    [Senate Hearing 115-608]
    [From the U.S. Government Publishing Office]

         MILITARY CONSTRUCTION, VETERANS AFFAIRS, AND RELATED AGENCIES
                      APPROPRIATIONS FOR FISCAL YEAR 2018

                                  ----------

                            THURSDAY, APRIL 27, 2017

                                           U.S. Senate,
               Subcommittee of the Committee on Appropriations,
                                                        Washington, DC.
        The subcommittee met at 10:33 a.m. in room SD-124, Dirksen
    Senate Office Building, Hon. Jerry Moran (chairman) presiding.
        Present: Senators Moran, Murkowski, Hoeven, Collins,
    Boozman, Capito, Rubio, Schatz, Tester, Murray, Udall, Baldwin
    and Murphy.

                         VETERANS HEALTH ADMINISTRATION

    STATEMENT OF DR. CAROLYN M. CLANCY, M.D., DEPUTY UNDER
                SECRETARY FOR HEALTH FOR ORGANIZATIONAL
                EXCELLENCE
    ACCOMPANIED BY:
            DR. HAROLD S. KUDLER, M.D., CHIEF CONSULTANT FOR MENTAL HEALTH
                SERVICES
            STEPHANIE A. DAVIS, PH.D., SUICIDE PREVENTION COORDINATOR AND
                STAFF PSYCHOLOGIST, VA EASTERN KANSAS HEALTH CARE SYSTEM

                    opening statement of senator jerry moran

        Senator Moran. Good morning, everyone. Welcome to my
    colleagues. And I think there will be more coming. As usual, we
    have more than one hearing occurring at the same time. And
    we're delighted to have our panelists join us. And we look
    forward to your testimony and our opportunity to ask you
    questions.
        This is our second subcommittee hearing in 2017. We were
    most recently at the Arlington National Cemetery, in which we
    looked at issues related to that aspect of this subcommittee's
    jurisdiction. But we take our responsibility very seriously
    when it comes to appropriations in involving the VA. And
    unfortunately we have a very serious and challenging difficult
    topic of conversation today. And I do think it's appropriate
    that this subcommittee's first hearing here in this building
    dealing with the Department of Veterans Affairs is related to
    something that has to be a priority for each and every one of
    us. The latest data suggests that 20 veterans a day take their
    own lives, and there is no one who would disagree that that
    number should be zero.
        We have a large panel, but each of the folks who are going
    to testify today and who we will have a conversation with have
    a lot of expertise in how to deal with veterans in crisis.
        Today, we'll discuss the impact of the Department's efforts
    to combat veteran suicide as well as how community-based
    organizations and cutting edge research are leading and
    supporting initiatives to eliminate that suicide.
        I do want to note that while headlines have often brought
    attention to the deficiencies of the VA's management of certain
    programs, the news does not tell the stories of the lives
    saved. And this hearing is also about bringing awareness not
    only to the issues that still need work, but also to share the
    successes that are occurring every day by mental health
    professionals across the VA who are saving lives of veterans.
    Thank you for your commitment to those of you who work at the
    Department of Veterans Affairs to see that we have even greater
    success.
        The subcommittee has responded with increased funding for
    veteran suicide prevention programs, the Veteran Crisis Line,
    and mental health care. There have been increases in funding
    each year, yet since 2001, the rate of veterans using VA health
    care who were diagnosed with a mental health or substance abuse
    disorder rose substantially from 27 percent to more than 40
    percent, and we've seen veteran suicides, the rate, remain
    pretty constant.
        I want to hear today from the Department on the plan to
    address that disconnect. If it's not an increase in funding,
    then what is required? I do not see a connection between
    increased funding and better outcomes. And I hope the community
    witnesses will speak to that disconnect, provide their
    perspective on resources, and share where they see the greatest
    need or opportunity for better investment to prevent suicide
    among our veterans.
        What should we be doing differently? What are we not doing
    that should be done? Where appropriate, are there complementary
    and alternative treatments that should be embraced? How are job
    training and education incorporated in the treatment plan for
    veterans? What about family support: marriage and family
    counseling, caregiver support, providing mechanisms for
    connecting families caring for veterans in need?
        We know especially in rural parts of our country, access to
    mental health care can be extraordinarily difficult. We need to
    make certain that no veteran feels abandoned by the country
    they served when they make the brave decision to seek mental
    health care services. I hope to hear today that the Department
    has a plan for increasing access to this crucial type of care
    in places that need it the most.
        Congress needs to know better how to support the
    Department. The Department needs to seek community partners and
    embrace the helpful findings of outside experts, and veteran-
    supporting groups need to be vocal about the needs of those in
    crisis and their families. I hope this hearing helps bring us
    together to end veteran suicide.
        I would like to introduce the panel.
        Dr. Carolyn Clancy, M.D., is the Deputy Under Secretary for
    Health for Organizational Excellence at the Veterans Health
    Administration. She is accompanied by Dr. Harold Kudler, M.D.,
    Chief Consultant for Mental Health Services.
        Dr. Stephanie Davis is a Suicide Prevention Coordinator and
    Staff Psychologist from the VA Eastern Kansas Health Care
    System.
        Ms. Melissa Jarboe is the Chief Executive Officer and
    Founder of the Military Veteran Project located in Topeka,
    Kansas, but with a worldwide presence. Melissa is a Gold Star
    Wife who has dedicated her life to support veterans and
    soldiers, a promise that she made to her late husband, Staff
    Sergeant Jamie Jarboe.
        The Honorable Michael Missal is the Inspector General at
    the Department of Veterans Affairs. And we welcome you and your
    debut appearance to this subcommittee, one that I expect will
    be repeated more than once.
        And Dr. Rajeev Ramchand is the Senior Behavioral Scientist
    at RAND Corporation who is an expert on the prevalence,
    prevention, and treatment of mental health in service members.
        Thank you very much, Doctor, for joining us.
        [The statement follows:]
                   Prepared Statement of Senator Jerry Moran
        Welcome to our second subcommittee hearing of 2017. The
    Subcommittee will come to order. Good morning. Thank you all for being
    here today to consider the important and tragic topic of veteran
    suicide. The latest data available suggests 20 veterans a day take
    their own life, and we all agree that even one is too many.
        Today we have a large panel--but each member brings valuable
    expertise on how to help veterans in crisis. Today we will discuss the
    impact of the Department's efforts to combat veteran suicide as well as
    how community-based organizations and cutting-edge research are leading
    and supporting initiatives to eliminate veteran suicide. I do want to
    note that while headlines have brought attention to deficiencies in the
    VA's management of certain programs, the news does not tell the stories
    of lives that are saved. This hearing is about bringing awareness not
    only to the issues that may need work, but also to share the success
    that is occurring every day by mental health professionals across the
    VA who are saving the lives of veterans.
        This subcommittee has responded with increases in funding for
    veteran suicide prevention programs, the Veterans Crisis Line, and
    mental healthcare. There have been increases in funding each year. Yet,
    since 2001, the rate of veterans using VA healthcare who were diagnosed
    with a mental health or substance abuse disorder rose ``substantially''
    from 27 percent to more than 40 percent; and we have seen veteran
    suicide rates remain steady. I want to hear today from the Department
    on the plan to address this disconnect--if not an increase in funding
    then what? I do not see a connection between increased funding and
    better outcomes. I hope our community witnesses will speak to that
    disconnect, provide their perspective on resources, and share where
    they see the greatest need or opportunity for better investments to
    prevent suicide among our veterans.
        What should we be doing differently; what are we not doing that
    should be done? Where appropriate, are there complementary and
    alternative treatments that should be embraced? How are job training
    and education incorporated into a treatment plan for veterans? What
    about family support--marriage and family counseling, caregiver
    support, providing mechanisms for connecting families caring for
    veterans in need?
        We know, especially in our rural areas, access to mental healthcare
    can be extraordinarily difficult. We need to make certain no veteran
    feels abandoned by the country they served when they make the brave
    decision to seek mental healthcare services. I hope to hear today that
    the Department has a plan for increasing access to this crucial type of
    care in the places that need it the most.
        Congress needs to know better how to support the Department, the
    Department needs to seek community partners and embrace the helpful
    findings of outside experts, and veteran-supporting groups need to be
    vocal about the needs of in-crisis veterans and their families. I hope
    this hearing helps bring us together to end veteran suicide.
        I'd like to introduce our panel:
        Dr. Carolyn Clancy, M.D., is the Deputy Undersecretary for Health
    for Organizational Excellence at the Veterans Health Administration.
    She is accompanied by Dr. Harold Kudler, M.D., Chief Consultant for
    Mental Health Services.
        Dr. Stephanie Davis is a Suicide Prevention Coordinator and Staff
    Psychologist from the VA Eastern Kansas Healthcare System.
        Mrs. Melissa Jarboe is the Chief Executive Officer and Founder of
    the Military Veteran Project located in Topeka, Kansas--but with a
    worldwide presence. Melissa is a Gold Star Wife, who has dedicated her
    life to support soldiers and veterans--a promise she made to her late
    husband, Staff Sergeant Jamie Jarboe.
        The Honorable Michael Missal is the Inspector General at the
    Department of Veterans Affairs; and,
        Mr. Rajeev Ramchand is a Senior Behavioral Scientist at the RAND
    Corporation who is an expert on the prevalence, prevention, and
    treatment of mental health in service members.

        Senator Moran. We welcome all of you.
        I now recognize my colleague, the Senator from Hawaii, Dr.
    Schatz. Dr. Schatz--Senator Schatz.

                   OPENING STATEMENT OF SENATOR BRIAN SCHATZ

        Senator Schatz. That's my father. Thank you, Mr. Chairman,
    for holding this hearing to shine a light on a life-or-death
    matter for many Americans, veterans who are struggling with
    painful and sometimes overwhelming mental health problems
    related to the unique challenges of military service,
    particularly during wartime.
        I want to welcome our witnesses, and I look forward to your
    testimony.
        Mr. Chairman, I commend you for assembling an impressive
    lineup of witnesses, and I'm glad to see you've reached out to
    witnesses from your home state of Kansas who are on the front
    lines in dealing with veteran suicide prevention at the local
    level and can give us their unique perspective.
        I have a longer statement, which I will insert into the
    record, but I am particularly interested in what we're doing
    about stigma. I'm particularly interested in the transition
    from being an active service member to veteran status. I think
    that there is still work to do in articulating the transition,
    talking to individual veterans, both in the active duty and
    guard context, it's not at all clear that we're doing
    everything that we can to open that aperture for people in that
    moment to avail themselves of mental health services.
        And I'll just note that it was around 2005, I was the
    executive director of a nonprofit that provided mental health
    services, and my head psychologist came to testify before the
    Veterans Committee, Chairman Daniel Akaka, and we talked a lot
    about what peers could do for peers in that context. So I'm
    particularly interested in whether there is any innovative
    thinking around peer counseling and peer support to make sure
    that people understand that they are entitled to and should
    seek mental health assistance before things accelerate and get
    worse.
        So with that, Mr. Chairman, I look forward to the
    testimony.
        [The statement follows:]
                   Prepared Statement of Senator Brian Schatz
        Thank you, Mr. Chairman. I appreciate your holding this hearing to
    shine a light on an issue that is truly a life-or-death matter to
    thousands of America's veterans who are struggling with painful, and
    sometimes overwhelming, mental health problems related to the unique
    challenges of military service, particularly during wartime.
        I would like to welcome our witnesses today, and I look forward to
    their testimony. Mr. Chairman, I commend you for assembling an
    impressive lineup of witnesses, and I am glad to see that you have
    reached out to witnesses from your home State of Kansas, who are on the
    front lines in dealing with veteran suicide prevention at the local
    level and can give us their unique perspective.
        Make no mistake about it, veteran suicide prevention is an all-
    hands-on-deck imperative. According to the VA approximately 20 veterans
    commit suicide every day. Tragically, of those 20 veterans, only six
    are getting care in the VA healthcare system. In other words, more than
    two-thirds of veterans who commit suicide on a given day have either
    never tried, or tried and failed, to receive help from the VA.
        This, I believe, is the crux of the problem. Veterans not only face
    unique risks of developing mental health issues, but they also face
    unique barriers to accessing treatment within the VA.
        Perceived stigma associated with seeking mental health treatment is
    particularly acute among veterans transitioning from a military culture
    that emphasizes individual toughness and aggressiveness. As a result,
    veterans are more likely to be deterred by pride, shame or
    embarrassment from seeking help.
        Simple logistical problems ranging from long travel distances to a
    shortage of clinicians in some areas, particularly rural and remote
    areas, can make it challenging to access treatment. Lack of
    understanding or awareness of mental health problems and VA treatment
    options are additional barriers. Unfortunately, studies have shown that
    as a result of these barriers, many veterans turn instead to self-
    medication with drugs or alcohol, exacerbating their mental health
    problems and heightening their risk for suicide.
        This calculus must change. I was heartened to see that Secretary
    Shulkin has said that veteran suicide prevention is his number one
    clinical priority. This is a laudable goal, but we now need to see the
    details. I hope that his plan starts with a veteran-centered approach
    to provide outreach at every possible opportunity, starting at the
    point of transition from the military and extending to routine VA
    healthcare visits, aggressive awareness campaigns, street-level contact
    with homeless veterans--whatever it takes to reach veterans before they
    reach a point of crisis. Identifying and reaching out to at-risk
    veterans to alleviate any barriers to access to care must be the first
    line of defense against veteran suicide.
        Mr. Chairman, I again thank you for holding this important hearing,
    and I look forward to hearing from our witnesses.

        Senator Moran. Thank you. Dr. Schatz would be proud of
    Senator Schatz.
        We now turn our attention to Dr. Clancy for her 5-minute
    opening statement.
        Doctor, thank you.

                   SUMMARY STATEMENT OF DR. CAROLYN M. CLANCY

        Dr. Clancy. Good morning, Chairman Moran, Ranking Member
    Schatz, and distinguished members of the subcommittee. Thank
    you for the opportunity to discuss the important topic of
    suicide prevention among our nation's veterans. I am joined
    today by Dr. Harold Kudler, Chief Consultant for Mental Health
    Services for VHA, and Dr. Stephanie Davis, Suicide Prevention
    Coordinator for the VA Eastern Kansas Health Care System.
        Our conversation and focus today happens at a time when
    suicide rates are up for all Americans, particularly in rural
    areas. This affects veterans more acutely, as shown by the
    recent research finding that 20 veterans die by suicide each
    day.
        We are committed to ensuring the safety of our veterans
    especially when they're in crisis. Losing one veteran to
    suicide shatters their family, their loved ones, and
    caregivers. Veterans who are at risk or reach out for help must
    receive assistance when and where they need it in terms they
    value.
        Our commitment is to prevent suicide among the veterans we
    serve directly and to reach all veterans through partnership
    and collaboration. To that end, I serve as co-chair of the
    National Action Alliance for Suicide Prevention, a public-
    private partnership with organizations across the Nation.
        Suicide prevention begins with tracking and managing
    suicide's possible precursors, whether that's mental health
    conditions, chronic pain, economic problems, or family issues.
    We can help veterans navigate these, but only when we reach
    them. The fact that 14 of the 20 veterans who die by suicide on
    average each day do not currently receive care within VA
    indicates that we at VA need to do more to engage them or
    connect them with partners who can assist. For those veterans
    who are receiving VA care, we have developed the largest
    integrated suicide prevention program in the country.
        Senator, when you spoke about the lives saved that
    sometimes don't warrant press coverage, that's Dr. Davis's job,
    and she has many fine, fine colleagues across the country.
    Screening and assessment processes have been distributed
    throughout our system to assist in identifying those at risk.
    Patients who have been identified as high risk receive enhanced
    care, including follow-ups of missed appointments, safety
    planning, weekly follow-up visits, and care plans that directly
    address their suicidality.
        Reporting and tracking systems have been established in
    order to learn more about veterans who may be at risk, to
    prioritize our areas for intervention. We also have two centers
    devoted to research, education, and clinical practice in
    suicide prevention. The centers focus on developing and testing
    clinical and public health intervention strategies as well as
    identifying clinical conditions and neurobiological factors
    that lead to increased risk of suicide, the implementation of
    interventions aimed at decreasing negative outcomes, and
    training future leaders in the area of VA suicide prevention.
        At VA, we believe that suicide prevention is everyone's
    business. To eliminate veteran suicides, all providers must be
    engaged. VA's basic strategy for suicide prevention requires
    ready access to high-quality mental health services
    supplemented by programs designed to help individuals and
    families engage in care and to address suicide prevention in
    high-risk patients.
        To address all possible approaches to reduce veteran
    suicide, we've initiated a program called REACH VET (VET
    Initiative Helps Saves Veterans Lives), which proactively
    identifies veterans at the highest predicted risk of suicide.
    Using a new statistical model derived from health records data,
    veterans receive enhanced outreach and services to potentially
    prevent further distress or crises. We also provide crisis
    assistance through the Veterans Crisis Line, and in the past 6
    months, we have nearly doubled the capacity to ensure
    appropriate access to veterans.
        Since January of this year, we at VA have answered over 99
    percent of calls received on a daily basis by the two VA call
    centers, thereby expediting access to services and assistance.
        We need to find a way to provide care and assistance to all
    veterans, not just those receiving care within VA. Therefore,
    VA intends to expand access to emergent mental health care for
    former service members with other-than-honorable, or OTH,
    administrative discharges. This initiative specifically focuses
    on expanding access to assist former service members with OTH
    discharge who are in mental health distress and may be at risk
    for suicide or other adverse behaviors. It's estimated there
    are just over 500,000 former service members in this group.
    These service members may come to VA seeking mental health care
    in emergency circumstances, and a VA provider will evaluate and
    treat the patient for their mental health condition for a
    period of up to 90 days.
        Mr. Chairman, all of us at VA are devastated by the crisis
    of suicide among our veterans. Our work to effectively treat
    veterans who desire or need mental health care continues to be
    our top clinical priority. We emphasize that we remain
    committed to preventing veteran suicide, and we are aware that
    prevention requires our system-wide support and intervention in
    addressing those precursors or risk factors for suicide. We
    appreciate your support and look forward to responding to any
    questions you have.
        [The statement follows:]
                    Prepared Statement of Dr. Carolyn Clancy
        Good morning Chairman Moran, Ranking Member Schatz, and
    distinguished members of the Subcommittee. Thank you for the
    opportunity to discuss the important topic of suicide prevention among
    our Nation's Veterans. I am joined today by Dr. Harold Kudler, Chief
    Consultant for Mental Health Services for the Veterans Health
    Administration (VHA) and Dr. Stephanie Davis, Suicide Prevention
    Coordinator for the VA Eastern Kansas Health Care System.
        Recent research suggests that 20 Veterans die by suicide each day,
    putting Veterans at even greater risk than the general public. VA is
    committed to ensuring the safety of our Veterans, especially when they
    are in crisis. Losing one Veteran to suicide shatters their family,
    loved ones and caregivers. Veterans who are at risk or reach out for
    help must receive assistance when and where they need it in terms that
    they value. Our commitment is to do everything possible to prevent
    suicide among the Veterans we serve and to reach all Veterans through
    partnerships and collaboration.
                          suicide prevention overview
        VA has developed the largest integrated suicide prevention program
    in the country. We have over 1,100 dedicated and passionate employees,
    including Suicide Prevention Coordinators, Mental Health providers,
    Veterans Crisis Line staff, epidemiologists, and researchers, who spend
    each and every day solely working on suicide prevention efforts and
    care for our Veterans. Screening and assessment processes have been set
    up throughout the system to assist in the identification of patients at
    risk for suicide. VA also developed a chart ``flagging'' system to
    ensure continuity of care and provide awareness among providers.
    Patients who have been identified as being at high risk receive an
    enhanced level of care, including missed appointment follow-ups, safety
    planning, weekly follow-up visits, and care plans that directly address
    their suicidality.
        Reporting and tracking systems have been established in order to
    learn more about Veterans who may be at risk and help determine areas
    for intervention. We also have two centers devoted to research,
    education, and clinical practice in the area of suicide prevention.
    VA's Veterans Integrated Service Network (VISN) 2 Center of Excellence
    in Canandaigua, New York, develops and tests clinical and public health
    intervention strategies for suicide prevention. VA's VISN 19 Mental
    Illness Research Education and Clinical Center (MIRECC) in Denver,
    Colorado, focuses on: (1) clinical conditions and neurobiological
    underpinnings that can lead to increased suicide risk; (2) the
    implementation of interventions aimed at decreasing negative outcomes;
    and (3) training future leaders in the area of VA suicide prevention.
                              current initiatives
        Every Veteran suicide is a tragic outcome and regardless of the
    numbers or rates, one Veteran suicide is too many. We continue to
    spread the word throughout VA that ``Suicide Prevention is Everyone's
    Business.'' The ultimate goal is to proactively eliminate suicide among
    Veterans via: strategic community partnerships, identification of risk,
    training, treatment engagement, effective treatment, lethal means
    education, research, and data science. Although we understand why some
    Veterans may be at increased risk, we continue to investigate and take
    proactive steps. The ultimate goal is eliminating suicide among
    Veterans. VA's basic strategy for suicide prevention requires ready
    access to high quality mental health services supplemented by programs
    designed to help individuals and families engage in care, and to
    address suicide prevention in high-risk patients.
    REACH VET
        Suicide prevention is VA's highest clinical priority. As part of
    VA's commitment to put resources, services, and all technology
    available to reduce Veteran suicide, Recovery Engagement and
    Coordination for Health Veterans Enhanced Treatment (REACH VET) was
    initiated. This new program was launched by VA in November 2016 and was
    fully implemented in February 2017. REACH VET uses a new predictive
    model in order to analyze existing data from Veterans' health records
    to identify those who are at a statistically-elevated risk for suicide,
    hospitalization, illnesses, and other adverse outcomes. Not all
    Veterans who are identified have experienced suicidal ideation or
    behavior. However, REACH VET allows VA to provide support and pre-
    emptive enhanced care in order to lessen the likelihood that challenges
    Veterans face will become a crisis.
        The VA REACH VET team and Army Study to Assess Risk and Reslience
    in Servicemembers (Army STARRS) teams have worked closely together, as
    both groups have developed predictive analytics capabilities. Because
    modeling risk is highly dependent on the available data, the approaches
    of both groups differ.
        DoD and VA have integrated a public health approach to suicide
    prevention, intervention, and postvention using a range of medical and
    non-medical resources through:

      --Data and Surveillance
      --Messaging and Outreach
      --Evidence-based Practices
      --Workforce Development
      --Federal and Non-government Organization Engagements

        Once a Veteran is identified, his or her mental health or primary
    care provider will review their treatment plan and current condition(s)
    to determine if any enhanced care options are indicated. The provider
    will then reach out to Veterans to check on their well-being and inform
    them that they have been identified as a patient who may benefit from
    enhanced care. This allows the Veteran to participate in a
    collaborative discussion about their healthcare, including specific
    clinical interventions to help reduce suicidal risk.
    Veterans Crisis Line
        Since 2007, VCL has answered over 2.8 million calls and dispatched
    emergency services to callers in crisis over 75,000 times. The VCL
    implemented a series of initiatives to provide the best customer
    service for every caller, making notable advances to improve access and
    the quality of crisis care available to our Veterans, such as:

      --Launching ``Veterans Chat'' in 2009, an online, one-to-one chat
            service for Veterans who prefer reaching out for assistance
            using the Internet. Since its inception, we have answered more
            than 336,000 requests for chat.
      --Expanding modalities to our Veteran population by adding text
            services in November 2011, resulting in nearly 69,000 requests
            for text services.
      --Opening a second VCL site in Atlanta in October 2016, with over 200
            crisis responders and support staff.
      --Implementing a comprehensive workforce management system and
            optimizing staffing patterns to provide callers with immediate
            service and achieve zero percent routine rollover to contracted
            back-up centers.

        VCL is the strongest it has ever been since its inception in 2007.
    VCL staff has forwarded over 463,000 referrals to local Suicide
    Prevention Coordinators on behalf of Veterans to ensure continuity of
    care with their local VA providers. Initially housed in 2007 at the
    Canandaigua VA Medical Center in New York, it began with 14 responders
    and 2 healthcare technicians answering four phone lines. In the past 6
    months, VCL has nearly doubled the capacity to ensure appropriate
    access to Veterans. Today, the facilities in Canandaigua and Atlanta
    employ more than 500 professionals, and VA is hiring more to handle the
    growing volume of calls. Atlanta offers 200 call responders and 25
    social service assistants and support staff, while Canandaigua houses
    310 and 43, respectively. Despite all this, there still is more that we
    can do.
        Prior to opening the Atlanta VCL call center in October 2016, VCL
    saw in excess of 3,000 calls per week roll over to back-up call
    centers. From January 8-14, 2017, we rolled over only 58 phone calls.
    Since then, we continue to keep rollover calls well below 1 percent.
    This means that on average, we answer over 99 percent of calls received
    on a daily basis by the Canandaigua and Atlanta call centers.
        The No Veterans Crisis Line Call Should Go Unanswered Act (Public
    Law 114-247) directed VA to develop a quality assurance document to use
    in carrying out VCL. It also required VA to develop a plan to ensure
    that each telephone call, text message, and other communication to VCL,
    including at a backup call center, is answered in a timely manner by a
    trained crisis hotline responder. This is consistent with the guidance
    established by the American Association of Suicidology. In addition to
    adhering to the requirements of the law, VCL has enhanced the workforce
    with qualified responders to eliminate routine rollover of calls to the
    contracted backup center. We also implemented a quality management
    system, to monitor the effectiveness of the services provided by VCL.
    This also will enable us to identify opportunities for continued
    improvement. As required by law, VA will submit a report containing
    this document and the required plan to the House and Senate Veterans'
    Affairs Committees by May 27, 2017.
    Other Than Honorable Discharges
        We know that 14 of the 20 Veterans who commit suicide on average
    each day do not receive care within VA. We need to find a way to
    provide care or assistance to all of these individuals. Therefore, VA
    intends to expand access to emergent mental healthcare for former
    Servicemembers with other than honorable (OTH) administrative
    discharges. This initiative specifically focuses on expanding access to
    assist former Servicemembers with OTH administrative discharges who are
    in mental health distress and may be at risk for suicide or other
    adverse behaviors. It is estimated that there are a little more than
    500,000 former Servicemembers with OTH administrative discharges. As
    part of the initiative, former Servicemembers with OTH administrative
    discharges who present to VA seeking mental healthcare in emergency
    circumstances for a condition the former Servicemember asserts is
    related to military service would be eligible for evaluation and
    treatment for their mental health condition.
        VA has authority to furnish care for service-connected conditions
    for former Servicemembers with OTH administrative discharges if those
    individuals are not legally barred from benefits. Such individuals may
    access the system for emergency mental health services by calling the
    Veteran Crisis Line, or visiting a VA Emergency Room, Outpatient
    Clinic, or Vet Center. Services may include: assessment, medication
    management/pharmacotherapy, lab work, case management, psycho-
    education, and psychotherapy. We may also provide services via
    telehealth.
                        expanding mental health services
        While focusing on suicide prevention, we know that preventing
    suicide for the population we serve does not begin with an intervention
    as someone is about to take an action that could end his or her life.
    Just as we work to prevent fatal heart attacks, we must similarly focus
    on prevention, which includes addressing many factors that contribute
    to someone feeling suicidal. We are aware that access to mental
    healthcare is one significant part of preventing suicide. VA is
    determined to address systemic problems with access to care in general
    and to mental healthcare in particular. VA has recommitted to a culture
    that puts the Veteran first. To serve the growing number of Veterans
    seeking mental healthcare, VA has deployed significant resources and
    increased staff in mental health services. Between 2005 and 2016, the
    number of Veterans who received mental healthcare from VA grew by more
    than 80 percent. This rate of increase is more than three times that
    seen in the overall number of VA users. This reflects VA's concerted
    efforts to engage Veterans who are new to our system and stimulate
    better access to mental health services for Veterans within our system.
    In addition, this reflects VA's efforts to eliminate barriers to
    receiving mental healthcare, including reducing the stigma associated
    with receiving mental healthcare.
        Making it easier for Veterans to receive care from mental health
    providers also has allowed more Veterans to receive care. VA is
    leveraging telemental healthcare by establishing four regional
    telemental health hubs across the VA healthcare system. VA telemental
    health innovations provided more than 427,000 encounters to over
    133,500 Veterans in 2016. Telemental health reaches Veterans where and
    when they are best served. VA is a leader across the United States and
    internationally in these efforts. VA's MaketheConnection.net, Suicide
    Prevention campaigns, and the Posttraumatic Stress Disorder (PTSD)
    mobile app (which has been downloaded over 280,000 times) contribute to
    increasing mental health access and utilization. VA has also created a
    suite of award-winning tools that can be utilized as self-help
    resources or as an adjunct to active mental health services.
        Additionally, in 2007, VA began national implementation of
    integrated mental health services in primary care clinics. Primary
    Care-Mental Health Integration (PC-MHI) services include co-located
    collaborative functions and evidence-based care management, as well as
    a telephone-based modality of care. By co-locating mental health
    providers within primary care clinics, VA is able to introduce Veterans
    on the same day to their primary care team and a mental health provider
    in the clinic, thereby reducing wait times and no show rates for mental
    health services. Additionally, integration of mental health providers
    within primary care has been shown to improve the identification of
    mental health disorders and increase the rates of treatment. Several
    studies of the program have also shown that treatment within PC-MHI
    increases the likelihood of attending future mental health appointments
    and engaging in specialty mental health treatment. Finally, the
    integration of primary care and mental health has shown consistent
    improvement of quality of care and outcomes, including patient
    satisfaction. The PC-MHI program continues to expand, and through
    January 2017, VA has provided over 6.8 million PC-MHI clinic
    encounters, serving over 1.5 million individuals since October 1, 2007.
                                hiring practices
        At VA, we have the opportunity, and the responsibility, to
    anticipate the needs of returning Veterans. As they reintegrate into
    their communities, we must ensure that all Veterans have access to
    quality mental healthcare. To serve the growing number of Veterans
    seeking mental healthcare, VA has deployed significant resources and
    increases in staff toward mental health services. The number of
    Veterans receiving specialized mental health treatment from VA has
    risen each year, from over 900,000 in fiscal year 2006 to more than
    1.65 million in fiscal year 2016.
        We anticipate that VA's requirements for providing mental
    healthcare will continue to grow for a decade or more after current
    operational missions have come to an end. VA has taken aggressive
    action to recruit, hire, and retain mental health professionals in
    order to improve Veterans' access to mental healthcare. As part of our
    ongoing comprehensive review of mental health operations, VA has
    considered a number of factors to determine additional staffing levels
    distributed across the system, including the following: Veteran
    population in the service area; the mental health needs of Veterans in
    that population; and the range and complexity of mental health services
    provided in the service area.
        Since there are no industry standards defining accurate mental
    health staffing ratios, VA is setting the standard, as we have for
    other dimensions of mental healthcare. VHA has developed a prototype
    staffing model for general mental health and is expanding the model to
    include specialty mental health. VHA will build upon the successes of
    the primary care staffing model and apply these principles to mental
    health practices. VHA has developed and implemented an aggressive
    recruitment and marketing effort to fill specialty mental healthcare
    occupations. Key initiatives include targeted advertising and outreach,
    aggressive recruitment of qualified trainees/residents to leverage
    against mission critical mental health vacancies, and providing
    consultative services to VISN and VA stakeholders.
        VA is committed to working with public and private partners across
    the country to support full hiring to ensure that no matter where a
    Veteran lives, he or she can access quality, timely mental healthcare.
    For example, multiple professional organizations, including the
    American Psychiatric Association and American Psychological
    Association, have offered support in getting announcements to their
    members about fulfilling career opportunities with VA.
                                   conclusion
        Mr. Chairman, all of us at VA are saddened by the crisis of suicide
    among Veterans. We remain focused on providing the highest quality care
    our Veterans have earned and deserve and which our Nation trusts us to
    provide. Our work to effectively treat Veterans who desire or need
    mental healthcare continues to be a top priority. We emphasize that we
    remain committed to preventing Veteran suicide, aware that prevention
    requires our system-wide support and intervention in preventing
    precursors of suicide. We appreciate the support of Congress and look
    forward to responding to any questions you may have.

        Senator Moran. Doctor, thank you.
        Dr. Davis, I understand that you don't have an opening
    statement, but we would be delighted to hear anything you would
    like to say, even if it's very brief.
        Dr. Davis. I don't have an opening statement prepared. I'm
    just grateful for being here, and thank you. This is an honor,
    and I just feel humbled. And I'm happy to answer any questions
    that you all have.
        Senator Moran. We're honored to have you with us, and we
    look forward to having a dialogue.
        I now would recognize Melissa Jarboe. Welcome.
    STATEMENT OF MELISSA D. JARBOE, CHIEF EXECUTIVE
                DIRECTOR, MILITARY VETERAN PROJECT
        Ms. Jarboe. Thank you, Chairman Moran, Ranking Member
    Senator Schatz, and other members, for the opportunity to
    appear before the committee today to discuss veteran suicide.
        Six years ago, my husband, Staff Sergeant Jamie Jarboe, was
    shot by a sniper while on patrol in Afghanistan. The sniper's
    bullet instantly paralyzed my husband from the chest down. We
    spent 11 months inside seven different hospitals stateside in
    an effort to heal him physically, however, it was during this
    fight of survival that we noticed a change in my husband
    mentally.
        With the assistance of doctors from across the Nation
    willing to educate me and take a moment to talk to a military
    spouse, I was able to assist Jamie's care plan and make
    recommendations of how to help my husband. We began tapering
    down his medications. Valium, Oxy, Percocet, and Klonopin were
    just a few of the nearly 50 doses of medication my husband was
    administered daily. That is when I came across a man by the
    name of Dr. Daniel Amen, a man who has researched the brain
    using SPECT imaging. SPECT imaging is a single-photo emission
    computed tomography imaging to focus on the physiology of the
    brain. We're looking at the underlining function instead of the
    anatomy, which is what our MRI and CT does.
        Through Dr. Amen and Dr. Van Kamp and their training, I
    learned that post-traumatic stress is indicated by an increased
    relative blood flow in the upper extremity of the brain. I
    further learned that ongoing usage of sensory deprivation as an
    alternative to narcotic medication has been proven in some
    places successful.
        We introduced sensory deprivation to my husband in October
    of 2011. Sensory deprivation works on resetting the brain by
    allowing it to shut down in a soundproof barrier.
        Now, while post-traumatic stress should not be confused
    with traumatic brain injury, it is indicated that post-
    traumatic stress has a decreased relative blood flow in the
    lower extremity of the brain. When combined with post-traumatic
    stress or if you have a veteran being treated for post-
    traumatic stress or post-traumatic stress disorder, and has
    TBI, the situations can be devastating effects to the brain if
    not properly diagnosed.
        We continued our efforts to taper down my husband's
    narcotics, and under the direct care of his primary doctors and
    pain management team, we introduced hypobaric chamber for his
    traumatic brain injury. The chamber helped heal him. Jamie
    sustained a traumatic brain injury when he was shot due to lack
    of oxygen.
        By January of 2012, Jamie was able to carry on somewhat of
    a normal schedule, with our ending goal to be home in Kansas to
    live out the American dream. On March 10, 2012, that dream was
    shattered when we were told that Jamie was not able to come
    home and that he was rendered terminal. My husband's tracheal
    and esophageal area detached from his upper extremity. The
    doctors told us it would only be a matter of time before my
    husband suffocated to death.
        We used the remaining moments of his life to help me plan
    the rest of my life. Jamie requested I carry on three dying
    wishes. The second wish that my husband made is the reason why
    I am addressing you today. In my husband's dying moments, he
    asked me to care for his fellow service members. To carry on
    this wish, I created the Military Veteran Project, a worldwide
    nonprofit now with the mission of military suicide prevention
    through research and alternative treatments.
        In the last 5 years, I have met with veterans in crisis
    contemplating suicide, widows, family members, and
    organizations helping assist. The bottom line is our men and
    women are returning home from war to fight a new battle on
    American soil. And each day, the casualties are increasing. It
    is estimated that anywhere from 14 to 22 veterans and active
    duty service members are taking their own lives. That would
    mean since September 11, 2001, we have lost, using 14 veterans
    a day, 76,930 veterans on American soil.
        Why has the number of suicides increased over the last few
    years? Well, the requirements to join the military were lowered
    to combat the attrition, and as a result, the increased number
    of service members with preexisting conditions were now deemed
    fit and suitable for service. For example, Robert Schultz, who
    suffered a prior mental diagnosis and psychological symptoms
    was now passed and allowed to join the United States military
    after 9/11 to rev up for the numbers.
        The need for the Department of Defense to bolster those
    numbers 16 years ago has put a tremendous strain on our
    Veterans Administration. By allowing these men and women who
    may be in physically or mentally fragile states to continue to
    serve, we have compromised not only the national security and
    the mission they have on foreign soil, but our families they
    come home to.
        We know without a question that our men and women who are
    in combat environment are exposed to traumatic events, and in
    direct impact of shock, trauma, and sleep deprivation during
    the average combat tour. The following recommendations would
    help start and assist with veteran suicide prevention.
        First in all, I do believe that our service members leaving
    the armed forces must be required and mandatory to register
    with our VA before they're relieved of duty.
        Secondly, we need to give our combat veterans veteran
    preference at our local Veterans Administrations to seek the
    care they so definitely need.
        Third is to open and create possibilities of community
    partnerships with organizations to assist with the credibility
    of our local Veterans Administrations to bridge the gap between
    the veterans that are not registering and the veterans that
    have, and allow the nonprofits like ours, as Military Veteran
    Project, and others to help fill the attrition the VA is
    missing with veterans not registering.
        In closing, I ask you to join in my mission to fulfill my
    husband's dying wish to care for his fellow service members
    because it's not something I can do alone.
        Thank you.
        [The statement follows:]
                      Prepared Statement of Melissa Jarboe
        Thank you Chairman and Ranking Member(s) for the opportunity to
    appear before this committee to discuss the topic of Veteran Suicide.
        Six years ago, on April 10, 2011, as I was driving to work, I
    received a phone call informing me that my husband, Staff Sergeant
    Jamie Jarboe, was shot by a sniper while on patrol in the Zhari
    District of Afghanistan. The sniper's bullet entered the left side of
    my husband's neck, and exited through the lower part of his right
    shoulder blade instantly paralyzing him from the chest down. Forty-
    eight hours later, I was standing at his bedside at Walter Reed
    Hospital. Jamie was able to open his eyes just long enough for me to
    tell him, ``I love you. Continue to fight because your family needs
    you''. My husband did just that. Over an 11-month period, Jamie endured
    over 100 surgical procedures in an effort to heal him physically;
    however, it was during this fight for survival that I noticed dramatic
    changes in my husband mentally. The hospital staff would come in,
    administer medications, day after day, hour after hour. At one point,
    he was on 59 different doses of medication in a single day. There would
    be entire days when Jamie would not even be able to open his eyes, and
    when I asked why my husband was so over-medicated, lethargic, the
    hospital staff would respond ``How would you like us to care for your
    husband?'' That is when I began to do my own research on symptoms,
    medications, and brain patterns. With the assistance of doctors from
    the Mayo Clinic, John Hopkins and Kennedy Krieger, I was able to
    educate myself, and those around me, on how to adequately care for
    Jamie. We began by tapering down his medications, starting with Elixir,
    Valium, Roxycotin, Oxycontin, Percocet, and Klonopin, just to name a
    few. We then introduced sensory deprivation treatments. This treatment
    is where one basically works on resetting the brain by allowing it to
    shut down in a soundproof barrier for 60 to 90 minutes at a time. The
    characteristics of post-traumatic stress my husband displayed was
    manifested each morning at 7:34 a.m., when he would gear up, put on his
    helmet, his vest, pick up his machine gun and then mime as if he was
    marching, ending when his head would suddenly jolt back violently. It
    took me weeks to figure out that my husband was reliving the fateful
    day when he was shot, over, and over, and over, in his mind. I was
    determined to find a way to help Jamie mentally, while Walter Reed
    continued to help him physically. That is when I came across a man by
    the name of Dr. Daniel Amen, who has researched the brain using SPECT
    imaging. From Dr. Amen, I learned that post-traumatic stress is
    indicated by an increased relative blood flow of the upper extremity of
    the brain. I further learned that ongoing usage of sensory deprivation
    as an alternative to narcotic medication has been proven successful.
    Dr. Amen also explained that a traumatic brain injury is indicated by
    the decreased relative blood flow in the lower extremity of the brain,
    and when combined with PTS, can have devastating affects on the brain,
    if not treated in a timely manner. We continued our efforts to taper
    down Jamie's narcotic dosages under the direct care of his primary
    doctors and pain management team, and introduced hyperbaric chamber
    treatments to Jamie's regimen. This assisted with the cerebral hypoxia
    his brain had sustained due to a lack of oxygen at the time of his
    injury. By January of 2012, Jamie was able to carry on a somewhat
    normal daily schedule: where he woke up at 7:30am, did daily activities
    for agility, and was able to finally sleep at night due to the
    fatiguing of his body both physically & mentally. Each day for the 11
    months Jamie was in the hospital, we both did everything we could to
    get back home to our children and family waiting for us in Kansas. All
    we wanted to do was live our own American dream, have a home with a
    white picket fence, raise our children, and love one another forever.
    On March 10, 2012 that dream was shattered when we were told that Jamie
    would not be coming home. Jamie's tracheal and esophageal area detached
    and it was only a matter of time before my husband would suffocate. I
    remember looking at my husband, in complete shock,after we got the
    news. With his crooked smile, he looked back at me and said, ``It
    figures that would happen. Honey, I want to get a pen and paper, so we
    can use the remaining moments of my life to help you plan the rest of
    yours.'' That day, my husband asked three wishes of me. One, never to
    re-enter the corporate world. Two, to care for his fellow service
    members, and three to never become bitter or tainted by this tragedy,
    so that I might find love again. The second wish of my husband, Staff
    Sergeant Jamie Jarboe, is why I address you today. To help me carry out
    Jamie's second wish, I created the Military Veteran Project, a 501c3
    military non-profit, with a mission of military suicide prevention
    through research and alternative treatments.
        In the last 5 years, I have personally met with veterans in crisis,
    veterans contemplating suicide, widows and family members who have lost
    their veteran loved one to suicide, and organizations assisting those
    affected by these all too frequent tragedies. The bottom line is our
    men and women are returning home from war to fight a new battle on
    their home soil, and each day the casualties are increasing. It is
    estimated that anywhere from 14 to 22 veterans and active duty service
    members take their own lives every day. That would mean since September
    11, 2001, using the conservative estimate of 14 veteran suicides a day,
    we have lost 76,930 heroes. So where does that leave us? Well, a few
    statistical questions remain unanswered. It is unclear the number of
    veterans that were combat-experienced versus non-combat, and the number
    of veterans that were enrolled in the Veterans Administration or not
    enrolled in the V.A. What is clear is that we have an information gap
    between the Department of Defense and the V.A. Currently, the computer
    systems, or databases, between these two government agencies are not
    compatible. The V.A. is currently relying only on documents veterans
    hand carry in, to render benefits and/or determine care. If these
    documents do not reflect a pattern of medical issues, services will not
    be provided. The disconnect is further evidenced by the discrepancy in
    Department of Defense discharges and registrations with the V.A. If the
    DoD releases 1,000 service members this year for retirement or service
    contract completion, only 37 percent will register with the Veterans
    Administration within the allotted time frame.
        The VA is further hampered by changes to recruitment quotas
    initiated after September 11th. Post 9/11, there was a steady increase
    in enlistment quotas recruiters were required to fill in order to
    prepare for the war on terrorism. The requirements to join the military
    were lowered to combat the attrition, and as a result, an increased
    number of service members withpre-existing conditions were deemed ``fit
    for service,whereas before they would have been classified ``not fit
    for duty.'' For example John Doe, who suffered prior mental diagnosis,
    or psychological symptoms, was passed and allowed to join the Armed
    Services after 9/11, while prior John Doe would have been dismissed.
    The need for the Department of Defense to bolster numbers 16 years ago
    has put a tremendous strain on our Veterans' Administration today. By
    allowing these men and women, who may be in physically and/or mentally
    fragile states, to serve, we have caused them further harm.
        There is also the very real fact that non-combat veterans make up a
    large percentage of those being served by our V.A. This can directly
    impact the wait times and availability of services for combat veterans
    who may be suffering.
        In reviewing the numerous cases we have received at the Military
    Veteran Project, and in consultation with medical and research teams
    across the nation, we find that the best approach to assisting with
    veteran suicide prevention is starting where the problem first
    manifests, in the brain. We know, without question, that our men and
    women, who are placed in the combat environment, are exposed to a
    myriad of traumatic events. Add in the direct impact of shock, trauma,
    sleep deprivation, and malnourishment during the average combat tour,
    and the resulting damage to the brain is nearly inevitable. If we can
    properly diagnose our veterans using brain scans or SPECT imaging to
    identify the harmful effects of combat service, and track them through
    the entirety of their military career, then we could apply the
    information gained to adequately diagnose and treat our heroes
    throughout and immediately following their service.
        The suffering of the men and women sent to protect us can no longer
    be considered status quo. We must take responsibility for providing the
    care that is necessary to protect them. To achieve this, we need to
    allocate a budget that allows the VA to properly diagnose our veterans.
    We need to adequately fund alternative treatment programs, which will
    empower our veterans to better understand their diagnosis, and result
    in more effective care plans for them. Have no delusions, this is only
    the first step in our mission to vanquish veteran suicide, and this is
    a battle our veterans should not have to fight alone. As a country, we
    can choose to stand up and unite as one and help our VA system succeed
    in the treatment of our veterans. We can show every veteran we have
    their six. The bottom line is this, if we continue to fight against our
    Veterans Administration we, as a country, will abandon our veterans,
    and each of us will be responsible for not helping to save a life.
        In closing, I ask you to remember the men and women of our
    military, not only while they hold a rifle and travel to distant lands
    to fight, but to remember them when they come home. I ask that you
    honor them by not merely thanking them for their service, but by taking
    care of them in their time of need, by fighting for them as they have
    for us. I ask that you fulfill my husband's dying wish, ``take care of
    my fellow soldiers.''
        Thank you for the invitation to join you this evening and for your
    leadership on this critical matter. I'm confident in our ability to
    unite for this bipartisan issue, together we can prevent military
    suicide. Thank you.

        Senator Moran. Melissa, thank you for being here and thank
    you for your testimony. And we honor you and your husband's
    service to our nation.
        Michael Missal.
    STATEMENT OF THE HONORABLE MICHAEL L. MISSAL, INSPECTOR
                GENERAL, U.S. DEPARTMENT OF VETERANS
                AFFAIRS
        Mr. Missal. Thank you, Chairman Moran, Ranking Member
    Schatz, and members of the subcommittee. I appreciate the
    opportunity to discuss the Office of Inspector General's recent
    work on the operations of the Veterans Crisis Line.
        The tragedy of veteran suicide is one of VA's most critical
    issues. The rate of suicide among veterans is significantly
    higher than the rate of suicide among U.S. civilian adults.
    VA's most recent estimate calculates that 20 veterans commit
    suicide a day. Of those veterans, approximately 14 have not
    been seen by VA. The VCL (Veterans Crisis Line) is essential to
    reduce veteran suicide for those who call in crisis.
        In our February 2016 VCL report, we identified several
    problems with the VCL, including crisis calls going to
    voicemail, a lack of a published VHA directive to guide
    organizational structure, quality assurance gaps, and contract
    problems. Our February 2016 report resulted in seven
    recommendations, and VHA concurred with the findings and
    recommendations. VHA provided an action plan and timeframe to
    implement those recommendations by September 30, 2016.
        In June 2016, we received an allegation related to the
    experience of a veteran with the VCL and its backup call
    centers. As a result of the complaint and in light of the open
    recommendations from our February 2016 report, we expanded our
    scope to conduct an in-depth inspection of the VCL. We also
    received in August 2016 a request from the Office of Special
    Counsel to investigate allegations regarding training and
    oversight deficiencies with social service assistance who
    assist call responders.
        Our March 2017 VCL report made the following findings.
        We substantiated that VCL staff did not respond adequately
    to a veteran's urgent needs during multiple calls to the VCL
    and its backup call centers. We also identified deficiencies in
    the internal review of the matter by the VCL staff. In the
    interest of privacy, information specific to this veteran is
    not included in our report. However, relevant information has
    been provided in detail to VHA.
        With respect to the governance structure, operations, and
    quality assurance functions, we identified a number of
    deficiencies. Among other findings, we reported that there was
    a lack of effective utilization of clinical decision-makers at
    the highest level of VCL governance, a lack of permanent
    leadership during much of the last few years, a failure to
    collect the appropriate clinical data necessary to assess
    performance, deficient oversight of the backup centers, lack of
    background and training in quality management principles, and
    the limited experience of supervisors in the new Atlanta call
    center.
        With respect to the allegations referred by the Office of
    Special Counsel, we found that the VCL lacked a process for
    monitoring the quality of performance by social service
    assistance and deficiencies in SSA training.
        Our 23 recommendations from our 2016 and 2017 VCL reports
    fall into the categories of governance, operations, and quality
    assurance. Governance recommendations include the establishment
    of a VCL directive that guides structure, roles, and
    responsibilities, appropriate collaboration between clinical
    and administrative leadership, and lines of authority that
    delineate that clinical policy decisions be made by clinical
    leadership.
        Operations recommendations include information technology
    infrastructure improvements, a better tracking of updated
    policies and procedures and related staff training, and that
    contractors be held to the same standards as the VCL.
        Quality assurance recommendations include QA leadership be
    fully trained in QA principles, negative clinical outcomes
    evaluated in order to improve, quality data be used to enhance
    performance, call recordings be used for quality assurance, and
    that the performance for the Canandaigua and Atlanta call
    centers be analyzed separately.
        We recognize the difficulties and great challenges in
    operating a crisis hotline. Our 2016 and 2017 reports
    identified various challenges facing the VCL in their mission
    to provide suicide prevention and crisis intervention services
    to veterans, service members, and the family members. Until VHA
    implements fully all of the recommendations from our two
    reports, they will continue to have challenges meeting VCL's
    critical important mission.
        Mr. Chairman, this concludes my statement. I'll be happy to
    answer any questions that you or other members of the
    subcommittee may have.
        [The statement follows:]
                  Prepared Statement of Hon. Michael J. Missal
        Mr. Chairman, Ranking Member Schatz, and Members of the
    Subcommittee, thank you for the opportunity to discuss the Office of
    Inspector General's (OIG) recent work on the operations of the
    Department of Veterans Affairs' (VA) Veterans Crisis Line (VCL). My
    statement will discuss two OIG reports, one from March 2017, Healthcare
    Inspection--Evaluation of the Veterans Health Administration Veterans
    Crisis Line, and one from February 2016, Healthcare Inspection--
    Veterans Crisis Line Caller Response and Quality Assurance Concerns,
    Canandaigua, New York.
                                   background
        The tragedy of veteran suicide is one of the Veterans Health
    Administration's (VHA) most significant issues. The rate of suicide
    among veterans is significantly higher than the rate of suicide among
    U.S. civilian adults. VA's most recent estimate calculates that 20
    veterans commit suicide a day. Of those veterans, approximately 14 have
    not been seen in VHA.
        In 2007, VHA established a telephone suicide crisis hotline located
    at the Canandaigua, New York, VA campus. Initially called the National
    Veterans Suicide Prevention Hotline, its name changed to the VCL in
    2011.\1\ VHA established the VCL through an agreement with the U.S.
    Department of Health and Human Services' Substance Abuse and Mental
    Health Services Administration (SAMHSA). This agreement provided for
    VHA's use of the already existing National Suicide Prevention Line
    (NSPL) toll-free number for crisis calls.\2\ The VCL was managed by the
    VHA Office of Mental Health Operations at the time of the February 2016
    OIG report. Subsequently the VCL was realigned under VHA Member
    Services (Member Services), an organization within the Chief Business
    Office that runs customer call centers for VHA.\3\
    ---------------------------------------------------------------------------
        \1\ Veterans Crisis Line 1-800-273-8255 Press 1, https://
    www.veteranscrisisline.net/About/AboutVeteransCrisisLine.aspx. Accessed
    December 4, 2016.
        \2\ The toll-free number is (800) 273-8255.
        \3\ VHA Member Services Member Services is an operation and support
    office within the Chief Business Office and has two main ``front-end''
    elements of interaction with VA's healthcare enrollee population,
    providing oversight, review, and direct service in the following areas:
    Eligibility and Enrollment Determination and Contact Management.
    ---------------------------------------------------------------------------
        The VCL is part of an overall strategy to reach out to veterans in
    a time of crisis with the goal of reduction of veteran suicide.\4\ The
    VCL's primary mission is ``to provide 24/7, world class, suicide
    prevention and crisis intervention services to veterans, service
    members, and their family members.''\5\ Since its launch in 2007, VCL
    staff have answered nearly 2.8 million calls and initiated the dispatch
    of emergency services to callers in crisis over 74,000 times.\6\
    Currently, the VCL responds to over 500,000 calls per year, along with
    thousands of electronic chats and text messages. The VCL initiates
    rescue processes for callers judged at immediate risk of self-harm. The
    number of calls to the VCL has increased markedly since the VCL's first
    full year of operation in 2007, with a corresponding increase in VCL
    annual funding. The total number of calls answered by the VCL and
    backup centers was 9,379 in 2007 and grew to 510,173 in fiscal year
    2016. In fiscal year 2010, the VCL was funded at $9.4 million,
    increasing to $31.1 million in fiscal year 2016.
    ---------------------------------------------------------------------------
        \4\ https://www.va.gov/opa/publications/factsheets/
    Suicide_Prevention_FactSheet_New_VA_
    Stats_070616-1400.pdf.
        \5\ VCL Mission Statement.
        \6\  https://www.veteranscrisisline.net/About/
    AboutVeteransCrisisLine.aspx. Accessed on March 27, 2017.
    ---------------------------------------------------------------------------
        A component of the VCL's long-term continuing operations plan was
    to expand beyond the Canandaigua Call Center to a second site, to
    ensure geographic redundancy and meet increasing VCL demands. The VCL
    and VHA Member Services leadership determined that the Canandaigua Call
    Center location did not have the necessary space or applicant pool to
    allow for the needed future growth. An expansion site was chosen in
    Atlanta, Georgia, because Member Services had a preexisting call center
    infrastructure at its Atlanta-based Health Eligibility Center (HEC).\7\
    Planning began in July 2016 with a phased rollout of responding to
    calls starting in October 2016 and continuing over the next 2 months.
    ---------------------------------------------------------------------------
        \7\ The HEC provides information and customer service on key
    veteran issues such as benefits, eligibility, billing, and pharmacy.
    https://www.va.gov/CBO/memberservices.asp. Accessed December 1, 2016.
    ---------------------------------------------------------------------------
        In our February 2016 VCL report, we identified several problems
    including crisis calls going to voicemail, a lack of a published VHA
    directive to guide organizational structure, quality assurance gaps,
    and contract problems. The February 2016 report resulted in seven
    recommendations and VHA concurred with the findings and
    recommendations. VHA provided an action plan and timeframe to implement
    those recommendations by September 30, 2016.
       inspection of veterans health administration veterans crisis line
        In June 2016, we received an allegation related to the experience
    of a veteran with the VCL and its backup call centers. As a result of
    the complaint, and in light of the open recommendations from the OIG's
    February 2016 report, we expanded our scope to conduct an in-depth
    inspection of the VCL. During our inspection, in August of 2016, we
    received a request from the Office of Special Counsel (OSC) to
    investigate allegations regarding training and oversight deficiencies
    with staff that assist call responders (Social Service Assistants/
    SSAs). This inspection, in addition to our previous inspection, found
    organizational deficiencies and foundational problems in the VCL. We
    also identified key changes needed by VA in order to achieve VA goals
    of service for veterans in crisis.
        Our inspection included the following objectives:

      --To respond to a complaint alleging that the VCL did not respond
            adequately to a veteran's urgent needs.
      --To perform a detailed review of the VCL's governance structure,
            operations, and quality assurance functions in order to assess
            whether the VCL was effectively serving the needs of veterans.
      --To evaluate whether VHA completed planned actions in response to
            OIG recommendations for the VCL, published on February 11,
            2016, in our report titled Healthcare Inspection--Veterans
            Crisis Line Caller Response and Quality Assurance Concerns,
            Canandaigua, New York.
      --To address complaints received from the OSC alleging inadequate
            training of VCL SSAs resulting in deficiencies in coordinating
            immediate emergency rescue services needed to prevent harm.

                             veteran's urgent needs
        Regarding the first objective, we substantiated that VCL staff did
    not respond adequately to a veteran's urgent needs during multiple
    calls to the VCL and its backup call centers. We also identified
    deficiencies in the internal review of the matter by the VCL staff. In
    the interest of privacy, information specific to this veteran is not
    included in the report. However, relevant information has been provided
    in detail to VHA.
              governance, operations, quality assurance functions
        Governance is defined as the establishment of policies, and the
    continuous monitoring of their proper implementation, by members of the
    governing body of an organization.\8\ During the time of our review,\9\
    the leadership, governance, and committee structure was in an immature
    state of development. Examples include a governance structure without
    clear policies and unclear mandates to review clinical performance
    measures and make improvements. These structural problems led to
    operational and quality assurance gaps.
    ---------------------------------------------------------------------------
        \8\ Business Dictionary's definition of governance.
        \9\ Our review period was from June through December 2016.
    ---------------------------------------------------------------------------
        In our February 2016 report, we cited the absence of a VCL
    directive as a contributor to some of the quality assurance gaps
    identified in the review. VHA concurred with this recommendation and
    provided an initial target date for completion of June 1, 2016. As of
    the publication of our March 2017 report, this action was not complete.
    We found continuing deficiencies in governance and oversight of VCL
    operations.
        During the August 2016 site visit to Canandaigua, the VCL's acting
    director told us that the VCL was using the Baldridge \10\ framework
    for governance. For the VCL, the central leadership group in this model
    would be the Executive Leadership Council (ELC).\11\ The ELC integrates
    the business and clinical aspects of operating the VCL. We requested
    all ELC draft policies to ensure that the ELC had a process for
    achieving its intended goals. We were informed that no current policies
    related to the ELC existed and that creation of such policies was in
    progress. The VCL and the services it provides have grown considerably
    since 2007, but VCL leadership did not develop a plan until 2016 that
    defined the strategic approach for the VCL to provide consistent,
    timely, and high quality suicide prevention services. For its Baldridge
    framework goals, VCL leadership was unable to provide policies,
    dashboards, or quality monitors for this governance initiative.
    ---------------------------------------------------------------------------
        \10\ The Malcolm Baldrige National Quality Award is the highest
    level of national recognition for performance excellence that a U.S.
    organization can receive. The award focuses on performance in five key
    areas: product and process outcomes, customer outcomes, workforce
    outcomes, leadership and governance outcomes, financial and market
    outcomes. https://www.nist.gov/baldrige/baldrige-award. Accessed
    December 23, 2016.
        \11\ ELC membership includes VCL Director, Chairperson, VCL Deputy
    Director, Business Operations Lead, Veteran Experience Lead, Employee
    Experience Lead, Partnerships Lead, Clinical Quality Lead, AFGE
    Leadership Member, Union Leadership Member, Clinical Psychologist, and
    CAC.
    ---------------------------------------------------------------------------
        Shortly after the publication of the 2016 OIG report, the VCL was
    realigned under VHA Member Services, although VA leadership stated that
    the VCL would remain closely tethered to VHA's clinical operations.
    VHA's Office of Suicide Prevention\12\ leads suicide prevention efforts
    for VHA and coordinates and disseminates evidence-based findings
    related to suicide prevention. However, we found a disconnect between
    the VHA Office of Suicide Prevention and Member Services in
    communicating about suicide prevention and the VCL. While the
    expectation was that Member Services and subject matter experts on
    suicide prevention would work closely together, we found substantial
    disagreement about key decisions and oversight between the two groups.
    ---------------------------------------------------------------------------
        \12\ The Office of Suicide Prevention leads suicide prevention
    efforts for VHA and coordinates and disseminates evidence-based
    findings related to suicide prevention.
    ---------------------------------------------------------------------------
        The lack of effective utilization of clinical decision makers at
    the highest level of VCL governance resulted in the failure to include
    fully clinical perspectives impacting the operations of the VCL.
    Administrative staff made decisions that had clinical implications.
    Examples include disagreements about the scope of services associated
    with core versus non-core calls \13\ and the selection of training
    staff who did not have clinical backgrounds. Clinical leaders stated
    concerns about staff morale, decisions impacting VCL capacity of
    responders to assist callers in crisis promptly, and effective training
    of new responders.
    ---------------------------------------------------------------------------
        \13\ Core calls are calls defined as calls resulting in referral to
    the Suicide Prevention Coordinator and/or calls requiring the
    application of crisis management skills (example: a suicidal caller).
    Non-core calls are defined as those that do not require specific crisis
    intervention skills (example: a caller inquiring about benefits).
    ---------------------------------------------------------------------------
        Another example of deficient governance was a lack of permanent VCL
    leadership. During most of 2015, the VCL was without a permanent
    director. At the end of 2015, a permanent director was chosen. However,
    the new permanent director resigned his position in June 2016. As of
    December 2016, the VCL continued to operate without a permanent
    director.
                                   operations
        The VCL was undergoing changes throughout our review. For example,
    there were three versions of the VCL organizational chart between June
    2016 and September 2016. The evolving VCL staffing model was based on a
    service level of zero percent rollover, answering all calls within 5
    seconds, and forecasting call volume based on historical interval data.
    Calls to VCL and Contracted Backup Centers
        To reach the VCL (Canandaigua or Atlanta) through its toll-free
    number, a caller is instructed to press 1 (for veterans) on the
    telephone keypad. If the caller does not press 1, the caller is routed
    to a National Suicide Prevention Line center. The caller still speaks
    with a responder. However, this route will take the caller to a non-VCL
    and non-VA contracted backup call center. If the caller presses 1, as
    instructed for veterans, and the call cannot be answered within 30
    seconds by the VCL, it rolls over to a VA contracted backup center.
        During our review, VHA leadership was in the process of
    implementing an automatic transfer function, which directly connected
    veterans who call their local VA Medical Centers to the VCL by pressing
    7 during the initial automated phone greeting. Member Services
    leadership determined that the implementation of various communication
    enhancements that increased VCL access, including Press 7, voice
    recognition technology, vets.gov, and MyVA311,\14\ created increased
    demand for services.
    ---------------------------------------------------------------------------
        \14\ VA is introducing 1-844-MyVA311 (1-844-698-2311) as a go-to
    source for veterans and their families who do not know what number to
    call.
    ---------------------------------------------------------------------------
        When a call is answered by VCL staff, a trained crisis responder
    answers the call, and after engaging with the caller and building
    rapport, the responder asks about suicidal ideation.\15\ Depending upon
    the caller's answer, the responder may conduct a more detailed
    assessment of lethality, which addresses a range of both suicide risk
    factors as well as protective factors. Callers may choose to remain
    anonymous and the responder may only be able to identify the caller by
    phone number.
    ---------------------------------------------------------------------------
        \15\ Suicidal ideation is thinking about, considering, or planning
    suicide. Centers for Disease Control and Prevention, http://
    www.cdc.gov/violenceprevention/suicide/definitions.html. Accessed
    December 2, 2016.
    ---------------------------------------------------------------------------
        We identified a deficiency in the VCL's processes for managing
    incoming telephone calls. Callers may decide to remain anonymous, but
    in every case responders document the incoming telephone number.
    However, responders must manually enter the number into the electronic
    documentation system, increasing the risk of human error. While
    reviewing responders' call documentation, we found that the
    documentation was often lacking in sufficient detail to facilitate
    retrospective assessment of the interaction between the caller and
    responder.
        VCL call complaint data included callers' complaints about being on
    hold. We found that some contracted backup call centers used a queuing
    (waiting) process that callers may perceive as being on hold. During
    the queue time, or wait time, the caller waits for a responder to
    answer. The caller's only option is to abandon the call (hang up) and
    call back, or continue to wait for a responder to pick up. The backup
    centers had processes to record wait times and abandonment rates. We
    found that VCL leadership had not established expectations or targets
    for queued call times, or thresholds for taking action on queue times,
    resulting in a systems deficiency for addressing these types of
    complaints. At the time of our review, there were four contracted
    backup centers. Two of the backup centers queued calls and two did not
    queue calls.
        VHA contracted with an external vendor\16\ to manage backup center
    performance and report back to the VCL, with administrative and
    clinical oversight of the contract terms by VCL managers. We found that
    the VHA contracting staff and Member Services and VCL leaders
    responsible for verifying and enforcing terms of the contract did not
    provide the necessary oversight and did not validate that the
    contracted vendor provided the required services before authorizing
    payment.
    ---------------------------------------------------------------------------
        \16\ Link2Health Solutions, Inc.
    ---------------------------------------------------------------------------
    Atlanta Call Center
        On July 21, 2016, planning for the new Atlanta-based call center
    started. By November 21, 2016, Member Services anticipated that
    staffing at the Atlanta Call Center would be sufficient to allow for
    zero rollover calls to backup call centers.\17\ Member Services leaders
    planned to have the Atlanta facility fully staffed and telephonically
    operational by December 31, 2016. Text and chat services would begin in
    June 2017.\18\
    ---------------------------------------------------------------------------
        \17\ Backup centers will be used on a contingent basis.
        \18\ Responders are required to have 6 months of VCL telephone
    experience, prior to engaging in training for text and chat services.
    ---------------------------------------------------------------------------
        Member Services leaders made the decision to roll out the Atlanta
    Call Center without first establishing on-site leadership, a critical
    piece to ensuring proficient execution of call center function. The
    September 2016 VCL organizational chart called for Atlanta to have its
    own Deputy Director and Director for Team Operations. However as of
    September 20, 2016, even though the leadership positions had not even
    been advertised much less filled, the Atlanta office held its inaugural
    responder training class with plans to begin operations on October 10,
    2016. As of November 8, 2016, this iteration of the organizational
    chart had been rescinded. VCL leadership structure reverted to that
    outlined in the July 2016 organizational chart, which does not include
    either a Deputy Director, a Director of Team Operations for Atlanta, or
    other leadership positions specific to the Atlanta Call Center.
        Bringing the Atlanta Call Center online in a three-month period
    entailed the rapid hiring and training of new staff. The training
    content is the same for responders at both the Atlanta and Canandaigua
    sites, but with notable differences in trainer-to-learner ratios. For
    instance, in order to accommodate the sizable number of trainees, class
    sizes were larger at the Atlanta Call Center, ranging from 44 to 62
    trainees, versus 20 trainees per class at the Canandaigua Call Center.
    Once the responders completed classroom training and passed a
    proficiency test, they were assigned to work with a preceptor for one
    to three weeks. The preceptor-to-responder ratio at the Canandaigua
    Call Center is 1:1. The original plan for the Atlanta Call Center
    called for a 1:2 or 1:3 preceptor to responder ratio. However, due to
    limited preceptor availability and large class sizes, the ratios were
    as high as 1:16.
        The supervisors hired to work at the Atlanta Call Center did not
    have the same skill set as those at the Canandaigua Call Center.
    Canandaigua Call Center supervisors first served in a responder role,
    while most Atlanta Call Center supervisors had not. Because of this, we
    were told that Atlanta Call Center supervisors would be required to
    complete responder training prior to supervisor training. One VCL
    supervisor told us that inexperience might detrimentally affect
    practice at the Atlanta Call Center because new responders,
    particularly linked with new supervisors, may be too quick to call
    rescues whereas more experienced responders may be able to de-escalate
    the situation. Despite the experiential and training differences
    between sites and the potential for variances in practice, with the
    exception of silent monitoring, we found no documentation of plans to
    compare metrics between sites, including rescue rates.
        The rapid establishment of the Atlanta Call Center required that a
    substantial number of staff from the Canandaigua Call Center be
    detailed to the Atlanta Call Center to train staff as well as assist
    with workload. The diversion of Canandaigua Call Center staff to
    Atlanta in order to achieve VCL programmatic milestones also
    contributed to a delay in the development and implementation of
    policies, programs, and procedures for the VCL. Examples of delays
    cited by staff include the deferral of annual lethality assessment
    training for responders, the delayed rollout of chat and text
    monitoring at the Canandaigua Call Center, and delayed implementation
    and utilization of wellness programs.
        Prior to the end of our review in December 2016, the VCL
    implemented audio call recording capability for incoming and outgoing
    calls for quality assurance purposes, but had yet to provide
    procedures, protocols, or policies that provided guidance for listening
    to or using recorded call information. VCL Quality Management (QM)
    program leaders could enhance performance improvement evaluations by
    using call recording to monitor the quality of interactions between
    responders and callers and by collecting and analyzing performance data
    from the new Atlanta Call Center separately from the Canandaigua Call
    Center. The new call center in Atlanta could have QM concerns that are
    no different from its Canandaigua partner, but the ability to recognize
    site-specific issues, especially in a new program, is facilitated by
    separating quality data elements by site.
                               quality assurance
        Systematic collection of relevant and actionable data for analysis
    is crucial when making decisions that will prevent problems. To be
    effective, VCL's QM data collection and analysis should be accurate and
    inform VHA and VCL leadership and staff whether their actions
    effectively serve veterans and others who use VCL services. In our
    February 2016 report, we recommended that VHA establish a formal
    quality assurance process and develop a VHA directive or VHA handbook
    for the VCL. We reviewed the VCL QM program structure and processes,
    the VCL QM program manual, and the draft VCL directive and identified
    systems deficiencies in QM program processes. We further found that
    neither the VCL QM program manual nor the draft VCL directive provided
    a framework for a QM program structure.
    Quality Management Leadership
        VHA does have a directive that outlines leadership responsibilities
    for program integration and communication, and the designation of
    individuals with appropriate background and skills to provide
    leadership to promote quality and safety of care.\19\ In order to
    implement the foundational principles of QM, leaders within a program
    must be able to promote, provide, and recognize QM practices that will
    lead to better outcomes. After reviewing the number and types of QM
    roles in the VCL, as well as QM staff experience and background, we
    determined that the challenges likely stemmed from the QM staff's lack
    of training in QM principles. Member Services leadership tasked QM
    staff with multiple responsibilities and competing priorities that
    included VCL QM program and policy development, data collection and
    analysis, data presentation for evaluation and action planning, and
    identification of outcomes measures. However, the QM staff had not been
    provided with training in the skills needed to provide leadership to
    promote quality and safety of care, leading to deficiencies in the QM
    program.
    ---------------------------------------------------------------------------
        \19\ VHA Directive 1028, VHA Enterprise for Framework for Quality,
    Safety, and Value, August 2, 2013.
    ---------------------------------------------------------------------------
    Quality Management Data Analysis
        We found that while VCL staff collect data on clinical quality
    performance measures, the QM program lacked defined processes for
    analyzing and presenting data and for developing a committee structure
    for reporting the analysis, making recommendations and following up.
    Quality Management Committees and Planning
        VHA requires a standing committee to review data, information and
    risk intelligence, and to ensure that key quality, safety and value
    functions are discussed and integrated on a regular basis. This
    committee should be comprised of a multidisciplinary group, should meet
    quarterly, and should be chaired by the Director. We did not identify a
    VCL standing committee that met the intent of VHA requirements outlined
    in Directive 1026.
    Policies, Procedures, and Handbooks
        VHA Directive 6330 (1), Controlled National Policy/Directive
    Management System, established policy and responsibilities for
    managing, distributing, and communicating VHA directives. VCL policies
    have been created in response to external reviews and internal
    processes but a controlling directive has not yet been published. A
    draft directive was in development, dated April 4, 2016; however, it
    lacked defined roles and responsibilities for VCL leaders, such as the
    VCL Director. We found that VCL policies, procedures, or handbooks were
    not readily accessible for staff reference.
        VCL leaders developed a QM Program Manual which was updated in July
    2016 (no initial publication date was available). The program manual
    did not outline a framework for the QM program that is consistent with
    relevant existing VHA directives providing guidance for QM programs.
    Outcome Measures for Quality Improvement
        We found that while the VCL measured internal performance of its
    staff (silent monitors, End of Call Satisfaction question, and
    complaints), its QM data analysis did not include measures of clinical
    outcomes for callers. During interviews, we inquired about outcome
    measures to evaluate the success of a veteran's transition from the VCL
    to other dispositions. We identified deficiencies in the VCL QM program
    including data analysis and presentation of clinical quality
    performance measures, lack of development of a directive consistent
    with established VHA guidance, lack of a reporting structure for
    regular review of performance measures, and frequent changes in the
    organizational structure of the QM program. We found that deficiencies
    in the QM program were related to VHA leadership failing to provide a
    developmental plan, appointing staff into positions without formal QM
    training, and assigning staff multiple competing priorities.\20\
    ---------------------------------------------------------------------------
        \20\ VHA Directive 1026, VHA Enterprise for Framework for Quality,
    Safety, and Value, August 2, 2013.
    ---------------------------------------------------------------------------
    Measurement of Program Success with Adverse Outcomes Reviews
        We found that the VCL had no process in place for routinely
    obtaining or reviewing data on serious adverse outcomes, such as
    attempted or completed suicides by veterans who made contact with the
    VCL prior to the event. We learned that adverse outcomes were not
    aggregated for review by VCL leadership in order to measure performance
    improvement for achieving more successful outcomes. The Acting Director
    and Acting Quality Assurance Clinical Officer confirmed that
    debriefings or other reviews were not conducted after known suicide
    attempts or completions. By not reviewing serious adverse outcomes, VCL
    QM managers missed opportunities for quality improvement.
        We reported systems deficiencies in the VCL Quality Management
    program in our 2016 and 2017 reports. VHA provides a framework for QM
    program structure and leadership to ensure delivery of safe and
    effective care; however, we found multiple program deficiencies
    remained during our second review.
               inadequate training allegations received from osc
        We found that VCL managers developed a process for monitoring the
    quality of crisis intervention services provided by responders;
    however, VCL lacked a process for monitoring the quality of performance
    by SSAs. We identified deficiencies in SSA training and substantiated
    complaints referred to us by the OSC in regard to SSA training and
    performance. Specifically, we substantiated that SSAs were allowed to
    coordinate emergency rescue responses independently after the end of a
    2-week training period, without supervision and regardless of
    performance or final evaluation; that in mid-2016, a newly trained SSA
    contacted a caller in crisis by telephone to solicit the veteran's
    location, although we found that no harm resulted from the interaction;
    and we substantiated a lack of documentation by an SSA when closing out
    a veteran's case in mid-2016. We could not substantiate an allegation
    that documentation by an SSA resulted in conflicting information about
    a veteran being contacted within 24 hours. The complainant (who
    remained anonymous) was not interviewed by us, and we did not have
    identifiers for the veteran caller.
                             report recommendations
        The OIG recommendations from 2016 and 2017 fall into the categories
    of governance/leadership, operations, and quality assurance. It is
    noteworthy that many of these recommendations cut across all three
    categories.

      --Governance.--Governance recommendations include the establishment
            of a VCL directive that guides structure, roles, and
            responsibilities. Additional recommendations include that the
            governance structure ensures cooperation between clinical and
            administrative leadership. We also recommended that lines of
            authority delineate that clinical leadership make clinical
            policy decisions.
      --Operations.--Operations recommendations include that SSAs are
            certified by supervisors before engaging in independent
            assistance with rescues. Other recommendations involve
            information technology infrastructure including an automated
            process for transcription of telephone numbers, and audio call
            recording with related policies and procedures. We recommended
            improved control of policy and document management so that
            updated policies and procedures and related staff training can
            be tracked. We issued recommendations related to backup center
            and contractor performance, including an enforceable quality
            assurance surveillance plan for contracted backup centers, and
            establishing targets for rollovers and call queuing. We
            recommended that contractors are held to the same standards as
            the VCL, and contract performance is monitored to assure that
            the terms of the contract are met. We also recommended that
            contractor performance is verified prior to payment.
      --Quality Assurance.--Quality assurance recommendations include
            establishing a formal quality assurance process that
            incorporates policies and procedures consistent with the VHA
            framework. Other recommendations include QA leadership being
            fully trained in QA principles, evaluating negative clinical
            outcomes in order to improve, and ensuring that VCL silent
            monitoring frequency meets established VCL standards. We also
            recommended that VCL develop structured oversight processes for
            tracking and trending of clinical quality performance measures.
            We recommended that quality data be used to enhance
            performance, that call recording be used for quality assurance,
            and that Canandaigua and Atlanta are analyzed separately with
            performance measures. We recommended consistent quality
            assurance and monitoring policies are established for responder
            staff and SSAs.
        A complete listing of the individual recommendations from both
    reports is attached in Appendix A and Appendix B.
                                   conclusion
        Our 2016 and 2017 VCL inspections identified various challenges
    facing the VCL in their mission to provide ``suicide prevention and
    crisis intervention services to veterans, service members, and their
    family members.'' We found numerous deficiencies and made seven
    recommendations in the 2016 inspection and sixteen additional
    recommendations in the 2017 inspection. Until VHA implements fully
    these recommendations, they will continue to have challenges meeting
    the VCL's critically important mission.
        Mr. Chairman, this concludes my statement. I would be happy to
    answer any questions you or members of the Subcommittee may have.
                                   appendix a
    recommendations from healthcare inspection--veterans crisis line caller
    response and quality assurance concerns canandaigua, new york (february
                                   11, 2016)
        Recommendation 1. We recommended that the OMHO (now VHA Member
    Services) \21\ Executive Director ensure that issues regarding response
    hold times when callers are routed to backup crisis centers are
    addressed and that data is collected, analyzed, tracked, and trended on
    an ongoing basis to identify system issues.
    ---------------------------------------------------------------------------
        \21\ The VCL was realigned under VHA Member Services in the spring
    of 2016. At the time the February 2016 OIG report regarding the VCL was
    published, the Office of Mental Health Operations was responsible for
    the VCL.
    ---------------------------------------------------------------------------
        Recommendation 2. We recommended that the Member Services Executive
    Director ensure that orientation and ongoing training for all VCL staff
    is completed and documented.
        Recommendation 3. We recommended that the Member Services Executive
    Director ensure that silent monitoring frequency meets the VCL and
    American Association of Suicidology requirements and that compliance is
    monitored.
        Recommendation 4. We recommended that the Member Services Executive
    Director establish a formal quality assurance process, as required by
    VHA, to identify system issues by collecting, analyzing, tracking, and
    trending data from the VCL routing system and backup centers, and that
    subsequent actions are implemented and tracked to resolution.
        Recommendation 5. We recommended that the Member Services Executive
    Director consider the development of a VHA directive or handbook for
    the VCL.
        Recommendation 6. We recommended that the Member Services Executive
    Director ensure that contractual arrangements concerning the VCL
    include specific language regarding training compliance, supervision,
    comprehensiveness of information provided in contact and disposition
    emails, and quality assurance tasks.
        Recommendation 7. We recommended that the Member Services Executive
    Director consider the development of algorithms or progressive
    situation-specific stepwise processes to provide guidance in the rescue
    process.\22\
    ---------------------------------------------------------------------------
        \22\ VCL staff consider rescues, welfare checks, and dispatch of
    emergency services to be equivalent terms.
    ---------------------------------------------------------------------------
                                   appendix b
    recommendations from healthcare inspection--evaluation of the veterans
          health administration veterans crisis line (march 20, 2017)
        Recommendation 1. We recommended that the Under Secretary for
    Health implement an automated transcription function for callers' phone
    numbers in the Veterans Crisis Line call documentation recording
    system.
        Recommendation 2. We recommended that the Under Secretary for
    Health ensure that Veterans Crisis Line policies and procedures, staff
    education, Information Technology support, and monitoring are in place
    for audio call recording.
        Recommendation 3. We recommended that the Under Secretary for
    Health implement a Veterans Crisis Line governance structure that
    ensures cooperation and collaboration between VHA Member Services and
    the Office of Suicide Prevention.
        Recommendation 4. We recommended that the Under Secretary for
    Health develop clear guidelines that delineate clinical and
    administrative decisionmaking, assuring that clinical staff make
    decisions directly affecting clinical care of veterans in accordance
    with sound clinical practice.
        Recommendation 5. We recommended that the Under Secretary for
    Health ensure processes are in place for routine reviewing of backup
    call center data, establish wait- time targets for call queuing and
    rollover, and ensure plans are in place for corrective action when
    wait-time targets are exceeded.
        Recommendation 6. We recommended that the Under Secretary for
    Health ensure processes are in place to require contracted backup
    centers to have the same standards as the Veterans Crisis Line related
    to call queuing and wait-time targets.
        Recommendation 7. We recommended that the Under Secretary for
    Health ensure that VHA Member Services leadership, Veterans Crisis Line
    leadership, VHA Contracting Officers, and Contracting Officer
    Representatives implement the quality control plan and conduct ongoing
    oversight to ensure contractor accountability in accordance with their
    roles as specified in the contract with backup call centers.
        Recommendation 8. We recommended that the Under Secretary for
    Health ensure that training is provided to Veterans Crisis Line quality
    management staff in the skills needed to provide leadership to promote
    quality and safety of care.
        Recommendation 9. We recommended that the Under Secretary for
    Health ensure the development of structured oversight processes for
    tracking, trending, and reporting of clinical quality performance
    measures.
        Appendix B
        Recommendation 10. We recommended that the Under Secretary for
    Health ensure processes for Veterans Crisis Line quality management
    staff to collect and review adverse outcomes so that established
    cohorts of severe adverse outcomes are analyzed.
        Recommendation 11. We recommended that the Under Secretary for
    Health direct the Veterans Health Administration Assistant Deputy Under
    Secretary for Health for Quality, Safety, and Value to review existing
    Veterans Crisis Line policies and determine whether the policies
    incorporate the appropriate Veterans Health Administration policies for
    veteran safety and risk management, and if not, establish appropriate
    action plans.
        Recommendation 12. We recommended that the Under Secretary for
    Health ensure that Veterans Crisis Line quality management staff
    incorporate call audio recording into quality management data analysis.
        Recommendation 13. We recommended that the Under Secretary for
    Health ensure that processes are in place to analyze performance and
    quality data from the Atlanta Call Center separately from the
    Canandaigua Call Center data.
        Recommendation 14. We recommended that the Under Secretary for
    Health ensure that quality assurance monitoring policies and procedures
    are in place and consistent for both Social Service Assistants and
    responders.
        Recommendation 15. We recommended that the Under Secretary for
    Health ensure that supervisors certify Social Service Assistant
    training prior to engaging in independent assistance with rescues.
        Recommendation 16. We recommended that the Under Secretary for
    Health ensure a process is in place to establish, maintain, distribute,
    and educate staff on all Veterans Crisis Line policies and directives
    that includes verifying the use of current versions when policies and
    directives are modified.

        Senator Moran. Thank you so very much.
        Dr. Ramchand.
    STATEMENT OF RAJEEV RAMCHAND, PH.D., SENIOR BEHAVIORAL
                SCIENTIST, RAND CORPORATION
        Dr. Ramchand. Thank you, Chairman Moran, Ranking Member
    Schatz, and members of the subcommittee, for inviting me to
    testify today. My name is Rajeev Ramchand, and I'm a senior
    behavioral scientist at RAND. For nearly 10 years, I've been
    studying suicide and the best ways to prevent people from
    taking their own lives. I've interviewed hundreds of people
    preventing suicide at crisis lines and suicide prevention
    programs. I've also spoken with the spouses, parents, siblings,
    children, and battle buddies affected by the death of a loved
    one. Today, I will summarize where our research shows efforts
    to prevent veteran suicide are working and where more effort is
    needed.
        The VA is the largest integrated health care system in the
    United States, and it provides the care, offers the programs,
    and conducts the research that make it a national leader in
    suicide prevention. The VA sees over 6 million patients each
    year, most of whom are middle-aged white men. This is the group
    at highest risk of suicide nationally.
        Many VA patients have also been exposed to atrocities in
    war zones from Vietnam to Afghanistan. As a result, a sizeable
    number have both visible and invisible wounds. RAND research
    shows that the VA is serving these veterans with the high-
    quality care that they deserve. Our analyses reveal that the
    mental health care delivered at the VA generally exceeds the
    care offered in other health systems and that the services
    provided by the Veterans Crisis Line surpasses most crisis
    lines operating in the USA today.
        As a member of a panel that reviews and scores VA research
    proposals, I can attest firsthand to the high-quality research
    proposed and funded by the VA that will continue to promote it
    as a national leader in suicide prevention. This is why the
    biggest challenge the VA currently faces is preventing suicide
    among those not enrolled in VA care.
        In 2015, we learned that veterans with other-than-honorable
    discharges had double the risk of suicide relative to those who
    separated honorably. Last month, Secretary Shulkin announced
    plans to extend services to these veterans who are
    traditionally ineligible for VA care.
        We also need to focus on women veterans. The rate of
    suicide among the youngest cohort of women veterans was 35 per
    100,000, a rate seven times that of their civilian
    counterparts. In collaboration with the VA, RAND interviewed
    responders working at the Veterans Crisis Line to investigate
    why women callers may be unreceptive to VA care. The women
    these responders talked to on the phones referred to a ``male-
    oriented'' culture at the VA that begins as early as check-in
    when receptionists presume a woman is supporting her husband
    and is not a veteran herself.
        Women most satisfied with the care they tend to receive
    have received services specifically for women veterans or who
    have developed strong therapeutic relationships with their
    health care providers. Women and those with other-than-
    honorable discharges are only two groups at risk.
        We must continue to figure out what other groups of
    veterans are at high risk of suicide, understand why they are
    not accessing care, and address those barriers as well. But not
    all veterans will ultimately access VA care, which is why
    community-based suicide prevention is a necessary part of
    preventing suicide. This requires support and leadership
    outside of the VA.
        Gun sellers, shooting ranges, and advocacy groups are
    playing a role with new campaigns that raise awareness and
    promote safe firearm storage. Veterans involved with the
    justice system likely represent another group at high risk.
    They can be enrolled in veterans' treatment, drug, and mental
    health courts, in which the goal is to rehabilitate and not
    punish. But only some veterans can access these services. These
    programs need to be evaluated so that we can determine whether
    there is a social business case to justify their continued
    expansion.
        Suicide is not just a veterans' issue. It is a national
    public health threat. Suicide is increasing nationwide, for
    young and old, men and women, white, black, and Hispanic.
    Strengthening community-based programs would not only help
    prevent veteran suicide, but could also help turn back the
    rising tide of suicides nationally.
        The VA could play a role in stemming this tide as well.
    Evidence-based suicide prevention strategies within the VA
    should be promoted and adopted by communities, many of which
    are facing acute suicide threats and are in dire need of
    support. It's only when we come together in a spirit of support
    and collaboration that we will begin to make a real dent in the
    public health threat that suicide poses to America today.
        Thank you again for inviting me to testify. I'll be happy
    to answer your questions.
        [The statement follows:]
                    Prepared Statement of Rajeev Ramchand\1\
    ---------------------------------------------------------------------------
        \1\ The opinions and conclusions expressed in this testimony are
    the author's alone and should not be interpreted as representing those
    of the RAND Corporation or any of the sponsors of its research.
    ---------------------------------------------------------------------------
                            the rand corporation\2\
    ---------------------------------------------------------------------------
        \2\ The RAND Corporation is a research organization that develops
    solutions to public policy challenges to help make communities
    throughout the world safer and more secure, healthier and more
    prosperous. RAND is nonprofit, nonpartisan, and committed to the public
    interest.
    ---------------------------------------------------------------------------
        Thank you, Chairman Moran, Ranking Member Schatz, and members of
    the subcommittee, for inviting me to testify today. My name is Rajeev
    Ramchand, and I am a senior behavioral scientist at RAND. For nearly 10
    years, I have studied suicide and thebest ways to prevent people from
    taking their own lives. I have interviewed hundreds of people
    preventing suicide at crisis lines and prevention programs. I also have
    spoken with the spouses, parents, siblings, children, and battle
    buddies affected by the death of a loved one. Today, I will summarize
    areas where our research shows efforts to prevent veteran suicide are
    working, as well as areas where more effort is needed.
        The Department of Veterans Affairs (VA) is the largest integrated
    healthcare system in the United States, and it provides the care,
    offers the programs, and conducts the research that make it a national
    leader in suicide prevention. The VA sees over six million patients
    each year, most of whom are middle-aged white men.\3\ This is the group
    at highest risk of suicide nationally.Many VA patients have also been
    exposed to atrocities in war zones from Vietnam to Afghanistan. As a
    result, a sizeable number have both visible and invisible wounds.\4\
    RAND research shows that the VA is serving these veterans with the
    high-quality care that they deserve. Our analyses reveal that the
    mental healthcare delivered at the VA generally exceeds the care
    offered in other health systems,\5\ and that the services provided by
    the Veterans Crisis Line surpass most crisis lines operating in the
    United States today.\6\ As a member of a panel that reviews and scores
    VA research proposals, I can attest firsthand to the high-quality
    research proposed and funded by the VA that will continue to promote it
    as a national leader in suicide prevention.
    ---------------------------------------------------------------------------
        \3\ RAND Health, Current and Projected Characteristics and Unique
    Health Care Needs of the Patient Population Served by the Department of
    Veterans Affairs, Santa Monica, Calif.: RAND Corporation, RR-1165/1-VA,
    2015.
        \4\ Rajeev Ramchand, Terry L. Schell, Benjamin R. Karney, Karen
    Chan Osilla, Rachel M. Burns, and Leah Barnes Calderone, ``Disparate
    Prevalence Estimates of PTSD Among Service Members Who Served in Iraq
    and Afghanistan: Possible Explanations,'' Journal of Traumatic Stress,
    Vol. 23, No. 1, 2010, pp. 59-68.
        \5\ Rajeev Ramchan, Resources and Capabilities of the Department of
    Veterans Affairs to Provide Timely and Accessible Care to Veterans,
    Santa Monica, Calif: RAND Corporation, RR-1165/2-VA, 2015; Katherine E.
    Watkins, Harold Alan Pincus, Brad Smith, Susan M. Paddock, Thomas E.
    Mannie, Jr., Abigail Woodroffe, Jake Solomon, Melony E. Sorbero, Carrie
    M. Farmer, Kimberly A. Hepner, David M. Adamson, Lanna Forrest, and
    Catherine Call, Veterans Health Administration Mental Health Program
    Evaluation: Capstone Report, Santa Monica, Calif.: RAND Corporation,
    TR-956-VA, 2011.
        \6\ Rajeev Ramchand, ``Is America's Crisis `System' in Crisis?'' US
    News and World Report, July 17, 2016.
    ---------------------------------------------------------------------------
        This is why the biggest challenge the VA currently faces is
    preventing suicide among those not enrolled in VA care. In 2015, we
    learned that veterans with other-than-honorable discharges had double
    the risk of suicide relative to those who separated honorably. Last
    month, Secretary Shulkin announced plans to extend services to these
    veterans who were traditionally ineligible for VA care.\7\ We also need
    to focus on women veterans: The rate of suicide among the youngest
    cohort of women veterans was 35 per 100,000, a rate seven times that of
    their civilian counterparts.\8\ In collaboration with the VA, RAND
    interviewed responders working at the Veterans Crisis Line to
    investigate why women callers might be unreceptive to VA care. The
    women these responders talk to on the phones refer to a ``male-
    oriented'' culture at the VA that begins as early as check in, when
    receptionists presume a woman is supporting her husband and is not a
    veteran herself. Women most satisfied with their care tend to have
    received services specifically for female veterans or have developed
    strong therapeutic relationships with their healthcare providers.\9\
    Women and those with other-than-honorable discharges are only two
    groups at risk: We must continue to figure out what other groups of
    veterans are at high risk of suicide, understand why they are not
    accessing care, and address those barriers as well.
    ---------------------------------------------------------------------------
        \7\ Mark A. Reger, Derek J. Smolenski, and Nancy A. Skopp, ``Risk
    of Suicide Among US Military Service Members Following Operation
    Enduring Freedom or Operation Iraqi Freedom Deployment and Separation
    From the US Military,'' JAMA Psychiatry, Vol. 72, No. 6, pp. 561-569,
    2015; Office of Public and Intergovernmental Affairs, Department of
    Veterans Affairs, ``VA Secretary Announces Intention to Expand Mental
    Health Care to Former Service Members with Other-Than-Honorable
    Discharges and in Crisis,'' press release, March 8, 2017.
        \8\ Office of Suicide Prevention, Department of Veterans Affairs,
    Suicide Among Veterans and Other Americans: 2002-2014, Washington,
    D.C., 2016.
        \9\ R. Ramchand, L. Ayer, V. Kotzias, C. Engel, Z. Predmore, P.
    Ebner, J. E. Kemp, E. Karnas, and G. Haas, ``Suicide Risk Among Female
    Veterans in Distress: Perspectives of Responders on the Veterans Crisis
    Line,'' Women's Health Issues, Vol. 26, No. 6, 2016, pp. 667-673;
    Charles Engel, Virginia Kotzias, Rajeev Ramchand, Lynsay Ayer, Zachary
    Predmore, Patricia Ebner, Elizabeth Karras, Janet E. Kemp, and Gretchen
    Haas, ``Mental Health Service Preferences and Utilization Among Women
    Veterans in Crisis: Perspectives of Veterans Crisis Line Responders,''
    presented at the American Association of Suicidology 50th Annual
    Conference, April 27, 2016.
    ---------------------------------------------------------------------------
        But not all veterans will ultimately access VA care, which is why
    community-based suicide prevention is a necessary part of preventing
    veteran suicide. This requires support and leadership outside the VA.
    Gun sellers, shooting ranges, and advocacy groups are playing a role,
    with new campaigns that raise awareness and promote safe firearm
    storage.\10\ Veterans involved with the justice system likely represent
    another group at high risk. They can be enrolled in veterans'
    treatment, mental health, or drug courts, in which the goal is to
    rehabilitate, not to punish. But only some veterans can access these
    programs, and such programs need to be evaluated so that we can
    determine whether there is a social business case to justify their
    continued expansion.
    ---------------------------------------------------------------------------
        \10\ M. Vriniotis, C. Barber, E. Frank, R. Demicco, and the New
    Hampshire Firearm Safety Coalition, ``A Suicide Prevention Campaign for
    Firearm Dealers in New Hampshire,'' Suicide and Life Threatening
    Behavior, Vol. 45, No. 2, 2015, pp. 157-163.
    ---------------------------------------------------------------------------
        Suicide is not just a veterans' issue. It is a national public
    health threat. Suicide is increasing nationwide, among young and old,
    men and women, white, black, and Hispanic.\11\ Strengthening community-
    based programs would not only help prevent veteran suicide, but could
    help turn back the rising tide of suicides nationally. The VA could
    play a role in stemming this tide as well: Evidence-based suicide
    prevention strategies within the VA should be promoted and adopted by
    communities, many of which are facing acute suicide threats and are in
    dire need of support. It's only when we come together in a spirit of
    support and collaboration that we will begin to make a real dent in the
    public health threat that suicide poses to America today.
    ---------------------------------------------------------------------------
        \11\ Sally C. Curtin, Margaret Warner, and Holly Hedegaard,
    Increase in Suicide in the United States, 1999-2014, data brief No.
    241, Hyattsville, Md.: National Center for Health Statistics, 2016.
    ---------------------------------------------------------------------------
        Thank you again for inviting me to testify. I will be happy to
    answer your questions.

        Senator Moran. Thank you for accepting our invitation.
        Let me begin with Dr. Clancy.
        You indicated in your opening remarks that suicide rates
    are increasing, especially in rural areas. What do you
    attribute that to? Is there a relationship between the
    inability to access care because of the rural geography, the
    demographics and programs that are available? Or do you have a
    basis for which that conclusion was reached? Is that just a
    fact or do you have an explanation?
        Dr. Clancy. That is a fact, and we are still working on an
    explanation. So it could be isolation that may be more common
    in rural areas. At the same time, that's often accompanied by a
    certain resilience and self-sufficiency. It could be that
    people with mental health conditions that may predispose them
    to being more vulnerable to the risk of suicide, for example,
    post-traumatic stress disorder, and so forth, may actually be
    more likely to move to rural areas, but we need to learn more
    about that. But that doesn't mean that we can't reach out now
    and work as hard as we can with partners in rural areas. And we
    have one very important asset, as I think you know, Senator,
    which is the capacity to reach these veterans virtually by
    telehealth and other capabilities.
        Senator Moran. Let me ask Dr. Ramchand, do you have
    research or know of research that addresses the causal
    relationship between rural veterans and increasing rates of
    suicide?
        Dr. Ramchand. Not among veterans. This is a national trend
    that we see higher rates of suicide in rural communities. And
    as Dr. Clancy pointed out and as you suggest in your question,
    access to mental health care is certainly one of the
    explanations that has been hypothesized. They've ranged. Some
    people have looked at altitude. A lot of people have thought
    about the high prevalence of firearms in households within
    rural communities relative to urban areas as well as potential
    causal factors as to why there might be this disparity in rural
    versus urban access to care.
        Senator Moran. Is my statement that access to care, mental
    health services, suicide prevention efforts, is it a true
    statement that it is less available in rural America?
        Dr. Ramchand. Absolutely.
        Senator Moran. That's a given.
        Dr. Ramchand. Yes.
        Senator Moran. Okay. And then, Dr. Clancy, how has the
    Choice Act given you additional tools or other VA community
    care programs? How have you integrated into mental health
    services to suicide prevention the opportunities that Congress
    gave the VA to allow private care to be provided?
        Dr. Clancy. So we have utilized the resources that you gave
    us to hire more mental health professionals as well as the
    strong encouragement from the Clay Hunt Act. I believe over the
    past several years--in any given year, we have roughly an 8
    percent turnover among all health professionals, but on top of
    that turnover, we have hired a net of just over 400 new mental
    health professionals, psychiatrists specifically, and more in
    other disciplines, so that is good news. So that's within our
    own system.
        Where we can and where there are resources available in
    rural communities, then we can actually purchase that through
    Choice for veterans who can't actually get into our facilities.
    And not specific to Choice, we have greatly expanded our
    capacity in telemental health, which, by the way, there's an
    awful lot of health care you can do by telehealth, but the
    strongest evidence base actually is for mental health.
        Senator Moran. That's a good point that I would be happy to
    make. The Choice Act, when I was asking the question, I was
    thinking of community providers. There was also $5 billion made
    available for the VA to hire additional professionals.
        Dr. Clancy. Yes.
        Senator Moran. And can you tell us how that--what the
    consequences of that $5 billion has been in hiring mental
    health professionals?
        Dr. Clancy. Well, that's why I noted that we have a net
    increase of just over 400 psychiatrists over the time since the
    law was passed. So even with turnover that we expect at all
    times, we have seen a net increase. Do we need to hire more?
    Yes. And ultimately this is an area where we're in competition
    with community providers, particularly in some areas that
    aren't necessarily instantaneously attractive to people as a
    place to live.
        Senator Moran. That's well spoken. You mentioned
    psychiatrists. I'll come later in questions about other
    professionals within the mental health arena and how the VA is
    or isn't utilizing those services.
        Is there anything that you could describe to me that's
    different today in almost May of 2017 than in December of 2016
    with a new Secretary? Has anything changed in regard to your
    efforts in the last 5 months?
        Dr. Clancy. So the two big changes is, one, the plan to
    expand emergency availability for service members with other-
    than-honorable discharges for all the reasons that my colleague
    from RAND just described and why it's important.
        The second is this deployment of the statistical model,
    which we call REACH VET, which actually says to veterans, ``We
    have reason to believe that you may be at increased risk of
    suicide and we'd like to stay in touch with you more often
    because we care.'' I understand that most of the time that
    conversation goes reasonably well, but it is a brand-new
    feature of health care in general--Right? To say, ``Gosh, no, I
    don't have a blood test, Senator Moran, but based on some
    numbers crunching, I'm worried about you.'' I mean, that's
    essentially what the conversation is.
        So those are the two biggest areas. I will tell you, there
    are two other features going on recently. One is that our
    experts here in D.C., working with colleagues across the
    country, including suicide prevention coordinators, community
    groups, VSOs, and so forth, were literally locked in a room all
    last week really focusing very hard on, ``What more, what more,
    what more can we be doing?'' And they came up with a lot of
    good ideas, so we'll be sharing a lot of that with you as we
    put this all together, very strong focus on tighter integration
    with the Department of Defense, which is good news. And I think
    those are the biggest differences. And Dr. Shulkin has made it
    very, very clear this is his top clinical priority period.
        Senator Moran. Dr. Clancy, I'll be back to you about the
    disconnect between increasing resources and not necessarily
    increasing outcomes in a follow-up opportunity, but let me now
    turn to Senator Schatz.
        Senator Schatz. Thank you, Mr. Chairman. Following up on
    the conversation about the transition from DOD to VA, in my
    conversations with veterans in the state of Hawaii, they sort
    of describe a scenario--and I don't know that it's precisely
    true, but certainly the sense of it is that the last question
    asked before you get to see your girlfriend, your spouse, your
    mother, your children, is, ``Are you experiencing any mental
    health difficulties?'' And unless you are incapable of getting
    through the rest of the day without getting some clinical
    assistance, your answer is very likely to be, ``No, I'm fine,''
    so you can see your loved one.
        And I guess the first question is, Is that still true? And
    in a lot of ways, I think you would agree that even if it's not
    exactly true, if that's the experience that a veteran has, a
    service member has, in transitioning out, then we have a
    challenge there. And I would like you to speak to that if you
    could.
        Dr. Clancy. I certainly have heard that same experience
    described just the way that you did. Without actually directly
    observing or in some ways doing it systematically, I can't say
    with any precision how often it happens.
        I would say, to make a broad statement, that in our
    country, we have often discounted signs of distress, of feeling
    hopeless as something one needs to just get over and pull up
    your socks and feel better about it. If you take people who
    have been trained for combat and have developed very
    sophisticated skills, and then say, ``Oh, by the way, is your
    mind playing tricks on you?'' you know, there are a lot of
    signals to say, ``No, I'm great.'' In fact, we have developed a
    public service announcement to just that effect. Where people
    keep saying, ``I'm good,'' ``I'm good,'' ``I'm good.'' Well,
    not really.
        Senator Schatz. What worries me the most, though, is that I
    think you've all got the right clinical and human perspective
    here, but to the extent that some of this happens on the DOD
    side of the fence, I'm wondering where the integration comes
    and how much you can reach over to when they are active service
    members because that transition is sort of your golden moment
    to convey that it is not just okay, it is expected, it is part
    of your obligation, to make sure that you're okay as you
    transition back to civilian life, if that's what you're doing.
        And I'm not persuaded that--I think you say all the right
    things, and I think when we hear from the service branches,
    they say all the right things, and yet in that moment, I'm not
    at all persuaded that much has changed, because you have the
    stigma, you have the sort of warrior ethic where, ``I'm fine, I
    can handle this.''
        I understand all that, but I think we really need to work
    harder on systems, processes, slowing that piece down, and
    making sure there is DOD and VA integration in that moment
    because it seems to me that that's your sort of--to borrow a
    clinical term, that's your assessment and intake even though
    it's really not that because they haven't volunteered that they
    need assistance, that's the moment. And if they go back home,
    it may be 18 months, and they may be in bad shape by the time
    they come back to you.
        Dr. Clancy. Yes. So if I were to just say it back to you--
    and tell me if I got this right--a warm handoff at the time of
    transition really can't overcome many, many messages about
    stigma and so forth. So I would say that our integrating more
    tightly and effectively with Department of Defense probably has
    to move upstream of that point because I think of the
    transition program as almost being the mirror image of sort of
    new employee orientation. I mean, you want to be done and get
    out of here, right? A lot of people come home, and their family
    members will say, ``So where are your insurance papers?'' ``Oh,
    I don't know. I just wanted out.'' So mental health issues are
    not the only thing getting overlooked at that moment.
        We have made some efforts with the Department of Defense.
    We clearly need to do a lot more. The really good news is our
    two suicide prevention programs work very effectively now. And
    Secretary Shulkin and Secretary Mattis have already met on this
    and agree that it is a priority.
        Senator Schatz. I also want to follow up--and, Ms. Jarboe,
    first of all, thank you for everything you've done, thank you
    for your service to this country, for your husband's service to
    the country--this idea that sort of upstream chronologically
    that you have this moment as they're discharged to put them in
    front of someone who can be helpful to them over time. But I
    think you're really right, that whatever we do systems-wise,
    process-wise, there are going to be people who still just get
    right out the door and then have to come back 3, 4, 5 months
    later. But I think it's peers. I think it's community groups. I
    think it's not-for-profit organizations that have community
    credibility that are going to be able to reconnect these
    service members to VA in a way that doesn't feel daunting, that
    doesn't feel institutional, doesn't feel like you're showing
    any weakness. And, Ms. Jarboe, I'm over time, but if you
    wouldn't mind commenting on that.
        Ms. Jarboe. I would agree with you, Senator Schatz. I think
    community partnerships, we--that's one of our organic reaches
    for the Military Veteran Project. We've partnered with all of
    our fellow organizations, we partner with Department of
    Defense, we've partnered with everybody we could for a united
    effort to help with military suicide prevention. We use the
    Elizabeth Dole Foundation to help our caregivers and give our
    families the support they need. And then if we do have a widow
    or a family that has sustained loss, we utilize Tragic
    Assistant Program for Survivors, and we also use the American
    Widow Project. So I think there's a lot of community
    partnerships we can do for an overall success of this measure.
        Senator Schatz. Thank you.
        Senator Moran. Senator, thank you.
        The Senator from West Virginia.
        Senator Capito. Thank you. Thank you, Mr. Chairman, and
    thank all of you for being here today.
        Dr. Clancy, thank you for coming to West Virginia and to
    talk with our VAs there.
        I would just like to start by saying that we have a
    researcher at WVU, Dr. Robert Bossarte, who does a lot of
    suicide research and has shared with me some trends and figures
    nationally, and I just want to recognize him for his--and I see
    some shaking heads on the panel, so thank you for that.
        Ms. Jarboe, thank you for coming. And your dedication to a
    cause greater than all of us is really impressive, and we thank
    you for that. But something that you said in your opening
    statement really hit me when you were talking about your
    husband, and you were talking about the combination of drugs
    that he was on and how you had begun to try to wean him off of
    that. And I think some of the statistics that come out show
    that in the VA's Suicide Data Report that rates of suicide are
    higher among those with opioid drug disorder than even
    depression. Now, we know we have blanketing across,
    particularly rural areas again here, this whole opioid and
    heroin abuse issue, and I'm certain that with our veterans,
    it's hitting them especially hard, too.
        So I guess my question would be, and I don't know who can
    answer this, in the research and in the follow-up through the
    VA, as you're tracking what kind of medications people are on,
    if they're on some opioids that could maybe lead to some
    addictive issues, are you tracking that, and are you seeing any
    nexus of that and the rate of suicide with our veterans? Does
    anybody have an answer to that?
        Yes, Doctor.
        Dr. Kudler. Yes. You know, we've been tracking opiates for
    some years now, actually long before a lot of people became
    aware of the issue. And there definitely is an association
    between suicide and opiate use and between all kinds of reasons
    for death and opioid use. These are very dangerous drugs. And
    we also have, through an academic detailing initiative and a
    general safety initiative and an education and training
    program, been working to reduce, and successfully, the number
    of veterans receiving opiates and the amount of opiates they
    receive, and certain combinations with opiates, as Ms. Jarboe
    was speaking about, that are particularly dangerous.
        Senator Capito. Well, we have had situations of veterans, a
    father who lost his son, and fully convinced--and I believe it
    to be true--that the combination of medications that he was on
    through the VA caused him to not wake up one morning, and I
    think this has happened. And I think the VA has addressed,
    begun addressing, this issue, not just today, but many, many
    years ago.
        But it does, I think, provide--when we're talking about
    veterans that are not accessing services, if you can track some
    medications, and you're trying to figure out how to get people
    more into the system to follow up with them after they've been
    released, particularly in rural areas, is that an avenue to
    maybe broaden the scope? I mean, Dr. Clancy, is that something
    you all have looked at?
        Dr. Clancy. We haven't looked at it specifically, but I
    think it's a terrific idea, particularly now that all of our
    facilities are reporting to the state prescription drug
    monitoring programs and so forth. The only thing I would add to
    what Dr. Kudler and you were just discussing is a lot of this
    comes down to effective pain management.
        About one in three Americans has chronic pain issues. It's
    a little over half of veterans. So on the one hand, you want to
    manage pain effectively and safely. On the other hand, some
    people actually are prompted to end their lives if we are too
    strongly encouraging that they stop, and so forth.
        Senator Capito. Right.
        Dr. Clancy. I think, importantly, we have seen dramatically
    big reductions in the proportion of veterans who are on an
    opioid and another drug usually in the antianxiety agent class
    that particularly puts them at high risk for this. But we have
    a lot more to do. And I think one of the most promising avenues
    for pain management is going to be the use of alternative and
    complementary interventions.
        Senator Capito. And that mirrors what we're seeing in the
    rest of the population certainly through some of the
    initiatives that have been going on and I think are going to be
    strengthened through the Care Act bill and the 21st Century
    Cures bill that we passed.
        Dr. Clancy. Yes. Yes.
        Senator Capito. And we had an incident over in our VA in
    Martinsburg in our psych unit that they had originally been
    serving folks in Virginia, Maryland, and West Virginia. They
    were going to close because they were losing their
    professionals. The folks are having to serve long hours and
    just burned out. ``Burned out'' would be I guess the term. They
    reversed their decision to close the unit thankfully. But is
    this something that you said you've hired 400 more
    psychiatrists and others? Is this something that's happening
    across the country where you've just got such tremendous
    burnout because of the lack of professionals, but also the
    burgeoning need for help?
        Dr. Clancy. We are seeing more of it. To some extent, we're
    seeing more of it. At the time, the Inspector General was
    giving us some very good feedback, even if tough to hear, about
    the Crisis Line, was also the time when we made it much easier
    to call the Crisis Line. It used to be if you called one of our
    facilities, they would tell you the number. So presumably, if
    you were in crisis at that moment, you would be writing down 1-
    800 and so forth, and then you'd hang up and call back. And we
    changed that, so that from any of our facilities now, you hit 7
    and you're directly connected. Needless to say, that increased
    the volume, so we had to increase the capacity, and at times we
    were way behind.
        There is no question that we have a shortage of mental
    health professionals across all disciplines in this country,
    and that's going to hit some areas harder than others. And,
    frankly, the heroic work that our suicide prevention
    coordinators, mental health nurses, and other professionals do
    does put them at some risk for burnout. It's an issue we're
    paying a lot of attention to, but it's something that we need
    to monitor closely.
        Senator Capito. Thank you very much.
        Senator Moran. Thank you, Senator.
        The Senator from Montana.
        Senator Tester. Thank you, Mr. Chairman.
        Dr. Clancy, did you just say that over half the veterans
    within the VA are dealing with pain in some manner or another?
        Dr. Clancy. Yes, they have pain, often from service-
    connected injuries.
        Senator Tester. Boy, you've got a tough job. And I'll tell
    you, recently I had a--well, it's been a little bit ago, I had
    a town meeting, and I had three or four veterans stand up and
    say, ``The VA will not give me the pain killers I need to deal
    with my back problems.'' The very next person got up and said,
    ``The VA overprescribed me, and my son committed suicide.''
        Dr. Clancy. Yeah.
        Senator Tester. I think we really need to focus on trying
    to figure out if we can get a non-opioid pain killer out there
    to help fix this problem, or it's never going to--so you're
    caught between a rock and a hard place.
        Dr. Clancy. Exactly.
        Senator Tester. That's not what I intended to talk about.
    But it's my understanding the OMB lifted the hiring freeze.
    That may not actually be the case, and waivers are still
    required in some non-exempt positions. In the context of this
    hearing, I know that mental health providers have been largely
    exempted, but there are a lot of other folks critical to the
    provision of mental health care that have not, whether it's
    administrative support staff or even HR folks needed to hire
    and process the hiring of more mental health professionals. So
    the question is, has the hiring freeze been lifted for the VA
    or not?
        Dr. Clancy. I think, as you know, Senator, we had about
    45,000 vacancies, and initially Dr. Shulkin got exemptions for
    about 38,000, which was mostly focused on those providing
    direct front-line care. HR and other administrative
    professionals for the most part were not part of that
    exemption. We are now working very hard on figuring out which
    others we will be getting exemptions for.
        Senator Tester. So the prioritization has been for front-
    line folks?
        Dr. Clancy. Yes.
        Senator Tester. Are waivers still needed?
        Dr. Clancy. Not for front-line folks, no.
        Senator Tester. Okay. So for 38,000 of 45,000 folks, there
    are no waivers that are needed, is that correct?
        Dr. Clancy. Correct.
        Senator Tester. Okay. So I've got a 100 percent service-
    connected vet who was offered and accepted a job at the VA. He
    sold his house. The hiring freeze was implemented. Now he's
    jobless, he doesn't have a house, and he's in limbo, and he
    can't get a waiver. What's happening?
        I mean, look, we hear stories all the time. You guys deal
    with a lot of people, and you can't be 100 percent successful
    all the time, but if I was this guy, I'd be ready to bounce
    somebody off the wall.
        Dr. Clancy. I would agree with that. We would be happy to
    follow up with him specifically and also to take for the record
    a very clear accounting of which other additional positions
    have been exempted.
        Senator Tester. But you're here to tell me of the 45,000
    people you need as front-line health care staff, you can hire
    38,000.
        Dr. Clancy. Yes.
        Senator Tester. You can hire all of them that are front
    line.
        Dr. Clancy. No. 45,000 is the total number of vacancies
    roughly in VHA, and of that, we estimated that about 38,000
    were front-line.
        Senator Tester. How about VBA?
        Dr. Clancy. That I would have to take for the record. I
    just----
        Senator Tester. Is the hiring freeze still on for VBA?
        Dr. Clancy. Technically, it's been lifted, but we are
    supposed to submit formal plans I believe to--the hiring freeze
    is lifted in the context of our developing formal plans for
    streamlining and so forth.
        Senator Tester. Well, I'm going to see President Trump this
    afternoon at the VA, and I'm going to take this issue up with
    him because I think that hopefully he will understand how
    critically important it is. You cannot do your job if you do
    not have the manpower.
        Dr. Clancy. Yes.
        Senator Tester. And so we need to make sure that you have
    that manpower.
        So the OIG listed three reports on staffing shortages--this
    is for you, Dr. Clancy--as required by the 2014 Choice law, and
    we know that mental health is central to that discussion.
    According to the VA this month, there are at least 17 mental
    health care vacancies within Montana VA alone. And if anything,
    I think we may be heading the wrong direction. We're losing
    ground. We've tried to provide resources, as the Chairman
    pointed out, and hiring assistance over the past few years,
    loan repayment programs. Can you tell me how VHA is maximizing
    the tools that we've given you?
        Dr. Clancy. I believe that we have for the first time over
    the past couple of years actually spent every nickel of the
    Loan Reduction Program and very, very pleased to have that.
    It's an important tool for people facing huge debt when they
    finish school and training. So that has been one tool.
        There are areas where it is still very difficult to recruit
    health professionals. And I would say for mental health
    professionals and primary care, those are going to be our
    toughest competition points with the private sector.
        Senator Tester. And so are there any other tools that you
    need other than the loan repayment? Is there anything else out
    there that you can think of that can get particularly mental
    health care folks into the VA? I would say rural areas, but the
    truth is you need them in urban areas, too.
        Dr. Clancy. Oh, absolutely.
        Senator Tester. Are there any other tools that we need to
    give you to be able to attract more people to help our
    veterans?
        Dr. Kudler. Well, as Dr. Clancy mentioned, we have spent
    every nickel in our education debt reduction program, including
    the monies for the Clay Hunt----
        Senator Tester. I got that. Is there anything else we can
    do?
        Dr. Kudler. Yes. More support for graduate medical
    education. The help we got through VACA to get more residency
    slots has been helpful, but there is still a big need in
    psychiatry, but in all fields. Psychology is actually our
    number one critical shortage area.
        Senator Tester. I thank you very much. If there's a second
    round, I may try to get back.
        Thank you, Mr. Chairman.
        Senator Moran. I would anticipate we have a second round.
        The Senator from North Dakota.
        Senator Hoeven. Thank you, Mr. Chairman.
        Thank you for being here today and addressing this very,
    very important issue.
        My first question is for Inspector General Missal. As noted
    in your testimony, the Office of Inspector General released a
    report that found unacceptable results related to the Veterans
    Crisis Line. Your office found that calls to the VCL went
    unanswered or were directed to a voicemail system. And
    obviously this is a very important tool to help save a
    veteran's life, particularly in rural areas, where mental
    health care access is not always immediately available.
        So my understanding is that the Office of the Inspector
    General made seven different recommendations regarding the
    Veterans Crisis Line.
        Since the report was released, which recommendations have
    been implemented, and are there any of the recommendations that
    have not been implemented? And if so, why?
        Mr. Missal. Senator, the report you're referring to was
    issued in February of 2016. We subsequently issued another one
    in March of 2017. At the time of our release of the March 2017
    report, all seven recommendations from the February 2016 report
    were still open. Just this week, we've met again with
    representatives of the VCL and VHA. We're hoping to close a few
    of the open seven recommendations, and so we're in the process
    of doing that now. But there still are going to be open
    recommendations from February 2016, including all 16 from the
    March 2017 report. Those remain open as well.
        Senator Hoeven. Why the time to get them addressed? Why is
    it taking as long getting them addressed?
        Mr. Missal. I don't have a great explanation. We are always
    open to discussing with VHA what we're expecting to close the
    recommendations. The way the process works, we put out a
    recommendation, they have concurred with it. They give us an
    action plan with a date in which they believe they can close
    it. We then test it when they provide us information,
    documents, or anything else, to determine whether we have
    sufficient information and that we're comfortable that they've
    closed the recommendation. We're always willing to discuss with
    them.
        One of the issues we found is it seemed like we were
    talking across each other. We would explain what we need. Let
    me give you an example. In the 2016 report, we said the VCL
    needs a VCL handbook because there have been a lot of
    governance changes, a lot of personnel changes. It's got to be
    clear who's doing what, who's responsible for what thing, how
    it's supposed to work. And what we got several times was an
    employee handbook talking about how the employees should
    operate. And we've explained to them that's not what we want;
    we want a VCL handbook.
        So just this week we're working through them, hoping to
    close that one. But that's an example of where they just don't
    seem to understand exactly how to best close these
    recommendations.
        Senator Hoeven. Dr. Clancy, do you want to respond to that
    one as well?
        Dr. Clancy. As Mr. Missal described, we have made some
    progress with the recommendations. I think that our biggest
    challenge--and you can correct me if you disagree--is actually
    making sure that the administrative portions of the Veterans
    Crisis Line, attending to the call centers and so forth, and
    making sure that the lines are answered, and, frankly, if
    there's an issue like the power source goes down or some
    problem with the power grid, that that is immediately picked up
    by the other center. That was the reason to open a second one.
    That's sort of the admin support, but that there is a very
    clear, easy, and effective handoff to the suicide prevention
    coordinators across our system and so forth.
        I do want to make one correction just so that all of you
    are aware. When calls roll over, they go to another crisis line
    that has been certified by SAMHSA (Substance Abuse and Mental
    Health Services Administration), which is part of HHS, with
    trained crisis counselors. They are not going to limbo or a
    voicemail. And that's actually very, very important to us. We
    think we can more rapidly expedite the transition to care and
    assistance if we can answer the majority, if not all, of the
    calls. And we're at about 99 percent since early January, so
    that's a good thing. But that was our top priority. At least
    one of the open recommendations requires a contract, which does
    not happen too, too swiftly.
        The issue about directives I think is very real in both the
    administrative and clinical area, and it is a high priority for
    us at the moment.
        Senator Hoeven. How about for other means, like text,
    email, those kind of things? Are you covering that as well?
        Dr. Clancy. Yes. You can text the Crisis Line, you can get
    into an online chat. We think it's very, very important to have
    24/7 coverage. And I myself have witnessed many, many instances
    of effective text exchanges and complete with follow-through to
    what happened next. If you are a clinician and refer someone to
    the Crisis Line, you get a very clear report-out, and it's kind
    of amazing to read about the heroic next steps.
        Senator Hoeven. Well, and clearly that's very important and
    going to continue to be more important just because of the way
    people communicate.
        Dr. Clancy. Yes. Yes, exactly.
        Senator Hoeven. Thank you.
        Senator Moran. Senator, thank you.
        The Senator from Washington.
        Senator Murray. Thank you very much, Mr. Chairman. And
    before I start, I do want to take a moment and just recognize
    and thank the Crisis Line staff. They have an incredibly
    difficult, stressful job, and lives are on the line every
    minute of the day, and their dedication and compassion is truly
    heroic, and I think we should recognize that. There is no more
    important role for VA than to be there when a veteran is in
    crisis, to take their own life, and when they have the courage
    to reach out, ask for help, the VA has to be there every single
    time, and that is true at the VA hospitals and the clinics, at
    the Crisis Line or anywhere else, so I just want to make that
    clear.
        I want to follow up on what Senator Hoeven was just asking
    about because it is deeply troubling to me that the VA has not
    implemented the IG recommendations or the GAO recommendations.
    There is still no governance structure or quality measures for
    the Crisis Line? That just doesn't feel to me like any sense of
    urgency whatsoever. And I expect the VA to deal with this
    problem.
        So, Dr. Clancy, let me just ask you directly, why has the
    VA failed for nearly a decade now to fix these issues? And who
    is being held accountable?
        Dr. Clancy. Mr. Missal just referred to sort of talking
    past some of our colleagues. In terms of the quality of care
    provided, I think in some instances we were using several
    different languages in terms of, what is the right kind of
    thing to do? We are now doing a lot more silent monitoring for
    the quality of that interaction and also the quality of the
    follow-through. We do have a quality assurance process in
    place. I believe that's with the Inspector General now for
    adjudication.
        I think our first focus was on capacity. We knew that it
    was urgently important to make it as easy as possible to reach
    the crisis line, but that that required capacity. We expected
    an increase in demand. I think it's fair to say that what we
    got was a bigger demand surge than that.
        Senator Murray. Well, Mr. Missal, thank you for being here.
    Thank you for what you're focused on here. I just am really
    disturbed by your finding in your testimony that disagreements,
    lack of collaboration, impacted important operations at the
    Crisis Line. You mentioned a number of problems. You just
    talked about the VCL handbook. Do you feel there's a sense of
    urgency from the VA to deal with this?
        Mr. Missal. Certainly in talking to a number of people,
    there is an urgency, but then we have the opposite effect, that
    these recommendations are not getting closed out as quickly as
    certainly we would like it so that veterans can be served even
    better. So that's why we're always available to talk with VHA
    to make sure they really understand what we're going to need to
    explain it. And again I just go back to they gave us the plan
    of what they thought they needed to do. We accepted the plan.
    So it's just implementing that plan so that we can close out
    these recommendations.
        Senator Murray. Yeah, it just feels to me like it's kind of
    bureaucratic infighting occurring at the VA and people not
    talking to each other. We've got people on the verge of suicide
    and crisis.
        Mr. Missal. Yes.
        Senator Murray. There has to be a sense of urgency. I just
    have to tell you as someone who has been involved in veterans'
    issues and been on top of this for a long time, these are
    issues that have to be resolved immediately.
        And I believe, Mr. Chairman, that this subcommittee should
    be updated monthly until they are met. And I hope that we can
    request, and I would like to ask that we request, that the VA
    update this committee on a monthly basis, and, Mr. Missal, your
    team validate that so that we know that these issues are being
    addressed.
        Dr. Clancy. And, Senator, if I might, we have made some
    internal changes to reinforce the issues and the effectiveness
    of bringing the administrative and the clinical pieces and the
    governance together. We will be bringing that to you I would
    guess within the next few weeks. We're realigning our internal
    focus on policy with those who focus on operations with the
    intent of getting to exactly the issues you're addressing.
        Senator Murray. I appreciate that. I just want to see it,
    and I hope that this committee would, too.
        Dr. Clancy. Yes.
        [The information follows:]

        VHA Directive 1503 Operations of Veterans Crisis Line Center is in
    the concurrence phase which is expected to be completed in the near
    term. Following organizational concurrence, the Directive will be
    presented to Labor Management Relations for review of any requirements
    to bargain by our union partners.
        The directive interfaces the Member Services business and
    administrative operations with the Office of Mental Health Operations
    and the Office of Suicide Prevention clinical operations by outlining
    roles and responsibilities.

        Senator Moran. Senator Murray, thank you very much for the
    intensity with which you raise this issue. And I share your
    concerns. The point being that the VA and the Inspector General
    has reached a conclusion as to what needs to be done. The issue
    is it's not being done----
        Senator Murray. Correct, and so that's why I would like to
    have a report----
        Senator Moran [continuing]. And let's have a report in a
    matter of weeks from the----
        Senator Murray [continuing]. By both.
        Senator Moran. A month from now we ought not be having this
    same conversation.
        Dr. Clancy. I especially agree, 10 years from now, yes.
        Senator Murray. Okay. Thank you very much, Mr. Chairman.
        Dr. Ramchand, thank you very much. You mentioned the high
    rate of suicide for women veterans, including a rate among the
    youngest cohort of women that is seven times the comparable
    civilian rate. That is deeply disturbing. And you found, and
    I've seen the same thing, that women veterans are often put off
    by a male-oriented culture at the VA that assumes that women
    are not veterans when they call, or either the woman assumes it
    or the person answering the call or talking to them.
        Dr. Ramchand. Not necessarily at the Crisis Line. So we
    interviewed responders at the Crisis Line to ask them what
    women said were barriers when they were answering calls and
    they were trying to recommend that women go to the VA. What
    were the barriers that the women who they spoke to raised? And
    this was one barrier that did get mentioned by the responders
    when they were talking to us.
        Senator Murray. Are there cultural shortcomings at the VA
    that would help explain the high rate of suicide among women
    veterans? Or are there other factors, other policies, that you
    think might impact this?
        Dr. Ramchand. In terms of policies, I think what we know
    from RAND's assessment through VA Choice is that there is
    variability in kind of women's services that are offered in the
    VA centers. So I think that variability, in some places, it's
    very well resourced and there is comprehensive women's care,
    and in others, there's not as strong of a focus on women
    veterans services.
        Senator Murray. So across the VA, we don't have a directive
    that is followed that says women veterans have to be responded
    to as a woman veteran?
        Dr. Ramchand. There are services, there are requirements
    for women, but there's variability in whether----
        Senator Murray. Implementation.
        Dr. Ramchand. Yes.
        Senator Murray. All part of this. Okay. I am way over my
    time, Mr. Chairman, but thank you very much.
        Senator Moran. Thank you, Senator Murray.
        The Senator from New Hampshire.
        Senator Collins. No.
        Senator Moran. Maine.
        Senator Collins. The great State of Maine.
        Senator Moran. I've never been to Maine.
        Senator Collins. How could you confuse the two?
        Senator Moran. That's why I forgot about it. I've never
    been invited to Maine.
        Senator Collins. Oh, you're now invited. You can do a field
    hearing of this subcommittee in Maine. We would welcome that.
    Mr. Chairman, thank you very much for holding this really
    important hearing. This has been one of those mornings where I
    was chairing a hearing myself in the Aging Committee, and I
    also had the HELP Committee markup, and so I apologize for my
    late arrival. It does not in any way reflect lack of
    appreciation for your holding this very important hearing.
        I was going to ask the very question that Senator Murray
    just asked. I'm very concerned that we're not seeing the kind
    of progress among suicides for women veterans compared to the
    adult civilian population. And I know we've made some progress,
    but clearly there are either cultural or other obstacles. And
    in Maine, at our VA hospital at Togus, we have a wonderful new
    women's center, and I think it's made a real difference in
    encouraging women to come to the VA for care. It is so
    different from the way it was 10 years ago when I would visit
    the hospital.
        So, Dr. Kudler, I would be interested in knowing whether
    you're replicating those kinds of women's centers in your CBOCs
    and in your--it's hard to run a community-based clinic, I
    realize, but in your veterans hospitals.
        Dr. Kudler. Yes, we are. In fact, we started doing this. I
    know--I worked the Durham VA for about 30 years, and about 15
    years ago we opened what was the seventh comprehensive women's
    health program in the country, and it was combined primary care
    and mental health, and we've learned an awful lot of lessons.
        This is a cultural growth factor for VA, and I think it
    really is true. Front-line staff, people who park your cars,
    doctors, how to set up the rooms, how to have a waiting room.
    Should there be a window to the outside if you're on the first
    floor if you're the women's clinic? Women, it turned out,
    really felt observed in a fish bowl. We had to fix all sorts of
    things. But we're learning how to do this, and we're making
    cultural inroads into the community of women veterans.
        Another aspect is--I just want to mention in this context--
    the relation of women veterans using firearms to end their
    lives, which is something you don't see in the civilian
    section, and which 9 out of 10 times that will be lethal as
    opposed to other means used by civilian women is a major
    factor. But we have to figure out the messaging to work with
    women veterans about firearms safety and means restriction.
        Senator Collins. Thank you.
        Dr. Clancy, according to the VA's 2016 Suicide Data Report,
    rates of suicide have decreased among VHA patients diagnosed
    with a mental health or substance use disorder with one
    exception, and that is the rate of suicide has increased for
    patients diagnosed with an opioid use disorder.
        In 2014, I worked to ensure that our service members and
    veterans could participate in safe prescription drug disposal
    programs that would be located at VA clinics and hospitals, and
    that effort provides veterans with a reliable, safe,
    accessible, and accountable method to dispose of unneeded
    medications, and that obviously reduces the risk of diversion
    and theft as well as overdose or misuse. And, indeed, drug
    take-back programs are occurring across the country this
    weekend.
        Additionally, in the Comprehensive Addiction and Recovery
    Act, which became law last year, there are numerous provisions
    to combat opioid abuse, such as mandating VA's participation in
    state prescription drug monitoring programs. There was a front
    page article in a Maine paper yesterday saying that there have
    been real problems getting the VA to comply with the new state
    law in Maine.
        Could you give us an update on the VA's opioid safety
    initiative and participation in those state prescription drug
    monitoring programs?
        Dr. Clancy. Thank you for that question, Senator. We are
    participating with all 49 States that have a prescription drug
    monitoring program. I believe it's the State of Missouri that
    does not yet have one. And, in fact, we can track it.
        [The information follows:]

        A recent local newspaper article detailed the fact that the VA is
    not bound by a new state of Maine law limiting opiate prescribing
    (since the VA is a Federal facility). However, as noted in the article,
    the VA's internal Opiate Safety Initiative mirrors many of the
    requirements in the law, and VA Maine continues to seek an aggressive
    program to reduce opiate prescribing. The attached fact sheet below
    details a summary of these activities at VA Maine.
                                    overview
        The VA Maine Opioid Safety Initiative (OSI) is a highly
    coordinated, system-wide program designed to improve opioid safety for
    Veterans, opioid safety education for all clinical staff members,
    improve access to and utilization of alternative pain treatments and
    support services, improve utilization of opioid safety universal
    precautions including naloxone, and prepare VA Maine for Maine PL
    Chapter 488.
        Components of the initiative include: Strategic Planning Pain Team
    led by Chief of Staff, clinical staff education, Academic Detailing
    Program, Naloxone Education and Distribution, quality improvement
    project (PDMP utilization), opioid tapering to meet objectives of Maine
    PL Chapter 488, community outreach to veterans and healthcare
    professionals
                                    outcomes
    Universal Precautions Chronic Opioid Cohort* as of April 2017
      --95 percent have informed consent (1111/1164)
      --90 percent have a urine drug screen in the past year (1045/1164)
      --95 percent have a PDMP review in the past year (1109/1164)
      --At least 95 percent Maine PDMP enrollment among opioid prescribers
      --157 naloxone kits dispensed to chronic opioid users at high risk of
            overdose as of April 2017 (defined as patients with MED>100 or
            co-prescribed a benzodiazepine)
      --306 naloxone kits dispensed to any patient at risk of overdose as
            of 5/1/17

    Chronic Opioid Cohort*  population changes as of April 2017
      --Total number of chronic opioid patients decreased 19 percent from
            1449 to 1179 since March 2016
      --Sum of MED in chronic opioid patients decreased 32 percent from
            76,110 to 51,775 since March 2016
      --55 percent decrease in # patients with > 100 MED from 186 to 84
            since March 2016
      --82 percent decrease in # patients with > 300 MED from 22 to 4 since
            March 2016
      --30 percent decrease in # patients co-prescribed a benzodiazepine
            from 338 to 242 since March 2016

    Pharmacy Data (all patients, all opioids)
      --17 percent decrease in number of opioid tablets dispensed from VA
            Maine pharmacy in March 2017 compared to March 2016 (from
            233,598 to 194,471)
      --10 percent decrease in number of opioid prescriptions dispensed
            from VA Maine pharmacy in March 2017 (2401) compared to March
            2016 (2642)

    Educational Outreach
      --Greater than 95 percent of opioid prescribers have received an
            academic detailing visit
      --100 percent of high priority opioid prescribers in primary care
            have received an academic detailing visit
    *Per VISN 1 metrics (excludes, palliative care, suboxone, and tramadol)

        Dr. Clancy. We developed and deployed and broadly
    disseminated a tool really focused on primary care clinicians
    so that they can see in one panel in a very easy way all of
    their patients who are on opioids, whether they are complying
    with recommended clinical practice guidelines, what the dose
    has been over time, what are their pain scores doing? what
    other medications are they on? and so forth. That same tool is
    a platform for us to track, how often have the state PDMPs been
    queried?
        I had not heard any particular problems with Maine, but I
    would be happy to check into it and follow up with you.
        Senator Collins. Thank you. I would very much appreciate
    that.
        Thank you, Mr. Chairman.
        Senator Moran. Thank you, Senator from Maine.
        The Senator from New Mexico.
        Senator Udall. Thank you, Mr. Chairman, and thank you to
    the panel. This has been excellent testimony here today. This
    is obviously a very difficult problem, and it's difficult for
    many to talk about and let alone solve, and bringing the
    veteran suicide rate to zero is obviously a daunting task, and
    I commend each of you for your work in that area.
        I wanted to focus on the issue of doctors and the DOD that
    want to get into the VA. But first a little bit about New
    Mexico and what's happening there. The increasing rate of
    suicide is a national crisis that strikes communities
    throughout my home state of New Mexico. In 2014, New Mexico was
    among five states with the highest suicide rate. And as you
    know, this rate is even higher among veterans, and I think that
    case is true also in New Mexico. The problem is made worse by a
    severe shortage of mental health practitioners, especially at
    the VA. Just this last week, Secretary Shulkin informed me that
    out of 80 beds in the mental health ward in Albuquerque, 20 are
    out of commission due to staffing problems, and even more beds
    are empty because an air conditioner is broken.
        And I've worked in this committee to improve the VA's
    ability to incentivize doctors, nurses, and PAs to work at the
    VA. And I know there are also doctors who are seeking to
    transition out of the DOD into the VA, but face a month-long
    application process.
        Is there a system in place that allows fully licensed and
    certified practitioners within the DOD to quickly and easily
    transition to providing mental health care at the VA?
        Dr. Clancy. We do have an overarching memorandum of
    understanding with the Department of Defense. To be completely
    candid, I'm not actually sure that at every single corner of
    our system everyone is aware of it, not for lack of effort, but
    we can actually quickly bring in--and you don't have to go
    through the credentialing process, and so forth if you've
    already been credentialed and privileged by the Department of
    Defense. I'll be happy to follow up and to make sure that the
    Albuquerque facility is plainly aware of that, but we'll
    double-check on that. It may or may not address the nurse
    staffing issue.
        [The information follows:]

        In 2011, VA and the Department of Defense (DoD) entered into a
    Memorandum of Understanding (MOU) for the sharing of practitioner
    credentials to facilitate assisting one another expeditiously. This MOU
    is intended to facilitate the credentialing of healthcare providers
    between VA and DoD and establish guidelines for sharing the
    credentialing data collected and verified by one Department with the
    other, expediting the appointment process of those providers who are
    shared across Departments. VA and DoD similarly credential many
    healthcare professions in accordance with the Joint Commission (JC)
    standards. The process involves the sharing of the credentialing
    information and primary source verifications from the provider's
    credentialing records as outlined in the MOU. VA is able to share this
    information electronically by giving the appropriate DoD official
    access to the respective file in VetPro. DoD is unable to share the
    file electronically at this time so the sharing of information with VA
    is in paper form (i.e., their Interfacility Credentials Transfer Brief
    (ICTB) with supporting documentation).
        This credentialing information is used to support the facility
    specific privileges that must be requested by the provider to reflect
    services that he/she is being asked to perform in their assignment. The
    privileges must still be reviewed by the receiving facility's Executive
    Committee of the Medical Staff (ECMS) and approved by the Director in
    accordance with Joint Commission standards. Facilities may call an ad
    hoc/emergent meeting of their ECMS for expeditious processing. The
    receiving facility is responsible for monitoring the provider's
    clinical performance through the Focused Professional Practice
    Evaluation/Ongoing Professional Practice Evaluation (FPPE/OPPE). In
    those rare instances where concerns related to substandard care,
    professional misconduct, professional competence, or professional
    conduct are identified, the VA Chief of Staff must contact the Chief of
    Staff at the DoD facility with documentation of concern. As the
    privileging authority, the VA Chief of Staff must ensure the
    investigation of all clinical care concerns and any necessary
    privileging actions in conjunction with VA care are addressed in
    accordance with VHA Handbook 1100.19, ``Credentialing and Privileging''
    and reported to the National Practitioner Data Bank and State Licensing
    Boards accordingly. If the provider's services will be a long term
    need, exceeding more than 180 calendar days, the provider will be fully
    credentialed during that time.
        In Summer 2018, DoD and VA will share a credentialing software
    platform and a common database of all providers credentialed in both
    agencies. At that time, the credentialing files will be easily shared
    electronically between agencies eliminating the need for two separate
    credentialing files or transfer of paper records.
        Regarding the Albuquerque VAMC, the VAMC's credentialing staff has
    been made aware of the VA/DoD MOU for the sharing of practitioner
    credentials to facilitate assisting one another expeditiously.

        Senator Udall. You bet. Thank you, Dr. Clancy.
        Dr. Clancy and Mr. Missal, it's troubling that so many
    veterans slip through the cracks. In your testimony, you
    described that over two-thirds of those veterans who take their
    life have never received care from the VA, and nearly 9 out of
    10 have never received mental health care. For years, this
    committee has examined and funded systems to make it easier for
    those who do seek treatment at the VA to bring their health
    records with them. And I recognize that no one can force a
    veteran to seek treatment.
        Currently, does the VA, in cooperation with the military
    branches, ensure that service members who have demonstrated
    need for mental health care when they are discharged, and they
    don't seek treatment at the VA, are they followed up on? So
    that's identified and then the discharge. And whether this is
    in the area of traumatic brain injury, PTSD, or suicidal
    ideation.
        Dr. Clancy. We make that warm welcome very, very apparent
    as, you are correct, we can't force anyone to come to VA, and
    some will get jobs and other insurance-related through
    employment or whatnot, and hopefully get care elsewhere. Very
    high on our urgency list, though, is tightening that link with
    integrating with the Department of Defense both at the time of
    transition, which is critical, but also upstream from that
    transition, particularly where it comes to minimizing stigma.
        Mr. Missal. I don't have anything more to add. Obviously
    that's an issue that we are well aware of, and it may be
    appropriate for a future project for us.
        Senator Udall. Great. Great. Thank you.
        And then just a quick question on telehealth. Dr. Clancy, I
    share your optimism for telehealth and the possibility of
    increased access to VA mental health care in rural areas. What
    is the VA doing to ensure that these areas are not left behind
    because of the latest developments in telehealth? You know,
    there are a lot of these areas that don't have broadband, and
    so you can't utilize telehealth. What are you all doing on that
    front?
        Dr. Clancy. So for our system, many times people are
    getting telehealth at a small outlying clinic, so it is not
    purely reliant on broadband availability in the area, which
    helps a lot. In other words, we're doing it through a hardline
    connection.
        Ultimately, with greater availability of broadband, it
    would be much, much nicer I think for many veterans to be able
    to not have to come to one of our facilities, particularly
    depending on where they live. Some get it at home. I have
    spoken with a number of veterans at home, not about their
    clinical issues, but, you know, because they happen to be at
    the end of a session that they had with one of our
    professionals.
        Senator Udall. Thank you very much.
        Thank you.
        Senator Moran. The Senator from Florida, Senator Rubio.
        Senator Rubio. Thank you very much. Thank you all for being
    here.
        I want to begin with you, Mr. Missal. First of all, I want
    to preface everything I say by saying I think the enormous vast
    majority of the people at the Veterans Administration do
    extraordinary work. These are incredible people who work hard,
    and many of them are veterans themselves.
        I think it's always important to say and to thank them for
    what they do, but we all understand that there are shortcomings
    in the system. And I know that you recently conducted an
    evaluation of the quality of care provided at the Orlando VA,
    obviously in Florida, and you reviewed several aspects of key
    clinical and administrative processes that affect patient care
    outcomes, including policies and procedures that address safe
    medication management and contraband detection.
        And potentially what I'm about to ask is outside the scope
    because I think you focused on anticoagulation medications
    specifically, but I want to ask your judgment on opioid
    medication because it's been reported that VA employees
    illegally diverted or stole controlled substances, including
    opioids. This, of course, is unacceptable. And the fact that a
    nurse was allowed to resign and another employee was merely
    suspended for 2 weeks I believe is outrageous and intolerable.
        And I lay that as a predicate for the follow-up question I
    have, but what can we first do? What recommendations do you
    have, whether it's opiates or anticoagulation, that we could
    impose to better mitigate the protocol and the abuse of these
    medications?
        I know we're focused on suicide prevention, but we've seen
    the link between substance abuse and suicide in veterans. And
    so it would be tragic if the source of whether it's an opiate
    addiction or the like is the VA system.
        So what can we do? What can be done to better mitigate the
    protocol, or change the protocol, and the abuse of medications?
        Mr. Missal. Well, we're looking at this from a number of
    different perspectives. In the past, as part of our inspection
    program, we inspect the medical facilities at least every 3
    years or so. In the past, we've had a protocol to look at it
    and to make any recommendations where their procedures may not
    have been as effective as they could be or that they weren't
    implementing those procedures.
        We also have a very aggressive criminal investigation into
    a number of drug diversions of controlled substances, another
    one. Unfortunately, we have a number of open investigations
    now.
        In the past, we've worked with the Department of Justice to
    prosecute a number of people, whether they were VA employees or
    those who had access to controlled substances within VA medical
    centers. And one of our goals is to try to act as a deterrent
    there to make sure that it's clear that if VA staff or others
    divert, steal, controlled substances, that we're going to be
    very aggressive in terms of the prosecution.
        Senator Rubio. Is there any indication that the diversion
    problem at the VA is substantially broader than what you may
    find at any other facility?
        Mr. Missal. I've seen some studies on that, and it's a
    problem across a number of facilities. I don't think it's
    substantially greater at VA than some of the others, but I'm
    not sure if all the studies are that broad.
        Senator Rubio. And so my follow-up question is for you, Dr.
    Clancy, and again I want to reiterate, as I said, the
    incredible work that the people who work under you are doing at
    the Administration. But I remain concerned, and that's why I've
    sponsored legislation to address it, that under existing civil
    service laws and rules, we're either unwilling or unable to
    sometimes hold the remaining few who are doing a poor job,
    whether it's a bad job or even worse in some instances, some of
    the things you've just outlined here today, that under the
    existing civil service laws, we are either unable or unwilling
    to hold accountable people for their actions.
        And so is it your view generally that the Department
    currently has the authority it needs to manage the workforce
    and its employees accordingly, and, in particular, hold people
    accountable?
        Dr. Clancy. We do have authority. I think where we have
    fallen down in the past is that it can be a lengthy process.
    And I will say in the area of opioid narcotic diversion,
    Secretary Shulkin has made it very clear our tolerance level is
    zero and that we will react promptly when employees divert that
    medication. We believe that it is, if anything, less than the
    private sector, but it's not easy to find consistently good
    data in the private sector.
        Secretary Shulkin has made accountability one of his top
    priorities. So I think that you're going to see that it's a new
    day at VA, and I will leave it at that. But we would be happy
    to follow up with specific questions for the record.
        Senator Rubio. Absolutely. And my closing, just to say that
    we have worked and continue to work on accountability
    legislation that the Secretary supports to give them the
    authority to remove people.
        Dr. Clancy. Absolutely.
        Senator Rubio. Not in an unfair way, we're not interested
    in witch hunts, we're not interested--we need good people. I
    don't think there is any interest in removing good people.
        Dr. Clancy. No.
        Senator Rubio. For political purposes or otherwise, but we
    remain concerned, and I think the Secretary shares this view in
    his public statements, that the VA at this time does not have
    the authority it needs to remove people in an expeditious
    manner if they choose or find the need to do so. And so I look
    forward to hopefully working with you and others to get that
    done.
        Mr. Chairman, thank you.
        Dr. Clancy. Well, if I might just note, Senator, just that
    this week we've had senior leaders across our system all
    together out at a meeting. And so the Secretary was very, very,
    very clear about this, and actually was doing problem-solving
    with individuals to say, ``How can we help you?'' Because
    oftentimes our leaders want to act more expeditiously, and it's
    tricky. And he walked us through what the legislation is and
    that he welcomes it.
        Senator Moran. The Senator from Wisconsin, Senator Baldwin.
        Senator Baldwin. Thank you.
        For Mr. Missal and Dr. Clancy, I would like to ask both of
    you about the VA's domiciliary program. I continue to have
    serious concerns about the safety of residents in those
    facilities and whether those facilities are appropriate for
    veterans who are at risk of suicide or overdose.
        Mr. Missal, as you know, I've been in communication with
    the Inspector General's Office since February of 2015 about
    multiple events that have happened in Milwaukee's domiciliary
    that have illustrated failures in security protocol and
    operations including a tragic drug overdose of veteran Cole
    Schuler. For well over a year, your office has been conducting
    an investigation into Mr. Schuler's death, and into overall
    operations at the domiciliary.
        So I want to ask you a couple of questions. First of all,
    when will your office complete and publicly release this
    investigation? And then I guess I have to emphasize the urgency
    of a timely review. We want to see a review and your
    recommendations and think they are urgently needed. Earlier
    this month, a syringe of heroin was found in a resident's
    possession at the domiciliary after he got it past security.
        And I'm going to start with you, and then I have additional
    questions of Dr. Clancy relating to the domiciliary program.
        Mr. Missal. I don't have a specific date. I know it's a
    priority for our office. I have been focused on this. I think
    there are issues across the country with the doms. They do
    provide an important service. I've personally been in some of
    them, and what I found is inconsistency in the approaches
    there. But we will get you that report as soon as possible, and
    then if you would like, we would personally brief you and your
    staff about it.
        Senator Baldwin. I very much would like to have that
    happen.
        And to you, Dr. Clancy, I would like to ask about the
    status of the Department's assessment that was required by last
    year's committee report of these security concerns that I'm
    discussing and whether the current domiciliary program can meet
    the needs of veterans who are at heightened risk for overdose
    or suicide. Our committee also directed the VA to include
    alternatives to the domiciliary program if it finds that the
    current program cannot meet the needs of these at-risk
    veterans.
        So what is the current protocol for monitoring residents,
    and, if necessary, intervening to move someone from the
    residential rehabilitation setting to an acute inpatient
    setting or another more supervised setting when warranted?
        Dr. Clancy. I'm going to ask my colleague, Dr. Kudler, to
    address this. He's closer to the details.
        Senator Baldwin. Very good.
        Dr. Kudler.
        Dr. Kudler. Yes. This year we've actually launched, in part
    because of the concerns raised, and we also have been observing
    these events, a national what we're calling a safety surge in
    domiciliaries. We have almost 8,000 domiciliary beds. They
    perform a unique function. There really aren't many places in
    America where a person can now go and get residential care,
    especially people who have been homeless and have sort of lost
    the ability to pull themselves out of that cycle. VA provides a
    way, a path, especially if you have a severe mental health
    problem and you're homeless and maybe drug addicted. These
    programs are really invaluable to veterans, and I think it's
    one reason why our program is a fully integrated mental health
    program. No others exist like this.
        Having said that, our homeless programs need additional
    training, additional staffing. Some of the facilities are
    older, have lots of blind spots, and long hallways, and we need
    new and better ways for surveillance. And certainly anytime a
    clinician in a residential rehab program sees that there is an
    acute problem, that patient can and should be and can be sent
    up to a higher level of care. It's certainly our intention to
    treat people in the least restrictive environment but at the
    highest level of care that's appropriate to them.
        [The information follows:]

        Domiciliary Program--The Committee notes recent reports of safety
    gaps in the VA domiciliary program. Therefore, the Committee directs
    the Department to address security concerns and assess whether the
    current program can meet the needs of veterans who are at heightened
    risk for overdose or suicide. The Department's assessment should
    include alternatives to the domiciliary program if it finds the current
    program cannot meet the needs of these veterans.
    Addressing Safety Concerns in MH RRTP Programs:
        In response to increasing adverse event trends in the Mental Health
    Residential Rehabilitation Treatment Programs (MH RRTP), otherwise
    known as Domiciliary Care programs, that included an increase in
    reported opioid overdoses and suicide attempts, all facilities with an
    MH RRTP were directed to conduct a Culture of Safety Stand Down of
    residential operations on November 16, 2016. The Stand Down required
    all MH RRTPs to suspend clinical operations for one day to complete a
    series of safety improvement activities that incorporated:

      --Facility and Mental Health leadership involvement
      --Completion of a unit Health and Safety Inspection including
            contraband search
      --Completion of a 52-item Annual Safety and Security Assessment by a
            team of program staff, Veterans and facility safety experts
      --Completion of mock safety drills on each shift
      --Schedule of events that include both Veteran and Staff activities
            with required areas of focus on safety
      --Engagement of staff that work during non-administrative hours
      --Mitigation of any safety gaps identified during the stand down

        As follow-up to these safety improvement efforts the medical
    centers were required to conduct a Surge on Safety starting March 16,
    2017. The MH RRTP Surge on Safety was a comprehensive effort that
    leveraged support from across all levels of VHA to ensure safe, high
    quality care in the MH RRTPs. Review of information from program
    managers and Veterans served as well as data from recent adverse events
    and available root cause analysis (RCA) reports had identified
    potential factors that may be impacting safety. These lessons learned
    provide the foundation for the ten steps for improving safety in MH
    RRTP which medical centers were required to review and implement as
    part of the Surge on Safety. The ten steps included:
      --Develop a medical center MH RRTP Safety Committee which includes
            the facility Safety Officer, Patient Safety Manager, VA Police
            Chief, Suicide Prevention Coordinator (SPC), MH RRTP Manager or
            Dom Chief, Resident Veteran and other stakeholders as needed.
            The committee should meet at least monthly to identify and
            address safety, security and supervision issues. The MH RRTP
            Safety Committee should provide medical center leadership with
            on-going reports on needed actions and as appropriate
            mitigation strategies to address gaps related to safety.
      --Review the medical center's fiscal year 2017 MH RRTP Annual Safety
            and Security Assessment (ASSA) and ensure any items assessed as
            ``partially met'' or ``not met'' are prioritized for
            appropriate action to address identified deficiencies.
      --Review the results of the ``Culture of Safety Stand-Down'' which
            each medical center completed in November 2016. Ensure issues
            identified during the Stand Down were addressed and that
            processes are implemented to ensure an on-going focus on safety
            throughout the year.
      --Review current MH RRTP staff vacancies to assess impact on safety,
            security, and 24/7 supervision. Specific attention should be
            focused on 24/7 and nursing staff, psychiatrists,
            psychologists, social workers, and medical staff. Ensure
            mitigation strategies are developed and implemented to address
            safety gaps related to staff gaps until vacancies can be
            filled. In reviewing 24/7 and nursing requirements,
            consideration of the physical layout of the residential
            facility and the recently released MH RRTP Nurse Staffing
            Methodology should be taken into account.
      --Develop a written discharge checklist that ensures:
      --all treatment team members participate in a decision to discharge a
            Veteran;
      --verification of appropriate housing and transportation;
      --a follow-up appointment within seven days of discharge has been
            scheduled and a warm hand-off to an outpatient provider has
            occurred;
      --alerting the Mental Health Treatment Coordinator (MHTC) and, as
            appropriate, the Suicide Prevention Coordinator (SPC) prior to
            a Veteran's discharge; and
      --VA Police are alerted when an irregular discharge has occurred.
      --Review screening criteria to ensure Veterans are not denied MH RRTP
            services based solely on a history of suicidality, opioid use
            disorder, recent overdose or suicide attempt, current length of
            abstinence or housing status.
      --Review medical center availability for access to Medication
            Assisted Treatment (MAT) for Opioid Use Disorder (OUD) and
            Alcohol Use Disorder (AUD) as recommended by the VA-Department
            of Defense (DoD) Clinical Practice Guideline for the Management
            of Substance Use Disorders. For OUD this would include
            buprenorphine, methadone and extended release injectable
            naltrexone and, for AUD, acamprosate, disulfiram, naltrexone,
            topiramate, and gabapentin. Further ensure naloxone is made
            available to Veterans in the MHRRTP during their residential
            admission via prescription and made available for staff use
            when responding to emergent situations involving potential
            opioid overdoses.
      --Review local MH RRTP program policy and procedures to ensure an
            integrated, individualized, Veteran-centered, recovery oriented
            service delivery model that reduces the utilization of rules-
            based approaches to milieu management. These procedures should
            include peer support approaches including assigning each
            Veteran a ``Recovery Buddy'' and use of a Veteran run Repair
            Council. The medical center's Local Recovery Coordinator should
            collaborate in the review, policy development and staff
            education
      --Ensure the Suicide Prevention Coordinator and MHRRTP treatment team
            reviews the safety needs and, as appropriate, makes necessary
            adjustments to the treatment or safety plan for Veteran's
            identified in the REACH-VET data base that are referred for
            residential treatment, currently pending residential admission,
            or already admitted. As appropriate, consideration should be
            given to expediting admission for those Veterans identified
            through REACH-VET who have been referred for residential
            treatment.
      --In collaboration with other programs and services at the facility,
            review, identify, and remove any access barriers to facility
            mental health or medical services not available directly within
            the MH RRTP that are necessary to meet the needs of Veterans
            such as, but not limited to, provision of pain management,
            primary care, and specialty mental health or medical care.

    Meeting the needs of Veterans who are at heightened risk for overdose
    or suicide in MH RRTPs:

        National trends in opioid overdoses and suicide rates are highly
    visible in MHRRTPs. These programs are open residential units where all
    admissions are voluntary. Veterans admitted are, by the nature of their
    medical, mental health and substance use disorders, at risk for
    negative outcomes. Lessons learned indicate a variety of factors impact
    safety in MHRRTP settings. As programs experience multiple risk
    factors, the probability of adverse events occurring increases when:

      --there are resource gaps, critical staffing gaps, staff turnover and
            burnout;
      --conformance to safety, security and supervision policy is not
            maintained;
      --program service delivery is rules-based rather the Veteran Centered
            and Recovery Oriented;
      --there is an over-reliance on group and self-help services and lack
            of individualized services and integrated care;
      --there are deficits in care coordination with other medical center
            services;
      --there are deficits in transition planning and coordination; and
      --the complexity and acuity of Veterans served is increasing.

        VHAs policies and procedures are designed to mitigate these safety
    risks. However, no institutional setting (public or private) can
    completely eliminate the risk for a negative outcome. In fiscal year
    2016, VHA provided over 2.1 million bed days of care to over 33,000
    unique Veteran in MH RRTPs. During this same period there were five
    Veteran suicides and six Veteran overdose deaths just prior to
    admission, during the program or just after discharge from an MH RRTP.
    VHA believes that even one Veteran death is too many and continually
    strives to improve safety. These efforts include comprehensive external
    reviews through dual accreditation by both the Joint Commission and the
    Commission on Accreditation of Rehabilitation Facilities (CARF). MH
    RRTPs meet or exceed the Residential Treatment Standards and Health and
    Safety Standards of both accrediting organizations. VHA also adheres to
    both the American Society for Addiction Medicine (ASAM) and the VA/DoD
    Guidelines for the Treatment of Substance Use Disorders which both
    supports residential treatment.
        When operated in conformance with national and local policy and
    resourced appropriately, MH RRTPs are safe and are an essential
    component of the broader mental health continuum of care. When a
    Veteran is assessed at heightened risk for self-harm, the Veteran is
    transferred to a VHA inpatient unit.

        Senator Baldwin. Mr. Chairman, I have an additional
    question. Are you planning on a second round of--okay, I will
    hold on.
        Senator Moran. Thank you very much.
        I recognize the Senator from Alaska.
        Senator Murkowski. Thank you, Mr. Chairman. And thanks to
    each of you for your testimony and all that you do for our
    veterans.
        I appreciated the question that Senator Udall was asking
    when I came in about the access to care that's provided to our
    veterans in rural parts of the country. And, of course, in
    Alaska, we're beyond rural.
        And it is a reality that more often than not, the services
    that may be provided when it comes to that level of support,
    maybe the Crisis Line on the phone or what we are doing through
    video conferencing technologies and effectively utilizing these
    technologies that allow us to connect a little bit better, it's
    not the preferred alternative, but it does give us some
    opportunities. And I had worked with this subcommittee a few
    years back to put some language in pushing VA to do more with
    allowing readily available video conferencing technology, so
    it's good to hear that we're making some progress there.
        I'm reading the comments from you, Dr. Ramchand, about the
    role of community-based prevention. And, again, in so many
    parts of Alaska, our veterans are out in a small rural village.
    There are no services. We may not have ability to hook into any
    technology that might be available for others. And so it is the
    community that more often than not that provides that support,
    and unfortunately our suicide statistics in the broader
    community are far and above other states in terms of our
    numbers. So we have a suicide issue amongst all of our
    population, and then our veteran population just adds to the
    real consequences and the severity of the problem.
        So to your comments, Dr. Ramchand, and the role that the
    community plays, I've had an opportunity just this past week to
    be down on the Kenai Peninsula, where I went to a facility
    where they are utilizing dogs to partner with our veterans who
    are suffering from PTSD and associated issues, to just allow an
    outlet, a focus, on something, a calming sense. I have
    personally seen, coming to my office here in Washington, D.C.,
    several Alaskan vets who have their animals with them, and they
    tell me that in terms of ways that they are able to address
    PTSD without the benefit, if you will, of drugs, these dogs are
    providing a great deal. Veterans' therapeutic courts is
    something that is also being considered. So there are these
    alternatives that are out there that I think the community can
    be very helpful.
        Can you speak to what we're seeing in terms of some of the
    innovation? It's one thing to talk about video technology, but
    the other areas that we can be more proactive from a community-
    based perspective in providing the assistance for these
    veterans particularly in our rural areas.
        Dr. Ramchand. Sure. From a research perspective, I think
    about this kind of a triad of innovation, quality, and
    effectiveness really. And unfortunately with suicide
    prevention, we don't have many studies that have been proven
    effective. But people are consistently thinking about new
    innovative ways to identify populations and to get programs
    that appear to work and that look valid, at least on the face.
    I know there's a lot of effort right now with respect to social
    media and ways that we can use social media to intervene, and I
    think that has a lot of potential, especially with younger
    veterans, high school students, who may be experiencing
    suicidal thoughts, but I think we need to test those
    interventions, and especially people in rural areas who are
    connected and who are on social media platforms, but we have to
    test how those things work.
        Senator Murkowski. Well, let me ask then, if any of these
    more experimental or perhaps less traditional--let's say that--
    are being considered beyond just the telehealth.
        Dr. Clancy. Absolutely. We know that we can learn a lot
    from social media. It probably is not for all age ranges of
    veterans, but particularly for younger veterans, this is
    actually a way of life, this is not out there, this is real
    life, right? And, frankly, we would leave no stone unturned.
        And, you know, as a senior official at the Department, I've
    often gotten emails from veterans saying, ``I don't know this
    person, but I saw it on my Facebook,'' or, ``I saw it somewhere
    else. Can you reach out and help?'' And I would say more than
    90 percent of the time somebody can locate that person. It's a
    different world, but it can be very, very effective,
    particularly for veterans who often use this as a lifeline to
    maintain connections with the community of people with whom
    they served.
        Senator Murkowski. Thank you.
        My time has expired, Mr. Chairman.
        Senator Moran. Thank you very much, Senator.
        The Senator from Connecticut, Senator Murphy.
        Senator Murphy. Thank you, Mr. Chairman.
        Thank all of you for your testimony and the VA and all of
    the staff you represent. We have a lot of veterans in
    Connecticut who are very pleased with their care, very proud of
    the association, so thank you.
        Dr. Clancy, I wanted to drill down a little bit more into
    this issue of care provided to veterans with bad paper
    discharges, those who have less-than-honorable discharges. You
    know, the numbers are pretty startling. If you have an other-
    than-honorable discharge, you are twice as likely to commit
    suicide, and if you're outside of the VA system, you're
    somewhere around 30 percent more likely to commit suicide, and
    I think the VA has recognized that.
        I had a back-and-forth about a year ago with Dr. Shulkin
    about the statutory authorization that I believe clearly allows
    the VA to provide care to those that have bad paper discharges.
    Again, these are individuals who have not been given a
    dishonorable discharge, but because of some conduct that they
    engaged in that was likely connected to their injury that was
    caused through their service, they have been given a less-than-
    honorable discharge. You've made a decision now, and you noted
    this in your testimony, to provide a small amount of care, 90
    days of care, to individuals who are in emergency
    circumstances.
        So let me first just get the predicate question out of the
    way. There was for a while an uncertainty about whether VA had
    the statutory authorization to provide this care to individuals
    who have bad paper discharges. With your decision to provide
    care in this limited manner, are we now clear that the VA has
    the statutory authorization to provide care for this
    population?
        Dr. Clancy. Yes. And I think the sense of urgency that came
    out at the summit that Dr. Shulkin had just over a year ago,
    Dr. Ramchand was quite insistent that if we were serious, we
    needed to focus on veterans with bad paper because of the
    increased risk. And as you point out, some subset of that
    group, which we believe to be just over 500,000 altogether, may
    actually be able to confirm a service connection for that
    diagnosis. That will take time to evaluate, but in the
    meantime, they will have at least that initial 90-day period.
        For those for whom we can't document that connection and
    therefore get them a path to enrolling in VA care permanently,
    then we will have time to actually enroll them and get them
    connected with other sources of mental health care.
        Senator Murphy. As you know, a very well-publicized recent
    report identified within the Army as that subset being 24,000
    veterans who had a less-than-honorable discharge who had a
    service-connected disability but were denied services in some
    way, shape, or form because of that less-than-honorable
    discharge.
        So then if it is clear that you have the statutory
    authorization, why limit care to 90 days? That's not a number
    that's based in medicine. Many of these veterans have no other
    outlet for care besides the VA. Why the 90-day limitation if
    there's not a dispute any longer over the statutory
    authorization?
        Dr. Clancy. So we can provide care on a humanitarian basis
    to anyone who shows up at one of our facilities on an emergency
    basis, that is a given, veteran or otherwise. Ninety days was
    what we thought was a reasonable timeframe to establish whether
    they could be permanently enrolled in VHA, and our lawyers
    agreed with that call after doing a lot of deep analysis of
    existing statutes.
        Senator Murphy. So there is an opportunity then at the end
    of that 90-day period to stay in VA care.
        Dr. Clancy. Yes. Yes. If we can establish service
    connection or other eligibility, yes.
        Senator Murphy. And then this term ``emergent mental
    illness'' or someone who's in an emergency status, that again
    is a--what's the guidance given to people who are doing intake
    as to what qualifies as being in emergency status?
        Dr. Clancy. So in general, it is more or less a prudent
    layperson. If the veteran thinks it is urgent, it is urgent,
    period. I mean, I'm referring to prudent layperson as a broader
    definition for use of any emergency room in America by any
    person, right? If you call it an emergency, if you, the
    patient, think--consider it an emergency, it is, period.
        And as you know, we have made access to care same day
    available for all the people enrolled in our system at our
    major medical centers as of the end of '16 everywhere, same
    day, for primary care and mental health. And in addition to
    that, we've reached a lot of the outpatient clinics already,
    and over the next couple of months, we're going to close that
    gap, so that actually you can go anywhere, and we will be
    following that very rigorously.
        Senator Murphy. I think this is really important progress
    that you've made here. I would argue that there's no reason to
    limit the care to those who are in emergency situations, nor to
    limit it to 90 days. And you were talking about the most
    vulnerable population. You're often talking about young men who
    just went AWOL for a short period of time because of a very
    serious service-connected disability, because of a TBI or PTSD,
    and because of that, they got a bad paper discharge, and then
    that disqualifies them for services. And, again, you're talking
    about a number that we know is in the tens of thousands at the
    very least.
        So I would hope that you continue your progress in opening
    up the pathway and not having these what I would argue are
    arbitrary limitations, and I don't think you need a statutory
    authorization, but to the extent you do, I don't see any reason
    why we wouldn't try to work together to give it to you.
        Dr. Clancy. We will be back. I promise you that. And I
    think part of working with the Department of Defense in a
    tighter link in integration isn't just the transition, that's
    important, but it's also upstream in terms of the kind of
    evaluation that you just referenced with respect to the Army.
        Senator Moran. Senator Murphy, thank you very much.
        We're going to have a second round, and try to make it-- at
    least I'll try to make mine quick, and I'll have an opportunity
    at the end if I have more. But to get to Senator Baldwin in
    particular.
        Let me, though, ask Dr. Davis, I described when I
    introduced you what your job title was. What does that mean?
    What do you do on a daily basis? And then I'll follow up from
    there.
        Dr. Davis. Thank you, Senator. You know, I think probably
    the only typical thing about my job is that there is no typical
    day. So it's sort of difficult to describe what I do on a daily
    basis because I could have all the best-laid plans, and then a
    crisis occurs. And so I'm going to drop everything that I had
    planned in order to help that veteran in acute need.
        But in general, my job description, what I do is--one of my
    primary jobs is to administratively flag the charts of veterans
    who are considered to be at acute risk for suicide. Oftentimes,
    I will----
        Senator Moran. These are veterans that are otherwise in
    the--that are in the VA hospital in Topeka for other reasons.
        Dr. Davis [continuing]. Absolutely. So they're probably
    being treated in our mental health clinic, or they may come in
    through other avenues. Oftentimes they're identified when
    they've come in through our acute psych unit after significant
    suicidal ideation or even an attempt. And so I will go up on
    the unit and meet with them and assess them and just make sure
    that they know who I am and so that they have a friendly face
    that they can call if they need anything at all.
        So we will flag those charts as being at acute risk for
    suicide, and typically those flags stay on for 90 days. And
    then if they're doing okay at the end of that, then we'll go
    ahead and remove that flag because it's designed to be--it's
    designed to genuinely tell providers, ``Listen, this is
    somebody that you need to pay attention to, you need to ask
    those follow-up questions of.'' If I don't see them in person
    for assessment, then we will take provider recommendations of
    somebody that needs to be flagged as high risk for suicide.
        Another primary part of my job is to respond to people who
    have called the Veterans Crisis Line. And so every morning when
    I come in, that's one of the first things that I do, is I pull
    up the list of people that called the Crisis Line the night
    before, and I start calling them back.
        Senator Moran. What's happened between the time that call
    was made by a veteran and your arrival in the morning in which
    you then call that caller back? What's transpired during the
    night?
        Dr. Davis. So when a veteran calls the Crisis Line, there
    are trained responders 24/7 that will answer the phone. And I
    have had responders that have stayed on the line for over an
    hour with a veteran just because they needed to talk. If it's
    an emergency situation, if that veteran is at imminent risk for
    self-harm or for any reason, sometimes they've had medical
    emergencies that responders have responded to, they'll send out
    emergency vehicles to bring the veteran into the hospital so
    that they can be treated immediately. If it's not an emergency
    situation, then they'll ask at the end of that call, ``Do you
    want a referral to your suicide prevention coordinator?'' And
    so they are aware that it will be a 24-hour business day return
    call. And so that's when I will--I will start calling them back
    in the morning. Most--oh, go ahead.
        Senator Moran. And the veteran apparently has the option of
    saying, ``No, I don't want to be referred''?
        Dr. Davis. They do. And sometimes that does happen. And so
    I'm not aware of the veterans in our area who have called the
    Crisis Line if they say, ``No, I don't want a referral.'' So
    that doesn't show up in my database, and I don't follow up with
    that.
        So then once--as I'm tracking them down, more often than
    not, I'm able to reach them, and those needs vary from maybe
    somebody who's never been enrolled in the VA system and they
    want to get enrolled for care. It might be somebody who has an
    established mental health team, and they've kind of fallen away
    from them, they've missed several appointments, they've stopped
    taking medications, and their symptoms are starting to
    increase. And so they just need to be reconnected with their
    mental health team.
        Senator Moran. Doctor, is it your experience in the follow-
    up that the individuals who indicated they wanted to have a
    conversation with you, have they been cared for appropriately
    in the intervening time in which they made the call and the
    time that you make the call to connect with them? In other
    words, are the right decisions being made by the individual on
    the phone during the night?
        Dr. Davis. You mean the actual--the veteran who's calling
    or----
        Senator Moran. Is the veteran receiving--is it your
    experience that when you talk to those individuals, that they
    have received the appropriate care they need during the
    timeframe from which they made the call on the hotline to the
    time that you actually talked to them? The right decision is
    being made about that veteran at the appropriate time.
        Dr. Davis. Yes. For the most part, actually what I've even
    heard from veterans is they got kind of ticked that the
    responder called emergency services because they were like, ``I
    was just talking,'' or, ``I was just expanding on something.''
    But----
        Senator Moran. Suggesting--I wouldn't suggest we would ever
    overreact because who knows what the circumstance is --
        Dr. Davis. Right, you never want to.
        Senator Moran [continuing]. But we're not underreacting is
    my question.
        Dr. Davis. That's been my experience. And, in fact, we
    actually had a situation where the Crisis Line responders, we
    had a really unfortunate situation where over a period of about
    3 days, myself, other mental health providers, were in contact
    with a veteran who was considering ending his life, and
    ultimately did, but he had also been in touch with the Veterans
    Crisis Line. And what we ended up finding out was that those
    Crisis Line responders were really emotionally involved in the
    situation as well, and they were reaching back out. They were
    initiating contact with this veteran desperately trying to get
    him help.
        And so at the end of that experience, it was emotionally
    difficult. And I actually ended up connecting with the Crisis
    Line responder that spent the most amount of time on the phone
    with him just because the two of us sort of needed to debrief.
        Senator Moran. Providing counseling to the counselors.
    Yeah. I interrupted your story about what you do on a day-to-
    day basis. Is there more to be said?
        Dr. Davis. There's lots more to be said.
        Senator Moran. Yeah.
        Dr. Davis. So those are the Veterans Crisis Line responses.
    I also provide consultation to people throughout the hospital.
    That might be--so an example of consultation that happened
    recently was a primary care psychologist who they were--you
    know, we were talking about the opioid issue, but I think one
    of the pieces that we don't see as much is when we do reduce
    opioid pain medication, then people's pain is there, and they
    may be at an increased risk for attempted suicide.
        And so I was consulting with the primary care psychologist
    in terms of kind of how to preplan for this because a veteran
    who they were going to discontinue their opioids with had
    previously stated that she would become suicidal if in fact
    that happened. So we were kind of creating a contingency plan
    there. Fortunately, it worked out well.
        Other consultations may be I might get an instant message
    on my computer that a staff member is on the phone with
    somebody and he has a gun to his head, and he's ready to end
    his life. I also provide training throughout the hospital in
    terms of best practices to happen when somebody enters the
    hospital with suicidal ideation.
        I'm also doing outreach into the community because, as we
    know, 14 of those 20 veterans who die each day by suicide
    aren't connected with the VA hospital. And so we recognize that
    we cannot do this alone. It's important for us to partner with
    our community resources as well.
        So I do a lot of outreach in the community. We've got Fort
    Leavenworth in our catchment area, and so one of the partners
    that I have spoken with frequently, as I provide annual
    trainings, some of the annual trainings, on suicide prevention
    for active duty and retired military there, and at the Command
    and General Staff College as well.
        I work very closely with our law enforcement agencies. So I
    am involved in crisis intervention training, so helping first
    responders understand what to do in a mental health crisis so
    that they are responding appropriately, and they can bring that
    veteran in for care rather than turning that into a legal
    situation if it doesn't need to be.
        We also--we partner with other of our traditional and non-
    traditional veteran service organizations. We recently had a--
    there was the Combat Veterans Motorcycle Association recently
    lost one of their own to suicide. And so they wanted to hold a
    memorial and a rally, and so we partnered with them. And we had
    over 100 motorcycles that came into the VA. They were escorted
    by the police. And there were two widows of veteran suicide who
    spoke elegantly and poignantly at that event. And it was an
    emotional event.
        And so as I'm talking to people in the community, I'm
    always saying to them, ``Awareness is one thing, but this is a
    call to action.'' And I say to them what I suppose I will say
    to all of you in this room, is each one of you here has
    somebody who you are worried about in your life, somebody who
    maybe has drifted away or maybe even somebody that you see on a
    regular basis and you don't even know their name, but you know
    they're hurting. And so my challenge always, as I outreach to
    the community is, ``Do something about that. Don't let this
    opportunity pass by. Reach out and be willing to ask that big
    question, 'Are you thinking about suicide?' And if they are,
    call the National Suicide Prevention Hotline or the Veterans
    Crisis Line.
        Senator Moran. Doctor, I'll be able to follow up with you
    momentarily. Let me turn to Senator Schatz. I would say now
    that I've asked you what you do every day, I would say thank
    you for doing what you do every day.
        Senator Schatz. Thank you, Mr. Chairman. I want to follow
    up on two issues. You know, a number of us on this panel are
    proponents of telehealth, and we've been very impressed with
    both what VA and DOD are doing, and we have legislation in this
    space. And what Senator Udall spoke about in terms of broadband
    availability, I know impacts the ability for VA to provide
    telehealth.
        But I would like to ask Dr. Clancy a question specifically
    about telehealth, but also if you could broaden it to tech
    generally. I'm a little concerned that if we allow the rate-
    limiting factor in terms of the uptake for telehealth to be
    broadband availability, there are going to be communities that
    are still unable to access care. Obviously, that observational
    aspect of psychiatry and psychology and clinical work cannot
    ever be replaced. But as you've talked about, tech can work but
    requires a broadband connection.
        And so I'm interested in maybe you don't call it officially
    telehealth, but how are we using tech to give better care? I'm
    thinking of when I ran a not-for-profit that provided clinical
    services for adults with severe and persistent mental illness,
    half the time, literally half the time, that our social workers
    were spending was finding the client. And I'm really interested
    in the extent to which either through GPS, as long as it's
    permission-based, that some of these problems can be eliminated
    or mitigated. I'm thinking about that.
        I'm thinking about the rep payee programs, which it seems
    to me might be able to be automated. Even 10 years ago when I
    was an executive director, we were starting to do direct
    deposit, auto bill pay.
        But I'm just very interested in how we can utilize modern
    technology to service veterans and their mental health care
    needs better.
        So, Dr. Clancy.
        Dr. Clancy. So there are a number of examples I could give,
    and I would also ask Dr. Kudler to chime in, in a moment.
        Senator Schatz. Sure.
        Dr. Clancy. One is the growing popularity of apps. So there
    are a lot of apps that we make available and point out to
    people that for folks who live by their and die by their
    smartphones, that this is a lifeline of sorts, whether that's
    the Virtual Hope Box or some other source of information about
    coping strategies if things are getting tough. That's one kind
    of thing. Video conferencing is another type of approach.
        Reaching Out is kind of interesting because of privacy
    concerns and so forth, but certainly reaching out to
    established groups via Facebook and so forth.
        I also neglected to mention--this is not so much
    technology, but it would be a message that we would be
    delivering through various platforms--the importance of our vet
    centers. We have about 800 points of contact, and many of them
    have partnerships. I mean, it's astonishing really with like
    local libraries and other kinds of facilities, again, expanding
    our reach in a different way.
        The one thing I would want to just say before turning to
    Dr. Kudler, I don't actually see this for mental health as a
    kind of cheap and almost as good alternative. In many ways,
    it's actually better because some people feel a little bit less
    intimidated if they are speaking virtually. And there are
    studies that show that people are more likely to share if they
    aren't in a face-to-face literal situation where they may feel
    a bit intimidated by their provider.
        Senator Schatz. Every parent knows that.
        Dr. Clancy. Yes, exactly.
        Senator Schatz. Dr. Kudler.
        Dr. Kudler. I'll add, you know, our 80 mobile vet centers
    actually have satellite links, they don't need broadband, and
    we can see patients through that. PTSD Coach, which VA
    developed with DOD, has not only been downloaded hundreds of
    thousands of times, but it's been translated into like 20 or 30
    other languages. It's used all over the world as a kind of
    self-help tool that also leads you into care. If in fact you do
    a self-assessment and you need help, it then connects you with
    that help, through your smartphone that you're carrying.
        I want to point out that in addition to more broadband and
    more high-tech equipment, if there were a legal solution to the
    problem of being able to project telehealth across state lines,
    that is probably the single biggest limitation to successful
    implementation of telehealth. So I can hire somebody in Chicago
    who can do treatment in Hawaii. They would have to be an
    insomniac, but they could do it. And I think those are things
    that would help.
        And we're also experimenting with apps. We're working
    through our innovation centers looking at, for instance, if
    your app in the morning tells you, ``You know, you didn't sleep
    last night,'' ``You know, you haven't been out of your house in
    the last 48 hours,'' and can trigger you to other behaviors and
    connect you to care where people can help you, these are other
    kind of tech things we can do short of the broadband and
    traditional solutions.
        Senator Schatz. Thank you, Dr. Kudler. Just a point of
    clarification. The inability to provide telehealth services
    across state lines, is that a matter of state licensure? Is
    that what the statutory limitation is?
        Dr. Kudler. I'm not a lawyer, but my understanding is that
    there has been a great deal of resistance against the idea of
    allowing doctors, even in VA, even with the idea of Federal
    supremacy, to say we're one system. I have one license in North
    Carolina, and I can practice through VA in any state I work in
    VA, but I can't do telehealth across state lines within my
    license. I would be vulnerable to being censored by the state
    in which I was offering the care, ``You don't have a license in
    my state,'' and that needs to be clarified.
        Senator Schatz. We'll follow up in writing. This seems like
    a problem that is very significant, but also solvable, but in
    the interest of time, I'll defer to my----
        Dr. Clancy. Can I just add one very quick?
        Senator Schatz. Sure.
        Dr. Clancy. That's particularly problematic for veterans
    who may want to get their treatment at home, across state
    lines. Dr. Kudler can provide care by telehealth within our
    system from D.C., North Carolina, wherever, and many of our
    mental health professionals do that, but if the veteran is at
    home and it crosses a state line, that has been a challenge.
        Senator Schatz. Thank you.
        Senator Moran. Senator Baldwin.
        Senator Baldwin. Thank you. The question I was posing right
    before time ran out, Dr. Clancy, was about the status of the
    Department's assessment required in last year's committee
    report of the security concerns relating to the domiciliary
    program. And I wanted to just revisit, is it complete yet? And
    will the subcommittee receive a report communicating the
    results of your assessment that we can then use and study?
        Dr. Clancy. I would have to check on current status, and
    we'll follow up with you promptly about that.
        Senator Baldwin. Thank you.
        Dr. Clancy. I do want to recognize that the Inspector
    General's terrific report in July of 2015 was a huge help for
    us. This was a comprehensive review of all of our domiciliary
    facilities, which really prompted and motivated the safety
    surge and stronger focus on security in particular.
        Senator Baldwin. Okay. So if you will get back to me on
    that. And I certainly would want to have the full subcommittee
    to be able to receive a report.
        The next question, Dr. Clancy, in 2015, I worked to ensure
    that the annual independent evaluation of VA mental health care
    and suicide prevention programs, as required by the Clay Hunt
    Act, includes a review of opioid prescribing practices.
    Veterans experiencing chronic pain, many of whom are prescribed
    opioids to manage it, also experience higher rates of mental
    health comorbidities like PTSD and depression. The Jason
    Simcakoski Memorial Opioid Safety Act, which was enacted into
    law as part of the Comprehensive Addiction and Recovery Act,
    requires enhanced guidelines in the newly updated clinical
    practice guideline for opioid therapy for chronic pain with
    respect to the treatment of patients who are at risk of
    suicide.
        So I was pleased to see that the updated guidelines
    includes a recommendation to assess suicide risk when
    considering initiating or continuing long-term opioid therapy
    and intervening when necessary. And I just would like to hear
    from you about the VA's efforts to assess, mitigate, reduce the
    risk factor of suicidality in the context of opioid therapy.
        Dr. Clancy. So, as you know, the clinical practice
    guideline was recently released and is in the kind of early
    dissemination phases, so we have not built a tracking system
    for that, although many of the features of what you're talking
    about we can actually build into that audit tool, which is also
    a kind of central focus of the Jason Simcakoski Act.
    Importantly, I think you know this, but the Simcakoski parents
    and family gave us valuable input on that guideline as well.
        Senator Baldwin. Absolutely.
        Dr. Clancy. So very, very appreciative of that input.
        And we recognize that the two issues are very much
    interdependent. That is not to say that everyone at risk of
    suicide has an opioid problem or vice versa, but as part of
    lethal means reduction, for example, that's why we leaned
    forward very early to make naloxone distribution a very big
    priority, because, in essence, the medications that some people
    get are a lethal means if stored up and so forth. I'm not sure
    I'm answering your question, though.
        Senator Baldwin. It sounds, though, as though, if you
    haven't fully implemented it, you can't answer the question.
        Dr. Clancy. Yes.
        Senator Baldwin. So I guess I will ask it again when you
    return. But I wanted to hear about the VA's efforts to mitigate
    the risk factor of suicidality in the context of initiating or
    continuing long-term opioid therapy.
        Dr. Clancy. Yes. Well, I can tell you it is on our list of
    near-term priorities for what we're doing to, frankly, address
    the question, what else and what more we can do to address
    suicide. And we would be happy to follow up with your staff or
    you.
        [The information follows:]
        VA has developed a factsheet with respect to Chronic Pain and the
    risk of suicidality, which is included with this response below.
        VA deployed two state-of-the art tools to help providers manage
    risk for Veterans receiving opioids. These tools are available now to
    all staff in VA facilities.

      --The Stratification Tool for Opioid Risk Mitigation (STORM) was
            designed to identify higher risk patients receiving opioid
            prescriptions for proactive care management and review. The
            STORM tool may be used to assess risk in patients on opioid
            medication and also in patients not on opioid medication that
            may be considered for opioid therapy. STORM incorporates
            predictive models to estimate the risk that a patient will
            experience a suicide-related event or overdose, respiratory
            depression event, or an accident or fall. STORM generates a
            nightly-updated report, including: current risk estimates, a
            list of clinical and prescription risk factors, a tailored
            checklist of recommended risk mitigation strategies, and
            information for care coordination. STORM can also provide risk
            estimates for any VHA patient considering opioid therapy,
            estimating their risk of adverse events if they were to
            initiate a low, medium or high dose trial of opioid medication.
            These estimates can help guide risk-benefit discussions and
            shared decisionmaking regarding pain management plans.
      --The Opioid Therapy Risk Report (OTRR) is a national dashboard that
            was developed to help primary care teams manage Veteran
            patients on long term opioid therapy. It includes information
            about the dosages of opioids and other sedative medications,
            significant medical and psychiatric co-morbidities that could
            potentially increase the likelihood of an adverse reaction,
            implementation of opioid risk mitigation strategies, and care
            coordination parameters. Thus, the tool aides in the review and
            management of complex patients. Primary care providers can get
            an overview of all patients in their panel and then review
            individual patients in detail. The tool is also available now
            to providers outside of primary care to review their patients
            on opioid medication.

        VA has deployed Veteran focused education and outreach. These
    programs include:

      --The Opioid Overdose Education and Naloxone Program (OEND) which
            aims to reduce harm and risk of life-threatening opioid-related
            overdose and deaths among Veterans. Key components of the OEND
            program include education and training regarding opioid
            overdose prevention, recognition of opioid overdose, opioid
            overdose rescue response, and issuing naloxone products. As of
            March, 2017, VA had dispensed over 70,000 naloxone kits to
            Veterans.
      --Patient Education campaigns including waiting room posters,
            pamphlets, and letters educating Veterans on the risks of
            taking too many medications, new treatments for pain and PTSD,
            and the VA Opioid Safety Initiative related to tapering of
            opioids.

        Senator Baldwin. Thank you.
        Senator Moran. Thank you, Senator Baldwin.
        Senator Schatz tells me he has no more questions.
        I have a few more.
        And, Tammy, anything?
        [No audible response.]
        Okay. We are about to conclude our hearing, and thank you
    all for your continued attention and patience.
        Dr. Ramchand, you indicated about care tailored for women.
    And one of the things that caught my attention is in the
    programs that the VA now is implementing with VA Choice and
    other community programs, does that increase the chance that--
    increase or decrease--is there a consequence to women veterans
    in the nature, the kind of care, the attitude, with which they
    are approached? Are there more community options for better
    care for women or more tailored care for women outside the VA
    than within?
        Dr. Ramchand. I can't answer the question of whether there
    are more options available through VA Choice. What I can say is
    that women responders, when we asked responders at the Veterans
    Crisis Line, were women accessing community-based care, and why
    were they choosing community-based care? Sometimes it had to do
    with services specifically for women, other times it had to do
    with logistics issues, that the center offered child care or
    that a center had scheduling availability during outside of
    work hours. So they were responsive to kind of competing
    demands placed upon women, especially work and family-related
    concerns.
        So women who are accessing this care preferred community-
    based care sometimes because of those reasons.
        Senator Moran. Thank you for that answer.
        Ms. Jarboe, I think you have so much that you could tell us
    about alternative care. Most of our questions this morning have
    been directed as to what the VA is doing. What's the increasing
    role or what's the opportunity you see for the kinds of
    services that you and other not-for-profits, volunteers,
    provide veterans? And what's the increasing chances that those
    opportunities create greater success in ending suicide?
        Ms. Jarboe. Well, that's a big question. I would say from
    the Military Veteran Project's standpoint, we are looking
    towards alternative treatments in the sense of sensory
    deprivation, hypobaric chamber, to kind of help our men and
    women sleep.
        If someone says, ``I have been diagnosed with PTS, here are
    my medications I'm on,'' we ask them about their sleep
    patterns. Our doctors, our medical team, go through and walk
    them through their diets, their exercise, everything, to see
    who this person is. But when we also take time, we look at the
    wife, and we talk to the children. And then we introduce a
    battle buddy program from an alternative--an alternate
    organization to help that wife or help that spouse and the
    children to kind of cope and deal with what's going on from an
    educational point. So to answer that, it's just like a--it's a
    big broad spectrum of everything we do here. So I would say
    that----
        Senator Moran. I could ask the question this way----
        Ms. Jarboe. Yeah, thank you.
        Senator Moran. What has been the VA's response? What's your
    relationship with the VA and their interest in the things that
    you find in your work?
        Ms. Jarboe. I would say we are on--we both have the same
    goal in mind, and that's preventing veteran suicide. But I also
    think that we're both doing two different things. I think we've
    been able to organically growth through social media and
    Facebook the Military Veteran Project and other military
    organizations with the credibility that the younger generation
    sees in us and the trust that they'll come forward with us.
    We're trying to siphon that into the Veterans Administration to
    help our Veterans Administration grow nationally as well to
    fill the void of some of the men and women who have not
    applied. We do not currently have a strong partnership with the
    Veterans Administration. We are there if they need us. We are
    not asked to attend any of their boards. We are not a part of
    their direct community approach or outreaches. But we will
    still eagerly assist the Veterans Administration when they're
    in crisis or in need because that's what we're supposed to do
    as Americans.
        Senator Moran. So any of the veterans who use the call
    center would not end up receiving any attention by you. If
    they're talking to the VA, they don't ultimately end up in a
    program that you're involved in.
        Ms. Jarboe. No. No, sir, they don't, but 10 times to 1, we
    may have our Battle In Distress coordinators actually on the
    phone making that veteran call the veteran crisis service to
    fill in to make sure that they're going somewhere good.
        Senator Moran. So one of your recommendations from your
    volunteers would be call the crisis center.
        Ms. Jarboe. Yes. We do. We're trying to promote the
    Veterans Administration. We're trying to shine a light on the
    progressive growth and the positivity the Veterans
    Administration has done in the past year or two, and trying to
    siphon our veterans into the system. So we may have programs
    that are a benefit. We also know that the big VA has a greater
    program and a greater goal and mission that we all need to
    unite for.
        Senator Moran. I hadn't thought of this until it came up in
    this hearing about vet centers. And they don't seemingly--and
    maybe this is me and not thinking about it-- but they don't
    receive the attention now. In large part, my understanding is
    they came into existence following the Vietnam War, and many of
    those veterans were not interested in going to a big brick-and-
    mortar VA facility, and vet centers became kind of the
    storefront opportunity in a more subtle and less challenging
    environment interface with the VA. Do you have experience with
    vet centers as well?
        Ms. Jarboe. I have visited some of the vet centers just to
    get an idea what our veterans are seeing when they attend.
    Sometimes I'll attend with a veteran. But I don't have an
    overall view of all of the vet centers in the Nation.
        Senator Moran. And this may be a question for the VA, or
    you, or maybe Ms. Davis, Dr. Davis, what happens at a vet
    center different than what if you present yourself at the
    Topeka--at the Colmery-O'Neil VA Hospital, what's different
    than when you present yourself in Manhattan, Kansas, at the vet
    center? What takes place differently?
        Ms. Jarboe. I would defer to Ms. Davis.
        Senator Moran. Ms. Davis defers to Ms. Clancy.
        Dr. Clancy. Or Dr. Kudler.
        [Laughter.]
        Dr. Clancy. I mean, I have visited the one in my
    neighborhood, and my impression is that there is a lot of
    counseling, and right there, and I mean like literally 3 feet
    away, there are also people helping you with employment
    opportunities and things like that. And it's, frankly, also a
    place for veterans to be together.
        Senator Moran. Socialize.
        Dr. Clancy. Yeah. And for some veterans who actually don't
    have that many places to go, this is pretty vital. And you're
    completely right, Senator, these were established at a time
    when people wanted--veterans wanted nothing to do with
    government or official.
        So there's a lot of informal communication between the vet
    centers and our VA facilities. In fact, when I visited mine,
    the one in my neighborhood, not too long ago, they were
    interested in using our telehealth capabilities for continuing
    education with local colleagues.
        Senator Moran. I would also highlight, this may be
    nationwide, but in Kansas, we have mobile vet centers who
    travel the state in a large truck van and----
        Dr. Clancy. Yes. Oh, they're great. There are about 80 of
    them, and as Dr. Kudler just pointed out, they also have the
    satellite technology, so you don't need broadband.
        Senator Moran. Dr. Kudler, does something different happen
    if you show up at the vet center than if you show up at the
    Colmery-O'Neil Hospital?
        Dr. Kudler. Yeah. The fact is that the vet centers, as you
    say, were created for people who didn't really want to
    medicalize their issues and maybe were a little afraid about
    talking mental health, and yet the vet centers are staffed
    primarily by combat veterans, the majority of people who staff
    the vet centers are veterans, and usually combat veterans.
    They're there for readjustment counseling, that's the official
    name, ``readjustment counseling service,'' so you don't have
    that stigma. ``I'm not going for mental health, I'm just going
    for readjustment counseling,'' whatever that may be.
        They can actually read VA medical records. If you're seeing
    a social worker or a psychologist at the vet center, they can
    read our record. We cannot read their record, and that's
    because veterans don't want it to go in that direction. But the
    idea is our teams can work together to coordinate care. For 10
    years, I did telehealth every month into one vet center, and I
    would drive out to another vet center and work with their staff
    and with patients. It is an outstanding complement to the range
    of what we do, and it greatly extends it. And we have yet to
    recognize the full potential of the vet center program.
        Senator Moran. Dr. Davis, let me follow up on your job
    description: people like you. I can better understand Kansas
    than I can all 50 states. So we have all of Kansas in the same
    region, and the eastern Kansas, you talked about Leavenworth
    and Topeka, and then we have the Dole VA Hospital headquartered
    in Wichita. So who in that, in our expanse of our state, does
    what you do? How many more of you are there?
        Dr. Davis. Jason Deselms is in Wichita.
        Senator Moran. So there are two of you.
        Dr. Davis. Mm-hmm.
        Senator Moran. One at the Dole VA Hospital and one at the
    Colmery-O'Neil.
        Dr. Davis. We now have two suicide prevention case managers
    at our VA, and they have one suicide prevention case manager at
    the Dole VA.
        Senator Moran. And what does your staff consist of you and
    those two case managers?
        Dr. Davis. That's us.
        Senator Moran. That's it.
        Dr. Davis. Yes.
        Senator Moran. And I don't know that you'd know this, but
    the amount of geography that you cover or the number of
    veterans, it's a significant expanse for three people.
        Dr. Davis. It is.
        Senator Moran. Three. And a significant demand sufficient
    that we have two VA hospitals in that region with three people
    doing what you do.
        Dr. Davis. And those are roughly 65 miles apart. And I work
    for both campuses, so I'm traveling back and forth between the
    two as well. But I think that the suicide prevention team is
    there in that moment of acute crisis, and then it's necessary
    for us to hand off care then of the veteran to the mental
    health teams. And so that partnership is essential between us
    and the mental health providers.
        Senator Moran. Okay. And is your staffing sufficient to
    meet the goals that you've established for Colmery-O'Neil in
    eastern Kansas?
        Dr. Davis. You know, it is--what we do is an overwhelming
    task. And I've talked about before that when I go meet with our
    mental health teams, unfortunately oftentimes when I'm talking
    about additional duties that we might need for enhanced care
    strategies for somebody who might be at acute risk or with the
    new REACH VET program, when I go meet with those treatment
    teams, I have more than once been met with tears of just
    anguish and frustration, because I think we've worked really
    hard to increase access to care at our VA, and with that, and
    with the increased influx through the Veterans Crisis Line,
    these providers have ever-expanding panels of pretty high-
    acuity mental health needs. And more than one provider has said
    to me that they feel sort of this ethical dilemma between
    trying to provide access to care and also providing the
    standard of care that they feel acceptable not only for our
    high-risk veterans, but also just for the general veteran.
        Senator Moran. You have a Ph.D. after your title, you have
    a title with a Ph.D. Tell me what your background is.
        Dr. Davis. Sure. I received my undergraduate in psychology
    from the University of Iowa, and I have a Ph.D. in counseling
    psychology from the University of Kansas.
        Senator Moran. And the two case workers, they have mental
    health professional credentials?
        Dr. Davis. So one is a mental health nurse. He recently
    transitioned over from our mental health clinic. And the other
    is a social worker.
        Senator Moran. Okay. A part of the theme of my conversation
    with you all today has been the Choice Act. It's been a
    constant conversation of mine with the VA over a long period of
    time. Dr. Davis, do you have the ability to refer those people
    that you talk to the next morning to providers in the
    community? And do you do that?
        Dr. Davis. So if we know that they won't be able to be seen
    in the mental health clinic within a reasonable time, they can
    be placed on the Choice list.
        Senator Moran. Let me ask this question, can they be placed
    on the Choice list simply if they want to be placed on the
    Choice list and don't want to come to the hospital, to the
    mental health center?
        Dr. Davis. Not necessarily. There have been some
    extenuating circumstances where a veteran, for very valid
    reasons, it's not appropriate for that person to be seen at the
    VA, maybe because of experiences that they've had. And so in
    those situations, what I've found is that our local leadership
    is responsive and veteran-centric, and they will absolutely
    allow that person to be placed on the Choice list, even if they
    don't meet the criteria for the number of days out for that
    appointment or I think it's 40 miles to the nearest community-
    based outpatient clinic or hospital. So they will make those
    exceptions.
        But what I've found in my own personal experience is that
    we're talking about the needs of a lot of these rural health
    veterans, when we try to refer out to the community, the VA
    really does a nice job of providing treatment especially for
    PTSD and combat-related PTSD, and there just may not be those
    providers out in the community that are able to do that.
        Senator Moran. I think that's a good point. There are
    certain things that the VA has through history and volume,
    experience, and the collection of professionals that don't
    exist in many other places.
        Let me ask then that question, the question related to
    that, you talked about the mental health center, we would send
    them to the mental health center within the VA is what you're
    telling me. What are the professionals there at your two
    hospitals? What's that mental health center? What do those
    professionals consist of?
        Dr. Davis. Sure. So we call them BHIP teams, Behavioral
    Health something. I'm not sure exactly what that stands for,
    but the mental health teams consist of typically a prescribing
    provider, so that's either a psychiatrist or a nurse
    practitioner, maybe a physician assistant, with a mental health
    nurse and a social worker and a psychologist. And so there are
    kind of varying iterations of that makeup. And so those teams
    exist, and they have veteran panels that consistently return to
    that team to be seen.
        Senator Moran. Okay. And, Ms. Jarboe, my assumption is that
    the people that Dr. Davis is describing in the mental health
    center at the Colmery-O'Neil VA Hospital don't have--I should
    ask the question more neutrally--do they have any experiences
    with the kinds of therapies and programs that your not-for-
    profit promotes and utilizes?
        Ms. Jarboe. I don't know exactly who is being seen there
    for sure, but I know that we've gone out to the Veterans
    Administration, and some people that have gone through an
    alternative program through MVP, we have been the ones who
    placed them in the VA care for additional support, whether it
    be for drug or alcohol treatment or other things. So we could
    kind of swipe back and forth, but I don't have an actual
    factual number.
        We don't bring people outside the PTSD ward from the VA and
    say, ``The Military Veteran Project has the cure-all, we're
    going to fix you today,'' but we're going to say, ``Look, we
    can assist you, but we want to start with the research, too,
    because we also want to see what the pattern is, what the
    diagnosis is.''
        Dr. Clancy. And, Senator, if I might just add briefly, the
    really good news in this space is notwithstanding a shortage of
    health professionals in mental health, we have a growing array
    of options. The real opportunity is going to be trying to
    figure out how to precisely match the options in our toolbox to
    the specific needs of the veterans. So to some extent, there is
    still a bit of shopping around on the part of individuals and a
    little bit of guesswork on the part of professionals. So we're
    getting smarter about that. It's a focus of our research and so
    forth, but there is no precise profile that says this veteran
    should fit in over here.
        Senator Moran. Dr. Clancy, tell me if my concern, the
    nature of these questions is, do we have a separate path that
    the Department of Veterans Affairs believes this is the care
    and treatment that should be provided, and these not-for-profit
    community organizations have a different set of techniques and
    care, and the two shall never meet? And I assume that you're
    going to tell me that that's not the case, we're trying to find
    the best care and treatment for each and every veteran based
    upon their circumstance.
        Dr. Clancy. That is absolutely true, Senator. And, frankly,
    it's a big guiding principle in terms of our thinking about,
    what does Choice 2.0 or the future of that program look like?
    To simply pay for what we're providing already, I mean, to use
    it as surge capacity is helpful, but Dr. Shulkin's aspirations
    are much higher in terms of creating a high-performing network.
    And we recognize that partnerships with organizations like the
    one that Melissa has started, which, I mean, just sounds
    phenomenal to me, enough to make me go to Kansas very soon.
        Senator Moran. We would welcome.
        Dr. Clancy. But, you know, we need to learn from each other
    frankly.
        Senator Moran. Ms. Jarboe, do you get compensated for any
    of the treatment that you provide, the counseling? Does
    somebody pay you?
        Ms. Jarboe. No, sir.
        Senator Moran. All right.
        Ms. Jarboe. I am 100 percent volunteer. Our 1,100
    volunteers, everybody is not paid.
        Senator Moran. And under Choice or other community
    programs, does the VA have the ability to--you talked about a
    partnership, but you could not reimburse an organization, a
    not-for-profit volunteer organization, for services provided?
        Dr. Clancy. I'm going to use Dr. Kudler's line and just
    mention that I'm not a lawyer. I believe the original language
    of VACAA actually framed this in terms of services that
    Medicare pays for.
        Senator Moran. So you would have to have a Medicare
    provider number in order to----
        Dr. Clancy. And that kind of thing, yes. How to make that
    more flexible in the spirit of moving beyond the 40-mile, 30-
    day----
        Senator Moran. [continuing] go with what you were just
    describing as your goal, there may be providers that are
    different than what we're using today.
        Dr. Clancy. Yes. Correct.
        Senator Moran. Okay. This I think is my final question. And
    it's to highlight once again, Dr. Kudler and I had a dialogue
    back in a hearing in the Senate Veterans Committee in 2014, and
    I raised the topic--and I'm going to ask this of Dr. Clancy--
    I've been working to get other professionals included within
    the VA system.
        I know from my experience in Kansas, as a rural state, it's
    hard to attract and retain professionals that we need anyplace
    within the mental health provider system. And one of the arenas
    that we've thought and the VA has admitted has a role to play
    is marriage and family therapists and licensed professional
    mental health counselors.
        And the conversation that Dr. Kudler and I had now 2\1/2\
    years ago indicated that those professions were being
    integrated into the VA across the country. I can't find any
    evidence that that's the case. And so while that direction has
    been given, the numbers--maybe again we can follow up and tell
    me how many people are now working who have that licensure
    within the VA system. But it's one more set of professionals
    that could help fill the gap in the VA. And it seems to me that
    there is a reluctance.
        In fact, the hiring of those individuals now go through
    the--what's the word? Someone help me. Outside. USAJOBS, which
    apparently adds a whole new set of criteria and is very
    discouraging to anybody who is looking to find a job in any
    kind of timeframe. And if you're trying to recruit people,
    sending somebody--you don't do this with all professionals at
    the VA, but these two categories have to go through that
    program, a different organization, to recruit, and it's
    diminishing the capabilities of you hiring folks that I think
    you want to be hiring. And I don't understand why it's more
    difficult for those individuals to find a job within the VA
    than other mental health professionals.
        Dr. Clancy. So we have always had some--one sticking point
    historically had been the accreditation of the training
    programs that some of these people pursued for their terminal
    degrees. It is my understanding that we have expanded our
    thinking, I think might be a better way to say it. And even
    before we did that, throughout our system there were some of
    these people hired anyway.
        I would like, with your permission, to take this for the
    record so that we could give you a very clear lay-down of the
    precise numbers that we have right now.
        [The information follows:]

        The addition of LPMHCs and MFTs to the VA mental health workforce
    has expanded VA facilities' staffing options and enabled VA to better
    meet the needs of a Veteran population increasingly in need of mental
    healthcare services.
        On September 28, 2010, VA facilities were authorized to hire
    Licensed Professional Mental Health Counselors (LPMHCs) and Marriage
    and Family Therapists (MFTs) as specialty mental health providers. This
    was after Congress recognized LPMHCs and MFTs as a specific
    occupational category of mental health specialists in the ``Veterans
    Benefits, Health Care, and Information Technology Act of 2006'' (Public
    Law 109-461). It is important to note the qualification standards for
    each core mental health profession require that an individual in that
    discipline graduate from a program that is accredited by an approved
    accrediting body that credits training programs in that discipline.
    This rule applies to all VA core mental health disciplines (Psychology,
    Psychiatry, Social Work, Nursing, Licensed Professional Mental Health
    Counseling, and Marriage and Family Therapy). Thus, the current
    standards for MFT and LPMHC graduate program accreditation are similar
    to and no higher than the standards for graduate program accreditation
    for other mental health professions in VA.
        As of March 1, 2017, there are now 263 LPMHCs and 123 MFTs onboard
    in the VA. As VA's demand for mental health professionals grows, we
    expect that VA will continue to successfully recruit LPMHCs and MFTs
    into its mental health workforce. LPMHCs and MFTs are still a
    relatively new profession within VA and decisions to hire into these
    occupations are made at a local level, thus the pace of hiring may vary
    from site to site. To ensure mental health leaders in the VA are
    familiar with the LPMHC and MFT professions and are aware of the many
    roles that these disciplines can serve, Veterans Health Administration
    (VHA) Mental Health Services (MHS) has presented information on the
    benefits of hiring LPMHCs and MFTs to VISN and facility level mental
    health leadership and local human resources staff. In addition, VHA MH
    also provided a detailed written presentation about the LPMHC and MFT
    professions for facilities to use in locally marketing these
    professions and promoting them as one of the ``core mental health
    professions'' within VA.
        With regards to ``liberalizing the hiring authorities'', the hiring
    authorities are the same for these professions as for all other Title
    38 hybrid professions. Of note, the qualification standards for the
    Licensed Professional Mental Health Counselors and Marriage and Family
    Therapists are in the process of being updated.

        Senator Moran. Okay. Let me conclude this part of my
    conversation by saying it appears to me that there are
    significant impediments and not much results in the hiring of
    these professionals. And if there is a justification for that,
    I would like to know it. If it's something just bureaucratic or
    cultural, let's see if we can get it resolved and solved for
    the benefit of our veterans.
        Dr. Clancy. Got it.
        Senator Moran. Okay.
        Dr. Clancy. Thank you.
        Senator Moran. The other one I would raise, in that same
    hearing, I raised the topic of the VA using community mental
    health centers. In Kansas, we have 105 counties, all of them
    are covered by a community mental health center. They are a
    gatekeeper. They are the community professionals that provide
    community counseling. And if they need hospitalization, we have
    two state hospitals in which they could be referred through
    that gatekeeper within the community.
        The goal of mine for a long time, long even before Choice
    was in place, was to get the VA to contract with those
    community mental health centers so there would be a point of
    contact.
        Now, Dr. Davis indicated that there are not enough
    professionals out there, but when it comes to counseling, and
    certainly the people who are professional trained and in our
    state are the ones who are by law to make a decision about what
    needs to happen next to someone with mental health issues, we
    still don't have that relationship going between the Department
    of Veterans Affairs and those community mental health centers.
    And I don't know what the impediment was, but if you would put
    that on your--as number two on that list of follow-through with
    me, that would be appreciated.
        Dr. Clancy. Absolutely.
        Senator Moran. Thank you. My final and usual question in a
    hearing like this is, is there anybody on the panel who feels
    like they have not had the opportunity to say what they want to
    say? And you have to say it in less time than I do. Anything?
    Does someone feel like they need to make the record more clear
    or a point that they failed to be able to make because of the
    nature of our questions?
        Dr. Clancy. I would like to thank you and your colleagues,
    Senator. I told one of your staff coming in here that the only
    thing that would have had me worried about this hearing was if
    you didn't care or weren't interested, and that is clearly not
    the case.
        [The information follows:]

        In follow up of Senator Moran's request during Dr. Kudler's
    testimony to the Senate Committee of Veterans Affairs on October 28,
    2015, Dr. Kudler requested that Dr. Rajeev Trehan, Mental Health Lead
    for VISN 15, open a discussion with the Community Mental Health Centers
    (CMHCs) of Kansas about how VA could partner with them to best meet the
    needs of Veterans. This led to a series of telephone and email
    discussions culminating in a meeting with the leaders of the
    Association of Leaders of CMHCs of Kansas held on February 19, 2016.
    Among those in attendance were representatives of 26 Kansas CMHCs, Dr.
    Trehan, the VISN 15 Business Manager, Chief Nurse and Rural Health
    Lead, and TriWest Healthcare Alliance leaders for Kansas. VA, Kansas
    CMHCs and TriWest leads shared information and considered options and
    opportunities. A key finding was that many Kansas CMHCs already had
    good relations with VA, but not all were aware of the possibility of
    becoming a Choice provider.
        Dr. Trehan remains in touch with Mr. Kyle Kessler who leads the
    Association of CMHCs of Kansas. They have discussed new options under
    what is being referred to as ``Choice 2.0'' (currently under
    development). Dr. Trehan is requesting that Mr. Kessler conduct an
    inventory of how many Kansas CMHCs are now Choice providers. Based on
    those findings, Dr. Trehan will work with the Association to explore
    current and newly evolving opportunities for Kansas CMHCs to become
    Choice providers. This would simplify issues of VA reimbursement to
    Kansas CMHCs and also open up new possibilities for exchange of medical
    records, secure communications and other synergies in the shared
    provision of Mental Health services to Kansas Veterans. VA, CMHCs, and
    the Choice network are working to ensure Veterans have ease of access
    to a full continuum of mental healthcare to meet their needs.

        Senator Moran. Thank you very much. And in that regard, I
    would compliment you. We've had a case in Kansas in which a
    physician assistant has been now charged of committing sexual
    acts against veterans within one of our hospitals, and you, Dr.
    Clancy, have been the one who seems most interested in
    providing accountability and answers to other veterans in that
    circumstance. Thank you.
        This gives me the opportunity to bring this hearing to a
    conclusion. Before I do that, I have four outside witness
    testimonies that I would like to have entered into the record:
    one is from Cerner, one is from TriWest, one is from Health Net
    and one is from the veterans of Foreign Wars (VFW). They are
    talking about their research in regard to detecting,
    determining, potential individuals who might be prone to
    suicide and other issues related to this topic today. And
    without objection, I would--I think I'm going to carry the
    day----
        [Laughter.]
        Senator Moran [continuing]. Without objection those reports
    will be made part of our record.
        And then, again, thank you all very much for being with us
    today. In my view, this has been useful. You saw I think almost
    every subcommittee member here for a significant part of this
    hearing, and we take this seriously.
        For veterans who may be watching or listening to the
    hearing, we want you to know that we care. People at this table
    care about you. And by ``table,'' I meant the one in front of
    me, but it's also true of the ones to my left and to my right.
    There is that 800 number, 1-800-273-8255, or text 838255, and
    it may be somebody who knows somebody who needs our attention.
    And one of the things that we've discovered in our efforts over
    a long period of time is there are many veterans and many
    veteran family members and friends who don't know what services
    are available. And so we send you to the call line.
        I would also say, with Ms. Jarboe in the room, there are
    people and volunteer organizations and not-for-profits who are
    interesting and willing in helping you with any challenges that
    you face. And so we encourage you to see folks at your
    community mental health center or VA vet centers, VA medical
    centers, our clinics, crisis centers, as well as suicide
    prevention coordinator at our hospitals.
        For members of the subcommittee, if you have any questions
    that you would like to place in the record to be answered by
    our panelists, please do so, and we would ask that you do that
    no later than May the 4th.

                             CONCLUSION OF HEARINGS

        And with that our hearing is concluded.
        [Whereupon, at 1:02 p.m., Thursday, April 27, the hearing
    was adjourned and the subcommitee was recessed, to reconvene
    subject to the call of the Chair.]

                  MATERIAL SUBMITTED SUBSEQUENT TO THE HEARING

        [Clerk's Note.--The following testimony was received
    subsequent to the hearing for inclusion in the record.]
        Prepared Statement of Douglas S. McNair, Engineering Fellow and
                           President Cerner Math Inc.
                                     cerner
        At Cerner, our mission is to contribute to the systemic improvement
    of healthcare delivery. We develop our solutions with the patient in
    mind, assisting providers with making care decisions that create a
    future where the healthcare system works to improve the long-term well-
    being of individuals and communities. Cerner's health information
    technologies connect people, information and systems at more than
    25,000 provider facilities. Cerner Millennium is the largest globally-
    deployed electronic health record (EHR), and we support clients in more
    than 35 countries, including national health programs in the U.K.,
    Australia, the Middle East, South America and Europe. Cerner's clinical
    solutions integrate behavioral health, lab and pathology, imaging,
    oncology, rehab and pharmacy needs to streamline information access and
    operations, but also to provide insight into diagnosis and care
    planning and make the patient's overall care experience a positive one.
      cerner: a partner who understands the unique government environment
        Cerner supports several Federal agencies including the U.S.
    Departments of Defense, Veterans Affairs, and Centers for Disease
    Control, with their respective missions and healthcare programs to
    better manage processes, as well as clinical data, from beginning to
    end--across all departments, disciplines and care settings--to help
    improve operational efficiencies, cost savings, and the business of
    healthcare. We work closely with our partner clients to get a deep
    understanding of their needs and challenges, then engage and empower
    stakeholders to be champions of change within their own agency. We also
    provide a network of adoption resources, and help to tangibly
    demonstrate value for agency clients by providing the data needed to
    make objective, informed decisions. We also support over 150 state,
    local, tribal and territorial public health agencies, and their health
    centers, safety net clinics, federally qualified health centers,
    community mental health centers, tribal health and drug treatment
    facilities.
        Cerner, as part of the Leidos Partnership for Defense Health, is
    delivering a modern and integrated health IT solution for the U.S.
    Department of Defense (DoD) and the Defense Health Agency (DHA),
    supporting their healthcare mission to provide safe and quality care
    for our nation's 9.6 million active-duty service members, military
    retirees, and family members. This integrated medical and dental health
    record, called MHS GENESIS, is built using one code set that is
    commercially available, off-the-shelf, with relatively little
    customization; that will ultimately inform the clinical decisions of
    the more than 150,000 healthcare professionals in the military health
    system. Access to medical records from the clinic to the battlefield
    will now be seamless, resulting in less errors and delays, improving
    safety and the quality of care for our men and women in uniform. MHS
    GENESIS replaces three existing EHRs to create a single patient record
    and is interoperable with 24 existing military tools and systems,
    including the DoD-VA Joint Legacy Viewer, which allows data sharing
    between the two agencies. The system also is engineered to enable
    interoperability between the private care system and public sectors
    allowing for easy access to a service member's comprehensive medical
    and health history, and the potential for service members to maintain
    their longitudinal healthcare history as they transition from active
    duty to civilian life.
                                     ______

      Prepared Statement of David J. McIntyre, Jr., President and CEO of
                          TriWest Healthcare Alliance
                                  introduction
        Chairman Moran, Ranking Member Schatz and Members of the Committee,
    I deeply respect you for holding this hearing on the critically
    important issue of preventing Veterans' suicides. As long as there is
    even one Veteran suicide in any community anywhere in our country, we
    should not rest. We should treat the loss of even one Veteran to
    suicide as a national tragedy and the loss of 20 Veterans a day as a
    national crisis.
        Veteran suicide is a heart-breaking issue, a complex issue that
    defies simple solutions. If the solutions were simple, Congress and VA
    would already have implemented those solutions. DoD and VA deserve
    credit for having invested untold efforts and resources into solving
    the suicide crisis, but the crisis continues because each case can be
    different from every other.
        While we might not ever be able to prevent every suicide, it should
    nevertheless be our goal. Striving for it should be our mission,
    together.
        I wish I could offer you today a guaranteed solution to this
    crisis, but no one can do that. What I am grateful and humbled to have
    the privilege to do is to share with you some of the lessons learned by
    TriWest as we have worked in partnership with DoD and VA for 21 years
    to reduce suicides by those who wear or have worn our nation's uniform.
    If sharing our experiences with you can help save the life of even one
    Veteran, I will forever be grateful to you for holding this important
    hearing.
        Mr. Chairman, I will share with you some background on TriWest
    Healthcare Alliance for one and only one purpose today: to help you
    understand the nature of our work and the lessons learned regarding
    suicide prevention.
        If I could summarize the most important lessons learned from
    TriWest's 21 years of working in support of DoD's and VA's suicide
    prevention efforts, it would be these:
        1. First, when a service member or Veteran is at the cliff's edge,
    it is critical that there is a clear, simple and quick way for them to
    reach out for help.
        2. Second, it is crucial that a Veteran on the verge of committing
    suicide can talk to someone who can relate to their service and
    situation. The insight of an Army General might explain this when he
    once said, ``Before the soldiers care about what I say to them, they
    have to know I care about them.'' In short, the Veteran needs empathy
    from a fellow comrade, not sympathy from a well-intentioned civilian.
        3. Third, the most effective way to prevent Veteran suicide is to
    intervene with accessible, timely and quality mental healthcare
    services long before the Veteran is seriously considering suicide. No
    healthcare system in our Nation is better equipped to provide that
    expert care than our VA healthcare system. Its expertise in dealing
    with PTSD, TBI, military sexual trauma and war-related combat wounds is
    second to none. However, until the day when VA has enough mental
    healthcare providers within its system to handle all mental healthcare
    patients' needs on a timely basis, VA community care must be used,
    expanded and improved to prevent the tragedy of Veteran suicide.
        Ensuring our nation's Veterans have access to the full range of
    timely, high-quality mental health services they have earned and
    deserve must be our collective mission. Meeting our Veterans' ever-
    growing demand for mental health services is an urgent, life-saving
    priority. We owe it to those who have sacrificed so much for us to
    provide them with the best care humanly possible. We should strive to
    not only prevent tragedy from striking, but also afford our Veterans an
    opportunity to live a healthy, full life.
                                    history
        Twenty-one years ago, TriWest Healthcare Alliance was formed by a
    group of non-profit health plans and university hospital systems. For
    the leadership team of TriWest and our more than 3,000 employees, most
    of whom are Veterans or family members of Veterans, what we do is more
    than a job; it is an honor to which we are steadfastly and passionately
    committed. Our first 18 years were spent helping DoD stand-up and
    operate the TRICARE program in a 21-state area.
        Today, TriWest serves as a partner to VA, administering the
    Patient-Centered Community Care (PC3) Program and Veterans Choice
    Program in our geographic area of responsibility, which includes 28
    states and three U.S. territories. Through this program, TriWest serves
    as a relief valve to VA when it is unable to provide the needed care to
    Veterans in house. TriWest now has over 185,000 community healthcare
    providers in our network, and we have helped over 860,000 Veterans
    receive more than 4.5 million total medical appointments since the
    start of the programs we administer on behalf of VA. This includes over
    25,000 behavioral health providers helping Veterans receive over 56,000
    behavioral healthcare appointments in their community when they cannot
    be seen by VA.
        Of particular focus to TriWest over the past 21 years has been
    serving the mental health needs of our nation's Veterans, active duty
    service members and their families. During our 18-year engagement with
    TRICARE, we learned a great deal and built an extensive mental health
    network around military bases in the 21 states we served. We continue
    to leverage much of that network today in support of the Veterans
    Choice Program and every VA Medical Center in our region.
                         key mental health initiatives
        Through our 21 years of operation, we have developed substantial
    experience in providing quality, accessible mental healthcare services
    and administering suicide prevention programs. We offer the following
    initiatives for your consideration as VA and Congress continue their
    work together to improve mental healthcare services and to prevent
    suicides for at risk service members and Veterans.
        1. Expand peer-to-peer support programs. In 2010, the U.S. Marine
    Corps asked TriWest for help in designing a pilot to increase access to
    mental health support for Marine Corps personnel returning from
    deployment(s). We were privileged to help create the ``DSTRESS Line''
    pilot providing 24/7/365, Marine-to-Marine Peer-to-Peer Call Center
    access to stress/suicide prevention support, staffed by Veteran
    Marines, Fleet Marine Force Navy Corpsmen who were previously attached
    to the Marine Corps, Marine spouses and family members, and licensed
    behavioral health counselors trained in Marine Corps culture. Under the
    program, we provided phone, chat and videoconference capability for
    non-medical, short-term, solution-focused counseling and briefings for
    circumstances amenable to brief intervention, including but not limited
    to stress and anger management, grief and loss, the deployment cycle,
    parent-child relationships, couples' communication, marital issues,
    relationships, and relocations based on the needs of the community
    being served. The Marine Corps leadership believes the program has been
    hugely successful as an efficient, effective and innovative peer
    support program for Marines to access mental health support by talking
    with a fellow Marine they can trust. TriWest provides the staffing
    resources for these critical programs aimed at serving the U.S. Marine
    Corps. On average, there are over 6,000 total program interactions each
    year through calls, chats, and Skype. We believe there are some
    valuable best practices learned in this program that could serve VA
    well as it continues to expand and enhance behavioral health services
    for Veterans.

        Another related program was launched by TriWest in 2016 with the
    Defense Suicide Prevention Office (DSPO). This program, the BeThere
    Peer Support Call and Outreach Center, provides peer-to-peer support as
    part of the DoD's efforts to combat suicide. TriWest provides a 24/7,
    global peer-to-peer suicide prevention program to serve all military
    service members, Guardsmen and Reservists, and their families. This
    program, staffed by Veterans of all the Service branches, builds on the
    successful DSTRESS program that TriWest has been running for the U.S.
    Marine Corps for nearly 7 years. The DSPO contract provides all Service
    personnel and their families with 24/7 comprehensive service member
    peer-to-peer support services through telephone, chat, text and email.
    Calls to the peer assistance line have increased steadily since the
    program launched in October, with an average of 60 interactions per
    week.
        2. Expand mental health training for community providers serving
    Veterans. With a desire to enhance access to needed behavioral health
    services to give VA the enhanced access to these critical services it
    needs, TriWest is moving beyond simply appointing to our substantial
    mental health network of more than 25,000 providers. We have invested
    in and are training our community mental health providers in evidenced-
    based therapies that are known to be maximally effective in meeting the
    needs of Veterans. Known as Operation Treat a Veteran, this
    collaboration between TriWest, the Department of Veterans Affairs, the
    Center for Deployment Psychology, and PsychArmor Institute offers
    evidence-based training to all community-based network providers in the
    28-state TriWest Healthcare Alliance regions of care. Training covers
    two broad topics: Military Lifestyle and Culture; and Evidence-based
    Psychotherapy. The three learning paths have four levels of training.
    Each level of completion corresponds to a level of patient acuity. With
    the completion of each level, TriWest will refer Veterans who require
    primary or specialty care, or the treatment of PTSD with either
    Cognitive Processing or Prolonged Exposure Therapy.
        3. Expand community-based tele-mental healthcare services serving
    Veterans. TriWest has designed and deployed a tele-behavioral health
    platform to connect community behavioral health providers with Veterans
    in need of counseling, who desire the use of this tested modality of
    care delivery. The initial rollout of this initiative was in Phoenix,
    San Diego and Texas, with geographic expansion to come soon as this
    begins to take hold. Under this prototype, we now have served almost
    230 Veterans. As long as there is a shortage of mental healthcare
    providers in many parts of our country, tele-mental health can truly be
    a life saver for Veterans who would otherwise not receive timely mental
    healthcare services.
        4. Expand community mental health options for urgent care. To
    ensure that those who are presenting themselves in VA Medical Center
    Emergency Rooms, where there is a lack of inpatient mental health beds
    to meet the needs of Veterans, VA and TriWest just designed and
    deployed a pilot program in Wichita, Kansas, that would enable us to
    place the Veteran in an inpatient bed with one of our nearby behavioral
    health network providers rather than letting him or her wander out the
    front door without receiving potentially live saving services. This
    pilot builds on a successful, similar one we conducted in Phoenix.
    While we have developed the prototype and have it ready to deploy, VA
    has not yet used this valuable tool in Kansas.
        5. Make it easier for Veterans to schedule an appointment. We are
    working with community providers to make scheduling easier for
    Veterans, including the launch of a self-appointing pilot in Tennessee.
    Under this pilot, Veterans can schedule their own community care
    appointments using TriWest's innovative self-scheduling solution,
    whereby Veterans are able to schedule and confirm appointments, and
    perform other functions such as receive appointment reminders, rate
    providers, or use chat to reach TriWest's customer service personnel.
    Simplifying a Veteran's access to timely care could mean the difference
    between life and death when it comes to providing urgently needed
    mental healthcare services. While the pilot currently is narrowly
    focused to fully evaluate the concept, mental health services are
    included in the pilot. In fact, the first successfully completed self
    appointment was for mental healthcare.
                                   conclusion
        Mr. Chairman, I salute you and this committee for placing a high
    priority on the issue of preventing Veterans' suicide. Our Veterans
    risk their lives to protect American values and society, so when their
    lives are at risk here at home, it is our moral obligation to protect
    them. They have had our back, so now we should have theirs.
    Collectively, we must seize the opportunity to enhance access and make
    the healthcare delivery model more efficient and effective. I believe
    doing so will necessitate leveraging the best of both the public and
    private sectors. No private healthcare system in the country has more
    expertise than VA in addressing the mental healthcare issues that put
    Veterans' lives at risk. The work ahead should not be to replace the VA
    system, but to learn from it and to supplement that VA care in the
    community, when necessary. We look forward to doing our part to support
    VA Secretary Dr. David Shulkin and his team in many areas going
    forward, including in the critical space of supporting VA in delivering
    on the mental healthcare need.
        As TriWest has done for 21 years, we stand ready today to do
    whatever it takes to work with Congress and VA to help protect the
    lives of our nation's heroes. Together, we can succeed and we must
    succeed in this mission, because our Veterans and their families
    deserve no less.
                                     ______

     Prepared Statement of Billy Maynard, President and CEO of Health Net
                             Federal Services, LLC
        Chairman Moran and Ranking Member Schatz, thank you for this
    opportunity to discuss how our experience at Health Net Federal
    Services (HNFS) can assist the Department of Veterans Affairs with
    effort to reduce the incidents of veteran suicides in the United
    States. Building upon almost 30 years of experience serving active duty
    military service members, their families, and Veterans, Health Net has
    developed a full continuum of programs to meet the behavioral health
    needs of this population. Throughout the design and implementation of
    these various programs, Health Net has collaborated with VA and DoD in
    delivering high quality, accessible programs which augment existing
    capacity and capability, both within VA and DoD.
        Specifically, I would like to focus on our experience with the
    Military Family Life Program (MFLC). The Department of Defense has
    engaged private sector firms like HNFS as partners in addressing the
    needs of service members and their families up to the point of
    discharge from the service through the (MFLC) Program. The MFLC Program
    provides short-term, problem- solving situational counseling; program
    includes a network of more than 5,000 credentialed, trained, and
    experienced counselors supporting 118 military installations in 23
    states and territories, and 14 countries. In our work on the MFLC
    Program HNFS provides approximately 35,000 total support contacts each
    week and averages over 1000 Briefings, Presentations and Trainings each
    week to the military and their families. Military Family Life
    Counselors provide brief, problem-oriented non-clinical counseling
    services. They are required to assess risk in the context of non-
    medical interactions and to make referral into clinical behavioral
    health services when indicated. They have particular expertise in
    engaging service members and their families in ways that minimize or
    mitigate stigma. Military Family Life Counselors are deployed on an as
    needed basis. When they are not deployed in support of the MFLC
    program, many of these masters-level behavioral health providers
    maintain clinical behavioral health practices in their home
    communities. As part of our program, MFLC counselors receive extensive
    readiness training and orientation to include military cultural
    sensitivity training. Many of the services developed for service
    members and their families as a result of this partnership are
    innovative, proven effective, and now considered ``best practices''
    throughout the military. Among the ``best practices'' developed through
    this partnership are the following:

      --The development and deployment of a standby capacity that is
            delivered when and where it is needed on a temporary basis.
            This ``surge'' capability can provide brief, non-medical,
            problem-oriented counseling to address issues that arise in
            connection with service related issues such as deployment-
            demobilization-re-deployment cycles of the troops and their
            families. For service members and their families, this means
            that issues that might have otherwise turned into tragedies
            were instead recognized proactively, addressed and referred to
            the appropriate resources for resolution.
      --The engagement of civilian and community-based networks of trained,
            credentialed, mental health professionals to reach the service
            members and their families who are not in the vicinity of a
            Military Treatment Facility. This is often the case for the
            National Guard and Reserve components. The networks also meet
            the clinical behavioral health needs of military beneficiaries
            assigned to a Military Treatment Facility when the demand for
            behavioral health services exceed the capacity or the scope of
            care which can be provided within the military facility.

        In May 2016, HNFS was tasked to begin supporting the United States
    Air Force surge effort to support the service goal to reduce Air Force
    suicides by 50 percent in CY 2016. In support of this mission, HNFS
    quickly deployed Military Family Life Counselors to 30 Air Force
    locations throughout the world providing support from 90 to 180 days.
    The MFLC programs' non-medical counseling structure allows for
    proactive support to be deployed to high risk areas.
        These are proven approaches to quickly and effectively address
    Veterans' need for mental health services, thus reducing the backlog
    and allowing VHA to provide timely appointments for new and established
    patients. To support VA in providing patients with timely access,
    organizations with a large network of mental health professionals with
    specialized training in military healthcare are able to immediately
    implement a ``surge'' model that offers rapid deployment of
    professional clinicians to alleviate short-term demand requirements at
    a VA Medical Center (VAMC) or a Community Based Outpatient Clinic
    (CBOC).
        These rapid-response providers could work alongside VA providers to
    enable the early identification of Veterans who might be at risk for
    suicide or have other serious mental health issues. Such Veterans could
    then be triaged to high priority access to VA providers and facilities
    as soon as possible.
        The surge model could be designed to meet the immediate care needs
    of Veterans, as specially trained clinicians are able to rapidly deploy
    in the communities where Veterans reside. The model works in
    partnership with VA and leverages VA clinical guidelines to deliver the
    high quality care for which VA is recognized. The surge model is cost-
    effective; it maximizes the resources of VA by serving as a short term
    solution to fill in staffing gaps while VA determines long term
    capacity requirements and recruits staff to meet veterans' needs. The
    ability to provide specialized mental health clinicians with immediate
    flexibility to deploy to a VAMC or CBOC would offer powerful support to
    VA in addressing capacity issues and reducing the backlog. It would be
    a significant means to address the urgent mental health needs of
    today's Veterans and help mitigate and prevent larger mental healthcare
    crises, including suicide.
        We appreciate and commend the Subcommittee's attention to this
    important issue and recommend that Congress direct the Department of
    Veterans Affairs to implement a surge program similar to DoD's MFLC
    Program to address the immediate shortfall in mental healthcare
    providers across the Veterans Health Administration.
                                     ______

      Prepared Statement of Carlos Fuentes, Director National Legislative
             Service, Veterans of Foreign Wars of the United States
        Chairman Moran, Ranking Member Schatz and members of the
    Subcommittee, on behalf of the men and women of the Veterans of Foreign
    Wars of the United States (VFW) and its Auxiliary, thank you for the
    opportunity to share our views on how to prevent veteran suicides.
                                 destigmatizing
        The VFW has worked tirelessly alongside Congress and the Department
    of Veterans Affairs (VA) to address suicide prevention. This topic, a
    long-standing priority for the VFW, has been in dire need of addressing
    from many angles. First, the VFW values the importance of getting the
    conversation started about mental health in daily life in efforts to
    destigmatize mental illness. As the stigma decreases, our nation's
    veterans will have the opportunity to become better educated about
    mental well-being and how to address suicide prevention.
        This is why the VFW launched our Mental Wellness Campaign in fall
    2016. We partnered with organizations such as The Elizabeth Dole
    Foundation, Give an Hour, PatientsLikeMe, Walgreens and VA to make
    certain the veterans community engages in conversations about mental
    health. This allows veterans to feel empowered about not only their own
    mental health status, but to also feel empowered to care for their
    fellow brothers and sisters who may be struggling as well. In October
    2016, the VFW launched a worldwide campaign to change direction and the
    narrative on how veterans and the general public discuss mental
    wellness. Throughout the world, over 200 VFW posts partook in various
    events based around education and discussion, with 17,000 service
    members, veterans, their families and communities joined together to
    discuss resources available to veterans and family members suffering
    from mental health conditions. This campaign is continuous, as we
    partner with Student Veterans of America to continue outreach and host
    more events to change direction. Now, the 17,000 who have already
    partaken know to look for the five signs of mental distress:
    personality change, agitation, withdrawn behavior, poor self-care and
    feelings of hopelessness.
        Thanks to new research conducted by VA and other government
    agencies, we now have a more accurate average of 20 veterans who die by
    suicide every day. Yet, only six out of these 20 use VA healthcare.
        This is why the VFW urges Congress and VA to expand mental health
    outreach efforts. VA must strive to remove the stigmas associated with
    mental health conditions. VA must also do more outreach to ensure
    veterans know of the mental health treatments and resources available
    to them not just in VA, but in local communities as well. If we fail to
    improve and expand outreach efforts, the unacceptable number of
    veterans who die by suicide may not decrease.
                                     access
        In order to eliminate veteran suicides, VA must also increase
    access to competent mental healthcare that is individualized to the
    patient. While VA data shows their mental healthcare is making a
    positive impact on those who use it, there is still room for
    improvement. More studies must be conducted to find more innovative,
    empirically proven ways to treat mental health conditions. VA has
    conducted research pertaining to areas such as service animals and
    emerging technologies, but other therapeutic alternatives need to be
    studied.
        When veterans do turn to VA in moments of mental health crisis, VA
    must be able to address these veterans' specific needs. Unfortunately,
    we have all heard stories of veterans who turned to VA in times of
    crisis and were denied the inpatient mental healthcare they urgently
    needed. Congress must fully fund VA inpatient mental health clinics so
    lack of beds is never a reason a veteran takes his or her life.
    Additionally, Congress and VA must expand peer-to-peer support
    programs, which have been successful in helping veterans cope with
    mental health conditions by partnering them with fellow veterans who
    have overcome similar challenges and received specialized training to
    help others do the same. In instances where VA is not able to provide
    immediate assistance, or a veteran requesting assistance does not meet
    the criteria for receiving inpatient care, VA must ensure veterans in
    need are given the opportunity to talk to and receive assistance from a
    peer support specialist. It is common practice in the private sector
    for hospitals and medical facilities to have professionals on call to
    assist patients who check into the emergency room, such as in cases of
    sexual trauma. If VA trains more peer-to-peer support specialists, VA
    medical centers would be able to have scheduled, on-call veterans to
    assist others in mental health crises.
        In the past 3 years, the VFW has conducted more than six surveys
    and compiled five reports on the VA healthcare system, which can be
    found at www.vfw.org/vawatch. A consistent concern we have heard from
    veterans is that VA needs to hire more mental healthcare providers.
    This shortage of providers has been continually highlighted by GAO and
    VAOIG reports in past years. Specifically, the VAOIG's yearly
    determination of occupational staffing shortages across the VA
    healthcare system has placed psychologists among the top five VA
    healthcare professions' staffing shortages. While this shortage of
    psychologists is not a problem specific to VA, but rather to the
    nation, Congress needs to ensure VA has the appropriations and
    authorization to properly hire and retain staffing necessities for
    providers.
                              veteran crisis line
        For veterans who are not physically at a VA facility, but struggle
    with a mental health crisis, the Veteran Crisis Line (VCL) is of dire
    importance. The VCL was established to provide 24/7 suicide prevention
    and crisis intervention to veterans, service members, and their
    families. This was necessary as a means of constant availability to
    individuals in need of crisis intervention. The VCL provides crisis
    intervention services to veterans in urgent need, and helps them begin
    their path toward improving their mental wellness. Each individual
    employee at the VCL is answering an average of nine calls per day, and
    those calls are being answered quicker than 911 and the National
    Emergency Number Association standards. This means that every VCL
    employee is assisting an average of nine veterans in need of immediate
    assistance on a daily basis. When necessary, employees at VCL also
    dispatch emergency assistance for callers in immediate risk of harming
    themselves or others.
        The VCL plays a vital role in VA's initiative of suicide
    prevention, and ongoing efforts to decrease veteran suicide. Yet
    adjustments are necessary for VCL to meet its full potential. The VFW
    believes expanding VA's Office of Patient Advocacy would greatly
    benefit the VCL. By improving and expanding the patient advocacy
    offices throughout VA, employees of these offices would have better
    visibility and means to assist non-crisis patients. If veterans become
    more aware of the patient advocate mission and capabilities, non-crisis
    callers to the VCL would decrease. The VFW has been working to expand
    and improve patient advocacy within VA and we will continue to monitor
    progress. The VFW urges this subcommittee to conduct extensive
    oversight of the VA Patient Advocate Program to ensure veterans are
    able to have their non-emergent concerns addressed without having to
    call the VCL.
        Employees at VCL undergo extensive training before being allowed to
    answer calls, and it takes at least 6 months before they may begin
    training to also answer chat and text conversations with veterans in
    crisis. Yet, it was not until late December 2016 that the VCL had the
    capability to record and monitor their calls. Without this crucial
    technological capability, there was no way for calls to be truly
    monitored for quality control. Now that this capability is available,
    the technology must be properly utilized. Staff at the Veterans Health
    Administration (VHA) and the VCL monitor some ongoing calls for quality
    assurance, but a better, constant process must be implemented to ensure
    these recordings are being used to improve the training and
    capabilities of VCL responders. This would not only improve crisis
    intervention, but would assist with ending allegations of responders
    not understanding or following protocol, instructions, and resources.
        There is no doubt that clinical oversight at the VCL is a
    necessity. Clinical decisionmaking must be made by clinicians and not
    by operations and administrative staff. Leadership running the VCL must
    also have clinical background. This would ensure veterans in crisis who
    call the VCL receive the best clinical judgement and assistance
    possible. Clear guidelines must be established for the VCL so non-
    clinicians are not forcing a clinically based crisis line to operate as
    a business. This has a clear link to quality control as well. The VFW
    believes that while the number of calls going to backup centers
    decreasing at such a rapid rate is a positive, it is not a sign of the
    quality of work being provided. Veterans, service members and their
    families deserve the best clinical care available, and VA is known for
    outperforming the private sector in many areas of healthcare. In fact,
    of the estimated 20 veterans who commit suicide every day, only six of
    them are enrolled in VHA. This shows that clinicians within VA know
    what they are doing, and they do it well.
        The VFW believes VHA must establish both clinical and operational
    policies specific to the VCL. This would allow for easier protocol
    standards to be understood and met on a regular basis, while
    establishing guidance and regulations to continue being followed by
    employees without clinicians stepping on the toes of operations, or
    operations stepping on the toes of clinicians.
        In March 2016, the VCL established a Clinical Advisory Board at the
    request of VHA Member Services. This board was intended to assist and
    work with VHA Member Services, to assure no clinical necessities were
    being dismissed after VCL operations were moved to the non-clinical
    office within VHA. This group was intended to assist VHA Member
    Services in collective expertise of clinicians to improve the veteran
    experience, efficiencies of employees and increased access to the VCL.
    The charter for the advisory board was later changed by different
    leadership within VHA Member Services. The board now has one meeting
    per month where they call in for one hour. Call data is presented to
    the board members, but a monthly hour-long meeting does not provide
    them with the means to effectively obtain clinical input for policy
    decisions to improve the VCL.
        The VFW firmly believes the VCL has improved and will continue to
    improve. Though that improvement will continue to be slow, frustrating
    and life-endangering if the VCL does not begin collaborating with
    others. Aside from working with patient advocacy offices to cut down on
    non-crisis calls and VHA Member Services to readjust the advisory board
    and increase clinicians, the VCL must also work more closely with the
    Office of Suicide Prevention (OSP). Member Services has undoubtedly
    assisted the VCL in quantity control, but OSP can also assist the VCL
    in quality control. If the goal of the VCL is to intervene for veterans
    in need of immediate assistance while they are in the middle of a
    mental health crisis, the VCL should be working with the subject matter
    experts and leaders in suicide prevention and outreach for VA. If all
    three offices could collaborate together, with better guidelines,
    Member Services must be able to continue improving the VCL call center
    expertise and business, while OSP can make sure the VCL is up-to-date
    with the most current clinical expertise on suicide prevention and
    outreach.