[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.
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    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.
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    \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).
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    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.
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    \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.
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    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.
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    \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.
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    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.
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    \16\ Link2Health Solutions, Inc.
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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\
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    \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.
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    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\
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    \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\
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    \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.
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                        the rand corporation\2\
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    \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.
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    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.
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    \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.
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    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.
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    \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.
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    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.
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    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.
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    \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.
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    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.