampton Roads, the Give an Hour Blueprint leveraged the
creation of the Military Alliance at Old Dominion University (ODU) to
coordinate faculty and students to create a campus-wide initiative to
support ODU servicemembers and their dependents. The Military Alliance
increased collaboration between Tidewater Community College (TCC) and
ODU to create joint events to assist the student military population.
Also, thanks to a Blueprint--Walmart Foundation grant, TCC's Center for
Military and Veterans Education was able to launch a pilot program (the
Military Spouse Career Readiness Training Program) to help military
spouses prepare for meaningful work and careers.
Employment
Through the Blueprint, Give an Hour has worked closely with the
U.S. Chamber of Commerce to help sponsor and promote multiple Hiring
Our Heroes (HOH) Job Fairs in both demonstration sites. At the
Fayetteville February 2011 HOH event, Give an Hour asked that booth
space be expanded to include resource-based organizations, which
created a more inclusive event. As a result of Blueprint support and
advertising, the event received high attendance from job seekers and
booth sponsors that far surpassed the target goal.
Family Strengths
For the April Month of the Military Child, the Fayetteville
Blueprint organized a bracelet-making project to honor the resiliency
and bravery of military children. It resulted in a successful technique
for engaging and honoring military children, which was replicated at
other events. Over two days, Blueprint volunteers spoke with over 250
individuals, and many of the families were unaware that April was the
Month of the Military Child. Families were able to strengthen family
bonding while enhancing knowledge of the unique culture and needs of
military families.
Financial/Legal Assistance
In September 2012, the Norfolk/Hampton Roads Blueprint hosted a
free Military Family Financial Summit at ODU, open to all
servicemembers, veterans, and their families. The event was family-
friendly with on-site day care, which encouraged family attendance.
Community Blueprint participants collaborated closely with ODU, Fleet
and Family Support Center, and Blue Star Families to sponsor this
event. Conference attendees gained valuable insight on personal
financial planning, post--military career planning, and portable
entrepreneurship, while connecting with other military families to
expand their network of support.
In November 2012, Give an Hour co-sponsored a Veterans Court Summit
with Booz Allen Hamilton in Virginia Beach, Virginia. The event engaged
stakeholders from across the community (legal, behavioral health,
nonprofit, military, government, corporate), who provided direct input
and leverage to move the Veteran's Court initiative forward. I spoke
about the importance of cross-sector collaboration and how that fit
with the Veterans Court model. Judge Robert Russell, who initiated the
Nation's first Veterans Court, served as an expert panelist and shared
lessons learned. The summit resulted in actionable items to begin the
process of implementation of a Veterans Court in Norfolk, which have
continued to date.
Volunteerism
Volunteer Hampton Roads received a Blueprint--Walmart Foundation
grant it used to host, in March 2012, a free ``Volunteer Management
Training'' course emphasizing engaging volunteers from the military
community. Key Hampton Roads military personnel discussed how to reach
out to the active duty, reserve, dependent, and retiree military
communities. The training demand was so high that Volunteer Hampton
Roads held a second event several months later.
Homelessness
In 2011 the Fayetteville Blueprint working group participated the
Veterans Affairs Homeless Stand Down. Participants included a large
cross-sector of the community and directly served veterans that were
homeless by providing material goods, food, and information and access
to resources.
Reintegration
In July 2012, the Fayetteville Blueprint hosted a free screening
and panel discussion of the Oscar-nominated documentary Hell and Back
Again, which features a Marine's combat experience in Afghanistan and
his reintegration process after being wounded. As a promising practice,
the event raised awareness about reintegration issues and created a
community dialog among civilians, servicemembers, and their families.
At a post-screening panel discussion, I was joined by local subject
matter experts Captain Jenny Hartsock, Military Liaison to U.S. Senator
Kay Hagan, and Staff Sergeant Kelly Schoolcraft, President of
Fayetteville State University Student Veterans of America. The
panelists provided information about local and national resources and
stressed the importance of community collaboration to assist with
reintegration for servicemembers and help family members as well.
Blueprint Engagement with the Department of Veterans Affairs
The Blueprint approach of increased collaboration and connecting
resources has directly assisted servicemembers--including those that
receive VA services. In both Community Blueprint demonstration sites,
Give an Hour staff members collaborate with the local VA offices on
various initiatives and events. As a result of this outreach, VA staff
members have become more involved in community efforts and have
connected with a wider range of organizations. Some examples of VA and
Blueprint partnerships include the following:
Fayetteville Community Blueprint Summit on Women Veterans:
In November 2011, Give an Hour collaborated with Booz Allen Hamilton to
hold a one-day Community Blueprint event entitled ``Fayetteville
Military Family Community Summit: Ensuring the Well-Being of Our Women
Veterans.'' Give an Hour invited the Director of the Fayetteville VA
Medical Center, Dr. Elizabeth Goolsby, to serve as a panelist at the
event along with other local female veterans. The event combined
engaging discussion and thoughtful, innovative approaches on how to
improve the lives of women veterans in the Fayetteville area.
Fayetteville Behavioral Health Professional Association:
As mentioned above, the Blueprint working group process helped
consolidate the multiple behavioral health groups in Fayetteville into
one consolidated group, the Behavioral Health Professional Association
(BHPA). Since December 2011, the BHPA group has been meeting on a
monthly basis, and among its active participants is a VA psychologist
in the area. The group focuses predominately on military issues and
includes a large cross-section of behavioral health leaders from the
Fort Bragg/Womack Army Hospital and the VA, as well as private
practitioners, Military Family Life Consultants (MFLCs), substance
abuse providers, faith-based providers, employees from the public
school system, and state-level affiliates.
Military Spouse Appreciation Day Event: Give an Hour
Blueprint staff reached out to Fayetteville VA Medical Center Director
Dr. Elizabeth Goolsby and invited her to serve as a guest speaker at
the May 2012 Military Spouse Appreciation Day Ceremony. The Give an
Hour Fayetteville Blueprint collaborated with the office of U.S.
Senator Kay Hagan to honor the sacrifice, resiliency, and courage of
the military spouses that serve on the home front.
North Carolina Dental Clinic /Mental Health Resource
Event: The Fayetteville Blueprint reached out to the VA to provide
mental health resources at the June 2012 North Carolina Dental Clinic/
Missions of Mercy Mobile Dental Clinic, which served individuals with
incomes below the poverty line. Give an Hour and Blueprint volunteers
handed out 400 resource bags with information on behavioral health
resources and other items such as coupons for free food. The free
mobile dental clinic served over 1,000 people--of which approximately
20% were identified as military-affiliated. This event reached an
underserved segment of the population, including low-income veterans
and their families, and connected them with behavioral health resources
alongside free dental services.
Give an Hour Blueprint Lessons Learned
Even when a community determines that cross-sector collaboration
offers the greatest promise to solving a complex social problem, the
process is by no means easy. Grass-roots community collaboration and
implementation centered on systemic change requires heavy lifting. The
primary lesson we have learned is to be prepared to work hard and not
expect the process to be quick or easy. Give an Hour staff found that
cross-sector collaboration and the development of working groups depend
on an open philosophy and long-range perspective. We learned to promote
a ``big tent'' concept and invite Blueprint members from among the
``willing and interested.'' In other words, collaboration requires just
that--no exclusivity. As long as members act with respect and embody
and uphold the principles of the Blueprint, they should be encouraged
to join. The other Blueprint lessons learned are as follows:
Focus on the servicemember and leave personal agendas at
the door: This philosophy has resulted in cohesive, thriving groups.
Positive, persistent collaboration results in creating larger, more
effective groups.
Take Quick Action: ``Pick something--anything--and do
it!'' People lose interest if a group does not appear to have a
purpose. Ensure that each Blueprint xmeeting has at least one action
item that leads to a promising practice or an initiative serving the
point of the Blueprint, i.e., to increase community collaboration and
improve the lives of servicemembers and their families.
Piggy-Back off Existing Events: Give an Hour staff learned
early in the process that time and money was saved and duplication
avoided by joining another community. Look for existing opportunities
to leverage or expand upon a community event.
the next step: greater coordination between the va
and community organizations
When I first developed the concept for Give an Hour it was with
the--perhaps idealistic--notion that I would build a network of mental
health professionals who were prepared to serve and I would ``give''
this resource to the VA and to DOD. Although I have successfully built
the network, giving this service to these agencies has proven to be
very challenging. And Give an Hour is but one of many organizations
that has much to offer veterans and their families.
Fortunately, we have made progress. Over the past year Give an Hour
and DOD have worked together to expand mental health services to
military personnel and their families. Give an Hour and the Veterans
Crisis Line signed a memorandum of agreement (MOA) to enhance the
quality and effectiveness of the services both organizations can
provide by sharing information about each other with those seeking
services. And a recently signed memorandum of understanding (MOU)
between Give an Hour and the Army National Guard will ensure that
National Guard servicemembers and families have factual information
about our services.
But we can do so much more. The question is how to get there. The
VA has tremendous potential to function as both a catalyst and a
convener, to engage and encourage national nonprofits and local efforts
in the service of our veterans. The VA can identify--without
necessarily endorsing--organizations doing important work to support
those who serve. It can bring these organizations together here in
Washington and in communities wherever there are VA facilities to
explore needs and develop specific strategies that result in actions
and outcomes.
If there are policies and regulations that prevent the VA from
functioning in this manner, then it is time to review and adjust these
policies. We can no longer be hampered by restrictions that prevent us
from leveraging all of the resources and expertise available in our
offices and in our communities. There is no doubt that greater
coordination and collaboration will improve well-being and save lives.
There is no doubt that we have the resources needed to attend to those
in need. The only doubt is whether we have the will and the
determination to meet the challenge together.
Chairman Sanders. Thank you very much Dr. Van Dahlen.
If there is no objection, Senator Murray, our former chair
who is now Chairman of the Budget Committee, has to run in a
few minutes, but I would like her to be able to say a few
words.
Senator Murray.
STATEMENT OF HON. PATTY MURRAY,
U.S. SENATOR FROM WASHINGTON
Senator Murray. Mr. Chairman, thank you very much. I want
to thank you for having this hearing. I know you have another
panel, so I appreciate you allowing my statement.
I really appreciate the focus on providing timely access to
health care. It is so important for our veterans, for our
servicemembers, and for their families.
I wanted to thank the panelists as well for coming. I know
it often takes a lot of courage to share personal stories but
your insight is critically important.
It is really clear that VA and Congress have made some
important strides toward addressing the invisible wounds of war
but we have a lot more to do. VA's recent report on suicides
among the Nation's veterans is really troubling and I was
really sad to note that my homestate of Washington has a very
high percentage of known veteran suicides.
So, over the coming year, VA has its work cut out for it.
We have to implement the Mental Health Care ACCESS Act. We need
to meet the goal of hiring 1,600 new mental health care
professionals. We have got to get these wait times down as we
just heard and we need to partner with our community providers.
But the Army and the DOD have their work cut out for them
as well. They have got to reform the IDES process and diagnose
mental health care conditions accurately. We have got to
address the issue of the integrated electronic health records
that plagues us and we have to end the unacceptably high rate
of military sexual trauma.
So, Mr. Chairman, I want to thank you for really focusing
on mental health care. I want to thank everyone who is working
on this and give you my support to continue to do that.
Thank you.
Chairman Sanders. Thank you very much, Senator Murray.
As I think Senator Tester indicated earlier, if we knew the
magical answer to mental illness, this country and this world
would have solved this problem a long time ago. There is no
easy answer but what I am hearing from all of you--and I
appreciate all of your testimonies--is that we have got to
think outside the box. We have to understand that something as
simple as an unpleasant person at a desk or a wait of 2 hours,
or a missed appointment can be the difference between life and
death with somebody who is struggling to stay alive, keep
themselves together. When you are healthy, an hour wait might
not matter. But that long of a wait does matter for people who
are struggling.
I think all of you have indicated that peer-supported
efforts of veterans talking to veterans is enormously
important. I think one of you said not everyone is alike and
different individuals will respond to different types of
approaches.
So, let me just start off with you, Dr. Van Dahlen. How do
we enable VA, which we all know is a huge bureaucracy--there
are no ifs, ands, or buts about that--to become more flexible,
to reach out to community-based groups and peer support groups?
Ms. Van Dahlen. Thank you. What we find in communities is--
and I know this from my work with several of my colleagues at
the VA--the desire often in the individual is there to work in
a collaborative way but they are unclear whether they are
allowed to.
So, one of the things that I would like to suggest is that
we literally work on what are the messages at each of the
local, every VA, whether it is a hospital center, whether it is
a vets center, they will know and have access to the community.
So, what we should do--and I think it would be pretty easy
to do--is determined what gets in the way of having regular, as
we have done in the community and others have done, gatherings
where the VA serves as the convener and the catalyst, what
stops that from happening. So that people begin to talk to each
other. They know then that if my organization cannot serve that
need TAPS can do it or NAMI can do it.
That is what needs to happen.
Chairman Sanders. Let me ask this question: one of the
cultural issues that we are struggling with--that the military
and VA are struggling with--is the culture of the stigma which
Colonel Allred discussed. The idea of questioning whether I am
a real man if I have an emotional or mental problem?
We understand if I lost an arm or a leg, I would go and get
treatment. How do we deal with a culture that says from a
military perspective, that, there is something not quite manly
about you if you have PTSD or you have TBI. How do we deal with
that?
Mr. Wood, do you want to respond to that?
Mr. Wood. I think it is very challenging. It is not a
problem that we are going to solve overnight. As a Marine
sniper, I was a part of one of the more elite units in the
military and certainly one that carries that stigma very
heavily.
We do not often go to seek counseling. If you do seek
counseling like Clay actually did after being wounded in Iraq
before being redeployed to Afghanistan, you are often seen as a
weaker link; and that is a stigma that we have to fight
absolutely.
I myself have gone to seek mental health counseling since
getting out of the military. I have worked with the VA and
their ``make the connection.net'' initiative to provide a video
testimonial to that.
I think what it does, though, is require regular
convenings, as Dr. Van Dahlen mentioned, where veterans can get
together. You know, we need to get veterans together in their
hometowns. We need to get Marines together with soldiers,
together with airmen, together with sailors in Omaha, NE, in
Davenport, IA, in Oakland, CA, where they can talk and share
with one another their experiences after transitioning out of
the military.
Chairman Sanders. OK. Thank you.
Andre, as you know, Vermont is a very, very rural State. We
sent a lot of National Guard people to Iraq and Afghanistan--
tell me about the peer-to-peer effort.
Is it important that veterans, just as Mr. Wood was saying,
who have been through that experience reach out to other
veterans. How do we do that?
Mr. Wing. Thank you, Senator. As you know, we have 10
Outreach Specialists on my team. We are all combat veterans. We
all had struggles with reintegration issues and transitioning
back to civilian life. I do not think the stigma is as severe
in the Reserve Component compared to the Active component. I
hear at this panel that we talked about community partnerships
which we have really forged in the State of Vermont with
different initiatives that I stated earlier in my statement.
We have a Director of Psychological Help that works
directly for the National Guard on the Air side and the Army
side. This stigma, I think, is more prevalent on the active
military side; but as far as peer-to-peer goes, as you know, we
go out and seek, and then, we meet the veterans.
Chairman Sanders. You knock on doors.
Mr. Wing. We knock on doors; and as I said, we have our
feet underneath the kitchen table. I know that the President
has got a new initiative to train and hire 800 peer support
specialist in the coming year, that is the best way to connect
with veterans and help with awareness and success to health
care. But I think you are hearing this today. The common
denominator here is the peer-to-peer approach. It is very, very
important because we veterans can communicate and have
experienced some of the same reintegration issues.
The other thing too that is important with the community
partnerships, is that my team understands the military culture.
So, I can go into AHS with the field directors and tell them,
hey, this is how you need to maybe approach some of these
veterans, as an example.
Chairman Sanders. Thanks very much.
Senator Burr.
Senator Burr. Mr. Chairman, thank you.
What you guys have provided are great suggestions,
directions for us to turn; and I want to thank you for doing
that. It is important to the Committee and it is as important
to the Veterans Administration. I think they have heard
everything that you said. It will stimulate additional
questions on my part that I am not prepared to ask today.
So, I would ask you, Mr. Chairman, on behalf of all of us
for unanimous consent that we would be allowed to follow up
with questions with this panel.
Chairman Sanders. Of course, without objection.
Senator Burr. For the sake of time, I am going to turn to
Barbara for just a second. You mentioned Community Blueprint,
specifically in Fayetteville. Can you share in a little greater
detail how that effort improved outcomes?
Ms. Van Dahlen. So, there are lots of ways. For example,
when we first started that work--and that work is a very
action-oriented plan to bring groups together, identify
specific gaps in services including bringing the VA in,
bringing in Fort Bragg--and it took us quite a while to get all
the stakeholders to come regularly but now it is happening.
One of the things that we recognize and one of the things I
want to highlight about the peer-to-peer and availability of
mental health care, one of the things that we identified was
that in that community the behavioral health providers did not
know each other, were not talking to each other. There was not
an easy access from the base to identify those who were in need
and which providers had cultural training.
So, through that effort, we have now created an ongoing
dialog so that the base knows, the VA knows what the resources
are. More families are being served whether it is because they
know each other or because they are developing specific plans.
One of the other things that we identified in Fayetteville
is that there are not enough behavioral health care providers
there. I believe there will not be enough to meet the need.
Before we got there, there was a lot of talk like, I do not
know what we are going to do, try to recruit them, which is not
going to happen.
What we need to do is look at how we leverage the people in
the communities who have mental health knowledge and expertise
to give that to peer-based efforts like we do with TAPS, like
we are building with Team Rubicon. How can we train teachers to
understand the signs better; how can we reach out to first
responders, primary care physicians?
So, if we have these models, and there are many, where the
community is bringing together and developing specific
programs, that is what we have seen in Fayetteville over and
over again.
Or a family at the end of the weekend that contacted us
because everybody else said they did not have resources. We
were able, because of the network, to find a home for this
family that was homeless with three young kids and then got
them long-term care.
There are so many examples. It is all about bringing the
right folks together and then having regular ongoing
conversations, not one off, not a one time and then everybody
goes home and continues to do what they have done.
Senator Burr. Thank you.
Thank you, Mr. Chairman.
Chairman Sanders. Thank you, Senator Burr.
Senator Tester.
Senator Tester. Thank you, Mr. Chairman.
My staff has got some great questions but you guys's
testimony has invoked even more so I am going with my gut.
Dr. Van Dahlen, you talked about--and I do not want to put
words in your mouth and I hope you are right--that there are
enough resources out there and you also said with the previous
question that you wanted to make sure that VA allows those
folks to be a part of the mix if they want to be a part of the
mix. And, I know you probably do not know the whole country
from Arkansas, is that right?
Ms. Van Dahlen. No.
Senator Tester. But the question is, do you really feel
that way, because I think that is really a good sign if you
think there are resources out there that we can use. Then we
have to talk to the VA about how we can best help them
integrate in the places where they have Vet Centers, where the
peer-to-peer stuff goes on. You can also insert somebody who
actually knows the problems from a clinical standpoint.
Ms. Van Dahlen. I think there is a tremendous number of
resources in communities that are not being tapped, they are
not being coordinated, and without the coordination they are
not being fully utilized.
Just looking again at our organization, we have got 7,000
people. They are not being used. All of them are not being
used. Would they step up and give more in their communities if
they were being asked? Absolutely. That is what they are there
for.
When we work with TAPS and we coordinate our efforts, it is
a value add. We know how to reach them, et cetera. So yes, I
believe there is tremendous opportunity that we have not yet
tapped.
Senator Tester. That is good news and we will probably be
talking to Dr. Petzel about that same thing, about ways we can
get VA involved in this.
Lieutenant Colonel Allred, first of all, I want to say I
have a tremendous amount of respect for your organization. You
guys do some incredible work in my State of Montana, and I want
to thank you for that.
You mentioned something in your testimony that I heard
before in that the rate of suicide amongst noncombat is higher
than combat vets. Are you guys aware of why that might be? Is
there a reason for that?
Colonel Allred. Well, I am not a clinician, Senator, so I
cannot give you a clinical answer on that, but my understanding
is that the veterans face a lot of the same stresses that
civilians do and it sometimes starts with unemployment, the
financial issues, the family issues, and then hopelessness.
The National Alliance on Mental Illness has programs to
address that, if we can be brought together.
Senator Tester. OK. Well, like I say, I appreciate your
work.
This goes to anybody who wants to answer this. There are a
lot of investments being made by the VA. Have you guys been
able to identify some of the smarter investments that we have
made through them?
Any of you can answer. You are nodding your head, Doctor.
Ms. Van Dahlen. One wonderful program that the VA has
developed is the SSVF programs, Support Services for Veterans
Families, but those programs, it is my understanding, do not--
we have not been able to work with that program because mental
health is not a piece of that. Yet, that is a really wonderful
program.
There is a lot going on in New York State; for example,
where communities are coming together, organizations are
fitting together, applying for that funding, and receiving that
funding. But mental health is not a piece of it.
So, I would say that is a great example of what is working
well and there are many others. I would like to see VA expand
that to include mental health care as part of that package
because then it would bring a lot more of those programs into
that combined effort. But that is a great program, SSVF.
Ms. Ruocco. The veterans crisis line has also been an
incredible asset for our veterans in crisis to have an
immediate place to call to get help and get hooked-up with care
if they are in crisis.
An offshoot of that, Vets4Warriors, are a peer-to-peer
support call line. They are answered by a peer 24/7. I could
see a real value in increasing those kinds of portals where
veterans call and talk to another veteran, and get families
involved in being able to call those numbers too and say this
is what I am seeing in my veteran what am I seeing, what do I
do with it, what will happen when I take him to treatment,
because there is a real lack of education around what treatment
looks like and whether you can get better.
And so, more portals like that, like the NVCL and
Vets4Warriors, I think is incredibly valuable and I think they
are working well.
Senator Tester. I just want to thank you all for your
testimony. I have about 15 pages of questions. We could do this
all afternoon. I appreciate your levels of expertise and your
willingness to help. Thank you.
Thank you, Mr. Chairman.
Chairman Sanders. Thank you, Senator Tester.
Senator Johanns.
Senator Johanns. Thank you, Mr. Chairman, and let me say to
all of you, thanks for being here. Tremendous insight is gained
from just listening to you.
Let me start with Mr. Wood. You said something that I must
admit gave me a different perspective of suicide and what
veterans are going through. At the risk of oversimplifying your
message, I found it very interesting that you were saying, you
know, a veteran comes home. They are out of the service. They
put the uniform away. The community that they have known, lived
with, trusted, prayed with, has pride with, disappears.
Now all of a sudden, this life experience is behind them
and the adjustment to that for anybody would be very, very
difficult.
Tell me a little bit more about that. Are you sensing as
you work with veterans that it is the break in that tie that is
maybe a first step or where problems develop that may lead to
suicide?
Mr. Wood. Absolutely. We see it all the time. Veterans
typically enter active duty right out of high school and they
grow up in their formative years in the military and they
experience incredible experiences, both good and bad, during
those formative years with a very close, cohesive unit of men
and women.
It creates a certain resiliency in that veteran, in that
servicemember while they are in. They are able to cope with
extraordinary things.
When they come out, they are ripped out of that fabric.
They are now a single thread instead of that tightly woven, you
know, fabric and unit that they had while they were in. Part of
that is also that elimination of purpose, that community, that
sense of self that they had that they formed while they were
in.
So, how is it that we can re-create that. I think the very
first step is helping veterans identify one another in their
hometowns so that they can re-create it through something else.
Obviously with Team Rubicon, we are trying to give them a
new mission that can provide all three of those things; and
with POS REP, we are trying to create, you know, an application
for their iPhones or their Android devices that helps them
discover one another so that they have a tool that is not the
VA, because the VA has got a horrible brand that a lot of
veterans do not trust.
So, we need to supplement what the VA can provide which is
first class mental health and medical health services with
something else; and that something else is community which has
to come from outside the VA.
Senator Johanns. I would like to hear from you on this
issue, Ms. Ruocco, this thought that once home that support
group is not there; kind of the fabric that kept things
together all of a sudden is torn apart.
What is your sense of that? Is that part of what we are
dealing with here?
Ms. Ruocco. It is a huge issue. We see veterans all the
time trying to transition back into communities and having a
lot of hope and a vision about what that is going to be like--
that there is going to be a job, that they are going to have
people appreciating their service, that they are going to be
able to use their military experience to find a job--and then
that does not happen.
They have difficulty finding jobs. They have traumatic
brain injuries and concussions and anxiety attacks and
sleeplessness and addiction issues and self-medicating that all
get in the way of that transition. And then, they cannot find
somebody else to talk to about what they have been through.
We had an example of one of our veterans who was out in
Wyoming in a very rural area. He went back. He started to find
a job and he had severe Post Traumatic Stress Disorder. Got a
job for like $9 per hour, but all of the chaos within the job
he could not deal with having PTSD and ended up, you know,
quitting his job, losing his job. But he wanted peer support.
So, he started going to The American Legion every day and
sitting on that bar stool trying to talk to other veterans so
he could heal the moral injuries he had, the post traumatic
stress, and the survivor guilt that he had. And, he actually
ended up committing suicide on that bar stool at The American
Legion without his needs being met.
So, we see a terrible self-destruction path there. We need
to get them integrated into a community with good jobs, good
care, and peer support where they find some sense of purpose, a
sense of meaning in their life, where they create a new
identity that is separate from the military identity they are
losing.
Senator Johanns. I am out of time. Like Senator Tester, I
could go on and on. But the lightbulb that comes on for me here
is this: if what is lacking here is that community, the peer
support, the group counseling, that force that kind of pulls
things together emotionally and mentally, those kinds of things
seem to me to be a real pathway forward here in terms of
dealing with suicide.
I had kind of come into this hearing thinking that this was
all about the trauma of war, and I am sure that is a piece of
it, and for some that might even be the dominant piece.
But you have given me a different insight that a major
piece of this may be that the community they relied on and
lived with is not there anymore in the way of this support
group. Like I said, that turned on the lightbulb for me.
Thank you Mr. Chairman.
Chairman Sanders. Thank you Senator Johanns.
Senator Isakson.
Senator Isakson. I want to thank everybody for their
testimony and for their service.
I want to follow up on what Senator Johanns said, because
my lightbulb went off too, particularly with the testimony of
Mr. Wood talking about that sense of purpose. My lightbulb went
off because it makes sense. I understand.
When you told the story about the guy leaving Omaha, NE,
going to Afghanistan, coming home, and getting out of the
service; and all of the sudden the structure he was in, the men
he served with, the purpose that he had is all gone and it is
hard to recreate.
I think that is a tremendous observation. You sought
counseling you said yourself at the VA, is that correct?
Mr. Wood. I did attempt to seek counseling with the VA. I
was completely underwhelmed with the care that I received and I
ended up pursuing counseling in the private sector.
Senator Isakson. You answered my question before I asked
it, because I was going to ask you if you felt like the
counselors there had an awareness of what the real problem was.
But obviously, you do not think so.
Mr. Wood. The counselor that I spoke to was a combat
veteran from Vietnam--a tremendous individual. However, after
spending my first three sessions doing nothing but data entry
with something that, through technology, probably could have
taken about 5 minutes but instead took probably a cumulative of
5 hours of my life. I was too frustrated to continue and sought
private sector care.
Senator Isakson. Well, I have a question for you regarding
Ms. Ruocco's testimony. Two of her four major recommendations--
one was at first contact assign a peer to help the veteran
navigate through the system before they have their first
counseling session, is that not right? That was observation
number 1, which I think is terrific.
Recommendation number 4 that she had was to cut out the
paperwork that it takes to get from making the appointment to
the actual appointment. From what I hear from you, both of
those, if adopted, would be a tremendous help for the Veterans'
Administration and for the veteran.
Mr. Wood. Absolutely, particularly regarding number 4.
There is no excuse in the age of Google and Facebook and
Twitter to have three straight sessions of nothing but data
entry. There is a simpler solution out there. We need to find
it and we need to implement it sooner rather than later.
Senator Isakson. Is RES PRO, the app that you have
developed, operational?
Mr. Wood. Yes. We launched live 8 weeks ago, Mr. Senator.
Senator Isakson. What has been the response so far?
Mr. Wood. It has been absolutely tremendous. It is still in
beta testing phase. We have got about 3,000 users on the
platform. Through the data that we have gathered and through
the observations that we have made, we know it has already
saved lives. We have seen connections happen in real life.
I could fire it up right now and we could find veterans
around the DC area who are using it. We could connect with
them. Veterans that I do not know myself, personally, but they
are out there.
Senator Isakson. This generation of war fighter and soldier
that we have is already connected when they get in the military
and connectivity in the military is a key part of the
organization.
So, you have a user-friendly group out there that just
needed your catalyst to really put them together if I am not
mistaken.
Mr. Wood. They just need to find one another.
Senator Isakson. My age group is probably not as connected
as that age group.
Mr. Wood. Well, the new generation of veterans, they do not
use The American Legion and the VFW like they used to. Those
are both tremendous organizations and they have a real role in
the veteran space moving forward. Absolutely, they do.
But our generation of veterans, the post-9/11 generation,
we live in technology. It is a part of us; it is an extension
of our body. And for us not to be leveraging technology to make
these connections is foolish, it is not using the resources
that we have available.
Senator Isakson. Well, in the interest of time, I will
submit my other questions for the record, but I just want to
thank all five of you for your testimony. It has been very
illuminating hearing for all of us.
Chairman Sanders. Thank you, Senator Isakson.
Senator Boozman.
STATEMENT OF HON. JOHN BOOZMAN,
U.S. SENATOR FROM ARKANSAS
Senator Boozman. Thank you, Mr. Chairman, and thank you for
the hearing today which is so important; you and Senator Burr,
especially inviting people that are on the front line.
You guys are out fighting the battle and we really do
appreciate your service in so many different ways and affecting
a very positive outcome for so many.
You know, this is just an interesting, very difficult
problem. We talk about the stress of a war and yet many were
not deployed, though were in situations that were stressful in
the sense of a job, but not stressful in the sense of combat.
We are having a lot of problems in the private sector, in
society in general, in the same way. We have the reintegration
problems like you have experienced, Mr. Wood, which again is so
common; and I can see how that happens and yet a lot of these
individuals are 50 years old; in fact, a pretty significant
portion.
So, I guess really what I am wondering about is the root
cause. How can we identify and get to the point before they are
actually on the phone with the suicide call.
I guess what I am wondering is what factor does marital
difficulties play and financial problems? I used to be a
ranking member and chairman of the House Economic Opportunities
Committee. I always felt that if you could put people to work
and get them where they could support their families and things
like that, a lot of this would diminish.
But besides, the suicide counseling you almost wonder about
financial counseling, marriage counseling, you know, things
like that--again the root cause.
The other thing I would like for you to comment on, I think
in an effort to help people in society today and just to be
doing something in very difficult situations, I think we are
overmedicating people. I would like for you to comment about
that.
I think that is a real problem and I think in some
individuals--I think the facts are there that they go the other
way and can become suicidal from being overmedicated.
So, if you guys would just like to comment on that. Mr.
Wood, you can start if you like; share whatever your thoughts
are about some of those things.
Mr. Wood. Well, I will echo Colonel Allred. I am not a
clinician. I am not a doctor, and so please take my testimony
simply for what it is worth.
Senator Boozman. It is worth a lot.
Mr. Wood. My experience, I have never been medicated for
mental issues myself. The experience that I have with it is
that most veterans that I know, particularly Clay Hunt found
themselves----
Senator Boozman. Did you self-medicate? Did you have
problems with alcohol and things like that?
Mr. Wood. No, I have not. No.
Clay Hunt was certainly overmedicated; and in his
experiences with the VA, he would jump from medication to
medication, and dosage to dosage, trying to figure out
something that would work.
He was medicated the day he died. He had a very telling
quote, though, at one point that we actually have on video.
After he got back from Port-au-Prince, Haiti, he said that his
experiences with Team Rubicon, his experiences helping others
in serving his community once again were more therapeutic, more
cathartic than any cocktail of drugs that the VA had ever put
him on.
And, that is something that I believe that we can use to
get away from overmedicating our veterans.
Senator Boozman. Ms. Van Dahlen.
Ms. Van Dahlen. If I might--you brought up something that I
think is very important that I continue to hear which is that
one size does not fit all. That is the issue. That is why we
have not found the solution.
As a mental health professional who has been working in
this field, you know, for 20+ years, what is critical now is
that we figure out how to ensure that in communities there are
different options of care, whether it is financial or
marriage--absolutely sometimes financial counseling is what
that family needs and they are back on the right track.
They may need a physician who can step in and say, ``This
young man is way overmedicated. Perhaps we need to send them to
Team Rubicon or send him to get some equine therapy out in
nature with horses.''
It is having options, because even though there are many
things that we know are helpful, even the very best evidence-
based treatment is only helpful for a certain percentage.
As a mental health professional, that is what I think we,
our community, can offer: our knowledge and expertise to ensure
that we identify other efforts and then make sure those are
accessible and link them together.
Senator Boozman. I agree. I think sometimes the easiest
thing to do is write a prescription, and that is kind of what
we have gotten into a little bit.
Colonel Allred. Senator, if I might, you are absolutely
correct. Older veterans are taking their own lives at twice the
rate that younger veterans are, and it is still to be
determined why that is.
As the Chairman and Ranking Member both said, if we had the
answers. But there is such a dissimilarity of cultures which is
why the technology age sometimes is not in touch with the
telegraph age, you know, my age. I go to some of these veterans
service organization meetings and I am the youngest one there.
So, we have got to figure out a way to get these folks
together, the young folks and old. The National Alliance of
Mental Illness, if I may say, has a number of programs that
address exactly what you are talking about. We have over 1,100
chapters around the Nation, in every State.
I would suggest that, just from the standpoint of our
relationship with the VA, get on the computer, find your
nearest NAMI affiliate, call them up and say, bring that
organization in with your volunteer training. It is free. There
has to be a push and a pull, and that is the pull part of it.
But many people, even though there is a crisis line, will
not call it. We have got to find them. POS REP is a good way to
do it for the young folks but what about all of us old people.
Thank you, sir.
Chairman Sanders. Senator Burr, did you want to ask a
follow-up.
Senator Burr. Jake, how long did it take you to put
together that app, to develop it?
Mr. Wood. It was in development for approximately 8 or 9
months.
Senator Burr. And what are the plans to market awareness of
that app to OEF/OIF vets?
Mr. Wood. We are working with various nonprofit
organizations across the country. We are providing
organizations like Give an Hour an opportunity to use the
platform to reach vets so long as they are using their social
media channels to push the application down to their followers.
So, we are trying to use a grassroots efforts to do it.
Senator Burr. If you recognize anything that this Committee
can do through government to facilitate the awareness of that,
would you let us know?
Mr. Wood. One hundred percent. I will shoot you something
over as soon as we are done here.
Senator Burr. Thank you.
Chairman Sanders. Thank you, Senator Burr.
Let me just include by once again thanking each of you for
the extraordinary efforts on behalf of veterans. We have
learned a lot from your testimony and thank you very much for
being here. Take care.
[Pause.]
Chairman Sanders. We would like to welcome our second
panel. Representing the VA is Under Secretary for Health, Dr.
Robert Petzel. Dr. Petzel, thanks for being here.
He is accompanied by Dr. Janet Kemp, who is the Director of
Suicide Prevention and Community Engagement for VA's National
Mental Health Program; Dr. Sonja Batten, Deputy Chief
Consultant at VA Specialty Mental Health Program; and Dr.
William Busby, Acting Director of the Readjustment Counseling
Service of VA and Regional Manager for the Northwest Region.
And from the Department of Defense, we have Colonel Rebecca
Porter, Chief of the Behavioral Health Division for the Army's
Office of the Surgeon General.
Thanks very much for being with us.
Dr. Petzel, why don't we begin with you.
STATEMENT OF ROBERT PETZEL, M.D., UNDER SECRETARY FOR HEALTH,
VETERANS' HEALTH ADMINISTRATION, DEPARTMENT OF VETERANS'
AFFAIRS; ACCOMPANIED BY JANET KEMP, RN, Ph.D., DIRECTOR OF
SUICIDE PREVENTION AND COMMUNITY ENGAGEMENT, NATIONAL MENTAL
HEALTH PROGRAM, OFFICE OF PATIENT CARE SERVICES; AND SONJA
BATTEN, Ph.D., DEPUTY CHIEF CONSULTANT, SPECIALTY MENTAL HEALTH
PROGRAM, OFFICE OF PATIENT CARE SERVICES; AND WILLIAM BUSBY,
Ph.D., ACTING DIRECTOR, READJUSTMENT COUNSELING SERVICE AND
REGIONAL MANAGER FOR THE NORTHWEST REGION
Dr. Petzel. Good morning, Chairman Sanders, Ranking Member
Burr, and Members of the Committee.
I appreciate the opportunity to discuss VA's comprehensive
mental health care and services for our Nation's veterans. I am
accompanied, as the Chairman mentioned, by Dr. Batten, Dr.
Kemp, and Dr. Busby.
Since early 2009, VA has been transforming and expanding
its mental health care delivery system. We have improved our
services for veterans but we do know that there is much more
work, much more work that has to be done.
My written testimony has more detailed information. I would
submit that for the record. This morning I will summarize those
remarks and update you on some of our major accomplishments.
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 the 2013 National Defense
Authorization Act.
We know these changes require investments. Last year, VA
announced an ambitious goal to hire 1,900 new mental health
providers and administrative support. As of March 12, 2013, VA
has hired 1,300 new clinical and administrative staff in
support of that goal. We are on track to meet the requirements
of the Executive Order by 30 June 2013.
VA has many entry points for care including 152 medical
centers, 821 community-based outpatient clinics, 300 Vet
Centers, the veterans' crisis line, and many more to name just
a few.
We have also expanded access to care by leveraging
technology, telehealth, phone calls, online tools, mobile apps,
and through outreach, primary care, primary care integration of
mental health, community partnerships, and our academic
affiliations.
Outpatient mental health visits have increased to over 17
million in 2012 up from 14 million in 2009. The number of
veterans receiving specialized mental health treatment rose to
1.3 million in 2012.
In part, this is because our primary care clinicians
proactively screen veterans for depression, PTSD, problem
drinking, and military sexual trauma to help veterans identify
that they may be in need of mental health care and to actually
get the treatment that they need. We are also refining how we
measure access and outcomes to ensure that we accurately
reflect the timeliness of the care we provide.
VA has chartered a workgroup to set wellness-based outcome
measures. Currently, five metrics have been selected and others
will be identified to include: patient satisfaction, did they
get the appointment when they felt they wanted it and when they
needed it; clinical quality effectiveness measures; and
clinical process assessment.
In 2012, we conducted site visits to all VHA health
systems, met with the leadership, the front-line staff, and
veterans and identified a number of areas for improvements in
staffing and scheduling.
VA is updating its scheduling practices, strengthening its
performance measures and changing our timeliness measures. We
will continue to measure performance and to hold employees and
leadership accountable to ensure that the resources are devoted
where they are needed for the benefit of veterans.
VA has been working with partners to address access and
care delivery gaps. In response to the Executive Order, we are
collaborating with the Department of Health and Human Services
to establish 15 pilot projects using federally qualified health
plans.
VA is also partnering with DOD to advance a coordinated
public health model to improve access, quality, and
effectiveness of mental health services through an integrated
mental health strategy developed jointly by VA and DOD.
We are committed to ensuring the safety of our veterans.
Even one veteran suicide is one too many. July 25, 2012, marked
the fifth year since the establishment of a veterans' crisis
line. VA offers this 24/7 assistance, and last year the crisis
line received more than 193,000 calls, resulting in over 6,000
life-saving rescues. The crisis line has totaled over its
lifetime 750,000 calls.
Earlier this month the VA released a suicide report. This
report includes data on the prevalence and characteristics of
suicide amongst veterans, including those that were not being
treated by the VA.
The report provides us with valuable information to
identify populations that need target interventions such as
women and Vietnam veterans. The report also makes clear that,
although there is more work to be done, we are making a
difference.
There is a decrease in suicide re-attempts by veterans
getting care in the VA. Calls to the crisis hotline are
becoming less acute, also demonstrating that VA's early
intervention is working.
Mr. Chairman, we appreciate your support 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 your
questions.
[The prepared statement of Dr. Petzel follows:]
Prepared Statement of Robert A. Petzel, M.D., Under Secretary For
Health, Veterans Health Administration, U.S. Department of Veterans
Affairs
Good morning, Chairman Sanders, Ranking Member Burr and Members of
the Committee. Thank you for the opportunity to discuss VA`s delivery
of comprehensive mental health care and services to our Nation's
Veterans and their families. I am accompanied today by Dr. Sonja
Batten, Deputy Chief Consultant for Specialty Mental Health; Dr. Janet
Kemp, National Mental Health Program Director, Suicide Prevention and
Community engagement, Mental Health Services, and Dr. William Busby,
Acting Chief Officer for Readjustment Counseling Service.
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. VA has learned a great deal about both
the strengths of our mental health care system, and the areas that need
improvement.
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, Servicemembers, 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 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 implementing the 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 developing 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.
My written statement will describe VA's mental health care delivery
system with specialized programs in suicide prevention, Post Traumatic
Stress Disorder (PTSD), and military sexual trauma as well as
readjustment counseling. It highlights ongoing research in mental
health, our process for continuous quality improvement as well as the
measurement of that improvement. It also describes our outreach and
access initiatives and VA's recent enhancement of mental health
staffing.
i. mental health care
VA operates one of the largest, highest-quality integrated
healthcare 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 assessing those complementary and
alternative treatment methodologies that need further research, such as
meditation and acupuncture in the care of PTSD.
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. Veterans treated
with these psychotherapies report fewer PTSD symptoms. The reported
reduction in PTSD symptoms, an average of 19-20 points on the Post-
Traumatic Stress Disorder Checklist,\1\ is clinically significant.
Furthermore, VA operates the National Center for PTSD, which guides a
national PTSD Mentoring program, working with every specialty PTSD
program across the VA system 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.'' \2\
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\1\ A self-report instrument that has been extensively used in
research and is well regarded. Chard, Ricksecker, Healy, Karlin, &
Resick, 2012; Eftekhari, Ruzek, Crowley, Rosen, & Karlin, in press.
\2\ Institute of Medicine of the National Academies. Treatment for
Posttraumatic Stress Disorder in Military and Veteran Populations
Initial Assessment. July 13, 2012.
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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 fiscal year (FY) 2012, every VHA facility provided MST
related outpatient care to both women and men, and a total of 64,161
Veterans who screened positive for MST received a total of 725,000
outpatient MST-related mental health clinical visits. 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 this month, 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 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. 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.
VA is continuing to receive state data and will update the Suicide Data
report later this year. Thus far, 39 states have reported suicide data
to VA; 6 additional states are preparing data for shipment. VA reviews
the data submitted by states to validate Veteran status.
In addition, VA has established the Mental Health Innovations Task
Force, which is working to identify and implement early intervention
strategies for specific high-risk groups. For example, Veterans with
PTSD, pain, sleep disorders; depression and substance use disorders are
at high risk for suicide. Through early intervention, we hope to reduce
the likelihood that Veterans in these groups will progress into even
higher risk status.
ii. mental health care access
At VA, we have the responsibility to anticipate the needs of
returning Veterans. Mental health care at VA is an extensive 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.\3\ 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.
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\3\ Institute of Medicine of the National Academies. Treatment for
Posttraumatic Stress Disorder in Military and Veteran Populations
Initial Assessment. July 13, 2012.
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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 FY 2013
using Internet Protocol (IP) video on Veterans' personal computers.
Mobile Apps and Technology
VA has made good progress toward 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
toward 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 Service--Vet Centers
VA's Readjustment Counseling Service (RCS) provides a range of
readjustment counseling services to those who have served in combat
zones and their families. In addition to the integration of mental
health with primary care, VA also provides comprehensive readjustment
counseling for Veterans who have experienced military sexual trauma, as
well as, bereavement counseling to families whose Servicemember died
while on active duty. These services are provided in a safe and
confidential environment through a National network of 300 community-
based Vet Centers located in all 50 states, the District of Columbia,
American Samoa, Guam, and Puerto Rico, 70 Mobile Vet Centers, and the
Vet Center Combat Call Center. In FY 2012, through Vet Centers, RCS
provided over 1.5 million visits to 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 who have left active duty. Furthermore, in FY 2012, Vet Center
staff provided over 21,000 unique families with over 117,500 visits to
help aid in the readjustment of their Veterans. This represents a 15
percent increase in the number of families and 28 percent increase in
the number of visits when compared to the previous fiscal year. The
increase in services provided to families is a direct result of the
Secretary of Veterans Affairs Initiative to place a licensed and
qualified family counselor at every Vet Center.
A core component of the Vet Center mission is to help those who
served and their families overcome barriers they may have to accessing
VA care and services. This is accomplished through an extensive program
of face-to-face community outreach. Since the onset of the program in
1979, Vet Center staff have actively engaged their fellow Veterans and
family members at targeted community events and provided them with
access to services. Recently, RCS has enhanced its outreach capacity to
recently returning combat Veterans through a fleet of 70 Mobile Vet
Centers (MVC). To ensure early intervention and access to services the
MVCs provide outreach and onsite confidential readjustment counseling
to Veterans who are geographically distant from existing Vet Centers.
RCS also offers services through the Vet Center Combat Call Center
(877-WAR-VETS), an around the clock confidential call center where
those that served in combat zone and their families can call and talk
about their military service and transition home. The call center is
staffed by combat Veterans from different eras as well as family
members of combat Veterans.
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
finalizing the regulatory process outlined in the law and are working
together to implement this expansion of services. The recently passed
FY 2013 NDAA also includes provisions that expand Vet Center
eligibility to members of the Armed Forces who served in any theater of
combat and to certain members of the Armed Forces, Veterans, and their
family members indirectly exposed to the trauma of war. 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 records, 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 clients' information unless required by law. Early access to
readjustment counseling in a safe and confidential setting has proven
an effective way to reduce the risk of suicide and promote the recovery
of Servicemembers returning from combat. Furthermore, more than 72
percent of all Vet Center staff members 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 FY 2012.
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.
VA 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.
iii. mental health care quality improvement
VA is committed to hiring and utilizing more mental health
professionals to improve access to mental health care for Veterans.
Access enables VHA to provide personalized, proactive, patient-driven
health care; achieve measurable improvements in health outcomes, and
align resources to deliver sustained value to 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. VHA has made
significant progress to this end, by hiring a total of 3,354 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.
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.
Site Visits
In FY 2012, the Office of Mental Health Operations (OMHO) conducted
site visits at all 140 VHA Healthcare Systems. The site visits reviewed
the implementation of the Uniform Mental Health Services Handbook
(UMHSH) and involved meetings with facility leadership; mental health
leadership; mental health program leadership; front-line staff,
including clerks and schedulers; Veterans who receive mental health
care and their families or supportive others; and community
stakeholders and partners. In addition to interview data obtained in
the 2 day visit, administrative data was reviewed for each healthcare
system, including: Mental Health Information System data, relevant
reports provided by the facility (e.g., The Joint Commission, System-
wide Ongoing Assessment and Review Strategy, Commission on
Accreditation of Rehabilitation Facilities, etc.), and other data
obtained from multiple sources across VHA (e.g., Office of
Productivity, Efficiency and Staffing, Allocation Resource Center,
Mental Health Services, etc.).
Areas identified for systemic improvement included:
- Ensuring adequate Mental Health staff;
- Improving the timeliness of Mental Health services;
- Improving scheduling of Mental Health services; and
- Increasing provision of required Mental Health services at
Community-Based Outpatient Clinics (CBOC).
Areas that were identified as for systemic improvement and
also identified as systemic strengths included:
- Integration of mental health services into Primary Care;
- Care coordination across levels of care;
- Implementations of evidence-based treatments; and
- Implementation of recovery-oriented care.
Areas identified as systemic strengths included:
- Suicide prevention services; and
- Development of diverse community partnerships.
Systemic actions that have resulted from the visits include
The use of targeted facilitation processes for programs at
VHA healthcare systems which may experience challenges in
implementation, including Primary Care-Mental Health Integration and
evidence-based psychotherapy;
Continued monitoring of Mental Health staffing levels,
access and scheduling, in conjunction with education and support for
new wait time metrics;
Expansion of telehealth services to outlying CBOCs and in
the home; and
Expanded dissemination of Strong Practices SharePoint for
Mental Health to support cross facility learning.
In addition, VHA healthcare systems are implementing site specific
action plans in response to recommendations from each facility site
visit. These plans are monitored quarterly. OMHO will be visiting
approximately 1/3 of VHA healthcare systems each year (45 in FY 2013)
from FY 2013 forward to review continued implementation of the UMHSH,
visiting each facility once every 3 years.
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
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 also has 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.
In April 2012, VA announced a goal to hire an additional 1,600
clinical providers and 300 administrative support staff. As of March 5,
2013, VA has hired 1,089 clinical providers and 230 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.
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.
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
140 Peer Specialists and Apprentices in recent months, and is hiring
and training nearly 660 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 the association between various measures of appointment
timeliness and the 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.
The study showed that new and established patients have different needs
and require different approaches for capturing wait times. The data
identified that the Create Date, the date that an appointment is made,
is the optimal method for new patients, since most new patients want
their visit or clinical evaluation to occur as close to the time they
make the appointment as possible. For established patients, VHA has
determined that using the Desired Date is the most reliable and
patient-centered approach. Desired Date is the ideal time a patient or
provider wants the patient to be seen. Armed with evidence that the
Create Date and the Desired Date best predict patient satisfaction and
health outcomes for new and established patients respectively, VHA
adopted these methods on October 1, 2012. With the recent evidence from
our wait time study, ongoing VHA performance measures, as well as
findings and recommendation from oversight entities, VHA believes it
now has reliable and valid wait time measures that allow VHA to
accurately measure how long a patient waits for an outpatient
appointment. 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. VHA's action plan is
aimed at ensuring the integrity of wait time measurement data so that
VHA has the most reliable information to ensure Veterans have timely
access to care and high satisfaction.
Outcome measures
VHA provides Veterans with personalized, proactive mental health
care to optimize their health and well-being. The ultimate unit of
outcome is the improvement in the quality of life for each Veteran. As
part of its commitment to transparency, stewardship, and exceptional
health care services, VHA is also eager to have a set of outcome
metrics to evaluate its mental health care system. There is no national
standard for measuring outcomes in mental health care. The literature
indicates the best approach is to use a variety of measures including
patient satisfaction, clinical quality effectiveness, and clinical
process assessment. In 2011, the National Quality Forum (NQF) published
a consensus report outlining a framework for mental health and
substance use outcome measures. VHA has chartered a workgroup to
identify a set of population-based, outcome-oriented metrics. The
development and use of these measures will be an iterative process over
a period of months and years, and additional metrics will be developed
using additional data sources. At present, VA has selected five initial
metrics, including standardized mortality ration, rates of suicide re-
attempt, drug screening of patients on opioid therapy, antipsychotic
medication adherence among patients with schizophrenia, and flu
vaccination rates in VA mental health patients.
In 2011, VHA raised the bar for the industry by setting a wait time
goal of 14 days for both primary and specialty care appointments. Last
year, VHA added a goal of completing primary care appointments within 7
days of the Desired Date. The intent is to come as close as possible to
providing just-in-time mental health care for patients. The ultimate
goal is same day access. VHA is focused on implementing new wait time
measurement practices, policies, and technologies along with aggressive
monitoring of reliability through oversight and audits. By taking these
steps, we are confident that we will be able to deliver accessible,
high quality, timely 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.
______
Response to Posthearing Questions Submitted by Hon. Bernard Sanders to
U.S. Department of Veterans Affairs
Question 1. A recent report found that 30 percent of veterans
seeking health care through VA seek treatment for PTSD. What is the
overall number of veterans in the VA system receiving mental health
care? How does this number compare with your estimate of those who
actually ``need'' mental health care?
Response. During fiscal year (FY) 2012, over 500,000 Veterans from
all eras of service received mental health treatment in VA for Post
Traumatic Stress Disorder (PTSD). Within the population of returning
Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn
(OEF/OIF/OND) Veterans, VA estimates 13-20 percent of those Veterans
may experience PTSD as a result of their military service. Given that
1,604,359 OEF/OIF/OND Veterans have become eligible for VA health care
between October 1, 2001, and December 31, 2012, that would mean that
between 208,567 and 320,872 eligible returning Veterans might
experience PTSD. As of December 31, 2012, 486,015 OEF/OIF/OND Veterans
have been seen in VA for a potential mental health diagnosis, 261,998
of whom have been seen in VA for a potential diagnosis of PTSD.
Regarding how this number compares with an estimate of the ``need''
for mental health care, VA assumes there are additional Veterans from
all eras of service who could benefit from VA's mental health care
system. There is no reliable way to estimate that number, however VA
monitors mental health treatment workload and staffing to ensure
sufficient capability is available to meet mission needs. In response
to the President's executive order on veterans' mental health, we have
increased our mental health staff to help meet this need.
Question 2. While many veterans receive mental health care through
VA, others elect to receive these services from community providers.
Under existing regulations, veterans enrolled in VA health care will be
ineligible to receive subsidies to purchase health insurance, even if
those veterans have not received care through VA in a number of years.
What steps are you taking to educate veterans about this and to help
them to understand their options for obtaining access to health care
and health insurance in the future?
Response. VA employs multiple methods to educate Veterans about
access to health care, to include options under the Affordable Care
Act. Methods include phone calls, letters, briefings, and Web site
postings by VA's 152 VA medical centers (VAMC), 817 Community-Based
Outpatient Clinics (CBOC) and 300 Vet Centers. Also, VA proactively
provides content to its local and national social media sites and
bulletin newsletters, etc. VA has created a specific portion of our Web
site to help inform Veterans about the Affordable Care Act: http://
www.va.gov/health/aca/.
VA continues to speak directly to Veterans using all available
communications avenues. It is important to demonstrate that mental
health is an extremely high priority for VA, and that Veterans who
receive VA's high quality health care services experienced improved
health.
VA promotes the importance of Veterans visiting their local VA
health care facility to learn more about VA enrollment and enrollment
options. VA encourages Veterans to learn more about their VA health
care system by going to http://www.va.gov/health/default.asp.
Also, VA engages with other stakeholders regarding VA mental health
to include, Members of Congress, Congressional committees of
jurisdiction, and staffs to provide information on mental health
services and initiative for Veterans. Also, VA works with other
government agencies such as the Department of Health and Human Services
and Department of Defense (DOD), to provide awareness of VA mental
health announcements.
Finally, VA media messaging will follow updates on all social media
platforms (to include Facebook, Twitter, Vantage Point, etc.) The
Veterans Health Administration (VHA) will also amplify announcements on
the www.facebook/com/VeteransHealth and www.twitter.com/VeteransHealth
accounts.
Question 3. Now that the Department has concluded its first round
of site visit reviews of mental health care services, please describe
any systemic areas that require improvement across the system and how
VA intends to implement these improvements. Please also describe any
best practices that you could be shared across the system.
Response. Qualitative data were analyzed from all site visit
reports to identify the most common strengths and opportunities for
improvement across all facilities. Areas identified for systemic
improvement in the action plans were:
Ensuring adequate mental health staff--VA is aggressively
monitoring mental health staffing levels, including actions to fill new
positions and backfill vacancies. VA has expanded its Mental Health
Staffing Model to include specialty mental health team care with the
goal of implementing a general mental health team in each facility by
the end of FY 2013. Additionally, the Mental Health Productivity
Directive is nearing completion. Once published, this directive will be
used by sites to establish systems that monitor staff productivity and
staffing requirements.
Improving the timeliness of mental health service
delivery--VA made targeted interventions to address access to services.
For example, hiring for vacancies and adding new mental health staff is
enhancing access in locations with staffing deficiencies. Facilities
with access shortfalls developed action plans to improve inefficient
system design. Sites are expanding the use of telemental health or
contracting where access challenges could not be resolved by hiring or
redesign. To monitor timeliness, VA created new metrics for FY 2013 to
monitor new and established patient access to care, and is continuing
site visits to collect information on access from the perspective of
front line staff, Veterans, and mental health leadership.
Improving scheduling of mental health services--Scheduling
guidance is being rewritten to address the changes in the access
metrics and education. The guidance requires schedulers to be audited
regularly to ensure scheduling follows the directive. In addition, the
ongoing site visits include interviews with scheduling staff to review
compliance with the scheduling directive.
Increasing provision of required mental health services to
CBOCs--VA is expanding telehealth services to CBOCs in order to improve
access to care. VA is also increasing the availability of specialty
telemental health services.
Other areas that needed improvement at some sites, but were
systemic strengths at other sites, include:
Integration of mental health services into primary care--
Research from VA's Mental Health--Quality Enhancement Research
Initiative has demonstrated that facilitation helps clinical
stakeholders implement or improve practices. Mental health has trained
staff in this technology to implement evidence-based methods of
consultation with facilities/Veterans Integrated Service Networks
(VISN). This process bundles an integrated set of interventions to
assist facilities through interactive problem solving. Intensive
facilitation assistance is currently being rolled out to help
facilities which request assistance with mental health in primary care.
Additional assistance includes consultation with subject matter experts
from the VA Center for Integrated Healthcare and the VA National
Primary Care-Mental Health Program Office, monthly national training
calls, educational materials available through a national SharePoint,
and the creation of VISN-wide training in integrated care, as
requested. Facilities identified as needing to grow integrated care
programs through the site visit process are being monitored quarterly
for their progress by VHA.
Care coordination across levels of care--The site visits
identified that many facilities faced challenges during transitions
from one level of care to another (e.g., from inpatient to outpatient
services, from outpatient to residential, etc.). Often times, this
involved difficulty scheduling follow-up appointments when Veterans
were discharged back to another VA or to a community resource.
Individuals being seen for follow-up in contract or fee-basis care do
not have visits which can be tracked in internal VA databases and local
solutions for tracking follow-up for these Veterans must be employed.
Currently, facilities with these challenges have developed improvement
plans and are reporting to VA quarterly on their progress.
Additionally, VHA is monitoring progress on nationally available data
such as the 7-day follow up after an inpatient hospital stay to measure
and assess progress.
Implementation of evidence-based treatment--VA is now
supporting facilities that desire more intensive assistance with
evidence-based psychotherapy (EBP) implementation. VHA is initiating
new EBP trainings for FY 2013 to increase the number of staff trained
in these therapies. The implementation of EBP templates will also
assist in ongoing monitoring of these efforts.
Implementation of recovery-oriented care--Peer support
services are part of a large expansion of recovery-oriented services.
Consistent with the President's executive order, VHA is hiring 800 peer
support specialists in 2013 to assist with this expansion.
Additionally, the site visits identified the need to expand recovery-
oriented services, especially on inpatient mental health units. VHA
provided two training events on recovery care in the summer of 2012 to
assist facilities transforming their inpatient units to become more
recovery-oriented. Site visits will continue to require action plans to
be submitted with quarterly updates on areas of concern related to
recovery-oriented care at facilities.
Strong Practices
VHA has developed a Mental Health Strong Practice SharePoint site,
which is an online repository of information about strong practices
that were identified during the site visits. The SharePoint site
provides contact information for all strong practices in order to
foster communication across the VHA health care community. Some initial
strong practices identified, at select sites, through the site visit
process include:
Appointment Scheduling Program--One facility created a
small graphical user interface program that allows clinicians to
quickly enter patient appointment information into the program with
little typing. Once entered, the software places the appointment in the
clinician's Outlook calendar with a numerical placeholder representing
the patient. Clerical staff enters the appointment into VistA ( VA's
Electronic Health Record), the Veterans Health Information Systems and
Technology Architecture, later the same day using automation. There is
also an application for simple, rapid scheduling of mental health
groups.
Dissemination of EBP via Telemental Health--Clinicians who
have completed training in an EBP are available at the main facility
and at each of the CBOCs to offer EBPs across site. Each location has
telehealth equipment readily available and all certified EBP clinicians
are trained in the use of telemental health. This allows for EBPs to be
offered across sites as needed, and provides for therapist gender
preference flexibility and opportunities to improve access to care for
a variety of Veterans.
Psychiatric Community Nursing Home Visits--A VA
psychiatrist travels to community-based, long-term, secured facilities
to provide regular weekly psychiatric care, and to provide training to
facility staff. This has facilitated increased communication between
nursing facility staff and VA providers, and provides community nursing
home residents with more frequent outpatient care. This practice has
reduced emergency room visits and inpatient hospitalizations.
Time Limited Case Management for Chemical Abusing Mentally
Ill (TLC-CAMI)--The TLC-CAMI program seeks to improve continuity of
care for Veterans with mental illness and co-morbid substance use
disorders through a combination of case management, a harm reduction
philosophy, and peer support designed to improve linkage to and
sustained engagement in outpatient substance use disorder services.
Question 4. Based on the findings from the first round of site
visit reviews of mental health services, how will VA ensure systematic
surveillance efforts are carried out to better understand care trends,
links between care processes and treatment outcomes, and facility-by-
facility differences in performance?
Response. Systematic review of progress is part of each site visit.
At the conclusion of each site visit, a report is issued outlining
recommendations for responses from each facility. Facilities have an
individualized follow-up call with VHA Central Office mental health and
VISN leadership to discuss the recommendations and to develop specific
strategic action plans. Facilities submit quarterly updates to document
progress. Return visits to each facility will occur at least once every
3 years to monitor the Uniform Mental Health Services Handbook
implementation. In addition, VHA will continue to analyze site visit
findings, administrative data and other data sources to determine
trends in care, barriers to implementation, and system-wide concerns.
Question 5. An important challenge for monitoring the outcome of
evidence-based mental health treatments is the availability of good
metrics to track the use of those treatments. VA's Office of Mental
Health Services has previously committed to fully implementing
psychotherapy session note templates by the end of FY 2013, which will
help the agency to develop better metrics. Please provide the Committee
with the status of the implementation of these session note templates.
Response. The information technology project to develop and
implement psychotherapy session note templates in support of the EBP
dissemination initiative is underway. Templates in support of the key
psychotherapy protocols for the treatment of PTSD and depression are
currently being piloted at four VAMCs. The templates are scheduled for
national deployment during the fourth quarter of FY 2013.
Question 6. It is important to recognize that there should not be a
``one-size fits all'' approach to mental health treatment. What steps
is VA taking to increase availability of alternatives for veterans,
including complementary and alternative medicine? What has VA done to
promote these care options?
Response. VHA's strategic priority is to provide personalized,
proactive, patient-driven health care to our Veterans. Providing this
care requires expanding health care options that are available to
Veterans. To this end, VA is moving toward a model of care that is
better aligned with integrative medicine principles, which include
complementary and alternative medicine (CAM). Integrative medicine as
defined by the Consortium of Academic Health Centers for Integrative
Medicine is:
``The practice of medicine that reaffirms the importance of the
relationship between practitioner and patient, focuses on the
whole person, is informed by evidence, and makes use of all
appropriate therapeutic approaches, healthcare professionals
and disciplines to achieve optimal health and healing.''
The ``practice'' has the Veteran at the center of the health care
team, and begins with their vision of health and their values and
goals. It links the Veteran's personalized health plan to what matters
to them in their lives, and it supports them in acquiring the skills
and resources they need to succeed in making sustainable changes in
their health and life. This approach, including the development of a
personalized health plan, will improve identification of Veterans
seeking CAM and better enable VA's ability to provide these services.
This aligns with both the Recovery Model and the personalized,
proactive, patient-driven approach, which is patient-centered care. VA
mental health is seeking to transform care through the rational
integration of CAM using this patient-centered care model.
Recognizing the alignment of integrative medicine and CAM and its
critical role in meeting the VHA strategic priority for health care
delivery transformation, the Office of Patient Centered Care and
Cultural Transformation (OPCC&CT) has deployed a number of clinical,
research, and education initiatives. These initiatives include clinical
pilots, work within existing VA Centers of Innovations, work with VA
Health Services Research and Development, as well as creating curricula
and piloting education in these areas. In support of this effort,
Mental Health Services is currently working collaboratively with
OPCC&CT to develop an innovative approach to mental health care in VA
for patient population groups at high risk for suicide. This initiative
will focus on providing mental health care to these groups of patients
based on how patients define their needs and include the use of both
established evidence-based treatment and alternative and complementary
strategies. This exciting campaign will involve both provider and
patient education messaging as well as the development of new tools for
providers to use to drive this use of alternative care strategies. We
anticipate starting to roll out this initiative later this year.
Question 7. Families are an important source of support for
veterans as they receive mental health treatment. What guidance has
been provided to VA facilities on engaging families in veterans' mental
health treatment?
Response. VHA Handbook 1160.01, Uniform Mental Health Services in
VA medical centers and Clinics, contains guidance for VA clinicians on
family involvement in the Veteran's mental health treatment. VHA has
developed a graduated continuum of services to meet the individual
needs of Veterans and their family members. Public Law (P.L.) 110-387,
Veterans' Mental Health and Other Care Improvement Act of 2008, added
Marriage and Family Counseling to the list of available family services
and removed limitations for non-service-connected Veterans (required
hospitalization and identified need of family services for discharge).
An Under Secretary for Health Information Letter was distributed to the
field providing guidance on implementing this expansion for family
services. The full continuum of family services ranges from family
resiliency (currently in pilot phase) to family education, to family
consultation, and then to more intense family psychoeducation and
marriage and family counseling. VHA has created a Family Services
SharePoint intranet site that is an internal resource for VHA staff and
clinicians and conducts monthly educational conference calls to assist
and educate VA clinicians.
This year's suicide prevention awareness campaign, ``Stand By
Them,'' is designed to encourage family members and friends to help
their Veteran seek help. Across the country, Suicide Prevention
Coordinators (SPC) is providing education and information about the
warning signs and symptoms as well as how to get help by calling a
local contact or the Veterans Crisis Line. Family members may also be
experiencing difficulty themselves. Through a series of calls with
Mental Health Liaisons, Local Recovery Coordinators, and OEF/OIF/OND
Coordinators, VA staff around the country have been educated about the
new provisions in Section 304 of the Caregiver Law, which authorizes VA
to provide mental health care and readjustment counseling for families
members of new Veterans for the first 3 years after their return from
deployment. Brochures, Web announcements, and posters have been
developed and are in different stages of distribution to encourage
family members to seek services through their local VA facility or Vet
Center.
Question 8. In the last year, how many veterans have received
psychotherapy via telehealth? What processes, if any, does VA have in
place to ensure that veterans are comfortable with receiving those
services via telehealth as opposed to in-person?
Response. In FY 2012, VA provided telemental health consultations
to 76,817 Veterans. VA does not have data currently available on the
number of these Veterans who received psychotherapy via telehealth. VA
does have data from FY 2006-2010 showing that between 57-62 percent of
telemental health encounters were for psychotherapy. In FY 2012, VA
provided 218,000 telemental health encounters to Veterans for all
mental health conditions.
VA standard practice is to offer all Veterans appropriate for
telemental health services the choice between traditional in-person
visits and telemental health. VA conducts and documents in the patient
record verbal informed consent for each Veteran choosing to commence
telehealth services (to include telemental health services). VA
conducts telehealth satisfaction surveys for Veterans choosing
telehealth services. In FY 2012, clinical video telehealth (to include
telemental health services) had a patient satisfaction score of 93
percent. VA is expanding teleconsultations into the home for mental
health conditions with over 800 Veterans receiving these services in FY
2013. Further expansion of this care is planned and facilitated by
technology innovations and VA's elimination of co-payments for video
consultation into the home in FY 2012.
Question 9. Although the VA/DOD Clinical Practice Guideline for
Management of Post-Traumatic Stress cautions clinicians against
prescribing sedatives for veterans with PTSD, there have been reports
of high rates of such practices in VA. Please provide the number and
percentage of veterans receiving treatment for PTSD through VA who were
prescribed sedatives over the past year.
Response. In FY 2012, 28.1 percent of 502,546 (140,713) patients
with PTSD were prescribed a benzodiazepine. Although benzodiazepines
are the type of sedative that the PTSD clinical practice guideline
recommends against prescribing in patients with PTSD, there are
instances where a co-morbid diagnosis would have benzodiazepine as an
appropriate treatment modality. Due to their lack of efficacy in the
management of PTSD and their potential adverse effects, VHA is
currently looking at benzodiazepine use in PTSD patients to ascertain
whether or not such sedatives were appropriately prescribed.
(a) To address the issue of prescribing of benzodiazepines in PTSD
patients, the National Center for PTSD has developed a number of
products to inform providers on guideline-concordant practices. In
addition to the peer reviewed articles listed in the recent PTSD
Research Quarterly that focused on benzodiazepines in PTSD, The Role of
Benzodiazepines in the Treatment of Posttraumatic Stress Disorder
(PTSD) RQ Vol 23(4). 2013, disseminated to over 19,000 VA subscribers,
there are numerous publications, lecture series, and educational
materials that have been widely disseminated by VA. Specific examples
include the Journal of Rehabilitation Research and Development Special
Single-Topic Issue Related to PTSD Available Online; a Clinician's
Guide to Medications on www.ptsd.va.gov that was visited over 47,000
times in 2012; 3 PTSD 101 Online Courses that provide recommendations
about pharmacotherapy for PTSD and include cautions about the use of
benzodiazepines that had a total of over 15,000 visits in 2012. There
was also a kickoff presentation by Dr. Matthew Friedman in the 2013
PTSD Psychopharmacology Lecture Series in which a warning about the use
of benzodiazepines was reiterated to over 350 VA clinicians. The
June 2013 lecture topic is ``Strategies to Decrease Benzodiazepine Use
in PTSD'' and will be given by Drs. Tasha Souter and Nancy Bernardy.
(b) The VA Academic Detailing Pilot Program, developed in VISNs 21
and 22, is a proactive outreach intervention aimed at improved patient
care by promoting use of evidence-based treatments in Veterans with
mental illness. The program uses clinical pharmacy specialists to meet
face-to-face with VA prescribing clinicians to share educational
program materials embedded with key messages and an informatics tool,
the mental health dashboard, to provide desktop caseload information to
target. Data collection for the dashboard includes 100 percent sampling
of updated daily clinical information and allows clinicians to have a
snapshot view of their patient panels to improve individual patient
care. One of the areas that the academic detailers have targeted is
PTSD and they have seen some positive effects through the pilot. These
include increases in clinician use of the PTSD Checklist, increases in
the use of prazosin to target PTSD-related nightmares, a practice
recommended by the guideline, and decreases in the use of off-label
atypical antipsychotic prescribing. Materials have been developed
specifically to target benzodiazepine prescribing in PTSD patients by
the academic detailing team and are now in use.
(c) The academic detailing work, outlined above, specifically
targets prescribing clinicians through one-on-one intervention. Various
research projects funded by VA to target benzodiazepine prescribing are
also currently under development. Currently, there is not a decision
support prompt nationally in the VA EHR that reminds prescribing
clinicians of the guideline. VA does, however, have alerts that come up
that caution prescribers about certain medications.
Question 10. What steps does VA take to inform veterans of
complementary and alternative medicine options at VA facilities?
Response. Complementary and alternative medicine (CAM) options are
currently provided within VA. There are currently several research and
demonstration projects in progress that will be used to determine
ongoing direction. In the meantime, Veterans are informed of CAM
services as available at local VA facilities given the variability in
options. Currently, a directive is being developed to help guide VA
facilities in their implementation of these practices. The estimated
time of completion for this directive is May 31, 2014.
Question 11. Please describe any recent and ongoing research that
VA has on the use of complementary and alternative medicine for
veterans.
Response. For PTSD and mental health conditions, VA research is
determining the potential benefit of a variety of CAM approaches,
several of which are highlighted here:
Meditative techniques to improve PTSD symptoms, including
mindfulness based stress reduction and mantram repetition are being
examined in small clinical trials. The findings from these studies will
be used to determine whether larger scale, more confirmative trials are
needed to show whether there is sufficient evidence to support adopting
these methodologies in clinical care.
Several small pilot studies are underway to examine
whether acupuncture improves symptoms related to PTSD or Traumatic
Brain Injury.
A study using bright light exposure in comparison to
placebo is evaluating whether this treatment relieves symptoms of PTSD
or other conditions.
A study will evaluate use of service dogs for individuals
diagnosed with PTSD. Objectives include: (1) to assess the impact
service dogs have on the mental health and quality of life of Veterans;
(2) to provide recommendations to VA to serve as guidance in providing
service dogs to Veterans; and, (3) to determine cost associated with
total health care utilization and mental health care utilization among
Veterans with PTSD.
In 2011, VA research supported an analysis of the available
research on CAM therapies for PTSD and concluded that there was a need
to support rigorous clinical trials to evaluate the efficacy of these
methods. In general, VA research has encouraged the exploration of CAM
for conditions important to Veterans and has included CAM as a priority
topic in clinical research.
Question 12. Although there may be limited evidence that wellness
programs--when combined with more traditional therapies--can improve a
veteran's quality of life, such programs may be a useful tool for
veterans. Do you agree that wellness programs, such as yoga and
meditation, have a place alongside VA's traditional mental health care
services? If so, please describe the steps, if any, that VA is taking
to promote wellness among veterans.
Response. Public Law 104-262, The Veterans' Healthcare Eligibility
Reform Act of 1996, called for VA to provide needed hospital and
medical services that will promote, preserve and restore health.
Disease prevention and health promotion are cornerstones of VA's
approach to care and VA strongly endorses the promotion of self-care
and wellness activities that are focused on improving the general
health and well-being of Veterans. Many Veterans, including those with
chronic mental illness, are experiencing problems with overweight and
obesity, which puts their health and quality of life at risk. VA has
made a concerted effort to measure weight in mental health settings and
offer the Managing Overweight/Obesity for Veterans Everywhere (MOVE!)
Weight Management Program to foster lifestyle change that promotes
maintaining a healthier weight. VHA has funded research efforts to
examine whether MOVE! can be enhanced for patients with serious mental
illness. VA has also implemented programs in stress management and
problem-solving skill development to improve quality of life among
Veterans.
There is increasing awareness within VA of the potential benefits
of non-traditional methods in the management of chronic diseases
including the management of mental health conditions. CAM practices,
while lacking the evidence of efficacy to become standard of care as
standalone therapies do show some promise as adjuncts to usual care.
Studies have shown that therapies such as acupuncture, yoga,
meditation, and tai chi may have beneficial effects and these effects
may be useful in our approach to care of the Veteran with chronic
health conditions. At the present time these CAM practices are not used
in a systematic way across VA. However, efforts are ongoing to help
improve our understanding of these modalities and how they may best
benefit Veterans.
One approach VHA is undertaking to foster this education and
understanding of the role of wellness in mental health treatment is
through the sponsoring of demonstration projects. VHA's Mental Health
Services is coordinating a series of demonstration projects at local
sites looking at the implementation of various types of meditation
programs to treat Veterans with PTSD. The focus is on learning how best
to introduce these modalities and integrate them into the Veteran's
plan of care as interventions. In addition, VA wishes to learn how to
support Veterans in sustaining these practices as well as measuring
such variables such as patient satisfaction and symptom reduction.
There are currently nine projects at eight different sites that will
complete their implementation and first rounds of data collection by
this summer. VA will then take the lessons learned to help implement
more programs across the country.
Question 13. How is VA collecting and analyzing data from the
Veterans Crisis Line and the Suicide Prevention Coordinators to ensure
all facilities can benefit from lessons learned?
Response. When calls come into the Veterans Crisis Line (VCL) there
is an internal referral mechanism via a secure web based program that
allows the VCL staff to submit a referral to the local facility that
they are required to respond to within 24 business hours. The VCL staff
checks these daily to assure no one ``slips through the cracks'' and
outcomes (admission, appointments, evaluations, etc.) are tracked. This
and all VCL information regarding phone calls, chats initiated, and
incoming texts are kept in a continual data system for VCL. Also, this
information is provided to the field on a monthly basis.
VA collects data from the SPCs on a monthly basis and returns a
monthly report to facilities including the numbers of suicide attempts,
known suicides, outreach events, safety plans completed, etc., so
facilities can track their progress and know how they compare within
the system. Within the VISNs, SPCs meet to determine best practices and
how to share ideas and interventions. There are monthly calls with all
SPCs to review data and new policies and practices. There is also a
suicide related analytic team that reviews all suicide related data on
an ongoing basis and provides information back to the field in the form
of memorandums or information sheets whenever specific information
might be useful.
All of this information is also discussed during the monthly SPC
calls to provide lessons learned about referrals and the Crisis Line
processes to everyone.
Question 14. What practices does VA believe have been most
effective in curbing suicides among veterans? Please also describe
additional strategies that VA could take to further reduce the number
of veteran suicides.
Response. VA believes that current programs (including the Veterans
Crisis Line, SPCs, and the Suicide Prevention Enhanced Care program
described further below) are effective.
The Veterans Crisis Line is a 24/7 call center that operates phone
lines, a one-to-one chat service and a texting service to provide
immediate mental health care and services to any Veteran,
Servicemember, and family member who is in crisis or concerned about
someone in crisis. Since its inception in 2007, over 800,000 calls, and
7,000 text messages have been received and responded to. There have
been over 28,000 instances when emergency services were sent to someone
in imminent danger.
SPCs and teams are at each VAMC and very large CBOC. These teams
have the responsibility to monitor and assure care to high risk
patients and respond to referrals from the Crisis Line and other
sources. Their objective is to ensure that no patient slip through the
cracks and that care is provided in a timely and individually
appropriate manner. They also serve as both internal training and
community education around suicide awareness, track events, participate
in quality improvement programs and provide a resource to their
facilities.
Each patient identified as being a high risk for suicide is
enrolled in the Suicide Prevention Enhanced Care program. This involves
having a chart notification flag placed on the medical record,
receiving increased follow up for missed appointments, a development of
a safety plan and mandated weekly follow-up visits. Through these
efforts, VA has been able to decrease the number of suicide re-
attempts.
If additional strategies become evident, VA will certainly
implement them. Hopefully, ongoing research will soon provide
additional intervention strategies, and continued outreach will result
in more Veterans seeking care earlier. It is difficult to determine the
direct effect that proactive outreach initiatives such as ``Make the
Connection'' have on suicide rates.
Question 15. We understand that the nationwide shortage of mental
health clinicians may present challenges to VA as the agency tries to
hire additional clinicians to fill mental health vacancies. Please
describe when VA facilities should coordinate with community providers
to meet veterans' mental health needs and the extent to which VA has
provided its facilities with guidance on this topic.
Response. VHA authorizes non-VA medical care when VA facilities or
other government facilities are not capable of furnishing economical
hospital care or medical services because of geographic inaccessibility
or are not capable of furnishing care or services required. The ability
to authorize non-VA medical care is legislated and subject to
restrictions in how and when care may be authorized. In general,
however, facilities have coordinated with community providers to
support care for Veterans in the community as part of non-VA medical
care. VA is developing additional guidance as part of the response to
the President's executive order on Mental Health (Executive Order
13625). As part of the response to this executive order, 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). Pilot
projects are varied and may include provisions for inpatient,
residential, and outpatient mental health and substance abuse services.
As these pilot projects are evaluated, lessons learned will be compiled
and shared with VA facilities nationwide.
Question 16. The most recent quarterly update from VA on the hiring
of an additional 1,600 clinicians reflects that the Department hired
just forty-seven clinicians in the last two months. During our hearing,
Dr. Petzel indicated that VA is on track to hire the remaining 495
clinicians by June 30th of this year. Please provide information on the
number of clinicians currently in the pipeline and VA's plan for
completing the hiring process by the deadline.
Response. VA will continue to execute an aggressive recruitment
campaign. As of June 30, 2013, 4,308 mental health professionals and
administrative support have been hired and are providing services to
Veterans since the start of VA's mental health hiring initiative in
April 2012. VHA has 213 positions remaining to meet the goal. As of
June 30, 2013, 42 job announcements were posted, 386 interviews and
selections were pending, 204 tentative job offers and 99 firm job
offers were made for a total of 731 potential hires in the pipeline.
The number of clinical mental health professionals hired is 3,833 which
includes the hiring efforts for existing VA positions and 1,669 new
positions to meet the 1,600 position goal outlined in the August 2012
Executive Order. VA has also hired 304 administrative support personnel
to meet the 300 position goal.
Question 17. How has VA supported the Army's efforts to improve the
diagnosis and evaluation of behavioral health conditions? Please
describe what VA has learned from the Army's efforts.
Response. In May 2012, the Secretary of the Army issued a directive
to investigate and identify any systemic breakdowns or concerns in the
Integrated Disability Evaluation System (IDES) as they affect the
diagnosis and evaluation of behavioral health conditions. As a result
of this directive, the Army Task Force on Behavioral Health was
established. VA supported the Army's efforts to improve the diagnosis
and evaluation of behavioral health conditions by having a senior
mental health staff member serve as an active participant on this Task
Force. From the Army's efforts, VA has learned that VA and the Army
need to continue to engage in active communications regarding the IDES
process. VA believes we are well positioned to have examiners evaluate
behavioral health conditions in a timely fashion as part of the IDES
process. VA will continue to support the Army and other branches of the
Armed Forces in ensuring that individuals are evaluated for behavioral
health conditions utilizing the American Psychiatric Association
Diagnostic and Statistical Manual of Mental Disorders.
______
Response to Posthearing Questions Submitted by Hon. Richard Burr to
U.S. Department of Veterans Affairs
Question 1. Executive Order 13625, regarding mental health services
for veterans, recognized the importance of peer-to-peer counseling by
directing the Department of Veterans Affairs (VA) to hire 800 of these
counselors by December 31, 2013. Information supplied to the Committee
by VA indicates that, as of March 5, 2013, VA has hired 149 peer-to-
peer counselors.
a. How many of the 149, noted above, were hired after the Executive
Order was signed on August 31, 2012?
Response. All of the 149 noted above were hired after the Executive
Order was signed.
b. How many of the 800 peer-to-peer counselor positions will be new
positions beyond those already employed by VA when the executive order
was signed?
Response. All 800 peer counseling positions are new. To meet the
requirements of Public Law 110-387, VA established a new, singular job
classification for peer-to-peer counselors that use the job titles of
Peer Specialists, for those who are certified to provide peer support
services, and Peer Support Apprentices, for those who are in training
but not yet certified. This new job classification provides significant
promotion possibilities for peers in demonstration of VHA's commitment
to employing Veterans in meaningful jobs that have a career potential.
All 800 peer counseling positions specified in the Executive Order are
using the new job classification. Also, 275 VA employees have met the
requirements to be converted to a peer specialist or peer support
apprentice position, and 582 new employees have been hired, for a total
of 857 new peer counselors.
c. What metrics will be used to determine which facilities will
receive the new peer-to-peer counselors, and how many counselors will
be needed at each facility?
Response. VA Mental Health Services has established a minimum
standard of three peers counselors per VAMC and two peers counselors
per very large CBOC. The majority of the 800 positions required by the
Executive Order will be used to ensure that each facility meets at
least the minimum standard. The remaining positions will be allocated
to facilities based on projected outpatient mental health service
demand and will be assigned to meet special needs as identified by the
facilities.
d. Please describe, in detail, the training process and length of
time training takes for new counselors.
Response. Peer counselors who have been hired but who are not yet
certified are receiving certification training through contracts with
community organizations. Training includes a week-long face-to-face
workshop in addition to training delivered over the internet or a 2-
week face-to-face course, covering such topics as communications
skills, group facilitation, mental health first aid, crisis management,
problem solving, the recovery process, understanding mental health
conditions, the effects and side effects of medications, and working in
a professional setting. Following the training activities, these peer
support apprentices take an examination to receive their certification
to provide peer counseling services.
Question 2. The Executive Order directed VA and HHS to develop 15
pilot projects, ``whereby [VA] contracts or develops formal
arrangements with community-based providers * * * to test the
effectiveness of community partnerships in helping to meet the mental
health needs of veterans in a timely way.'' According to information
provided to the Committee, 11 pilot projects have been established with
five more to be established by May 31, 2013.
a. Please describe, in detail, the metrics that went into deciding
the locations of the pilot projects.
Response. VA has 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 VAMCs and/or
CBOCs, to determine its top priorities for collaboration. 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 between VHA facilities, patient need, and the local
availability of mental health professionals. Additionally, the programs
developed have considered 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.
b. In the past, VA medical centers (VAMC) have not referred
veterans for care outside of VA on a consistent basis. How does VA
intend to ensure that VAMC's, Clinics, and Vet Centers refer veterans
for mental health care under these pilot projects?
Response. The first pilots initiated under the direction of the
Executive Order were brought online during the last week of
February 2013. There has been a positive response not only from the
associated VAMC staff and the community partners, but among Veterans.
VA leadership, from the Under Secretary for Health to the Network
Directors to VAMC Directors, have made this a priority to implement and
oversee these pilots. By early inclusion of both sides of the
partnership in the planning 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 e-mail and local announcements to ensure staff are
aware of the pilot program and the potential for inclusion of Veterans
in the pilot. The Veteran's situation must be reviewed in order to
ensure a good match for the treatment types and locations being offered
through the pilots. VA staff contact the Veteran, explain the program,
and offer the opportunity to participate. The key to a successful
outcome and continued participation by all parties is coordinated
communication among VA, the community partner, and the Veteran.
Community partners are also reviewing their files for Veterans that may
not be enrolled with VA and working with their pilot contacts at VAMCs
to contact and enroll these Veterans.
c. Please provide the Committee with any directives, memoranda, or
other communication to VAMC's, Clinics, and Vet Centers regarding the
pilot projects.
Response. Each of the local VA sites will identify the best process
for establishing a contract or other formal arrangement based on their
unique local needs. There is no additional document that provides
information on the pilot programs at this time. The VA pilot sites have
been provided the Executive Order and a welcome letter from the Under
Secretary of Health designating them as pilot locations. Routine
conference calls are held to facilitate the process to determine
status, identify any risks or issues, resolve or follow up on issues
and questions, and provide lessons learned and best practices among the
participating VAMCs. When establishing these pilots, VA is required to
comply with regulatory and procedural policies that exist in the areas
of procurement law, purchased care, and space utilization.
Question 3. Last April, VA announced the hiring of 1,600 mental
health providers and 300 administrative staff. Please provide the
Committee with the number of mental health providers and administrative
staff hired. Please break this information out by provider type, by
VISN and other offices, and by stage in the process (i.e. positions
pending recruitment requests, positions pending draft announcement,
number of positions advertised, positions with interviews pending,
positions awaiting hiring manager decision, number of positions with a
tentative job offer, number of positions with a firm job offer, and
number of people hired and on board).
Response. As of June 30, 2013, VA hired a total of 1,669 mental
health clinical providers and 304 nonclinical personnel to meet the
goal of 1,600 new mental health professionals and 300 mental health
administrative support staff. Attachment 1 provides information
regarding the hired clinical providers and nonclinical staff by VISN.
attachment 1
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Question 4. At the hearing, VA testified that ``* * * one of the
takeaways from this hearing is to go out and * * * have a summit in the
community of mental health providers,'' to work with community
organizations in a more systematic way and ``* * * stimulate our people
to think about using the community in a larger sense.'' VA testified
these mental health summits would be modeled after the homeless summits
held by local VAMC's.
a. What directives will the Veterans Health Administration (VHA)
provide to local VAMCs to ensure that facilities hold these mental
health summits and follow through with the goal of involving the
community in providing mental health care to veterans?
Response. These directives are in the process of being developed
along with timelines and goals. We will share them as they are
completed. VHA Mental Health Services will organize and support these
summits and provide technical assistance to facilities to develop
needed partnerships at the local community based level. Each VHA
facility is required to complete their Mental Health Summit between
July 1, 2013, and September 30, 2013.
b. How will the information gathered be translated into new
partnerships within the community?
Response. This will be a locally driven endeavor but will be
tracked centrally to assure participation and ongoing monitoring.
Again, the plans for these are being developed now and will be shared
as we move ahead.
c. Please provide a list of all VHA facilities that have held
homeless summits since 2009 and any agenda or information that was
developed for these homeless summits.
Response. Beginning in FY 2011, VA asked VAMCs to host Homeless
Veteran Summits to synchronize Federal, state, and community resources
in VA's efforts to end Veteran homelessness. As requested, please find
below a list of all VAMCs that conducted a Homeless Summit in FY 2011
and FY 2012. VA is also providing a list of Homeless Summits already
held in FY 2013 or planned for FY 2013.
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Question 5. During the hearing, Committee members discussed the use
of alternative and complementary treatments for PTSD and TBI. It is
important that treatment for mental health be tailored to specific
veterans and their needs.
a. Please provide all complementary and alternative treatments
(fishing, golfing, acupuncture, etc.) available for veterans with PTSD
and other mental health diagnoses, and which VA medical facilities
offer the treatment.
Response. It is difficult to capture CAM services provided to
Veterans with mental health diagnosis. The boundaries between CAM and
conventional medicine overlap and change with time. VA uses several
types of administrative data that might capture evidence of CAM being
provided in mental health encounters: Health Care Common Procedure
Coding System (which includes Current Procedural Terminology (CPT)
Codes), stop codes, International Classification of Diseases (ICD-9)
procedure codes, and VA drug classes. While many Veterans use herbal or
nutritional supplements on their own or through non-VA providers,
Federal regulations prohibit VA from prescribing products that are not
approved as treatments by the Food and Drug Administration. Both CPT
codes and ICD-9 codes are set external to VA and have significant gaps
in identifying CAM treatments.
The findings show that the availability of CAM, and/or use of
procedure codes specific to CAM, is uneven across VA facilities. These
interventions have mostly come into existence due to the dedication and
persistence of staff who work in VA settings, and the desire to provide
a wider range of care.
There is also a variety of research and demonstration projects
across the country that will be useful to help determine CAM
effectiveness and how best to implement programs more consistently and
uniformly. Currently, a directive is being developed to help guide VA
facilities in their implementation of these practices. According to a
2011 survey by VA's Healthcare Analysis and Information Group, 89
percent of VA facilities offered CAM treatments, an increase from 84
percent in 2002. The most common types of CAM provided are meditation
(72 percent of VAMCs); stress management/relaxation therapy (66
percent); and, guided imagery (58 percent). Animal-assisted therapy is
provided by 44 percent, acupuncture by 41 percent, and yoga by 44
percent. The most common uses of CAM are for stress management, anxiety
disorder, PTSD, depression, back pain, and wellness-promotion (in order
of frequency). Appendix A of the 2011 survey by VA's Healthcare
Analysis and Information Group provides detailed information about CAM
use at VA facilities.
Appendix A. Excerpts from Health Care Analysis and Information Group
survey, 2011
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As part of the national evaluation of Mental Health Residential
Rehabilitation Treatment Programs (MH RRTP), programs are asked whether
they offer any CAM interventions, and whether those interventions are
delivered inside or outside of the RRTP programming itself. Out of 237
RRTP programs nationally, 65 percent offer at least one CAM
intervention. Of those, 44 percent provide the CAM intervention
directly within the RRTP program. The attachment below of the national
evaluation of the programs report lists the locations of the programs
that offer CAM services.
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A recent survey of specialized PTSD treatment programs found that
96 percent of all programs offer at least one type of CAM treatments to
their patients with PTSD (Table 1); and, 88 percent offered at least
one CAM intervention other than those that are commonly part of
conventional PTSD treatments (guided imagery, progressive muscle
relaxation, and stress management/relaxation therapies).
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Question 6. In 2006, VA commissioned the RAND Corporation and
Altarum to evaluate VA's mental health system. That evaluation,
published in November 2011 in Health Affairs, found that there was a
reliance on medication and that VA had a ``low rate of delivery for
some evidence-based practices.'' Similarly, an article published
February 2013 in the Journal of Traumatic Stress found that, of the 38
residential treatment programs for Post-Traumatic Stress Disorder
visited by the authors, only 10 programs fully integrated Cognitive
Processing Therapy and no program fully integrated Prolonged Exposure
therapy.
a. When new evidence based practices are adopted how long does it
typically take to fully integrate these practices into the clinical
care setting?
Response. A variety of sources, including the New Freedom
Commission on Mental Health, the Institute of Medicine, and the peer-
reviewed scientific literature have documented the substantial delay in
the adoption of EBPs in routine clinical care in both private and
public health care settings. VHA has taken significant steps to
expedite the process, including but not limited to, implementing
national competency-based training programs in Cognitive Processing
Therapy (CPT), Prolonged Exposure Therapy (PE), and other EBPs, and
establishing national policy requiring the availability of these
treatments. These efforts, which began in 2006, have significantly
increased the availability of these therapies in VHA. In fact, all
facilities have implemented CPT and/or PE, two of the most effective
treatments for PTSD. More than 4,700 VA therapists have received
training in one or both of these treatments through VHA's CPT and PE
training programs.
Although implementation of CPT and/or PE has occurred at all sites,
there is variability in the magnitude of EBP delivery across the
system. Increasing the magnitude across sites is a major current focus.
One initiative designed to promote the magnitude of EBP delivery is the
implementation of CPT and PE through telemental health modalities. More
than 100 staff have been hired or reassigned to focus on the delivery
of CPT and/or PE telemental health services. In addition, three pilot
regional CPT and PE telemental health clinics have been established to
augment the local delivery of these therapies and expand their reach to
more rural areas. Another mechanism to promote local implementation of
these therapies is the issuance of VHA Handbook 1160.05, Local
Implementation of Evidence-Based Psychotherapies for Mental and
Behavioral Health Conditions. This Handbook specifies the requirements
for fully implementing EBPs at the local level, including staffing
needs, clinic and scheduling requirements, treatment planning and
clinical implementation issues, and training needs. In addition,
technical assistance and support on best practices for promoting local
EBP implementation are being provided to sites. Furthermore, CPT and PE
documentation templates to be released into VA's electronic medical
record by fourth quarter of this fiscal year will allow for precise
monitoring of the extent to which these therapies are being delivered
at specific facilities. This is currently not possible through the use
of current procedural terminology codes, which do not specify the type
of psychotherapy provided.
VA also supports research to facilitate the adoption of EBP. For
example, a new project--Collaborative Research to Enhance and Advance
Transformation and Excellence (CREATE)--has the overall goal to improve
Veteran access to and engagement in evidence-based PTSD treatments.
This CREATE project includes complementary projects that together
accomplish the following: (1) test Veteran- and family-directed
outreach interventions to reduce delay in help seeking for PTSD; (2)
test interventions to ensure that Veterans with PTSD seen in VA primary
care clinics, including CBOCs receive evidenced-based treatment for
PTSD; and (3) identify strategies to improve the reach of evidence-
based treatment for PTSD among treatment-seeking Veterans.
b. Please provide the Committee with the number of veterans that
have a mental health diagnoses who only receive medication, the number
who only receive therapy, and the number of veterans who receive both
medication and therapy?
Response. VA currently tracks initiation of new episodes of
psychotherapy separately in specific subpopulations of mental health
patients because the types of treatment and modes of delivery of
psychotherapy that are evidence-based vary by mental health diagnosis.
For this request, the response has combined these subpopulations, and
provides the number of patients with (1) depression, (2) PTSD, (3)
substance use disorders (SUD), or (4) serious mental illness who
initiated a new episode of psychotherapy and/or received a VA
prescription within the last 4 quarters. For comparison, we also
include these rates for patients with serious mental illness (SMI),
SUD, or PTSD, as these populations are more frequently treated in
specialty mental health programs and accept and receive psychotherapy
at somewhat higher rates.
Some Veterans will have mental health diagnoses that do not fall
within any of these categories, and some Veterans will have mental
health diagnoses within multiple categories. We note that only new
episodes of psychotherapy are considered. Veterans receiving continuous
monthly or bi-monthly psychotherapy with no breaks in care are not
included in the psychotherapy counts. Additionally, we note that all
prescriptions were counted, regardless of whether the medication is
primarily used for treatment of psychiatric or medical problems.
Because of high rates of medical problems in VA patients with mental
health diagnoses, we expect many of these patients to receive
prescriptions for medical conditions.
----------------------------------------------------------------------------------------------------------------
Number who
Number (%) who didn't
Number (%) who Number (%) who initiated initiate
Diagnostic subpopulation initiated received a psychotherapy and psychotherapy
psychotherapy prescription only received a and didn't
only prescription receive a
prescription
----------------------------------------------------------------------------------------------------------------
SMI, SUD, PTSD, or Depression............. 26,530 (1.7%) 769,848 (49.7%) 698,930 (45.1%) 53,310 (3.4%)
SMI, SUD, or PTSD......................... 19,394 (1.9%) 422,403 (42.4%) 527,777 (53.0%) 26,964 (2.7%)
----------------------------------------------------------------------------------------------------------------
Question 7. VA's testimony states that ``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.''
a. Please provide a list of all mobile applications that will be
delivered during fiscal year 2013 and fiscal year 2014. In addition,
please include the following information associated with each mobile
application: when the application is expected to be delivered, any
contracts associated with the development of the application, the
length of time it took to develop the application, the development and
sustainment cost associated with the application, and any performance
measures associated with the application.
VA Response:
Stay Quit Coach. Integrated Care for Smoking Cessation:
Treatment for Veterans with PTSD.
- iOS and Android versions are complete and are currently
available internally for research and evaluation. Public
release was in spring 2013 (iOS) and autumn 2013 (Android).
- Contractor: Vertical Product Development. Development took 7
months for iOS and 4 months for Android (following completion
of the iOS version).
- Development costs: $38,500 for iOS and $50,000 for Android.
Sustainment costs are $0.
- Performance measure: monthly download reports indicating
number of users to begin upon public launch. Research on
usability, clinical outcomes, and implementation is planned.
CBT-I Coach. Cognitive Behavioral Therapy for Insomnia.
- iOS version is complete and is currently available
internally for research and evaluation. Public release was in
spring 2013 (iOS). DOD has funded an Android version which was
deployed autumn 2013.
- Contractor for iOS: Vertical Product Development.
Development took 7 months for iOS. Android version funding and
development are with DOD.
- Development costs: $30,000 for iOS. Sustainment costs are
$0.
- Performance measure: monthly download reports indicating
number of users to begin upon public launch. Research on
usability, clinical outcomes, and implementation is planned.
Pilot projects are underway. Two funded trials are beginning
shortly.
Mindfulness Coach. Mindfulness-Based Stress Reduction.
- iOS version is complete and is currently available
internally for research and evaluation. Public release is
expected autumn 2013 (iOS).
- Contractor for iOS: Vertical Product Development.
Development took 5 months for iOS.
- Development costs: $38,500 for iOS. Sustainment costs are
$0.
- Performance measure: monthly download reports indicating
number of users to begin upon public launch. Research on
usability, clinical outcomes, and implementation is planned.
ACT Coach. Acceptance and Commitment Therapy.
- iOS version is complete and is currently available
internally for research and evaluation. Public release is
expected autumn 2013 (iOS).
- Contractor for iOS: Vertical Product Development.
Development took 8 months for iOS.
- Development costs: $30,000 for iOS. Sustainment costs are
$0.
- Performance measure: monthly download reports indicating
number of users to begin upon public launch. Research on
usability, clinical outcomes, and implementation is planned.
CPT Coach. Cognitive Processing Therapy.
- iOS and Android versions are complete and are currently
available internally for research and evaluation. Public
release is expected autumn 2013 (iOS) and autumn 2013
(Android).
- Contractor for iOS: Vertical Product Development.
Development took 7 months for iOS. Android development was
funded and completed by DOD.
- Development costs: $30,000 for iOS. Sustainment costs are
$0.
- Performance measure: monthly download reports indicating
number of users to begin upon public launch. Research on
usability, clinical outcomes, and implementation is planned.
Moving Forward. Problem Solving Training.
- iOS version is complete and is currently available
internally for research and evaluation. Public release is
expected autumn 2013 (iOS).
- Contractor for iOS: Vertical Product Development.
Development took 6 months for iOS.
- Development costs: $25,250 for iOS. Sustainment costs are
$0.
- Performance measure: monthly download reports indicating
number of users to begin upon public launch. Research on
usability, clinical outcomes, and implementation is planned.
Safety Plan. Mobile version of VA safety planning for
crisis management.
- iOS version is in development. Public release is expected
autumn 2013 (iOS).
- Contractor for iOS: Vertical Product Development.
Development has been going on for 4 months for iOS.
- Development costs: $40,000 for iOS. Sustainment costs are
$0.
- Performance measure: monthly download reports indicating
number of users to begin upon public launch. Research on
usability, clinical outcomes, and implementation is planned.
SPR Coach. Skills for Psychological Recovery (secondary
prevention for PTSD).
- iOS version is in development. Public release is expected
winter 2013 (iOS).
- Contractor for iOS: Vertical Product Development.
Development has been going on for 5 months.
- Development costs: $40,000 for iOS. Sustainment costs are
$0.
- Performance measure: monthly download reports indicating
number of users to begin upon public launch. Research on
usability, clinical outcomes, and implementation is planned.
The following additional mobile applications are for self-
management of concerns common to Veterans and their families:
Parenting2Go. Parenting training for Veterans and
Servicemembers.
- iOS version is in development. Public release is expected
winter 2013 (iOS).
- Contractor for iOS: Vertical Product Development.
Development has been going on for 4 months.
- Development costs: $25,250 for iOS. Sustainment costs are
$0.
- Performance measure: monthly download reports indicating
number of users to begin upon public launch. Research on
usability, clinical outcomes, and implementation is planned.
PTSD Family Coach. Education and self-management for
families of those with PTSD.
- Version 1.0 of this app for iOS and Android was completed in
2011. Version 1.1 for iOS and Android versions are in
development. Public release is expected autumn 2013 (iOS) and
autumn 2013 (Android).
- Contractor: Vertical Product Development. Development took 6
months for both iOS and Android.
- Development costs: $40,000 for updates to both iOS and
Android. Completed version 1.0 cost $30,000 for iOS and $60,000
for Android. Sustainment costs are $0.
- Performance measure: monthly download reports indicating
number of users to begin upon public launch. Research on
usability, clinical outcomes, and implementation is planned.
Concussion Coach (formerly TBI Coach). Self-management for
Veterans with mild Traumatic Brain Injuries.
- iOS version is complete and currently available internally
for research and evaluation. Android version is in development.
Public release is expected autumn 2013 (iOS) and winter 2013
(Android).
- Contractor: Vertical Product Development. Development took
- 4 months for iOS and has taken 2 months so far for Android
(in process).
- Development costs: $40,000 for iOS and $60,000 for Android.
Sustainment costs are $0.
- Performance measure: monthly download reports indicating
number of users to begin upon public launch. Research on
usability, clinical outcomes, and implementation is planned.
______
Response to Posthearing Questions Submitted by
Hon. John D. Rockefeller IV to U.S. Department of Veterans Affairs
Question 1. Do VA and DOD collaborate and coordinate on research
initiatives regarding the treatment of PTSD and mental health issues?
If so, what is the process, and how is it evaluated? If not, why not,
and does it require legislation to establish such collaboration? (10P)
Response. VA and DOD collaborate and coordinate research
initiatives regarding the treatment of PTSD and mental health issues,
as well as other conditions affecting military Servicemembers and
Veterans, and their families. The history of our collaboration is rich
with examples of well-coordinated, highly integrated working
relationships across research funding offices. Formal collaborations
have been instituted to share mental health research portfolios based
on a joint integrated research approach to present information
systematically and consistently. We will plan our third annual
portfolio review by the end of 2013. The portfolio reviews, as well as
ongoing working relationships, enable agencies to identify research
needs or gaps in real time, and determine the best way forward.
Legislation is not required to establish collaboration or a process for
collaboration, as each agency continues to operate within respective
authorities for sponsored research.
Regarding collaborative initiatives, VA and DOD have determined
that a major collaborative consortium effort focused on PTSD is a
research need. Thus, a request for proposals was published in 2012 to
solicit applications for a joint VA/DOD Consortium to Alleviate PTSD
(CAP) award. The primary purpose of CAP is to improve the health and
well-being of Servicemembers (active duty, National Guard, and
Reservist) and Veterans, with the most effective diagnostics,
prognostics, novel treatments, and rehabilitative strategies to treat
acute PTSD and to prevent chronic PTSD. This Consortium is responsive
to the findings of the Institute of Medicine report focused on
``Treatment of PTSD in Military and Veteran Populations.''
Key priorities of this Consortium are elucidation of factors that
influence the different trajectories (onset/progression/duration) of
PTSD and associated chronic mental and physical sequelae (including
depression, anger/aggression, and substance use/abuse, etc.), and
identification of measures for determining who is likely to go on to
develop chronic PTSD. The Consortium will therefore work to improve
prognostics, advance treatments, and mitigate negative long-term
consequences associated with traumatic exposure.
Following scientific peer review, CAP was awarded in September 2013
to a collaboration involving the University of Texas Health Science
Center at San Antonio and VA's National Center for PTSD, Boston VA
Medical Center (www.ptsd.va.gov). They will attempt to develop the most
effective diagnostic, prognostic, novel treatment, and rehabilitative
strategies to treat and prevent PTSD.
Further, in August 2012, President Obama issued a Mental Health
Executive Order (13625) requiring a National Research Action Plan that
was submitted to the White House and released in July 2013. It further
describes the extensive collaborations between VA and DOD, as well as
other Federal research funding agencies, focused on PTSD and other
mental health issues. The goals clearly describe the joint vision for
this research focused on advancing treatment for Veterans, military
Servicemembers, and their families.
Question 2. What is the most innovative and experimental research
underway at DOD and at VA to develop innovative care and treatment for
PTSD and mental health?
Response. ``Innovative'' and ``experimental'' describe the research
VA sponsors to advance care and treatment for PTSD and mental health.
Examples from the research portfolio that are focused on basic
mechanisms underlying disorders will provide the platform for
identifying possible biological targets for treatment development. One
such example is a study examining the potential benefit of a novel
medication, a corticotropin-releasing factor antagonist, for reducing
PTSD symptoms. Other medication trials may develop from the recent
Federal Register notice to develop public-private collaborations for
new pharmacological treatments for PTSD, an experimental approach to
identify potential treatment targets. Innovation is also underway in
the form of multiple clinical trials focused on determining if there is
a benefit to complementary and alternative medicine approaches such as
meditation techniques for PTSD. VA is also supporting innovative ways
to deliver treatments through technology based systems such as
Internet, phone apps, and telehealth. Future research efforts will
continue to use an experimental approach to determine whether proposed
innovation is beneficial for treating PTSD and mental health conditions
in Veterans.
Question 3. How do VA and DOD review and evaluate outside research
on PTSD and mental health treatments from the non-profit and private
sector?
Response. VA uses a variety of strategies to review and evaluate
research conducted outside of VA, some of which is conducted by VA
scientists supported through non-VA funding sources such as non-profit
or private sector mechanisms. In general, the scientific community and
the respective research funding offices use multiple sources to remain
current on outside research. Results from VA supported and non-VA
supported work appear in the public domain through resources such as
the National Library of Medicine's PubMed system. Clinicaltrials.gov is
also a registry and results database of publicly and privately
supported clinical studies of human participants conducted around the
world utilized by researchers and funding offices. Such public domain
information, including that posted to the National Institutes of Health
RePORTER as is done by VA, increase the transparency and availability
of research study information to evaluate efforts underway and results
of scientific work. VA scientists, in making research applications for
funding, must also describe ongoing work or impactful results, e.g., if
a non-Veteran population showed beneficial effect of a treatment that
might be beneficial to the Veteran population. Additionally, VA
research conducts annual reviews of activities within the PTSD and
other mental health conditions research portfolio with other agencies,
allowing a systematic review and evaluation of ongoing and completed
work.
The VA Evidence-Based Synthesis program was established to provide
timely and accurate syntheses of research on targeted health care
topics of particular importance to clinicians, managers, and
policymakers. The program reviews research conducted within and outside
VA to generate evidence syntheses on important clinical practice
topics. Recent reports on mental health include: Screening for Post-
Traumatic Stress Disorder (PTSD) in Primary Care; Suicide Risk Factors
and Risk Assessment Tools; Suicide Prevention Interventions and
Referral/Follow-up Services; Family Involved Psychosocial Treatments
for Adult Mental Health Conditions; and, Efficacy of Complementary and
Alternative Medicine Therapies for Posttraumatic Stress Disorder.
In addition, VA's National Center for PTSD (the Center) creates and
disseminates research reviews using a range of formats. The PTSD
Research Quarterly provides reviews and authoritative bibliographies on
selected topics in trauma and PTSD; recent topics include: The Role of
Benzodiazepines in the treatment of PTSD; Complementary and Alternative
Treatments for PTSD; and, PTSD Disability Assessment. The Center also
publishes the Clinician's Trauma Update--Online, a bi-monthly review of
research on the clinical care of trauma-related problems in Veterans
and Servicemembers. The Center also conducts two monthly online lecture
series to provide syntheses of current evidence on a range of topics
relevant to treatment of PTSD and related disorders in Veterans. All of
these products are complemented by additional online research reviews
disseminated as fact sheets through the Center's Web site,
www.ptsd.va.gov.
______
Response to Posthearing Questions Submitted by Hon. Mark Begich to
U.S. Department of Veterans Affairs
Question 1. What plans are there to increase staffing to meet the
following needs? I understand the Alaska VA did not request more MH
positions, considering the problems with wait times, etc. will you be
hiring more Mental Health personnel?
Response. The Alaska VA Healthcare System (AVAHCS) has 15 vacancies
for mental health positions as of September 23, 2013. AVAHCS has plans
that it is executing to recruit and hire mental health providers to
fill these positions. AVAHCS is at various stages in the hiring process
for these positions as indicated by the chart below:
------------------------------------------------------------------------
Positions
Positions with
Beginning Positions Positions Positions Candidates
the Pending Posted in the Selected & In TOTAL
Recruiting Posting to for Hire Interview Credentialing VACANCIES
Process USAJOBS Process or Hiring
Processes
------------------------------------------------------------------------
1 2 4 4 4 15
------------------------------------------------------------------------
These data include ongoing recruitment efforts for 15 mental health
provider vacancies for the AVAHCS Domiciliary Care for Homeless
Veterans (DCHV) Program. In addition, AVAHCS has made progress in
hiring six personnel for the Health Care for Homeless Veterans (HCHV)
Program.
Question 1a. According to staff and veterans using the facilities:
There is a need for additional therapists, especially dedicated to OIF/
OEF veterans.
Response. As noted above, we do have mental health vacancies;
however, all Patient Aligned Care Team (PACT) Social Work vacancies are
currently filled. We have integrated OIF/OEF/OND case management into
the PACT structure. This avoids fragmentation of care and is consistent
with the Medical Home concept of the PACT.
Question 1b. There is a need for case managers who have time to
keep track of veterans, their needs, to call them if they are not
coming in, and refer them to appropriate services.
Response. As noted above, our OIF/OEF/OND case management
activities are integrated into the PACT structure, which provides the
benefit of Veterans having one identified case manager who is familiar
with their needs and can coordinate services with both the Primary Care
PACT and mental health services. They are clinically skilled and are
able to provide the first line of behavioral health interventions as
well. In addition to the OIF/OEF/OND case managers, we also have an
OIF/OEF/OND Program Manager and a Transition Patient Advocate who
ensure seamless transition from active duty/National Guard to VA
services, assist with enrollment for health care and benefits, and
provide linkages with community partners serving this population of
Veterans.
Question 1c. There is a need for administrative support to help
therapists and case managers.
Response. As of June 19, 2013, the Administrative Officer position
to assist the therapists and case managers has been filled. Six of the
seven identified Medical Support Assistant positions have also been
filled. A vacancy announcement for the remaining position recently
closed, and the list of candidates is being certified. When all
positions are filled, adequate support should be in place for the
therapists and case managers to be integrated into the PACTs. Specialty
mental health providers currently have adequate administrative support.
Question 1d. Additional staff as listed above could help to reach
out to rural Alaska; the VA has the technology to do so. What are the
plans to use tele-health technology?
Response. AVAHCS is currently partnering with the State of Alaska
on a Health Resources and Services Administration grant to increase
enrollment and access for rural Veterans. VA mental health staff have
provided training in Sitka, Juneau, Bethel, Barrow, and other sites to
enhance the knowledge of Veteran issues and care among rural providers.
As a part of this grant, VA clinicians will provide training in EBP
that targets PTSD for providers in the Alaska Island Community Services
in Southeast Alaska. As part of a VA Office of Rural Health grant, a
partnership with the Southeast Alaska Regional Health Consortium
(SEARHC) has been initiated to provide PTSD treatment by a VA
psychologist using telemental health technology. The psychologist will
partner with the SEARHC psychiatrist to provide a truly integrated
service. These pilots are planned for replication at other rural sites.
The clinical video teleconferencing to the home using secure software
is currently being rolled out to Veterans in a variety of sites
throughout the state. In addition, home telehealth monitoring is now
available to address schizophrenia, bipolar disorder, and depression,
PTSD, and substance use disorders. We are currently exploring use of
telemental health at all AVAHCS sites to allow assistance from other
facilities in our VISN.
Question 1e. There is a need for people with chronic pain
management experience/expertise, also trained in non-traditional means
to help vets cope with pain. Are there plans to hire more Physical and
Occupational Therapists to help these vets?
Response. We currently have a chronic pain group clinic that
provides opportunity for management and treatment of chronic pain
issues. In addition, we also have physical and occupational therapy
services available via referral. We have built a business case for
hiring an additional physical therapist and physical therapy assistant
to increase access to those services. We are actively recruiting for
the physical therapist. The physical therapy assistant position is
awaiting posting.
AVAHCS is a participant in the multi-site Office of Patient
Centered Care grant for Healing Touch. Alaska received funding to begin
training in Healing Touch as a shared best practice in the VA system.
Question 1f. Human Resources is still too slow to process
advertisements, applicants etc; part of this is due their staffing,
perhaps also the bureaucratic process. Whatever the reasons, the
process takes too long and we lose good applicants. What is the VA plan
for expediting hiring?
Response. We have recently hired two human resource assistants to
improve throughput in our hiring process. As evidenced by the hiring
actions noted above, we are actively and aggressively recruiting,
selecting, and bringing staff on board.
______
Response to Posthearing Questions Submitted by Hon. Mazie Hirono to
U.S. Department of Veterans Affairs
Question 1. In working to meet Secretary Shinseki's goal of hiring
1,600 new mental health clinical providers and 300 administrative
support staff, does VA have a goal to fill a percentage of these
positions with veterans outside of peer specialists?
Response. There exists in VA a 40 percent Veteran hiring goal.
Beyond that, many of the specialized disciplines will be difficult to
fill with Veterans in that timeframe.
Question 2. In your testimony, you point to a widespread use of
complementary and alternative medicine for treating mental health
problems in the VA system, around 89%. What barriers remain to achieve
universal access to this care for all our veterans and what steps is
the VA taking toward this? Does VA have the ability to provide
culturally appropriate care for example, traditional Hawaiian medicine
and therapies in Hawaii for our Native Hawaiian veterans?
Response. There is increasing awareness within VA of the potential
benefits of CAM practices in the management of mental health problems.
Although the use of CAM in VA is widespread, the scope of CAM
encompasses a broad range of treatments from whole systems of care
(traditional medicine, Ayurveda, traditional Chinese medicine,
homeopathy, naturopathy) to natural products (e.g., botanicals,
probiotics) and mind-body practices to name a few.
The barriers to achieve universal access to CAM are complex and
include internal and external factors including: synthesis of the
rapidly growing scientific literature to determine efficacy and
strategies to integrate into clinical practice; resources to build
infrastructure and capacity to integrate CAM; lack of occupational
series for CAM providers; provision of coverage of CAM services in the
medical benefits package and gaps in Current Procedural Terminology--
Relative Value Unit (CPT-RVU) modeling for CAM workload capture and
tracking; and regulatory restrictions. For example, Federal regulations
prohibit VA from prescribing products that are not approved as
treatments by the Food and Drug Administration.
VA Mental Health Services is coordinating a series of demonstration
projects, gathering lessons learned, and reviewing the scientific
literature to guide future policy and program development. VA is
committed to providing culturally relevant services to Veterans of all
ethnic and cultural groups. The VA Office of Rural Health (ORH) and the
Office of Tribal Government Relations support robust programs serving
American Indian Veterans. ORH completed a survey in October 2012
identifying American Indian traditional practices (e.g., sweat lodge,
drum ceremonies, traditional healers) in 19 of VA's 21 VISNs. The
survey can be accessed on the ORH Native Domain Web site at: http://
www.ruralhealth.va.gov/native/services.asp. A survey by VA's Chaplain
Service, using different criteria from the ORH survey identified access
to traditional healing services in all 21 VISNs. Because of the
spiritual nature of American Indian healing practices, VA's Chaplain
Service provides guidelines for traditional practitioners on these
services and the processes for identifying and, through local American
Indian tribes, verifying the competency of traditional healers. This
guidance can be accessed through the National Chaplain Center Web site:
www.va.gov/chaplain.
With regard to access of Native Hawaiian Veterans to traditional
healing practices, the VA Pacific Islands Health Care System (VAPIHCS),
like the rest of VA, is proud to offer a variety of state-of-the-art
evidence-based mental health treatments to our Veterans, such as CPT
and PE Therapy for PTSD. VA is able to offer these modalities to
Veterans throughout their service area, including the neighboring
islands of Guam, Saipan and American Samoa, either in-person or through
telemental health. However, VAPIHCS recognizes that in a culturally
diverse population, it must integrate a culturally sensitive approach
to the holistic treatment of their Veterans. As such, VA staff work
with members of the Veteran's cultural support network, which includes
family, clergy, and other providers as requested by the Veteran, and
certain aspects of evidence-based treatments have been modified to
better fit the particulars of cultures represented by their patient
population. VAPIHCS is a training site for the University of Hawaii
Department of Psychiatry, which is home to the National Center on
Indigenous Hawaiian Behavioral Health (http://blog.hawaii.edu/dop/
research/ncihbh/nhmhrdp/). Native Hawaiian Veterans are also eligible,
as residents of the State of Hawaii, for culturally based services
available through the State of Hawaii Adult Mental Health Division
(AMHD), with whom VA has a collaborative relationship. For example,
many Veterans at VAPIHCS receive mental health case management services
through the AMHD in conjunction with VAPIHCS mental health services as
part of their comprehensive mental health treatment plan.
Question 3. Marriage and family relationships play a major factor
in veterans' mental health. Many in the Marriage and Family Therapist
community in Hawaii nearly half of all MFTs do not have the opportunity
to work for the VA due to VA's accreditation limitations. Hawaii does
not have any COAMFTE accredited schools. To address the current limited
access to practitioners that is encountered especially in rural areas,
can the VA look at reevaluating its restrictive policy in this area and
establish an alternative qualification?
Response. The VA qualification standard for Marriage and Family
Therapists (MFT) was developed by a group of highly qualified subject
matter experts (SME) and leadership within VHA Mental Health Services.
The qualification standards require that a Marriage and Family
Therapist have a degree from a program accredited by the Commission on
Accreditation for Marriage and Family Therapy Education (COAMFTE). This
standard was developed to assure the provision of the highest quality
of care to our Nation's Veterans. COAMFTE is a specialized accrediting
body that accredits master's degree, doctoral degree, and post-graduate
degree clinical training programs in Marriage and Family Therapy
throughout the U.S. and Canada. Since 1978, it has been recognized by
the U.S. Department of Education as the national accrediting body for
the field of Marriage and Family Therapy. Having a COAMFTE
accreditation ensures the program has undertaken an extensive external
evaluation and meets the standards established by the profession.
Requiring that a MFT possesses a COAMFTE accredited degree assures VA
that the MFT has undertaken a superior course of professional
preparation, and that the individual has been trained in the
appropriate knowledge and skill areas required of the profession. If an
individual has not graduated from a program that has been COAMFTE
accredited, VA cannot be assured that the provider has graduated from a
program that has met professional standards developed by a national
consensus of professionals in the MFT field. Please note, all other
mental health professions within VA must also be accredited by national
accrediting bodies specific to their disciplines. Therefore, the
standards for MFT graduate program accreditation are at the same high
level as that required for other mental health professions in VA. For
example, all Psychologists must have graduated from programs that have
been accredited by the American Psychological Association and all
Licensed Professional Mental Health Counselors must have graduated from
programs that have been accredited by the Council on Accreditation of
Counseling and Related Educational Programs. When developing the
qualification standards, the SMEs reviewed documentation on current
industry standards and practices and included consideration of all
state requirements. While VA does not plan to change the MFT
qualification standard, VA is supportive of increasing telemental
health services to rural areas. These services may include services
provided by MFTs.
Question 4. Kimberly Ruocco's testimony mentioned the experience of
a surviving father who came to TAPS and was grieving the death of his
veteran son by suicide and harmful effects that breaking of the bond
with the counselor has on his healing. What is VA's current policy and
practice on maintaining veteran-counselor relationship for the duration
of therapy?
Response. VA recognizes the importance of a consistent therapeutic
relationship and strives to sustain those relationships throughout
treatment whenever practicable, taking into account the patient's
preference as well as provider availability. However, there is no
current, specific policy regarding the maintenance of the relationship
between VA mental health providers and the patients for the duration of
therapy. All providers are bound to operate within the ethical and
practice standards of their professions, and to participate and
communicate fully as a member of the Veteran's health care team.
Chairman Sanders. Thank you very much, Dr. Petzel.
Colonel Porter.
STATEMENT OF COLONEL REBECCA PORTER, CHIEF, BEHAVIORAL HEALTH
DIVISION, OFFICE OF THE SURGEON GENERAL, U.S. ARMY, DEPARTMENT
OF DEFENSE
Colonel Porter. Chairman Sanders, Ranking Member Burr, and
distinguished Members of this Committee, thank you for the
opportunity to appear before you to discuss the Army's
initiatives to improve soldier readiness and resiliency. I
would like to have my full statement entered into the record.
The U.S. Army has fought for over 11 years, the longest
period of conflict in our Nation's history. The unprecedented
length and the persistent nature of conflict during this period
have tested the capabilities and the resilience of our soldiers
and the Army as an institution and of our supporting families.
Taking care of our own, mentally, emotionally, and
physically, is the foundation of the Army's culture and ethos.
The Army is keenly aware of the unique stressors facing
soldiers and families today and continues to address these
issues on several fronts.
The Army's Ready and Resilient Campaign Plan and Behavioral
Health Service Line are two major groups of initiatives that
address stressors and improve resiliency across the Wellness
Continuum, from pre-clinical prevention activities through
clinical treatment and surveillance efforts.
The Ready and Resilient Campaign Plan was mandated through
a directive issued on February 4, 2013. This campaign
integrates and synchronizes multiple Army-wide programs aimed
to embed resiliency into day-to-day operations. The campaign
directs us to review programs, processes and policies to ensure
effectiveness and reduce redundancies, improve methods for
commanders to understand high-risk behaviors and intervene
early, and continue improvements to the Integrated Disability
Evaluation System.
The Behavioral Health Service Line is the treatment
component of the Ready and Resilient Campaign Plan. The
Behavioral Health Service Line codifies 28 Behavioral Health
enterprise programs identified to support the behavioral health
and well-being of soldiers and their families. Its key areas of
focus are Embedded Behavioral Health, child and family
services, integrated behavioral health support in the Army's
Patient Centered Medical Homes, and the Behavioral Health Data
Portal.
I want to highlight the success of some of our programs.
The Embedded Behavioral Health program provides multi-
disciplinary behavioral health teams to provide community
behavioral health care to soldiers in close proximity to their
units and in coordination with their unit leaders.
Utilization of this model has demonstrated statistically
significant reductions in inpatient behavioral health
admissions; off-post referrals; high risk behaviors; and the
number of non-deployable soldiers for behavioral health
reasons.
Leaders have a single trusted behavioral health point of
contact and subject matter expert for questions regarding the
behavioral health of their Soldiers. Embedded team members know
the unit and are known by the unit, knocking down access
barriers and stigma commonly associated with behavioral health
care in the military setting.
Our Tele-Behavioral Health program increases access to
specialty care in geographically isolated areas to include more
than 60 sites in Afghanistan. It enables greater continuity of
care and provides surge capacity for enhanced behavioral health
evaluations at soldier Readiness Processing sites.
Furthermore, Telehealth is being leveraged to recruit
behavioral health providers for hard to fill locations, by
allowing clinicians to provide care from alternate geographic
areas where it is easier to hire clinical professionals.
The Army is also implementing new programs to provide care
to spouses and children in the communities where they live
through school based programs and by placing behavioral health
providers in our Patient Centered Medical Home primary care
clinics.
The Behavioral Health Data Portal is an information
technology, or IT, platform that tracks patient outcomes,
patient satisfaction, and risk factors by way of a web
application, enabling improved surveillance and assessment of
program and treatment efficacy.
While the Army continues to improve behavioral health care
to our soldiers and families, we recognize that we must pay
special attention to soldiers in transition, whether they are
relocating to another assignment, returning from deployment,
transitioning from active duty to reserves, or preparing to
leave the service.
The Army has established a system internally to ensure
continuity of care for soldiers moving from installation to
installation. We also support the DOD In Transition Program,
which provides ready access to Nationwide cadre of experienced
and independent Behavioral Health professionals for soldiers
pending transition. We also utilize Military OneSource as an
equivalent resource for soldiers that are transitioning.
We work actively with the VA to ensure continuity of care
for soldiers transitioning to leave military service. For
complex medical conditions, these include Warrior Transition
Units and the Integrated Disability Evaluation System.
Behavioral Health care and resiliency are important factors
in the readiness of the Army and important issues for our
veterans. The Army's capable and honed behavioral health
personnel, evidence based practices and far-reaching programs
comprise key pillars in its commitment to an Army that is ready
and resilient.
Thank you again for the opportunity to testify before the
Committee.
[The prepared statement of Colonel Porter follows:]
Statement by Col. Rebecca I. Porter, Chief, Behavioral Health Division,
Office of the Surgeon General, United States Army
Chairman Sanders, Ranking Member Burr, and Distinguished Members of
this Committee, Thank you for the opportunity to appear before you to
discuss the Army's initiatives to improve Soldier readiness and
resiliency.
The United States Army has fought for over eleven years, the
longest period of conflict in our Nation's history. The unprecedented
length and the persistent nature of conflict during this period have
tested the capabilities and the resilience of our Soldiers and the Army
as an institution and of our supporting Families. The majority of our
Soldiers have maintained resilience during this period. However, the
stresses of increased operational tempo are evident in the increased
demand for Behavioral Health Services.
Taking care of our own--mentally, emotionally, and physically--is
the foundation of the Army's culture and ethos. The Army is keenly
aware of the unique stressors facing Soldiers and Families today and
continues to address these issues on several fronts. The Army's Ready
and Resilient Campaign Plan and Behavioral Health Service Line are two
major groups of initiatives that address stressors and improve
resiliency across the Wellness Continuum, from pre-clinical prevention
activities through clinical treatment and surveillance efforts. Both
the Ready and Resilient Campaign Plan and the Behavioral Health Service
Line emphasize the shared responsibility amongst medical assets,
commanders and leaders, and individual Soldiers and Family Members in
optimizing the readiness and resiliency of our Force.
The Ready and Resilient Campaign Plan was mandated through a
Directive issued on February 4, 2013. This campaign plan will create a
holistic, collaborative and coherent enterprise to increase individual
and unit readiness and resilience. This campaign integrates and
synchronizes multiple Army-wide programs aimed to embed resiliency into
day to day operations. The campaign directs us to review programs,
processes and policies to ensure effectiveness and reduce redundancies,
improve methods for commanders to understand high risk behaviors and
intervene early, and continue improvements to the Integrated Disability
Evaluation System. Several key programs and initiatives are nested
under the Ready and Resilient Campaign Plan, including the Behavioral
Health Service Line, the Army Suicide Prevention Program, The
Performance Triad and Comprehensive Soldier and Family Fitness. These
programs will teach Soldiers, Families, and DA Civilians coping skills
for dealing with the stress of deployments and everyday life.
The Behavioral Health Service Line is the treatment component of
the Ready and Resilient Campaign Plan, designed to provide consistent
and ready access to integrated and evidence-based behavioral health
services across the Soldier's Lifecycle, delivered by the most
appropriately trained and credentialed providers and teams to meet the
needs of the Army Family.
While the Behavioral Health Service Line codifies 28 Behavioral
Health enterprise programs identified to support the behavioral health
and well-being of Soldiers and their Families, its key areas of focus
are Embedded Behavioral Health programs that put our behavioral health
teams into the unit footprint, integrated behavioral health departments
to simplify access for our beneficiaries and to integrate our services,
child and family services, integrated behavioral health support in the
Army's Patient Centered Medical Homes, and the Behavioral Health Data
Portal, an IT capability that enables us to capture and share real time
patient wellbeing status, risk assessment and treatment outcomes for
the first time.
I want to highlight the demonstrated success of the Embedded
Behavioral Health program, which provides multidisciplinary behavioral
health teams to provide community behavioral healthcare to Soldiers in
close proximity to their units and in coordination with their unit
leaders. Utilization of this model has demonstrated statistically
significant reductions in: (1) inpatient behavioral health admissions;
(2) off-post referrals; (3) high risk behaviors; and (4) number of non-
deployable Soldiers for behavioral health reasons. Leaders have a
single trusted behavioral health point of contact and subject matter
expert for questions regarding the behavioral health of their Soldiers.
Embedded team members know the unit and are known by the unit, knocking
down access barriers and stigma commonly associated with behavioral
healthcare in the military setting. Currently, 26 Brigade Combat Teams
and 8 other Brigade Sized Units are supported by Embedded Behavioral
Health Teams. Expansion of Embedded Behavioral Health teams to all
operational units is anticipated no later than FY16.
Our Tele-Behavioral Health (TBH) program increases access to
specialty care in geographically isolated areas to include more than 60
sites in Afghanistan, enables greater continuity of care, and provides
surge capacity for enhanced behavioral health evaluations at Soldier
Readiness Processing sites. Furthermore, Telehealth is being leveraged
to recruit behavioral health providers for hard to fill locations, by
allowing clinicians to provide care from alternate geographic areas
where it is easier to hire clinical professionals. These Army
Telehealth (TH) services are provided across 19 time zones in over 30
countries and territories at over 70 sites across all five RMCs and
over 90 sites in the operational environment, a global net to extend
capable accessible services wherever the Army goes.
The Army is also implementing new programs to provide care to
spouses and children in the communities where they live through school
based programs and by placing behavioral health providers in our
Patient Centered Medical Home primary care clinics.
The Behavioral Health Data Portal is an IT platform that tracks
patient outcomes, patient satisfaction, and risk factors via web
application, enabling improved surveillance and assessment of program
and treatment efficacy. It provides improved patient tracking within
behavioral health clinics, provides real-time information regarding
Soldier's behavioral health readiness status, and enhances provider
communication with Commanders to ensure optimal, coordinated behavioral
health care. The Behavioral Health Data Portal was rapidly deployed and
trained at 31 Military Treatment Facilities by the end of last year.
While the Army continues to improve behavioral health care to our
Soldiers and Families, we recognize that we must pay special attention
to Soldiers in transition, whether they are relocating to another
assignment, returning from deployment, transitioning from active duty
to reserves, or preparing to leave the service. The Army has
established a system internally to ensure continuity of care for
Soldiers moving from installation to installation. We also support the
DOD inTransition Program, which provides ready access to nationwide
cadre of experienced and independent Behavioral Health professionals
for Soldiers pending transition. These coaches teach life skills,
provide guidance in obtaining long-term behavioral health assistance
and resources, and provide current and relevant education on specific
Behavioral Health conditions. We also utilize Military OneSource as an
equivalent resource for Soldiers that are transitioning.
We are actively working with the VA to ensure continuity of care
for Soldiers transitioning to leave military Service. For Soldiers with
complex medical conditions, to include Behavioral Health, Warrior
Transition Units ensure personal support, case management and a warm
hand-off to the VA. We continue to collaborate with our DOD and VA
partners to improve the Integrated Disability Evaluation System to
ensure timely access to benefits that Soldiers have earned during their
time on Active Duty Service and to ensure appropriate transfer of care
to the VA. Army Medicine has increased IDES capacity by putting more
resources (people) in place, reducing the number of days Servicemembers
are in the process (and reducing the backlog), decreasing the amount of
time spent on the Narrative Summary by accepting the proposed VA rating
as the single rating, and conducting Army-wide training on customer
service. VA Nurse Case Managers are assigned to Soldiers in the
Integrated Disability Evaluation System to further support continuity
of care upon separation from military service.
Behavioral Healthcare and resiliency are important factors in the
readiness of the Army and important issues for our Veterans. The Army's
capable and honed behavioral health personnel, evidence based practices
and far-reaching programs comprise key pillars in its commitment to a
ready and resilient Army family. Thank you again for the opportunity to
testify before the Committee and for your steadfast support to our
Soldiers and Veterans.
______
Response to Posthearing Questions Submitted by Hon. Bernard Sanders to
COL Rebecca Porter, Chief, Behavioral Health Division, Office of the
Surgeon General, U.S. Army
Question 1. The Army's Task Force on Behavioral Health recently
completed a comprehensive report which contained a significant number
of recommendations to improve both behavioral health care and the
disability evaluation system Army-wide. Please describe how the Army
plans to ensure these recommendations are implemented consistently
across all installations.
Response. The Army Task Force on Behavioral Health made
recommendations to many commands within the Army. The Army Medical
Command (MEDCOM) has primary responsibility for 23 of the 47
recommendations and has assigned the oversight of its implementation to
a team of personnel within its Operations section. MEDCOM has already
begun to implement most of the recommendations and will report its
progress to the Secretary of the Army on a quarterly basis.
Question 2. Given the expertise the Army has gained in the area of
mental health, please provide information on how the Army is sharing
lessons learned with the other uniformed services and the Department of
Defense as a whole. Has the Army engaged DOD's Office of Warrior Care
Policy in order to determine whether these recommendations could be
utilized to strengthen behavioral health care and the Integrated
Disability Evaluation System across the Services?
Response. The Army has shared the lessons it has learned in the
area of mental health in many forums. Most recently the Army submitted
documents describing over 20 key programs to DOD for consideration of
possible dissemination to other services.
Question 3. Has VA supported the Army's efforts to improve the
diagnosis and evaluation of behavioral health conditions?
Response. The Army has worked closely with the VA to improve the
diagnosis and evaluation of Soldiers, especially during the IDES
process. Specifically, Army and VA medical providers synchronize
diagnostic conclusions before the Physical Evaluation Board reviews a
Soldier's case.
Question 4. Why has the Army projected it will take several more
years for Embedded Behavioral Health Teams to be expanded to all
operational units?
Response. Establishing the Embedded Behavioral Health (EBH) model
of outpatient care depends on several factors, including hiring and
training adequate personnel and establishing new clinical facilities in
each brigade's areas on the installations. The Army is accomplishing
those tasks as quickly as possible and has established over 30 EBH
teams to date on 18 installations.
______
Response to Posthearing Questions Submitted by Hon. John D. Rockefeller
IV to COL Rebecca Porter, Chief, Behavioral Health Division, Office of
the Surgeon General, U.S. Army
Question 5. Do VA and DOD collaborate and coordinate on research
initiatives regarding the treatment of PTSD and mental health issues?
If so, what is the process, and how is it evaluated? If not, why not,
and does it require legislation to establish such collaboration?
Response. Yes, Departments of Defense (DOD) and Veterans Affairs
(VA) collaborate on Post-Traumatic Stress Disorder (PTSD) and mental
health research initiatives. A variety of Federal agencies including
the DOD, VA, National Institute of Drug Abuse (NIDA) and Department of
Education each fund research programs devoted to scientific discovery
to advance health. DOD and VA focus specifically on military/Veteran
populations, whereas other agencies address health issues in the
general population such as in minors or other subpopulations.
Collectively, the agencies support research covering the broad spectrum
of the human population that will lead to a better understanding,
prevention, and treatment of the physical injuries and mental health
and substance abuse problems related to stress and trauma experienced
by servicemembers and Veterans.
DOD and VA held a combined research review addressing psychological
health in Nov 2011. A similar review was held in Jan 2013 and this
process is expected to continue on an annual basis. Together, DOD and
VA developed a framework for research using a ``Joint Integrated
Research Continuum Approach'' model that describes the entire research
spectrum from foundational (basic) through prevention, treatment,
follow-up care, and services research. The latter category addresses
how care is delivered and issues associated with stigma regarding
seeking mental health care and barriers to obtaining the desired
services. This framework highlights the areas in which the two agencies
are in a complementary manner seeking treatment solutions as well as
elucidating areas where more research is needed.
In the past year, DOD provided more than $30.5 million to VA
researchers for 351 projects. DOD currently funds VA scientists to
investigate several high-priority topics, including: PTSD, alcohol
abuse, resilience to mitigate combat stress and post-deployment
reintegration problems, mental health of female Veterans (including
military sexual trauma), treatment of Traumatic Brain Injury (TBI),
treatment for amputations and improved prosthetics, rehabilitation,
telemedicine, and illnesses in Veterans of Operation Iraqi Freedom and
Operation Enduring Freedom. VA scientists frequently partner with DOD
scientists, who serve in a supporting role as co-investigators.
Approximately 80% of the Defense Health Program Research Development
Test and Evaluation psychological health research efforts underway have
VA involvement through investigator participation.
Recently initiated activities include two new joint DOD/VA
consortium efforts to support PTSD and TBI biomarker studies (the
Consortium to Alleviate PTSD [CAP] and the Chronic Effects of
Neurotrauma Consortium [CENC]), new treatment studies to be generated
from biomarker studies, and new treatment response studies to be
incorporated into clinical trials.
Question 6. What is the most innovative and experimental research
underway at DOD and at VA to develop innovative care and treatment for
PTSD and mental health?
Response. Below are just a few examples of innovative research
approaches in PTSD and Mental Health:
Combined Psychotherapy, Virtual Reality, and Cognitive Enhancers:
This project addresses the use of Prolonged Exposure Psychotherapy, in
combination with Virtual Reality techniques and the testing of a
medication for ``cognitive enhancement'' that will augment the
learning/memory aspects of the psychotherapeutic process. The research
question to be answered is how much is the already evidence-based
practice of prolonged exposure therapy further improved via the
additions of virtual reality techniques and the cognitive enhancer when
treating PTSD.
Transcranial Electro-magnetic Stimulation of the Brain: Cranial
Stimulation applies the use of low voltage electrical stimulation in a
non-invasive manner to specified exterior locations on the skull of
PTSD patients. Pilot research has indicated that this technique
demonstrates some potential for PTSD symptom relief.
Intranasal Administration of Thyroxin Releasing Hormone (TRH) to
Offer Short-term Relief from Acute Suicidal Thinking: TRH has
demonstrated properties that offer short-term relief from acute
depression and associated suicidal ruminations. The challenge with
administration of the compound is delivering an effective therapeutic
dose in a manner that is not toxic while still crossing the blood brain
barrier. This project seeks to develop an intranasal administration
protocol as well as a device that will reliably provide only the
prescribed dosage for short term use.
Development of Compressed Treatment Protocols for the Delivery of
Evidence-Based Psychotherapies for PTSD: This research compares the
standard delivery of psychotherapy that includes weekly or greater
intervals between psychotherapy appointments, to the delivery of
psychotherapy on a ``compressed regimen'' of daily session. This
research has the potential to decrease the span of psychotherapy
treatment for PTSD from a regimen that is several months or more long
to one that consists of a period of three weeks or less. The goal of
the research is to demonstrate comparability of the therapeutic result
but within a much shorter treatment interval.
Mindfulness Training for Resilience: Several projects within this
area of complementary and alternative medicine are evaluating the pre-
deployment instruction and training of soldiers in mental resilience
awareness, activities, and exercises that improve coping abilities for
the psychological challenges typically associated with combat
deployment.
Question 7. How do VA and DOD review and evaluate outside research
on PTSD and mental health treatments from the non-profit and private
sector?
Response. Generally, when DOD and the US Army Medical Research and
Materiel Command's Military Operational Medicine Research Program
(MOMRP) accept specific psychological health research requirements, a
working group meeting is held that includes civilian researchers
representing a variety of organizations (universities, private research
foundations and enterprises) as well as leaders and experts within the
VA and DOD research and provider communities. These meetings evaluate
the current state of research in the designated areas and result in
identification of future research needs. . Once research projects are
selected and underway, we participate in periodic In Progress Reviews
(IPRs) of funded projects. Reviewer participants on the panels include
subject matter experts from a variety of domains, both military and
civilian. These panels bring the expertise of cutting edge research in
the field to MOMRP's research review meetings, which in turn serve as
forums for both critical review, course correction, and the
identification of future research needs. MOMRP annually conducts a
number of IPRs for psychological health topics and working group
meetings are typically held on an ad hoc basis.
Within specific research areas there are additional means of
information sharing. One example is the Suicide Research Consortium
(MSRC), which is charged with broadly monitoring civilian and military
suicide research and ensuring that DOD/VA funded efforts reflect
current research needs. The MSRC includes DOD, VA and civilian experts
and researchers. Another example is the National Center for PTSD,
operated through the VA, which includes a variety of civilian, VA, and
DOD experts and researchers that track findings within the larger
research community for PTSD and ensure that this information is widely
disseminated for use in treatment policy development and planning as
well as informing the future course of PTSD research. There are also
several PTSD-specific research consortiums, including Strong Star and
INTrUST, that also function in a manner loosely analogous to the MSRC.
______
Response to Posthearing Questions Submitted by Hon. Mazie Hirono to COL
Rebecca Porter, Chief, Behavioral Health Division, Office of the
Surgeon General, U.S. Army
Question 8. What is your assessment of outreach to female soldiers
to seek mental health services including for military sexual trauma?
Response. The Army is committed to ensuring its behavioral health
(BH) programs and outreach services for victims of sexual assault are
designed to support the needs of both male and female Soldiers.
Behavioral Health Care is an important factor in the readiness of
the Army. The Army is committed to ensuring resources are available to
address behavioral health needs of all Soldiers. We are embedding BH
assets in unit areas and in the facility to reducing stigma associated
with seeking behavioral health services. The Embedded Behavioral Health
(EBH) Program provides multidisciplinary BH care located in the unit
area to maximize coordination with unit leaders. This care model has
demonstrated significant reductions in key behavioral health measures
while knocking down access barriers and reducing stigma associated with
help seeking behaviors. Additionally, we have embedded BH assets into
the primary care clinic in the Patient Centered Medical Home, providing
increased access to behavioral health assets.
The recent professional credentialing of Sexual Assault Resource
Coordinators (SARCs) and Victim Advocates (VA) provides a standard
consistent pathway to direct both male and female Soldiers to the
mental health resources. We are working to modify the periodic health
assessment, pre- and post-deployment health reassessment forms to
include specific sexual assault questions to support mental-health
outreach efforts concerning sexual trauma.
Chairman Sanders. Colonel, thank you very much.
Let me begin with Dr. Petzel. I mentioned in my opening
remarks that as we have spent 10 years at war in Iraq and 11 in
Afghanistan, the cost of war is a lot heavier and more tragic
than many people realize.
So, let me start off with a very simple question. I do not
know if you have the answer in front of you. When we talk about
individuals suffering from Post Traumatic Stress Disorder and
Traumatic Brain Injury, how many people are we talking about?
Dr. Petzel. Thank you, Mr. Chairman. Right now, the VA is
taking care of slightly over 500,000 people with Post Traumatic
Stress Disorder.
Chairman Sanders. Let us stop right there. 500,000
returning soldiers?
Dr. Petzel. Correct. Not just returning; this is our whole
population, Mr. Chairman.
Chairman Sanders. This is not just Iraq and Afghanistan?
Dr. Petzel. I was about to get to Iraq.
Chairman Sanders. OK.
Dr. Petzel. We have about 119,000 people from the present
conflicts that carry the diagnosis of Post Traumatic Stress
Disorder.
Chairman Sanders. OK. This is an issue. That is just a huge
number; and it gives us an indication of the enormity of the
problem that we are trying to address here. It is a lot of
people.
There is an issue that we did not talk about very much
today or in your testimony, and that is TBI, Traumatic Brain
Injury. As we all know, this is one of the signature wounds of
these wars due to the incredible amount of explosions our
soldiers were exposed to.
How many folks are we talking about who have the diagnosis
of Traumatic Brain Injury?
Dr. Petzel. We have tested since several years ago, more
than 5 years I believe, everybody that comes back from combat
experience, we have evaluated them for posttraumatic, for
Traumatic Brain Injury. There are three levels of Traumatic
Brain Injury.
There is severe TBI. I think we are all familiar with that.
These are people who are often cared for in our polytrauma
centers and have many other complications such as amputations
and blindness. A relatively small number of people measured in
the couple of thousand.
395,000 people have been screened. We identified 54,000 of
those people who screened positive so far for possible
Traumatic Brain Injury and, out of that with quite
sophisticated testing, have identified 35,000 people that have
mild to moderate Traumatic Brain Injury.
Chairman Sanders. You are telling us that we have some
35,000 people from Iraq and Afghanistan who have mild to
moderate Traumatic Brain Injury?
Dr. Petzel. Yes. Most of them are from Iraq and
Afghanistan. There are some who have been injured in training
accidents, et cetera, but the vast majority are from the
conflict.
Chairman Sanders. And TBI is a tough illness to deal with,
is it not?
Dr. Petzel. Mr. Chairman, the biggest issue there is that
we do not know what the long-term consequences are of mild-to-
moderate Traumatic Brain Injury. This is one of the reasons why
we have a registry, why we tested all of these people,
identified people with that diagnosis, had them on a registry
and now can follow them over an extended period of time with a
very good baseline evaluation.
It is speculated that depression, anxiety, PTSD, and
endocrine disorders may be more common in those people with
mild-to-moderate TBI going forward.
Chairman Sanders. OK. We are going to have a second round
of questions but let me conclude my questions by asking Dr.
Petzel one final question. You have engaged in a very ambitious
effort to hire mental health clinicians. My understanding is
that in order to reach your goal--and that is at the end of
June, I believe, is that correct?
Dr. Petzel. Correct.
Chairman Sanders. You are going to need to hire some 495
more mental health clinicians?
Dr. Petzel. Correct.
Chairman Sanders. Are you really going to be able to hire
the quality people that you want in that period of time?
Dr. Petzel. We believe so, yes. We are involved in a stand
down and blitz, if you will, to look at--the big interval, the
big problem for us in hiring is 100 days plus that occurs after
the person has applied, after we have sorted through the
applications, the process of vetting them for criminal
activity, credentialing them, and interviewing all of them is
what is taking the time, and we have plans to compress that
substantially.
Chairman Sanders. I am going to take a little bit extra
time which I will give to my colleagues up here as well because
I wanted to get to Colonel Porter on an issue.
Look, I think the issue on everyone's mind with regard to
the military right now is that last year we lost more soldiers
to suicide than to armed combat, and we are talking somewhere
around 350 or so individuals.
Why is this number so incredibly high? Why is that
occurring? And later on we will talk about what the Army is
doing to address it.
I think the average American would be shocked that we are
losing more people to suicide than to armed combat. But tell
me, in your judgment, why do you think that number is as high
as it is?
Colonel Porter. Thank you, Mr. Chairman, that is, as you
indicated earlier, a very complex issue and a complex question.
I think a couple of things if you want to compare the number
lost to the suicide to the number lost in combat, part of that
is attributable to the fact that we have a high survivability
rate in combat right now. So, the number that we are losing in
combat is decreased significantly from past combat.
With regard to suicide in particular, though, sir, I think
what we can say is that it is a complex issue, as you noted,
that will take more than just behavioral health people to
solve; and that is why the senior Army leadership is looking at
bringing in our senior leaders all the way down to our squad
leaders to try to combat this with respect to improving
resilience in our soldiers, improving resilience in our family
members, and giving our soldiers coping skills for whatever
life throws at them, whether it is a combat situation or just
the daily stressors of being in the Army or being an American
citizen.
Chairman Sanders. OK. Thanks very much.
Senator Burr.
Senator Burr. Dr. Petzel, let me pick up where Senator
Sanders left off. When the VA started the increase of 1600
mental health staff and the administrative staff, were
facilities given any options other than hiring this additional
staff, like memorandums of understanding with organizations in
their community that would enhance and beef up their mental
health ability?
Dr. Petzel. Senator Burr, those options have always been
there but the short answer is no. This was aimed at how many
people do you need to bring your staffing up to the levels you
think you need in order to provide the access that we have said
we do.
Senator Burr. Was there a matrix that you created that came
up with the number of 1,600 mental health providers?
Dr. Petzel. It was a combination of using the only existing
staffing outpatient model for mental health. I think, as you
know, there are not very good staffing models for mental
health. In fact, the VA is probably a pioneer in developing
staffing models for mental health.
We used that and we used discussions with the individual
medical centers about what their view of their needs were.
I want to emphasize the fact that this is not an end. This
is going to be an ongoing evaluation.
Senator Burr. I am confident that is an accurate statement.
Dr. Petzel. We are going to be, in an ongoing way,
evaluating whether we have got the resources available and
properly deployed.
Senator Burr. But what you are saying is that every
facility has the option to partner with community-based
organizations. Not all of them choose to do it; and in the
absence of that, we said you have got to have more people. We
did not necessarily look to see to what degree there was
outreach for community-based solutions.
Dr. Petzel. That was not a part of the original assessment.
But I have to say that I am taking away from this hearing a
reinforced desire to go out and do as we did with homeless,
have a summit in the community of mental health providers.
Senator Burr. I remember a similar stimulation that you had
last year.
Dr. Petzel. What was that?
Senator Burr. Because I am not sure that we heard anything
from the witnesses this year that we did not hear last year
about the need for community collaboration between DOD, in the
case of Fayetteville and other military towns, VA, and the
community-based providers.
What do you think of the VA system when you hear somebody's
testimony like Mr. Woods about their firsthand experience?
Dr. Petzel. I am sad that he did not have a better
experience. I want to find out what went wrong, where it was,
and correct it.
Senator Burr. Do you think he is one out of everybody that
went in or is this----
Dr. Petzel. I do not think he is a one of. I think that it
is a relatively uncommon experience out of the 17 million
outpatient visits that we have.
Senator Burr. What outside-the-box options have been
stimulated for you that stick out right now that the VA could
pursue that they are not?
Dr. Petzel. Well, first of all, enhancing the effort that
we are making with the federally-qualified health plans.
Second, bringing together--and we have done this in some
communities but I do not think it has been done universally--
bringing together NAMI, these other organizations that
testified earlier.
We have worked with NAMI and we have worked with Give an
Hour but doing this in a systematic way across the country with
every one of our medical centers and large Community-Based
Outpatient Clinics to, indeed, do an inventory of what is
available and to stimulate our people to think about using the
community in a larger sense.
Senator Burr. Every person who testified in one way or
another referred to the fact that veterans could not get mental
health treatment when they needed it through the VA.
So, I guess I would ask you, are your measurement tools
flawed, and are they not picking this up, or have your
measurement tools shown this and we just have not addressed it?
Dr. Petzel. Well, when we talk about access, Senator, we
talk about 95 percent of the people can get an appointment
within 14 days. When we are talking about 17 million
appointments, there are a substantial number of people who are
not getting seen that quickly.
I cannot deny the fact that there are people who are not
being seen as quickly as we want, and I want to provide them
with whatever they need in order to get a hold of and get
involved in the mental health services that they have, and I
think that partnering with the community will help that.
Senator Burr. I am glad to hear you say that. There is a
huge difference between reality and goals; and I think what we
heard today were realities; and I think what you have stated to
us are the goals of what VA would like to hit; and
unfortunately, I do not think the proof suggests that we hit
it.
Dr. Batten, in September 2012, VA surveyed its mental
health providers to measure their opinions regarding VA's
mental health program. Can I ask you today if you would provide
the Committee, for the record, the results of that survey and
the individual responses to the open-ended question,
``additional concerns about mental health services at my
facility?''
Ms. Batten. Thank you, Senator. I believe we have just been
finalizing the report. We will have to take for the record
exactly what is available. Perhaps, Dr. Petzel would like to
speak.
Dr. Petzel. The intention is to share that, Senator Burr.
Senator Burr. Do I have your assurance that you are going
to share it with the Committee?
Dr. Petzel. We will share the report with you, yes, sir.
Senator Burr. Thank you. As well as the open-ended
question?
Dr. Petzel. I think that we are able to do that as well.
Senator Burr. Thank you, Dr. Petzel.
The Executive Order that you have addressed with the 1,600
people also created the Military and Veterans Mental Health
Interagency Task Force; and it was directed to provide the
President with recommendations to improve health and substance
abuse services by February 2013.
Has the task force provided its recommendations to the
President, and if so, could you provide the Committee with a
copy of that report?
Dr. Petzel. The task force has provided its report to the
President. That was on, I believe, the 1st of March. It is my
understanding that it is going through coordination and
concurrences by a number of Federal departments and you will
have it available to you as soon as it is released.
Senator Burr. What does that mean, going through
coordination?
Dr. Petzel. I do not know. I am sure that there are numbers
of bases that need to be touched in terms of what the report
said. When it is released by the President, you will be able to
have it.
Senator Burr. You do not suggest that it is going through a
process of being changed?
Dr. Petzel. No, sir.
Senator Burr. OK. Thank you, Mr. Chairman.
Chairman Sanders. Thank you, Senator Burr.
Senator Tester.
Senator Tester. Thank you, Mr. Chairman.
On these reports that we are getting back, is it possible
we could look at them as a Committee, because I hear a lot of
requests for reports and quite frankly I do not get them. I
would love to have a discussion within the Committee about
these reports once we get them if we have the time.
I think that if we are going to ask the VA for these
reports, I think we owe it to them to make sure we discuss them
and find out what is in them and make sure they are worthwhile.
Chairman Sanders. I think that is an excellent suggestion.
Senator Tester. Thank you, Mr. Chairman. I appreciate your
leadership.
I want to visit on a couple of different things. I do not
know if I have ever asked you this, Dr. Petzel. Does the VA
have a definition for ``rural''?
Dr. Petzel. They do. It is not a definition that is really
exclusive to the VA. It can be defined in two ways. One is the
travel distance to a metropolitan area or the distance, and we
have used both of those measurements in defining rural.
Senator Tester. Well, the reason I want to come to this is
that we are hiring--we have got 1,300 and another 600 or so
people you are hiring in the mental health profession.
Dr. Van Dahlen spoke earlier and we have some issues. I
guess if you were up again I would ask you how widespread,
countrywise, your program is because I think those resources
are great where they exist.
But I am more concerned about rural where there are no
resources. My question is, when you assign these folks, what is
the priority you do it on? Is it based on where there are
limited service or no service, or how do you make that
decision?
Dr. Petzel. Well, we do not assign them. We ask, as an
example in your instance, we would ask the Fort Harrison and
the VISN what are the needs out there. They would tell us that
they need an additional two psychiatrists, let us say, and four
psychologists and five psychiatric social workers.
That would be then what we would expect them to go after
and expect them to try to hire. We do not hire people and then
assign them someplace.
Senator Tester. So, you get the recommendations ahead of
time before you hire the folks. If you need somebody in
Plentywood, MT, for example, at that CBOC, and I do not even
know if that is the way you work it; but if you need somebody
in Plentywood, in the far northeastern corner, 600 miles away
from the nearest medical VA hospital, then you hire that person
to fill that slot.
Dr. Petzel. That is what we would try to do. I have to say,
Senator, that a better alternative would be to use telehealth--
--
Senator Tester. Got you.
Dr. Petzel [continued]. And provide that service remotely
by having it done by a psychiatrist back in Helena.
Senator Tester. Point well taken, and I am going to get to
you, Colonel Porter, in a second.
Veteran suicide is a huge issue and an incredible worry and
something we have got to improve. Have you got any data on the
veterans that have contacted the VA and their suicide rate
versus the veterans who you never can get out and touch and
their suicide rate?
Dr. Petzel. Yes, Senator, we have. The people that are
under mental health care in the VA have a lower and declining
suicide rate than those veterans who are not in contact with
the VA, not getting care in our system.
Senator Tester. Have you any figures on that, because I
know there is a pile of vets out there that do not utilize the
VA.
Dr. Petzel. I would have to ask Dr. Kemp, who is our expert
in suicide.
Ms. Kemp. As you know, we are just now beginning to be able
to gather that information directly from the States; and as a
result, we were able to put out that first suicide data report
just this year.
Senator Tester. OK.
Ms. Kemp. As we add states, we will be able to firm up
those numbers.
Senator Tester. Very good. As soon as you get those, I
would love to see them.
Ms. Kemp. Yes.
Dr. Petzel. Senator, could I just make a couple of other
comments about suicide. There was a discussion about combat
experience and suicide earlier. I think it is important to
point out that in veterans, not servicemembers but in veterans,
there is no relationship necessarily between their combat
experience and whether or not they take their lives.
Senator Tester. I have got you in that. I think that was a
question I asked the gentleman from NAMI if there was any idea
on that. I guess the point is that you cannot help the people
you do not have access to; and that is what I want to see,
whether they served in combat or not, they have earned the
benefits. We have got to encourage them to step up to the VA
because I think there is a good health care system there. But
if we cannot get them in, we cannot help them.
Dr. Petzel. That is absolutely right.
Senator Tester. OK. One last question. Oh good, I have more
minutes than I thought. [Laughter.]
Colonel Porter, you talked about 350, or maybe it was the
Chairman actually who said 350 suicides a year in the active
military. Is that number correct for last year?
Colonel Porter. I do not know that we finalized the number
from last year.
Senator Tester. Is it close?
Colonel Porter. I think it is close, Senator.
Senator Tester. OK. Is that all the branches of the
military?
Colonel Porter. I think it does include all of the
military.
Senator Tester. OK.
Colonel Porter. Including the Reserve components.
Senator Tester. It does include the Guard and Reserve
component?
Colonel Porter. Yes.
Senator Tester. That is good to know. Thank you.
Continuing with you, we talked about the stigma attached.
Is the military doing anything about that stigma because we are
seeing unacceptable levels quite frankly; and we do not do a
good job as a society. I do not know that any society does a
good job with mental health issues and that can be fixed. We
talked about all that stuff.
But is the military doing anything to address the stigma
challenge associated with mental health?
Colonel Porter. Senator, what the Army is doing is they
have a stigma reduction campaign that is intended to educate
soldiers and leaders about the benefits of accessing mental
health care.
But I think what really makes a difference is, and what we
know actually from literature about behavior change and
attitude change, is that having the behavioral health providers
around soldiers and having the soldiers have access in their
brigade areas to those soldiers, like our embedded behavioral
health program where we take the behavioral health providers
from the hospital and actually make their place of duty a
building that is authorized for health care use in the brigade
area so that the brigade leaders know those behavioral health
providers and vice versa.
Senator Tester. Is this widespread throughout?
Colonel Porter. We are rolling it out across the Army.
Senator Tester. OK. When do you anticipate it will be fully
implemented?
Colonel Porter. We anticipate that we will have all
operational units supported by this program by the end of
fiscal year 2016.
Senator Tester. OK. There is a huge problem here. This is
the veterans Committee and we hold the VA accountable. But I
think the Department of Defense has a responsibility here to
train people of what they are going into so that they
understand what to expect as they go through their military
service.
I just want to thank everybody for their testimony today
and I want to thank you, Mr. Chairman.
Chairman Sanders. Thank you, Senator Tester.
Senator Boozman.
Senator Boozman. Thank you, Mr. Chairman.
Dr. Petzel, do we have a good idea of--we heard about the
community-based programs, we have heard about different things
that seem to work.
You have got the classic therapy. One of our witnesses
talked about an individual that was in Haiti helping other
people and that seemed to help a lot. I heard about a young guy
that was an amputee that literally a golf pro tapped him on the
shoulder and said I am going to teach you how to play golf when
he was lying in the bed suicidal, and that changed his life.
There are all of these ancillary things. Do we have good
metrics to know what is working and what does not work?
Dr. Petzel. That is an excellent question, Senator Boozman.
We do know there are a group of evidence-based therapies that
have been developed relatively recently. Two of them for Post
Traumatic Stress Disorder. There are some relatively new
evidence-based therapies for depression and anxiety and other
things.
So, yes, there are areas where we do know what to do. There
are lots of areas, however, where we do not know what to do.
I really want to hearken back to what in the previous
panel, Mr. Wood said, this idea of purpose and community is
very important. The idea of people having purpose in their
lives, something that they look forward to, I think, is very
important.
I would ask Dr. Batten if there are any other comments
about what we have available that is effective in treating the
multiplicity of mental health disorders, not just PTSD.
Ms. Batten. I am happy to be able to speak to that. I think
that we want to make sure that all veterans have access to our
evidence-based psychotherapies and we want to make sure that
they understand that treatment works because one of the biggest
barriers for people coming into care is not knowing that there
is something there that will help them.
But we also know that not any one thing is going to apply
to everybody. So, what we need to do is we need to have our
clinicians ready to ask the questions about what is important
to that individual veteran when he or she walks through the
door.
It may be reducing symptoms but it may be about getting out
and getting a job. It may be about being able to go to their
grandchild's T-ball game and not have to be looking over their
shoulder.
It is important to find out what is important to that
veteran, and we want to make sure that we use a wide array of
services that include peer support, getting back out into the
community, and really living a healthy lifestyle overall.
Senator Boozman. No, I agree, and I think, you know, one of
our previous witnesses said the same thing in the sense that
one size does not fit all.
You mentioned having a summit and I would encourage you to
have a summit along those lines as to, you know, with the
community-based and other programs.
My concern is, you know, in an effort--you guys work very,
very hard to try to solve this problem. The trouble is that you
are receiving the patient at the end stage. So, we are not
addressing the cause of the problem.
So, you are having to deal with this and probably the least
expensive thing is to write a prescription. I think you really
need to look very hard--and we can help you with that--but you
need to look very hard at overprescribing.
We are seeing this in the private sector, what has happened
with pain management. They are consuming more opiates than all
the rest of the world put together.
The other thing that you might consider having a summit
about is looking at the causative thing and treat this as a
whole in the sense that we need to look at the divorce rate in
the military. You know, that is every bit as important because
it all factors in.
We need to look at how our soldiers are doing financially,
and also important is we almost need--maybe we have already--
but we need to have a marital hotline at the bases, again to
get our guys and girls in a situation where they are dealing
with those problems while in the military for when they get
out.
Also, the employment picture is so important; getting them
hired where they can. What I see so often is with the multiple
deployments you might not come back with PTSD, but I can tell
you are probably coming back with family problems, particularly
if you have had seven or eight deployments in the last 11
years. That is a tough thing.
Dr. Petzel. Senator, can I make two comments? Those are
excellent, by the way, comments and I think you put your finger
on what we really are trying to work on.
First of all, we need to be able to identify these people
much earlier in the course of these illnesses. The new
transition assistance program that is mandated for everybody
that the VA is devoting almost half a billion dollars to is
going to go a long way toward helping us see these issues very
early, before patients, before the soldiers are discharged. We
can identify people in trouble and we can also make them aware
of everything that is available.
But the other part of what you said, identifying the
antecedents, the VA population that harms themselves is the 60
plus population. That is the big group, the majority of people
who commit suicide in the VA.
In that instance, we are talking about depression. We are
talking about chronic pain. We are talking about sleep
disorders. We are talking about substance misuse and, as you
mentioned, life stressors like loss of a job.
They are often retiring and it is a big change. Just like
leaving the military, retirement can be a huge change in
someone's life.
We have chartered a workforce group that is going to be
looking at new approaches to those five things, doing these
things differently so that we can do a better job of
identifying people who may be at risk.
So, I think you are right on the issues.
Senator Boozman. I agree. As you said earlier and in our
previous panel, loss of purpose.
Dr. Petzel. Right.
Senator Boozman. In that group in particular, you know,
feeling like----
Dr. Petzel. Life is over.
Senator Boozman [continued]. Life is over, exactly.
Thank you, Mr. Chairman.
Chairman Sanders. Thank you, Senator Boozman.
I believe that Senator Blumenthal will be here in a second.
In the meantime, let me bring some other issues and ask some
questions.
I think it is fair to say that both VA and DOD, have a very
good reputation for treating the wounds of war in terms of
prosthetics, in terms of how we take care of amputees. There
are probably no institutions in the world that do a better job
than VA and DOD. You are leaders in the world on that.
Mental health is a different issue, and it is a much more
complicated issue, whether it is in the private sector or
within the military and the VA.
And on top of that, if we take a deep breath and we look at
the magnitude of the issues that VA has to deal with, hundreds
of thousands of soldiers coming back with PTSD or TBI on top of
the problems that our older veterans have from Korea, Vietnam,
World War II. This is a mammoth issue, the number of veterans
that are suffering.
I think a recurring theme in the previous testimony that we
heard was that every soldier is different. Every problem is
different, and that we have got to think a little bit outside
of the box, and I think Senator Boozman raised that issue.
Talk a little bit about out-of-the-box therapies, talk a
little bit about complementary medicine. There was a piece on
CNN just the other day and they were talking about
overmedication which is a very real issue.
In the story, some of the overmedicated individuals were
moved toward acupuncture as pain relief which, apparently, in
what we saw on CNN at least, worked pretty well. To what degree
is the VA aggressively looking at complementary medicine,
acupuncture, meditation, massage therapy?
And the second issue, and Senator Boozman raised that as
well what we are dealing with our real-life problems? Life is
complicated; it is not necessarily just dispensing some
medicine. It is certainly not filling out pages and pages of
forms which would drive me, among many other people, quite nuts
if I needed help.
How we break through that old bureaucracy? Senator Boozman
mentioned the idea of veterans playing golf. If four veterans
spend an afternoon out playing golf and feeling good about each
other and come back feeling a little bit better about
themselves--or they go trout fishing or camping together--those
are real improvements which may mean a lot more to the veterans
than getting some more medication.
So, the question is, to what degree are we thinking out of
the box to make people feel better about themselves in whatever
way works for them, understanding that we have to be careful
when we make these recommendations not to see front-page
stories that VA pays for golf outings on the part of veterans.
That is a very easy target for the media.
Senator Boozman. No. I agree totally and that is why I was
asking if they had some evidence-based data as to what is
working, you know.
Chairman Sanders. Yes. OK. But that is the question I want
to throw out if you could answer it.
Dr. Petzel. Thank you both. Let me first deal with a little
bit about the out-of-the-box. We partner with a tremendous
number of organizations around the country--Give an Hour as an
example--of psychotherapy.
The professional golf association and the local
professional golf associations have programs in virtually every
city where we have a medical center that provide the
opportunity for handicapped people, particularly, to play golf.
We actually sponsor a golf tournament for the blind that occurs
every year in Iowa City.
There are many other examples of recreational activities:
horseback riding, fishing, kayaking, where individual veterans
and service organizations have put together these nonprofits
that provide these opportunities.
We are looking for them everywhere we can find them.
Whether or not there are enough and whether we are using it
enough is, I think, an open question. But we are very much open
to those opportunities.
Chairman Sanders. I want to get back to the issue again
that Senator Boozman appropriately raised of overmedication and
looking at other ways to deal with pain and other distress.
Dr. Petzel. Again, excellent. Let me deal first with
opioids which is the most dangerous, in my mind, of our
overmedication issues. We have got a three-pronged approach.
There is, first of all, what we call the stepwise process where
you begin with the least invasive, least dangerous, least risky
things to manage chronic pain; and this is being done at all of
our medical centers.
And, that may include acupuncture. We provide acupuncture
at the vast majority of our medical centers. And then
progressively, more complicated things such as rehabilitation,
et cetera; and eventually when you are not able to manage the
pain in any other way, it is opioids. And then, there are very
careful protocols about how that prescribing should be done.
The second step in that is that we have just begun
producing the computer program that provides to the medical
center the listing of patients who are taking unusually large
number of opioids and prescribers who are prescribing an
unusually large number, and that is transmitted back to the
medical center. A person is responsible for tracking that down
at the medical centers and seeing what the issues are.
Then, the third thing is that we are participating now in
the State reporting of opioids. That is very important because
some of our patients are getting prescriptions outside of the
VA and we need to be able to bring that data together. So, we
fully understand the extent of the problem.
So, we will be giving them our data and we will be able to
have access to the State-wide data.
Chairman Sanders. Thanks very much.
Senator Blumenthal.
STATEMENT OF HON. RICHARD BLUMENTHAL,
U.S. SENATOR FROM CONNECTICUT
Senator Blumenthal. Thank you, Mr. Chairman.
First of all, my thanks go to Senator Sanders for having
this hearing, which I hope will be just the first of a number
of steps to dig deeper into this issue of mental health and to
pursue the line of questioning that Senator Sanders has raised.
Thank you all for your service on this issue.
Regarding the collection of data on the use of pain
medications, many of us know that this issue has bedeviled our
society. I know from my own experience as State attorney
general how challenging it was when we were finally able to
establish an electronic health records system that keeps track
of who is prescribing and who is taking pain medications like
opioids.
My first question is, would it not be helpful to have a
single system of record keeping that applies to men and women
of our military while they are on active duty that works
seamlessly transfer to the VA? This system was on track to go
forward, a billion dollars has been spent on it, and now
apparently it has been scrapped.
Would it be advisable and desirable to have that kind of
system for the purposes of tracking exactly this kind of
potentially useful but also highly dangerous medication.
Dr. Petzel. Senator Blumenthal, the integrated medical
record between DOD and VA will enhance greatly our capacity to
manage patients in general and some of the specific things such
as medication issues even better.
The integrated medical record has not been scrapped. That
is going forward as we speak, and we are expecting that by 2014
we will have the initial operating capacity for that integrated
record.
Senator Blumenthal. Well, I am glad to hear you say that.
Dr. Petzel. VA is absolutely committed to doing that.
Absolutely committed.
Senator Blumenthal. I know, but as with dancing it takes
two.
Dr. Petzel. Yes.
Senator Blumenthal. And, the public announcement by
Secretary Panetta and General Shinseki was certainly not
encouraging. I have since heard conflicting reports and my
concern is that this interoperable system may not be the same
as a seamless, fully-integrated system that enables real-time
tracking of how opioids and other highly powerful medications
may be prescribed.
Dr. Petzel. I am not an expert in IT. I will confess from
the beginning, I'm probably one of the least literate
physicians around IT. But I am told that this will be a
seamless record. And, I share your concern. This is a thing
that the VA particularly has been paying constant attention to.
Our Secretary is absolutely relentless in pushing forward the
need for having this integrated record.
Senator Blumenthal. I am really delighted to hear that
point reaffirmed. I have spoken to him about it and I know of
his personal interests and his commitment to it which I commend
fully and enthusiastically.
Let me ask you about, again to take Senator Sanders point
about thinking a little bit outside the box, what about
prescription drug take-back programs?
Dr. Petzel. By the way, thank you for sponsoring, I
believe, that legislation with the FDA. We think it is an
excellent idea. Anything that can get these dangerous
medications out of people's hands that do not need them; keep
them away from teenagers who sometimes rifle their parents
medicine chest, et cetera.
We are looking at how we can do this. Certainly, mailing
back is no problem for us and we will institute that as quickly
as we can. The receptacle collection depends on a ruling that
our police are actual law enforcement officers. We think that
is going to come but we need to establish, in fact, that they
are.
And then, I believe the other provision was handing these
over, at the time of a visit, to practitioners. We are looking
at whether we legally can do that or not. It is an excellent
idea, and we fully endorse it and are going to do everything we
can to participate.
Senator Blumenthal. Great. Well, anything we can do or at
least I can do, I would be delighted to undertake.
During the proceedings I saw ESCAPE FIRE, the documentary
that I think the Chairman mentioned earlier and I hope that
more people have the opportunity to view it because I think it
makes a very graphic and dramatic case for the need to be
vigilant on this issue, particularly where we are using
medications that may be every bit as advanced as some of the
equipment of warfare that are used on the battlefield, in terms
of their effect on individual people. So, I hope that all of
you will continue to do the good work that you are doing in
this area.
Let me ask you on a more general level, and I do not know
whether you have had a point on this. You looked like you were
about to say something. I did not mean to interrupt you.
Dr. Petzel. I do not want to take up your time.
Senator Blumenthal. Well, that is why you are here, to take
up our time.
[Laughter.]
Dr. Petzel. I was just going to remark on the wonderful
vignette about acupuncture in ESCAPE FIRE and the
transportation of patients from Landstuhl back to United States
where they used acupuncture in substitution of opioids and how
effective that was. I thought that was a very moving vignette.
That was all.
Senator Blumenthal. Well, that leads to the question I was
going to ask. In your experience as professionals having dealt
with veterans, particularly individuals exposed to combat, is
there a factor, a tendency, and an experience that leads
veterans to be more likely to overmedicate on pain medication?
And I do not mean to suggest that they do, but that is part of
the question.
Dr. Petzel. I will make a brief comment and then I will ask
of anybody else here.
The tremendous physical stress that they undergo, marching
with 80 pound packs, et cetera, when you look at the complaints
that returning veterans have, musculoskeletal are far and away
the leaders. Forty-five percent of people returning to this
country after deployment complain about neck, arm, shoulder,
and back pain, et cetera. That is the only thing that I
personally can testify to.
I would ask if anyone else--Sonja.
Ms. Batten. Thank you. I think these are the sorts of
questions that we need to ask if we want to really move from
just saying, OK, here is the diagnosis, here is the treatment.
I think we need to understand some of those underlying
mechanisms that are going on that influence both physical and
mental health functioning.
So, one of the examples I will give is when we think about
the etiology of PTSD. So, why do some people develop PTSD and
some people do not? One of the factors that is involved with
the development of PTSD and its maintenance is when somebody,
you know--it is natural for any of us, if we experience an
unpleasant or traumatic event to try not to think about it, to
try not to have those memories, those sensations, and feelings.
So, that sort of initial level of avoidance, that is just
natural.
That is human nature. But when somebody uses avoidance or
numbing as their primary way of coping with that sort of
trauma, then they are going to be more likely to develop
something like Post Traumatic Stress Disorder.
And, it is not a far step to say that when somebody is not
willing to experience emotional pain, it is probably also the
case that they are not willing to experience physical pain.
So, we need to look at some of those underlying factors
around avoidance and difficulty sitting with uncomfortable
thoughts, feelings, emotions, and physical sensations that may
tie some of those propensities together.
So, if you are not willing to have the emotional pain, it
may be also that it is difficult to sit with the physical pain
and you may be more likely to turn toward things like pain
medication rather than psychotherapy or other techniques to
cope.
Senator Blumenthal. Thank you.
Thank you, Mr. Chairman.
Chairman Sanders. Senator Blumenthal, thank you for your
questions.
Let me just conclude by thanking all of you. The enormity
of the problem that both DOD and VA are facing is
extraordinary, and in many ways is unprecedented.
I appreciate the hard work the VA is doing, the seriousness
upon which they are addressing this issue. Clearly we have a
long way to go. Clearly, we have a lot of problems out there.
This Committee looks forward to working with you to address
those problems.
Thank you all very much for being here.
[Whereupon, at 12:26 p.m., the Committee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Hon. John D. Rockefeller IV,
U.S. Senator from West Virginia
Chairman Sanders and Ranking Member Burr, Thank you for leadership
for veterans, especially this hearing to focus on the importance of
improving mental health care in VA.
The suicide rate among veterans is a sad, stunning alarm. Each
individual case is a tragedy for families and the community. The
invisible wounds for war are real and they deserve as much care and
support as physical wounds.
This hearing is important because we start by hearing about the
concerns our veterans and families have. I believe it is imperative for
VA and the medical profession to reach out to care for our veterans
with PTSD and mental health issues. It is good that both VA and DOD
testified today. Both departments must find ways to coordinate care,
transfer files and share practice and programs.
VA also needs to engage in bold research to find new and better
ways to care for our veterans who are suffering because of their
service. I am interested to know what the innovative treatments that VA
researchers are studying as well as DOD researchers. The reoccurring
theme of the testimonies seems to be that various care options are
needed to meet the specific needs of individuals. I agree that ``one
size does not fit all.'' I want to know what new and promising research
for mental health treatment exists. I believe that we need to follow
the science to determine the promising treatments.
How are we using technology to meet the needs of our younger
veterans and interact with them as they prefer, by technology?
Chairman Sanders and Ranking Member Burr, I stand ready to work
with you to tackle this serious challenge of improving VA mental health
and dealing with the stigma of mental health in our country.
______
Prepared Statement of the Veterans Affairs and Rehabilitation
Commission, The American Legion
A veteran in crisis, suffering from mental health problems, became
so furious with the telephone delays he faced while trying to make a
mental health appointment at the VA, assaulted his wife and dog after
being repeatedly placed on hold. Veterans are struggling to access
their mental healthcare across the country, and in Richmond, Virginia
appointments for mental health (PTSD) issues are at least a six to
eight month wait. Further, when calling for assistance, veterans are
placed on hold before being asked whether the call is regarding an
emergency, or whether the veteran is currently a danger to them self or
to someone else.
On behalf of National Commander James Koutz and the 2.4 million
veterans of The American Legion, we would like to thank this Committee
for the opportunity to address this critical issue affecting veterans
across the Nation.
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.
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\1\ ``Suicide Data Report, 2012'' Department of Veterans Affairs
Mental Health Services Suicide Prevention Program, p 15.
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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 11, 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 fiscal year (FY) 2013. 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 Secretaries 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, servicemembers 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 to the Executive Order, the Veterans Crisis Line was to
be increased by 50 percent, 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 campaign, which began on
September 1, 2012, which focuses on the positive benefits of seeking
care and encourage veterans and servicemembers to proactively reach out
to support services. However, 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\
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\2\ GAO Report 13-130, December 2012.
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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 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 servicemembers for mental health conditions,
including PTSD, testimony from a November 30th, 2011 Senate 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 veteran's ability to
receive care in a timely manner.
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\3\ Testimony of Dr. Van Dahlen--11/30/11 Senate Veterans' Affairs
Committee.
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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 believes 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 servicemembers 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\
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\4\ American Legion Resolution No. 136: The Department of Veterans
Affairs to Develop Outreach and Peer to Peer Programs for
Rehabilitation.
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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.
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\5\ OIG Report 12-00900-168, April 23, 2012.
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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 servicemembers.
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\
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\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 task force, 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.
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\7\ GAO Report 13-130, December 2012.
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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 an 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.
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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 5, 2012 developed by the VHA;\9\ however, the Directive was
rescinded less than a week later on September 11, 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 of access
for veterans requiring primary care, including women's health and
mental health services. Unfortunately, the implementation of this
Directive is not expected until 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.
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\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 multipronged 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 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 30, 2013, 6 weeks
from now.
---------------------------------------------------------------------------
\10\ GAO Report 13-130, December 2012.
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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 1, 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 2012 the FY 2013
appropriations for the same facilities was eliminated 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, 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 have 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.
______
Prepared Statement of Joy J. Ilem, Deputy National Legislative
Director, Disabled American Veterans
Chairman Sanders, Ranking Member Burr, and Members of the
Committee: Thank you for inviting DAV (Disabled American Veterans) to
provide this statement for the record of today's important hearing
assessing the mental health needs of veterans. We appreciate the
opportunity to provide this information.
Mr. Chairman, each year DAV participates with our partner veterans
organizations, AMVETS, Paralyzed Veterans of America, and Veterans of
Foreign Wars of the United States, in presenting the Independent Budget
to Congress, the Administration and the American people. It is a budget
by veterans, for veterans. This statement is a synopsis of this year's
Independent Budget report on mental health. For more in-depth
information, we invite your professional staff to review the
Independent Budget in its entirety, at www.independentbudget.org.
The Department of Veterans Affairs (VA) offers a wide array of
mental health services that ranges from treating veterans with milder
forms of depression and anxiety in primary care settings, to intensive
case management of veterans with serious chronic mental illness such as
schizophrenia and bi-polar disorder. VA also offers specialized
programs and treatments for veterans struggling with substance-use
disorders and post-deployment mental health readjustment difficulties,
including providing evidence-based treatments for Post Traumatic Stress
Disorder (PTSD) for combat veterans and for veterans who have
experienced military sexual trauma. VA has placed special emphasis on
suicide prevention efforts, launched an aggressive anti-stigma and
outreach campaign, and provided services for veterans involved in the
criminal justice system. Peer-to-peer services, mental health consumer
councils, and family and couples services have also been evolving and
spreading throughout VA.
Over the past five years, the VA health care system has
accommodated a 35 percent increase in the number of veterans receiving
mental health services while absorbing a 41 percent increase in mental
health staff. In fiscal year 2012, VA provided patient-centered
specialty mental health services to 1.3 million veterans. These
services were integrated in primary care.\1\
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\1\ Department of Veterans Affairs Press Release, ``New VA Mental
Health Outpatient Clinic to Open in Reno,'' August 10, 2012.
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funding is key
Historically, VA has been plagued with wide variations among VA
medical centers and their community-based outpatient clinics (CBOCs) in
adequacy and availability of specialized mental health services. To
address these concerns, over the past several budget cycles VA has
provided facilities with targeted mental health funds to augment
specialized mental health services. This funding was intended to
address VA's recognized gaps in access to and availability of mental
health and substance-use disorder services, to address the unique and
growing needs of veterans who served in Operations Enduring and Iraqi
Freedom and New Dawn (OEF/OIF/OND), and to create a comprehensive
mental health and substance-use disorder system of care within VHA that
is focused on recovery. Experts note that timely, early intervention
services can improve veterans' quality of life, address substance-use
problems, prevent chronic illness, promote recovery, and minimize the
long-term disabling effects of untreated mental health problems.
Despite a 39 percent increase in resources since 2009, VA continues to
struggle to meet demands and provide timely mental health services to
many veterans.\2\
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\2\ Department of Veterans Affairs Press Release, ``New VA Mental
Health Outpatient Clinic to Open in Reno,'' August 10, 2012.
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DAV is concerned about VA's apparent plan to cease separately
accounting for mental health expenditures beginning this year, and
instead to integrate all mental health funds in VA's global casemix-
based allocation system. The unintended effects of this shift may
diminish VA's intensity in providing for veterans' mental health and
post-deployment readjustment services at a time when needs continue to
rapidly escalate and program implementation is incomplete. It may also
inadvertently increase the variation in veterans' access to mental
health and substance-use disorder services. It is well accepted that
setting strategic goals and objectives, allocating and tracking budget
expenditures and measuring performance against those objectives result
in demonstrable progress and improved health care quality. We recommend
that the Veterans Health Administration (VHA) continue to utilize these
principles in managing mental health and substance-use disorder
programs. We intend to monitor this shift to determine its effects on
veterans who need effective services, and we ask your Committee to
provide oversight to ensure VA continues to meet its mental health
mission.
current challenges
As a consequence of a July 2011 hearing by this Committee, and
pressed to reconcile the disparity between VA policy and practice on
waiting times, VA surveyed mental health providers across the system.
Nearly 40 percent responded they could not schedule an appointment in
their own clinics for new patients within 14 days. A startling 70
percent responded that their sites lacked both adequate staff and space
to meet current demands, and 46 percent reported lack of off-hour
appointments to be a barrier to care. In addition, more than 50 percent
reported that growth in patient workloads contributed to mental health
staffing shortages and one in four respondents stated that demand for
compensation and pension examinations diverted clinical staff away from
direct care.\3\ Based on the results of this internal VA survey and
continuing reports from veterans themselves, it appears that despite
the significant progress--specifically an increase in mental health
programs and resources, and the number of mental health staff hired by
VA in recent years--significant gaps still plague VA efforts in mental
health care. The impact of these gaps may fall greatest on our newest
war veterans, many of whom are in urgent need of services.
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\3\ Veterans Health Administration, A Query of VA Mental Health
Professionals: Executive Summary and Preliminary Analysis (Washington
DC: September 9, 2011).
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In October 2011, the Government Accountability Office (GAO) issued
a report entitled VA Mental Health: Number of Veterans Receiving Care,
Barriers Faced, and Efforts to Increase Access, covering veterans who
used VA from FY 2006 through FY 2010. Approximately 2.1 million unique
veterans received mental health care from VA during this period.
Although the number steadily increased due primarily to growth in OEF/
OIF/OND veterans seeking care, the GAO noted that veterans of other
eras still represent the vast majority of those receiving mental health
services within VA. In 2010, 12 percent (139,167) of veterans who
received mental health care from VA served in our current conflicts,
and 88 percent (1,064,363) were veterans of earlier military service
eras. The GAO noted that services for the OEF/OIF/OND group had caused
growth of only two percent per year in VA's total mental health
caseload since 2006. Given these findings, we believe there is a
misperception that the majority of the recent mental health resources
are needed for the OEF/OIF/OND population. We understand from VA
officials that the overall improvements in VA mental health services
over the past five years have benefited all eras of veterans--
particularly older veterans and Vietnam era veterans--many of whom are
accessing VA mental health services for the first time. Increased
resources from Congress have been beneficial for all VA patients and
should be sustained. One of the more obvious benefits is universal
mental health screening in primary care with direct access to services
within that care setting.
Additionally, RAND Corporation released a technical report in
October 2011 entitled Veterans Health Administration Mental Health
Program Evaluation, which identified 836,699 veterans in 2007 with at
least one of five mental health diagnoses (schizophrenia, bipolar
disorder, PTSD, major depression, and substance-use disorders). While
this group represents only 15 percent of the VHA patient population,
these veterans accounted for one-third of all VHA medical care costs
because of their high rate and intensity of use of medical services.
These high costs of mental health services may not be adequately
recognized in VA's national allocation system. Interestingly, the
majority of health care received by veterans with these diagnoses was
for non-mental health conditions, reflecting the high degree to which
veterans with mental health and substance-use conditions also face
difficulties maintaining their general health.
The RAND research team concluded that the quality of VA mental
health care is generally as good as, or better than, care delivered by
private health plans, but that VA does not always meet its own explicit
guidelines for local performance. One notable finding was that the
documented treatment of veterans using evidence-based practices was
well below the reported capacity of VA facilities to deliver this
treatment. For example, only 20 percent of veterans with PTSD and 31
percent of those with major depression were reported to have received
this type of treatment. The research team also found variances in
quality of care across regions and populations; however, when most
veterans were asked to express satisfaction with their care, 42 percent
rated their care at 9 or 10 on a 10-point scale, but only 32 percent
perceived improvement in their symptoms as an outcome of care.
VA indicates it is developing methods to improve access and address
barriers; but veterans who seek VA assistance while struggling with
mental health challenges too often face difficulty gaining timely
appointments, despite VA official policies governing 24/7 access for
emergency mental health care and scheduling of mental health specialty
visits within 14 days of initial contact. In April 2012, the VA
Secretary announced VA would add approximately 1,600 mental health
clinicians and 300 support staff to its existing mental health staff of
20,590, in an effort to help VA facilities sustain these access
goals.\4\
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\4\ Department of Veterans Affairs Press Release, ``VA to Increase
Mental Health Staff by 1,900,'' April 19, 2012, http://www.va.gov/opa/
pressrel/pressrelease.cfm?id=2302.
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mental health services for a new generation of war veterans
Mr. Chairman, eleven-plus years of war have taken a toll on the
mental health of American military forces. Combat stress, PTSD, and
other combat- or stress-related mental health conditions are prevalent
among veterans who have deployed to the wars in Iraq and Afghanistan
and some of these veterans have been severely disabled. DAV believes
that all enrolled veterans, and particularly servicemembers, National
Guardsmen, and reservists returning from contingency operations
overseas, should have maximal opportunities to recover and successfully
readjust to civilian life. They must be able to gain ``user-friendly''
and timely access to VA mental health services that have been validated
by research evidence to offer them the best opportunity for full
recovery.
Regrettably, as was learned from experiences in other wars,
especially the Vietnam conflict, psychological reactions to combat
exposure are common and could even be called expected. Experts note
that if not readily addressed, these problems can easily compound and
become chronic. Over the long term, the costs mount due to impact on
personal well-being, family relationships, educational and occupational
performance, and social and community engagement of those who have
served. Delays in addressing these problems can culminate in self-
destructive behaviors, including substance-use disorders and suicide
attempts, and can result in incarceration. Increased access to mental
health services for many of our returning war veterans is a pressing
need, particularly in early intervention services for substance-use
disorders and provision of evidence-based care for those diagnosed with
PTSD, depression, and other consequences of combat exposure.
Unique aspects of deployments to Iraq and Afghanistan, including
the frequency of deployments, decreased time between deployments,
intensity of exposure to combat, perception of danger, guerilla warfare
in urban environments, and suffering or witnessing violence, are
strongly associated with a risk of chronic PTSD. Applying lessons
learned from earlier wars, VA anticipated such risks and mounted
earnest efforts for early identification and treatment of post-
deployment behavioral health problems experienced by returning
veterans. VA instituted system-wide mental health screenings, expanded
mental health staffing, integrated mental health into primary health
care, added new counseling and clinical sites, and conducted wide-scale
training on evidence-based psychotherapies. VA also has intensified its
research programs in mental health. However, critical gaps remain
today, and the mental health toll of these wars is likely to grow over
time for those who have deployed more than once, do not seek or receive
needed services, or face increased stressors in their personal lives
following deployments.\5\
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\5\ Brett T. Litz, National Center for Post-Traumatic Stress
Disorder, Department of Veterans Affairs, The Unique Circumstances and
Mental Health Impact of the Wars in Afghanistan and Iraq, A National
Center for PTSD Fact Sheet (January 2007).
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Much debate has occurred about VA's ability to manage the new
wartime population and provide timely access to the variety of VA's
specialized mental health services. The primary question is whether VA
should outsource or partner with community mental health sources to
provide this care when local waiting times exceed VA's own policies.
The VA has the authority to develop contracts for veterans to receive
mental health services in the community if it cannot provide such care.
Clearly, nevertheless, VA employs the largest number of mental
health providers with expertise in successfully treating post-
deployment mental health conditions in veterans, such as PTSD. VA is
also able to coordinate a comprehensive set of primary and specialty
services for substance-use disorders, Traumatic Brain Injury (TBI) and
other co-occurring disorders that are designed to meet veterans'
complex needs.
VA should re-engineer its mental health service delivery system to
maximize utilization of its integrated health care and delivery of high
quality, accessible care to meet the dynamic needs of veterans. This
may mean adoption of new systems of care and technology such as
telemedicine and mobile applications for home care, as well as ensuring
that it has expert mental health and substance-use disorder providers
onboard. DAV prefers VA to be the provider of such services when
possible, but access to care is a critical factor and must be
maintained. We believe VA should make a determination for each patient
based on the unique treatment needs presented, VA's ability to treat
them, and then develop a treatment plan that meets those needs.
substance-use disorders
Misuse of alcohol and other substances including overuse of
prescription drugs is a recognized problem for many veterans enrolled
in VA care, including many OEF/OIF/OND veterans. VA reports that for FY
2011, 97 percent of VA patients were screened annually for at-risk
drinking. The annual prevalence of substance-use disorder among all VA
users was 8.5 percent (almost 500,000 veterans). VA offers these
patients a wide variety of treatment options from motivational
counseling in the primary care setting to more intensive inpatient and
outpatient services. Unfortunately, there are a number of barriers to
seeking or accessing treatment for substance-use disorder, including
patients perceiving there is no need for treatment; believing treatment
won't work; stigma of acknowledging substance use is a problem; and
other family related concerns.\6\ Experts note that an untreated
substance-use disorder can result in emotional decompensation, an
increase in health care and legal costs, additional stress on families,
loss of employment, homelessness, and even suicide. Therefore, ready
access to pharmacotherapy and psychosocial interventions are important
treatment options for veterans with substance-use disorder.
---------------------------------------------------------------------------
\6\ Daniel Kivlahan, Ph.D., Associate National Mental Health
Program Director Addictive Disorders, Office of Mental Health Services,
``VHA Evidenced Based Practices for Identification and Management of
Substance Use Conditions in VHA,'' PowerPoint presentation,
November 2011.
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The VA has acknowledged that it should focus on ways to enhance
access to its substance-use disorder programs with a particular
emphasis on the needs of OEF/OIF/OND populations as well as women,
justice-involved, and homeless veterans. VA notes that the best
resolution for substance-use disorder problems comes from early
intervention. There is also a need to reduce stigma associated with
seeking care for a substance-use disorder--and treatments for co-
occurring conditions should be coordinated and done simultaneously. VA
recommends that a community of substance-use disorder--PTSD specialists
should be created and that family involvement can be very helpful in
the treatment of both conditions. Additionally, VA indicates that the
attractiveness of substance-use disorder services should be enhanced
and that more computerized aids and the Internet should be used to
provide or supplement substance-use disorder services. Most important,
DAV believes that integration of services should be employed to address
complex problems presented in patients with combinations of substance-
use disorder and TBI, chronic pain, homelessness, nicotine dependence,
and community/family readjustment deficits. VA reported that about two-
thirds of patients with a substance-use disorder diagnosis are treated
in a VA primary care or mental health clinic rather than in substance-
use disorder specialty services.\7\ The OMHS reports that a SUD-PTSD
specialist has been funded for each VA medical center to promote
integrated care but that currently there is no ``Gold Standard''
treatment developed for co-occurring SUD-PTSD.\8\
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\7\ John P. Allen, Ph.D., MPA, National Mental Health Program
Director, Addictive Disorders, Department of Veterans Affairs,
``Substance Use Disorder (SUD) Services for Veterans Having PTSD''
(PowerPoint presentation to veterans service organizations, 2011).
\8\ Dr. D. Kivlahan, Substance Use Disorder (PowerPoint,
November 2011).
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suicide prevention program
VA reports that 18 veterans take their own lives each day, which
translates into 6,750 suicides per year, or almost 75,000 in the 11
years since the conflicts in Afghanistan and Iraq began. VA estimates
that on an annual basis, less than 25 percent of veteran suicides were
enrollees receiving health care from VA.\9\ In 2008, the last year when
official data were used to identify veterans' suicide by matching
suicides from the National Death Index with the roster of veterans in
VA administrative data, the rate of suicide was 38 per 100,000 for OEF/
OIF male and female veterans enrolled in VA health care. These data do
not include unsuccessful suicide attempts.\10\ As a comparison, the
current Army suicide rate seven months into 2012 is 29 deaths per
100,000 soldiers. The veteran and active duty suicide rates greatly
surpass the 2009 civilian rate--the latest available data--of 18.5 per
100,000.\11\
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\9\ Department of Veterans Affairs, Office of the Inspector
General, Combined Assessment Program Summary Report Re-Evaluation of
Suicide Prevention Safety Plan Practices in Veterans Health
Administration Facilities (March 22, 2011).
\10\ Erin Bagalman, Analyst in Health Policy, Congressional
Research Service, Suicide, PTSD, and Substance Use Among OEF/OIF
Veterans Using VA Health Care: Facts and Figures (Washington, DC:
July 18, 2011).
\11\ Greg Zoroya, USA Today, ``Army suicide rate in July hits
highest one-month tally,'' August 16, 2012, http://
usatoday30.usatoday.com/news/military/story/2012-08-09/army-suicides/
57096238/1.
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With news that suicide rates are ever increasing, in September 2012
a new national strategy for reducing the number of deaths by suicide by
better identifying and reaching out to those at risk was released by
the U.S. Surgeon General and the National Action Alliance for Suicide
Prevention. The 2012 National Strategy for Suicide Prevention report
includes community-based approaches to curbing the incidence of
suicide, details new ways to identify people at risk for suicide and
outlines national priorities for reducing the number of suicides over
the next decade. In conjunction with the report, the Secretary of
Health and Human Services announced $55.6 million in new grants for
suicide prevention programs.\12\ VA and DOD also announced a new public
awareness campaign, Stand by Them: Help a Veteran, as part of the
national strategy on suicide prevention in the veteran and military
populations. The campaign stresses the influence family members,
friends, and colleagues can have in stopping suicide and aims to get
those who know troubled servicemembers or veterans to call the Veterans
Crisis Line, 1-800-273-TALK (8255), to obtain information and alert VA
of the need for possible intervention.\13\ We at DAV applaud these
developments and urge their continuation and expansion.
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\12\ Steve Vogel, The Washington Post, ``National suicide
prevention strategy released Monday,'' September 10, 2012, http://
www.washingtonpost.com/blogs/Federal-eye/post/national-suicide-
prevention-strategy-being-released-monday/2012/09/07/66102792-f92f-
11e1-8b93-c4f4ab1c8d13_
blog.html.
\13\ Patricia Kime, Army Times, ``DOD, VA roll out new suicide
awareness effort,'' September 10, 2012 http://www.armytimes.com/news/
2012/09/military-national-suicide-prevention-strategy-091012w/.
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RAND analysis suggests needed changes include making servicemembers
aware of the advantages of using behavioral health care, ensuring that
providers are delivering high-quality care, and ensuring that
servicemembers can receive confidential help for their problems.
Despite these efforts and progress made, this issue still remains a
significant concern to DAV, and we urge Congress to provide clear
oversight to ensure adequate focus and attention remains on this
issue.\14\
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\14\ RAND Corporation, News Release, ``U.S. Military Should Improve
Behavioral Health Programs in Response to Rising Number of Suicides
Among Armed Forces'' (February 17, 2011).
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veterans justice program
VA also reports it is increasing its justice outreach efforts by
working in collaboration with a number of state-based veterans' courts
to assist in determining the appropriateness of diversion for treatment
rather than incarceration as a consequence of veterans' behaviors.
Likewise, VA reports it is participating in crisis intervention
training with local police departments to help train and provide
guidance to police officers on approaches to deal effectively with
individuals who exhibit mental health problems (including veterans) in
crisis situations. VA is working with veterans nearing release from
prison and jail to ensure that needed health care and social support
services are in place at the time of release. Finally, each VAMC has
been asked to designate a facility-based Veterans' Justice Outreach
Specialist, responsible for direct outreach, assessment, and case
management for justice-involved veterans in local courts and jails, and
in liaison with local justice system partners.
We salute VA mental health leaders for taking these proactive steps
that not only can prevent recurrence of involvement with the justice
system but are cost-saving to local and state governments and VA
itself, and benefit society at large. Although this program is only in
its beginning stages, it appears to have been beneficial for many
veterans who have had the opportunity to get needed treatment for PTSD,
TBI, depression and substance-use disorders rather than being punished
by incarceration after committing wrongdoing against themselves,
family, community, or society.
We also believe that DOD and VA should step up their primary and
secondary prevention efforts and programs to promote coping and
readjustment. These programs may reduce the likelihood that veterans
will engage in risky or violent behavior that results in contact with
the military or civilian justice systems.
women veterans: unique needs in va's post-deployment
mental health services
The number of women serving in our military forces is unprecedented
in U.S. history, and today women are playing extraordinary roles in the
conflicts in Afghanistan and Iraq. They serve as combat pilots and
crew, heavy equipment operators, convoy truck drivers, military police
officers, civil affairs specialists, and in many other military
occupational specialties that expose them to the risk of serious injury
and death. To date, more than 150 women have been killed in action in
the two current wars, and women servicemembers have suffered grievous
injuries, with almost 950 wounded in action, including those with
multiple amputations.\15\ The current rate of enrollment of women
veterans in VA health care constitutes the second most dramatic growth
of any subset of veterans. In fact, VA projects the number of women
veterans coming to VA for health care services is expected to double in
the next two to four years. According to VA, as of June 2012, 56.2
percent of female OEF/OIF/OND veterans have received VA health care. Of
this group, 89.4 percent have used VA health care services more than
once; 53.5 percent have used VA health care 11 or more times.\16\
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\15\ Department of Defense Personnel, Defense Casualty Analysis
System (Retrieved October 29, 2012). https://www.dmdc.osd.mil/dcas/
pages/casualties.xhtml.
\16\ Department of Veterans Affairs, Women Veterans Fact Sheet,
August 2012 http://www.womenshealth.va.gov/WOMENSHEALTH/docs/
WH_facts_FINAL.pdf.
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Researchers have found that many women veterans need help
reintegrating back into their prior lives after repatriating from war.
Some women have reported feeling isolated, difficulties in
communicating with family members and friends, and not getting enough
time to readjust. Post-deployed women often complain of difficulties
reestablishing bonds with their spouses and children and resuming their
role as primary parent, caretaker of children and disciplinarian. Women
reported feeling out of sync with their families and that they had
missed a lot during their absences. Additionally, it appears that women
are at higher risk for suicide. A National Institute of Mental Health
five-year research study with the goal of identifying Army soldiers
most at risk of suicide released findings in 2011 and noted that women
soldiers' suicide rate triples in wartime from five per 100,000 to 15
per 100,000.\17\
---------------------------------------------------------------------------
\17\ Gregg Zoroya, USA Today, ``Female Soldiers' Suicide Rate
Triples When at War'' (March 18, 2011).
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For these reasons, it is vitally important that VA continue its
outreach to women veterans and adopt and implement policy changes to
help women veterans fully readjust. Public Law 111-163 includes
provisions that require VA to conduct a pilot program of group
counseling in retreat settings for women veterans newly separated from
the Armed Forces. VA reports that a total of 67 women were served in
fiscal year 2011 in three retreats and that three additional events
were completed in 2012.\18\ The VA's Readjustment Counseling Service
(RCS) or ``Vet Center'' program, worked with the Women's Wilderness
Institute to develop the locations and agenda for the retreats. We
understand feedback from women veterans participating in the retreats
thus far has been very positive and we expect the remaining retreats
will be very successful. DAV recommends that an interim report be
issued to Congress on the retreats to include the number of women
served and overall satisfaction of women veterans with the retreats as
well as any recommendations from the VA's RCS director on extension or
expansion of the retreats.
---------------------------------------------------------------------------
\18\ Joan Mooney, ``Update on Legislation Related to Women
Veterans,'' PowerPoint presentation.
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Given the unique post-deployment challenges women veterans face,
all of VA's specialized services and programs--including those for
transitional services, substance-use disorders, domestic violence, and
post-deployment readjustment counseling--should be evaluated to ensure
women have equal access to services. Likewise, VA researchers should
continue to study the impact of war and gender differences on post-
deployment mental health care to determine the best models of care and
rehabilitation, to address the unique needs of women veterans.
expanding access through community mental health providers
Chairman Miller of the House Committee 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 veteran
might need such care, we urge the Committee to work with VA 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.
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 crucial, 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 mental health resource, we would insist the care be
coordinated with VA. Because of a high degree to which this particular
patient population also has difficulties with physical functioning and
general health, these patients will very likely need other health
services VA is able to provide. 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. Not obtaining this kind of health
information poses a barrier to implementing 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.
the way forward: gaps must be closed
DAV agrees that VA must do a great deal more to meet veterans where
they are, and must also improve access and timeliness of mental health
care within VA facilities, reducing and hopefully eliminating gaps
between national policies and variations in practice. To illustrate, in
2007, VA developed an important policy directive that identifies the
wide range of mental health services that VA facilities should make
available to all enrolled veterans who need them, no matter where they
receive care.\19\ But more than five years later VA has acknowledged in
testimony based on external reviews that the directive is still not
fully implemented.\20\ However, we understand that VA is still
conducting self-assessment surveys followed up with site visits from VA
Central Office officials to verify progress and to help resolve any
gaps in services, and in fiscal year 2012, all VAMCs were visited and
that overall progress was observed. DAV recommends the Office of Mental
Health Services brief Congress on these findings to continue fully
funding VA mental health programs.
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\19\ Department of Veterans Affairs, VHA Handbook 1160.01, Uniform
Mental Health Services in VA medical centers and Clinics.
\20\ Senate Committee on Veterans Affairs, Hearing, ``Seamless
Transition--Meeting the Needs of Service Members and Veterans,''
May 25, 2011. The link: http://veterans.senate.gov/
hearings.cfm?action=release.display&release_id=fa634e3e-df82-4e87-b305-
f5356fec9779
---------------------------------------------------------------------------
VA faces a particular challenge in providing rural veterans access
to mental health care. Almost half of VA's rural facilities are small
community-based outpatient clinics (CBOCs) that offer limited mental
health services.\21\ Access also remains a problem and geographic
barriers are often the most prominent obstacle. Research suggests that
veterans with mental health needs are generally less willing to travel
long distances for needed treatment than veterans with other types of
health problems. The timeliness of treatment and the intensity of the
services a veteran ultimately receives are affected by the geographic
accessibility of that care.\22\ VA policy directs that facilities
contract for mental health services when they cannot provide the care
directly, but some facilities have apparently made only very limited
use of that authority. VA also must do more to adapt to the
circumstances facing returning veterans who are often struggling to re-
establish community, family, and occupational connections and
associated challenges. These challenges may compound the difficulties
of pursuing and sustaining mental health care.\23\ VA has proven that
PTSD and other war-related mental health problems can be successfully
treated, but if returning rural veterans are to overcome combat-related
mental health issues and begin to thrive, critical gaps in the VA
mental health-care system must be closed.
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\21\ John R. Vaughn, Chad Colley, Patricia Pound, Victoria Ray
Carlson, Robert R. Davila, Graham Hill, et al., Invisible Wounds:
Serving Servicemembers and Veterans with PTSD and TBI. National Council
on Disability, 4March 2009. (www.ncd.gov/newsroom/publications/2009/
veterans.doc). Accessed 14 May 2009, 46.
\22\ Benjamin Druss and Robert Rosenheck, Use of Medical Services
by Veterans with Mental Disorders, Psychosomatics, 1997 Sep-Oct, Vol.
38 No. 5, pp. 451-8.
\23\ C. R. Erbes, K. T. Curry, and J. Leskela, Treatment
Presentation and Adherence of Iraq/Afghanistan Era Veterans in
Outpatient Care for Posttraumatic Stress Disorder, Psychological
Services 6(3): (2010) 175-183.
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summary
DAV applauds efforts made by VA and DOD to improve the safety,
consistency, and effectiveness of mental health care programs for
veterans. We also appreciate that Congress is continuing to provide
increased funding in pursuit of a comprehensive package of services to
meet the mental health needs of veterans, in particular veterans with
wartime service and post-deployment readjustment needs. Yet we have
concerns that these laudable goals may be frustrated unless proper
oversight is provided and VA enforces mechanisms to ensure its policies
at the top are reflected as results on the ground in VA facilities.
Given the significant indications of rising self-medication, problem
drinking and other substance-use disorder problems in the OEF/OIF/OND
population, DAV urges VA to aggressively initiate early intervention
programs to prevent chronic long-term substance-use disorder in this
population. We are convinced that efforts expended early in this
population can prevent and offset much larger costs to VA and American
society in the future.
DAV also urges closer cooperation and coordination between VA and
DOD and between VAMCs and Vet Centers within their areas of operations.
We recognize that the Readjustment Counseling Service is independent
from the VHA by statute and conducts its readjustment counseling
programs outside the traditional medical model. We respect that
division of activity, and it has proven itself to be highly effective
for over 30 years. However, in addition to having concerns about VA's
ability to coordinate with community providers in caring for veterans
at VA expense, we believe veterans will be best served if better ties
and at least some mutual goals govern the relationship of Vet Center
counseling and VA medical center mental health programs.
DAV urges continued oversight by the Committees on Veterans'
Affairs, Committees on Appropriations, as well as by the Secretary of
Veterans Affairs, to ensure that VA's mental health programs and the
reforms outlined in this discussion that we synopsized from The
Independent Budget, meet their promise--not only for those returning
home from war now, but for all veterans who need them.
Mr. Chairman, this concludes DAV's statement, and we appreciate the
opportunity to provide it to the Committee.
______
Prepared Statement of Wounded Warrior Project
Chairman Sanders, Ranking Member Burr and Members of the Committee:
We are grateful to you for conducting this hearing and for continuing
oversight on 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 this Committee has
provided, particularly regarding access to timely treatment. We also
welcome such initial steps as VA's hiring additional mental health
providers and its plans to contract with qualified providers across the
country to provide Patient-Centered Community Care (PCCC), including
mental health care. But these steps alone, even if fully realized, will
not close all the gaps we see in VA's mental health system.
engagement in treatment as a first step
For example, 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 (e.g. 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, ``* * * 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\
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\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).
\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.
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\4\ http://articles.washingtonpost.com/2013-02-01/national/
36669331_1_afghanistan-war-veterans-suicide-rate-suicide-risk.
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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\
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\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).
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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 3.
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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, Servicemembers, and Military
Families'' (Aug. 31, 2012)
\13\ WWP Survey, at 54.
\14\ Sec. 304, Public Law 111-163.
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Given research findings that high percentages of OEF/OIF veterans
are not engaging in or are dropping out of mental health programs,\15\
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.
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\15\ Hoge, supra note 3.
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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.\16\ 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.
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\16\ 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).
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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,\17\
wide gaps remain between well-intentioned policies and on-the-ground
practices.
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\17\ 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).
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need for outcome measurements
Against the backdrop of this Committee's oversight highlighting
long delays in scheduling veterans for mental health treatment, the VA
last April released plans to hire an additional 1900 mental health
staff.\18\ While appreciative of VA's course-reversal, WWP has urged
that other related critical problems also be remedied. It is not clear,
for example, 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,
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\18\ 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.'' \19\
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\19\ Id.
Providing effective care requires building a relationship of trust
between provider and patient--a bond that is not necessarily instantly
established.\20\ 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.\21\ 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.\22\
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\20\ 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, Psy.D.,
Licensed Clinical Psychologist).
\21\ 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).
\22\ 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.
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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.'' \23\ Prior hearings also
documented instances of such measures being ``gamed.'' \24\
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\23\ WWP Survey of VA Mental Health Staff (2011).
\24\ 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.''
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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.\25\\26\ 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.
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\25\ U.S. General Accountability Office, ``Reliability and Reported
Outpatient Medical Appointment Wait Times and Scheduling Oversight Need
Improvement,'' GAO-13-130 (Dec 2012).
\26\ VA Office of Inspector General, ``Review of Veterans' Access
to Mental Health Care'' (Apr 2012).
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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 has welcomed the Department's acknowledgment of a ``need [for]
improvement'' in its mental health system.\27\ 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,''
\28\ 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 last September;
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.
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\27\ 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).
\28\ Id.
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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.\29\ 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.\30\ 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.\31\ 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.
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\29\ 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/
SW2502BreakingThe StigmaOfBehavioralHealthcare.html.
\30\ National Defense Authorization Act for Fiscal Year 2013, supra
note 18, at Sec. Sec. 580-583 and 723-730.
\31\ Id. at Sec. 726.
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Finally, 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:
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;
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;
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;
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;
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;
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
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.