    [Senate Hearing 116-209]
    [From the U.S. Government Publishing Office]

                                                            S. Hrg. 116-209

       HARNESSING THE POWER OF COMMUNITY: LEVERAGING VETERAN NETWORKS TO
                                 TACKLE SUICIDE

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

                                    HEARING

                                   BEFORE THE

                         COMMITTEE ON VETERANS' AFFAIRS
                              UNITED STATES SENATE

                         ONE HUNDRED SIXTEENTH CONGRESS

                                 FIRST SESSION

                                   __________

                                 JUNE 19, 2019

                                   __________

           Printed for the use of the Committee on Veterans' Affairs

                  [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

            Available via the World Wide Web: http://www.govinfo.gov

                                   __________

                          U.S. GOVERNMENT PUBLISHING OFFICE

    40-610 PDF                 WASHINGTON : 2020

                         COMMITTEE ON VETERANS' AFFAIRS

                       Johnny Isakson, Georgia, Chairman
    Jerry Moran, Kansas                  Jon Tester, Montana, Ranking
    John Boozman, Arkansas                   Member
    Bill Cassidy, Louisiana              Patty Murray, Washington
    Mike Rounds, South Dakota            Bernard Sanders, (I) Vermont
    Thom Tillis, North Carolina          Sherrod Brown, Ohio
    Dan Sullivan, Alaska                 Richard Blumenthal, Connecticut
    Marsha Blackburn, Tennessee          Mazie K. Hirono, Hawaii
    Kevin Cramer, North Dakota           Joe Manchin III, West Virginia
                                         Kyrsten Sinema, Arizona
                           Adam Reece, Staff Director
                    Tony McClain, Democratic Staff Director

                                C O N T E N T S

                                  ----------

                                 June 19, 2019

                                    SENATORS

                                                                       Page
    Isakson, Hon. Johnny, Chairman, U.S. Senator from Georgia........     1
    Tester, Hon. Jon, Ranking Member, U.S. Senator from Montana......     3
    Murray, Hon. Patty, Chairman, U.S. Senator from Washington.......    12
    Boozman, Hon. John, U.S. Senator from Arkansas...................    14
        Prepared statement

    Brown, Hon. Sherrod, U.S. Senator from Ohio......................    17
    Tillis, Hon. Thom, U.S. Senator from North Carolina..............    18
    Sullivan, Hon. Dan, U.S. Senator from Alaska.....................    22
    Sinema, Hon. Kyrsten, U.S. Senator from Arizona..................    24
    Manchin, Hon. Joe, III, U.S. Senator from West Virginia..........    24
    Moran, Hon. Jerry, U.S. Senator from Kansas......................    26
    Cassidy, Hon. Bill, U.S. Senator from Louisiana..................    29
    Blumenthal, Hon. Richard, U.S. Senator from Connecticut..........    31

                                   WITNESSES

    Wilkie, Hon. Robert L., Secretary, U.S. Department of Veterans
      Affairs; accompanied by Dr. Keita Franklin, Executive Director,
      Suicide Prevention Program, Office of Mental Health and Suicide
      Prevention, Veterans Health Administration.....................     4
        Prepared statement...........................................     6
        Response to posthearing questions submitted by:
          Hon. Jon Tester............................................    60
          Hon. Patty Murray..........................................    61
          Hon. Sherrod Brown.........................................    63
          Hon. Richard Blumenthal....................................    70
          Hon. Kyrsten Sinema........................................    75
    Howe, Col. Miguel D., USA (Ret.), April and Jay Graham Fellow for
      the Military Service Initiative, George W. Bush Institute......    33
        Prepared statement...........................................    34
        Response to posthearing questions submitted by Hon. Johnny
          Isakson....................................................    78
    Haynie, J. Michael, Ph.D., Vice Chancellor for Strategic
      Initiatives and Innovation, Founder and Executive Director,
      Institute for Veterans & Military Families, Syracuse
      University, Syracuse, NY.......................................    40
        Prepared statement...........................................    42
    Kavanagh, Jessica, Founder & President, VetLinks.................    44
        Prepared statement...........................................    45
    Quinn, Maj. Gen. Matthew T., Adjutant General and Commander,
      Montana National Guard.........................................    48
        Prepared statement...........................................    50
    Lorraine, Lt. Col. James, USAF (Ret.), President & CEO, America's
      Warrior Partnership, Augusta, GA...............................    51
        Prepared statement...........................................    53
        Response to posthearing questions submitted by Hon. Johnny
          Isakson....................................................    79

                                    APPENDIX

    Satterly, Jennifer, All Secure Foundation; prepared statement....    83
    Wright, Wanda A., Director, Arizona Department of Veterans'
      Services (ADVS); letter........................................    86
    Falke, Ken, Chairman, Boulder Crest Retreat Foundation & EOD
      Warrior Foundation; prepared statement.........................    88
    Kaufmann, Kristina, Code of Support Foundation; prepared
      statement......................................................    95
        Attachment 1.................................................    99
        Attachment 2.................................................   101
    Boerstler, John, CEO, Combined Arms; letter......................   104
    Kelleher, Robin, President/CEO, Hope For The Warriors (HOPE);
      prepared statement.............................................   106
    Parrott, Kim, Sister of Commander John Scott Hannon (Deceased);
      prepared statement.............................................   108
    Kuntz, Matt, J.D., Executive Director, National Alliance on
      Mental Illness (NAMI), Montana; prepared statement.............   109
    Team Red, White & Blue (Team RWB); prepared statement............   115
    Wounded Warrior Project (WWP); prepared statement................   118

       HARNESSING THE POWER OF COMMUNITY: LEVERAGING VETERAN NETWORKS TO
                                TACKLE  SUICIDE

                                  ----------

                            WEDNESDAY, JUNE 19, 2019

                                           U.S. Senate,
                                Committee on Veterans' Affairs,
                                                        Washington, DC.
        The Committee met, pursuant to notice, at 2:30 p.m., in
    room 418, Russell Senate Office Building, Hon. Johnny Isakson,
    Chairman of the Committee, presiding.
        Present: Senators Isakson, Moran, Boozman, Cassidy, Tillis,
    Sullivan, Tester, Murray, Brown, Blumenthal, Manchin, and
    Sinema.

       OPENING STATEMENT OF HON. JOHNNY ISAKSON, CHAIRMAN, U.S.
                          SENATOR FROM GEORGIA

        Chairman Isakson. I call this meeting to order--this
    hearing. I welcome everyone who is here and I think we will
    have a great hearing. We have the good fortune to have
    Secretary Wilkie here and we will hear his testimony in a
    second. We have a second panel of five guests which will be
    very important on many of the issues that are confronting us.
    We will have Q&A from all the Members, the Ranking Member ,and
    myself, as well.
        I have a few things I want to say in my opening remarks and
    then I will turn it over to Senator Tester for his.
        You know, last week was a great week for our country. It
    was the 75th anniversary of D-Day, the 75th anniversary of when
    the American soldiers, sailors, Marines, and paratroopers, went
    into France and then all of Europe and liberated the world from
    Adolf Hitler.
        There would be no democracy in the world today were it not
    for those men that fought for us on those days. There would be
    no place like the U.S. Capitol. There would be no place like
    Washington, DC. There would be no diseases being cured. There
    would not be much of anything going on because that type of
    mentality did not have anything to do with the betterment of
    people.
        Because the American soldier, the American military, and
    the American Congress at the time had the fortitude and the
    guts to commit the money and the resources, we beat
    overwhelming odds and won.
        As I told a friend of mine the other day, I went to
    Normandy last week for the 75th anniversary of the invasion on
    D-Day, and for the 75th year in a row we won. [Laughter.]
        I knew you would get it eventually. And, we won because we
    were the best men and women at the time. We beat insurmountable
    odds and we overcame unbelievable difficulties.
        Yet, a second victory took place last week. The VA MISSION
    Act went into force. So, this was the anniversary. This was the
    75th anniversary of invading D-Day, invading France. It was the
    first anniversary of trying to fix the Veterans
    Administration's delivery of health care.
        I want to say--and Senator Tester and I did not practice
    this, but we have asked each other today twice, and then
    pinched each other when we answered it, and we know this is
    playing with fire to say this, and then all of a sudden you
    cause something to happen, but we have not had any complaints.
    I mean, I did not wake up Monday morning in the last 2 years
    without having a complaint from the VA within 3 or 4 minutes of
    getting up. I did not know what to do.
        I looked around and all the VA hospitals and everything was
    hitting on every cylinder. The doctors were getting veteran
    patients on time to their CBOC or to the hospital they were
    going to. Veterans were getting appointments made in less than
    30 days. Veterans with uniquely difficult injuries, or lifetime
    injuries I call them, the spoils of the type of wars we fight
    today with the type of weapons that we use, people are living
    that never would have lived before, and because of that they
    have to have specialized care with accessibility to specialized
    doctors, of which there are not that many.
        But now, with the new MISSION Act in place, and with the
    VA's attitude--which I commend Secretary Wilkie, first and
    foremost, because every organization is, in a large measure, a
    reflection of its leadership--but what they have done to have a
    can-do attitude about tackling those problems and solving them
    is just unbelievable.
        We have got a lot of problems that need solving; I mean, a
    lot of them. We can talk all day long about the few we have
    solved and be sad about the few we have not.
        But, we are going in the right direction and I think this
    Committee deserves a lot of credit. Jon Tester deserves a lot
    of credit. I can tell you three occasions in the last year
    where the Ranking Member got us through a difficult time on a
    particular issue, that he could have scuttled if he wanted to.
    I knew it and he knew it. He did what he thought was right and
    we got the legislation done, and I am very proud to serve with
    him on this Committee.
        There were times that I did some things for him that I
    wanted to do for him because of the same reason. If you are a
    good team and you are looking for the right goals, you can do
    anything. Well, we are a good team and our goal is to see to it
    that the MISSION Act is first and foremost our mission, to see
    to it that our veterans get the best possible health care.
        So, I just want to thank the Secretary for being here today
    for this hearing and I am going to let you testify in just a
    minute. We are going to have an opening statement by Senator
    Tester. And, all of you that are here for the hearing, welcome
    to the hearing. With that said, I will recognize the Ranking
    Member, Jon Tester.

      OPENING STATEMENT OF HON. JON TESTER, RANKING MEMBER, U.S.
                          SENATOR FROM MONTANA

        Senator Tester. Well, thank you, Johnny. You are way too
    kind. We appreciate your leadership. There is not a person that
    is sitting in this room that does not appreciate what you have
    done as Chairman of this Committee. It has been exemplary, so
    thank you.
        We are here today to--we are here today because suicide is
    a national public health crisis. In different ways, it has
    impacted nearly one of us in this room and as many as 20
    veterans die each day by suicide. That is 20. Stop and think
    about that number.
        I think of folks like Commander John Scott Hannon, a
    Montanan and former Navy SEAL. After returning from war Scott
    rescued and rehabilitated wild animals from the Montana wild.
    He worked with at-risk youth at Habitat for Humanity and with
    the Prickly Pear Land Trust to help veterans access natural
    trails. He was open about his mental health challenges. In
    fact, he was involved with the Montana Chapter of the National
    Alliance for Mental Illness, and was passionate about improving
    veterans' access to mental health care.
        This was a man that mattered. He defended lives while
    fighting our Nation's enemies and he dedicated himself to
    improving lives when he returned back home. Tragically, he
    ended his own life on February 25th of 2018. We need to reflect
    on folks like Scott Hannon before we start patting ourselves on
    the back for a job well done, because this job is far from
    done. What we have done is not enough.
        VA needs to do more. Congress needs to do more. Everybody
    needs to do more. This is not a criticism. It is a reality to
    be acknowledged if we are going to tackle this crisis together,
    and I do not believe it will be solved unless we tackle it
    together. Ultimately, the VA must play a critical role in
    combating this crisis and coordinating veterans' care. We need
    a tip of the spear, someone that can be held accountable for
    the joint efforts moving forward. You, Secretary Wilkie, are
    that person.
        I am pleased that you recently convened a meeting of the
    task force created by the President's PREVENTS Initiative, and
    I hope you continue to bring relevant stakeholders to the table
    for productive discussions that will lead to results.
        The challenges are daunting and addressing the complex
    needs of a diverse veteran population will require a great deal
    of focus, energy, and creativity.
        Women veterans are dying by suicide at nearly twice the
    rate of civilian women, but nobody can tell us why. Former
    members of the National Guard and Reserve who have never been
    activated represent an estimate 15 percent of former
    servicemembers who die by suicide, yet they lack access to many
    VA services. And, veterans with other-than-honorable
    discharges, many who were discharged because of behavior
    stemming from underlying mental health conditions, need
    constant outreach and access to VA services.
        Senator Moran and I, plus several colleagues, have
    introduced the Commander John Scott Hannon Veterans Mental
    Health Care Improvement Act. I believe this legislation will
    improve VA's mental health services and ensure veterans have
    access to both the tradition and complementary mental health
    services that they need.
        Mr. Secretary, to be frank, I need your help and support on
    this bill. It tracks closely with everything you said in your
    testimony and with what we have discussed in person. In States
    like Montana, which VA recently identified as the most
    underserved VA system in the country for mental health, we have
    got a lot of work to do. We know that the VA provides some of
    the best mental health care in the country. The problem is that
    many veterans do not know that and there are often no mental
    health care providers on the ground to provide that care.
        I would like to see the VA increase and improve its
    outreach, expand its telehealth access, and do a better job
    recruiting and retaining mental health providers. I think you
    would agree with that.
        I applaud the VA ATLAS Initiative for working with the VFW
    post in Eureka to set up a telehealth hub less than 10 months
    from the Hi-Line in Montana. Coordinating with outside partners
    can often make a tremendous difference, and I look forward to
    hearing from the community partners on the next panel. They
    deserve a seat at the table because their voices are also very
    important.
        I also want to thank Major General Matt Quinn from the
    Montana National Guard. The Montana National Guard has been
    doing some great work partnering with the State of Montana to
    extend assistance and services to members of the Guard. General
    Quinn's efforts are a great example of local stakeholders
    coming together and finding a solution that makes a difference
    in the lives of our troops and of our veterans, and I want to
    welcome him also to the second panel.
        I look forward to our discussion today, and as always, Mr.
    Secretary, it is good to hear from you.
        Thank you, Mr. Chairman.
        Chairman Isakson. Senator Wilkie, the floor is yours. It is
    yours at any time, except when you see this.
        Secretary Wilkie. Yes, sir.

    STATEMENT OF HON. ROBERT WILKIE, SECRETARY, U.S. DEPARTMENT OF
       VETERAN'S AFFAIRS; ACCOMPANIED BY KEITA FRANKLIN, Ph.D.,
       EXECUTIVE DIRECTOR, SUICIDE PREVENTION PROGRAM, OFFICE OF
         MENTAL HEALTH AND SUICIDE PREVENTION, VETERANS HEALTH
                             ADMINISTRATION

        Secretary Wilkie. Yes, sir. Yes, sir. Well, I cannot thank
    you both enough, not only for the many kindnesses that you have
    shown to me, but for making the cause of veterans in a very
    contentious time in America a nonpartisan endeavor. I thank you
    also for your mentioning of the MISSION Act and the wonderful
    work that thousands of VA employees across the country put into
    making that a success, and turning the corner on a new world of
    veteran service.
        I am also--I would be remiss if I did not thank the person
    sitting next to me, Dr. Keita Franklin. I have had the
    privilege of working with Dr. Franklin both at the Department
    of Defense and the Department of Veterans Affairs. There is no
    person in this country who has done more to raise awareness and
    fight what is a terrible but preventable tragedy in this
    country, and that is the issue of suicide. It is an honor for
    me to be here and I think it is wonderful that the Committee
    has asked her to be here.
        Senator Tester said it--we are the tip of the spear in
    leading an American conversation about the deep causes of
    suicide. In this fiscal year we have screened 900,000 veterans
    for mental health issues, and of those 900,000 we are following
    3,000 because they have given us every indication that they are
    in deep need of additional care.
        Our Veterans Crisis Line has expanded to three call centers
    and is now taking over 1,700 calls a day, which we are, on a
    daily basis, following up with about 200 of those calls with
    active action.
        That is how things have changed at Veterans Affairs. We
    have also seen the beginnings of the cultural change in the
    Armed Forces of the United States. In my father's day, Vietnam,
    nobody talked about mental illness. Nobody talked about
    feelings of anxiety. Now they do, and that will make VA's job
    in the future all that much easier. That is the first step in
    suicide prevention, being able to talk about this issue, both
    privately and publicly.
        The second step is, as Senator Tester said, a national
    conversation, not just about the final tragic act of suicide
    but about factors leading up to that very, very sad day--mental
    health, substance abuse, and homelessness. We must have a
    conversation about the totality of life in America. We are just
    beginning the national conversation that we need, and this
    hearing is part of that beginning.
        So far this year, I have had 85 media engagements, and
    nearly all of them have included a discussion about efforts to
    reduce veteran suicide. Last week I participated in a
    roundtable discussion hosted by the American Foundation for
    Suicide Prevention, hearing from many experts in the field.
        Just 2 days ago, I chaired the inaugural meeting of the
    President's task force on veteran suicide, which is charged
    with developing a roadmap to combat this tragedy. This roadmap
    will create a template showing how government, at all levels,
    NGO's, and others can work together in this effort. It will be
    based on a whole-health approach recommended by experts. It
    will also take account of a whole-of-government effort that has
    been lacking, bringing together VA, Defense, HHS, NIH, and HUD
    to address the many factors that contribute to suicide.
        If we only look again at the last tragic events in a
    veteran's life we will never get our arms around what we need
    to do to prevent this tragedy. Our whole-health approach will
    make inroads in suicide prevention, just as it has made inroads
    in the fight against homelessness. But, the key is flexibility.
    Mental health is the final frontier of medical science. I said
    to the New York Times last month, ``We are not even at the
    Sputnik stage when it comes to getting our arms around mental
    health in this country, and an understanding of where we need
    to go will be a prime factor in combating the issue of veteran
    suicide.''
        So, there is still a lot we do not know as a Nation. One
    thing we do know is that many of those veterans who have taken
    their lives do not have a mental health diagnosis. They may be
    struggling with a change-of-life problem. About half of the
    veteran suicides involve people older than 50, dealing with the
    normal issues of aging, but tragically, most of those are from
    the Vietnam era. For context, Lyndon Johnson left Washington,
    DC, 50 years ago, in January, and we are still dealing with the
    aftereffects of that terrible conflict in Southeast Asia.
        So, we cannot just focus simply on mental health. If we are
    going to make a whole-health effort we have to be able to shift
    resources to where we need them, the one reason I applaud this
    Committee's efforts, in that it is contemplating legislation to
    fund suicide prevention grants that could cut red tape and get
    money and resources to the States, localities, and the NGO's,
    tribal governments, those people who are closest to those on
    the ground that we need to contact. Caring for veterans,
    wherever they are, will be the focus of the task force, and
    your support for that approach is much needed.
        Finally, Mr. Chairman, I want to beg your indulgence and
    just mention something that you, Senator Tester, and I know I
    have had this conversation with Senator Brown, are concerned
    about, which is the Blue Water Navy issue. As soon as we were
    aware that the Federal court would be moving on Blue Water we
    began the process of creating the system that needs to be in
    place to address the claims of thousands of veterans who will
    come under the Blue Water rubric.
        Our people are working. We are working with the Department
    of Defense and the Department of Navy to make sure that we have
    those adequate lists. I cannot tell you the numbers now. I can
    tell you we are working on them.
        I will promise to come back to this Committee if we need
    additional resources, if there is an issue in terms of its
    effect on the progress of claims modernization and appeals
    modernization. But, I did want to assure this Committee, as I
    did several months ago, that I would not oppose the court
    decision and that I would move out smartly in making sure that
    the needs of those who served in the territorial waters of
    Vietnam were taken care of. I thank you for letting me get off
    the beaten track.
        [The prepared statement of Secretary Wilkie follows:]
             Prepared Statement of Hon. Robert Wilkie, Secretary,
                      U.S. Department of Veterans Affairs
        Good afternoon, Chairman Isakson, Ranking Member Tester, and
    Members of the Committee. I appreciate the opportunity to discuss the
    critical work VA is undertaking to prevent suicide among our Nation's
    Veterans. I am accompanied today by Dr. Keita Franklin, Executive
    Director, Suicide Prevention Program, Veterans Health Administration.
                                  introduction
        The health and well-being of our Nation's men and women who have
    served in uniform is the highest priority for VA. VA is committed to
    providing timely access to high-quality, recovery-oriented, and
    evidence-based health care that anticipates and responds to Veterans'
    needs and supports the reintegration of returning Servicemembers. Our
    promise to Veterans remains the same: to promote, preserve, and restore
    Veterans' health and well-being; to empower and equip them to achieve
    their life-goals; and to provide them with state-of-the-art treatments.
        Veterans possess unique characteristics and experiences related to
    their military service that may increase their risk of suicide. They
    also tend to possess skills and protective factors, such as resilience
    or a strong sense of belonging to a group. Our Nation's Veterans are
    strong, capable, and valuable members of society. Therefore, and it is
    imperative that we connect with them as early as possible as they
    transition into civilian life; facilitate that transition; and support
    them over their lifetime.
        Suicide is a national public health issue that affects communities
    everywhere. Just as there is no single cause of suicide, no single
    organization can end Veteran suicide. We must work side-by-side with
    our partners at all levels of Government and in the private sector to
    provide our Veterans with the mental health and suicide prevention
    services they need. As such, VA is dedicated to saving Veteran lives by
    using bundled approaches to prevention that cut across various
    sectors--faith communities, employers, schools, and health care
    organizations--to reach Veterans where they live, work, and thrive.
        These efforts are guided by the National Strategy for Preventing
    Veteran Suicide. Published in June 2018, this 10-year strategy provides
    a framework for identifying priorities; organizing efforts; and
    focusing national attention and community resources to prevent suicide
    among Veterans through a broad public health approach with an emphasis
    on comprehensive community-based engagement. This approach is grounded
    in the following four key focus areas:

         Primary prevention that focuses on preventing suicidal
    behavior before it occurs;
         Whole health that considers factors beyond mental health,
    such as physical health, social connectedness, and life events;
         Application of data and research that emphasizes evidence-
    based approaches that can be tailored to fit the needs of Veterans in
    local communities; and
         Collaboration that educates and empowers diverse
    communities to participate in suicide prevention efforts through
    coordination.
        executive order 13861: national roadmap to empower veterans and
                                  end suicide
        Influenced by the National Strategy for Preventing Veteran Suicide,
    Executive Order (EO) 13861, the National Roadmap to Empower Veterans
    and End Suicide, was signed on March 5, 2019, to improve the quality of
    life of our Nation's Veterans and develop a national public health
    roadmap to lower the Veteran suicide rate. EO 13861 established the
    Veterans Wellness, Empowerment, and Suicide Prevention Task Force (Task
    Force) and charged the Task Force with the development of the
    President's Roadmap to Empower Veterans and End a National Tragedy of
    Suicide (PREVENTS) that includes community integration; state and local
    collaboration aimed at integrating service delivery to and coordinating
    resources for Veterans; and an implementation strategy. The Task Force
    is also required to submit a legislative proposal that establishes a
    program for making grants to local communities that will enable them to
    increase their capacity to collaborate on and integrate service
    delivery to Veterans and to coordinate resources for Veterans.
    Additionally, EO 13861 calls for the development of a national research
    strategy that fosters greater collaboration. The focus of these efforts
    is to streamline research for the prevention of Veteran suicide, as
    well as to provide support service such as employment, health, housing,
    education, and social connection to Veterans at risk of suicide.
        I, along with the Assistant to the President for Domestic Policy,
    co-chair the Task Force and much of the work outlined in EO 13861 is
    well underway. For example, the White House lead and co-chairs hosted
    the inaugural Task Force meeting on June 17th, bringing together EO
    mandated agency representatives, line of effort leads, and work group
    members. To accomplish its assigned duties, the Task Force is working
    with a variety of representatives from across public and private
    sectors.
        PREVENTS (the roadmap) will use the National Strategy for
    Preventing Veteran Suicide as its foundation and will outline
    strategies to effectively lower the rate of Veteran suicide.
    Specifically, PREVENTS will be created by experts within the following
    five lines of effort: 1) workforce and professional development; 2)
    state and local Action team; 3) research strategies; 4);
    communications; and 5) partnerships. Through a holistic public health
    approach, PREVENTS will ensure extensive engagement with Veterans'
    local communities and will leverage the tremendous resources available
    to Veterans. PREVENTS' approach will include strategies and
    opportunities to harmonize existing efforts, and identify promising
    initiatives across the Federal, state, local, and territorial
    governments, as well as non-governmental entities.
        The PREVENTS lines of effort are supported by work groups tasked
    with supporting implementation of EO 13861. For example, the Grant
    Making Work Group, which falls under the state and local Action team
    line of effort, will create a framework for awarding grants to local
    communities to increase collaboration and delivery of resources to
    Veterans. Part of this Work Group's objectives include developing
    program criteria for grant eligibility, eligible organization
    standards, and program evaluation. The purpose of the grant program is
    to promote community integration and bring together Veteran-serving
    community organizations to provide Veterans with coordinated
    streamlined access to services and supports such as employment, health,
    housing, benefits, recreation, education, and more.
        The research strategies line of effort, comprised of
    representatives from multiple agencies and partners, including the
    White House Office of Science and Technology Policy, is charged with
    developing the national research strategy to improve the coordination,
    monitoring, benchmarking, and execution of research in the field of
    Veteran suicide prevention. Much of what we know about suicide has been
    revealed through research. By applying innovative and streamlined
    research, we will continue to develop and deepen our understanding of
    suicide prevention practices and interventions that save lives.
        PREVENTS efforts, including roadmap and research strategy
    development are on track and several actions have completed. The
    completed actions include the development of charters and project
    management plans for each line of effort; the Research Strategies
    Request for Information; and the PREVENTS project plan and timeline.
        The implementation of PREVENTS will empower Veterans to pursue an
    improved quality of life; prioritizes related research activities; and
    prompts collaboration across the public and private sectors, which
    furthers VA's efforts to collaborate with partners and communities
    nationwide to use the best available information and practices to
    support all Veterans, whether or not they are engaging with VA. EO
    13861, in addition to VA's National Strategy, advances the public
    health approach to suicide prevention by leveraging synergies and
    clearly identifying best practices across the Federal Government that
    can be used to save Veterans' lives.
        Through PREVENTS, VA strengthens the national strategy's call to
    action to every community, organization, and system interested in
    preventing Veteran suicide. VA has made great strides in developing
    partnerships. We are leveraging a network of more than 60 partners in
    the public, private, and non-profit sectors to help us reach Veterans
    where they live, work, and thrive, and our network is growing weekly.
    For example, VA and the PsychArmor Institute (PsychArmor) have a non-
    monetary partnership focused on creating online educational content
    that advances health initiatives to better serve Veterans. Our
    partnership with PsychArmor Institute resulted in the development of
    Signs, Ask, Validate, and Encourage and Expedite (S.A.V.E.) a free
    online training course that enables those who interact with Veterans to
    identify signs that might indicate a Veteran is in crisis and how to
    safely respond to and support a Veteran to facilitate care and
    intervention. Since its launch in May 2018, S.A.V.E. training has been
    viewed more than 18,000 times through PsychArmor's internal and social
    media system and 385 times on PsychArmor's YouTube channel. S.A.V.E.
    training is also mandatory for VA clinical and non-clinical employees.
    Ninety-three percent of VA staff are compliant with their assigned
    S.A.V.E. or refresher S.A.V.E. trainings since December 2018. This
    training continues to be used by VA's Suicide Prevention Coordinators
    at VA facilities nationwide, as well as by many of our Veterans Service
    Organizations. By bringing together Federal entities, PREVENTS assists
    VA in our efforts to improve the quality of life of our Nation's
    Veterans and develop a national public health roadmap to lower the
    Veteran suicide rate.
                      mental health and suicide prevention
        We know that an average of approximately 20 Veterans die by suicide
    each day; this number has remained relatively stable over the last
    several years. Of those 20 Veterans, only six used VA health care in
    the two years prior to their deaths. In addition, we know from national
    data that more than half of the Americans who died by suicide in 2016
    had no mental health diagnosis at the time of their deaths.
        When we look at our data, we are concerned that, in the past two
    years, we are seeing a rise in the rates of Veteran suicides among
    those aged 18 to 34. Efforts are already underway to better understand
    this population and other groups that are at an elevated risk, such as:
    women Veterans; never federally-activated Guardsmen and Reservists;
    recently separated Veterans; and former Servicemembers with Other Than
    Honorable discharges.
        We have seen a notable increase in women Veterans coming to us for
    care. Women are the fastest-growing Veteran group, comprising about
    nine percent of the Veteran population, and that number is expected to
    rise to 15 percent by 2035. Although women Veteran suicide counts and
    rates decreased from 2015 to 2016, women Veterans are still more likely
    to die by suicide than non-Veteran women. In 2016, the suicide rate of
    women Veterans at 257 was nearly twice the suicide rate of non-Veteran
    women after accounting for age differences.
        These data underscore the importance of our programs for this
    population. VA is working to tailor services to meet their unique needs
    and have put a national network of Women's Mental Health Champions in
    place to disseminate information, facilitate consultations, and develop
    local resources in support of gender-sensitive mental health care.
        For all groups experiencing a higher risk of suicide, including
    women, VA also offers a variety of mental health programs such as
    outpatient services, residential treatment programs, inpatient mental
    health care, telemental health, and specialty mental health services
    that include evidence-based therapies for conditions such as Post
    Traumatic Stress Disorder (PTSD), depression, and substance use
    disorders.
        While there is still much to learn, there are some things that we
    know for sure. Suicide is preventable, treatment works, and there is
    hope.
       promoting va suicide prevention, whole health, and mental health
                                    services
        Suicide prevention requires a holistic view--not just at the
    systems level but at the personal care level as well. VA is expanding
    our understanding of what defines health care, developing a whole
    health approach that engages, empowers, and equips Veterans for life-
    long health and well-being. VA is uniquely positioned to make this a
    reality for our Veterans and for our Nation. The whole health delivery
    system includes the following three components: empowering Veterans
    through a partnership with peers to explore their mission; aspiration,
    purpose, and beginning their overarching personal health plan;
    equipping Veterans with proactive, complementary, and integrative
    health approaches like stress reduction, yoga, nutrition, acupuncture,
    health coaching, and aligning Veterans' clinical care with their
    mission and personal health plan.
        By focusing on approaches that serve the Veteran as a whole person,
    whole health allows Veterans to connect to different types of care, new
    tools, and teams of professionals who can help Veterans better self-
    manage chronic issues such as PTSD, pain, and depression.
        VA is dedicated to designing environments and resources that work
    for Veterans so that people find the right care at the right time
    before they reach a point of crisis. However, Veterans must also know
    how and where they can reach out and feel comfortable asking for help.
        VA relies on proven tactics to achieve broad exposure and outreach
    while also connecting with hard-to-reach targeted populations. Our
    target audiences include, but are not limited to women Veterans; male
    Veterans age 18-34; former Servicemembers; men age 55 and older;
    Veterans' friends and family; organizations that regularly interact
    with Veterans where they live, work and thrive; and the media and
    entertainment industry which has the ability to shape the public's
    understanding of suicide, promote help-seeking behaviors, and reduce
    the risk of copycat suicides among vulnerable individuals.
        VA uses an integrated mix of outreach and communications strategies
    to reach audiences. We proactively engage partners to help share our
    messages and content; including Public Service Announcements (PSA);
    educational videos; and use paid media and advertising to increase our
    reach.
        Outreach efforts included the Mayors and Governors Challenge
    Program, care enhancements for at-risk Veterans, the #BeThere campaign,
    and development of the National Strategy for Preventing Veteran
    Suicide. This also included, in partnership with Johnson & Johnson,
    releasing a PSA titled ``No Veteran Left Behind,'' featuring Tom Hanks,
    via social media. VA continues to use the #BeThere Campaign to raise
    awareness about mental health and suicide prevention, and educate
    Veterans, their families, and communities about the suicide prevention
    resources available to them. In September, Suicide Prevention Month,
    the suicide prevention program implemented a dedicated outreach effort
    for the #BeThere Campaign, including several Facebook Live events that
    reached more than 160,000 people, a satellite media tour promoting the
    campaign that reached more than 8.9 million on television and 33.9
    million on radio, partner outreach, and more. Through this outreach, we
    generated more than 347,000 visits to the Veterans Crisis Line Web site
    during Suicide Prevention Month.
        Data is also an integral piece of our outreach approach, driving
    how we define the problem; target our programs; and deliver and
    implement interventions. Each element of our strategy is designed to
    drive action. These elements are intended to be collectively and,
    wherever possible, individually measurable so that VA can continually
    assess results and modify approaches for optimum effect.
        All these efforts are with the intent to serve Veterans at risk of
    suicide whether or not they receive services at VA. We continue to work
    to better understand and target prevention efforts toward the 14
    Veterans who die by suicide every day who were not recent users of VA
    health services. These groups comprise many of our target audiences.
    For example, in 18-34 year-olds, suicide rates among this age group are
    increasing, and we are focusing on channels and strategies to get in
    front of this audience.
        We are leveraging new technologies and working with partners on
    live social media events and continuing our digital outreach through
    online advertising. However, VA also continues to rely on our
    traditional partners like Veterans Service Organizations, non-profit
    organizations, and private companies to help us with their person-to-
    person networks and to help spread the word.
                                   conclusion
        VA's goal is to meet Veterans where they live, work, and thrive and
    walk with them to ensure they can achieve their goals, teaching them
    skills, connecting them to resources, and providing the care needed
    along the way. I am honored to co-chair the Task Force with the
    Assistant to the President for Domestic Policy. We will utilize a
    public health approach and include input from cross sectors at all
    levels of government and non-governmental entities. Within one year of
    the EO 13861 signing, the Task Force will submit to the President a
    roadmap to empower Veterans to pursue an improved quality of life,
    prevent suicide, prioritize related research activities, and strengthen
    collaboration across public and private sectors. The Task Force will
    monitor the implementation of PREVENTS and disband two years following
    the submission of the Roadmap to the President. I want to thank the
    Committee for your ongoing support for improving the lives of Veterans
    and in preventing Veterans Suicide.

        This concludes my testimony. My colleague and I are prepared to
    respond to any questions you may have.

        Chairman Isakson. Thank you for getting off the beaten
    track because the next question I was going to ask was about
    that. So, we are glad that you have taken that initiative.
        Let me ask, Senator Brown, did you get a response? You left
    me a voicemail before--you said the Blue Water Navy had some
    question about eligibility?
        Senator Brown. Yes, thank you. I spoke with Senator Tester
    about it. We do not know for sure yet, but I know you have been
    cooperative throughout the whole process. There may have been
    some language that was not quite precise, which I talked to my
    staff about and I know they have talked to yours since then.
    But, we will follow up, and thank you.
        Chairman Isakson. I wanted to make sure that got addressed,
    first of all, and as soon as you know what you can put your
    finger on, if it is there, get it to Secretary Wilkie and we
    will try to work on it together.
        Thank you for what you are doing, Secretary Wilkie, as the
    head of the VA. A couple of questions I want to ask you about--
    and can we ask questions directly to Ms. Franklin?
        Secretary Wilkie. Oh, yes.
        Chairman Isakson. OK. Well, I will ask this to Dr.
    Franklin. Dr. Franklin, how successful are our hotlines that we
    have put in? We put three hotlines in, I think a year ago,
    around the last year, for better access for our veterans when
    they are in a time of trouble and strife. How well has that
    performed? Has it improved accessibility for veterans? What
    experience are we having with it?
        Ms. Franklin. I believe the access has improved. We have
    same-day access to care and we are doing everything we can to
    streamline access. I actually brought the figures with me in
    terms of how many people come in under these same-day access
    hotlines. I can just pull them if you would like.
        Chairman Isakson. Please.
        Ms. Franklin. Off the top of my head I remember over
    100,000, but 1 second. I have the figures with me. [Pause.]
        I am sorry. I cannot put my fingers on it this quickly.
        Chairman Isakson. That is OK. I do that all the time.
        Ms. Franklin. I am sorry.
        Chairman Isakson. We will skip--I will let you look
    through----
        Ms. Franklin. OK.
        Chairman Isakson. You are going to be up here for a while.
        Ms. Franklin. I have the figures with me.
        Chairman Isakson. Well, the reason I was asking the
    question was that when I went out to the new one that was
    established in Atlanta, I guess it was over a year ago now, I
    was astounded how many calls were coming in and how rapidly
    they were coming in. I assume that has only gotten better. And,
    from everything I read about suicide and mental health issues,
    the quicker a person who is in trouble or at risk can make a
    direct contact with a trained or a professional individual,
    that is the best thing you can do to get somebody stabilized
    and not have the actual suicide take place before they get some
    help.
        Secretary Wilkie. Mr. Chairman, while she is looking for
    the figures, I appreciate that comment. This Committee has been
    of great help in getting the message out. One of the myths that
    we had to combat was that when a veteran called the Veterans
    Crisis Line that that veteran would be thrown into voicemail.
    The system does not have a voicemail capability, and the
    average wait time for a live person on the other end to pick
    that phone up is 8 seconds. There are 1,700 calls a day, but
    1,700 calls that require 200 acts of individual intervention,
    which is something that we are seeing play out on a daily and
    weekly basis; it is the front line in the fight.
        Chairman Isakson. Well, the reason I brought it up is 2
    years ago we had a problem with people getting referred to
    voicemail, or ``call in after 10 tomorrow,'' responses that
    made no sense at all if, in fact, you are at your most risk
    when you have that time to call and know you are having a
    problem. So, I think the fact those things--using telemedicine
    to do that has been a big help.
        Secretary Wilkie. I would also add, Senator Manchin is not
    here, but we are working with him to create a national three-
    code call-in to make the process even easier than it is now. We
    have turned over information to the FCC in response to what he
    has been trying to do, to make the system even easier.
        Chairman Isakson. The same question I will ask again, with
    regard to suicide. What have the numbers looked like the last 2
    years? Has it increased? Has it decreased? Is the rate about
    the same?
        Secretary Wilkie. It has barely gone down. One of the
    problems we have is that this is a lagging indicator. We have
    to wait for reports from thousands of coroners across the
    country, in cities, towns, counties. So, the figure that we
    have fall back on 2016-2017. We know that 2 years prior to
    those figures the rate of suicide among veterans was about 22.
    It is down to 20.
        The tragedy there is that 14 of those 20 have no contact
    with VA. Several are on active duty, several in the Guard and
    Reserve, as Senator Tester pointed out, and then another
    tranche, about 10 that we have never had contact with.
        Chairman Isakson. Well, I am glad you answered the question
    that way because--and I will end my time by saying this--
    suicide is a terrible thing. I experienced it in my own family
    and it is a terrible thing to go through for a family; it is
    something you want to block out and not talk about. But, the
    most important thing you can do is talk about it.
        I hope that we will understand that victories are not going
    to be fast or swift when you are dealing with something like
    suicide. The fact that the numbers have not moved that much, or
    they have moved down a little bit, that is good--it does not
    surprise me, because it is a very difficult situation to deal
    with. But, the better we do at making our services accessible
    and our people providing that service educated to deliver the
    service, the better we are going to be for our veterans, and
    the more, over time, we will address the subject, and we will
    reduce the rate of suicide.
        Secretary Wilkie. Mr. Chairman, may I ask your indulgence.
    One note that I made in my opening remarks, and I would like to
    repeat it, is that this is a process for the military that
    really has to begin in basic training, making our troops aware
    of signs within themselves and within their comrades. That is
    something that was anathema in the military culture that I grew
    up around. It is changing.
        Secretary Mattis was all behind that and I took his charge
    as the Under Secretary of Defense for Personnel to get that
    entrained, so that when they enter and they leave they are told
    that it is all right to come to others for help if they feel
    anxiety, if they feel depressed, and that is the first step in
    getting this right.
        Chairman Isakson. Senator Murray.

            HON. PATTY MURRAY, U.S. SENATOR FROM WASHINGTON

        Senator Murray. Mr. Chairman, thank you so much for having
    this hearing. I really appreciate it. Senator Tester, thank you
    for your courtesy, allowing me to go forward.
        I heard Senator Tester's opening remarks. I could not
    concur more. Mr. Chairman, I did not hear yours, but I am sure
    you said all the right things too, so thank you.
        Secretary Wilkie, undoubtedly, community mental health
    providers, social services, many others, have really a key role
    to play in establishing a comprehensive system of support for
    veterans to reduce the number of suicides. A 2014 Rand report
    found only 13 percent of community providers met readiness
    criteria to deliver mental health care to veterans, and last
    year Rand found just over 2 percent of community providers in
    New York meet all seven criteria for readiness to be able to
    treat veterans.
        It seems like we have a long way to go in creating a highly
    effective network in our communities to address this crisis. I
    wanted to ask you, how will you oversee the quality of mental
    health care and services from our community providers and make
    sure care for veterans in need is seamlessly coordinated?
        Secretary Wilkie. That is the key, and I think the goal--
    well, I know the goal of our task force is to make sure that we
    not only have the best standards when it comes to mental health
    care, but that we guarantee that those community providers meet
    those standards. Part of the task force is to create a national
    research roadmap, and I think we will augment the standards
    that VA already has.
        I see the grants, the research grants, the community grants
    that will come out of this--and Senator Boozman has introduced
    legislation today that will get us farther down that road--as
    being the key to making information more readily available to
    our community providers and make their care more robust. Dr.
    Franklin can give you more figures.
        Ms. Franklin. No, I definitely also appreciate the
    question. As a clinician myself, the importance of training
    providers on evidence-based practices and cultural competency
    or cultural humility, if you will, for the military sector and
    veteran is critical important.
        We do have a partnership with an organization called
    PsychArmor that has also taken it on as their mission to train
    mental health providers across the Nation, not only mental
    health providers, but employers and a host of others on how to
    interact with veterans, what are the evidence-based protocols,
    and things like that. I think there is going to have to
    continue to be a push toward this, not only from our partners,
    but also from trade organizations like the National Association
    of Social Workers, APA, the Psychological Association,
    Psychiatry, and getting the standards into their credentialing
    and protocols, then continuing to hit it hard over time will be
    part of the way forward.
        Senator Murray. OK. Thank you. A critical issue covered in
    the Department's National Strategy for Preventing Veteran
    Suicide, but was not touched on in your written testimony, is
    the issue of restricting access to lethal means. Even a few
    seconds that disrupts an individual's intent can end up saving
    their life. This is incredibly important, especially given the
    high proportion of veteran suicide by firearm. VA, I know, has
    taken some steps to restrict access to lethal means, like
    distributing gun locks, but to build on that work, how will
    your strategy expand these efforts to restrict access to lethal
    means?
        Secretary Wilkie. Well, you are correct and it is key.
    Seventy percent of veterans who take their lives do so with
    firearms.
        Senator Murray. Correct.
        Secretary Wilkie. Now, we are dealing with a culture that
    has special familiarity with firearms. It has been part of
    their ethos. The goal here--and we have worked with the
    American Foundation for Suicide Prevention and groups like the
    American Shooting Sports Foundation--is to build into a
    veteran's life time and space between the impulsive thought and
    the final act. That comes with greater awareness in terms of us
    reaching out to veterans and educating them.
        We have a comprehensive education program that we are now
    providing on gun safety. As you mentioned, we give gun locks
    out. ``Lethal means safety'' is something that we take very
    seriously and it is that psychological condition that we have
    to build in, that I think we are starting to do, to increase
    the likelihood that the impulse will not increase the last act.
        But, to go further, the budget that I presented to this
    Committee has $9.5 billion for mental health services. I think
    the House will actually up that number when it finishes its
    work. Part of that will be dedicated to outreach and education
    when it comes to the conditions that lead to a death by
    firearms.
        Senator Murray. I am out of time. Mr. Chairman, I really
    appreciate it. I just want to make sure--I am going to submit
    some questions for the record. One is about our other-than-
    honorable discharge folks and how we can make sure they get
    better access, and also women veterans. I was alarmed that your
    testimony said the suicide rate among women veterans is nearly
    twice that of their civilian counterparts. I often hear from
    women that they do not get the care they need because they feel
    harassed or assume that when they are there they are waiting
    for their husbands. We need to do a better job there. So, I
    will be submitting questions and would like a response on those
    as well.
        Chairman Isakson. I will leave the record open for 5 days
    for additional submissions should you want to.
        Senator Murray. Thank you.
        Chairman Isakson. Senator Boozman.

             HON. JOHN BOOZMAN, U.S. SENATOR FROM ARKANSAS

        Senator Boozman. Thank you, Mr. Chairman. I thank you and
    Senator Tester for having this very, very important hearing,
    leveraging the community to try and do a better job with
    suicides.
        Secretary Wilkie, first I want to thank you for being so
    proactive in this area. We have had a lot of conversations over
    a long period of time, and I know that this concerns you as
    much or more than anyone. We do appreciate your leadership, and
    then also, Dr. Franklin, for the job that you are doing.
        Let me congratulate you, too, on Community Care. We are
    probably not out of the woods yet. There are going to be some
    issues that crop up, but again, I know that you and your team
    have worked very, very hard to do the best you could on the
    rollout. So far, so good; that is very, very good.
        As I mentioned, we have spent a lot of time talking about
    suicide. The problem is that we have the statistics. They do
    not seem to be changing very much. And, as you just pointed
    out, in 2010, the VA requested $62 million for suicide
    prevention outreach, and in 2020, that number nearly quadrupled
    to $222 million. In mental health funds, more generally, we
    gone from about $4.5 billion to almost $9.5 billion. So, we
    have spent a lot of money, and then again, despite this
    significant increase in funding, we have not done a good job of
    reducing our numbers.
        Now, as you point out one of the major problems is most of
    these people are not within the VA system, so it is very
    difficult for you to be able to have a positive impact on that
    if you are not taking care of them. Yet, that is why this
    hearing is so important. What do we do? How do we use the
    community? How do we use all of the things that are out there
    to try to get people in the VA system?
        I would even argue, you know, right now there are
    tremendous resources there but they are not coordinated. And,
    it might even be such that if you Google help, if you are
    somebody in need, you will get probably, I think it is 40,000
    search returns. You know, that can almost be another stressor
    if you are in that problem.
        Again, this is really what it is all about is trying to
    make it such that we can work together to reduce the risk.
        So, I guess the question is, talk to us a little bit about
    kind of what is going on now. You mentioned that myself and
    Senator Warner drafted a bill. We worked very closely with you
    all to try to do things a little bit differently, where we can
    use the community to try to capture folks, you know, and also
    put the metrics in place. What we want to do is recognize
    programs that are working well, plus those up through grants
    and funding, as opposed to just throwing money at the problem.
        Secretary Wilkie. Yes. So, I am going to tell you what the
    five lines of effort are that I have laid out for the suicide
    prevention task force and tell you how the ideas that you have
    put into legislation have actually worked in Little Rock for
    homelessness, and I use that as a guide for the national
    effort.
        So, we will have five lines of effort. One is what you
    said, State and local grants, getting out to the people who are
    closest to those that we do not see in the Department of
    Veterans Affairs. A national research strategy that brings in
    NIH and the National Academy of Medicine. Workforce and
    professional development for our own people, to make them more
    cognizant of the signs that exist in our veterans who may be in
    danger. Then, better communication, and then cementing those
    partnerships that start with grants.
        So, Little Rock has eliminated veteran homelessness. That
    is important because Little Rock has--I mean, Arkansas has one
    of the highest per capita levels of veterans in its State's
    population. What Little Rock went out and did, in coordination
    with the State, was bring in the churches, bring in the
    charities, create a city- and county-wide roadmap for them to
    go into areas where the Federal Government was not, bring
    people off of the streets, get them in transitional homes, and
    then give them to us to help with vocational rehabilitation and
    education.
        I see that happening now with suicide. Senator Sullivan is
    walking in. In his State, 50 percent of the veterans are not in
    contact with VA. Alaska is a State where people can go and get
    lost on purpose. The Alaska Federation of Natives and I have
    had deep discussion about how to get into those remote areas
    and help us find those veterans. State and local grants, of the
    kind that you have laid out in your legislation, will make it
    easier for me to help his people, and then the charities in a
    State like Arkansas, to get out and find those folks. What you
    have is the key, I think, to unlock part of this crisis.
        Senator Boozman. Well, thank you. I really appreciate your
    support, and again, all your hard work.
        Mr. Chairman, thank you.
        [The prepared statement of Hon. John Boozman follows:]
                  prepared statement from hon. john boozman,
                           u.s. senator from arkansas
        Secretary Wilkie, thank you for being here and for bringing Dr.
    Franklin with you to talk about this important issue.
        You and I have spent quite a bit of time talking about what we need
    to do differently in suicide prevention.
        Congress has provided significant resources to the VA to decrease
    veteran suicides, yet the number of veterans who take their own lives
    everyday remains unchanged.
        In 2010, the VA requested $62 million for suicide prevention
    outreach. In 2020, that number nearly quadrupled to $222 million. In
    mental health funds, more generally, we have gone from about $4.5
    billion to almost $9.5 billion.
        Despite the sharp increase in funding, the rate of veterans'
    suicide has remained roughly unchanged at 20 per day.
        You have helped to highlight that many of those 20 per day do not
    have a connection to the VA. Only six of the 20 are receiving
    healthcare services at VA.
        This points to a significant need to empower VA to work through
    community partners to expand outreach, so the topic of this hearing--
    leveraging community networks to reduce veterans' suicide--could not be
    more appropriate.
        Earlier today, I introduced legislation with Senator Warner and
    some of my colleagues on this Committee to enable the VA to harness the
    potential in what is going on in the community.
        The legislation, called the IMPROVE Wellbeing for Veterans Act,
    creates a new grant program at the VA to expand the reach of services
    aimed at preventing veterans' suicide.
        As I was putting this bill together, I put myself in the shoes of a
    veteran who needs help. What I discovered was that there are really
    amazing services available, but they are hard to find and access.
        As you all know, a veteran at risk of suicide may have multiple
    needs--housing, employment, help with a difficult relationship, medical
    care, counseling, and other things.
        The veteran who has to search for help with every individual need,
    is a veteran unlikely to actually access and use the support. Rather
    than those services helping prevent a slide toward hopelessness and
    suicidal thoughts, the experience may be an added stressor that becomes
    another risk factor for suicide.
        A quick search on GuideStar for the term ``veteran suicide
    prevention'' gets you results for almost 40,000 organizations. That
    tells me that the help is out there, it just needs to be coordinated.
        I addressed this in my bill by requiring the VA to work with
    outside groups--before the first grant is awarded--to develop a
    framework for data collection and information sharing to make it easier
    for currently disparate organizations to coordinate. As we will hear in
    our next panel, there are groups that have already figured out what is
    needed to enable that broader coordination.
        Another thing that I focused on as I drafted this bill was the need
    to measure more than just capacity. I am the chairman of the VA
    appropriations subcommittee, so I believe in capacity. I fund it in my
    bill, and as I said earlier, we have significantly increased funding to
    support capacity.
        But, we need to get beyond measuring what we have the capacity to
    do and start measuring the impact of our efforts. As I have been around
    and talked to different groups operating in this space, I have become
    convinced that we can work together to create and use a standard
    measurement tool that helps us in this area. The bill also directs the
    VA to work with outside groups on that.
        I have talked to mental health experts and read up on mental health
    measurement, and I think this is a gap in what is currently being done
    nationally.
        VA has a real opportunity to work with its partners to develop a
    measurement tool that can be used to measure not just what services
    were made available to a veteran but the effects.
        Did the services they received improve their mental outlook and
    mental resiliency? Are they less reactive to stress? Are they eating
    better and making healthier decisions? Are they more connected with
    family, friends, church, and community? Do they feel like their life
    has purpose?
        This is an area where some organizations have already started to
    develop their own tools for measuring these types of outcomes. If we
    could have a common measuring tool, then we could really unleash the
    power of our collective efforts.
        So, the bill will provide VA with the ability to reach far more
    veterans by tapping into what is going on within communities already
    and it provides a framework for better coordinating those community
    efforts and measuring the results.

        Chairman Isakson. Senator Boozman, thank you, and thank you
    for your tireless effort throughout the last year. You have
    been a stalwart of this Committee with the work you have done
    on the MISSION Act, and we appreciate it very, very, very much.
        Senator Brown.

                   STATEMENT OF HON. SHERROD BROWN,
                         U.S. SENATOR FROM OHIO

        Senator Brown. Thanks, Mr. Chairman. Thank you, Mr.
    Secretary, and Dr. Franklin, thank you for joining us.
        The last year we know, for sure, 245 Ohio veterans
    committed suicide, one just this spring while at Stokes Medical
    Center, as you know, the Stokes VA facility in Cleveland.
        We know a number of things. We know that servicemembers
    face stresses that most of the rest of us do not have. It could
    be worry about the disruption when families move and are apart
    from each other. So often that can mean getting a VA debt
    letter because of an overpayment, and worrying about how you
    pay that back. That is why we changed that law. It can be--if
    the Department of Defense was at the table, we would talk about
    multiple deployments, as we do not have enough people volunteer
    for the military. I mean, you know all those things and I
    appreciate your comment that there is no single cause of
    suicide.
        I have concerns. I appreciate the President's Executive
    order. I have concerns it is more of a strategic plan than it
    is an operational plan, and I would like to hear you talk about
    that, in terms of this. My understanding is for every 20
    veteran suicides, 14 of those were veterans who did not receive
    VHA care. Some of them were active duty. That is another issue
    that tells me that the DOD should be at the table with you as
    you figure all this out and work to implement the Executive
    order and other things.
        In some cases, my understanding is that we hear a story
    about veterans who had mental health and addiction issues who
    did not receive a so-called warm handoff when they left the
    service. So, talk to me about how you--if you look at all this
    you see that generally, if the VA has contact with this
    veteran, regular, medical, and psychiatric contact, the chance
    of suicide seems to be significantly less. Talk to me about
    how, when people leave with a less-than-honorable discharge,
    perhaps they did not serve the country as well as they should
    have. I guess it is implicit in that. But, they are still human
    beings. They are still Americans. They still wore the uniform,
    and we have got to find a way to reach them. Calling an 800
    number or sending them a letter obviously is not enough.
        So, what is the follow-up there on particularly those who
    the VHA has not connected with?
        Secretary Wilkie. I am going to take a step back and answer
    your first observation by putting on my former military hat. We
    have not had a national strategy on suicide, both public and
    private, and in order to operationalize the efforts, if we do
    not have a national strategy we will not know where to go.
        You mentioned Stokes. For the Committee's understanding of
    what happened in Stokes, this points to the great difficulty
    that we have had without a national strategy in getting our
    arms around it. That veteran took his life because he was
    facing life-altering surgery. He was going to lose an eye, his
    vocal cords, and his jaw. He did not want to live like that. He
    came to the VA in Cleveland because he knew the care was good.
    He took his life, leaving us a note saying, ``Would you take
    care of my mother?'' That points to the myriad of issues that
    we have.
        The other-than-honorable--again, putting on my military
    hat--we have a lot of ground to make up. You and I talked about
    this in the week before my confirmation hearing. Other-than-
    honorable is an important tool in a commander's toolbox.
    However, in this country it has been abused in the past.
    Thousands of gay Americans were dismissed with an other-than-
    honorable discharge. That has to be rectified. Thousands of
    Americans were dismissed from the service because of injuries
    that nobody could diagnose, and those are the people that we
    have to reach out to.
        Now, they do not represent the majority of those other-
    than-honorably discharged, and the reason it has been so hard
    to contact these people is many of them have a very dim view of
    government, because they were asked to leave the service. We
    have contacted, through letters, 500,000. We have followed up.
    94,000 of those letters have been returned. We know that we
    have treated thousands who did respond. We will continue to
    work that.
        You also rightly pointed out that it is not going to work
    unless DOD is at the table. We have to have more robust
    communication with them on getting their help in finding these
    people. But, I am not skirting the question. It is an
    incredibly difficult population to find because of the nature
    of that military judicial decision that was laid out.
        Senator Brown. In closing, Mr. Chairman, that really
    underscores the importance of it, because the VA has done,
    through all administrations, a reasonably good job of dealing
    with people once VA has them in their embrace, while those that
    you do not need special attention, which you have said, so
    thank you.
        Chairman Isakson. Thank you, Senator Brown.
        Senator Tillis.

                    STATEMENT OF HON. THOM TILLIS,
                    U.S. SENATOR FROM NORTH CAROLINA

        Senator Tillis. Thank you, Mr. Chairman and Senator Tester
    for holding this hearing. Secretary Wilkie, it is great to see
    you. Thank you for your generous time talking with me earlier
    this week as well.
        First off, I want to thank Senator Boozman for the Improve
    Wellbeing for Veterans Act. I look forward to doing everything
    I can to help that be successful, and I expect that it is going
    to be very well-received on both sides of the aisle, on both
    sides of the Hill.
        Going back to, I mentioned when we were on the phone call
    earlier this week, that I firmly believe that with the
    implementation of the new electronic health record and with the
    focus on the integration between DOD and the VA that we should
    be able to get to a point to where we could almost predict, at
    the point of transition, maybe at the point during service, of
    certain experiences that these men and women have had that
    could put them at risk, be a risk indicator for suicide.
        So, as you are going through and implementing, you are
    going over a 10-year process of implementing the new system, I
    know we have work to do, but what are we thinking about now so
    that when we have these integrated system, could be much more
    helpful for us to find somebody, perhaps even before they know
    they may have a challenge?
        Secretary Wilkie. Well, the beauty, Senator, of the
    integrated electronic health record--and we are testing it out
    in the Pacific Northwest and Alaska--I am going to use my own
    father as an example. He was commissioned 2 months before
    Kennedy was inaugurated, 30 years of combat wounds, jumping out
    of airplanes, carried around a 800-page paper record, and it
    was the only record. Almost impossible for a medical provider
    to go through that and determine what the impact of his war
    wounds and the wear and tear of jumping out of airplanes.
        This electronic record will have in it a catalogue of
    training injuries, combat injuries, battlefield exposure. That
    is a guide to any health care provider to divine what might be
    going wrong in that veteran's life and what will be needed to
    support that veteran. I hope it does not last 10 years to
    develop. It is moving forward.
        I hope to have, for the Chairman and the Ranking Member, a
    name for the head of the Joint Program Office. I can tell you
    that Secretary Mattis and I were both committed, that this is
    the wave of the future, and if we can have a record of everyone
    who served in our system, and just punch in a few code words,
    we can make great strides in this.
        You are correct. Right now we do not have those complete
    records.
        Senator Tillis. You actually did work, when I had the
    privilege of having you be the senior advisor in my office, and
    the Department has done great work on trying to extend mental
    health services to veterans. I think that is helpful. What data
    have we seen in terms of the response, to anyone, regardless of
    the status of their discharge, after these policies were
    implemented? What data suggests that we are actually making
    headway, Dr. Franklin?
        Ms. Franklin. Thank you so much. I have the numbers here in
    front of me. After we put the 500,000 letters out to the other-
    than-honorable, 3,520 came in for a visit or a hospital stay,
    an experience in the hospital system. Of those, 2,466 were
    actually treated with a mental health condition, and of those,
    there was follow-on treatment in the context of their
    diagnosis, with 1,413.
        This is important as well, related to your prior question
    to the Secretary, with regard to the electronic health record
    in my sort of part of the world. In suicide prevention we have
    a tool that we often use called a Red Flag. It is a patient red
    flag sort of system, so that immediate when any provider gets
    onto a system they can see if they have a red flag, which means
    that they are at high risk for suicide. So, making sure that
    the same methodologies apply across DOD and VA with the red
    flag process is critically important, and we are eager to see
    it come to light.
        Secretary Wilkie. I would also add, Senator Tillis, that
    this is interoperable, so that if I am treated by VA in
    Fayetteville and I go to my hometown doctor in Aberdeen, and he
    gives me something that VA did not want to give me, then that
    provider puts that into the record and the red flag goes up. It
    is very comprehensive.
        Senator Tillis. Just to dial in, I will just have the staff
    support it, maybe for the record, but I am glad that we are
    reaching out to people with other-than-honorable discharges.
    You mentioned a whole class of people that probably never
    should have been given an other-than-honorable discharge. What
    work is the VA doing on a proactive basis to try to go back
    through that baseline and reach out to say we want to help
    reconsider this and potentially do what we should have done to
    begin with?
        Ms. Franklin. Yes, so the 500,000 letters that went out are
    for all other-than-honorable, not only recent ones. So, in some
    cases they may have gone out to a veteran that received an
    other-than-honorable in the '60s or '70s. The tough spot is
    that 90,000 or so that we are not able to reach. So, I know
    that there has been some conversation between the Department of
    Defense and the VA to try to improve any and all outreach
    measures so that we can reach them, maybe through social media
    or other types of outreach. I do not know if the Secretary
    might have something more.
        Secretary Wilkie. Well, I would also add, as an answer to
    your question, that in my opening remarks I mentioned that in
    this fiscal year we have screened 900,000 veterans for mental
    health issues. We are following 3,000 more closely, who have
    given us indications that they might want to harm themselves.
    We have same-day mental health services. We have reached out
    and are reviewing the records of those who have suffered
    military sexual trauma, for instance. It does not matter what
    their status is as a veteran. Some might not be eligible for
    full VA care, but we are asking them to come in.
        The transition that is now available for troops once they
    leave the service, whether or not they are going to be in VA
    for the rest of their lives, is there. We are not turning away
    anyone who has a mental health issue. That is the key to
    getting our arms around this.
        Chairman Isakson. Senator Tester.
        Senator Tester. Thank you, Mr. Chairman. I want to kind of
    follow on the less-than-honorable that Senator Brown and
    Senator Tillis brought up, as in the rules around it. They can
    come in now for up to 90 days.
        I am hearing that many veterans are getting turned away
    because schedulers were not informed of the change. Have you
    heard that?
        Secretary Wilkie. I have not.
        Senator Tester. It is unfortunate, because the truth is if
    you have not heard it, you cannot fix it.
        Secretary Wilkie. Right.
        Senator Tester. But, the bottom line is I will probably
    have my staff talk with you guys, because that is the
    information we have been getting so there needs to be some
    information trickle down to you.
        In December and January--and you talked about this for a
    second--the Department sent 400,000 letters--maybe it is
    500,000 but 400,000 is what I wrote--to newly eligible
    veterans. These were not necessarily--well, from all types.
    Twenty percent were returned as undeliverable. Do you have a
    plan on how to deal with the 20 percent that never got to its
    ultimate destination, or intended destination?
        Ms. Franklin. I think we are just going to continue to do
    other methods through electronic means, pushing out information
    through other portals, with our partners, The American Legion,
    the VFW, when they are pushing out their literature, and just
    trying to use a host of resources at our disposal.
        Secretary Wilkie. I would say, Senator, again--and this is
    not a reason to slow down--but because of the nature of the
    population, there are many out there who do not want to be
    found, and that is something that I do not have an answer for.
        Senator Tester. Right. You are right; and as you pointed
    out, in Alaska you can get lost, and you can get lost in our
    State if you want to get lost. But, the bottom line is that I
    think we still need to try to do what we can do----
        Ms. Franklin. Absolutely.
        Senator Tester [continuing]. To reach out.
        Last year's suicide data stated that the VA planned to
    expand suicide prevention activities to former members of the
    Guard and Reserve. So, what suicide prevention is the VA now
    offering to those folks? Dr. Franklin?
        Ms. Franklin. Yes. We have spent the last year building up
    increased robust services to the National Guard and the Reserve
    and it began with, like you said, a look at our data. The
    Secretary brought in the leadership of the Reserve and the
    Guard to come to the table on critical discussion. One of the
    first things out of the gate was a lash-up of our mobile Vet
    Centers to every drill weekend. So, we put pen to paper on this
    plan, and they are driving those Vet Centers out across America
    to these drill weekends, with the goal of executing the
    Secretary's vision for building trust and confidence with
    veterans as an organization. We hope to get with them early,
    while they are still serving in the National Guard and Reserve.
        Also, we developed and published a toolkit that really
    speaks to the data, and went on a road show to educate others
    about it. The toolkit has practical application for making sure
    these folks know that they can get into care under something
    that we are calling humanitarian care, if it is emergent; and
    they always have access to our Veteran Crisis Line.
        Senator Tester. Yep.
        Ms. Franklin. Then, from there we have also been working
    with the Congress on a piece of legislation to look at access
    to care for this unique population. Hopefully that will come to
    bear in the coming year.
        Senator Tester. OK. Good. Do you have any metrics on what
    the use is for those mobile Vet Centers? If you do not, that is
    fine, but if you do, could you get that to us?
        Ms. Franklin. Sure. Absolutely. I appreciate also, because
    Chairman Isakson asked me in the opening and I was unable to
    find the numbers then. Forgive me, Chairman. But, it is
    actually astounding. In fiscal year 2018, in terms of access to
    care, with established patients we served over 694,000
    veterans. Then, first-time patients that were just new to
    mental health, and this includes substance abuse as well, we
    served over 129,000. So this, to me, for a large health care
    organization, it is astounding in terms of access to care, such
    large numbers getting same-day appointments.
        But, I will certainly pull the figures on the Vet Centers.
        Senator Tester. Very good.
        Ms. Franklin. Yes, Chairman.
        Chairman Isakson. Thank you very much.
        Senator Tester. Yes. I think this question is for you, Mr.
    Secretary, but under the leadership of Dr. Stone I understand--
    well, maybe it is for Dr. Franklin--VHA is planning to sign a
    memorandum of agreement with the National Guard Bureau. What
    new services would the Guard members gain once that MOA is
    signed?
        Secretary Wilkie. The Guard members will have access more
    readily to, as Dr. Franklin said, our mobile facilities.
        Senator Tester. Right.
        Secretary Wilkie. We are enhancing the transition period
    that now exists for the Guard and Reserve when they leave, more
    robust services during that period.
        Senator Tester. Yep.
        Secretary Wilkie. The same kinds of things that we offer to
    the active side when they come.
        Senator Tester. OK. When will it be signed?
        Secretary Wilkie. We are starting that now.
        Senator Tester. So, is the MOA signed now?
        Secretary Wilkie. I will have to check, but we have already
    put in train the plans for that.
        Senator Tester. OK. And, on the Guard weekends, are they
    serving all Guard members or just those that have been
    deployed?
        Secretary Wilkie. Well, no. We are serving all Guard
    members. We go to their encampments. Obviously, we do not have
    trucks and centers for everybody, but it is important that we
    get out there.
        Senator Tester. I appreciate that. Thank you.
        Chairman Isakson. Thank you, Senator Tester.
        Senator Sullivan.

                    STATEMENT OF HON. DAN SULLIVAN,
                        U.S. SENATOR FROM ALASKA

        Senator Sullivan. Thank you, Mr. Chairman, and, Mr.
    Secretary, thanks again for being here. I appreciate the job
    you are doing. I think you are doing a really good job in a
    really hard position. Your visit to Alaska was very impactful.
    We look forward to having you up there soon. And, I think all
    of us and you agree that this is a hugely important issue. So
    many of us have been impacted by this issue. So, many of our
    constituents have been impacted by this issue of suicide.
        You know, I lost a young Marine who was under my command to
    suicide many years ago, but I think most people in this
    position, whether in the military or otherwise, we are always
    asking, you know, what more could we have done? What more could
    we have done? So, I think this is why you are seeing this very
    bipartisan focus.
        You already talked about Alaska, a great place to--I think
    you said it; I did not say it--to get lost. But, it is big and
    open wide and we are looking forward to, like I said, getting
    you up there. But, you know, the broader national metrics of
    the 20 suicides of veterans per day, my understanding is that
    70 percent--I think you may have touched on this--are not using
    the VA services, nationally. In Alaska I think it is over 50
    percent. Our VA, our Alaska VA, is working on a big initiative
    to try to close that gap, get people in the system. And, as a
    critical first step your VBA has selected the State of Alaska
    as a case study and pilot initiative to look at broader
    components of a national outreach strategy.
        What exactly are you looking at us--us, meaning my State--
    but others to try to do here, and how can we make sure that as
    we team up with the VA--we, Alaska--that the pilot study and
    initiative is best utilized?
        Secretary Wilkie. Well, I think because of Alaska's unique
    relationships within the State, with tribal governments, with
    the Native Health System, and the ability of the State of
    Alaska that is unique to Alaska to have State resources get out
    into the most remote sections of this country, what we are
    looking at in Alaska is the ability to partner with all of
    those entities.
        You know, when I addressed the Federation of Natives I
    asked them to double the number of tribal representatives that
    they have, to get out into the wilderness and help us. I
    mentioned Senator Boozman's legislation being a vehicle for us
    to give them the support that they need to do that. The beauty
    of Alaska is that the Tribal Health System is second to none,
    and we have an advantage there that we do not have in a lot of
    places.
        Opening the aperture on grants, opening the aperture on
    Federal Government to State, local, and tribal governments is
    the key to getting our arms around this.
        Senator Sullivan. Thank you. We look forward to working
    with you on this, and we appreciate being part of that
    initiative.
        Let me kind of broaden it. You mentioned Alaska Natives and
    lower 48 Indians. The PREVENTS Task Force, which I certainly am
    supportive of what the President is doing, it has
    representatives from 10 separate executive agencies, but I do
    not think that IHS is part of that. And, as you know--and maybe
    I am wrong here--but as you know, in my State, and I think
    nationally, you have this incredible, what I call in Alaska, a
    special patriotism with regard to our Native community, that
    serves at higher rates than any other ethnic group in the
    country, lower 48 Native Americans as well, which is amazing,
    something that is wonderful. But, these communities often also
    have very high suicide rates.
        So, is there any thought about getting IHS in there,
    because it seems like it is a natural that it should be part of
    this task force.
        Secretary Wilkie. I will make a confession, and that is I
    will check. I had a whole panoply of Federal officials in front
    of me yesterday. I will say that we buy $1 billion a year worth
    of care from IHS. I was actually on Native American radio in 70
    tribal areas yesterday, talking about this. You are absolutely
    right. If I find that they are not in the room I will get them
    in there.
        Senator Sullivan. Yeah. I think they should not just be
    kind of asked on occasion. I think they should be permanently
    part of it.
        Let me just ask one final question, Mr. Chairman, if it is
    all right. Can you speak, Mr. Secretary, very quickly, to the
    progress on the VA's Mental Health Hiring Initiative, which
    again, is another very important related topic?
        Secretary Wilkie. The Mental Health Hiring Initiative
    started, in part, because of the efforts of this Committee in
    June 2017. The goal was to increase the population of mental
    health professionals in VA by 1,000. Since that time, we have
    hired 3,900 mental health professionals, and there is a net
    gain in there of several hundred.
        Where we have a palpable vacancy is among mental health
    nurses. We have about an 8.5 percent vacancy rate there, that
    we have to do better. Yet, we are actually ahead of the goal
    that the Committee wanted us to have when we started down this
    road back in June 2017.
        Senator Sullivan. Thank you. Thank you, Mr. Chairman.
        Chairman Isakson. Thank you, Senator Sullivan.
        If Senator Sinema would pause for 1 second before I
    recognize her.
        We always talk about the quality of our recruits, to make
    our military the best it can be in the 21st century. We talk
    about the STEM subjects. We talk about the youth of our
    country. We talk about all the people we need to make our
    military strong. I noticed a couple of them happened to wander
    in the room a minute ago, and I think they ought to be
    introduced.
        Senator Manchin, would you introduce these two suspects
    over here?

         HON. JOE MANCHIN III, U.S. SENATOR FROM WEST VIRGINIA

        Senator Manchin. I would be delighted to introduce those
    two suspects. I am happy to have part of my family with me
    today. I have my brother-in-law, Manuel Llaneza, and his
    grandsons and my nephews, Domenic and Manny. They are right
    behind you. They are learning. [Applause.]
        And, they understand the services that have been given to
    our veterans and the importance for us to serve them now, so I
    am very happy that they are here and enjoying this.
        Chairman Isakson. Senator Sinema.

                   STATEMENT OF HON. KYRSTEN SINEMA,
                       U.S. SENATOR FROM ARIZONA

        Senator Sinema. Thank you so much, Mr. Chairman. I
    understand that Senator Manchin has to take these young men on
    a tour so they can get ready to take his job some day. If I
    might, could I----
        Senator Manchin. Sooner than we think.
        Senator Cassidy. I am hoping they are Republicans, but that
    is OK.
        Senator Manchin. Well, Manny is from Louisiana, Baton
    Rouge.
        Senator Sinema. He is coming for you.
        Might I yield a moment of my time to Mr. Manchin so that he
    could ask his question and then take his nephews out? Would
    that be OK?
        Chairman Isakson. That would be fine.
        Senator Sinema. Thank you so much.
        Senator Manchin. Thank you, Senator Sinema. Let me just say
    that, first of all, Secretary Wilkie, I want to thank you
    because your office has been working with us on the three-digit
    hotline, which is so important.
        So, for our audience and for the public, one of the first
    lines of defense that we have, all of us know, in times of
    emergency, and especially preventing a veteran suicide or the
    crisis line is the hotline that we have. The number is 800-273-
    8255. How many of us could remember that? I mean, right now we
    know 911 is ingrained in our minds.
        So, we are going for that three digit. You all have been
    real receptive. I want to thank you. It is something that we
    need to do. We have that bill, and we will be introducing that
    bill shortly. I am asking all of my Senators to cosponsor, if
    you would. I think it is a great tool for our veterans, and
    hopefully we can help save some of our brave young men and
    women.
        Next, I would like to talk to you about the gold standard
    for care integrated-coordinated services, which the VA does, I
    believe, better than anyone in the private sector. For many
    veterans in West Virginia and across the country, the VA is the
    best, most cost-effective care that they can get, and it is
    what they want. So, it is our duty to make sure that community
    care is as good or better than the VA and that it is as
    coordinated and integrated, especially with a whole set of
    veterans accessing community care now through the MISSION Act.
        So, my question would be, Mr. Secretary, how has the VA
    determined how each community is prepared to coordinate with
    the VA when dealing with mental health and suicide prevention?
        Secretary Wilkie. Well, first of all, I cannot thank you
    enough for your work that you are doing on those three numbers.
    We have turned over, at your request, our findings to the FCC
    and hope they turn those decisions around quickly in
    anticipation of introducing the legislation.
        Our VISN directors across the country are responsible for
    making sure that those parts of the Community Care network,
    also in coordination with the system that provides for
    community care, meet the standards that we expect of those
    treating our veterans with mental health issues. I think you
    are right. Our care is second to none on mental health. I do
    not anticipate many veterans leaving our system to take
    advantage of community care, because you have said it in your
    presentations--it is the one place where they go and people
    understand the culture and speak the language.
        The other thing that is important, particularly in a State
    like West Virginia, and also on the issue of mental health, is
    getting telehealth out into the counties, to the libraries,
    making it as easy as possible for people to access that.
        Senator Manchin. Let me just tell you, the challenge we
    have there is called Rural Broadband Initiative. We have got so
    many people that are not connected in rural America, rural West
    Virginia, and that is something we have to do, and do
    immediately.
        The other thing, just as I am finishing up, in the
    community, the network that will take care of these veterans,
    do you all vet them to make sure they are able to give the
    services at your standard and the standard we expect veterans
    to get?
        Secretary Wilkie. Yes, sir. We are still actively vetting,
    so, yes, we do. We are not going to send a veteran out into the
    field without us knowing where he or she is going.
        Senator Manchin. Thank you, Mr. Secretary. Thank you, Mr.
    Chairman.
        Secretary Wilkie. Mr. Chairman, may I ask your indulgence?
        Chairman Isakson. Absolutely.
        Secretary Wilkie. The question was about the mental health
    providers, and the number that we have, in VA we have, right
    now, about 6,000 psychologists on the payroll, and 3,300
    psychiatrists, in addition to that 500 mental health nurses. We
    are 8 percent vacant in that area and we are trying our best to
    engage in more nursing school relationships across the country
    to increase the flow of nurses into the system.
        Chairman Isakson. Thank you very much.
        Now did you yield some of your time to Mr. Manchin, or did
    you want me to go to you next?
        Senator Sinema. Mr. Chairman, I did, but he took it all,
    so----
        [Laughter.]
        Chairman Isakson. You actually have 1 minute and 38
    seconds.
        Senator Sinema. How about we have another Member go and I
    will take my time later. Is that OK?
        Chairman Isakson. OK.
        Senator Sinema. All right. Thanks.
        Chairman Isakson. Without objection.
        Senator Moran.

                    STATEMENT OF HON. JERRY MORAN,
                        U.S. SENATOR FROM KANSAS

        Senator Moran. Thank you, Mr. Chairman. Thank you and
    Senator Tester for this hearing.
        Secretary Wilkie, you perform some of your best work while
    wearing a boot. I have joined you, and I hope to do that as
    well.
        You have--let me start with this. The grant-making working
    group that is proposed, how do you envision it? Do you envision
    that there will be community organization stakeholders to be
    members of that working group?
        Secretary Wilkie. Absolutely.
        Senator Moran. Then, I think it makes sense to me and I may
    have some suggestions if you are willing to entertain those.
        Your proposal that the Department is working on to connect
    community organizations and State and local governments, you
    mentioned Senator Boozman's efforts; Senator Tester and I are
    leading an effort in regard to suicide prevention called the
    Commander John Scott Hannon Veterans Mental Health Care
    Improvement Act.
        Here is my question and/or request. Is there any reason
    your proposal could not be incorporated into the legislation
    that we are talking about, that a number of the Members on this
    Committee have introduced, and mark up in that fashion to move
    to the Senate floor? Here is a bit of a complaint. We are
    waiting on VA technical assistance on our bill, and we have
    been waiting a couple of months. As you do that VA technical
    assistance, perhaps you can incorporate your suggestions and
    improvements into the bill. I would encourage you, if you are
    interested in this, to visit with Senator Tester and me and
    other Members of the Committee to see if we can have a result
    that maybe is more-----
        Secretary Wilkie. Yes. I will come visit you. I will be
    very candid. We are just starting down this road to develop a
    national strategy and then operationalize those efforts. I do
    think that having a list of things that we must do, without
    having that national roadmap, may create a problem for us in
    terms of our capacity to carry out those programs.
        We are very deep into alternative therapies on the opioid
    front and the pain management front. I do not know that we have
    the abilities to carry out many of the programs that are in the
    legislation. I will go back and take another look, but when I
    sit down and talk with you, that will be the premise that I
    start with, that if we are going to make these programs work we
    have to be able to carry them out, and right now, as the head
    of this task force, what I see as the most readily available
    means at our disposal to address veteran suicide will be that
    grant portion, where we can engage the local community.
        Senator Moran. That is useful and understandable. A
    significant portion of Senator Tester's and my bill is related
    to community organizations and their involvement in suicide
    prevention--you and I have had conversations. This Committee
    has worked on Community Care. How do we get things closer to
    where people live and more readily available. So, there is no
    question. I think that we are aligned and I would welcome that
    conversation.
        Mr. Chairman, I know the vote has been called. I will not
    have a chance, I suppose, to--I want to hear the next panel's
    testimony, but in my absence I would like to highlight that we
    have a Kansan, Ms. Kavanagh, who is a panelist on that, and she
    has impressed me and my staff greatly; I am pleased that she is
    here today to testify. I encourage my colleagues on this
    Committee to pay specific attention to her and her story and
    her mission. Her daughters are with her as well, and we are
    delighted to have them here.
        Mr. Chairman, I thank you for the opportunity to testify
    before I go vote.
        Chairman Isakson. Senator Sinema.
        Senator Sinema. Thank you so much for your understanding
    and kindness, Mr. Chairman, and thanks to both of our witnesses
    for being here today. Secretary Wilkie, I look forward to
    meeting with you to discuss the priorities we have for Arizona
    for the VA, and I am really glad you are here before the
    Committee so we can hear about the VA's work to address veteran
    suicide.
        As you know, the VA's national strategy for preventing
    veteran suicide states, ``we must go beyond engaging mental
    health providers to involve the broader community and reach
    veterans where they live and thrive before they reach a crisis
    point.'' I could not agree more, which is why I authored the
    Sergeant Daniel Somers Network of Support Act.
        Sergeant Daniel Somers was an Army veteran who completed
    two tours in Iraq, participated in over 400 combat missions as
    a machine gunner in the turret of a Humvee. Like many veterans,
    Daniel suffered from nightmares, depression, and symptoms of
    Post Traumatic Stress Disorder and Traumatic Brain Injury.
    Sadly, Daniel lost his life to suicide and he became part of
    the reason we are having this hearing today.
        My bill, which was recently included in this year's
    National Defense Authorization Act, requires the Department of
    Defense to collect from new servicemembers the names and
    contact information of loved ones that they consider to be
    members of their own personal support network. Using this
    information, the Department of Defense can provide information
    to those families and loved ones about available benefits and
    services. Members of this network of support are often the
    first in the line of defense to prevent suicide, and they are
    the best people to reach veterans where they live and where
    they thrive.
        So, my first question for both of you is, is this something
    you believe the VA could benefit from, in incorporating this
    program into its unit, and if yes, can I get your commitment to
    work with my ops and my team to help develop this program for
    newly enrolled veterans after they disconnect from service?
        Secretary Wilkie. I will; and I am going to now put on my
    old hat as the Under Secretary of Defense for Personnel.
        I talk a lot about culture. What you are doing is part of
    that change. It is no longer the 1940s version of military
    service. There are not tens of thousands of draftees coming
    into the pipeline, so that people are more readily moved out.
    Family support is key. Having that information, I think, is
    vital, and I will do everything that I can to make that happen.
        Ms. Franklin. Yes. I also appreciate the question and I
    have also been working with the Somers for quite a few years. I
    worked on the DOD side and now on the VA side, and I am so
    pleased that you were able to push that through. Also, I am a
    bit embarrassed that it took a bit piece of congressional
    legislation to do it, because it is a very simple, common-sense
    approach. And despite the fact that it seems so simple, it is
    actually also life-saving.
        And, just because a young man, a young soldier like Daniel
    Somers, was over the age of 18, and you might think that his
    parents might not know or need to know. It is absolutely not
    the case.
        Your legislation that pushes out proactive education and
    content to loved ones and family members of people that have
    served and teaches them about signs and symptoms of suicide
    risk, Post Traumatic Stress, even just everyday coping skills,
    it is an important piece and I am very grateful that you did
    it, so thank you.
        Senator Sinema. We are really looking forward to expanding
    this through the VA, so that servicemembers, from the time they
    start to the end of their natural lives, will be able to have
    this network of support, and people who are ready and prepared
    to help them. Thank you.
        All you all know, 14 of every 20 veterans who die at the
    hands of suicide are not being seen by VA providers today. As
    the national leader in suicide prevention, and the largest
    integrated health care system with experience in preventing
    veteran suicide, the VA has a lot to offer.
        In 2014, when I was in the House, I cosponsored the Clay
    Hunt Act, the SAVE Act. We signed it into law in 2015, and it
    is was an important stepping stone. But, one piece of the bill
    requires the VA to annually evaluate its mental health and
    suicide prevention program. What are the things that you are
    learning from these assessments, and how are you using the
    information that you are learning to improve programs and
    community initiatives?
        Ms. Franklin. Yes. We are tracking quite closely on the
    Clay Hunt Act and appreciate the opportunity to provide you an
    update on that question. There has been a number of positive
    results that have come about since the Clay Hunt Act was
    passed, and we have learned about those from the third-party
    evaluations.
        We have learned that veterans that come in report that
    their health care has had a positive impact, that there has
    been an increase in psychological health care as a result of
    the Clay Hunt work. We also evaluate satisfaction, whether they
    have satisfaction reports related to their care, and all of
    those metrics are going in the right direction.
        At the same time, we are learning that the veterans would
    like us to have more flexible work schedules, more flexible
    work structures. Also things like uncommon work schedules,
    nights, evenings, things that need to occur to improve employee
    retention and employee satisfaction.
        We are also learning that we need to dedicate the peer
    support specialists that you authorized through the Clay Hunt
    Act. We, in some cases, have existing employees become
    collateral duty, if you will bear with that term, but
    additional duty as assigned, peer support specialists, which we
    learned fast and early that we had to shift from that model. We
    have now hired over 1,065 peer support specialists with a way-
    forward plan to hire even more.
        Then, the other sort of big lesson that we have learned is
    we need to improve the connection between VA programming and
    non-VA programs. Sometimes the coordination was not there, and
    that is what our third-party evaluation highlighted. So, we
    have put a number of practices in place to improve that,
    encouraging our employees to join coalitions in their community
    and to engage and make sure that the programming outside the
    gates, if you will, is coordinated, targeted, and responsive
    and complementary, overlapping, and duplicative.
        Senator Sinema. Thank you. Thank you, Mr. Chairman.
        Senator Tester [presiding]. Senator Cassidy.

             HON. BILL CASSIDY, U.S. SENATOR FROM LOUISIANA

        Senator Cassidy. Thank you. Mr. Secretary, thank you for
    being here.
        Just to set context, you and I previously discussed
    something which is not well understood, which is that the
    veteran who did not see combat is more likely to commit suicide
    than the veteran who did see combat.
        Now, the fact that that veteran, while in the service, was
    not put into combat, suggests to me that the Department of
    Defense has a way of psychologically evaluating folks who would
    be able to handle the stress of combat and who are not; and
    those who can, are, and those who are not, not.
        So, Senator Tester and I have a bill that we are going to
    submit for NDAA that would encourage--and you and I have spoken
    of this concept, but this is a bill that kind of codifies--that
    would have VA and DOD coordinate more closely so that if there
    has been an evaluation by DOD that someone is not emotionally
    resilient, therefore, should not go to combat, that that
    information would somehow be transmitted to VA. We know the
    transition points are most when someone is at risk--the first
    period of time, 6 months or so, after separation from active
    duty is the peak for suicide.
        You and I have spoken of that, so I guess my first question
    is has any progress been made in terms of this coordination of
    information between the two, DOD and VA? We have spoken of that
    previously in terms of the integration of the electronic health
    record, which you had mentioned in the past would be a priority
    of yours, to make sure there was top-level accountability on
    that. Then, more broadly, the concept of how are we getting
    information from the DOD to VA, regarding the emotional
    resilience of someone when they separate from the service?
        Secretary Wilkie. Based on your efforts, it is part of the
    discussion on the electronic health record. That has been the
    focus, because that is going to be the most readily available
    tool.
        When I look at the combat statistics, the tooth-to-tail
    ratio in Vietnam was 1-to-17, meaning 17 people supporting the
    one person in combat. It is almost there this time. And, the
    more I look at it, wearing my Air Force officer hat, it is not,
    in most cases, an issue of psychological resiliency. In most
    cases it is just a question of need. There are very few units
    in the military where psychological testing is a be-all and
    end-all. The submarine service----
        Senator Cassidy. No, I am not--I am not--just because we
    have limited time, may I interrupt. I am not necessarily
    digressing as to what is the measure of resiliency or whether
    or not it takes place. The fact that if you are in combat you
    are less likely to commit suicide does tell me something. And
    what I am really concerned about, is there a communication of
    who would be at increased risk from DOD to VA?
        Ms. Franklin. Yes. If I--thank you, Mr. Secretary. We do
    have a program called In Transition, and this is a program that
    we put in place to help guide those that are at risk when they
    leave DOD into VA, and it ensures a very warm handoff from the
    agencies.
        Senator Cassidy. And how are you ascertaining who is, in
    particular, at risk?
        Ms. Franklin. These are from the medical officers on the
    active duty side. They are put on a high-risk sort of a list.
    The DOD flags them and they roll into this In Transition
    program. I should have also shared that they do not necessarily
    have to be at high risk to be put in the program. They could
    just be receiving ongoing mental health care. And we want to
    make sure that that----
        Senator Cassidy. So, let me ask, if you have the ability to
    compare, since that is a relatively new program, with the
    results of similar sort of folks from before that program was
    instituted, if you will, a historical control. Have we seen
    benefits of that warm handoff in terms of decrease in the
    suicide rate among those who are enrolled, and what is the
    comparative rate of those in that program, compared to those
    who are not enrolled in that program.
        Ms. Franklin. You know, that is a very good question and I
    do not have the data in front of me in terms of doing the
    analytics, but I think you are onto something. The point in
    time when the policy letter got written on the DOD side to
    implement In Transition and just do a basic pre/post and track
    those and run that. The death certificate data that we get that
    tells us whether someone has died from suicide is a 2-year lag.
    The implementation of In Transition was within the last year.
    So, it will catch up, and that is a very good analysis and
    potential study.
        Senator Cassidy. My only suggestion would be--and I am out
    of time almost--is that if somebody who is 35 or 25 who was
    healthy a year before----
        Ms. Franklin. Yes.
        Senator Cassidy [continuing]. Quite likely it is--more
    likely it is a suicide than it is anything else. And I know
    Social Security tracks that almost real-time, because they have
    to cutoff Social Security checks for those who died. So,
    because we would be very interested to know the effects of this
    program, maybe just kind of good enough for government work,
    just take death rates in general of those enrolled and those
    not enrolled. We would appreciate that, and I think we look
    forward to receiving that.
        Ms. Franklin. Tracking. Yes, sir.
        Senator Tester. Thank you, Senator Cassidy.
        Senator Blumenthal.

                       HON. RICHARD BLUMENTHAL,
                     U.S. SENATOR FROM CONNECTICUT

        Senator Blumenthal. Thanks, Mr. Chairman. Since my time is
    limited before the vote expires I am going to be really quick.
    First, thank you for your work on veteran suicide. It is one of
    the most emotionally vexing for all of us who care about
    veterans, of all the problems that we deal with, because it is
    a preventable death.
        There are two statistics I know you are aware of: 70
    percent of veteran suicide deaths involve a firearm; and a
    veteran is three times as likely to die as a result of suicide
    if there is a firearm in the house.
        So, I would like your commitment that you will form--call
    it whatever you want, a task force, a working group that will
    work with us on gun violence prevention causing suicide among
    veterans.
        Secretary Wilkie. Yes, sir, that is a part of this task
    force.
        Senator Blumenthal. Well, I know it is a part of a task
    force, but I would like a working group or a task force whose
    mission it is to focus on this issue, and that reports back to
    us.
        Secretary Wilkie. Yeah. I am happy to do that within the
    President's Executive order. And, I mentioned that the goal--
    and you have stated this in the past--is to build time and
    space between the impulse to harm oneself and----
        Senator Blumenthal. That is a theory that makes sense for
    all suicide, and that is the reason that guns cause more deaths
    by suicide, because the time and space, if somebody tries to
    commit suicide by taking overdoses of prescription drugs, you
    have got hours. In gun violence, you have no time.
        Let me focus on two steps that can actually save lives--
    emergency risk protection orders. A number of States now have
    them. I am working on bipartisan legislation that will enable
    judges to take away firearms from people who are dangerous to
    themselves or others after a court due process that results in
    a warrant. Would you endorse that kind of legislation?
        Secretary Wilkie. Not being a practicing lawyer I would be
    happy to take a look at it and give you my opinion.
        Senator Blumenthal. I would appreciate your opinion.
        Secretary Wilkie. Yes, sir.
        Senator Blumenthal. Second, gun storage measures. I have
    introduced a measure called Ethan's Law. It is named for a
    young man who did not take his own life and is not a veteran,
    but as a result of an accident in the home, playing with a
    firearm, because there was no adequate storage. But, as you
    know, a gun in the home triples the risk of suicide, as I just
    mentioned, and if a caregiver can impose some discipline, as in
    gun storage, locks, and so forth--I know you hand out locks,
    but this takes it a step further. Would you endorse that kind
    of measure?
        Secretary Wilkie. I will say educating family members is
    absolutely key in things as simple as gun storage, et cetera.
        Senator Blumenthal. Right. I appreciate that. I am sorry
    that I am going to have to leave to vote. I would just ask you,
    is the surgical processing trailers and other facilities still
    on track in West Haven?
        Secretary Wilkie. Yes, sir.
        Senator Blumenthal. Thank you.
        Senator Tester. Thank you, Senator Blumenthal. You know,
    Secretary Wilkie and Dr. Franklin, you just had your best hour
    and 25 minutes of this week, and we appreciate you being here.
        I only have one request. Senator Moran did some of my heavy
    lifting for me earlier, and I appreciate that. If you could get
    technical assistance for the John Scott Hannon Suicide
    Prevention Bill to us ASAP we can go to work, we can work
    together, and we can get something done.
        Thank you for your service to this country. Thank you for
    being here today, and now we will go to the second panel.
    [Pause.]
        Senator Tester. While everybody is getting ready for the
    second panel I am going to introduce them, because we are in
    the middle of a series of five votes, so there is going to be a
    lot of folks here that get up and leave and come back.
        The witnesses for our second panel include Col. Miguel
    Howe, U.S. Army, Retired, the April and Jay Graham Fellow for
    the Military Service Initiative, George W. Bush Institute. It
    is great to have you here, Colonel.
        We have J. Michael Haynie, Ph.D., Executive Director of the
    Institute for Veterans and Military Families. Great to have you
    here, Michael.
        We have Jessica Kavanagh, who is Founder and President of
    VetLinks. Jessica, good to have you here.
        We have one of my favorite generals, Major General Matthew
    Quinn, Adjutant General, the great State of Montana National
    Guard. Good to have you here, Matt.
        We have Lt. Col. James Lorraine, U.S. Air Force, Retired,
    President and Chief Executive Officer of America's Warrior
    Partnership. He is from the Chairman's home State of Georgia,
    Augusta specifically, and works extensively with the Atlanta
    veteran community.
        The rules here, folks, are you get 5 minutes. Chairman
    Isakson will be back shortly. He is a lot meaner than I am so
    he will gavel you right down, so try to keep it to 5 minutes.
    Know that your entire statement will be put in the record.
        I am going to start with you, Col. Howe, and let the fun
    begin.
        I just want to say one other thing. I appreciate you all
    taking time out of what I know is a very busy schedule, to be
    in front of this Committee. I apologize ahead of time. When
    votes happen this thing is all screwed up, but needless to say
    we appreciate you being here and we appreciate your testimony
    ahead of time.
        Colonel, the floor is yours.

    STATEMENT OF COL. MIGUEL HOWE, U.S. ARMY (RET.), THE APRIL AND
     JAY GRAHAM FELLOW FOR THE MILITARY SERVICE INITIATIVE, GEORGE
                           W. BUSH INSTITUTE

        Colonel Howe. Senator Tester, Chairman Isakson, thank you
    for giving me the opportunity to testify this afternoon. I am
    Col. Miguel Howe. I served for 24 years in the Army as an
    infantry and special forces officer, deploying throughout Latin
    America, Iraq, and Afghanistan. My grandfather, father, and
    father-in-law served in World War II and Vietnam. My son is on
    his way to West Point and my daughter will soon be an Army ROTC
    cadet.
        Six years ago I retired from the Army and was honored to
    join the George W. Bush Institute in Dallas, where I currently
    serve as the April and Jay Graham Fellow for the Military
    Service Initiative.
        Since 2013, the Bush Institute has honored the service and
    sacrifice of post-9/11 veterans by fostering a successful
    transition from military service to civilian life. We believe
    our Nation has a duty to honor our warriors and empower them
    after that service.
        I detailed four recommendations, based upon our work, in my
    submitted testimony, and I will highlight three of those
    recommendations now.
        First, we advocate for an approach that integrates
    education, economic opportunity, and health and well-being, and
    sets the conditions for all veterans to thrive. We recommend
    more be done to establish a common vision and comprehensive
    framework for veteran services and outcomes. This new vision
    and framework must promote collaboration and instill a culture
    of accountability and measurement for outcome across all
    sectors, government and private.
        Second, we recommend reducing barriers that veterans face
    in seeking and connecting to high-quality health care. Some of
    our war fighters return home with a visible injury; many come
    home with the invisible wounds of war, like Traumatic Brain
    Injury and Post Traumatic Stress. Our research shows that not
    enough veterans are seeking the care that they need. Eight out
    of 10 post-9/11 veterans say that embarrassment or shame is a
    barrier to seeking out care. Some simply do not believe that
    effective care exists, and others believe that asking for help
    will impact their future successes and careers.
        But, of course, effective treatments are available. Public-
    private partnerships help to bridge this gap, and there are
    examples of these partnerships already at work. When the Bush
    Institute recognized the need to connect veteran peer networks,
    which instill purpose and belonging, with best-in-class
    clinical providers, we created the Warrior Wellness Alliance. I
    am glad that the VA is a partner with us on those efforts,
    because with peer connections, community collaborations and
    integration, and clearer data, we can better serve our veterans
    while maximizing national effort and resourcing.
        Finally, we must improve access to and delivery of high-
    quality mental health care for all veterans and their families.
    The Administration, Congress, and the VA should focus the full
    weight of the Federal Government on enforcing consistent
    quality standards and partnering with the private and nonprofit
    sectors to identify comprehensive solutions for increasing the
    availability and the quality of effective care.
        Like many of us here today, for me veteran suicide is not
    only very real it is also personal. When I was a young
    lieutenant, my communications section chief was Sergeant First
    Class Terry Dennis, a Panama Invasion and Gulf War veteran. We
    all widely considered him the strongest man in our unit. But,
    Terry also suffered from the invisible wounds, and, tragically,
    while still on active duty, Terry killed himself.
        Sergeant Josh Burnette was one of my Green Berets. He was
    severely wounded in Afghanistan, leaving active duty as a
    double amputee. After struggling with both his visible and
    invisible wounds, and, frankly, with all aspects of his
    transition, Josh took his own life.
        I will leave you with a more hopeful story. Corporate Dave
    Smith served in the Marine Corps, during two deployments to
    Iraq. Afterwards, when he came home, he experienced PTS. He
    came home drunk one night, stared down the barrel of a shotgun,
    and contemplated his own suicide.
        Thankfully, Dave put that gun down. With support from
    family and friends, he sought professional counseling and
    treatment. He found new purpose, volunteering with Team
    Rubicon. He graduated from Cal Berkeley. He connected with
    other veterans while mountain bike riding with President Bush
    and our own Team 43. Dave is married now. He has a fulfilling
    career, and this year he welcomed a baby girl.
        Dave is living proof that all veterans can live a
    meaningful life and thrive. I am encouraged by the work that
    all of you are taking on now to save lives and help us to
    ensure that Dave's story is the rule and not the exception.
        Thank you again for this invitation, and I look forward to
    answering your questions.
        [The prepared statement of Col. Howe follows:]
     Prepared Statement of Col. Miguel D. Howe, USA (Ret.), April and Jay
                 Graham Fellow, The George W Bush Institute \1\
    ---------------------------------------------------------------------------
        \1\ The George W. Bush Institute is a non-profit, nonpartisan
    organization advancing policy, programs and leadership development to
    address our Nation's most pressing challenges.
    ---------------------------------------------------------------------------
        Chairman Isakson, Ranking Member Tester, Members of the Committee,
    Thank you for the opportunity to testify today. I am Colonel Miguel
    Howe. I served for 24 years in the Army as an Infantry and Special
    Forces officer deployed throughout Latin America, Iraq, and
    Afghanistan. Military service has been my family legacy. My
    grandfather, father, and father-in-law served in World War II and
    Vietnam. My son is an Army ROTC Cadet on his way to West Point, and my
    daughter will soon be an Army ROTC Cadet. Six years ago, I retired from
    the Army and was honored to be asked by President Bush to lead his
    Military Service Initiative. Today I serve as the April and Jay Graham
    Fellow for the Military Service Initiative at the George. W. Bush
    Institute in Dallas, Texas.
        Since 2013, the Military Service Initiative has honored the service
    and sacrifice of all post-9/11 veterans by fostering their successful
    transition and reintegration from military to civilian life. We believe
    our Nation has a duty to honor our warriors and empower them after
    their service.
        For many veterans the transition process will be smooth, but still
    others face challenges finding new and meaningful education and
    employment opportunities. Some are adjusting to life with a wound,
    injury, or illness--either visible, invisible or both. Many face
    challenges re-establishing a sense of purpose, belonging, mission and
    identity. All of these factors are not only elements for ensuring
    successful transition, but they can also represent risk factors for
    veteran suicide.
        While public awareness campaigns and acute crisis response are
    essential to a sustainable and comprehensive suicide prevention
    program, by themselves, they are not sufficient to address such a
    pervasive social, economic, and health challenge.
        The PREVENTS Executive Order contains important elements to
    prioritize research, coordinate and align effort across the Federal
    Government, and to develop proposals to offer grants to state and local
    governments to support community level efforts toward a comprehensive
    approach to prevent veteran suicide. These mandates are key elements to
    a more expansive approach to suicide prevention while bringing to
    fruition several key goals and objectives of the VA's National Strategy
    to Prevent Veteran Suicide.
                                recommendations
        To address the systemic challenges associated with reducing suicide
    risk among veterans and to promote a life worth living among our
    Nation's veterans, I offer five recommendations designed to create more
    effective solutions for supporting veterans.
    1. Establish Overarching Vision for Veteran Health and Wellbeing
        At the Bush Institute, we advocate for an integrated and
    comprehensive approach focused on setting conditions for veterans to
    thrive by promoting overall wellbeing and a life worth living. This
    includes ensuring education, economic opportunity, and health and
    wellbeing--the three elements that are key to a successful transition.
    These three areas of transition success also incorporate key aspects of
    the social determinants of health that mitigate risk for not only
    suicide, but a host of other veteran outcomes. Our framework
    acknowledges those social determinants of health and applies a public
    health approach that simultaneously addresses the entire veteran
    population, those veterans at an elevated risk, and most critically
    veterans at highest risk, including those in acute crisis.
        This focus on the full continuum of wellbeing drives our veteran
    transition work at the Bush Institute, and our work with other
    nonprofit organizations, businesses, government entities and partners
    to advance positive outcomes. We believe a common vision and
    comprehensive framework should be established that focuses specifically
    on veteran outcomes and aligns services and resources, especially
    across Federal agencies. This framework can be the basis of a national
    blueprint that promotes collaboration with private, non-profit, and
    philanthropic organizations that support veterans.
        A comprehensive approach and holistic framework would empower
    veterans as leaders, provide them economic opportunities, ensure access
    to high quality health care for those in need, and guarantee needed
    social support and basic services for the most vulnerable. It would
    also more effectively leverage the full continuum of veteran services
    from the government and non-government sectors across the full
    continuum of transition issues. The primary goal should be to drive
    services for veterans that lead to positive outcomes.
        The framework also should instill a culture of accountability and
    measurement for not only the government, but also for non-government
    entities and funders that serve veterans. It should include measurable
    goals and objectives for all spheres of veteran social, economic, and
    health and wellbeing outcomes. Federal resourcing should not only
    facilitate public-private partnerships at national, state, and local
    levels to deliver the full continuum of resources, services, and
    solutions to advance veteran outcomes, but also include resources to
    collect data and measure the effectiveness and impact of services.
        In the non-governmental sector, educational institutions and
    employers each also have a role to play. In partnership with the
    Department of Defense (DOD), Department of Veterans Affairs (VA), and
    the Small Business Administration (SBA), corporate America should
    recommit and act to codify a new era in veteran and military spouse
    employment by improving recruiting, hiring, onboarding, integration,
    development and retention of veterans and their spouses. Leaders in
    higher education must foster a national effort for veteran recruiting,
    admissions, on-campus interaction, and education and career placement
    success. Both sectors must ensure mental health resources, peer-to-peer
    networks and environments that leverage and values veterans while
    promoting treatment seeking behaviors for those in need.
        By setting the conditions for veterans to thrive across and within
    all settings we promote holistic wellbeing and life of continued
    purpose, belonging, and identity. Developing and acting on a cohesive
    national blueprint would ensure successful transitions across the
    lifecycle, as well as promote more effective and sustainable crisis
    response efforts to not only suicide prevention but, homelessness,
    chronic unemployment, substance abuse, and other mental health
    conditions.
    2. Reduce Barriers and Increase Access to Effective Mental Health Care
        As you know, some of our warfighters return home or leave the
    military with a visible injury. Many come home with invisible wounds of
    war--both physical (Traumatic Brain Injury [TBI]) and psychological
    (Post Traumatic Stress [PTS]). Mental health conditions (inclusive of
    the invisible wounds), substance abuse, and access to lethal means are
    critical factors that contribute to veteran suicide.\2\ While most
    servicemen and women return home without any injuries or recover
    successfully from these conditions, the number of post-9/11 veterans
    experiencing the invisible wounds has been high compared to historical
    rates. At any given time, as many as 10%-20% of servicemembers who have
    deployed to Iraq and Afghanistan experience symptoms consistent with
    PTSD.\3\ Since 2001, more than 383,000 have been diagnosed with TBI.\4\
    Some veterans may also experience comorbid conditions like depression
    or anxiety.
    ---------------------------------------------------------------------------
        \2\ Department of Veterans Affairs, National Strategy for Veteran
    Suicide Prevention, 2018
        \3\ Ramchand et al., Prevalence of, Risk Factors for, and
    Consequences of Posttraumatic Stress Disorder and Other Mental Health
    Problems in Military Populations Deployed to Iraq and Afghanistan; Curr
    Psychiatry Rep (2015) 17:37; DOI 10.1007/s11920-015-0575-z
        \4\ Department of Defense Worldwide Numbers for Traumatic Brain
    Injury, available at https://dvbic.dcoe.mil/dod-worldwide-numbers-tbi
    ---------------------------------------------------------------------------
        Although evidence-based treatments exist for the invisible wounds
    of war, barriers to seeking or accessing high-quality care include:
    stigma about seeking help, difficulty navigating a confusing landscape,
    and limited capacity of effective mental health care.\5\ Below, I
    outline two specific methods for reducing barriers and increasing
    access to mental health care:
    ---------------------------------------------------------------------------
        \5\ Matthew Amidon, Christopher Lu, Miguel Howe, Dr. James Kelly,
    Dr. Charles Marmar, and Terri Tanielian, Addressing the Invisible
    Wounds of War: Creating a Collaborative Tomorrow. Dallas TX: George W.
    Bush Institute http://gwbcenter.imgix.net/Resources/gwbi-addressing-
    invisible-wounds.pdf

                2a. Improve Connections to Care through Peer Networks
        Veteran and military culture and perceived societal stigmas still
    serve as significant barriers to care seeking behavior. We know from
    our research that 8 out of 10 post-9/11 veterans think that
    embarrassment or shame is an extreme or moderate barrier to seeking
    care for conditions such as PTS or TBI.\6\ Less than 50% of those who
    need care seek care for their issues, and less than 50% of those
    receive an evidence-based care.\7\ Our research also indicates that
    over 80% of veterans indicate concern of family, employer, or educator
    reaction as a barrier to seeking care.\8\
    ---------------------------------------------------------------------------
        \6\ Confronting the Invisible Wounds of War: Barriers,
    Misunderstandings and a Divide. Dallas TX: George W. Bush Institute.
    https://gwbcenter.imgix.net/Resources/GWBI-invisiblewounds
    perceptionssurvey.pdf
        \7\ Tanielian, Terri and Lisa H. Jaycox, eds., Invisible Wounds of
    War: Psychological and Cognitive Injuries, Their Consequences, and
    Services to Assist Recovery. Santa Monica, CA: RAND Corporation, 2008.
    https://www.rand.org/pubs/monographs/MG720.html
        \8\ Confronting the Invisible Wounds of War: Barriers,
    Misunderstandings and a Divide. Dallas TX: George W. Bush Institute.
    https://gwbcenter.imgix.net/Resources/GWBI-invisiblewounds
    perceptionssurvey.pdf
    ---------------------------------------------------------------------------
        Veteran peer-based organizations can help to reduce these barriers
    to access and better connect veterans to care. As a promising practice,
    the Bush Institute established the Warrior Wellness Alliance to
    increase the number of Warriors seeking and accessing comprehensive and
    effective care, improve the delivery of effective high-quality care,
    and increase accurate awareness and understanding of invisible wounds
    and their impact. The Alliance links peer-to-peer veteran networks with
    effective clinical care providers so that ultimately more veterans get
    the care they need.\9\
    ---------------------------------------------------------------------------
        \9\ Warrior Wellness Alliance: Connecting Best-In-Class Health care
    Providers and Peer Veteran Networks https://www.bushcenter.org/
    publications/resources-reports/reports/invisible-wounds.html Dallas TX.
    George W. Bush Institute
    ---------------------------------------------------------------------------
        In addition to serving as critical assets to facilitate connection
    to quality care, peer-based organizations can also serve to address
    other key aspects of suicide prevention. These veteran peer-based
    organizations can help to empower members promoting use of self-care
    skills, improving identification of individuals at risk, and promoting
    their member awareness of acute crisis response and intervention tools
    and resources. All of these efforts are part of comprehensive suicide
    programs.\10\ Peer organizations can also help educate their members on
    the benefits of healthy lifestyles--better sleep, fitness and diet, and
    reduced alcohol use--to reduce suicide risk. Peer-based organizations
    can also raise awareness of the dangers of firearm access for those
    veterans at elevated risk and in acute crisis, and promote safe storage
    and removal when necessary.
    ---------------------------------------------------------------------------
        \10\ Ramchand Rajeev, Joie D. Acosta, Rachel M. Burns, Lisa H.
    Jaycox, and Christopher G. Pernin. The War Within: Preventing Suicide
    in the US Military. https://www.rand.org/pubs/monographs/MG953.html CA:
    RAND Corporation, 2011
    ---------------------------------------------------------------------------
        To increase numbers of warriors seeking and accessing care,
    Federal, state, and community leaders should empower all veteran peer-
    based organizations and nonprofits, health care providers, and
    community organizations that foster effective connectivity and
    referrals. Congress should authorize and appropriate Federal grant
    funding to support infrastructure requirements for organizations
    conducting peer referrals to VA mental health care, and referrals back
    to peer-based organizations upon completion of clinical care.
        To ensure effectiveness of services, accountability of outcomes,
    and better understand the veteran population and their needs, Congress
    should mandate the use of common data, measurement and evaluation
    elements for recipients of Federal aid. All recipients of Federal
    grants that support veterans in the community should be required to
    adhere to common data collection on individuals and population served-
    requirements that should be defined by and reported to the VA.
    Reporting should also include not only outputs of services provided,
    but impart of services provided, and most importantly outcomes for the
    population served. Federal grants should include resourcing that
    supports infrastructure required for data collection, storage and
    analysis, and Federal contracts must be awarded only to those entities
    who are able to commit to the common data elements established by the
    VA.
                2b. Foster Meaningful Community Coordination and
                        Partnerships
        Connection to comprehensive services and solutions is most
    essential at the community level. Congress should provide additional
    resourcing and oversight to successful public-private partnership
    opportunities as a mechanism to connect veterans to high-quality health
    care and needed social support and basic services at the local
    level.\11\ Congress should ensure adequate funding for infrastructure
    and connectivity to the full continuum of health and social services at
    the local level, inclusive of community, state, tribal, and Federal
    providers, as well as appropriate non-governmental entities. The VA,
    supported by other agencies, should provide appropriate infrastructure
    to facilitate meaningful partnerships and provide access to national
    level resources, services, and solutions, while improving integration
    and coordination of effort across all sectors, from the national to the
    community level. Such an effort can better facilitate local and state
    connectivity and coordination of Federal resources, programs, and
    services.
    ---------------------------------------------------------------------------
        \11\ Pedersen, Eric R., Nicole K. Eberhart, Kayla M. Williams,
    Terri Tanielian, Caroline Batka, and Deborah M. Scharf, Public-Private
    Partnerships for Providing Behavioral Health Care to Veterans and Their
    Families: What Do We Know, What Do We Need to Learn, and What Do We
    Need to Do? Santa Monica, CA: RAND Corporation, 2015. https://
    www.rand.org/pubs/research_reports/RR994.html.
    ---------------------------------------------------------------------------
        In order to maximize current grant funding in support of veteran
    services, Congress should consider repurposing Support Services for
    Veteran Families (SSVF) that focus primarily on ending homelessness,
    and consolidate that program with new community-based grants to more
    broadly support the full continuum of economic and health and human
    service needs in community-based networks that support My-VA
    communities.
        Again, these recipients should be held to the standards of
    accountability as outlined above through the use of common data
    measurement and evaluation. Federal grants should include resourcing
    that supports infrastructure required for data collection, storage, and
    analysis.
    3. Improve Access to and Delivery of High-Quality Mental Health Care
            for Veterans
        Given that one of the most effective approaches to preventing
    suicide is the receipt of effective mental health care and substance
    abuse treatment, we must do more to ensure the delivery of high-quality
    mental health care in our Nation. Demand for effective mental health
    care exceeds capacity. Nationwide, there is a shortage of mental health
    providers. In the U.S., 60% of counties are without a psychiatrist.\12\
    And, we know very little about the quality of care provided by mental
    health professionals in the private sector. Only 13% of community-based
    mental health providers are ready to deliver culturally competent,
    evidence-based care to veterans confronting the invisible wounds.\13\
    Congress should continue to support programs that increase the number
    of clinicians in the community who can provide effective mental health
    care.\14\ Education and training resources, many funded by the VA,
    Department of Defense, and the philanthropic sectors, are available to
    community providers, but are not frequently used. Incentive programs
    encouraging community providers to take advantage of these available
    training resources could help to improve the workforce capacity to
    deliver high-quality services to veterans with mental health
    conditions.
    ---------------------------------------------------------------------------
        \12\ American Medical Association, 2017
        \13\ Terri Tanielian, Coreen Farris, Caroline Batka, Carrie M.
    Farmer Eric Robinson, Charles C. Engel, Michael Robbins, and Lisa H.
    Jaycox, Ready to Serve: Community-Based Provider Capacity to Deliver
    Culturally Competent, Quality Mental Health Care to Veterans and Their
    Families, Santa Monica Calif.; RAND Corporation, RR-806UNHF, 2014
    (https://www.rand.org/pubs/research_reports/RR1542.html)
        \14\ Martsolf GR, Tomoaia-Cotisel A, Tanielian T. Behavioral Health
    Workforce and Private Sector Solutions to Addressing Veterans' Access
    to Care Issues. JAMA Psychiatry. 2016;73(12): 1213-1214. doi:10.1001/
    jamapsychiatry.2016.2456
    ---------------------------------------------------------------------------
        Public-private partnerships can help bridge the gap in access to
    high quality behavioral health care and connect more veterans to
    care.\15\ These partnerships can also link veterans to effective social
    services wherever they exist, to both better treat veterans and their
    families, and address all of the social determinants of health that
    should be incorporated into a comprehensive strategy for suicide
    prevention. Health care providers, nonprofits, and community
    organizations all working to advance health and wellbeing must improve
    and streamline service delivery and improve integration and
    coordination effort across all sectors, from the national to the
    community level. The VA should set appropriate quality standards and
    apply them consistently across all care delivered and furnished by the
    VA and their funded community providers. Research indicates that
    veterans who receive evidence-based mental health care make fewer
    visits to the doctor in the next year.\16\ This data indicates that
    veterans not only feel better, but it also saves money and reduces the
    overall cost to society.\17\ Demanding consistently applied high-
    quality standards across the public and private sectors in order to
    receive Federal reimbursement would help to elevate the quality of
    mental health care available in this country.
    ---------------------------------------------------------------------------
        \15\ Terri Tanielian, Lisa S. Meredith, Caroline Batka, Bridging
    Gaps in Mental Health Care, Lessons Learned From the Welcome Back
    Veterans Initiative, Santa Monica Calif.; RAND Corporation, RR-2030-
    MTF, 2017 (https://www.rand.org/pubs/research_reports/RR2030.html)
        \16\ https://www.ncbi.nim.nih.gov/pubmed/23148769
        \17\ https://academic.oup.com/milmed/article/178/1/95/4210920
    ---------------------------------------------------------------------------
        Challenges exist in finding, connecting, and ensuring completion of
    high-quality mental health care for some segments of the veteran
    population. The VA should use existing data and innovation to develop a
    consumer driven approach to mental health care to increase engagement
    in treatment and improve outcomes for all veterans, not only those
    veterans who are engaged directly with the VHA, peer networks, or
    community-based efforts. While there are innovative predictive
    analytics efforts that are underway to identify veterans who may be at
    risk earlier and with greater precision than clinical assessment (such
    as VA's REACH VET program), these existing efforts are only using data
    available from within the health care system, which is limited.
    Meanwhile there is a burgeoning research base that provides great hope
    that nonclinical data, such as social media and fitness tracker data,
    can be leveraged to identify veterans who may be at risk for suicide
    and months in advance before a downward spiral ensues. Research
    projects that are currently underway such as Our Data Helps,\18\ and
    our own Warriors Connect,\19\ are examples of best practices in how
    this type of data can be leveraged ethically for mental health and
    suicide prevention research ethically. In addition, although 14 of the
    veterans who die by suicide every day are not engaged in VHA, there are
    significantly more veterans who are engaging with VBA, Department of
    Labor, and other non-health care sources of support across the Federal
    sector, and we recommend that innovative data science solutions that
    harness the power of existing available data be utilized.
    ---------------------------------------------------------------------------
        \18\ https://OurDataHelps.org
        \19\ https://WarriorsConnect.OurDataHelps.org
    ---------------------------------------------------------------------------
        Finally, Congress and the Administration must also work toward full
    parity in benefit coverage and reimbursement between physical and
    mental health care. The Mental Health Parity Act of 2008, which was
    signed by President George W. Bush, attempts to prevent health insurers
    from providing less favorable benefits for mental health needs.
    Unfortunately, insurers have not been held accountable for successfully
    implementing mental health parity. Mental health care providers in the
    field indicate that over 10 years later, they continue to experience
    significant challenges with reimbursement for the quality care they
    deliver, and many ultimately resort to only accepting private pay.
                                   conclusion
        An integrated approach to address all risk factors for a successful
    veteran transition--benefits, housing, education, economic opportunity,
    and quality health care -will not only better reduce risk for suicide,
    homelessness, substance abuse, and unemployment, it sets the conditions
    for veterans to thrive. To do so, and to maximize national resources,
    we recognize that more must be done to establish a common vision for
    veteran services, especially across Federal agencies and the full
    continuum of care, that promotes collaboration and instills a culture
    of accountability and measurement for not only the government, but for
    nonprofits and communities serving veterans.
        We know that not enough veterans are seeking and accessing the care
    they need to treat the invisible wounds. Eight out of 10 post-9/11
    warriors say that embarrassment or shame is a barrier to seeking out
    care. Some simply don't believe that effective care exists. And others
    believe that asking for help will impact their future successes, career
    and education opportunities, access to security clearances, or future
    deployments.
        The reality is that most warriors will not seek care from the VA.
    Public-private partnerships help bridge the gap. And there are examples
    of these partnerships already at work. When the Bush Institute
    recognized the need to connect veteran peer networks, which instill
    purpose, camaraderie and reduce stigma, with best in class clinical
    care providers, we created the Warrior Wellness Alliance. I'm glad that
    the VA is a partner with us on those efforts. With community
    collaboration, clearer data, and a leading strategy, we can better
    serve our veterans, while maximizing national effort and resourcing.
        We must improve access to, and delivery of quality mental health
    care for active duty servicemembers, veterans, and their families. The
    Administration, Congress, and the VA should focus the full weight of
    the Federal Government on enforcing quality standards, and partnering
    with private, nonprofit, and philanthropic sectors to identify thorough
    solutions for providing effective care. Community-based collaboratives,
    such as those piloted by America's Warrior Partnership, Combined Arms,
    America Serves, San Diego 211, and many others are promising practices
    for how to better connect our veterans and their family members to the
    full continuum of health and social services at the local level.
        For us, this status quo is not acceptable. Effective treatments are
    available, and we must reduce the barriers that veterans face in
    seeking and receiving high-quality care. The risks otherwise are too
    great.
        When I was a young Lieutenant, my communications section chief,
    Sergeant First Class Terry Dennis, a Gulf War and Panama Invasion
    veteran who was the strongest man in our unit, died by suicide. Two
    years ago, one of my 7th Special Forces Group Green Berets Sergeant
    First Class Josh Burnette, a double amputee who struggled with his
    visible and invisible wounds, and all aspects of his transition, died
    by suicide. So, for me, like many of us here today, veteran suicide is
    not only very real, but personal.
        I'll leave you with Corporal David Smith's story. He served in the
    Marine Corps during two deployments to Iraq. Afterward, he experienced
    severe PTS. He came home drunk one night and stared down the barrel of
    a shotgun, contemplating his own suicide.
        Thankfully Dave put the gun down. With support from family and
    friends, he sought professional counseling and treatment. He graduated
    from the University of California at Berkeley. He found new purpose
    volunteering with Team Rubicon and connecting with other veterans while
    mountain bike riding with President Bush and our own Team 43. Dave's
    married now, has a fulfilling career, and welcomed a baby girl last
    year.
        Dave's experience is proof that all veterans can live a meaningful
    life and thrive. His story must be the rule and not an exception. I'm
    encouraged by the work you all are taking on now to help us ensure that
    and save lives.

        Thank you again for inviting me to testify today. I look forward to
    your questions.

        Senator Tester. Thank you, Colonel.
        Dr. Haynie.

      STATEMENT OF J. MICHAEL HAYNIE, Ph.D., EXECUTIVE DIRECTOR,
              INSTITUTE FOR VETERANS AND MILITARY FAMILIES

        Mr. Haynie. Thank you, Ranking Member Tester, Chairman
    Isakson, and the Members of the Committee. I would like to
    start by thanking you for your work on behalf of America's
    veterans and their families, and more immediately for the
    opportunity to be here today.
        I am an Air Force veteran myself and I am here today
    representing Syracuse University's Institute for Veterans and
    Military Families (IVMF), the only academic institute of its
    kind in the Nation, focused exclusively on the post-service
    lives of our veterans and military-connected family members.
        In addition to the Institute's research mission, we serve
    veterans through vocational and community coordination programs
    across the United States. This year alone, these programs will
    assist more than 25,000 servicemembers and veterans in the
    transition out of uniform, and toward civilian careers,
    schools, and communities.
        Most simply, the point is that the transition experience
    for servicemembers and their families is the mission of our
    institute, and I emphasize that mission here to highlight that
    one of the most consistent findings stemming from our work and
    our scholarship is the powerful and enduring linkage between
    the lived transition experience of servicemembers and their
    families, and the overall well-being and mental health of our
    veterans. In other words, ``getting transition right'' is
    central to ensuring long-term wellness and mental health of our
    veterans.
        Alternatively, a negative transition experience is highly
    likely to position a veteran--and, by extension, their family--
    on a trajectory of compromised wellness and mental health, from
    which our experience suggests it is difficult to recover.
        Today, given this context, I would like to address efforts
    to meaningfully engage the communities where our veterans live,
    work, and raise their families, as partners in a national
    effort to address the compromised mental health and suicidal
    acts and ideations among our veterans.
        Research conducted by the IVMF focused on the transition
    experience of more than 8,000 post-9/11 servicemembers, found
    that effective and efficient navigation of available services,
    resources, and benefits to be the most commonly cited challenge
    associated with the transition from military to civilian life.
    To be clear, that is saying it is not finding a job, it is not
    finding a school, it is not relocating. It is navigating the
    help they need, when they need it, in the communities in which
    they live, they cite as the most significant challenge they
    face in the context of transition.
        There are several additional insights that we glean from
    that research, first that the mental health of our veterans is
    powerfully impacted, beyond clinical care, by the many social
    and economic determinants of well-being, including access to
    resources that help veterans meet basic human needs like food,
    safety, and shelter; pathways to vocational success and career
    fulfillment; and positive connections with family, friends, and
    the broader community they call home.
        Second, that in the majority of communities across the
    U.S., the existing base of public and private-sector resources
    positioned to provide social services to veterans is already
    well positioned. However, those resources are either unknown to
    veterans or the community-based providers lack the ability to
    offer culturally-competent care to veterans in their community.
        Taken together, we recognized that creating an accessible
    and accountable means to navigate veterans to the help they
    need, when they need it, within their own communities, could
    serve to blunt those social and economic factors linked to
    compromised mental health. That single insight was the seminal
    motivation for the Institute for Veterans and Military Families
    to launch an innovative community care coordination program
    called AmericaServes.
        The AmericaServes initiative is based on the simple idea
    that if existing community-connected social service providers
    were organized into an interconnected system of social service
    provision, a veteran accessing any individual resource would
    instead access a comprehensive continuum of resources and care.
        Today I am proud to say that in 16 communities across the
    U.S., including New York City, Pittsburgh, San Antonio, Dallas,
    and across the entire State of North Carolina, the IVMF's
    AmericaServes provider networks represent the backbone
    infrastructure supporting community-care coordination, aligning
    almost 900 community providers to address what, over the course
    of the last 3 years, has now been 52,000 requests for support
    from veterans across the network.
        AmericaServes community networks are launched in
    partnership with the communities that they serve and supported
    by local and national funders. In Pittsburgh, it is the Heinz
    Endowment. In North Carolina, it is Walmart and the North
    Carolina State Department of Health and Human Services. In New
    York City, early support came from the Robin Hood Foundation,
    and the success of that network generated funding from the city
    of New York.
        The networks themselves are typically comprised of, on
    average, 40 to 50 local social and clinical service providers,
    that include the VA medical centers and Vet Centers in many
    cases. And, each of these networks, at its core, is a Care
    Coordination Center, which acts as the ``Quarterback,''
    navigating the veteran within the network and leveraging robust
    networks to provide performance accountability for providers in
    the network.
        The networks use HIPAA-compliant care coordination
    technology to streamline referrals between providers in the
    network and connect veterans directly to in-network providers
    who are able to meet their needs. Providers are able to
    securely share protected client information and case referrals
    through the technology. The care coordination models solve the
    problem most commonly cited by veterans, which is navigation.
        For time, Miguel told two very compelling stories. I am
    going to skip my stories for time. But, I do want to end with
    highlighting that in this era of all-volunteer military, it is,
    in my experience, a false and too-closely-held assumption that
    it is the VA's responsibility alone to serve and support the
    post-service lives of our veterans and their families.
        One real consequence of that assumption is the significant
    social and cultural divide present between those who have
    served and those who have not, and that divide really does
    serve to foster, among some veterans, a feeling of social
    isolation and disconnectedness, which, in turn, is directly
    linked to the mental health challenges and the suicide numbers
    that have been cited throughout this hearing.
        It is my hope that we engage comprehensively local
    community-connected providers, nonprofits, local government,
    cities, and counties in a national effort to address this
    crisis.
        Thank you very much.
        [The prepared statement of Mr. Haynie follows:]
      Prepared Statement of J. Michael Haynie, Ph.D., Vice Chancellor for
     Strategic Initiatives and Innovation, Founder and Executive Director,
       Institute for Veterans & Military Families, Syracuse University,
                                  Syracuse, NY
        Chairman Isakson, Ranking Member Tester, and the Members of the
    Committee, I'd like to start by thanking you for your work on behalf of
    America's veterans and their families, and more immediately for the
    opportunity to address you today on the subject of ``Harnessing the
    Power of Community: Leveraging Veteran Networks to Tackle Suicide.''
        I'm here today representing Syracuse University's Institute for
    Veterans and Military Families, the only academic institute of its kind
    in the Nation, focused exclusively on the post-service lives of our
    veterans and military-connected families. In addition to our research
    mission, the IVMF serves veterans through vocational and community
    coordination programs across the United States. This year alone, these
    programs will assist more than 25,000 servicemembers and veterans in
    the transition out of uniform, and toward civilian careers, schools,
    and communities.
        Most simply, improving the transition experience for servicemembers
    and their families is the mission of the IVMF. I emphasize that mission
    here, as a means to highlight that one of the most consistent findings
    stemming from our work and scholarship, is the powerful and enduring
    linkage between the lived transition experience of servicemembers and
    their families, and the overall wellbeing and mental health of our
    veterans.
        `Getting transition right' is central to ensuring long-term
    wellness and mental health. Alternatively, a negative transition
    experience is highly likely to position a veteran--and by extension,
    the veteran's family--on a trajectory of compromised wellness and
    mental health, from which our experience suggests it is often
    exceedingly difficult to recover.
        Today, given this context, I'd like to address the efforts to
    meaningfully engage the communities where our veterans live, work, and
    raise their families, as partners in a national effort to address
    compromised mental health, and suicidal acts and ideations, among our
    veterans.
        Research conducted by the IVMF, focused on the transition
    experience of more than 8,000 post-9/11 servicemembers, found that
    effective and efficient navigation of available services, resources,
    and benefits to be the most commonly cited challenge associated with
    the transition from military to civilian life. In addition, this early
    research also opened the door to two additional and less understood
    truths informing the relationship between transition, community, and
    mental health.
        First, that the mental health of our veterans is powerfully
    impacted by the many social and economic determinants of well-being,
    including access to resources that help veterans meet basic human needs
    like food, safety, and shelter; pathways to vocational success and
    fulfillment; and positive connections with family, friends, and the
    broader community they call home.
        Second, that in the majority of communities across the U.S., the
    existing base of public and private-sector social service providers is
    already well-positioned to improve the mental well-being for our
    veterans. However, often those resources are either unknown or
    inaccessible to veterans, or the community-based providers lack the
    ability to offer culturally competent care to veterans in their
    community.
        Taken together, we recognized that creating an accessible and
    accountable means to navigate veterans to the help and support they
    need, when they need it, within their own community, could serve to
    blunt those social and economic factors linked to compromised mental
    health. This single insight was the seminal motivation for the IVMF
    team to launch an innovative community care coordination program called
    AmericaServes.
        The AmericaServes initiative is based on the simple idea that if
    existing community-connected social service providers were organized
    into an inter-connected system of social service provision, a veteran
    accessing any individual resource would instead access a comprehensive
    continuum of resources and care. Today, I'm proud to say that in 16
    communities across the U.S.--including New York City, Pittsburgh, San
    Antonio, Dallas, and across the entire state of North Carolina--the
    IVMF's AmericaServes provider networks represent the backbone
    infrastructure supporting community-level care coordination, aligning
    almost 900 individual providers to address what more than 52,000
    requests for support from veterans across the network.
        AmericaServes community networks are launched in partnership with
    the communities they serve, and supported by local and national
    funders. In Pittsburg, it's the Heinz Endowment. In North Carolina,
    it's Walmart, and the State Department of Health and Human Services. In
    New York City, early support came from the Robin Hood Foundation, and
    the success of the network generated funding from the City.
        The networks themselves are typically comprised of, on average, 40-
    50 local social and clinical service providers, to include VA medical
    centers and Vet Centers in many cases. At the center of each
    AmericaServes network is a Coordination Center, which acts as the
    network's ``Quarterback''--navigating the veteran within the network,
    and leveraging robust network performance data to hold providers
    accountable on behalf of the veteran.
        AmericaServes utilizes a HIPAA-compliant care coordination
    technology platform to streamline referrals between participating
    providers, and to connect veterans directly to in-network providers who
    are able to meet their unique needs. Providers are able to securely
    share protected client information through case referrals, enabling an
    integrated and transparent system of local support and care. The care
    coordination center model solves the veteran's most compelling problem:
    navigation. The most powerful way to make that point, is through the
    voice of a veteran.
        Nathan transitioned from the U.S. Army with significant
    disabilities stemming from service in both Afghanistan and Iraq. Not
    long after his transition, Nathan found himself in need of immediate
    assistance that the VA was unable to provide. At the time Nathan
    contacted the TXServes care coordination center, he was a single
    father, homeless, and unemployed. Because of his homelessness, Nathan's
    young son had recently been placed into state-sponsored care. The
    TXServes care coordination center conducted a holistic assessment of
    Nathan's situation, and shared a detailed accounting of Nathan's co-
    occurring needs across the North Texas provider network. The immediate
    task was to stabilize Nathan's situation. Nathan was connected to a
    provider able to secure him temporary housing, and referred to another
    who found Nathan a temporary, living wage job. At the same time, other
    TXServes providers began working with Nathan to access and secure his
    VA benefits, and to engage local workforce development programs on
    Nathan's behalf. Through this continuum of coordinated care, Nathan was
    able to secure permanent housing, and receive training that landed him
    a job at Dell Computer in Austin, TX--and most importantly, as a
    result, reunite with his son. Nathan says that TXServes literally saved
    his life, in part because he only had to tell his story one time--to
    the TXServes care coordination center--and that initial storytelling
    engaged a network of more than 50 local providers, each working in
    concert on Nathan's behalf.
        Nathan's story--unfortunately--is not unique. In fact, Nathan's
    story represents one of the most persistent and compelling challenges
    facing our veterans; that is, inadequate coordination and insufficient
    collective purpose among public, private, and social sector
    organizations that purport to serve this community.
        In the era of an all-volunteer military, it is a false but too
    closely held assumption that it is the VA's responsibility alone to
    serve and support the post-service lives of our veterans and their
    families. One consequence of that assumption is a real and significant
    social and cultural divide, present between those who have served, and
    those who have not--a divide that serves to foster among some veterans
    a feeling of social isolation and disconnectedness. Social
    disconnectedness, in turn, is directly linked to compromised mental
    health and suicide among veterans. Too often, well-intentioned policy
    fails to leverage opportunities to purposefully engage the community of
    non-public sector providers, for the specific purpose of `building
    community' in a way that fosters social and community connectedness
    among veterans. Importantly, engaging the veteran-serving community, by
    itself, is not enough. While it is true that there are more than 40,000
    nonprofit service providers in the military-connected space, many have
    evolved to become narrowly focused and increasingly siloed.
    Consequently, many of these organizations fail to purposefully engage
    the broader community of human service providers, in a way that fosters
    social and community connectedness among veterans.
        It is my view that any holistic strategy positioned to support the
    overall mental wellbeing of our veterans, must include engaging the
    communities where our veterans live, as partners and stakeholders in
    our effort. To ``Harness the Power of Community'' as a strategy to
    tackle veteran suicide requires that government, industry, and non-
    profit partners act together to create accessible pathways connecting
    veterans and their families to community-connected services and support
    representing the full continuum of social and economic determinants of
    wellbeing. Acting on this opportunity need not be exceedingly
    complicated, or costly. Examples of how this engagement could proceed
    include specific grant funding to support care coordination and
    navigation services in local communities; enhanced opportunity for
    community organizations and non-profit providers to access military
    cultural competency training; and support for community-level resource
    mapping, aligned with the objective of enhancing information available
    to veterans related to providers of social and human services within a
    given community. Investments like these will enhance and extend the
    impact of funds this Committee has already directed toward clinical
    interventions and, most importantly, best serve the enduring mental
    health concerns of our veterans and their families.

        On behalf of the veterans and military-connected families the IVMF
    serves in partnership with this Committee, thank you for the
    opportunity to provide testimony today.

        Senator Tester. Thank you, Dr. Haynie.
        Jessica Kavanagh.

     STATEMENT OF JESSICA KAVANAGH, FOUNDER AND PRESIDENT, VETLINKS

        Ms. Kavanagh. Good afternoon Chairman, Ranking Member, and
    Members of the Committee. Thank you so much for having me here
    today. I am grateful for the opportunity to speak on behalf of
    my late husband, Major Brian Kavanagh, our two young children,
    Meryn and Evie, who are 7 and 5, and the millions of veterans
    and families who deserve access to care and benefits. In
    addition, I am pleased to be here to represent VetLinks.org and
    the many community-based organizations, particularly those in
    rural communities, that support veterans trying to navigate the
    VA system, and who need our advice and resources to get that
    help.
        Brian was diagnosed with Post Traumatic Stress in December
    2011. In May 2014, we realized that he needed serious help for
    his Post Traumatic Stress and substance abuse. We went to our
    VA doctor and to our VA social worker, who both had no
    recommendations of where to send him for inpatient treatment.
        So, I looked on the Internet, scouring it for hours and
    hours, and all I could find were places that were private for
    $30,000 to $50,000--nothing that we could afford--until I found
    a place locally here, the Washington Institute of Psychiatric
    Care, where I sent my husband, who was an infantry officer, to
    a psych unit for 2 weeks, with 14 other women who were raped
    and sexually assaulted as children. Obviously, I knew that was
    not the right place to go but we were desperate and needed
    help.
        Fast forward to July 2015. He was not getting any better.
    We were paying for private care at that point, for a full year.
    I called the VA and they put him on a six-week--late time for a
    mental health care appointment, which ironically fell on
    September 11, 2015. We went and saw our social worker. We
    explained the situation again, how his substance abuse and Post
    Traumatic Stress was not getting any better. We were in dire
    need. He was not working at that point. All she could offer was
    the psych unit at the Baltimore VA.
        I went home. We were both just very defeated, very
    frustrated with the system. I started making phone calls to VAs
    across the country to see what other specialized programs they
    had, and not one VA called me back. I was calling vet
    advocates, until someone called me from Houston and said, ``I
    have heard your story from multiple people. There is a VA
    Committee hearing on October 7, 2015. Secretary Bob McDonald,
    at the time, was going to be there. You should go.''
        I went. I went up and introduced myself to Mr. McDonald,
    and he helped me get Brian into the Martinsburg VA inpatient
    unit.
        While Brian was there he was coming across other veterans
    who were not getting the benefits they were entitled to. That
    is where the idea of VetLinks.org was created, to help other
    veterans navigate through the system to get the help that they
    needed and deserved.
        When he was discharged he was sent to a Vet Center that
    could help him with one trauma appointment once every 3 to 4
    weeks. We went back to private care for Brian, paying for
    someone to help him twice a week, along with myself, paying for
    care once a week. We were turned down for caregiver support
    multiple times.
        Then, on June 28, 2016, Brian ultimately lost his battle to
    Post Traumatic Stress, and it was then, during the eulogy, that
    I vowed to carry on his mission for VetLinks.org to help. Even
    if it was just one family to not have to live through the hell
    that we did, we were going to do it.
        So, we started VetLinks.org, and now we help not just the
    veteran but the caregiver and the family, and we get them the
    immediate help that they may need for post-traumatic stress,
    substance abuse, or TBI, in the immediate fashion, and we pay
    for those services as well. We have partnered with Code of
    Support. They are a great organization as well, locally. With
    their peer navigators we are able to help the veteran and the
    family members walk through the entire process, from A to Z,
    whatever help they might need, and again, while paying for
    those services.
        So, we still have a lot of work to do. I think we all have
    a lot of work to do. We are sending these men and women to war,
    they are doing their jobs, and we need to do ours to help them
    in an immediate fashion for mental health care. We all know
    there are still 20 suicides a day, and we are not even counting
    the statistics for caregivers or children who are also
    committing suicide.
        So, as we have all sat here today there has been one more
    family affected and now is going through pure hell, just like
    our family.
        [The prepared statement of Ms. Kavanagh follows:]
     Prepared Statement of Jessica Kavanagh, Founder & President, VetLinks
        To the Committee on Veterans' Affairs, I'm writing to you today on
    behalf of my late husband, MAJ Brian Kavanagh. Brian was commissioned
    through the Reserve Officer Training Corps as a Second Lieutenant in
    the Infantry branch of the Army. As a 2nd LT, Brian completed the
    Ranger School and was assigned to Bravo Company, 1/8 Infantry, 3rd
    Brigade, 4th Infantry Division. As a Platoon Leader, Brian led in
    garrison and combat, receiving two Bronze Stars for actions during his
    first deployment in Iraq. During his time with 1/8 Infantry, he was
    promoted to 1st Lieutenant and then Captain. CPT Kavanagh transitioned
    to the Military Intelligence Branch and served as an Intelligence
    Advisor to the Afghanistan Army where he received another Bronze Star
    for actions in combat. Brian finished his Active Duty career as the
    Company Commander for Alpha Company, 308th Military Intelligence
    Battalion, 902nd Military Intelligence Group where he earned the
    Meritorious Service Medal for his service to both Alpha Company and the
    Aberdeen Proving Ground Military Intelligence Detachment. Brian
    transitioned to the US Army Reserves and was promoted to the rank of
    Major. He was activated to serve as the Chief of Joint Operations for
    the Joint Reserve Intelligence Support Element to the United Stated
    Africa Command J2--Intelligence Directorate.
        I met Brian in August 2009 after he started command of Alpha
    Company at Aberdeen Proving Ground. Roughly two years later we got
    married in June 2011. In December 2011, Brian was diagnosed with PTS
    and was placed on medications for depression, anxiety, and sleep
    problems including a particularly disturbing pattern of nightmares.
    After Brian's initial diagnosis and treatment for PTS while on Active
    Duty, his symptoms steadily worsened. When Brian transitioned from
    active service into Federal Government service we sought treatment with
    a Psychiatrist within the Maryland VA system. We were assigned a social
    worker at a local Veteran Center where Brian had regular sessions along
    with couple's therapy. Despite what we thought were our best efforts to
    manage Brian's symptoms for PTS, they continued to worsen.
        In May 2014, Brian acknowledged that he needed something more
    intensive as his symptoms were getting worse. We asked our VA counselor
    for recommendations, and they were unaware of where to direct Brian for
    inpatient help. I called the Veterans' crisis hotline, but they said
    that if he was not suicidal, they were unable to assist. As I
    researched for an inpatient unit that would be able to help Veterans'
    with PTS and substance abuse, I found that nothing seemed to exist.
    Every Google search came back to ``VA Health System,'' except our
    social worker at the VA was not even able to provide a location. I
    ended up finding a place in Washington DC, the Psychiatric Institute.
    It did not seem to be the right fit for Brian, but we were desperate in
    our efforts to find anything to help his symptoms ease. For two weeks,
    Brian stayed at this location with 14 women who suffered PTS from
    sexual assault. Upon discharge, Brian started with a private practice
    for further therapy hoping different professionals would be able to
    help. Our family paid out of pocket for this private treatment.
        Fast forward to July 2015, Brian was unable to continue working. He
    was severely depressed, would lay in bed for days if not weeks, and his
    symptoms were becoming unmanageable. We saw his primary care doctor at
    the VA, and with the request to see a mental health professional to
    discuss further options, we were given a 6 week wait time.
        Meantime, I continued my research to find inpatient units that
    specialized in PTS and substance abuse, specifically for Veterans.
    Little came to fruition except for a few private locations around the
    country that all required cash payments.
        On September 11th, when we finally had our highly anticipated
    appointment with the VA social worker, I told her of these private
    practice locations that might be able to help. She said that she would
    have no way of getting Brian a referral to any of those facilities, but
    could get him a consult so that he could go into the Psych Unit at the
    Baltimore VA. We felt very defeated and left feeling as if we were back
    at square one.
        By this time, I made it my full-time job to start calling Veterans'
    advocates and anyone who would listen to me to try to get Brian the
    help he needed. I started calling VA Centers across the United States
    to see what specific programs they had for PTS and substance abuse
    disorder. Not ONE VA center returned my call. I spoke with one veteran
    advocate who let me know about a new program called the Choice program.
    I called the number they provided me, and they let me know that Brian
    was not eligible. I called the Baltimore VA multiple times until I
    finally spoke with someone, and they let me know that the Choice
    program did not cover inpatient facilities, only doctor's appointments
    that had a 30 day wait time or had a distance further than 40 miles
    from the closest VA.
        At this point, Brian was still not back to work, and we were both
    feeling hopeless. I received a phone call mid-September from a woman in
    Houston who had heard about our struggles from one of the many phone
    calls I had made. She let me know that there was going to be a VA
    Congressional Hearing and the former VA Secretary Bob McDonald was
    going to be there. She was flying in for the hearing and suggested that
    I go to try to meet him and ask for assistance. So, on October 7th, of
    2015, that's exactly what I did. I introduced myself to Bob McDonald
    and told him our story along with the battles we were facing. He said
    ``give me three days, and I will help you.'' Sure enough, a couple of
    days later, the Martinsburg VA called me and said they could get my
    husband into their program in 2-4 weeks. Needless to say, I called Mr.
    McDonald's cell phone after this and let him know their status after he
    promised me he could help immediately. The VA then called me back a
    couple of hours later that Friday, and on Monday I was able to get
    Brian enrolled into their program. I will pause to publicly thank Mr.
    McDonald for taking the time to personally help Brian.
        The program itself lasted 90 days. It consisted of all group
    sessions and classes, no individualized care. Brian seemed to be doing
    well while he was there, and seemed to enjoy being around other
    Veterans. While he was there, he realized that many of his fellow
    Veterans were not receiving a lot of the benefits that they had earned
    or were entitled to. Brian started holding classes there showing them
    with his laptop how to get set up for their benefits until he was told
    that he was not able to do this being a patient himself. He continued
    to do so anyhow. Over Thanksgiving, three weeks before his anticipated
    discharge, Brian was able to come home for the holiday. He had a
    complete relapse, and he did not do well being home with myself and our
    two girls (Meryn and Evie), 3 and 1 at the time. Our family priest had
    to take him back to Martinsburg early, and I was left with severe angst
    about his discharge in three weeks. When I spoke with the social worker
    after the holiday and expressed my concerns, she said there really
    wasn't anything more they could do, and that he had already almost
    competed all of the group sessions. We had an emergency family meeting,
    and his program lead ensured me that we would have a thorough discharge
    plan to help continue his progress.
        On December 21st, Brian was discharged, and we were to start one-
    on-one trauma therapy sessions at the local Veteran Center. After
    starting in January, he was able to see the social worker there once
    every 3 to 4 weeks. The social worker explained that there were not
    enough resources, and that was all he could do for Brian. Brian also
    decided that he could no longer go back to work doing Counter
    Intelligence and officially resigned from his position. He decided
    based on what he experienced during his stay at Martinsburg that he
    wanted to start a Non-Profit and help Veterans find the immediate
    resources they might need and get them the benefits they may be
    entitled to. I thought that this was a great idea and stated that this
    should be for caregivers and the family as well, considering my own
    difficulties trying to find Brian help.
        Brian's struggles continued. Seeing the social worker at the
    Veteran Center was not productive with the amount of time we were
    allotted. Through my own private therapist, I found Brian a trauma
    therapist who was a Vietnam Vet and had previously worked at the VA. We
    were paying for two sessions a week for Brian and one session a week
    for myself. And couples therapy when we could afford it. I applied for
    Caregivers support and was turned down. We were applying for increased
    disability for Brian and also turned down. Being able to ``prove PTS''
    proved difficult. I reapplied for Caregivers support and was turned
    down again. I felt like I was fighting a war on the inside of our
    household and a war on the outside against the VA, all while working a
    full-time job and caring for our two young daughters.
        On June 28th, 2016 Brian ultimately lost his battle to PTS. I
    received the phone call from the Baltimore police while driving down
    95, and it was the worst moment of my entire life. My entire soul was
    shattered in the matter of an instance. Never once did I feel that it
    would have ended like this, we were always just going to continue our
    fight. While his life did not end with suicide, it was directly related
    to his PTS and substance abuse disorder.
        During my eulogy, I vowed to continue the fight even if it simply
    meant saving just one family from the hell that we had to experience.
    The day after his funeral, I sat around with his best friends and told
    them of his desire to start a Non-Profit, and then and there in my
    living room VetLinks.org was created. I threw my grief into
    VetLinks.org, and we officially became a 501(c)3 on December 20th,
    2016. A Christmas present from Brian.
        VetLinks.org assists with helping the Veteran, the Caregiver, and
    family members get the immediate resources they might need,
    specifically for PTS, TBI, and Substance Abuse disorder while also
    paying for those services. We have partnered with Code of Support who
    offers Peer Navigators to each Veteran or Caregiver who calls in to
    walk them through the entire process and finding them their immediate
    resources they may need. VetLinks.org then pays for those services so
    the process is seamless and helps the Veteran and their family not
    incur any costs to getting the care they deserve.
        To date, we have helped almost 30 families in need. One Veteran
    worked for the VA himself, was suicidal and suffered from PTS and
    alcoholism. The VA gave him a 6-week lead time, and we were able to get
    him into a private inpatient unit and pay for the treatment in two
    days.
        I believe that I met Brian for a bigger purpose. But in a perfect
    world, VetLinks.org along with the thousands of other non-profits
    wouldn't have to exist if our government did their job taking care of
    our Veterans and Caregivers. I don't understand when less than 1% of
    our Nation selflessly serve our military why the rest of the 99% can't
    take care of these men and women. If we as a country are going to
    decide to send our men and women to WAR, we have got to do a better job
    taking care of them when they come home.
        As I now close my remarks, I urge you with every fiber of my being
    to use your positions of influence within our government to allocate
    significant resources to help our veterans, caregivers, and family
    members fight against the effects of PTS, TBI, and substance abuse
    disorder. Without your help, thousands of veterans and their families
    will continue to struggle. Please help me honor my late husband--MAJ
    Brian Kavanagh--and decide to take action--now.

        Senator Tester. Thank you for your testimony. I am sorry,
    but I actually have to go vote, General Quinn. Otherwise I will
    get shut out on this, so we have got to recess for a second.
    And, Chairman Isakson should be back here shortly.
        We are in recess. Smoke them if you have got them.
    [Laughter.]
        [Recess.]
        Chairman Isakson. We are going to go ahead and start. I
    will bring us back to where we were. Jon will be here in just a
    second. Thank you for your patience. We are sorry, we had to
    vote, but we got them all done. There are no more votes
    tonight, so we are all yours for the rest of the night, if you
    want us, but I know you do not want us for the rest of the
    night, so we will get right to our business now.
        Maj. Gen. Matthew Quinn, Adjutant General of the Montana
    National Guard.
        General Quinn?

      STATEMENT OF MAJ. GEN. MATTHEW T. QUINN, ADJUTANT GENERAL,
                         MONTANA NATIONAL GUARD

        Maj. Gen. Quinn. Good afternoon Mr. Chairman. I am Maj.
    Gen. Matt Quinn, Adjutant General and CDR of the Montana
    National Guard. I am here today to testify on actions the State
    of Montana has taken to protect our National Guard
    servicemembers, our Montana veterans, and their family members.
        I have been the Adjutant General for just over 7 years and
    in that time we have lost 11 soldiers. We did not lose soldiers
    to combat. Rather, every tragic loss was due to death by
    suicide. Over half of our losses to suicide had never deployed,
    nor did they have the qualifying amount of active duty service
    for veteran eligibility. Only 33 percent of our current
    National Guard servicemembers qualify for VA care, so this was
    and continues to be a challenge that we had to solve as a
    State.
        At the direction of Governor Bullock, Montana Departments
    of Military Affairs and Administration joined forces to
    determine potential resources available within Montana State
    government that could be used to support the National Guard
    women and men who serve our State and Nation. We have a
    servicemember living in every one of our 404 ZIP codes of
    Montana and we needed a benefit that would be convenient and
    accessible by any servicemember across the State.
        Each employee of the State of Montana, through our State
    health insurance plan, is a participant in an employee
    assistance program designed to provide counseling services to
    the employees and their families or household members. The
    Department of Administration, working with employee assistant
    provider, EAP for short, determined that the benefit could be
    expanded to include every National Guard servicemembers.
        In the fall of 2016, the State of Montana enrolled every
    member of the Montana National Guard in Montana's Employee
    Assistance Program. This benefit allows for in-person
    counseling services across the State for any issue the
    servicemember or family member is facing, from alcohol, to job,
    family, financial, or deployment stressors, any issue which can
    be helped with counseling.
        These visits are totally confidential; Montana National
    Guard leadership will not know who has sought counseling. I am
    encouraged by the number of Montana National Guard men and
    women taking advantage of the benefit, but additionally
    encouraged by the number of spouses and children of
    servicemembers seeking care.
        After deploying the benefit, the first call received was
    from a former National Guard member who had served 30 years in
    the National Guard but did not have veteran eligibility. So,
    another call was made to the EAP provider, and shortly
    thereafter we rolled out the Veteran Assistance Program, or
    VAP.
        VAP provides free counseling to any former servicemember or
    veteran within the State of Montana. Montana has the second
    highest per-capita percentage of veterans, and we are looking
    to not only provide support to those who had previously served
    our State in the National Guard, but also to augment the
    services provided by the Veterans Administration. Although the
    usage by former servicemembers is not great, several did
    utilize the benefit expressing an intent for self-harm. If one
    veteran or former servicemember is helped in a time of need and
    is stopped from making a final, fateful decision through this
    program, I will continue the advocacy, in spite of limited
    usage.
        As a result of our work and the work of the cities of
    Helena and Billings in a VA Health and Human Services program
    titled The Mayors Challenge, Montana has been selected as one
    of seven States to participate in The Governor's Challenge. The
    Governor's Challenge is a collective effort with the Veterans
    Administration and Health and Human Services Administration's
    SAMHSA group to combat the loss to suicide of our veterans,
    servicemembers, and family members.
        The effort in Montana has three primary objectives: (1)
    identify those citizens who have served or have family members
    who have served, (2) Provide universal screening to those
    individuals; and (3) connect veterans through a peer-to-peer
    support network. This effort is in its early stages but we are
    encouraged by the progress made so far to bring all of
    Montana's communities together to better support our veterans,
    our current servicemembers, and their families.
        I will conclude with a thank you to Senator Tester and this
    Committee's work to allow for readjustment counseling services
    to our National Guard servicemembers at the Vet Centers across
    the Nation. Although a National Guard servicemember may not
    have served in a combat theater, many may be suffering from the
    traumatic stress of recovering neighbors from hurricanes,
    tornados, fires, floods, and landslides. When they leave a
    drill location at the conclusion of a weekend or an annual
    training period, they return to their communities potentially
    without the blanket of care provided by our Veterans
    Administration. I would encourage this Committee to recognize
    the service provided to our States and nation by our National
    Guard and continue to seek ways to care for those who serve.
        Mr. Chairman, that concludes my testimony.
        [The prepared statement of Major General Quinn follows:]
    Prepared Statement of Maj. Gen. Matthew T. Quinn, Adjutant General and
                       Commander, Montana National Guard
        Good afternoon Mr. Chairman and Members of the Senate Veterans
    Affair Committee. I am Major General Matt Quinn, Adjutant General and
    commander of the Montana National Guard. I am here today to testify on
    actions the State of Montana has taken to protect our National Guard
    servicemembers, their family members, and Montana Veterans.
        I have been the Adjutant General for just over seven years and in
    that time, we have lost 11 Soldiers. We did not lose Soldiers to
    combat, rather every tragic loss was due to death by suicide. After
    each death we looked at the possible mitigating factors leading to the
    suicide and in nearly every case there was a concern by the Soldier
    that if they sought help for depression or emotional issues they were
    dealing with, they would either not be allowed to deploy, or worse yet,
    would be removed from the Guard. Over half of our losses to suicide had
    never deployed, nor did they have the qualifying amount of active duty
    service for Veteran eligibility. Only 33% of our current National Guard
    servicemembers qualify for VA care, so this was and continues to be a
    challenge that we had to solve as a state.
        At the direction of Governor Bullock, Montana military affairs and
    Department of Administration joined forces to determine potential
    resources available within Montana state government that could be used
    to support the National Guard women and men who serve our state and
    Nation. We have a servicemember living in every one of the 404 zip
    codes of Montana and we needed a benefit that would be convenient and
    accessible by any servicemember across the state. Each employee of the
    State of Montana, through our state health insurance plan, is a
    participant in an employee assistance program designed to provide
    counseling services to the employees and their families or household
    members. The Department of Administration, working with our EAP
    provider, determined that the benefit could be expanded to include our
    National Guard servicemembers. In the fall of 2016, the State of
    Montana enrolled every member of the Montana National Guard in
    Montana's Employee Assistance Program, or EAP for short. This benefit
    allows for in-person counseling services across the state for any issue
    the servicemember or family member is facing, from alcohol, to job,
    family, financial, or deployment stressors, any issue which can be
    helped with counseling. These visits are totally confidential; Montana
    National Guard leadership will not know who has sought counseling. I am
    encouraged by the number of Montana Guard men and women taking
    advantage of the benefit, but additionally encouraged by the number of
    spouses and children of servicemembers seeking care.
        After deploying the benefit, the first call received was from a
    former National Guard member who had served 30 years in the National
    Guard but did not have Veteran eligibility. So, another call was made
    to the EAP provider, and shortly thereafter we rolled out the Veteran
    Assistance Program, or VAP. VAP provides free counseling to any former
    servicemember or Veteran. Montana has the second highest per-capita
    percentage of Veterans and we are looking to not only provide support
    to those who had previously served our state in the National Guard, but
    also to augment the services provided by the Veterans Administration.
    Although the usage by former servicemembers is not great, several did
    utilize the benefit expressing an intent for self-harm. If one Veteran
    or former servicemember is provided assistance in a time of need, and
    is stopped from making a final, fateful decision through this program,
    I will continue the advocacy, in spite of limited usage.
        As a result of our work and the work of the Cities of Helena and
    Billings in a VA/DPHHS program titled the Mayors Challenge, Montana has
    been selected as one of seven state to participate in the Governor's
    Challenge. The Governor's Challenge is a collective effort with the
    Veterans Administration and the Department of Public Health and Human
    Services Administration's Substance Abuse and Mental Health Services
    Administration to combat the loss to suicide of our Veterans,
    Servicemembers and Family members. The effort in Montana has three
    primary objectives: 1) Identify those citizens who have served or have
    family members who have served; 2) Provide Universal Screening to those
    individuals; and 3) Connect Veterans through a peer-to-peer support
    network. This effort is in its early stages but we are encouraged by
    the progress made so far to bring all of Montana's communities together
    to better support our Veterans and their servicemembers.
        I will conclude with a thank you to Senator Tester and this
    Committee's work to allow for readjustment counseling services to our
    National Guard servicemembers at the Vet Centers across the Nation.
    Although a National Guard servicemember may not have served in a combat
    theater, many may be suffering from the traumatic stress of recovering
    neighbors from hurricanes, tornados, fires, floods, and landslides.
    When they leave a drill location at the conclusion of a weekend or
    annual training period, they return to their communities potentially
    without the blanket of care provided by our Veterans Administration. I
    would encourage this Committee to recognize the service provided to our
    states and nation by your National Guard and continue to seek ways to
    care for those who serve.

        Mr. Chairman that concludes my testimony.

        Chairman Isakson. Well, General, thank you very much. Jon
    did not get here. I guess he is still----
        Anyway, I am sure you are proud of Senator Tester. He is a
    great Member of the Senate, does a great job and has worked a
    lot, tirelessly on the suicide program. And, many of the things
    you told me meant a lot and I am glad you are doing them,
    particularly involving the National Guard. I was a guardsman
    myself. Georgia is in that situation. We have a lot of National
    Guardsmen who have deployed many times, but some of them have
    not been deployed.
        When Rumsfeld reformed the military, in the first couple of
    years under George W. Bush, he basically equalized benefits for
    Guard and Reserve units that were called up, which they were
    then repositioned to come up for the first time. In fact, the
    first people in Afghanistan and in Iraq, almost all the first
    people in there were Guardsmen, either for the fire, people at
    the airport, people of that nature.
        The fact that you have tried to reach out to those who were
    not eligible, per se, but were serving the country is a
    tremendous testimony to you but also a testimony to what we all
    need to do to make sure that kind of information is accessible
    and available to all of our veterans in the United States. I
    commend you for what you have done, very much.
        And our next--who has been left out? It surely was not
    Jessica. OK.
        Lt. Col. James Lorraine, you are recognized.

     STATEMENT OF LT. COL. JAMES LORRAINE, U.S. AIR FORCE (RET.),
       PRESIDENT AND CHIEF EXECUTIVE OFFICER, AMERICA'S WARRIOR
                              PARTNERSHIP

        Lt. Col. Lorraine. Thank you, Sir. Chairman Isakson,
    Ranking Member Tester, and Members of the Committee, thank you
    for the invitation to testify on the implementation of the
    community-based strategy to eliminate veteran suicide.
        Mr. Chairman, in September 2017, you said ``suicide is a
    terrible, terrible, terrible loss, and a wasteful loss of life,
    and a preventable loss of life.'' No truer words could be
    spoken. In those 22 months, our Nation has spent millions to
    prevent veteran suicide and still an estimated 13,000 veterans
    took their lives, and we continue down the same path.
        Mr. Chairman, in 2016, you and Senator Tester said we
    needed to find unique ways to provide services that benefit
    veterans. You were on target with your vision. We need to get
    moving, as veteran suicide has become a public health crisis.
        I have been a critical care nurse for more than 35 years. I
    have cared for thousands of wounded, ill, or injured, on the
    battlefield and in the clinical environment. The greatest care
    I can provide is to give hope.
        In 2009, a fellow soldier and friend took his life in the
    parking lot of an Army medical center because he could no
    longer endure the pain caused by 13 blasts that he had been
    exposed to during his combat tours. He left me a note saying
    that he had lost hope and he was sorry for giving up. Ten years
    later, we still have veterans taking their lives because they
    have lost hope.
        A renowned University of Kansas researcher, C.R. Snyder,
    studied not only the measurement of hope but also the
    correlation to post-traumatic stress, wellness, and suicide.
    Dr. Snyder identified a direct correlation between hopelessness
    and suicide. Hope is a powerful determinant in the person's
    quality-of-life.
        In our annual survey that America's Warrior Partnership
    conducts, we find that 80 percent of the veterans are hopeful
    and are seeking connection to other veterans, volunteer
    opportunities, and recreational opportunities. Word is the
    less-hopeful veterans sought improved transportation, spiritual
    and emergency financial assistance.
        America's Warrior Partnership's proven scalable community
    approach supports 48,000 veterans in communities of New York,
    South Carolina, our great State of Georgia, Florida, the tribal
    areas of Arizona, and Southern California, with measurable
    increase in hope. Our model seeks to proactively build
    relationships with all veterans before the crisis occurs,
    especially those not enrolled in the VA, in order to provide
    veterans hope by knowing the community has their back.
        The PREVENTS Executive order is a unique, game-changing
    approach to ending veteran suicide. As Congress determines how
    to operationalize this order, I would like to offer some joint
    recommendations developed with our partners at Combined Arms in
    Houston and the Institute for Military Veterans and Families at
    my alma mater of Syracuse University.
        We strongly recommend the proposed veteran suicide
    prevention effort be implemented through community-focused
    grants similar to the VA's Supportive Services for Veterans and
    Families Program. This effort must require grantees to outreach
    to all veterans while facilitating collaboration between local
    and national service organizations in a coordinated effort to
    holistically serve the veterans.
        It is important to highlight that mental health access is a
    critical element in preventing suicide. However, it is one
    element of the solution. Community programs must provide access
    to holistic resources such as employment, health care, housing,
    benefits, education, personal and professional networking, and
    much more, to improve the hopefulness of the veteran and their
    family.
        To better understand veteran suicide there must be greater
    collaborative research and data-sharing between academic
    institutions, the Department of Veterans Affairs, and
    Department of Defense, as well as with local coroners and
    medical examiners. Today we are using incomplete veteran
    suicide data to develop programs for a problem that we do not
    fully understand.
        In December 2017, America's Warrior Partnership joined with
    the University of Alabama and the Bristol-Myers Squibb
    Foundation to launch Operation Deep Dive, a 4-year, 14-
    community national research study that is the first of its
    kind, to examine the community-level factors involved in
    veteran suicide.
        We have developed a socio-cultural investigation tool and
    utilize a cutting-edge technology to better understand how the
    communities can combat veteran suicide. We believe granted
    communities should use this methodology to establish a baseline
    of veteran suicide and annually assess the rate as a measure of
    the program's success. With Operation Deep Dive we are moving
    from net fishing to hunting for veterans who are about to take
    their life.
        In summary, as Congress decides the best path forward, I
    urge this Committee to consider the successful precedent of the
    SSVF program as a template to end veteran suicide. And last, we
    must understand more about veteran suicide to include the
    impacted from the military service experience, community
    influence, and the service provided by Veterans Affairs.
        I am hopeful. I am hopeful for our military, I am hopeful
    for our veterans, and I am hopeful for our success in ending
    veteran suicide. Thank you for the opportunity to present
    recommendations to the Committee.
        [The prepared statement of Lt. Col. Lorraine follows:]
    Prepared Statement of Lt. Col. James Lorraine, USAF (Ret.), President &
                CEO, America's Warrior Partnership, Augusta, GA
        Chairman Isakson, Ranking Member Tester, and Members of the
    Committee: Thank you for the invitation to testify today on the
    implementation of a community-based strategy to eliminate suicide among
    our Nation's military veterans. My name is Jim Lorraine, and I am the
    president and CEO of America's Warrior Partnership. I served as an Air
    Force Officer and Flight Nurse for 22 years. I was the founding
    director of the United States Special Operations Command Care
    Coalition; a Department of Defense wounded warrior advocacy
    organization that has been recognized as the gold standard in
    supporting wounded, ill or injured warriors along with their families.
    I also served as Special Assistant for Warrior and Family Support to
    the Chairman, Joint Chiefs of Staff, where I helped to transform the
    Chairman's ``Sea of Goodwill'' concept into a strategy. America's
    Warrior Partnership is a national nonprofit organization dedicated to
    empowering communities to empower veterans, their families and
    caregivers. Our organization intimately understands the importance of
    building collaborative partnerships between national resources and the
    local community groups who interact with veterans on a daily basis.
        Empowering communities is a proven approach, and I have seen for
    myself what coordinated networks of veteran-serving organizations can
    accomplish and how our approach of developing a relationship with
    veterans before the crisis occurs has paid dividends on improving the
    quality of life for veterans, their families and their communities.
    This has been the core of our work at America's Warrior Partnership
    since we launched our Community Integration service model in June 2012.
    Our service model is currently active in six affiliate communities and
    has positively impacted the lives of more than 48,000 warriors in the
    last seven years.
        We are not alone in emphasizing the role of communities in serving
    veterans. Groups such as Combined Arms in Houston and the AmericaServes
    programs of the Institute for Veterans and Military Families (IVMF) at
    Syracuse University have built local collaboratives that bridge the
    gaps between disconnected service providers.
        The VA has documented the impact that suicide is having on veteran
    communities across the country. The latest report from 2018 found that,
    on average, 20 veterans die by suicide every day, 6 of whom are under
    Veteran Health Administration care and 14 who are not. These numbers
    may speak for themselves, but for many of us in the veteran-serving
    community, suicide prevention has become a personal mission. Ask any
    veteran and you will likely hear stories similar to the ones I have to
    share. Stories of fellow servicemembers who died even after we begged
    them to reach out for assistance. Stories of trying to comfort the
    friends and family members who are left wondering if there was more
    they could have done. Stories of close friends leaving behind notes
    asking for our forgiveness.
        It cannot be overstated how dire of a public health crisis that
    veteran suicide has become.
        The PREVENTS Executive Order signed by the President in March of
    this year provides the Nation the greatest opportunity to change how
    our whole nation ends veteran suicide. Mr. Chairman, I know you
    understand this because in 2016 you made it your top priority to change
    the paradigm at the Department of Veterans Affairs in delivery of
    quality services in unique ways that benefit veterans. Both you and the
    Ranking Member, Senator Tester, have recognized in words and
    legislation that communities where veterans live provide the greatest
    opportunity for positive, sustained, collaborative impact toward ending
    veteran suicide. Harnessing the services and compassion that exist in
    our Nation's communities to end veteran suicide is both unique and
    revolutionary.
        The PREVENTS Executive Order established a Department of Veterans
    Affairs Task Force to develop a roadmap to help veterans achieve an
    improved quality of life while strengthening community-based programs
    to prevent suicide among veterans. I strongly encourage the Department
    to not only begin the Task Force's work, but also look beyond
    government membership and include national leaders in community
    integration programs to play an active role in implementing the
    PREVENTS Executive Order.
        As Congress determines how to operationalize this initiative, I
    would like to offer a joint recommendation developed by three of the
    leading authorities in community-based services for veterans: Combined
    Arms, IVMF and our own team at America's Warrior Partnership. We
    developed this recommendation based on our organizations' combined
    history of developing and operating veteran community integration
    programs with more than 1,000 partners in 26 rural and urban
    communities representing 18 states. Our programs have collectively
    impacted more than 70,000 veterans, military families and caregivers
    across the country.
        We strongly recommend that the PREVENTS Executive Order be
    implemented through a community-focused grant program that requires
    grantees to facilitate collaboration between national and local
    veteran-serving organizations in a coordinated effort to serve veterans
    holistically. The support provided by grantees should be delivered
    proactively to addresses both the mental health and social determinants
    affecting veterans' outlook on life.
        Along with our collective experience, we have based our
    recommendation on the successful roadmap established by the Supportive
    Services for Veterans and Families Program (SSVF). In 2008, Public Law
    110-387, Section 604 of the Veterans' Mental Health and Other Care
    Improvements Act, authorized the VA to develop the SSVF program, which
    awards grants to select private non-profits and consumer cooperatives
    that assist low income veteran families who are residing in or
    transitioning to permanent housing. These grants continue to enable
    communities to reduce veteran homelessness through integrated networks
    of government and non-government resources, which empower veterans to
    thrive even after they secure stable housing. The community-based
    approach of the SSVF program was a great success, and we strongly
    believe it should serve as the foundation of the mission to end veteran
    suicide.
        Eliminating suicide is the mandate of the PREVENTS Executive Order,
    so it is also essential to consider how grantees can improve the
    quality of life and hopefulness of veterans in a holistic manner. Every
    veteran is different, which means every veteran will be affected
    differently by the varying geographical and cultural characteristics of
    the community in which they live. That is why it is also critical that
    grantees should be required to coordinate programs and services that
    not only track and support the mental health of veterans, but also the
    wide range of social factors that can impact their outlook on life.
    Holistic resources should be available to support veterans with
    employment, healthcare, housing, benefits, education, personal and
    professional networking, and much more.
        It is important to highlight that we believe access to mental
    health treatment is a critical element of preventing suicide, but it is
    only one element of the solution. In our annual survey, America's
    Warrior Partnership uses a validated measure of hope in the surveying
    of veterans across the Nation. Using Dr. C. R. Snyder's Adult Hope
    Scale, we correlate hopefulness or hopelessness to what veterans are
    seeking within their community. We measure hope because it provides for
    the veteran's future perspective and correlates well to suicide. In our
    studies, we find that veterans with the greatest hope are seeking
    connection with other veterans, volunteer opportunities and
    recreational opportunities, whereas veterans with the lowest hope
    sought improved transportation, spiritual assistance and emergency
    financial assistance. We believe proactively developing a relationship
    with veterans ahead of the crisis and connecting them to a wide range
    of community services that not only provide support, but also provide
    purpose has increased veterans' hopefulness for the future. In the end,
    veterans know that someone in the community cares, can help them
    navigate barriers, and has their back.
        With such a broad range of areas to support, grantees must balance
    the unique services that their community will prioritize with a
    systemic approach to tracking progress and monitoring results. This
    should all start with communities using established research methods,
    such as those endorsed by IVMF and other veteran-focused researchers,
    to form a baseline that indicates the current outlook of local veterans
    and the specific factors that are affecting those at greatest risk for
    suicide.
        Registering a baseline of veteran suicide within the community and
    annually measuring the change as a result of the grant, planning
    appropriate measures to improve veterans' lives and establishing
    metrics to holistically track progress should all be monitored using a
    comprehensive information management system, such as America's Warrior
    Partnership's WarriorServe system, throughout the duration of the
    grant. This information management system should also serve as a tool
    for grantees to coordinate outreach to veterans between various service
    providers and programs.
        Last, to better understand veteran suicide there must be greater
    collaborative research and data sharing between academic institutions,
    the Departments of Veterans Affairs and Defense, and local coroner and
    medical examiner offices. In December 2017, America's Warrior
    Partnership joined the University of Alabama and the Bristol-Myers
    Squibb Foundation to launch Operation Deep Dive, a four-year research
    study that is the first of its kind to examine the community-level risk
    factors involved in suicides and early mortality due to self-harm among
    veterans. The project is currently active in 14 communities across the
    country, with locally based Community Action Teams directing the study
    under the guidance of a national research team in order to coordinate
    prevention and postvention techniques on a community level that can
    adjust in real-time as data is collected and analyzed. When Operation
    Deep Dive concludes, we expect to understand the community-level
    factors contributing to veteran suicide, as well as have a methodology
    that any community can implement locally to identify the unique risk
    factors affecting their veterans, along with guidelines on how they can
    address these issues through proactive, holistic outreach programs. For
    Operation Deep Dive to succeed, both local, state and Federal
    Government in conjunction with non-government data must be available to
    researchers to understand the veteran most at risk, in a specific
    community to take their life.
        In summary, as Congress decides on the best path forward to
    operationalize the PREVENTS Executive Order, I join the leaders of our
    country's largest veteran community collaboratives in urging this
    Committee to consider the successful precedent of the SSVF program. We
    recommend a grant program adopt the community focus of the SSVF
    initiative and complement it with an emphasis on holistic measures that
    are inclusive of both the mental health and social factors that affect
    veterans at risk for suicide. A community's progress in coordinating
    services and bringing positive change to local veterans should be
    monitored using established research methods and a comprehensive
    information management system.
        One final point I will add is that all grantees should
    authentically represent the communities in which they serve. This means
    that each organization actually resides within their community and has
    documented agreements in place that show they have the support of local
    government and non-government leaders. The goal of this initiative,
    after all, is not to supplant the hard work that community
    organizations have done to help their veterans, but to empower them to
    take it to the next level.
        Thank you for the opportunity to present this recommendation to the
    Committee. As Chairman Isakson has said, ``Suicide is a terrible,
    terrible, terrible loss, and a wasteful loss of life and a preventable
    loss of life.'' Veteran suicide is an undisputed public health crisis,
    and it will take a highly coordinated level of collaboration between
    local community groups and national veteran-serving organizations to
    end it. Our country's legislators have already taken the first steps
    toward providing communities the support they need. I speak for my
    fellow leaders within the veteran-serving community when I say that we
    are all here to offer our continuing help and support to complete this
    mission.

        Chairman Isakson. Well, Colonel, thank you very much. Are
    you a resident of Augusta, GA, or were you from Augusta, GA?
        Lt. Col. Lorraine. I work out of Augusta, GA, but I am a
    resident of Aiken, SC, sir.
        Chairman Isakson. Well, that is a good place, too. It is
    almost as good as Augusta.
        Lt. Col. Lorraine. Almost as good, sir. Not quite as good,
    but almost as good.
        Chairman Isakson. We have got a lot of soldiers at Fort
    Gordon. We have got a lot of military personnel there. In
    particular, the NSA has built a huge, modern intelligence
    facility there that is second to none in the world, and
    certainly our military. That is the home base of many people
    that have a lot of conditions or opportunities for conditions
    we talk about.
        I appreciate so much your focus on getting over the hump,
    thinking about what the problems are and finding out what the
    problems are, because sometimes they are not what you think,
    and sometimes they are things we overlook without intention to
    do so. I enjoyed your testimony tremendously.
        Paige Thornton--Paige?
        Ms. Thornton. Yes, sir?
        Chairman Isakson. Donna Stitcher. These two beautiful women
    flew up on here on Delta Airlines from Georgia just to visit
    today, because of their interest in this particular issue,
    particularly PTSD and some of the other problems we face.
        Have you all enjoyed the day and picked up something?
        Ms. Thornton. We sure did.
        Ms. Stitcher. Yes, sir. It is a delight to be here and to
    see people that have common situations, that I have personally
    lost a loved one due to combat, a veteran, Desert Storm. So,
    thank you so much for having this hearing.
        Chairman Isakson. We know we are going to be altogether
    better if we are always all together, and sharing is critically
    important. The sharing of information, the willingness to share
    the information, and the ability to seek out that information
    can make all the difference in the world. You do not need a
    situation of stigmas and stereotypes. What you need is
    opportunity and hope. That is the way I try and always--just
    give me a chance to get your question answered and I will give
    you a chance to get to somebody who can give you help.
        Thank you for what you are doing. I appreciate you all
    coming up, and I will turn it over to the Ranking Member.
        Senator Tester. Thank you, Mr. Chairman, and thank you all
    once again for your testimony. I will apologize. Normally this
    Committee is here to grill you guys, and I know you were
    looking forward to that grilling, but unfortunately it is just
    me and Johnny, so it is my turn first.
        General Quinn, thanks for being here. Thanks for
    representing Montana and the views of the National Guard in
    Montana. In your testimony you highlighted the importance of a
    state-run program like the Montana Employees Assistance and
    Veterans Assistance Program, that provides mental health
    services for State employees and for members of the Guard. Why
    was it important for the State of Montana to get involved?
        Maj. Gen. Quinn. Thanks, Senator, for that question, and
    thanks for your support.
        It was important because of those servicemembers serving in
    the National Guard, and that was the initial focus, for those
    that do not have veteran eligibility. We were not trying to
    take away from the veterans program. If we have National Guard
    members who are veterans then we would like to augment the
    Veterans Administration and the program that they have.
        When the statistics showed that over half of those
    individuals that lost their life to suicide were not veterans,
    did not have eligibility for veteran care, then there needed to
    be something that we should do in order to provide them the
    services they need.
        The numbers are looking good. The number of soldiers and
    airmen who are seeking counseling services is encouraging to
    us. The number of family members who are seeking counseling
    services are encouraging to us. I do not want to know who those
    individuals are. I want them to seek the help and not be
    worried about what the military will do if we find out that
    they are seeking help.
        So, it was important to have an outside program that they
    can turn to. Military OneSource is out there, but
    servicemembers are seeing that as related to the military and
    they do not want to seek that help. That is why we went to an
    outside agency. That is why we went through the State and
    provided or offered those benefits to the soldiers and airmen
    that serve our National Guard.
        Senator Tester. What impact do you think guardsmen's access
    to Vet Centers will have?
        Maj. Gen. Quinn. I think, Senator, the access to Vet
    Centers is critical. I often use as an example military sexual
    trauma, and servicemembers that are in our National Guard that
    have suffered military sexual trauma, or sexual trauma outside
    the military. But, they are a member of our force. They are
    currently serving our State and our Nation. Their ability to
    seek help through the Vet Centers, if they do not have veteran
    eligibility is important to them. They are looking for that
    care. They are looking to continue to serve but they just need
    the care that will allow them to continue to serve.
        The ability to have veterans--we opened the one in Helena
    maybe, what, 2 years ago. That is important, and I have a lot
    of servicemembers willing to go to a Vet Center and look for
    that care, even if they are not VA eligible.
        Senator Tester. Last question for you. Are there any gaps
    that you see out there that we should be looking at?
        Maj. Gen. Quinn. Senator, I still worry about those who are
    not seeking the care that they need to serve, and the
    transition services that have been talked about today--you have
    mentioned it, Secretary Wilkie mentioned it--that transition
    care, I think is very important. If I have a Guard member who
    departs after 20 years or 30 years, who is not veteran
    eligible, who does not have that care, I think we need to look
    harder at that transition care, and how can they continue to be
    able to rely, either on the Vet Center or on the Veterans
    Administration, if that is possible. I think that transition is
    critical, Senator.
        Senator Tester. Thank you, and thank you for being here.
        Dr. Haynie, in your testimony--I have got it written down
    in my notes--getting the transition right is critical. You
    talked about, in that transition--and do not let me put words
    in your mouth, but navigating and getting the help they need,
    navigating through the jungle of issues that you are dealing
    with when you are a veteran.
        Could you, number 1, flesh that out a little bit more for
    me, talk with some more specifics, and then what do we need to
    do, or better yet, if, in fact, it is not just the VA but the
    DOD, because I think you might have mentioned that too, or
    somebody up there did. What do we need the DOD to do to make
    the transition right?
        Mr. Haynie. Thank you for the question, Senator. I think
    what I highlighted in my testimony was sort of the learned
    experience now, over 10 years of developing programs to support
    the transition, and, more importantly, hearing directly from
    servicemembers and their families about their barriers at the
    point of transition. You know, it was unexpected, even for us,
    to learn that among all of the challenges servicemembers and
    their families face when they make that transition from
    military to civilian life, the most significant challenge they
    cite is simply understanding--I think the way I put it is--how
    to get the help they need, when they need it, and, importantly,
    in their own communities. We tend to think that we transition
    veterans to national programs. At the end of the day, our
    servicemembers are transitioning to towns, villages, cities,
    and the extent to which those towns, villages, and cities are
    resource and culturally competent to accept them and welcome
    them into their communities I think makes all the difference.
        There is also an economic argument here. The work that we
    have done in communities around the United States, we have not
    come to a single one where we have identified a gap in
    resourcing as it relates to boots on the ground, nonprofit,
    community-connected providers, clinical health care providers,
    et cetera, the stock of resources that exists to actually
    address the needs of our veterans. I guess what I am say is we
    do not need to build more things. What we really need to do is
    create a system that connects all of those resources, at a
    community level, and then shepherds the veteran and their
    family to those resources when they need those resources.
        To your point about transition, our other big insight, all
    of the conversation that we have had today related to mental
    health, et cetera, you know, we are essentially working behind
    the curve. The consequence that is the subject of this hearing
    is really a function of our ability to effectively manage the
    transition of a military-connected family to civilian life.
        And, as Jim pointed out and others have spoken to, we have
    not had the discussion about the social and economic
    determinants of health and well-being. It is the case that
    jobs, careers, connections to community, stable families, all
    of that plays into the compromised-or-not mental health
    situation of our veterans, and all of that is aligned with a
    healthy and robust transition.
        So, from my perspective, if we get the transition right,
    that is the most powerful way to blunt some of the unfortunate
    consequences that we see down the road as it relates to
    suicide.
        Senator Tester. Last question, if I might, Mr. Chairman.
        Chairman Isakson. Certainly.
        Senator Tester. Jessica, as I listened to your statement--
    first of all, thanks for being here and for sharing your story,
    and Brian's story. As I listened to your statement I was hoping
    that it ended up better than it ended up. I had read about your
    story and I just want to thank you for making a negative
    situation into a positive situation, and I just cannot thank
    you enough. Little did I know that you happened to be FROM my
    friend, Jerry Moran, of Kansas. He has a note here that says
    Pittsburg, KS, which is a bit confusing to a guy from Montana.
        Nonetheless, I think that through your statement you have
    shown that VetLinks has the ability to make personal
    connections----
        Ms. Kavanagh. Correct.
        Senator Tester [continuing]. With the veteran, their
    caregivers, their family. It would be my hope that the VA would
    work closely with you. I would like you to comment on if they
    have been. I would also like you to comment on if there are
    areas that they can improve in making it more seamless and more
    effective, things that you would like to see them do.
        Ms. Kavanagh. Yes. Thank you, Senator. I have not reached
    out to the VA as of yet to partner with them to help. We worked
    directly with Code of Support. They are also a local nonprofit.
    And together we just--they have people who hear of Code of
    Support and they send them in our direction, where we are able
    to provide the finances for them, whether they are in need of
    something for substance abuse or Post Traumatic Stress or
    Traumatic Brain Injury, for the veteran, for the child who
    might need any sort of therapy, for the caregiver.
        It is very situational. I mean, I think it is all
    individualized care, and everybody has a different need. Which
    is what is so great about our partnership: we can take their
    individual need, run them through A to Z, see what they
    specifically need, just not for the veteran but for the entire
    family, and then we are able to provide the resources and pay
    for what they are in need of.
        Senator Tester. Thank you, and thank you all. Hopefully we
    did not screw up your life by this hearing going until 5:30
    when it probably should have ended an hour ago. The bottom line
    is we appreciate your input. It will make a difference in the
    decisions we are able to make because of the expertise that all
    of you offered up, either in your statements or in your answers
    to the questions. Thank you.
        Ms. Kavanagh. Thank you.
        Chairman Isakson. I, too, want to thank you and I apologize
    that you got caught in the crossfire of Committee and votes.
    But, I do not think I have ever had a situation as Chairman
    where everybody wanted our guests to stay until we came back,
    because they want them to go. But, they did not want you all to
    go anywhere; and after hearing your testimony, we know why.
        I want to add one thing for Mr. Haynie. The handoff from
    the Department of Defense to the Veterans Administration is
    horrible. There is a black hole out there somewhere that every
    active duty military person falls into when they leave DOD
    health care, and each does not come out of it until after they
    should have already been in the VA health care for a year or
    so.
        We are addressing that. One of the ways we are doing it is
    DOD's software and computer systems and the Veterans, they are
    not interoperable. So, the first thing we have to do is--we
    have got two important sources of information that do not talk
    to each other. Senator Tester and I, along with the leadership
    of the VA, signed the largest contract in the history of the VA
    with Cerner to get an interoperable information system for
    medical IT with DOD and VA systems together, and that is going
    to make a big difference.
        Because more of these causes or contributors to the
    psychological and mental problems that are associated with
    suicide are health related and not necessarily narcotics
    related or heritage related or anything else, and sometimes
    that information does not flow with veterans as easy as it
    should. Something is missed for a time while the veteran is
    getting used to talking about the problem they have. That
    absence of information available to the professional could hurt
    them a lot.
        So, I want to thank you for your testimony. We know we are
    short on that. We know we need to do better, and we are doing
    better, everything we can. Secretary Wilkie is a great
    Secretary. He is doing a wonderful job, and I think his service
    is going to be great to this country and great to the veterans
    of our country. And we are going to do everything, our
    Committee together, to keep working to make the veteran system
    and the benefits to a veteran's service to his country, or her
    country, they get every benefit they are supposed to get, and
    they get it the way they need to get it, and that we are
    helping people and saving their lives, that we are not hurting
    people and keeping them away from the health care they need.
        Thank you for coming. Thank you for your testimony. We are
    going to leave the record open for 5 days, for any additional
    questions, and we will get them to you if they are for you
    specifically, or anything you might want to add to the
    testimony that you gave.
        Unless there is any further information, I will call the
    meeting adjourned.
        [Whereupon, at 5:30 p.m., the Committee was adjourned.]
     Prepared Statement from Hon. John Boozman, U.S. Senator from Arkansas
                                  for Panel II
        I know you all were here for the first panel and heard my
    description of the bill that my colleagues and I introduced today.
        I won't rehash the whole thing, but as a recap, the legislation
    will accomplish three broad objectives:

        1. It will enable the VA to directly or indirectly reach more
    veterans;
        2. It will increase coordination among currently disparate
    organizations that all play a part in reducing the purposelessness that
    ends in suicide; and
        3. It will drive adoption of a standard measurement tool that will
    help us determine the effects and outcomes of our services.

        I would emphasize that we believe organizations like those on this
    panel have already figured out how to do some of the work that needs to
    be done.
        It's simply a matter of taking the best of what works, sharing
    ideas, and working together within a shared framework.
                                     ______

       Response to Posthearing Questions submitted by Hon. Jon Tester to
                      U.S. Department of Veterans Affairs
        Question 1. Do you have any metrics on what the use is for those
    mobile Vet Centers? If you do not, that is fine, but if you do, could
    you get that to us?
        Response. Readjustment Counseling Service (RCS) maintains a fleet
    of 80 Mobile Vet Centers (MVC) to extend focused-outreach, direct
    services, and referral services to Veterans, as well as to serve as a
    resource for VA's emergency response mission. In FY 2018, MVCs were
    present at 4,880 events where staff engaged in over 49,000 encounters
    (outreach and direct counseling) with Veterans, active duty
    Servicemembers, and their families. In addition, in FY 2018, MVCs were
    deployed in response to 11 emergency situations including shootings in
    Las Vegas, Yountville, Santa Fe, and Parkland; the Hawaii Big Island
    Volcano; the Northern California, Carr, and Mendocino Fires; and
    Hurricanes Florence, Maria, and Harvey. During these deployments, Vet
    Center staff provided services to over 13,125 individuals during these
    events.
                                     ______

      Response to Posthearing Questions submitted by Hon. Patty Murray to
                      U.S. Department of Veterans Affairs
        Question 1. What kind of meaningful outreach is VA doing to ensure
    veterans with Other Than Honorable discharges are aware of the care
    available to them and how to access that care?
        Response. VA coordinated and conducted focused outreach to former
    Servicemembers with OTH discharges twice over the past 18 months. This
    included joint outreach efforts in support of the President's
    January 9, 2018, EO 13822 which focuses on mental health and suicide
    prevention support for newly separated Servicemembers in the first 12
    months after separation. The joint efforts with the DOD and DHS
    included outreach materials that focused on recently separated
    Servicemembers with OTH discharges. This occurred from March 2018 to
    December 2018. More recently, VA conducted internal and external
    digital media engagement, to augment the January notification by mail
    to OTH former Servicemembers. This effort included a blog at https://
    www.blogs.va.gov/VAntage/60349/other-than-honorable-discharge/; posts
    on VA's Facebook page (1.19 million followers); and a Twitter feed
    (624,000 followers). This information was also distributed by email to
    over one million subscribers to VA's This Week newsletter.

        Question 2. What specifically is VA doing to remove barriers for
    women to access mental health care?
        Response. The Women's Mental Health Section of the Office of Mental
    Health and Suicide Prevention (OMHSP) has recently developed an
    infrastructure and strong clinical trainings initiatives to support the
    availability of gender-sensitive mental health care for women Veterans.
        As part of this infrastructure, OMHSP has established a national
    network of Women's Mental Health Champions. Each VA medical center has
    appointed at least one clinician to this role. Women's Mental Health
    Champions disseminate information; facilitate consultations; develop
    resources that increase the visibility and accessibility of gender-
    sensitive women's mental health care; and contribute to a welcoming
    care environment.
        VA has also developed specialized training initiatives to advance
    the clinical competency of mental health providers who care for women
    Veterans, including those at risk for suicide. These training efforts
    contribute to a welcoming treatment environment for women Veterans by
    improving access to gender-sensitive Veteran-centered care. Examples of
    innovative clinical training initiatives include the following:

         The Women's Mental Health Mini-Residency which is a 3-day
    training that covers a broad range of topics related to the treatment
    of women Veterans, such as understanding suicide risks in female
    patients and working with women whose mental health problems are
    influenced by hormonal changes.
         The STAIR (Skills Training in Affective and Interpersonal
    Regulation) training teaches clinicians to deliver a trauma treatment
    that focuses on strengthening emotion regulation and relationship
    skills. These areas of functioning are often disrupted in women who
    have experienced severe interpersonal traumas, such as sexual assault.
    Research suggests that emotion dysregulation is associated with
    suicidal ideation and behaviors.
         Parenting STAIR training teaches therapists to deliver a
    component of the STAIR treatment that is designed to help Veterans who
    have persistent trauma-related reactions that negatively impact their
    parenting and parent-child relationships.
         The Multidisciplinary Eating Disorder Treatment Team
    training aligns with the Joint Commission's rigorous standards for the
    outpatient treatment of eating disorders. Eating disorders are
    associated with increased risk for suicide attempts and death by
    suicide.
         The National Women's Mental Health Monthly Teleconference
    Series is a monthly clinical training designed to enhance knowledge of
    gender-tailored treatment approaches, including prescribing practices.
    Physiological changes across women's reproductive lifecycles can affect
    their mental health and suicide risk. For example, women who have
    premenstrual dysphoric disorder (PMDD) have a greater likelihood of
    having suicidal thoughts, plans, and attempts. Treating PMDD is
    different than treating depression. Only some antidepressants are
    effective for PMDD, and dosing only during the luteal phase (2nd half,
    after ovulation) of the menstrual cycle is effective. Proper
    recognition, diagnosis, and treatment of PMDD can substantially reduce
    suicide risk for this subset of women Veterans.

        Question 3. How will VA identify these veterans who have
    experienced military sexual trauma especially when some of these
    veterans are reluctant to identify themselves this way and help get
    them into care?
        Response. Recognizing that many survivors of sexual trauma do not
    disclose their experiences unless asked directly, it is VA policy that
    all Veterans seen for health care are screened for military sexual
    trauma (MST). This is an important way to ensure that Veterans are
    aware of and offered the free MST-related care available through the
    VHA. For Veterans who experienced MST, it also helps ensure that their
    trauma history is considered in the provision of their care.
        All Veterans seen in VA's health care facilities must be screened
    at least once using the MST clinical reminder in the Computerized
    Patient Record System. However, since some Veterans may not feel
    comfortable disclosing an MST experience when first screened, national
    educational resources highlight the importance of creating multiple
    opportunities for disclosure of MST experiences. For example, VA
    encourages additional MST screening for any Veteran receiving mental
    health care. Veterans who decline to respond to the MST screen are
    automatically re-screened after 1 year. Veterans who respond ``yes'' to
    either of the screening questions (indicating the Veteran did
    experience sexual assault/harassment during military service) are
    offered a referral for mental health services via an automated question
    in the MST clinical reminder. This referral question standardizes the
    referral process system-wide and helps streamline access to mental
    health care for Veterans who express interest in MST-related mental
    health treatment.
        For Veterans, services for any mental and physical health condition
    related to MST are available for free at every VA medical center, and
    eligibility is expansive: Veterans do not need to have reported their
    experiences at the time or have any documentation that they occurred
    and may be able to receive free MST-related care even if they are not
    eligible for other VA care. Under its new treatment authority (38
    U.S.C. Sec. 1720I), VHA is now offering mental health care free-of-
    charge to former Servicemembers with an OTH discharge who experienced
    MST. VHA has several initiatives to help ensure that targeted,
    specialized services are available and that Veterans and former
    Servicemembers are aware of these services. Every VA health care system
    also has a designated MST Coordinator who serves as the local point
    person for MST-related issues and can help Veterans and eligible former
    Servicemembers access MST-related services and programs.

        Question 4. What is known about the prevalence or causes of suicide
    among dependents and family members of veterans?
        Response. Research is needed about the prevalence of suicides among
    Veterans' dependents and family members. Even more so than just
    understanding the prevalence of suicide, it is important to understand
    why this subgroup may have elevated suicide rates. Research has shown
    that suicide bereavement in the general population is often accompanied
    by experiences of trauma, guilt, anger, shame, stigma, perceived
    preventability, social isolation, family relational disturbance, and
    perceived rejection that can increase vulnerability to persistent
    distress, psychiatric disorders, and a survivor's own suicide risk.
    There are additional complexities faced by survivors of military
    suicide, including challenges around the shame and stigma of a
    ``dishonorable'' death, the violence of the death, lengthy
    investigations to determine benefits, and the culture around remaining
    strong and self-reliant at all costs. Researchers have called for more
    research and resources into the impact of suicide on military suicide
    loss survivors and culturally sensitive postvention supports needed for
    their care.

        Question 4a. Is VA doing anything to better integrate families into
    the suicide prevention process?
        Response. Although family conflict and social isolation are risk
    factors for suicide, at this point there are no published evidence-
    based interventions to engage relatives and loved ones to address
    suicide risk in adults. Therefore, OMHSP Family Services Section (FSS)
    is developing best practices that can be used by mental health
    providers who interact with Veterans at risk for suicide and their
    loved ones, while waiting for stronger empirical data to be available.
    FSS has three initiatives in this regard.
        First, over the past 2 years, FSS co-developed and sponsored two
    system wide webinars for VA mental health providers to educate them
    about family issues and suicide. The webinars provide information on
    the Interpersonal-Psychological l Theory of Suicide, which emphasizes:
    1) the importance of feeling like a burden to others; 2) feeling
    alienated from others; 3) the capacity for suicide (knowing how to use
    a weapon, not fearing death, high pain tolerance) in increasing suicide
    risk in adults; and 4) ways to interact with Veterans and relatives and
    alert them to these issues and proactive in addressing them. FSS
    developed these webinars with the VA Suicide Prevention Coordinator
    Leadership and the leadership of the VA Coaching into Care Program and
    they have been well-received.
        Second, FSS has integrated training into the intensive evidence-
    based training programs on Integrative Behavioral Couples Therapy for
    Marital Distress and Cognitive-Behavioral Conjoint Therapy for PTSD for
    VA mental Health for engaging relatives and Veterans to promote dialog
    about suicidal ideation and develop conjoint safety planning.
    Clinicians are provided with empirical information on family factors
    that have been identified as helpful and harmful by adults at risk for
    suicide, and recommendations about effective ways they can interact
    with Veterans and loved ones to reduce suicide risk. Clinicians are
    also given ample time to consult with project staff about these issues
    during these training as well.
        Finally, FSS is collaborating on two VA research pilot trials to
    better understand family factors in Veteran suicide and to develop
    effective family interventions. The most developed of these projects is
    being led by Dr. Marianne Goodman at the Bronx, New York (NY) VA, who
    is testing a family-based intervention to address Veteran suicide risk
    in a feasibility trial. It should be noted that one of the important
    findings from this trial is the wide variability in Veterans' and loved
    ones' interest and comfort in family interventions addressing suicide.
    One size does not fit all. Many Veterans appear ashamed of their
    suicidal feelings, and do not wish to share them with their relatives,
    and a subset of relatives are either incredulous at the idea that their
    Veteran loved one is suicidal or are angry/dismissive about it.
    Clinicians need thoughtful and effective strategies to address these
    barriers. This is a small pilot, but it is clear there is much work to
    be done in this area.
        A second project for which a grant proposal is just being written
    is building from a study on Cognitive-behavioral Conjoint Therapy for
    PTSD, led by Dr. Leslie Morland at the San Diego, California (CA) VA.
    Given the prevalence of suicidal ideation observed in Veteran couples
    in this study, Doctors Chandra Khalifian and Morland are collecting
    data on couples' interest and willingness to address suicide
    conjointly. This study just received Institutional Review Board
    approval to pilot a novel couples-based suicide intervention with
    Veterans, called Treatment for Relationships and Safety Together in
    collaboration with Doctors Craig Bryan and Feea Lefiker.
                                     ______

     Response to Posthearing Questions submitted by Hon. Sherrod Brown to
                      U.S. Department of Veterans Affairs
        Question 1. How is VA working with DOD to ensure servicemembers who
    suffer from addiction and mental health receive a warm hand off once
    separated from service?
        Response. VA and the Department of Defense (DOD) collaborate
    closely to provide a single system experience of lifetime services for
    the men and women who volunteer to serve in our military services. VA
    and DOD collaboration includes programs to facilitate the transition to
    including help with enrollment, to VA health care for eligible
    Veterans; increase availability and access to mental health resources;
    and decrease negative perceptions of mental health problems and
    treatment among Servicemembers, Veterans, and providers. The following
    is a summary of VA policies and programs that support continuity of
    care for Servicemembers as they separate from service.

         Coaching into Care: VA provides a national telephone
    service for Veterans, their family members, and other loved ones
    seeking services at local VA facilities and in the community. Coaching
    is provided free-of-charge by licensed psychologists or social workers
    to family members and friends who are seeking care or services for a
    Veteran family (https://www.mirecc.va.gov/coaching).
         Community Provider Toolkit: Launched in March 2016, the
    Community Provider Toolkit is a one-stop web-based interagency
    repository of resources and tools that support the behavioral health
    and wellness of Veterans receiving care from community providers. The
    Toolkit was developed with input from VA, DOD, and the Department of
    Health and Human Services (HHS) Substance Abuse and Mental Health
    Services Administration (SAMHSA). The repository provides a single
    point of access to resources including the National Resource Directory,
    the SAMHSA Treatment Locator, Military OneSource, and the Military
    Families Learning Network (https://www.mentalhealth.va.gov/
    communityproviders).
         Community Resource and Referral Centers: These Centers
    provide Veterans who are homeless or at risk of homelessness with one-
    stop access to community-based multiagency services to secure permanent
    housing, health and mental health care, career development, and access
    to VA and non-VA benefits (https://www.va.gov/homeless/Crrc.asp).
         Concierge for Care: Former Servicemembers are called
    within 30 days of separation by VA staff who can answer questions;
    process the VA health care enrollment application over the phone; and
    assist eligible Veterans with setting up their first VA medical
    appointment.
         MakeTheConnection.net: A one-stop web resource where
    Veterans, families, and friends can privately explore information on
    mental health issues; listen to fellow Veterans and their families
    share their stories of resilience; and easily find and access support
    and resources. In May 2019, for Mental Health Awareness Month, VA
    launched The Moment When campaign to highlight the many positive
    moments or steps in one's recovery process. The overarching goals of
    the campaign were to improve access to mental health care and encourage
    Veterans to reach out for support at http://maketheconnection.net/.
         Mobile Applications (Apps): VA has a suite of award-
    winning mobile apps to support Veterans and their families with tools
    to help them manage emotional and behavioral concerns. In addition, VA
    actively and routinely coordinates with DOD's Defense Health Agency to:
    1) ensure that Servicemembers are aware of VA mobile apps during their
    service and in their transition out of service; 2) ensure that DOD and
    VA mobile technologies are coordinated and aligned in the types of
    content and services they provide; and 3) share best practices for
    delivering mobile health to Veterans and Servicemembers. Available
    mobile apps include those for use by Veterans (self-help) to support
    their ability to cope with a range of issues (e.g., Post Traumatic
    Stress Disorder (PTSD) symptoms, alcohol use, or smoking cessation) as
    well as mobile apps designed as an adjunct to psychotherapy and used
    with a mental health provider to support Veterans' engagement in care
    and their use of skills learned in therapy. VA's mobile apps enable
    Veterans to engage in self-help before their problems reach a level of
    needing professional assistance and aim to promote active engagement
    when they are in care. The goals are to empower Veterans and their
    families and support VA's efforts to improve access to care (https://
    mobile.va.gov/appstore/).
         Peer Specialists: VA continues to expand access to Peer
    Specialists who are VA employees in recovery from mental illnesses and
    substance abuse disorders that help other Veterans to successfully
    engage in mental health and substance use treatment. Consistent with
    the Clay Hunt Suicide Prevention for American Veterans Act, community-
    oriented peer support programs have been developed in 9 networks at 21
    VA sites to assist Servicemembers transitioning from military service
    and to improve access to mental health services. These collaborative
    outreach events in the community are bringing in many more Veterans for
    care. In addition, in implementing section 506 of the VA Maintaining
    Internal Systems and Strengthening Integrated Outside Networks
    (MISSION) Act of 2018, VA has added 30 peer specialists to work in
    Patient Aligned Care Teams (PACT) in 15 VA facilities this year and
    will expand to an additional 15 VA facilities next year to further
    increase Veterans' access to mental health care through primary care.
         Same-day Services for Urgent Primary and Mental Health
    Care Needs: In addition to the Emergency Department/Urgent Care Centers
    available at all VA medical centers, VHA offers Same Day Services in
    Mental Health for Veterans and eligible former Servicemembers. Same-day
    services may include: a face-to-face visit with a clinician; advice
    provided during a call with a nurse; a telehealth or video care visit;
    an appointment made with a specialist; or a prescription filled the
    same day, depending upon what best meets the needs of the Veteran.
         Transition Assistance Program (TAP): TAP provides
    information, tools, and training to ensure Servicemembers and their
    spouses are prepared for the next step in civilian life, whether
    pursuing additional education, finding a job in the public or private
    sector, or starting their own business. As part of TAP, Servicemembers
    learn about VA benefits and health care and start the 10-10 EZ health
    care enrollment application during the weeklong course that occurs
    prior to separation from the military. The recently redesigned TAP is
    the result of an interagency collaboration, including work by VA, to
    offer separating Servicemembers and their spouses better, more easily
    accessible resources and information to make their transitions more
    successful. Site: https://www.benefits.va.gov/tap/tap-index.asp
         Transition and Care Management (TCM) Services: Every VA
    medical center has a TCM Team that provides case management to Post-9/
    11 Combat and Non-Combat Veterans who are eligible for VA care and
    elect to enroll in TCM. Case Managers, who are either nurses or social
    workers, are available to help newly enrolled Veterans navigate the VA
    system and to coordinate all patient care activities and needs. All
    recently separated Veterans who are eligible for VA care can use this
    program.
         VA/DOD Joint Executive Committee (JEC) and Work Group
    Activities: The JEC provides senior leadership a forum for
    collaboration and resource sharing between VA and DOD. By statute, the
    Deputy Secretary of Veterans Affairs and the Under Secretary of Defense
    for Personnel and Readiness co-chair the JEC. The JEC consists of the
    leaders of the Health Executive Committee (HEC), the Benefits Executive
    Committee, the Interagency Program Office (IPO), additional Independent
    Work Groups, and other senior leaders designated by each Department.
    The JEC works to remove barriers and challenges that impede
    collaborative efforts; assert and support mutually beneficial
    opportunities to improve business practices; ensure high-quality cost-
    effective services for VA and DOD beneficiaries; and facilitate
    opportunities to improve resource utilization. Other specific JEC work
    group activities are as follows:

        (1) HEC Psychological Health Work Group (PHWG): The HEC PHWG
    actively collaborates on several initiatives, including:

              - The inTransition Program: A voluntary, confidential
            telephonic coaching program that provides continuity of care
            (i.e., warm hand-off) within and between VA and DOD health care
            systems as Servicemembers and Veterans with psychological
            health needs transition between duty stations and from active
            duty service to civilian life. The program was created to
            bridge that gap by supporting Servicemembers as they transition
            between health care systems to facilitate connecting to and
            engaging with a new provider. VA is working with DOD to promote
            self-referral to inTransition among Veterans with any category
            of discharge and to strengthen referrals from in Transition to
            VA health care and Vet Centers.
              - Separation Mental Health Assessment: In accordance with the
            National Defense Authorization Act for FY 2018, section 706,
            DOD and VA are standardizing practices in support of separation
            mental health screenings that are part of the Separation Health
            Assessment process for all separating Servicemembers within 180
            days prior to discharge. The VA/DOD Joint Action Plan for
            Suicide Prevention, mandated by EO 13822, Supporting Our
            Veterans During Their Transition From Uniformed Service to
            Civilian Life, includes the requirement to offer mental health
            screening to 100 percent of transitioning Servicemembers. Once
            implemented, the separation mental health assessments will
            ensure that separating Servicemembers with mental health needs
            are appropriately referred for transition services.

        (2) HEC Care Coordination Business Line (CCBL): CCBL provides joint
    leadership to drive continuous integration of care, benefits, and
    services provided to Servicemembers, Veterans, and their families.
    Current priorities include: evaluating and refining transition
    processes for all recovering SMs, to include those with complex care
    needs and improving Interagency Comprehensive Plan interoperability.
        (3) HEC Pain Management Work Group (PMWG): While primarily focused
    on assessment and management of pain conditions, HEC PMWG works
    collaboratively with VA and DOD leaders to synchronize pain management
    and opioid safety education and training of DOD and VA providers and
    patients. By coordinating DOD and VA patient and provider education,
    HEC PMWG strives to provide a similar approach to pain management and
    opioid safety across the two Departments; thus, making the transition
    smoother for those suffering from pain-related conditions. HEC PMWG
    developed and continues to update a basic pain curriculum for primary
    care providers (Joint Pain Education Program) which includes training
    on opioid use disorder. The HEC PMWG is also working on the alignment
    of pain/opioid safety metrics and outcomes collection to maximize the
    value of DOD-collected data after transition to VA.
        (4) JEC Separation Health Work Group (SHAWG): The JEC SHAWG
    coordinates VA and DOD responsibilities to perform separation and
    disability exams to meet requirements and enable the delivery of VA
    benefits at discharge in a way that avoids duplication of effort and
    minimizes burden on the separating Servicemember. Effective
    coordination also ensures completeness of the Service Treatment Record
    so that it will efficiently support any future claims by the Veteran.
    In FY 2018, the SHAWG developed and tested a common workflow to enable
    VA and DOD electronic systems to interface. Once implemented, this
    interface will eliminate the need for Servicemembers to courier a copy
    of the Service Treatment Record to VA and for VA claims processor to
    manually return the VA Disability Benefit Questionnaire to DOD.
        (5) Integrated Disability Evaluation System--Disability Evaluation
    System Improvement Work Group (DES WG): The DES WG supports process
    improvements to make the Integrated Disability Evaluation System (IDES)
    process faster and more efficient. On July 30, 2018, DOD published
    policy reducing the timeliness goal for the Integrated Disability
    Evaluation System (IDES) from 295 days to 230 days. This change impacts
    ill and injured Servicemembers who are no longer medically fit for
    continued military service. VA benefits from increased efficiencies by
    reducing the time to evaluate and award VA disability benefits to
    former Servicemembers.
        (6) VA/DOD Interagency Program Office (DOD/VA IPO)--Health Data
    Sharing: The purpose of the DOD/VA IPO is to jointly oversee and
    monitor the efforts of the DOD and VA in implementing national health
    data standards for interoperability and act as the single point of
    accountability for identifying, monitoring, and approving the clinical
    and technical data standards and profiles to ensure seamless
    integration of health data between the two Departments and private
    health care providers. DOD/VA IPO activities include:

              - Data Mapping: To maintain and enhance interoperability, the
            Departments and IPO continued regular mapping updates for data
            quality assurance. Throughout FY 2018, the IPO's
            Interoperability Standards and Documentation Change Control
            Board reviewed, analyzed, and approved a total of 8 DOD
            clinical data maps. VA continues to advance its data mapping
            capabilities as it proceeds with additional electronic health
            record enhancements. Moving forward, the IPO will continue
            working with VA and DOD to provide data quality assurance and
            explore opportunities to refine the process for reviewing and
            deploying data mapping updates.
              - Joint Legacy Viewer (JLV): VA and DOD continue deployment
            and infrastructure improvements of JLV. At the end of FY 2018,
            there were 422,370 total JLV users (96,187 at DOD; 308,529 at
            VHA; and 17,654 at VBA). To further enhance data sharing, DOD
            and the U.S. Coast Guard signed a Memorandum of Agreement to
            expand the use of JLV.
              - Interoperability Metrics: To measure the impact of
            interoperability, the IPO works with the Departments, academia,
            and other subject matter experts to develop and monitor
            Transactional and Outcome-Oriented Metrics to assess
            interoperability's impact on the health care received by our
            Servicemembers, Veterans, and their families (SMVF) through the
            DOD, VA, and their private partners. With this information, the
            IPO will be able to demonstrate the amount of data being
            exchanged (transactional metrics) and further improve the
            quality of care our beneficiaries receive (Outcome Oriented
            Metrics). Results from these metrics will ultimately determine
            interoperability's progress and its impact on our wounded
            warriors, our men and women in uniform separating from service,
            as well as the general population's health.
              - VA/DOD Electronic Health Record (EHR) Modernization
            Efforts: The IPO supports the EHR modernization efforts of VA
            and DOD, encouraging and enabling collaboration by serving as
            an interagency resource for EHR modernization and supporting
            system information technology (IT) governance and health data
            interoperability. As the Departments continue their efforts to
            implement Cerner EHR products, the IPO will continue to support
            interoperability and modernization goals of the Departments to
            ensure our Veterans and transitioning Servicemembers receive
            seamless health care.

        (7) Federal Electronic Health Record Modernization: DOD and VA are
    developing a Federal Electronic Health Record Modernization (FEHRM)
    joint governance strategy to further promote rapid and agile
    decisionmaking. This structure will maximize DOD and VA resources,
    minimize EHR deployment and change management risks, and promote
    interoperability through coordinated clinical and business workflows,
    data management, and technology solutions while ensuring patient
    safety. The FEHRM program office will be responsible for effectively
    adjudicating functional, technical, and programmatic decisions in
    support of DOD and VA's integrated EHR solutions. DOD and VA will
    jointly present the final construct of the plan to Congress, including
    our implementation, phase execution, and leadership plans.
         VA Liaisons for Health Care: VA has liaisons stationed at
    military medical treatment facilities and Army Warrior Transitions
    Units to support the transfer of severely wounded Servicemembers. They
    coordinate care and provide consultation on VA resources and treatment
    options. Liaisons contact the Servicemember's local VA medical center
    and Operation Enduring Freedom/Operation Iraqi Freedom/Operation New
    Dawn Care Management Team to ensure that appointments and care plans
    are in place before the Servicemember leaves the military medical
    treatment facilities.
         VA Mental Health Services website for Transitioning
    Servicemembers: This new site provides simple guidance and direct links
    on how to access VA mental health services for Post Traumatic Stress
    Disorder, psychological effects of military sexual trauma, depression,
    grief, anxiety, and other needs. This site makes clear that some of
    these services are available to former Servicemembers even if they are
    not enrolled in VA health care (https://www.va.gov/health-care/health-
    needs-conditions/mental-health/).
         Veterans Benefits Administration (VBA) Call Center: VBA is
    expanding an existing call center to call Veterans at least three times
    during the first year after separation. The call center will provide
    information about the variety of VA benefits and health care resources
    available, including mental health care services, as well as create a
    caring contact with each Veteran.
         Vet Centers: Vet Centers are community-based counseling
    centers that provide a wide range of social and psychological services
    including professional readjustment counseling to certain Veterans and
    active duty Servicemembers, to include members of the National Guard
    and Reserve components. All Vet Centers maintain regularly scheduled
    nontraditional hours, including evenings and weekends, to ensure that
    Veterans and Servicemembers can access these services. There are 300
    total Vet Centers with locations in every state, the District of
    Columbia, Puerto Rico, American Samoa, and Guam (https://
    www.vetcenter.va.gov).
         VHA Directive 2014-02: VHA Directive 2014-02, Continuation
    of Mental Health Medications Initiated by Department of Defense
    Authorized Providers, allows VA providers to continue mental health
    medications initiated by DOD authorized providers for recently
    discharged Servicemembers, even when the medication is not included in
    the VA National Formulary (VANF). In the interest of Veteran-centered
    care principles, VA medical facilities must streamline local processes
    to ensure prompt access to DOD-prescribed VANF non-formulary or
    restricted mental health medications for recently discharged
    Servicemembers.
         VHA Health Eligibility Center: In addition to starting the
    VA Form 10-10EZ during TAP, separating Servicemembers can start the VA
    application in person at any VA Medical Center, by phone at 1-(877)
    222-VETS, online at https://www.va.gov/health-care/how-to-apply, or by
    sending the application to Health Eligibility Center, 2957 Clairmont
    Road, Suite 200, Atlanta, GA 30329.
         Web-Based Self-Help Tools: VA launched an online portal in
    2014 for Web-based self-help resources to provide one-stop shopping for
    Veterans and their families. Award-winning courses available at https:/
    /www.veterantraining.va.gov/index.asp include:

              (1) Path to Better Sleep--an online tool to support cognitive
            behavioral therapy for insomnia;
              (2) Moving Forward--an educational and life-coaching program
            that teaches problem-solving skills to help Veterans better
            handle life's challenges; Anger and Irritability;
              (3) Management Skills--offers a wide range of practical
            skills and tools to manage anger and develop self-control over
            thoughts and actions; and
              (4) PTSD Coach Online--a Web-based version of the award-
            winning PTSD Coach for trauma survivors, their families, or
            anyone coping with stress.

         Whole Health Orientation Groups: Veterans may attend Whole
    Health Orientation groups that give them the opportunity to connect
    with VHA and, if needed, receive a referral for VA mental health care.
    The Whole Health model is a holistic look at the many areas of life
    that can affect Veteran health from work environments, relationships,
    diet, sleep patterns, and more. The Components of Proactive Health and
    Well-Being helps illustrate how these areas are all interconnected
    (https://www.va.gov/patientcenteredcare/explore/about-whole-
    health.asp).
         VA/DOD Identity Repository (VADIR): VADIR makes DOD
    service record information available to VA. Among regular operational
    uses, VA utilizes information from VADIR to identify at risk groups who
    may benefit from further care enhancement and engagement.

        Question 1a. Which Department is required to inform the individual
    about services and benefits?
        Response. VBA provides mandatory training to Transitioning
    Servicemembers (TSM), their families, and caregivers at over 300
    military installations worldwide, with information about services and
    benefits available to them in their communities. Training is mandated
    through the Interagency Transition Assistance Program where the
    Department of Labor, DOD, and VA are required to provide information in
    a cohesive, modular, outcome-based program that bolsters and
    standardizes the opportunities, services, and training that
    Servicemembers receive.
        TSMs participate in these training courses through a varied
    approach that includes in-class instruction, Joint Knowledge Online,
    Military Life Cycles, installation engagements (which are tailored to
    the audience such as military spouses), and one-on-one counseling
    sessions where TSMs can approach a Benefits Advisor to inquire about
    additional services and opportunities available in a private setting at
    the installation.
        VA is committed to providing the most up-to-date information on VA
    benefits and services to foster TSMs opportunities to achieve economic
    success and total well-being from Military service through civilian
    life.

        Question 1b. How do the two Departments work together to ensure
    that veterans don't fall through the cracks?
        Response. The joint VA/DOD efforts associated with Executive Order
    (EO) 13822 (EO) on transitioning Servicemember mental health have
    resulted in improved transition, access, outreach, and monitoring of
    TSMs and Veterans. Sixteen lines of action were developed, 10 of which
    are now in a steady operational state. In December 2018, DOD and VA
    began conducting mental health screening on all TSMs prior to
    separation. VA will reach out to all TSMs within 90 days of separation
    and again at 180 days and for a third time before the end of the first
    year of separation. VA, DOD, and the Department of Homeland Security
    (DHS) collaborated to develop a ``one team'' messaging campaign,
    disseminated to all VA facilities to ensure that transitioning
    Servicemembers, Veterans, family members, providers, and staff are
    aware of the impact and benefits resulting from the EO. Specific
    products developed included frequently asked questions resources, a
    placemat with EO benefits, brochures, social media posts, blogs, and an
    EO specific Web site that has been widely circulated.

        Question 2. Veterans who receive care with VA are less likely than
    those who don't to commit suicide. What is the detailed plan for the
    two EOs to improve mental health and suicide prevention programs to
    benefit veterans?
        Response. Suicide is a complex issue with no single cause. It is a
    national public health issue that affects people from all walks of
    life--not just Veterans--and for a variety of reasons. VA, alone,
    cannot end Veteran suicide. We know that some Veterans may not receive
    any or all their health care services from VA, and we want to be
    respectful and cognizant of a Veteran's choice to obtain care
    elsewhere. This means using prevention approaches that cut across all
    sectors in which Veterans may interact and collaborate with Veteran
    Service Organizations, state and local leaders, medical professionals,
    criminal justice officials, private employers, and many other
    stakeholders.
        The Joint Action Plan for EO 13822, Supporting Our Veterans During
    Their Transition From Uniformed Service to Civilian Life, outlines the
    detailed plan for implementation, and 10 of 16 of these tasks are
    already complete. The Roadmap for EO 13861, National Roadmap to Empower
    Veterans and End Suicide, will outline the plan for implementation and
    enhancement to improve mental health and suicide prevention programs
    across Federal agencies, states, and communities to improve Veteran
    care.

        Question 2a. What steps is VA taking to reach veterans who may have
    an OTH discharge, or who might not be associated with the broader
    veterans' community or a VSO?
        Response. Former Servicemembers with OTH discharges can be
    difficult to locate. However, in January 2019, VA mailed 477,404
    letters to OTH former Servicemembers' last-known addresses, as part of
    our public outreach efforts.

        Question 2b. What are the metrics VA is using to see if the
    programs are working?
        Response. Because no one strategy is effective in isolation, the
    public health model advocates for bundled approaches that reach all
    Veterans, selected subgroups of some Veterans that may be at increased
    risk, and the relatively few indicated Veterans at high risk. We have
    developed measurement strategies for each line of effort in our program
    to track and measure impact of activities on suicide reduction. VA
    tracks and assess numerous metrics associated with suicide prevention
    priorities, activities and efforts aligned with the 2018-2028 National
    Strategy for Preventing Veteran Suicide.
        This list focuses on some of the metrics associated with the VA's
    suicide prevention priorities that are regularly tracked to monitor
    trends to include our enhanced care delivery, education and training,
    and outreach and awareness interventions:

         Lethal Means and Safety Planning which encompasses the
    following:

              - Suicide Risk Identification using a three-step approach to
            ensure universal suicide risk screening for all Veterans seen
            in clinics throughout VHA;
              - High Risk for Suicide and Enhanced Care (HRF) patient
            record flag for patients assessed to be at high risk for
            suicide. VA tracks numerous metrics tied to the HRF program to
            ensure compliance and appropriate follow up for these
            vulnerable Veterans;
              - Number of gunlocks we deliver;
              - Pounds of medication disposed;
              - Suicide safety planning throughout VHA;
              - Suicide Awareness Voices of Education (SAVE) training
            compliance among VA staff;
              - SAVE trainings provided externally in the community; and
              - VCL use and metrics associated with efficient and effective
            crisis line efforts.

         Partnerships, Outreach, and Awareness which includes the
    following:

              - Awareness campaigns--Online interaction with our campaign
            materials to gauge how effectively we are reaching the right
            people with the right information: site usage patterns, traffic
            to site, time on site, number of pages visited, public service
            announcement views, impressions and distribution, broadcast and
            billboard efforts (for more information on paid media see
            response to question 5);
              - Engagements with other key resources such as downloads of
            campaign materials, uses of SAVE training, views of our
            educational videos and public service announcements;
              - Outreach events completed by VHA staff within their
            communities and number of participants in attendance;
              - The number of community partners and an assessment of the
            gaps in sectors to ensure VA is developing partnerships across
            all areas that intersect with suicide; and
              - Action plans and efforts from Mayor's and Governor's
            Challenge partners.

         Enhanced Health Care Services such as the following:

              - Mental Health and Suicide Prevention Coordinator staffing
            metrics;
              - Number of Veterans identified by predictive analytics that
            receive the recommended interventions;
              - New mental health appointments within 30 days;
              - Same day access to mental health appointments;
              - Mental Health appointments delivered by telehealth; and
              - Post discharge follow up from inpatient care, emergency
            department, residential facilities, substance abuse, etc. to
            engagement in outpatient care.

        Metrics related to our enhanced care delivery interventions have
    been developed through several automated dashboards to identify
    Veterans at highest risk for suicide to aid providers in improved
    decisionmaking and safety planning. Examples of these tools include the
    following:

         Suicide Prevention Quarterly Dashboard--reports quarterly
    metrics on core suicide prevention priorities, tracking trends, needs,
    and gaps for quality improvement, and is adaptable to track new
    priorities. Specifically, the dashboard maps out Veterans who have
    recently been identified as high risk for suicide and placed on our
    HRF. This dashboard marks the percentage Veterans that:

              - Have a Safety Plan documented within 7 days before or after
            flag initiation, or on or before discharge;
              - Received at least 4 mental health encounters within 30 days
            of flag initiation;
              - Have a new assignment, reactivated, or continued HRF who
            received a case review within 100 days after flag initiation.

         Recovery Engagement and Coordination for Health--Veterans
    (REACH VET): is Enhanced Treatment, which identifies patients at
    statistical risk of death by suicide in the next month.
         The Stratification Tool for Opioid Risk Mitigation
    (STORM): identifies patients at statistical risk of overdose or
    suicide-related health care events or death in the next year.
         The Suicide Prevention Population Risk Identification and
    Tracking for Exigencies unifies information from the following: HRF,
    STORM, REACH VET, post-discharge engagement, positive secondary suicide
    risk screens and intermediate or above risk levels captured by the
    comprehensive suicide risk evaluation to identify and reduce care gaps
    and ensure high levels of care for patients identified at high risk for
    suicide.
         Suicide Prevention Application Network (SPAN): a database
    that allows Suicide Prevention Coordinators to report suicides and
    suicide attempts; manage treatment plans; follow patient progress; and
    provide outreach. SPAN is designed to capture the number of suicides
    and non-fatal suicide attempts among the Veteran population. This
    information is calculated monthly and continuously updated.

        VA developed the Strategic Analytics for Improvement and Learning
    (SAIL) Value Model to measure, evaluate, and benchmark quality and
    efficiency at medical centers to promote high quality, safety, and
    value-based health care. SAIL assesses 25 Quality measures including
    specific metrics assessing mental health care. These metrics are
    reviewed and utilized for decisionmaking and technical assistance to
    close gaps to offering the best care. These reports are publicly
    available on the
    VA website: https://www.va.gov/qualityofcare/measureup/
    strategic_analytics_for_ improvement_and_learning_sail.asp.

    ----------------------------------------------------------------------------------------------------------------
                                                                                    Number of OTH     Percentage of
                                                                  Number of OTH     Veterans who      OTH Veterans
                                                                Veterans seen in    received VHA     seen in VHA who
                                FYQ                              VHA in the last    specialty MH    received care in
                                                                   4 quarters     treatment in the    specialty MH
                                                                                   last 4 quarters      settings
    ----------------------------------------------------------------------------------------------------------------
    FY 2017 Q4................................................         426               301             70.65%
    FY 2018 Q1................................................         912               641             70.28%
    FY 2018 Q2................................................        1388               980             70.60%
    FY 2018 Q3................................................        1957              1393             71.18%
    FY 2018 Q4................................................        2350              1651             70.25%
    FY 2019 Q1................................................        2580              1818             70.46%
    FY 2019 Q2................................................        3130              2227             71.15%
    ----------------------------------------------------------------------------------------------------------------

        In the 4th quarter, ending March 31, 2019, VHA treated 3130 OTH
    Veterans, with 2227 receiving care in a specialty mental health
    program.

        Question 2c. Will the Department require additional funding from
    Congress to implement the EOs?
        Response. Executive Order (EO) 13822, is well underway, and
    additional funding is not required. Funding requirements for EO 13861
    are currently being assessed for FY 2020 and the Department will
    execute these requirements within its FY 2020 budget request.
                                     ______

    Response to Posthearing Questions submitted by Hon. Richard Blumenthal
                     to U.S. Department of Veterans Affairs
        Question 1. Can you please describe the training provided to VA
    personnel following enactment of the Honor Our Commitment Act?
        Response. VA conducted multiple trainings, including sessions for
    executive leaders, clinical providers, and administrative staff on the
    new 38 United States Code (U.S.C.) Sec. 1720I, which authorizes VA to
    provide mental and behavioral health care to certain former
    Servicemembers with other-than-honorable discharges (OTH). The training
    included information about the changes made to the Veterans Health
    Administration's (VHA) policy governing eligibility determinations to
    implement section 1720I.

        Question 1a. What actions has VA taken to ensure personnel are
    aware of the eligibility changes for other than honorable veterans so
    that they know not to deny these veterans mental health and behavioral
    care?
        Response. VA enrollment staff recently completed updated training
    provided by VA's Health Eligibility Center. In addition, VA has
    established training plans for all employees who process compensation
    claims for former Servicemembers with OTH discharges, in the Veterans
    Benefits Administration's Veterans Service Centers.

        Question 2. Can you please provide an update on VA's progress
    implementing GAO's recommendations outlined in their report
    Improvements Needed in Suicide Prevention Media Outreach Campaign
    Oversight and Evaluation?
        Response. We have implemented the recommendations of the Government
    Accountability Office (GAO). Recommendation 1 was to establish an
    approach for oversight of Suicide Prevention media outreach, including
    a clear delineation of roles and responsibilities and periods of staff
    turnover or program changes. This recommendation has been implemented
    and is closed. In April 2019, VA provided a new oversight plan that
    indicated leadership and contract oversight roles. The plan specified
    reporting structure and identified positions that can serve in acting
    capacities during periods of turnover. GAO closed the recommendation.
        Recommendation 2 was for VA to establish targets for the metrics
    the office uses to evaluate the effectiveness of its suicide prevention
    media outreach campaign. VA is looking at metrics related to the
    following areas:

         Awareness: Reaching people, getting content and messaging
    in front of people;
         Education: Interaction with informational materials like
    data sheets or views of educational videos; and
         Engagement: People using Veterans Crisis Line (VCL) call,
    chat, text. Downloads and usage of products, resources and tools, link-
    outs to trusted resources like Make the Connection or self-check quiz.
    Deepest level of engagement.

        Question 2a. How is VA evaluating the data it collects on its
    suicide prevention media outreach campaigns?
        Response. In addition to the metrics presented in response to 2b
    below, the following are outcomes of the Crisis Intervention campaign
    and special activations:

         A paid media campaign started on March 12, 2019. Since the
    campaign launched:

              - Monthly site visits to VCL.net increased from roughly
            44,000 to over 90,000.
              - Increase of 103.2 percent, with 48 percent of all site
            traffic arriving from paid advertisements.
              - Monthly increases in the amount of calls, texts, and chats
            because of our ads:

              - Monthly calls increased by 64.7 percent since launch. In
            February2019, before the launch, calls averaged around 4,500;
            by April, calls averaged around 7,500.
              - Monthly chats increased by 124.6 percent since launch. In
            February, chats averaged around 1,500; by April, chats averaged
            around 3,300 in April.
              - Monthly texts increased by 290 percent since launch. In
            February, texts averaged around 900; by April, texts surged to
            3,800.

         Billboards: March 1-April 30

              - 682 billboards disseminated in each of 100 largest markets
            in the United States;
              - Estimated 440 million impressions, donated value of $2.5
            million;
              - Monitored web traffic in 17 markets that first confirmed
            placements; and Traffic increased by 248.7 percent, from 201
            visits in February to 701 visits in April, average 41 visits
            per month per market.

         Major League Baseball Ads: Gameday programs estimated to
    gain 18.6 million impressions;
         Times Square: Drove 6 percent of traffic for the week
    (about 31 visits).

        Question 2b. What targets is VA using to determine if a campaign is
    effective in reaching its intended audience?
        Response. The paid media strategy is composed of the following
    three primary components that are monitored monthly:

    Campaign 1: Crisis Intervention
         Campaign success will be gauged by actions taken on
    VCL.net as a direct result of the marketing campaign, measuring key
    performance indicators (KPI) such as paid traffic, calls, chats, and
    texts against baselines established in past years' campaigns.

    ------------------------------------------------------------------------
                                                Fiscal Year
             Keyword Search Metrics              (FY) 2019        Monthly
                                                  Targets         Targets
    ------------------------------------------------------------------------
    Impressions.............................    5,200,000        740,000
    Calls...................................       14,000          2,000
    Texts...................................       14,000          2,000
    Chats...................................       14,000          2,000
    Self-check Quiz Link-outs...............        7,000          1,000
    ------------------------------------------------------------------------

    Campaign 2: National At-Risk
         In order to assess the immediate efficacy of this
    campaign, we will measure web KPIs and engagement with display and
    video content.
         Over a longer period of time, we will conduct search and
    brand lift studies on campaign YouTube content--examining lifts in
    awareness, as measured by organic search activity.

                                Top-line Metrics
    ------------------------------------------------------------------------
          FY 2019 Display Targets:              FY 2019 Video Targets:
    ------------------------------------------------------------------------
     Impressions: 132,000,000     Impressions: 19,000,000
     Traffic to site: 520,000     Traffic to site: 40,000
     Site-specific conversion     Video views: 7,000,000
     TBD                                  Site-specific conversion
                                          TBD
    ------------------------------------------------------------------------

    Campaign 3: High-Burden Communities
         In order to assess the immediate efficacy of this
    campaign, we will measure web KPIs and engagement with display and
    video content.
         Over a longer period, we will conduct search and brand
    lift studies on campaign YouTube content--examining lifts in awareness,
    as measured by organic search activity.

                                Top-line Metrics
    ------------------------------------------------------------------------
          FY 2019 Display Targets:              FY 2019 Video Targets:
    ------------------------------------------------------------------------
     Impressions: 132,000,000     Impressions: 19,000,000
     Traffic to site: 520,000     Traffic to site: 40,000
     Site-specific conversion     Video views: 7,000,000
     TBD                                  Site-specific conversion
                                          TBD
    ------------------------------------------------------------------------

        Question 2c. What action has VA taken to ensure its outreach
    content reaches veterans and others in the community to raise awareness
    of VA's suicide prevention services?
        Response. Additional detail is presented in the response to
    question 2b above, but in general terms, the campaign can be outlined
    as follows:

         Awareness: promote VA suicide prevention resources and the
    #BeThere campaign to increase awareness among Veterans and their
    supporters through:

              - Impressions from ads, videos, out-of-home placements; and
              - Site visits to VeteransCrisisLine.net,
            BeThereForVeterans.com, VA.gov/BeThere.
         Education: increase familiarity with suicide prevention
    information to equip audience with skills to apply at an individual and
    systemic level through:

              - Time on site;
              - Pages visited; and
              - Interaction with informational resources (clicks to State
            data sheets, views of educational videos).
         Engagement: increase interaction with campaign and
    external resources that align with public health approach to suicide
    prevention through:

              - Downloads or use of actionable campaign resources (VCL
            chat, social media toolkits, clinical guides) and
              - Link-outs to other trusted partner and VA sites (self-check
            quiz, Make the Connection).

        Question 3. Can you please provide an update on VA's progress
    implementing 14 of the remaining 16 recommendations outlined in GAO's
    July 2018 report, Actions Needed to Address Employee Misconduct Process
    and Ensure Accountability?
        Response. A summary update on VA's progress toward implementing
    each of GAO's 16 recommendations set forth below:

         Recommendations 2, 3, 5 and 11 are closed.
         The VA Office of Inspector General (OIG) will respond
    separately to the Senate Committee on Veterans' Affairs for
    Recommendations 6 and 13.
         In response to recommendation 1, the VA Office of Human
    Resources and Administration (HRA) is defining requirements for one or
    more information systems that will collect misconduct and associated
    disciplinary action data Department-wide. Upon system implementation, a
    policy will be created that directs procedures on addressing blank data
    fields; lack of personnel identifiers and standardization among fields;
    and accessibility. The target date for system implementation, which is
    dependent on approved funding and acquisition related requirements, is
    January 1, 2020.
         Regarding recommendation 4, since November 1, 2018, the
    Oversight and Effectiveness (OE) Service assessed misconduct related
    files and documents at 14 VHA facilities in conjunction with scheduled
    human capital management assessments. OE will review any additional
    five VHA facilities during the 4th quarter of FY 2019. To ensure files
    are consistent with statute, regulation, and VA policy, to include VA
    Handbook 5021, OE uses checklists provided by the Employee Relations
    and Performance Management Service (ERPMS) to verify required documents
    and notices are maintained in the case files. Disciplinary actions that
    have a related processed Standard Form 50, Notification of Personnel
    Action are reviewed. OE identifies actions and requires human resources
    management offices to provide proposed and decision disciplinary
    letters and related case files. At the end of the assessment, OE
    provides feedback to the facility and human resources office. OE's
    findings and completed checklists are shared with ERPMS. VA has
    requested that recommendation 4 be closed.
         To address recommendation 7, non-criminal matters
    involving allegations of misconduct by senior officials that are
    referred to Office of Accountability and Whistleblower Protection
    (OAWP) by OIG, OAWP ensures that responses submitted back to the OIG
    address the six elements required in VA Directive 0701: (1) evidence of
    an independent review by an official separate from and at a higher
    grade than the subject/alleged wrongdoer; (2) specific review of all
    allegations; (3) findings of each allegation, which are clearly
    identified as either substantiated (``founded'') or unsubstantiated
    (``unfounded''); (4) description of any corrective action taken or
    proposed as a result of a substantiated allegation, (e.g., change in
    procedures, disciplinary or adverse action taken, etc.); (5) Supporting
    documentation for the review, such as copies of pertinent documents, a
    summary report of the board of investigations, etc.; and (6)
    designation of a point of contact for additional information.

              - OAWP is working with other offices in the Department to
            understand VA's current processes for receiving and tracking
            recommendations from OIG, the U.S. Office of Special Counsel
            (OSC), VA's Office of the Office of Medical Inspector (OMI),
            and GAO. OAWP is establishing a new VA compliance and oversight
            directive to cover the requirements under 38 U.S.C.
            Sec. 323(c)(1)(F) to record, track, review, and confirm
            implementation of recommendations from audits and
            investigations carried out by OIG, OMI, OSC, and GAO. The
            target date for staffing the team to track the requirements
            under 38 U.S.C. Sec. 323(c)(1)(F) and finalize the OAWP
            directive on these requirements is fall 2019.
              - Per 38 U.S.C. Sec. 323(c)(1)(F), OAWP is responsible for
            ``[r]ecording, tracking, reviewing, and confirming
            implementation of recommendations from audits and
            investigations carried out by the Inspector General of the
            Department, the Medical Inspector of the Department, the
            Special Counsel, and the Comptroller General of the United
            States, including the imposition of disciplinary actions and
            other corrective actions contained in such recommendations.''
              - Consequently, the process described in GAO's report to
            respond to OIG findings or results will be changed to require
            all such reports be submitted to OAWP, which will record,
            track, review, and confirm implementation of the
            recommendations. As part of this oversight process, OAWP will
            also be responsible for reviewing responses to recommendations
            from facilities or program offices to ensure that they address
            the six elements identified in VA Directive 0701. The
            publication of guidance is expected by fall 2019.

         To address recommendation 8, OAWP is establishing a new VA
    investigations directive, which will cover the investigation of senior
    leader misconduct, poor performance or whistleblower retaliation by
    OAWP, and OAWP's referral of whistleblower disclosures to the
    appropriate investigative entities. The directive will include
    provisions for tracking the implementation of any recommended action.
    The directive is currently undergoing review within the Department and
    OAWP anticipates that will be formerly issued before October 2019.
              - All misconduct by senior leaders in VA is handled by OAWP
            from intake, through investigation to working with the
            proposing and deciding officials (including preparing the
            proposal and decision letters). The Proposing and Deciding
            Officials have independent authority to determine whether an
            action should be proposed or taken and the appropriate levels
            of discipline, if any, to impose. OAWP then works with the
            appropriate servicing personnel office to ensure the action
            decided upon is implemented. The publication of written
            guidance is expected by fall 2019.

         In response to recommendation 9, OAWP is working closely
    with HRA, which owns the primary human resources system of records for
    VA, to ensure that disciplinary actions taken in response to findings
    of misconduct are recorded within this official system of records.

        OAWP maintains an internal management information system to record
    all phases of work processes and the outcomes for all disclosures of
    wrongdoing received by OAWP. Information regarding senior leader cases
    is maintained in greater detail. Both results (those from all
    disclosures and those specifically focused on senior leaders) are
    routinely used to inform VA leadership regarding accountability efforts
    involving senior leaders throughout the Department.
              - The ad-hoc VA-wide discipline tracking system using de-
            identified data was created in response to a specific request
            from the Congressional Oversight Committees and was never
            designed as a robust management information system. It will be
            phased out once the Human Resources Information System
            (HRSmart) can capture and record similar data. OAWP is working
            with HRA to refine VA's HRSmart to capture all types of
            disciplinary information.

         Regarding recommendation 10, all allegations of misconduct
    by senior leaders within the Department are resolved by OAWP. An
    investigative report or summary generally will not include a
    recommendation for any specific penalty. All investigative reports or
    executive summaries involving senior leaders, regardless of origin
    (e.g., OAWP Investigations Division, OIG, OSC), are reviewed by OAWP's
    Advisory and Analysis Division to determine the appropriate
    accountability actions to recommend to the proposing official. The
    Advisory and Analysis Division then prepares a draft proposed action,
    which is submitted for legal review to the Office of General Counsel
    (OGC) and shared with the proposing official, the management official
    responsible for proposing disciplinary action, for consideration. OAWP
    then works with the proposing officials as they consider whether to
    propose an action and determine the level of penalty to propose.
              - When OAWP began operations, it started with a legacy
            caseload of 116 cases, involving 216 persons of interest (POI).
            Since June 23, 2017, through June 1, 2018, OAWP has received an
            additional 261 cases for investigation, involving 482 POIs.
            From June 23, 2017, through June 1, 2018, OAWP completed 128
            cases involving 236 POIs. From June 23, 2017, through June 1,
            2018, 39 cases, involving 65 POIs, were received from other
            investigatory efforts and sent directly by the OAWP Advisory
            and Analysis Division for review and disposition. The release
            of written guidance is expected by fall 2019.
              - See, also, update on the response to recommendation 8.

         Regarding recommendation 12, per 38 U.S.C.
    Sec. 323(c)(1)(F) OAWP is responsible for ``[r]ecording, tracking,
    reviewing, and confirming implementation of recommendations from audits
    and investigations carried out by the Inspector General of the
    Department, the Medical Inspector of the Department, the Special
    Counsel, and the Comptroller General of the United States, including
    the imposition of disciplinary actions and other corrective actions
    contained in such recommendations.''
              - See also the update for recommendation 8.

         In response to recommendation 14, the internal VA policy
    (an interim policy step via memorandum) is expected to be published by
    fall 2019. The subsequent Directive and Handbook will be published as
    rapidly as staff coordination permits.
         As for recommendation 15, VA is committed to ensuring that
    employees who report wrongdoing are treated fairly and are protected
    against retaliation. VA was one of the first cabinet-level agencies to
    be certified by OSC's 2302(c) Whistleblower Protection Certification
    Program in October 2014. Under the program, VA:

              (1) places informational posters regarding prohibited
            personnel practices (PPP), whistleblowing, and whistleblower
            retaliation in a public setting at VA facilities and VA
            personnel and equal employment opportunity offices;
              (2) provides new hires with written materials on PPP,
            whistleblowing, and whistleblower retaliation;
              (3) establishes a website on PPP and whistleblower rights and
            protections; and
              (4) developed, in cooperation with the OSC, supervisory
            training on PPP and whistleblower rights and protections. VA
            executives, managers, and supervisors must complete this
            training on a biennial basis.

              - Regarding the training discussed above, OAWP is working
            with OSC to revise the training to comply with the requirements
            of 38 U.S.C. Sec. 733 and anticipates issuance of that training
            by fall 2019.
              - Regarding whistleblower protection, since the appointment
            of OAWP's first Assistant Secretary, Dr. Tamara Bonzanto, OAWP
            has completely stopped referring disclosures alleging
            whistleblower retaliation by senior leaders or supervisors to
            other VA entities for investigation. Instead, those allegations
            of retaliation are investigated directly by OAWP staff to
            mitigate the potential of a conflict of interest or further
            retaliatory acts against the whistleblower.
              - OAWP also works closely with OSC and OGC to implement the
            whistleblower protections codified under 38 U.S.C. Sec. 714(e).
            Under that subsection, VA cannot take a 38 U.S.C. Sec. 714
            disciplinary action if an individual has a pending complaint
            with OSC (unless OSC allows VA to proceed) or has an open
            disclosure with OAWP.
              - The process and procedures for making a whistleblower
            disclosure and reporting PPPs, including retaliation, to OSC
            are posted at every VA facility. OAWP is also responsible for
            receiving and, in certain instances, investigating allegations
            of whistleblower retaliation.
              - Additionally, whistleblower protections are written into 38
            U.S.C. Sec. 714, one of the authorities that VA uses to
            discipline employees. OAWP and OSC have developed a functional
            process to ensure those protections are implemented. Section
            714(e) prohibits VA from effecting an action under that section
            when the employee against whom the action is proposed has
            alleged that they either: (1) are seeking corrective action
            with OSC for an alleged prohibited personnel practice or (2)
            have a disclosure pending with OAWP.
              - From June 23, 2017, through June 1, 2018, OAWP, in
            cooperation with OSC, has resolved 73 matters and has 90 open
            cases involving the whistleblower protections under 38 U.S.C.
            Sec. 714(e).
              - The Secretary of VA has delegated authority to the
            Executive Director, OAWP, to hold individual personnel actions
            if the action appears motivated by whistleblower retaliation.
            OAWP has hired two Whistleblower Program Specialists,
            specifically to increase awareness of whistleblower protections
            and work with individual disclosing employees to ensure they
            are treated fairly and protected from retaliation for their
            disclosures.

         For recommendation 16, OAWP is finalizing training
    required under 38 U.S.C. Sec. 733, which includes:

              (1) an explanation of each method established by law in which
            an employee may file a whistleblower disclosure;
              (2) the right of an employee to petition Congress regarding a
            whistleblower disclosure in accordance with 5 U.S.C. Sec. 7211;
              (3) protections against being prosecuted or reprised against
            for lawfully disclosing information to Congress, OIG, OAWP,
            OSC, or another investigatory agency;
              (4) an explanation of the language required in non-disclosure
            agreements and policies to ensure wrongdoing may still be
            reported;
              (5) the right of contractors to be protected from reprisal by
            their employer for disclosing substantial violations of
            contracting law; and
              (6) An explanation of the prohibited personnel practices and
            the rights of employees when reporting wrongdoing.

              - As part of Public Law 115-41, the VA Accountability and
            Whistleblower Protection Act of 2017, the Department is
            required to provide whistleblower training to all employees on
            a biennial basis (codified in 38 U.S.C. Sec. 733). The training
            will include the reporting lines for disclosures of wrongdoing,
            the manner in which disclosures flow once they are made, how
            information is shared among the whistleblower entities and what
            protections exist for those who disclose wrongdoing. The
            required training is expected to be released by fall 2019.

        Question 3a. Would VA support increasing the independence of the
    Office of Accountability and Whistleblower Protection? If so, what
    action would VA take to increase independence, and what, if any,
    resources or authorities would VA need from Congress?
        Response. OAWP is an integral part of VA. As required by law, the
    Secretary of Veterans Affairs provides OAWP with the staff, resources,
    and access to information as is necessary to carry out its statutory
    functions. As with other VA offices, except OIG which, by law has its
    own counsel, OAWP relies on OGC legal guidance as it pertains to the
    execution of its statutory functions.
                                     ______

     Response to Posthearing Questions submitted by Hon. Kirsten Sinema to
                      U.S. Department of Veterans Affairs
        Question 1. Has the VA discovered what could be the main reasons or
    trends that veterans have for discontinuing mental health treatment so
    early on?
        Response. VA is learning that the reasons Veterans may discontinue
    mental health treatment early vary based on age, gender, race, and
    mental health condition. However, there are several cross-cutting
    factors such as competing demands from work, school, and family
    responsibilities. We also know from studies with Active Duty
    Servicemembers that, as a group, they value self-reliance and tend to
    believe they can handle mental health problems without professional
    intervention. Other factors associated with lack of ongoing engagement
    with mental health treatment include lack of trust in mental health
    professionals; concerns about confidentiality; and general issues with
    the procedures of treatment, such as the length of a course of
    treatment, frequency of appointments, and taking medications.
    Additionally, several studies have found that the stigma associated
    with mental health treatment is also a major factor in a Veteran's
    choice to leave treatment.
        It is worth noting that discontinuing mental health treatment
    earlier than expected may not always be associated with negative
    outcomes. Recent research suggests a significant portion of Veterans
    who discontinued evidence-based treatment demonstrated significant
    clinical benefit. This was true for an estimated 50 percent of Veterans
    treated for PTSD; 65 percent of those treated for Alcohol Use Disorder;
    and 68 percent of those treated for depression.
        Annually, VA contacts a random sample of Veterans to inquire about
    their experience with mental health care. The Veterans Outcome
    Assessment Survey is administered by telephone to approximately 10,000
    Veterans each year at the time when they are beginning treatment in a
    mental health program and again after 3 months. In 2017, approximately
    11 percent of Veterans reported that they had not received mental
    health services between the baseline and follow-up interviews.
    Approximately 5 percent reported that they discontinued because they
    did not want or need services, while 8 percent reported that they had
    experienced problems that led to their dropping out. Three percent
    reported both types of reasons.
        An example of the reasons provided by the 11 percent of the
    Veterans who agreed to participate and subsequently dropped out of the
    survey is as follows:

         ``Specific services or programs I wanted weren't
    available'' (2.1 percent);
         ``It was too difficult to travel to appointments'' (2.7
    percent);''
         ``Services were available but not at times that were
    convenient for me'' (2.9 percent);
         ``Services were available, but I didn't like my options''
    (2.0 percent);
         ``I started to get services and didn't like them'' (1.7
    percent);,
         ``I wasn't able to see the provider I wanted'' (1.2
    percent); and,
         ``There were problems with eligibility or insurance'' (0.6
    percent).

        VA has since used this data to consider strategies needed to
    improve Veteran satisfaction.

        Question 1a. What is the VA doing to encourage veterans to reengage
    with mental health if they quit treatment early?
        Response. VA is attempting to decrease the number of Veterans who
    unexpectedly or prematurely leave treatment. For example, when Veterans
    are engaged in a shared decisionmaking conversation with a mental
    health care provider to help them adequately understand their mental
    health conditions and problems and then provided sufficient and
    understandable information about appropriate treatment alternatives,
    they are more likely to develop an informed treatment preference.
    Research indicates when Veterans are offered the treatment they prefer,
    they are more likely to engage in treatment, complete the course of
    care, and receive increased benefit from treatment. Several shared
    decisionmaking training resources have been developed for use by VA
    mental health providers. Additionally, standardized tools for use in
    the shared decisionmaking conversation to ensure quality of information
    provided have been developed for depression, PTSD, insomnia, Substance
    Use Disorder treatment, and pain.
        When Veterans discontinue treatment unexpectedly, policy guides
    providers to make multiple attempts to contact the Veteran to discuss
    the situation and encourage treatment engagement. If Veterans cannot be
    reached by telephone, they receive a letter from the provider
    encouraging contact. VA has also attempted to remove any process
    barriers to Veterans returning to care. For example, Veterans can use
    appointments to meet with a mental health provider when they desire
    (rather than having to wait for an appointment) and all VA facilities
    offer evening appointments. If the Veteran has been identified as being
    at risk for suicide, the facility-based Suicide Prevention Coordinator
    activates additional means of contacting the Veteran and ensure his or
    her safety and advocating for re-engaging with treatment.
        Veterans with serious mental illnesses (SMI) constitute a highly
    vulnerable population. Studies have shown that individuals with SMI
    have a higher rate of mortality compared to patients without SMI. In
    VHA, the SMI Re-Engage Program identifies Veterans with SMI who have
    been lost to follow-up care for at least a year; attempts to locate and
    contact them; and invites them to return to VA for the mental health
    and physical health services they need. Through this program, 42
    percent of Veterans who were contacted returned to care within 18
    months of being contacted, significantly more than the percentage of
    Veterans who were not able to be contacted (27 percent).
        VA's Primary Care Mental Health Integration (PCMHI) initiative
    provides mental health care in the primary care clinic. For many
    Veterans, receiving mental health care within primary care reduces the
    stigma associated with mental disorders. PCMHI has developed brief
    versions of some evidence-based therapies that are often more
    acceptable for Veterans who are unable or unwilling to engage in the
    usual mental health services. PCMHI clinicians are part of the primary
    care PACT and serve as resources for patients who have discontinued
    mental health treatment but continue enrollment in PACT.

        Question 2. Can the VA explain the lack of reporting?
        Response. VA was one of the first institutions in the United States
    (U.S.) to implement comprehensive suicide surveillance and has
    continuously improved data surveillance related to Veteran suicide. VA
    and DOD collaborate to search the National Death Index (NDI) of the
    Centers for Disease Control and Prevention (CDC) to assess vital status
    and cause of death for Veterans and other Servicemembers. CDC compiles
    NDI data from data from State vital statistics offices. These are
    provided to the CDC's National Center for Health Statistics through
    agreements with the States. NDI data are considered the gold standard
    of mortality data. They include indicators of date, State, and cause of
    death.
        NDI releases death records for request approximately 11 months
    after the end of the calendar year. At this time, a coordinated VA/DOD
    search of millions of records is completed, leading to the
    identification of the matching death records and cause of death for
    Veteran decedents, followed by analyses and reporting of this
    information. This synchronized, multiagency process leverages the best
    available data to report and track Veteran mortality.
        The most recent national-level Veteran suicide data was released in
    September 2018, (reflecting data through 2016), and is available in the
    VA National Suicide Data Report, 2005-2016. The 2017 data are scheduled
    to be released later this summer. Recent additional reporting has
    included State-level longitudinal data and information on former
    Servicemembers who never were activated by the Federal Government as
    National Guard and Reserve members.
        A limitation of the CDC's National Death Index is that it does not
    include additional fields that are captured in death certificates
    (e.g., district and county of death, occupation, and detail regarding
    manner of death). This limitation constrains ongoing VA suicide
    surveillance, including county-level assessments.
        VA recommends enhancement of the CDC's National Death Index, at
    least for the purposes of Federal mortality surveillance, to enable
    collection of these important measures.

        Question 2a. How many researchers are actively working in this
    database and does the VA have a plan to expand its research team, and
    does the VA have a plan to create sharing access to these databases
    with academics?
        Response. In addition to the annual Veteran suicide statistics
    reported in VA's 2005-2016 National Suicide Data Report, and
    accompanying State-level analyses, VA provides Suicide Data Repository
    NDI mortality data, by request, to approved VA researchers with an
    Internal Review Board-approved research project or VA program-office
    sponsored non-research operations project. From 2014 through June 2019,
    VA provided mortality data to more than 110 VA research and operations
    projects, including 22 specifically focused on examining suicide
    mortality in the Veteran population. VA's provision of these data to
    these researchers led to the development of at least 16 peer-reviewed
    publications specifically in the area of suicide prevention,
    contributing to a greater understanding of suicide mortality among the
    Veteran population.
        Through VA's agreement with NDI, these data are only available to
    VA researchers, and must be maintained within the VA IT environment.
    Should non-VA affiliated researchers be interested in mortality
    information, they should work directly with NDI to receive mortality
    data.

        Question 2b. How are you using these databases to inform how you
    resource suicide prevention programs and efforts on the ground?
        Response. Ongoing collection, analysis, and dissemination of
    suicide-related data is crucial for understanding Veteran suicide and
    informing suicide prevention initiatives. Data drives the public health
    approach. VA analyzes and reports on suicide data to gain insight into
    high-risk populations.
        VA is using data to tailor the best possible targeted prevention
    strategies to reach all Veterans--not just those who are identified as
    being at risk. Universal strategies reach all Veterans in the U.S.
    (e.g., the #BeThere campaign). Selective strategies are intended for
    some Veterans in subgroups that may be at increased risk for suicidal
    behavior, such as women Veterans or Veterans with substance use
    challenges (e.g., mental health care for OTH discharged Veterans, the
    Mayor's Challenge, and the Executive Order). Indicated strategies are
    designed for the relatively few individual Veterans identified as
    having a high risk for suicidal behaviors (e.g., REACH VET; the
    expansion of VCL; and discharge planning and follow-up enhancements).
        VA uses, and will continue to use, data to improve its strategies,
    programs, and resources. Additionally, we will share data with
    community-based health care providers and partners to help them support
    Veterans in their communities.

        Question 3. Are you looking at how the states with higher rates are
    resourced versus states with lower rates and using that to inform your
    prevention work moving forward?
        Response. Disparities in suicide rates exist between states and, in
    some cases, regions. Numerous factors that contribute to suicide risk
    and incidence must be considered when examining a state's suicide data.
    Some states have relatively large Veteran populations or overall
    populations, which can affect suicide rates. While there is no single
    reason why one state has higher suicide rates than others, factors such
    as access to health care; rural versus urban settings; and access to
    lethal means are relevant considerations when examining differences in
    rates.
        In March 2018, VA and SAMHSA launched a partnership to give 24
    cities the tools and technical assistance needed to address Veteran
    suicide at the local level. The program began with seven cities--
    Albuquerque, New Mexico (NM); Billings, Montana (MT); Helena, MT;
    Houston, Texas (TX); Las Vegas, Nevada (NV); Phoenix, Arizona (AZ); and
    Richmond, (VA)--participating in a policy academy process that had
    previously only been available to States and territories. The cities
    were invited based on Veteran population data, suicide prevalence
    rates, and the capacity to lead the way in this first phase of the
    Mayor's Challenge. The teams developed an understanding that a multi-
    stage, multi-faceted approach will likely yield the greatest long-term
    impact on Veteran suicide. Ongoing engagement and support for teams at
    the local level is critical for success in not just one but all seven
    areas of the CDC identified strategies.
        One year after the launch of the Mayor's Challenge, building on the
    aforementioned successes, the program is now expanding to 24 sites
    nationwide: Albuquerque, NM; Atlanta, GA; Austin, TX; Billings, MT;
    Charlotte, NC; Clarksville, TN; Columbus, OH; Detroit, Michigan;
    Helena, MT; Hillsborough County, FL; Houston, TX; Jacksonville, FL;
    Kansas City, MI; Las Vegas, NV; Los Angeles, CA; Manchester, NH;
    Oklahoma City, OK; Phoenix, AZ; Reno, NV; Richmond, VA; Suffolk County,
    NY; Topeka, KS; Tulsa, OK; Warwick, RI.
        The Mayor's Challenge served as a model for the State-based
    Governor's Challenge, which launched February 2019, in Alexandria, VA.
    State leaders from Arizona, Colorado, Kansas, Montana, New Hampshire,
    Texas, and Virginia are creating plans to implement the National
    Strategy for Preventing Veteran Suicide to provide a framework for
    identifying priorities, organizing efforts and contributing to a
    national focus on Veteran suicide prevention in their states. VA and
    SAMHSA will ensure the work is, evaluated for effectiveness, and shared
    with communities to help optimize the efforts of all partners and
    stakeholders committed to preventing suicide across the SMVF
    demographic group.
        To reach all 20 million Veterans in the U.S., including those who
    do not--and may never--seek care within our system, VA has launched a
    community-based public health approach to effectively implement
    multiple target goals outlined in the National Strategy for Preventing
    Veteran Suicide. Veteran Integrated Service Network (VISN) 23, which
    includes Iowa, Minnesota, Nebraska, North Dakota, South Dakota and
    portions of Illinois, Kansas, Missouri, Wisconsin, and Wyoming,
    provided the innovative first step of creating roles in its facility
    suicide prevention programs dedicated to expanding education and
    outreach for suicide prevention across the network. VISN 23 then
    partnered with VA OMHSP to initiate a pilot program within VISN 23 to
    improve the effectiveness of its localized public health approach by
    reaching Veterans through proactive, community-based measures.
                                     ______

     Response to Posthearing Questions Submitted by Hon. Johnny Isakson to
                             Lt. Col. Jim Lorraine
        Question 1. Your testimony also notes the need for a greater
    collaborative research and data sharing relationship between the
    Federal, state, and local governments as well as academic institutions.
    This is why your organization launched Operation Deep Dive which is
    currently active in 14 communities across the country.

        Question 1a. Can you discuss in greater detail the mechanism you
    have in place to assess and analyze data in real-time?
        Response. Operation Deep Dive has two phases of data collection and
    analysis:

         Phase 1 is a retrospective study designed to more
    accurately understand the veteran suicide crisis at the community
    level. This phase will obtain all non-natural death records from
    coroner/medical examiners offices in 14 communities across the United
    States for those who have died by suicide or accidental death (i.e.
    single car accident, overdose, accidental death by fire arm) between
    2014-2018. There is no standard across states or counties for
    identifying if the deceased is a former servicemember. Therefore, all
    names are provided to the University of Alabama's secure database. Once
    the Department of Defense's Institutional Review Board (IRB) has
    approved our protocol, these records will be shared with the DOD to
    identify who in our database was a former servicemember and who was
    not. The former servicemembers identified by DOD will then be provided
    to the VA which also require a separate IRB. The VA will conduct their
    own data analysis on the former servicemembers who were enrolled into
    the VA, and provide us with de-identified aggregate data. While this is
    taking place, we will be submitting a second phase of the IRB to the
    DOD to provide extensive service history of confirmed former
    servicemembers to the University of Alabama. Without the VA, DOD and
    coroner/medical examiners and states sharing data, and the University
    of Alabama analyzing the information in its entirety, the trends would
    be unable to be shared directly to the communities. As results/trends
    are identified they are immediately presented to the community for
    which the data was obtained.
         Phase 2: We will be collecting all non-natural deaths
    prospectively until 2021 to continue confirmation of veteran status.
    From 2019 forward, we are conducting interviews with loved ones who
    have lost a veteran to suicide or self-harm within a two to six month
    time period of their death. This qualitative data is being obtained
    through the Sociocultural Death Investigation tool (a semi-structured
    interview instrument developed by America's Warrior Partnership and
    University of Alabama that examines community factors related to
    suicide or self-harm for veterans). That information will be obtained
    and shared with the community as trends become apparent.

        Throughout this study, each community has a multidisciplinary team
    made up of community stakeholders who champion the study and drive the
    prevention strategies within the communities as the data identifies
    trends.

        Question 1b. Additionally, how quickly will the communities be able
    to adjust once taking this new data into consideration?
        Response: Communities are reliant on aggregate data in order to
    provide prevention services. Communities are unaware of the uniqueness
    of their former servicemembers who have taken their lives compared to
    other communities. Therefore, once they are made aware of their
    population, they will have the information to immediately target the
    specific needs of their former servicemembers in their community.
                                     ______

     Response to Posthearing Questions Submitted by Hon. Johnny Isakson to
                              Col. Miguel D. Howe
        Question 1. In your testimony you mention that any community grant
    program should adopt the Supportive Services for Veteran Families
    (SSVF) Model. Can you elaborate why you believe this is the best model?
        Response: Mental health conditions, substance abuse, and access to
    lethal means are the most critical factors that contribute to veteran
    suicide. Although evidence-based treatments exist for mental health
    conditions and substance abuse, barriers to seeking and accessing high-
    quality care include: stigma about seeking help; difficulty navigating
    a confusing landscape; and limited capacity of effective care.
    Connection to comprehensive services and solutions at the community
    level is paramount. The full complement of risk factors in the military
    and veteran populations for suicide mirror the social determinants of
    health and successful transitions for veterans from military service to
    civilian life. An integrated community level approach that addresses
    all of these variables inclusive of not only quality health care for
    mental health and substance abuse, but also comprehensive resources and
    services for benefits, housing, transportation, emergency financial
    assistance, education, employment, and social connections, will better
    reduce risk for suicide.
        The PREVENTS Executive Order contains important elements to
    prioritize research, coordinate and align effort across the Federal
    Government, and to develop proposals to offer grants to state and local
    governments to support community level efforts toward a comprehensive
    approach to prevent veteran suicide.
        In my June 19, 2019 testimony to the Senate Veteran Affairs
    Committee Hearing, Harnessing the Power of Community: Leveraging
    Veteran Networks to Tackle Suicide I delineated five recommendations to
    maximize those elements of the PREVENTS EO:

         Establish an overarching vision for veteran health and
    wellbeing;
         Reduce barriers and increase access to effective mental
    health and substance abuse care;
         Improve connections to care through peer networks;
         Foster meaningful community coordination and partnerships;
         Improve access to, and delivery of, high-quality mental
    health care for veterans.
        As part of my fourth recommendation, Foster Meaningful Community
    Coordination and Partnerships, I wrote:

              ``In order to maximize current grant funding in support of
            veteran services, Congress should consider repurposing
            Supportive Services for Veteran Families (SSVF) that focus
            primarily on ending homelessness and consolidate the program
            with new community based grants to more broadly support the
            full continuum of economic and health and human services needs
            in community based networks that support My-VA communities.''

        The SSVF model has proven to be an effective public policy program
    that affords important lessons learned for an integrated community-
    based approach for suicide prevention in the veteran population. The
    SSVF has proven to be a successful and relatively cost-effective model
    for reducing veteran Homelessness. The underlying risk factors for
    Homelessness and Suicide are parallel and overlapping, and the
    supportive services to ameliorate those factors are similar. SSVF
    services benefit veterans at elevated risk for Suicide as well as
    Homelessness.
        I do not know if the SSVF Model is the best model (as you attribute
    to me in your question), but as delineated in this response to your
    question, the SSVF model does provide important lessons learned, and
    existing capacity that can serve as a start point for any new community
    based grant program for suicide prevention. There are important
    differences between the driving mandate for Homelessness (``Housing
    First'') and for Suicide Prevention (``Mental Health and Substance
    Abuse Services, and Reducing Access to Lethal Means''), but the
    underlying risk factors for Homelessness and Suicide are parallel and
    overlapping. The individualized veteran approach to wrap around
    services ameliorate risk factors for both Homelessness and Suicide.
        I advocate for you to both consider the SSVF model, and to consider
    integrating funding of the SSVF model into any new community grant-
    based programs and public-private partnerships for ending veteran
    suicide. Integrating any new community-based grant programs for Suicide
    Prevention, with the SSVF program could result in service delivery
    efficiencies, improved outcomes for more veterans, and cost savings to
    the government. It would also provide authorization to Federal agencies
    to work with community-based connectors to, and providers of, services
    creating efficiencies for all parties that results in veteran access to
    the full complement of services across all sectors.
        Established in FY 2012, the Department of Veterans Affairs
    Supportive Services for Veteran Families (SSVF) is a short-term case
    management program that targets homeless veterans and those at imminent
    risk of losing their housing. The program awards grants to private Non-
    Profit Organizations and Community Cooperatives that provide a range of
    supportive services to eligible very low-income families. These
    services are individualized to meet each veteran's need and include:
    health care, daily living services, personal financial planning,
    transportation, fiduciary and payee services, legal, child care,
    housing counseling, and can also pay rent to third party entities for
    short periods of time.
        SSVF operates on a housing first model. As such, the VA executes
    SSVF in partnership with the Department of Housing and Urban
    Development's Veteran Affairs Supportive Housing (HUD-VASH) program. A
    veteran does not have to receive a HUD-VASH voucher to take part in
    SSVF, however, in 2017 29% of all permanent housing placements through
    SSVF were conducted in conjunction with HUD-VASH vouchers.
        Housing is not contingent on compliance with support services. The
    veteran agrees to lease agreements and then is provided support
    services in direct support of the lease. While the veteran is able to
    utilize all programs under SSVF, there is particular emphasis placed on
    services related to the specific situation currently faced by the
    veteran. The average length of participation in SSVF has been 116 days.
    The typical veteran successfully assisted through SSVF rapid rehousing
    spent 125 days enrolled in SSVF, with half of their program time spent
    working with SSVF to find and secure permanent housing, and the other
    half of their program time spent receiving case management, rental
    assistance, and other tenancy supports from SSVF while stabilizing in
    permanent housing.
        In FY 2017, SSVF served over 299,176 veterans and family members
    with over 80% (238,197) successfully transitioned to permanent housing
    following the program, and only 3% returning to unsheltered locations
    (with the status of 7% unknown). The remaining 10% either transitioned
    to shelters, temporary housing, or moved in with family. Those that
    remained in the program longer than 90 days have had a significantly
    higher chance of remaining in the housing than those who leave the
    program sooner.
        Since 2012 over 464K veterans have been served through SSVF grants
    at an average cost of $3539. Over the same period of time 55,000 of
    those veterans have been leverage HUD-VASH grants at an average cost of
    $6818 per veteran served. Overall, the SSVF has been viewed as highly
    effective in getting veterans into permanent housing, reducing the
    number of homeless veterans by 49% from 2010-2018.
        Important elements of SSVF success include: a Housing first
    approach; Federal partnership with HUD; and public-private partnerships
    that result in connection to the full continuum of supportive services
    at the community level beyond the capacity of Federal agencies. Those
    services address the underlying risk factors that resulted in
    Homelessness. These are the aspects of SSVF which could be leveraged in
    a community base public-private partnership model to address suicide.
        Just as the SSVF/HUD-VASH program makes housing first the key
    pillar in eliminating homelessness, a community-based program should
    make mental health care and substance abuse for veterans in acute
    crisis, or at elevated risk, the key pillar of suicide prevention
    services. While the VA does not deliver actual housing services
    (relying on HUD and community based private sector partners) the VA
    does deliver health care services for Mental Health and Substance
    Abuse. Not only is the VHA the largest integrated health care system in
    the United States, its mental health and substance abuse programs for
    veterans are best in class. As such Congress should consider how to
    integrate VHA services as a foundational element of any new suicide
    prevention programs.
        Congress should also integrate new VA grant programs with Health
    and Human Services (HHS) as a critical partnership and key component of
    any VA community-based veteran suicide prevention program. Just as HUD
    provides grants and expertise to SSVF programming, HHS can provide
    expertise and existing grant programs for mental health services.
    Whether under SAMHSA, the CDC or HRSA (Health Research Services
    Administration), HHS has a number of grant programs which foster
    connection and access to mental health and substance abuse services for
    veterans. The VA could provide not only VHA health care services, SSVF
    lessons learned, and staff and oversight to a partnered program, while
    the HHS could provide infrastructure and expertise in community level
    grant making for mental health and substance abuse services.
        In addition to existing SSVF grant partners, community based
    collaboratives such as those piloted by America's Warrior Partnership,
    Combined Arms, the IVMF's America Serves, San Diego 211 and the
    National Veterans Initiative are promising practices for how to better
    connect our veterans and their families to the full continuum of health
    and social services at the community level (to include VHA). They also
    follow a similar approach to the SSVF model, and reduce risk factors
    for not only Homelessness, but Unemployment, Suicide, and set the
    conditions for a successful transition from military service to
    civilian life for veterans. An integrated approach--Federal-State-
    Local, and public-private--that connects veterans to the full suite of
    health, human and social services, will not only reduce risk for
    suicide, but set the conditions for veterans to thrive.

                                A P P E N D I X

                                  ----------

             Prepared Statement of Jennifer Satterly, Co-Founder,
                             All Secure Foundation
        To the Members of the Senate Committee on Veterans' Affairs: All
    Secure Foundation was founded more than three years ago to help combat
    warriors and their families heal from the invisible wounds of war,
    Post-Traumatic Stress. Our very first speaking engagement was a
    Congressional Briefing held by NAMI on veteran mental health issues in
    November 2017, and while we would have preferred to get our start at a
    VFW hall or a high school, my husband, Command Sgt. Major (retired) Tom
    Satterly and I jumped at the opportunity to share our story in hopes to
    create awareness of the issues millions of American servicemen and
    women and their family face.
        We were told by many, including a former House of Representative
    elected official that our presence and statement wouldn't make a
    difference; that we would be met with a hand shake and a photo op, and
    that we would be forgotten as soon as the room cleared of staffers
    headed to the next briefing. We had to try though, we had to make our
    voices heard, and maybe, just maybe, the stories we shared that
    afternoon would reach the heart of someone who not only could stand up
    and say no more but someone who actually WOULD stand up and say no
    more. Not our warriors. Not our spouses and caregivers. Not our
    children.
        We walked, more like ran, the halls of the Capital buildings and
    sat one on one with several Members of the Senate, Congress, and House
    of Representatives. My husband who was a Delta Force CSM for over 20
    years shared his story about nearly becoming a veteran suicide himself
    just 4 years prior. As he choked back his tears telling his story of
    yet another divorce, a son he barely knew, chronic pain from multiple
    explosions and surgeries which lead him to a place he never thought he
    would be, sitting in a parking garage, gun in hand trying to decide if
    today was the day to pull the trigger. As Tom and I became emotional,
    Senator Patty Murray reached across the table to put her hand on mine,
    looked me in the eyes and said, ``tell me your story, tell me about the
    spouses.''
        It was the first time that day, and the only time that day, that
    someone at the Capital asked us about those who also serve this great
    Nation, those who have sacrificed a stable home life, those who watch
    their children painfully leave another house and have to adapt to a new
    town and school yet again, those who go to bed with a prayer that the
    love of their life will make it back to the base that night safely in a
    very unsafe place thousands of miles away, those who wait patiently for
    the day they will be together again only to discover that when they
    are, the person they married is now a stranger who's wounds may not be
    visible, but are no less painful, deep, and in need of treatment.
        You might be thinking, ``What does a spouses' story have to do with
    combating veteran suicide?'' My answer is . . .  everything.
        I have spent the last 7 years working alongside and with Special
    Operation Soldiers, Sailors, Airmen, and Marines. I have talked to
    hundreds of the toughest, most elite, intelligent, and highly trained
    warriors that our country dispatches around the world to do it's
    bidding. I have heard combat stories that would keep any listener awake
    at night with images so disturbing that you wonder just how a person
    ever comes home ok after that experience, not to mention dozens of
    those experiences. I have heard stories of unbearable loss, of
    heartbreak and of guilt for making it out when their brother or sister
    did not. I have heard more stories than I can count that are just like
    Tom's, a well-trained and elite soldier who everyone thought was ok
    sitting alone with a loaded gun in their hand trying to decide if today
    is the day to leave the debilitating emotional and physical pain
    behind. I am most often a stranger to these men and women, a voice on
    the phone who cares, who listens, who lets them know that the heartache
    and pain they feel and try to bury is the very thing that makes them
    human not weak, and after what they saw and did, that they have the
    fight of their lives ahead of them at home to rebuild what war took
    away from them. That the trauma has shaped them into a new person and
    that person has value in this world not in spite of it but because of
    it. That they matter. That they are seen and heard. That they don't
    need to fill the empty void and pain with toxic and addictive quick
    fixes in the vast darkness that they occupy day and night. That they
    are not evil, bad, or monsters that they sometimes feel they are, but
    instead heroes our Nation called to fight evil, to remove the bad, and
    battle the monsters that our politicians have labeled as such.
        Very few, if any, share the stories they share with me with their
    spouses. They tell me over and over again, ``I don't want to bring the
    war home. I can't tell them what I saw and what I did. They've already
    been through so much.'' The protection they feel for their spouse is
    also a cover; a cover for the fear that they will be judged or no
    longer loved for who they were and what they had to be overseas.
    Vulnerability is a path toward healing yet they are conditioned and
    trained to keep quiet and that vulnerability is a weakness. Yet there
    is no healing without it. Distance and isolation in the relationship is
    created, just another symptom of PTS. The spouse gets tired of asking
    ``what's wrong?'' with no response and the warrior doesn't know how to
    share the unthinkable. The war torn home is not reserved alone for
    countries thousands of miles away, the war torn home is an American
    home and to heal the veteran you have to heal the whole family unit.
    Hurt people, hurt people. If you don't heal everyone involved, the hurt
    persists, the cycle cannot be broken, and the pain becomes
    generational. When a veteran takes his or her life the impact is
    greater than they can imagine. And that pain is passed on.
        Let's talk about what no one wants to talk about, the anger, the
    physical and emotional abuse, the neglect, the pain, the addiction, the
    reckless behavior, the anxiety, the perfection-driven aggression, the
    paranoid behavior that keeps everyone in the house on eggshells. This
    is the face of Post-Traumatic Stress. These are suicide triggers. The
    feeling of no longer being who they were and not being able to control
    or understand what is going on in their mind or with their bodies. No
    one has explained the biology of PTS, that it is a normal and natural
    response to a traumatic event, so they feel it's something they should
    be able to control verses a biological response that is beyond their
    control and in need of treatment just like any other wound. In the
    veteran family, no one speaks up, no one asks for help, no one knows
    where to turn.
        Veterans are not just killing themselves because of what they saw
    and did and lost overseas it is also what they saw and did and lost at
    home. The shame of another divorce. The pain and heartbreak of a child
    who doesn't really know who they are, or worse, is afraid of them. The
    drinking and abuse of pills to dull the senses and memories. The
    feeling of uselessness, hopelessness, chronic physical pain, and the
    loss of a tribe that you once would have given your life for. The
    military's cultural stigma that asking for help is a sign of weakness.
    The toxic belief that they should ``just get over it'' now that they're
    home or the ringing in their ears they've heard from the ignorant
    masses of ``they knew what they were getting into when they signed up
    to serve.'' The insecurity of starting a new career over in their 30's
    or 40's. Not fitting in civilian life, a stranger in a strange land.
        It is the spouse, the caregiver, that is most often their advocate,
    sometimes their only advocate for healing. When a veteran is in crisis,
    they are not thinking clearly and a spouse or caregiver often is the
    only one to get them the help they need. That is if they know where to
    turn for help.
        In a recent study by the VA, 80% of veterans would like more family
    involvement in their care. 80%. We are asking our veterans to take
    healing upon themselves alone, but that is not what they are asking
    for. They want their families help. They need their families help. If
    you want to tackle veteran suicide you must include the family in the
    treatment of PTS.
        There are days that Tom doesn't want to get out of bed. There are
    days when he wants to bury the pain with one drink too many. There are
    days he is in so much physical pain that he can barely walk and doing
    the smallest task causes excruciating pain. There are days when he is
    so angry that his friends won't see their children graduate or walk
    down the aisle because their number was up that he takes it out on me,
    the person who will still be there when the anger settles. There are
    sleepless nights and long tired days. There is depression.
        Then there are my days as a spouse. Days I force him to get out of
    bed. Days that I take him on a trip for a hike verses a trip to the
    bar. Days and nights researching alternative treatment options because
    no one has told or helped us battle PTS. The weeks and months of
    driving him daily to Transcranial Magnetic Stimulation treatments,
    physical therapy, and Cognitive Behavioral therapy sessions. I searched
    and applied for a scholarship for him to learn Transcendental
    Meditation. I became certified as a health coach just to gain the
    knowledge and to understand the way food, vitamins and minerals can
    heal his body and mind. I worked with doctors to get him off
    medications that were making him worse, not better. I make sure to be
    aware of loud noises and clutter in the home because I know those are
    triggers. I make him sit at a restaurant with his back to the door and
    tell him to relax because I'm keeping an eye out. I cry with him on
    anniversaries of friends he's lost in combat. I hold his hand as he
    answers yet another call that one of his friends he served with died
    from a rare cancer, or had a stroke at 45 years old, or has taken their
    life. No one tells you being a military or veteran spouse means you
    need to be a healer, a doctor, a therapist, a researcher, and a teacher
    but that's what's required. If you have an invested spouse in healing
    measures, you will most likely have an invested veteran. Spouses and
    caregivers need the tools to help their loved ones heal, to help
    identify signs of severe distress, and what to do in a crisis
    situation. We are left out here on the battlefield alone, no weapons,
    no armor, no training to fight this unseen enemy. We suffer from
    Secondary PTS. We are tired, frustrated, angry, confused, and
    heartbroken too.
        When a warrior gets help and the spouse does not, there is a
    greater chance for substance abuse relapse, there is a greater chance
    for divorce, there is more turmoil in the home in front of the
    children, and there is a greater chance for suicide. This is something
    we have heard and experienced with those we work with over and over and
    over again. The story is so similar we can play it back before it's
    even been said.
        Why do so many veteran's commit suicide? The reasons are as many
    and as varied as there are people. This is not a one size fits all
    problem or a one size fits all solution.
        How can we reduce veteran suicide? The answers are also as many and
    varied as there are people. This is not the government, the VA, the
    military, or any organizations' task alone. This is an epidemic the
    country must address together and we need all hands on deck. No one
    answer alone is right or wrong. Not all treatments work for all
    veterans. It takes years to address and heal from PTS. There is no
    magic pill or cure. This is the long game and why it is critical for
    the veteran to have support at home.
        Let me ask you then, what area of helping and healing can you
    tackle today? Not just the Senate Committee, but you personally. Who
    will you call? What program will get the attention it deserves? How can
    you create policy or help to push one through that's been sitting on
    someone's desk for far too long? How can your voice and vote help the
    millions of American veteran families suffering at home who don't know
    who to turn to or how to get the help they so desperately need and
    deserve?
        There are many places to start, like encouraging and funding the
    exploration and research of alternative methods of healing Post-
    Traumatic Stress, implement a training program for VA doctors and staff
    on alternative modalities of healing, or create a bill to allow our
    veterans to get coverage for those treatments and allow families
    suffering from secondary PTS to also partake and heal through
    alternative methods of healing. We have to dispel the myth that raising
    your hand for help while serving in an active duty role will mean a
    loss of security clearance or your job, you can set policy to help
    protect those that do reach out. The DOD needs additional funds to
    train military leaders, doctors, therapist, and social workers on how
    to get help for the war fighters and their families post-deployments.
    We have heard far too many times that there was no help while in
    service, there was no one to turn to after, and that no one really
    cares about them anyway. Will you show our heroes you care? That as a
    country, we all care and their lives mean something.
        Last, I ask for a minute of silence, not only to honor the
    thousands of veteran lives lost to suicide but to the more than 22
    veteran lives that will be lost today at their own hands. America has
    failed them. We all have failed them. And after a moment of silence for
    our fallen veterans, I ask you to be anything but silent and leave no
    man, woman or child behind.

        Thank you.
                                     ______

                      Arizona Department of Veterans' Services,
                                            Phoenix, AZ, June 19, 2019.
    Hon. Johnny Isakson,
    Chairman,
    Committee on Veterans' Affairs,
    U.S. Senate, Washington, DC.

        Dear Mr. Chairman and distinguished Members of the Committee: My
    name is Wanda A. Wright, Director of the Arizona Department of
    Veterans' Services (ADVS), member of the National Association of State
    Directors of Veterans Affairs (NASDVA) and the VA Advisory Committee on
    Women Veterans. I am honored to present my state's efforts to reduce
    suicide in the veteran community.
                     National Landscape of Veteran Suicide
        According to the Department of Veterans Affairs, we lose 20
    veterans to suicide on average each day. While veterans make up just
    8.5 percent of the total U.S. population, they account for 18 percent
    of total deaths from suicide nationally. Despite significant efforts
    and financial investment in programs and initiatives, the rate of
    suicide among veterans has been steadily increasing and is 32 percent
    higher than it was in 2001. Additionally, we know that completed
    suicides are only the tip of the iceberg of a larger ongoing mental
    health crisis and that many more veterans are struggling with suicidal
    ideations and attempts.
        According to the CDC Preventing Suicide Technical Package, for
    every 1 completed suicide, an estimated 227 people have experienced
    serious thoughts of suicide. Applying these same estimates to the 6,079
    known veteran suicides recorded by the Department of Veterans Affairs
    in 2016, this translates into over 1.3 million veterans who had
    thoughts of suicide in that year alone. Additionally, we can estimate
    that over 164,000 veterans attempted suicide and over 54,000 veterans
    were treated in hospital emergency rooms for self-harm injuries. While
    there are a confluence of complex factors contributing to this tragic
    loss of life, it is clear that immediate and collective action is
    necessary. In order to truly honor the service and sacrifice of our
    veterans, we must identify, innovate and support initiatives that help
    those that served and their families in not only navigating, but also
    thriving, in civilian life.
                           Veteran Suicide in Arizona
        In Arizona and the west, we are witnessing some of the highest
    veteran suicide rates in the country. A 2017 survey of Arizona
    servicemembers, veterans and their families revealed that half of all
    respondents know of a servicemember or veteran who has died by suicide
    and 41 percent reported experiencing thoughts of suicide themselves.
    Approximately one-third of Arizona veterans have had traumatic
    experiences that put them at risk for elevated chronic physical and
    mental health conditions. One in three respondents reported a current
    mental health condition related to depression, anxiety or Post
    Traumatic Stress Syndrome and another third know a servicemember or
    veteran with unmet mental health needs. 43 percent of our
    servicemembers and veterans report having sustained physical injuries
    or issues as a result of their military service. Additionally, 1 in 10
    Arizona veterans use and/or abuse substances to cope with trauma,
    depression and anxiety. When considering the role of location, veterans
    in our rural communities appear to carry a heavier burden than their
    urban counterparts regarding this issue with 20 percent higher risk of
    suicide compared to urban-dwelling veterans and less access to services
    that address their social determinants of health.
              Crisis Intervention vs. Upstream Suicide Prevention
        Historically, suicide prevention has been primarily focused on
    crisis intervention. Though this is a critical and necessary service in
    the spectrum of suicide prevention tactics, it represents only a narrow
    window of opportunity for intervention. While we continue to advocate
    for the expansion of the existing national, state and local crisis
    intervention infrastructure, particularly in rural areas with limited
    access, we also believe that it is time to take a different approach to
    suicide through upstream prevention. Upstream suicide prevention
    creates a wider window of opportunity to reach individuals and ideally
    provides support before an individual reaches the point of a mental
    health crisis. However, it is critical that we work towards added
    coordination and state-level infrastructure to connect existing
    resources in urban and rural areas as well as continue to educate the
    community on their role.
                             The Collective Impact
        Arizona is responding to this crisis through a collaborative
    statewide suicide prevention initiative led by ADVS and Arizona
    Coalition for Military Families (ACMF), a nationally-recognized public/
    private partnership that focuses on building Arizona's capacity to care
    for, serve, and support servicemembers, veterans, their families, and
    communities. Through the use of a collective impact model, we have
    successfully engaged and convened key stakeholders across Arizona to
    lead a coordinated and targeted effort to reduce suicide among the
    military and veteran community. Collective impact is a model defined by
    Stanford University that brings together people, organizations and
    systems in a structured way to achieve social change. There are five
    key elements: 1) common agenda, 2) shared measurement, 3) mutually
    reinforcing activities, 4) continuous communication, and 5) strong
    backbone team. It's important to note that with a collective impact
    model, many different efforts can be aligned to work toward a common
    goal.
        Arizona's collective impact initiative around suicide prevention is
    built upon a highly effective program implemented at the height of the
    post-9/11 deployments. In partnership with the Adjutant General and
    numerous state partners, ACMF led the development of a program
    specifically for the Arizona National Guard called ``Be Resilient''
    which focused on reducing stigma, shifting military culture regarding
    suicide and mental health through training, and increasing access to
    care. Be Resilient included 24/7 support by phone and training for all
    Arizona National Guard members on resiliency, suicide prevention, and
    recognizing stress levels. Using this approach, Be Resilient
    successfully reduced suicide rates from their highest-ever level in
    2010 to zero suicides during the 3 years the program was in operation.
                              Be Connected Arizona
        In 2015, the Clay Hunt Suicide Prevention for American Veterans Act
    was signed into law and through the support and leadership of the late
    Senator John McCain, Arizona was selected as a pilot site to test new
    methods of preventing veteran suicide through VA/community partnership.
    Based on the successful program model of Be Resilient, ADVS and ACMF
    launched a statewide suicide prevention initiative for all
    servicemembers, veterans, and their families called Be Connected in
    2017. The Be Connected program includes a 24/7 support line, online and
    in-person resource navigation, and training on military culture and
    resources for everyone in the community. The Be Connected program is
    unique in its approach of reducing veteran suicide by formally
    recognizing and building support services to address the complex web of
    social, emotional, economic and systemic factors that contribute to
    mental health crises experienced by our veterans and their families,
    with a focus on upstream prevention before crises develop. By
    leveraging all the existing resources of national, state, and
    community-based agencies serving veterans, Be Connected provides a
    statewide point of coordination for any servicemember, veteran, family
    member, or helper to turn to for help and support.
                 Role of the VA in Community Suicide Prevention
        We know that as many as 70 percent of veterans who have died by
    suicide were not actively seeking care from the VA at the time of their
    death. This illustrates the importance of crafting solutions that think
    outside of the health care system and use every possible community
    resource to connect with our veterans and get them the support they
    need. We also feel it is important to get our veterans engaged with the
    VA for assistance, care and support if they aren't connected already.
    We know that veterans are less likely to die by suicide if they are
    supported by their health care system. Be Connected drives traffic back
    to the VA to give the veteran an opportunity to seek care with
    providers who understand the complex issues that can surround a
    veteran's health. The more veterans we can get enrolled in the VA, the
    better their health outcomes will be overall. Be Connected acts as a
    care coordination model to connect veterans to health-related services
    provided by the VA as well as the many social services offered in the
    community. The goal of this model is to provide the right resource at
    the right time to the right individual. No matter the need, if a
    veteran requests support from Be Connected, they should know that we
    will do everything in our power to get them the help they need.
                                 Kevin's Story
        To demonstrate the power of Be Connected, let me share with you the
    story of Kevin. Kevin is a disabled Air Force veteran who called the Be
    Connected support line because he was struggling financially and in
    fear of losing his home. During his first couple of phone calls, Kevin
    reported that he would likely commit suicide if he lost his home and
    the belongings inside. The Be Connected support line responder
    contacted several organizations in Kevin's community that were able to
    provide him with legal assistance, donations, and volunteers to help
    him make necessary home repairs. Kevin is now financially stable and
    able to live in his own home. He told the responder that he is very
    grateful for Be Connected and that thanks to these efforts, he now has
    hope again. Kevin's story is one of thousands whose lives have been
    changed for the better by Be Connected.
                       Expansion of Be Connected Arizona
        In the past 2 years of operation, Be Connected has fielded over
    10,000 support line calls, provided resource navigation to over 8,000
    individuals, and provided training to thousands of community members.
    The majority of those requesting assistance from Be Connected are not
    explicitly seeking mental health services. Analysis of support line
    data shows that 44 percent of calls were related to housing,
    employment, or financial concerns, while only 6 percent of calls were
    specifically requesting mental health services. In addition to
    expanding access to mental health care and crisis services, we urge
    this Committee to also consider the importance of addressing the
    ``upstream'' factors of suicide. This upstream approach not only
    recognizes the importance of access to health care services, but also
    the daily impact of a myriad of other social determinants outside of
    the clinical walls. Restricting our interventions to health care
    specific issues presents missed opportunities to address these upstream
    factors. As such, it is imperative that we tackle this devastating
    issue collaboratively and purposefully as an entire community to ensure
    that we are properly meeting our duty to those that met theirs.
                                   Next Steps
        We are encouraged by Congress's interest in this issue and the
    White House's action through the President's Roadmap to Empower
    Veterans and End a National Tragedy of Suicide, also known as PREVENTS.
    We ask that Congress continues to build on this roadmap and explore
    legislation that supports and expands the capacity of Be Connected and
    other developing initiatives across the country through three main
    recommendations: 1) capacity building on the state level to ensure
    states and communities are coordinated 2) funding for backbone teams in
    states, such as the Arizona Coalition for Military Families 3) support
    for initiatives using the upstream suicide prevention model, such as Be
    Connected.
        This is in contrast to an approach that is purely service delivery
    oriented with no focus on organizing and connecting efforts. In order
    to create an effective national strategy to preventing veteran suicide,
    we need to embrace a national collective impact initiative that
    engages, equips and connects states and communities. Those states and
    communities will then be able to engage, equip and connect serve
    members, veterans and family members through an upstream suicide
    prevention model with a collective impact approach. Every state and
    community does not have to have the exact same program, however every
    state and community needs to be working toward a common goal with
    common standards.

                Sincerely,
                             Col. Wanda A. Wright, USAF (Ret.),
                                                              Director,
                                  Arizona Department of Veterans' Services.
                                     ______

       Prepared Statement of Ken Falke, Chairman, Boulder Crest Retreat
                      Foundation & EOD Warrior Foundation
        Our nation has been at war for nearly 18 years--the longest stretch
    of conflict in our Nation's history. Over that period of time, we have
    lost more servicemembers and veterans to suicide than we have on the
    battlefield. This is true despite a great deal of attention and
    resources being poured into solving this problem across the public and
    private sector.
        As a 21-year Navy combat veteran, and the Chairman of the EOD
    Warrior Foundation and Boulder Crest, which includes two privately-
    funded wellness centers--Boulder Crest Retreat Virginia and Boulder
    Crest Retreat Arizona--and the Boulder Crest Institute for
    Posttraumatic Growth, that serve combat veterans and family members
    struggling with suicidal thoughts and other mental health challenges,
    we have gained a unique perspective not only on the question of why
    suicides continue to happen, but how we can prevent them.
                             the causes of suicide
        At its core, suicide is the result of hopelessness and loneliness.
    Suicide stems from a belief that tomorrow will always be the same or
    worse than yesterday, and that there is no path to a life that is worth
    living and that nobody really `knows me or gets me'. Why is it that far
    too many veterans find themselves on the precipice of suicide? What
    contributes to their struggle?
        We would be reticent to declare that we have all the answers. If
    there is one thing I can conclude after 21 years in the Navy and now 15
    years of working closely with veterans and attending far too many
    funerals for my brothers and sisters who died by their own hand, it is
    that there is no such thing as a suicide expert. The data do tell us
    that depression--not PTSD--is correlated with suicide. Depression is
    perhaps best defined in the words of the psychologist, Rollo May, who
    said: ``Depression is the inability to construct a future.''
        This focus on depression is consistent with the VA's research
    indicating that depression--not PTSD--is the biggest challenge
    affecting veterans, particularly during and after their transition.
        Since opening Boulder Crest Retreat Virginia in September 2013, and
    Boulder Crest Retreat Arizona in November 2017, we have hosted more
    than 4,000 combat veterans and family members, and run more than 120
    short-duration, high-impact programs. Before, during, and after those
    visits and programs, we have spoken with guests about their struggles,
    their experiences with the mental health system, and why they pursued a
    non-clinical approach. The insights they offered, integrated into our
    work at Boulder Crest, provide a powerful roadmap for ensuring that we
    end the epidemic of veteran suicides, and more significantly, enable
    veterans to create lives worth living--the true opposite of suicide.
        As we reflect on all that they have shared, we see six major causes
    of struggle for veterans that put them at risk of suicide:

    1. VA's Myopic Focus on PTSD
        The idea that depression--not PTSD--is the biggest challenge for
    veterans might come as a surprise to many. That--in fact--is a key
    element of the challenge. As George Bonano and Meaghan Mobbs noted in a
    2018 Clinical Psychology Review article, ``Even more problematic,
    despite the looming uncertainty of future treatment needs, currently
    available interventions for returning veterans have focused narrowly on
    extreme psychopathology, and typically only on Posttraumatic Stress
    Disorder (PTSD).''
        The assumption that when veterans struggle it must be PTSD-related
    contributes to applying the wrong treatment to the wrong person, and
    can, in fact, make veterans worse. The evidence-based treatments for
    PTSD are not the same treatments one would assign for depression; this
    is particularly true for Prolonged Exposure. This helps explain why
    many veterans will never seek treatment and often dropout prior to its
    conclusion--and struggle mightily as a result.
    2. Transition Issues
        A second and related issue to the first is the difficulty that many
    veterans have transitioning. Bonano and Mobbs explain:

            One of the primary reasons for past failures in veteran
            treatments, arguably is that the dominant focus on PTSD has
            obfuscated other, often highly pressing transition issues.
            Research has documented, for example, that many returning
            veterans may struggle regardless of whether they have PTSD or
            not. Recent population survey studies have suggested that 44%
            to 72% of Veterans experience high levels of stress during the
            transition to civilian life, including difficulties securing
            employment, interpersonal difficulties during employment,
            conflicted relations with family, friends, and broader
            interpersonal relations, difficulties adapting to the schedule
            of civilian life, and legal difficulties (Morin, 2011).
            Struggle with the transition is reported at higher, more
            difficult levels for post-9/11 veterans than those who served
            in any other previous conflict (i.e., Vietnam, Korea, World War
            II) or in the periods in between (Pew Research Center, 2011).
            Crucially, transition stress has been found to predict both
            treatment seeking and the later development of mental and
            physical health problems, including suicidal ideation
            (Interian, Kline, Janal, Glynn, & Losonczy, 2014; Kline et al.,
            2010). What is more, the majority of first suicide attempts by
            veterans typically occur after military separation (Villatte et
            al., 2015).

        As evidenced by much lower (albeit growing quickly) suicide rates
    of active duty servicemembers, much about military service is
    fulfilling and rewarding. In fact, military service provides
    servicemembers with many of the factors that contribute to strong
    mental health--identity, purpose, meaning, connection, growth, and
    service. Imagine for a moment a Marine--he joins at 18, and in a short
    period of time is transformed from an ordinary civilian into a proud
    Marine. For perhaps the first time in his life, he knows who he is (a
    Marine), why he exists (to locate, close with, and destroy the enemy),
    and who his tribe his (his fellow Marines).
        That Marine goes on to serve for four years or forty years with
    honor and distinction, and then gets out. He is thrust from a world of
    certainty, community, purpose, and meaning into the rather cold and
    uncaring civilian-dominated world. He begins to struggle as he
    navigates a deep, profound, and existential journey into who he is now,
    why he exists (or if he still should), and where he belongs. He has a
    job but hates it. The struggle starts to get the best of him--he begins
    to distance himself from his loved ones and friends, and starts self-
    medicating with alcohol. After an alcohol-related incident, he is
    persuaded to go see someone. After mentioning that he deployed to Iraq
    and Afghanistan, the therapist immediately circles in on PTSD as the
    cause of his issues. He is diagnosed and medicated and turns to
    disability payments for sustenance; and is now destined to live out the
    rest of his life as a diminished version of his once powerful and
    remarkable self. What was a temporary issue of adjustment has now
    become a permanent diagnosis. At some point, he might decide that this
    life--just barely getting by, surviving each day feeling numb, broken,
    and useless--isn't worth living.
        This story is not merely an anecdote. It is the story of far too
    many veterans who struggle with how to transition effectively.
    3. A Society Filled with Disconnection and Struggle
        A third reason why veterans struggle is encapsulated in the
    remarkable work of Sebastian Junger. In his book Tribe, and in his
    other writings and TED Talk, Junger speaks about his belief that much
    of the struggle that veterans experience has far more to do with what
    they are coming home to rather than what they are coming home from. His
    belief is supported by the devastating statistics related to civilian
    mental health--from suicides (in 2017, there were 129 suicides per day,
    and a stunning 1.4 million suicide attempts--3,836 per day) to opioid,
    drug, and alcohol overdoses.
        When they leave the military, veterans depart a world filled with
    identity, purpose, meaning, connection, growth, and service and enter
    one filled with despair, struggle, and disconnection. This despair
    proves to be contagious--as misery loves company--and combined with
    transition challenges, overwhelms veterans. The result is self-
    medication and far too frequently, suicide.
    4. Military Training
        A number of researchers have studied the symptoms of PTSD and
    explored the connection between PTSD symptoms and the training
    servicemembers receive to thrive in combat. One researcher, Dr. Charles
    Hoge, a retired U.S. Army Colonel and one of the world's most published
    authors on PTSD, identified the clear connection between military
    training and veterans struggle, depicted in the table below.

    ----------------------------------------------------------------------------------------------------------------
                                  Military Training                                       Symptoms of Struggle
    ----------------------------------------------------------------------------------------------------------------
    Sharply Tuned Threat Perception, Rapid Reflexes                                Hyperalert, Hypervigilant
    ----------------------------------------------------------------------------------------------------------------
    Intense Mission Preparation, Rigorous Training, After-Action Reviews (AARs)    Reliving Events, Guilt, Second
                                                                                    Guessing
    ----------------------------------------------------------------------------------------------------------------
    Attention to Details, Minimize Mistakes                                        Intolerance of Mistakes
    ----------------------------------------------------------------------------------------------------------------
    Adrenaline/Intensity to Accomplish the Mission                                 Anger/Rage
    ----------------------------------------------------------------------------------------------------------------
    Emotional Control in Combat                                                    Detached, Numb
    ----------------------------------------------------------------------------------------------------------------
    Unit Cohesion, Unit is Family                                                  Social Withdrawal
    ----------------------------------------------------------------------------------------------------------------

        On the left column of this chart are six key elements of military
    training that allow servicemembers to thrive in combat. On the right
    side are the symptoms of PTSD. We take ordinary civilians and train
    them so they can function effectively in combat--the list of items in
    the left column. On this path to gain courage and strength, we call
    them Warriors. As they return home from utilizing, refining, and
    integrating that skill set and attempt to apply it at home, we call
    them broken. This is the ultimate Catch-22.
        What is clear is that there is nothing wrong with many of our
    servicemembers and veterans--they are merely a function of their
    training and experiences. They are struggling because of what
    happened--not what's wrong. This understanding--which is a foundational
    element of our Warrior PATHH program at Boulder Crest, the subject of
    more discussion below--liberates combat veterans to realize that they
    are far from broken or damaged; they simply need additional training to
    learn how to apply their unique set of skills, strengths, and abilities
    at home. This training is particularly important as it relates to one
    of life's most important skills--the ability to self-regulate. We do
    know that in the absence of the capacity to self-regulate, most humans
    will self-medicate. This self-medication often creates a vicious and
    downward spiral that ends in self-destruction or suicide.
    5. An Accumulation of Trauma
        As Bonano and Mobbs noted above, the struggle of veterans is viewed
    nearly exclusively through the prism of PTSD. Some devastating event
    from the battlefield is claimed to be the cause of all that ails the
    combat veteran, and with the right treatment and medication, all will
    be well. Unfortunately this view of life is simply not supported by
    data.
        A great deal of research conducted in recent years explores the
    childhoods of members of the all-volunteer force, working to understand
    the range of reasons why people join. These reasons include a yearning
    for discipline, community, challenge, purpose, and service. It is also
    clear that a key reason that many join is to escape a dangerous or
    abusive situation. Members of today's military have experienced more
    childhood trauma than members of the general public--by a factor of at
    least two, and possibly more.
        As the American Psychological Association notes, ``High rates of
    suicide among military servicemembers and veterans may be related to
    traumatic experiences they had before enlisting, making them more
    vulnerable to suicidal behavior when coping with combat and multiple
    deployments . . .''
        The growing science related to childhood trauma--known as Adverse
    Childhood Experiences (ACEs)--speaks to how such trauma affects core
    belief systems as well as an individual's capacity to deal with future
    trauma. By attributing combat veterans struggle solely to what happened
    on battlefield, we fail to recognize that what they struggle with is an
    accumulation of traumatic experiences--not a single event.
    6. Failure of Treatment
        The final factor I want to discuss as it relates to why veterans
    are at risk for suicide relates to our Nation's approach to mental
    health. In short, our mental health system--and approach--simply is not
    working--for depression, PTSD, and suicide.
        This is not my opinion, but the findings of the world's most
    prestigious medical journal--the Journal of the American Medical
    Association (JAMA). In August 2015, JAMA called for a new and
    innovative approach to PTSD for veterans. In January 2017, JAMA
    Psychiatry declared that, ``These findings point to the ongoing crisis
    in PTSD care for servicemembers and veterans. Despite the large
    increase in availability of evidence-based treatments, considerable
    room exists for improvement in treatment efficacy, and satisfaction
    appears bleak based on low treatment retention . . . we have probably
    come about as far as we can with current dominant clinical
    approaches.''
        The reliance on evidence-based treatments, noted in the JAMA
    Psychiatry quote above, has proven to have serious limitations.
    Jonathan Shedler, Ph.D., noted in a 2015 article entitled ``Where is
    the Evidence for `Evidence-Based' Therapy?,'' ``Research shows that
    ``evidence-based'' therapies are weak treatments. Their benefits are
    trivial. Most patients do not get well. Even the trivial benefits do
    not last.'' Shedler continues:

            ``In the typical randomised controlled trial for `evidence-
            based' therapies, about two-third of the patients get excluded
            from the studies a priori (Westen et al, 2004). That is, they
            have the diagnosis and seek treatment, but because of the
            study's inclusion and exclusion criteria, they are excluded
            from participation. Typically, the patients that get excluded
            are those who meet DSM criteria for more than one diagnosis, or
            have some form of personality pathology, or are considered
            unstable in some way, or who may be suicidal. In other words,
            the two-thirds that get excluded are the patients we treat in
            real-world practice. So two-thirds of the patients who seek
            treatment get excluded before the trial begins. Of the one-
            third that do get included, about half show improvement. So we
            are now down to about 16 percent of the patients who initially
            sought treatment. If we consider the percentage of patients who
            actually get well, we are down to about 11% of those patients
            who originally sought treatment. If we consider the percentage
            that get well and stay well, we are down to roughly 5
            percent.''

        The concerns expressed by many of the best and brightest in the
    field are proven out in the statistics. The veteran suicide rate has
    barely budged from 20 a day for several years. More concerningly, of
    those 20 suicides a day, only six are in active VA care. This
    unwillingness to seek care keeps at least 50 percent of veterans who
    might benefit from mental health from ever going to see someone. Of
    those who do access mental health, between 40-80 percent will dropout
    prior to the conclusion of the treatment, often due to a lack of
    provider-patient connection, or a sense that treatment is making them
    feel worse. As noted above, the near-exclusive focus on PTSD (rather
    than transition struggles) may contribute to this fact. Only 40 percent
    of those who complete treatment will experience any benefit, which is
    often fleeting, as Shedler noted above.
        Notably, in June 2018, in response to a CDC report indicating that
    suicides across the United States had increased 33 percent since 1999,
    Dr. Thomas Insel--the former director of the National Institute for
    Mental Health--asked, ``Are we somehow causing increased morbidity and
    mortality with our interventions?''
        When we have asked combat veterans who have attended programs at
    Boulder Crest Retreat Arizona or Virginia why they didn't benefit from
    traditional treatments, they shared the following reasons:

        1. Veterans report that they have been trained not to acknowledge
    weakness and are experts at suffering in silence. Seeking mental health
    treatment while on active duty is often a career ender, and that
    thinking follows them out of the military.
        2. Veterans are unable to connect with their providers (often
    civilians who lack a strong understanding of the military culture and
    have no basis for understanding combat experiences); this results in a
    lack of trust, safety, and an unwillingness to return for further
    treatment.
        3. Veterans report that mental health treatments focus on helping
    them manage and mitigate their symptoms through a combination of talk
    therapy and medicine, rather than on living a great life. The majority
    of veterans are not interested in learning how to live with a
    diminished version of themselves.
        4. Veterans report that a diagnosis-focused approach means that
    therapists and clinicians only want to hear enough to label and judge
    them, and have little interest in listening to them.
        5. Veterans are seeking direction and purpose, and find that
    consistently talking about past experiences leaves them stuck in their
    struggle, and unable to move forward.
        6. Veterans report that most programs and therapies they experience
    are catch-and-release. They feel better while they are at a program or
    in treatment, but as soon as it ends, they return back to their prior
    baseline.

        In sum, of the 900,000 post-9/11 combat veterans who are struggling
    with mental health related challenges, only 3 percent will find
    meaningful and sustained help from the current mainstream approaches.
    We can and must do better.
                                what can we do?
        I have shared six of the reasons why the veterans suicide epidemic
    is continuing to go from bad to worse. The critical question that the
    Committee is asking--as are many who are gravely concerned about the
    state of veteran's well-being--is what do we do about it?
        This question is what I have worked to answer since starting the
    EOD Warrior Foundation in 2004, opening Boulder Crest Retreat Virginia
    in September 2013, Boulder Crest Retreat Arizona in November 2017, and
    the Boulder Crest Institute for Posttraumatic Growth in September 2018.
    Our mission is to ensure we provide combat veterans with what they
    require to live great lives--filled with passion, purpose, growth,
    connection, and service. This is truly the opposite of suicide.
        In May 2014, after nine months of operating Boulder Crest Retreat
    Virginia, I began a journey to understand what actually worked when it
    came to mental health, PTSD, and suicide. I traveled around the country
    and met with leading psychiatrists, psychologists, social workers, life
    coaches, and trauma experts. Time and time again, when I asked them,
    ``What works to allow people to live great lives in the aftermath of
    trauma?''--I was told, ``Nothing.''
        In principle this is true because it is not what our mental health
    system--broadly speaking--is focused on accomplishing. The mental
    health system is nearly exclusively focused on one thing when it comes
    to its clients and patients--managing and mitigating the symptoms
    associated with times of struggle; often through a combination of
    medication and talk therapy.
        The first glimmer of hope I encountered on my journey would be
    found at the University of North Carolina, Charlotte, in the person of
    Dr. Richard Tedeschi. Dr. Tedeschi, along with his colleague, Dr.
    Lawrence Calhoun, coined the term Posttraumatic Growth (PTG) in 1995 to
    describe the ways in which people reported growth in areas of their
    life in the aftermath of traumatic events and experiences.
        I asked Dr. Tedeschi if he was interested in partnering with us to
    develop a training-based program for combat veterans that would, for
    the first-time ever, be designed to cultivate and facilitate
    Posttraumatic Growth in those who were struggling. Dr. Tedeschi agreed,
    and since 2014, we have been hard at work on the development and
    delivery of Warrior PATHH.
         a new, innovative, and effective approach to ptsd and suicide
        Warrior PATHH is an 18-month program that begins with a 7-day
    intensive and immersive residential initiation for combat veterans who
    struggle with a range of challenges--from depression to PTSD,
    transition issues to suicide. The 7-day initiation is supported by
    Boulder Crest's custom-built myPATHH technology platform, which
    connects and supports students through the remaining 77 weeks--
    providing ongoing training, connection, and accountability.
        Warrior PATHH trains combat veterans through the proven framework
    of PTG: educating them about the value of struggle and what stress and
    trauma do to the mind, body, heart, and spirit; teaching proven non-
    pharmacological techniques designed to self-regulate thoughts and
    emotions; creating an environment of trust and safety to facilitate
    disclosure of past challenges from childhood and military service,
    which is supported by a delivery team composed of combat veterans;
    beginning to craft a new story that harnesses the lessons of the past
    and looks forward; and a renewed commitment to service--to one's
    family, community and country--here at home.
        In January 2016, after more than two years of research,
    development, piloting, and success, the Marcus Foundation funded the
    development of the first-ever curriculum effort designed to cultivate
    and facilitate Posttraumatic Growth. The curriculum effort included
    Student and Instructor Guides, a Journal, Syllabus, and Schedule; four
    pilot programs; and an 18-month longitudinal study.
        The 18-month study, led by Dr. Tedeschi and Dr. Bret Moore, was
    completed in January 2019, focused on exploring the impact of Warrior
    PATHH in three key areas: Symptom Reduction, Quality of Life
    improvement, and Posttraumatic Growth experienced. With responses at
    the pre, post, 1, 3, 6, 12, and 18-month marks and the use of 24 well-
    respected and bespoke measurement tools, this effort represents one of
    the most robust evaluations of a mental health effort ever initiated.
    The evaluation effort included 8 Warrior PATHH Programs (49 students)
    and a response rate of 95 percent. Key highlights include:

    Symptom Reduction:
          54% sustained reduction in PTSD symptoms
          52% sustained reduction in depression symptoms
          41% sustained reduction in anxiety symptoms
          39% sustained reduction in Insomnia
          44% sustained reduction in drug use
        ??? 24% sustained improvement in positive emotions experienced; and
    25% sustained reduction in negative emotions experienced
    Quality of Life Improvement:
          14% sustained improvement in Couples Satisfaction
          33% sustained reduction in stress reactivity
          11% sustained improvement in physical activity
          26% sustained improvement in nutrition
          12% sustained improvement in financial wellness
    Posttraumatic Growth:
          56% sustained improvement in Personal Growth (PTG)
          78% growth in Spiritual-Existential Change
          69% growth in Deeper Relationships
          58% growth in New Possibilities
          36% growth in Personal Strength
          26% growth in Appreciation for Life
          32% sustained improvement in ability to change
    perspective/psychological flexibility
          23% sustained improvement in capacity to integrate
    problematic life experiences.
          22% sustained improvement in self-compassion
          40% sustained increase in reading
          9% sustained decrease in disruption to core beliefs

        In short, we have a program that achieved the vision that we set
    forth--to ensure combat veterans could be as productive at home as they
    were on the battlefield, and live great lives--filled with passion,
    purpose, growth, connection, and service--at home. In response to this
    unparalleled success, we are now working with partners so that Warrior
    PATHH can be scaled to ten locations across the country.
                            why warrior pathh works
        Warrior PATHH is modeled on military-style training. It is
    intensive, immersive, and team-based, and provides participants with a
    new fire team to support their road to wellness, strength, and
    thriving.
        Warrior PATHH is based on the decades-old science of Posttraumatic
    Growth, and provides veterans with a pathway to a life that is more
    authentic, fulfilling, and purposeful than ever before. This
    opportunity to continue growing and contributing speaks to the deepest
    needs of veterans, and allows them to feel valued and needed on the
    home front.
        Warrior PATHH is delivered by a team of combat veteran peers who
    leverage the inherent understanding, trust, and connection that is
    implicit within the brotherhood and sisterhood.
        Warrior PATHH is sustained over 18 months, and ensures that
    participants build connection, confidence, and capabilities over the
    long-term. The impact of this approach is demonstrated in the program
    evaluation study.
        Warrior PATHH focuses on training not treatment, allowing veterans
    to harness the power of the military training and combat experiences
    and be Warriors and leaders in their own lives, and the lives of their
    families, communities, and country.
        Ultimately, Warrior PATHH works because it acknowledges the wise
    words of Dr. Vikram Patel, a pioneering psychiatrist who has developed
    incredibly effective, peer-based programs across the developing world:
    ``Mental health is too important to be left to mental health
    professionals alone.''
                                measuring impact
        As a retired bomb disposal specialist, I come from a world with the
    unofficial motto: Initial Success or Total Failure. Bomb techs simply
    cannot make mistakes; if we do, and are lucky enough to survive, we
    certainly don't make them again. Throughout my journey--15 years of
    supporting combat veterans and the establishment of two non-profits--I
    have grown immensely frustrated by the willingness of advocates and so-
    called experts to insist that we continue to do the same thing over and
    over again when it simply does not work. Albert Einstein called this
    ``insanity.''
        The current mental health community approach is not working. The
    data are beyond clear about that. As we explore new and innovative
    approaches, however, we must move beyond anecdote. The story of the
    horse or the dog that saved a veteran's life simply is not good enough.
    We need concrete and conclusive evidence of what does work so we can
    scale it to meet the massive need that exists.
        We believe our comprehensive program evaluation represents an
    important first-step in that direction for several major reasons.
        First, we must get beyond exploring just symptom reduction.
    Veterans who struggle are not simply looking for the absence of
    particular symptoms--they are seeking the existence of positive
    elements in their life; things like growth, joy, love, connection,
    passion, meaningful work, and the ability to be of service again. The
    evaluation methodology we utilize explores outcomes in three ways:
    symptom reduction, quality of life improvement, and Posttraumatic
    Growth/cognitive flexibility experienced. This explicit focus on
    improvements in a veteran's quality of life speaks to the way in which
    any kind of intervention is meaningfully impacting their day to day
    life. The focus on growth is critical; as humans, we yearn for two
    things: to be able to grow and to feel like we are making a
    contribution to the world.
        Second, we must measure the impact of what we are doing, with a
    focus on each individual veteran. One of the most stunning parts of the
    independent evaluation conducted as a result of the Clay Hunt Act was
    the lack of VA data and tracking related to the well-being of
    individual veterans. If we aren't asking them how or if treatment is
    working, how can we possibly adapt or alter it?
        Third, we must listen to the voices of those who struggle. In my
    testimony, I have sought to share the first-hand views of the thousands
    of veterans who we have hosted over the past six years. Our belief in
    listening--versus acting as an expert who sits on the sidelines--is how
    Posttraumatic Growth came into existence (with bereaved parents) and
    the source of Dr. Vikram Patel's innovations in the developing world.
        Importantly, we must be willing to listen to veterans so we can
    understand why they do not seek treatment; why they dropout early; why
    they fail to benefit from traditional approaches; and what they are
    seeking in terms of support, guidance, and training.
        We must not hide behind evidence-based treatments to proclaim that
    any patient who doesn't experience meaningful progress must be
    ``treatment-resistant.'' Veterans surely deserve better than a label
    that evokes hopelessness and despair.
        Fourth and finally, we must explore how veterans respond to
    interventions over the long-term. Our evaluation was an 18-month
    exploration across seven different collection points with a 95 percent
    response rate. We understand the trajectory of a Warrior PATHH graduate
    and how their life ebbs and flows over time, and what additional
    support, guidance, and training they may require.
        I believe deeply in the power of research and the importance of
    data. Throughout my Navy career, my business, and nonprofit life, I
    have used such information to guide me in the pursuit of effective
    solutions and strategies. Research and data only work, however, if they
    are collected with an open mind and a focus on solving a problem, not
    propping up institutional interests or protecting the way things are
    done.
        We must stop doing the same thing over and over again and expecting
    a different result. Far too many veterans have paid the ultimate price
    as a result, and the impact on their families, friends, and communities
    is incalculable.
                                   conclusion
        Rather than focusing on suicide prevention and more of the same in
    terms of mental health services, we should focus to ensure veterans can
    live great lives at home--lives filled with joy, passion, love,
    service, and purpose. We should ensure my fellow veterans can use the
    great military training they receive as a launching pad for a
    productive and purposeful life as a Warrior at home.
        We must ensure that, to paraphrase the words of a good friend and
    USMC General officer, their time in the service cannot be the greatest
    accomplishment of their lives. Doing so requires an integrated and
    collaborative approach, and we look forward to being a part of the
    solution and any questions that arise from this written testimony.

        Finally, I have personally hosted the last three Secretary's of the
    VA at Boulder Crest Retreat, Bob McDonald, Dr. David Shulkin, and most
    recently, Robert Wilkie. All three Secretaries have sat at a table in
    our kitchen and within minutes of their arrival to our Virginia Retreat
    said ``this is exactly what post-9/11 veterans want.'' Let's make this
    happen together!
                                     ______

      Prepared Statement of Kristina Kaufmann, Code of Support Foundation
                                  the problem
        Despite a massive effort and billions of dollars spent by the
    government, and tens of thousands nonprofit organizations dedicated to
    supporting the military/veteran community over the past 18 years of
    war, the needle hasn't moved for Servicemember and Veteran suicide.
    Americans who have served in our Armed Services are twice as likely to
    die by suicide than their civilian counterparts.
        And, while it's not talked about openly (or tracked) military/
    veteran spouses and children are taking their own lives as well. As an
    Army wife, and the CEO of Code of Support Foundation (COSF), I myself
    have personally known five wives and caregivers who have died by
    suicide. COSF has also covered the funeral cost for a 13-year-old boy--
    whose father, a veteran died by suicide after losing his battle with
    PTS. Four years later, his son Alex--wearing his Dad's dog tags--took
    his own life as well (see attached Huffington Post article ``Collateral
    Damage''). The one thing we do know for certain about suicide--is that
    its ripple effects and impact on family and community, are wide spread
    and devastating.
        So, with all this effort, why aren't we seeing better outcomes?
        Simply put--Servicemembers, Veterans and their Caregivers/Family
    Members (SMVCF) are adrift in a sea of resources available to serve
    them. This fragmentation of effort, and lack of coordination exists
    within government agencies (i.e. VA, DOD and HHS), it's happening
    between these agencies, between government agencies and community-based
    organizations, and between nonprofits themselves.
        Forty plus years ago, when our Vietnam Veterans returned home, they
    had next to no services to address their needs. This generation of
    Post-9/11 veterans has so many, it's almost impossible to navigate.
    Either way, the end state is the same--too many SMVCF are not getting
    the support they need to stabilize and thrive.
        We know that our approach to preventing suicide must be a holistic
    one. The number of veterans receiving mental health care from the VA
    had steadily risen, yet the number of veterans dying by suicide has
    remained essentially the same. This is in no way to suggest that there
    are enough mental health resources available to meet the needs of our
    military/veteran community (or for civilians for that matter).
    Additional investments must be made to increase capacity--especially
    within the community.
        A whole health approach to suicide prevention includes providing
    services to address not just physical, mental health and substance
    abuse issues, but family unrest, access to benefits, transportation,
    employment services, legal problems, financial instability, housing
    insecurity and social disconnection.
        As such, COSF strongly supports the funding of local coordination
    hubs as proposed the draft legislation (Commander John Scott Hannon
    Veterans Mental Health Care Improvement Act of 2019) co-sponsored by
    Senators Moran and Tester. But local coordination hubs won't be enough.
    Building and maintaining high functioning local hubs require 1) a
    sustainable funding stream 2) a ``backbone'' organization responsible
    for delivering case coordination 3) a local culture willing to work
    together and 4) technology platform(s) to facilitate the coordination.
    Obtaining and sustaining all four of these capabilities in every city,
    or every state for that matter, is a bridge to far.
        Providing the necessary coordination of services for SMVCF across
    the country requires a national strategy, and integration of effort
    between public and private sector organizations that does not currently
    exist.
                               how do we fix it?
    National Case Coordination Center and a Centralized Veteran Resource
            Navigation Platform Integrated into Transition Assistance
            Program
        ``Collaboration'' and ``Collective Impact'' have become buzzwords
    in the veteran support sector over the past several years. And, there
    are some encouraging trends. The VA's Office of Veterans Experience has
    executed Memorandums of Understanding and is working closely with a
    number of nonprofit organizations (including COSF, AWP and America
    Serves/IVMF).
        In the nonprofit sector, there are some fantastic local
    coordination models and initiatives happening across the country
    (detailed below). However, our concern is that these few local
    coordination hubs, are not networked amongst themselves (i.e. existing
    in the same stove-pipes they were meant to breakdown). The fact is,
    most SMVCF don't know about these local hubs, and/or aren't fortunate
    enough to live near one. They need a national organization to turn to,
    one number to call. A non-governmental organization that knows where
    all the local coordination hubs operate, and can perform warm handoffs
    when appropriate, or provide one-on-one case coordination services to
    them directly.
        Code of Support Foundation is the only national organization
    providing in-depth case coordination to troops, veterans and family
    members regardless of service era, discharge status or geographic
    location. As such, 65% of our clients are referred to us from partner
    organizations and agencies (including 20% from the VA), who are unable
    to serve the totality of their needs.
        The need for a National Coordination Center was made even more
    clear on April 24th of this year, when the VA sent out a newsletter
    highlighting COSF's Case Coordination Program and our PATRIOTlink
    resource navigation platform. Within 48 hours, 250 veterans and
    caregivers applied for our case coordination services, and over 7,500
    signed up for PATRIOTlink.

        As per our SOPs, our Veteran and Caregiver Peer Navigators (Case
    Coordinators) performed warm handoffs to local coordination hubs for
    the 80 veterans fortunate enough to live in their geographic coverage
    area. The rest of the cases, we took on ourselves. As we said in our
    report back to the VA, if the level of need for case coordination from
    one email isn't an indication of how badly SMVCF need help navigating
    the morass of resources out there, we don't know what does. We serve as
    the hub to the many spokes of local collaboratives and the thousands of
    points of service delivery across the country.
        In addition, the transitioning servicemember and veteran support
    sector desperately needs one portal by which SMVCF can get connected to
    resources and opportunities (including local coordination hubs),
    regardless of their geographic location. Code of Support Foundation,
    with $2 million dollars of seed funding from Bristol Myers Squibb
    Foundation, has developed this portal--PATRIOTlink. Currently over
    8,000 SMVCF and providers are using PATRIOTlink, quickly and easily
    identifying the help they need, while searching from over 12,000 (a
    number increasing every day) pre-vetted and verified services
    (additional information attached and demo's available upon request).
        COSF is already working with the VA to deploy PATRIOTlink with
    Suicide Prevention Coordinators (SPCs), the Veterans Crisis Line (VCL),
    VA social workers and Vet Centers. We also have an MOU with the Army
    Reserve and are working with the National Guard to deploy the platform
    to the over 400 Family Assistance Centers across the country. Marine
    for Life and Soldier for Life are also actively using the platform. In
    addition, over 100 nonprofit organizations are using the PATRIOTlink--
    so we're off to a good start. PATRIOTlink compliments and enhances
    current coordination efforts and CRMs (i.e. case management/share
    technologies). A landscape analysis of coordination efforts and
    technologies is included below.
        But it's integrating PATRIOTlink into the Transition Assistance
    Program (TAP), that will transform access to support for the 200,000
    transitioning servicemembers that leave the military every year.
    Servicemembers will be able to identify and leverage resources--both
    public and private--where they are relocating (as most active duty
    members don't stay where they ETS). In addition to ensuring resource is
    getting to need, the aggregated search data PATRIOTlink captures will
    allow COSF and the VA to perform real time trend identification (hot
    spots of need around the Nation) and gap analysis (local resource
    deserts). Currently, the needs assessments (which are often a year old
    by the time they're released) and VSO membership surveys (which can be
    skewed based on an organizations membership demographics), are what we
    have to inform program, policy and funding decisions. Real time data to
    inform real time decisions is what we need.
        While we are talking to the VA about getting PATRIOTlink upstream
    in TAP, it's going to be difficult to do without legislation (to
    include appropriated funding) from Congress. PATRIOTlink is the one-
    stop-shop portal we've all been talking about for years, and once
    widely deployed and adopted, it will be a game changer in our
    collective efforts to drastically minimize negative outcomes for
    SMVCF--including suicide.
                             additional information
    Hasn't a National Veteran Resource Navigation Platform Been Attempted
            Before?
        Yes. The National Resource Directory (NRD), currently managed by
    the Office of Warrior Care Policy in the Office of the Secretary of
    Defense, has been in existence for ten years. Frankly, if NRD had
    worked, COSF wouldn't have had to develop PATRIOTlink. NRD has
    underperformed and been underutilized for several reasons.
        The first, and most important of which, is that the government is
    not well-positioned to vet and verify non-governmental organizations,
    as they cannot be perceived as favoring on over another. Each resource
    in PATRIOTlink has undergone 90 minutes of vetting. NRD has limited
    capacity to keep data clean or to market the platform to SMVCF and
    community-based organizations, even though the majority of veterans and
    essentially all their family members are getting care and support
    outside of the VA. It doesn't allow for targeted searches based on
    eligibility criteria and does not have the ability to capture user
    behavior in the back end or integrate with other technology platforms,
    unlike PATRIOTlink, which has these capabilities.
    Coordination Models and Technology in the Veteran Support Sector: A
            Landscape Analysis
        There is a fair amount of confusion about who is doing what to help
    troops, veterans and their family members navigate, identify and
    leverage the services, support and benefits they need, and how these
    organizations differ from each other.
        COSF recognizes that we are not the only organization working to
    provide and facilitate service coordination--although we are the only
    one providing case coordination to SMVF in crisis, regardless of when
    they served, discharge status or where they live. America Serves (14
    sites/9 states), AWP (5 sites with 2 under development/5 states) and
    Mission United (22 sites/11 states), are all community integration
    initiatives providing valuable service coordination in local
    communities. These three nationally driven, locally implemented
    collaboratives are functioning in a total of 16 states combined,
    whereas COSF serves SMVF in every state.
        National Veterans Intermediary (NVI), works primarily with the
    Community Veteran Engagement Boards (CVEBS) across the country
    (currently over 70 communities/32 states) to identify best practices
    and provide small grants to nonprofit organizations to facilitate
    collective effort, but they do not provide service coordination
    themselves. We are working with NVI to ensure CVEB member organizations
    have access to PATRIOTlink.
        There are also a number of ``homegrown'' collaboratives (i.e.
    Houston Combined Arms; San Diego 211, BeConnected Arizona, Illinois
    Joining Forces, TexVet, etc.) actively providing coordination of
    services in their states and local communities. COSF is the national
    backstop for SMVF who aren't fortunate enough to have access to case
    coordination in their geographic location (which is the majority of
    SMVF).
        All collective effort requires technology platforms to facilitate
    resource coordination and navigation between service entities.
    Organizations providing services to this community are all using some
    type of CRM (customer relationship management) platform. Many
    organizations are moving to Salesforce as their CRM, as it is highly
    customizable, and PATRIOTlink will have the capability of integrating
    with Salesforce by the end of 2019. That way, providers using the CRM
    can import search results from PATRIOTlink into their own case
    management systems. However, a CRM in and of itself does not address
    the challenge of ensuring troops, veterans and their families are
    connected to resources, benefits and opportunities.
        There are four nationally deployed technology platforms in the
    veteran support space facilitating coordination of resources via
    several functionalities (PATRIOTlink, UniteUs, Warrior Serves, 211). Of
    the four, PATRIOTlink is the only pre-populated and centrally managed
    resource navigation platform. It complements the other three CRM
    platforms--all of which have some level of case share/coordination
    capabilities--but contain primarily local resources. PATRIOTlink is
    populated with local, regional and national resources, which opens the
    aperture of services for those communities. And of course, the majority
    of organizations across the country do not belong to a collaborative,
    so PATRIOTlink provides access to resources those organizations might
    not otherwise have known existed.
                                  Attachment 1
                               collateral damage
    Kristina Kaufmann, Code of Support Foundation
    Huffington Post, December 2, 2015.

        Four years ago, combat veteran James Christian Paquette lost his
    battle with Post Traumatic Stress and shot himself in the head. This
    summer, his son Alex, wearing dog tags with his dad's picture, followed
    in his father's footsteps. His mother found a note in his room that
    read in part, ``I'm going to see dad in heaven.''
        Alex was 13 years old.
        The American public hears stories about the devastating impact that
    mental wounds of war can have on a combat veteran, and how far too
    often, the Department of Veterans Affairs is failing them.
        But there's an untold story behind these tragic deaths that no one
    is talking about, an invisible population of veterans' children whose
    entire lives have been shaped by a war that has come home. An estimated
    22 veterans die by suicide every day in this country, leaving shattered
    families behind--collateral damage from wars that have all but left the
    headlines.
        We now have an entire generation of military families who know
    nothing but war. An estimated 30-35% of the 2.7 million troops who have
    deployed since 9/11 are struggling with Post Traumatic Stress (PTS),
    Traumatic Brain Injury (TBI) and/or substance abuse. These are
    conditions known to affect entire families, and can derail the mental
    health and development of the over two million children who have had a
    parent deployed over the past 14 years.
        A growing body of evidence indicates that some children of military
    families--especially those living in PTS/TBI households--have been
    negatively affected by their parent's deployments. Research conducted
    by the University of Southern California found that military connected
    adolescents have a higher rate of suicidal thoughts than their civilian
    counterparts, and other studies indicate that military spouses --
    particularly those serving as caregivers to support their wounded
    veterans--are more at risk to suffer mental health problems.
        To make matters worse, in most cases spouses and children of the
    over 60% of post-9/11 troops who have left active duty, are not
    eligible for healthcare from the Department of Veterans Affairs. No one
    Federal agency is held accountable, and there is no coordinated system
    to respond to the needs of these families. In fact, for the most part
    they are invisible to the systems that could be providing them
    services. While the Department of Defense has been directed by Congress
    to start tracking suicides among active duty family members, the VA has
    no such mandate to track family members once they leave active duty.
        We, as a Nation, are failing these families, many of whom feel
    abandoned by the country their loved ones fought to protect. Helping
    these families isn't just a moral imperative, it's a public health
    concern. RAND estimates that the lost productivity among post-9/11
    caregivers (mostly young wives) will confer a societal cost of almost 6
    billion dollars. And the National Center for Child Traumatic Stress
    reports that poverty, addiction and mental illness are just some of the
    conditions that have their roots in untreated childhood traumatic
    stress.
        What can be done?
        Children and Family Futures, a California based advocacy
    organization, recommends the Departments of Defense, Veterans Affairs
    and Health and Human Services expand their research program to better
    assess the behavioral health needs of veteran children. Currently, the
    bulk of research focuses on active duty families, who have far better
    access to care. In addition, mental health conditions related to
    wartime service sometimes take years to manifest, which means hundreds
    of thousands of veteran family members are at risk of falling through
    the cracks.
        Second, an estimated 350,000 veteran families lack health
    insurance. This requires a targeted outreach campaign--at both the
    Federal and local levels--to educate and enroll these families in
    health coverage under the Affordable Care Act.
        Third, the VA must do more to identify and help these families.
    Currently, there are no screening or assessment protocols used to
    determine the service needs of veteran caregivers or children. The VA
    is struggling to keep up with the growing demand in mental health
    services for veterans, and does not have the capacity (or congressional
    authority) to provide behavioral health support for family members.
    But, they can certainly do a far better job of ensuring warm hand-offs
    to community based mental health agencies.
        The fact is, the majority of veteran families in need of behavioral
    health care will be seen by community based organizations. These
    agencies will require the funding, cultural competency and education in
    evidence based practices to expand their capacity and effectively serve
    veteran families in crisis. The VA's Supportive Services for Veteran
    Families (SSVF) program, which grants $300 million dollars a year to
    community based organizations, has been widely credited for helping to
    drastically reduce veteran homelessness. This same model can be used to
    support community based behavioral health care for veterans and their
    families.
        The yellow ribbons have faded and the welcome home parades are a
    distant memory. But there's a price to pay for outsourcing our national
    defense to less than one percent of the population over 14 years of
    war. This isn't a military problem. It belongs to all of us.
        Alex's mom, Jami, and her remaining son are now getting the
    counseling they need through a local Vet Center. As painful as it is
    for her to speak openly about her tragic losses, she is committed to
    raising awareness. It's too late for Alex, but we can still save
    hundreds of thousands of families damaged by war, and give them a
    chance to become whole again.
             Attachment 2: Case + Coordination Program, March 2019

                      Attachment 3: PATRIOTlink newsletter

                                     ______

            Prepared Statement of John Boerstler, CEO, Combined Arms
        Chairman Isakson, Ranking Member Tester, distinguished Members of
    the Committee: Thank you for this opportunity to discuss the important
    topic on how communities leverage networks and systems to actively
    prevent veteran suicide.
        After serving in the government and veteran nonprofit space for
    over 19 years, and now as the CEO of Combined Arms, I am excited to
    report that in Houston, community collaboration with the VA has never
    been stronger. It's stronger because of the work of our local VHA and
    VBA leadership to understand the value that our 56 member agencies
    composed of other government agencies and nonprofit organizations can
    serve as agile and effective force multipliers for VA programming and
    customer service.
                            the combined arms model
        Combined Arms is a dynamic, ever-evolving collaborative impact
    organization that is using an innovative approach of technology and
    service delivery to disrupt the veteran transition landscape. By
    providing a holistic online assessment that efficiently connects
    veterans to member organizations, Combined Arms is accelerating veteran
    transition in order to deliver maximum impact in Houston. Combined Arms
    operates its collaborative system through four major pillars:

        1. Combined Arms runs a co-working space for 56 government and
    nonprofit agencies that is centrally-located and creates intentional
    collaborative collisions for those professionals that serve military
    veteran families. The Combined Arms Center is also a single point of
    entry from transitioning servicemembers, veterans, and their families.
        2. Combined Arms created an integrated technology platform that
    ensures thousands of military veteran families have access to 399
    customized resources provided by our 56 vetted member organizations.
    Combined Arms has flipped the accountability from the veteran to the
    service organizations through their unique data driven methodology.
        3. Combined Arms has developed an innovative marketing campaign
    that reaches further upstream to attract more military veteran families
    still on active duty or looking for their next opportunity. Combined
    Arms is serving the community by attracting more military talent to
    Houston as a means of economic development for our region.
        4. Combined Arms is recruiting, training, and deploying community
    leaders who have successfully made the difficult transition from
    military to civilian life to engage those veteran families still making
    the transition at the neighborhood level to ensure we are all
    #unitedaftertheuniform. This model not only positively activates
    successful veterans to volunteer and make a social impact on our
    community but also ensures more veterans in transition have direct
    access to the resources provided by our member organizations.

        These four pillars have effectively connected over 5,000 unique
    veteran clients to the 399 resources provided by the 56 member
    organizations since 2016. It is self-driven by the veteran and custom-
    fit for their needs based on how they answer the assessment. Little
    effort is required on behalf of clients who may be in crisis mode,
    unable to access other services, or unaware of services that exist. If
    a client reports a score less than 13 from the World Health
    Organization wellbeing index or ``WHO 5'' on the profile, then an alert
    is sent to the intake team for additional follow up on mental health.
    Every time a client returns to our system 30 days apart, the system
    automatically asks for an update on the WHO 5 and tracks the data so we
    can see trends of their responses. Similarly, if clients report being
    homeless or living in a shelter, then an alert is sent to the Intake
    Team for additional follow up and assessment to ensure the client is
    properly referred to vetted housing programs. The Intake Team provides
    ongoing follow up with veterans reporting they are homeless until
    permanent housing has been confirmed. The Combined Arms Intake Team is
    trained on STRONG STAR's Crisis Response Plan (https://www.strongstar
    training.org/what-we-do) if they engage with clients demonstrating
    suicidal ideation.
        The Combined Arms system actively prevents client retraumatization,
    as pertinent information can be shared between the Combined Arms system
    and the member organization delivering services. Clients are not asked
    the same questions multiple times, thus reducing frustration and
    increasing speed and efficiency of service delivery. The standard
    procedure is that Combined Arms member organizations follow up with the
    referred client within 4 days per the contract agreed upon. All of the
    aforementioned components act as ``prevention nudges''--minor yet
    impactful structural supports that keep clients engaged in care and
    community which are both preventative measures and facilitators of
    veteran health. Case progression is monitored by Combined Arms
    regularly to ensure that no clients are slipping through the cracks.
    Because of this experience, we firmly believe that suicide prevention
    lies in the ability to provide direct access to social services to the
    veteran as far upstream in their transition process as possible. If we
    can prevent unemployment and underemployment, substance abuse, family
    challenges, homelessness, and criminal behavior by accelerating veteran
    access to critically needed resources in a faster, more efficient way
    then we will prevent veteran suicides.
                                va collaboration
        15 different VA programs and clinics at the Michael E. DeBakey VA
    Medical Center (MEDVAMC) have been assigned to work within the Combined
    Arms system ranging from the Post Deployment Clinic to Womens Clinic to
    the Mental Health and TBI and Benefits programs and other peer support
    or outreach programs. The objective is for the VA to utilize the
    Combined Arms system to refer veteran patients to vetted government and
    nonprofit agencies delivering social services not provided by MEDVAMC.
    Similarly, other agencies can refer veteran clients into the VBA and
    VHA programs. Additionally, on a monthly basis, Combined Arms, MEDVAMC,
    and Houston Regional Office (VBA) join forces on ``Vet Connect Days''
    to make VBA and VHA programs and care more accessible to veteran
    clients seeking services through the Combined Arms system. These events
    increase client enrollment into VA programs. Finally, through the work
    of the Mayor's Challenge, the Combined Arms Transition Center is a
    distribution site for gun locks from the VA.
        MEDVAMC is also one of few VA hospitals in the Nation that work
    with local organizations like Combined Arms and county Medical Examiner
    to track, analyze, and report veteran suicides in the region served.
    Based on the data available to these partners, the Combined Arms team
    and VA partners discovered that approximately 65 veterans died by
    suicide in Harris County--the fourth largest veteran population in the
    United States--last year. Their average age is 53 with the most
    vulnerable populations being the youngest and oldest generation of
    veterans, aged 25-33 and 65+ years. This data is important for Combined
    Arms partners to better understand what programs and services can be
    deployed to actively prevent future veteran suicides and ensure that
    the number of deaths by suicide each year continues to decline.
                                   conclusion
        Combined Arms remains in constant communication with our member
    organizations and the community and are provided ongoing reports of
    incidents of veterans in crisis in need of outreach including via
    social media, suicides, and attempted suicides. The Intake Team will
    follow up, assess needs, and connect to appropriate partners including
    the VA who are notified in advance of the system referral regarding the
    severity of the situation to ensure immediate follow up by our
    partners. This innovative model can better prevent suicide if our
    member organizations are given the opportunity to provide direct access
    to social services to veterans as far upstream in their transition
    process as possible. If we can prevent unemployment and
    underemployment, substance abuse, family challenges, homelessness, and
    criminal behavior by accelerating veteran access to critically needed
    resources in a faster, more efficient way then we will prevent more
    veteran suicides in the communities veterans return to.

        Thank you again for your consideration of this written testimony
    and for your continued service to our military veteran community.
                                     ______

            Prepared Statement from Robin Kelleher, President/CEO,
                             Hope For The Warriors
       harnessing the power of community: leveraging networks to tackle
                                    suicide
        Veteran suicide is a tragic reality and has become an oft-cited
    data point; the reality is that clearly defined predictors are
    difficult to catalogue as part of a logical equation where the sum of
    all factors leads to another self-inflicted veteran death. HOPE
    appreciates the Committee recognizing the power of community to enhance
    veteran wellness. Our experience supporting post-9/11 servicemembers,
    veterans and military families for the last 13 years provides a window
    into the myriad issues that veterans and their families deal with, and
    oftentimes struggle with.
        Hope For The Warriors (HOPE) knows that the opportunity to instill
    resilience starts at a young age at home, but can be impacted by an
    individual's engagement with society, military service, and community.
    Therefore, we all--the VA, the Department of Defense, community
    organizations, and care providers--have an obligation to ensure
    military family wellness is a priority at every level--individual,
    community, state, and national--through continuous collaborative
    communication with each other.
                          about hope for the warriors
        The mission of Hope For The Warriors is to restore self, family and
    hope to the warrior communities we serve--servicemembers, veterans,
    military families, caregivers and families of the fallen. It's more
    than a mission, however; it's who we are. HOPE was founded by military
    families aboard Marine Corps Base Camp Lejeune, North Carolina, in
    2006, as we felt the effects of war on our friends, colleagues,
    families and ourselves. What began as post-combat bedside care and
    support has evolved to a national organization that has adapted to
    ongoing changes within the military community. We stayed the course
    with our country's post-9/11 veteran population as physical wounds
    healed, but emotional wounds still needed care. We recognize that there
    are many factors aside from combat that can contribute to mental
    health, including trauma from life events not directly associated with
    service. We've opened our arms to those who seek hope.
        Our work today is still just as individualized and community-based
    as it was in HOPE's earliest years. We provide more than 12,000
    services to over 4,200 military families in all 50 states annually. We
    believe warriors can thrive with access to integrated services focused
    on their individual and collective well-being. We recognize every
    servicemember and military family has their own goals and needs, and
    ideal resources do not always exist in their communities. We will
    restore SELF, FAMILY and HOPE through our national services, virtual
    capabilities and partners in mission.
              lead factors to veteran crisis and risk for suicide
        Isolation and a feeling of detachment are two of the primary causal
    factors in a person's ultimate decision to choose suicide. Military
    servicemembers are, by definition, trained to succeed in the
    unrelenting environment that is combat. Very often, disconnecting from
    one's own emotions is critical in order to execute the physical and
    mental requirements of combat operations. ``Compartmentalization'' is a
    by-product of the DOD's training skillset but the consequences of the
    last 18 years of continuous global combat operations has resulted in
    the current crisis of psychological health issues. Isolation is further
    compounded by an increasing disconnectedness from foundational belief
    systems, family, faith, and identity, all leading to a feeling of
    hopelessness.
        how communities provide suicide prevention resources to veterans
        The military unit is a servicemember's first ``community
    organization,'' therefore the important aspects of community that the
    VA, veteran organizations and this Committee recognize as a critical
    power to harness must begin at the start of military service, and
    continue in a collaborative ecosystem of supporting organizations.
        Military service is connected to a belief system. We shouldn't
    ignore faith, patriotism, moral obligation and legacy of service as
    important conduits to the feeling of a greater purpose. In a society
    where there are groups actively attacking spirituality, the National
    Anthem and our country's flag, it's easy to see how a veteran who
    answered a greater calling can feel isolated. Community combats
    isolation, and our job is to reconnect veterans to supportive
    communities. We must view communities in a broader scope to maintain
    the necessary constant connection. It's not just what is found in one's
    neighborhood; it's tapping in to virtual resources, social media,
    veteran-based programming and promoting military cultural awareness in
    existing community resources, like houses of faith and special interest
    groups. HOPE activates each of these communities to carry out
    integrated case management.
                  how the va can leverage community resources
        Sustainable care for the veteran population doesn't reside in one
    place, rather it exists in a network of support that surrounds an
    individual. The VA must function within a comprehensive system of
    strategic relationships with the Department of Defense, veteran and
    military service organizations and other community groups, to ensure
    ongoing, sustainable, individualized care for the veteran population.
    The first step in building emotional/psychological fitness MUST become
    part of the DOD/military training programs. Building resiliency . . .
    and the methods and modalities to ensure it's sustained and maintained
    . . . needs to begin while a servicemember is still in uniform. There
    should be a clear handoff from DOD to VA and veteran community
    organizations to ensure continuity of care. Organizations like Hope For
    The Warriors that emphasize a veteran's holistic well-being, and
    includes his or her family in the healing journey, open access to the
    communities he or she needs for life-long support and resiliency.
        hope for the warriors' efforts to reduce suicide in the veteran
                                   community
        Hope For The Warriors has built programs that address the known
    risk factors associated with military suicide, specifically
    disconnection and isolation. Our programs are designed to restore
    connection to self, family and most importantly, Hope. Our programs
    build emotional strength, resiliency, purpose and sustainable coping
    skills that are all necessary to combat isolation and detachment,
    thereby keeping the thought of suicide from becoming the act.
        Our greatest tool is community connection, through virtual
    workshops, meaningful events, military family-based programming and a
    strong referral system to like partners in mission. Collaboration is
    necessary to create an environment where everywhere a veteran looks, he
    or she sees Hope.
        Additionally, Hope utilizes innovative techniques to identify
    wellness risk factors, propensity for risk behaviors, etc. Artificial
    Intelligence is actively used across businesses to increase performance
    and ``drill down'' into human factors of their customers--veteran
    support networks must be just as innovative.
        Our dedication to mental health services includes the entire
    military family. We thrive on connecting veterans and families to
    communities of support in order to bridge the gap of understanding
    between military and civilians. Our constant is a message of Hope.
       how community organizations collect/use data for community-based
                           veteran suicide prevention
        Suicide provides definitive data, only captured after it's too
    late, so we must work together in tracking trends among an ever-
    changing veteran population. Basic demographic information, health
    trends and regional data from the VA will help non-profits better
    understand the veteran community's needs. Identifying and sharing the
    VA's service gaps can lend to a team approach to fill every gap and
    meet every need by outsourcing services. It is critical that we
    leverage innovative technology to support predictive analysis allowing
    for intervention and ultimately eliminating veteran suicide crisis.
        Understanding that sustainable care and successful suicide
    prevention is individualized, there is no single program that works for
    everyone, we must do more than share data; we must collaborate to
    create a national community of support and tackle suicide one person at
    a time.
                                     ______

      Prepared Statement of Kim Parrott, Sister of CDR John Scott Hannon,
                                    Deceased
        My brother, John Scott Hannon, joined the military at 18 and
    retired 23 years later as a Navy SEAL Commander. In the course of his
    career he was awarded 10 service medals, including two bronze stars. He
    was also awarded over 100% disability for PTSD, Traumatic Brain Injury,
    chronic pain, depression and bi-polar disorder. His re-entry into
    civilian life was anything but smooth. It ended with him taking his
    life on February 25, 2018.
        As our family sought out effective treatments over the course of a
    decade, we discovered an extraordinary multitude of resources available
    to veterans through the government, non-profit and for-profit sectors.
    Upon closer inspection, however, the majority of these programs stand
    alone as isolated initiatives, with no connection to what happened
    before or after in the veteran's life. This pattern is echoed in the
    anecdotal evidence we've heard from other injured vets--that their
    post-military treatment has been disjointed at best.
        This led us to ask: What if a larger template was created to
    integrate multiple treatment modalities? For example a customized
    pathway for vets and their families that addresses physical, emotional
    and spiritual healing as well as financial and vocational skills?
        I met with providers at a VA Hospital and a Vet Center. They
    agreed.
        Currently the demobilization process consists of several days chock
    full of lectures and thick binders on transitioning back into civilian
    life. The information is good but it's overwhelming and mostly landing
    on the deaf ears of soldiers fixated on getting home as soon as humanly
    possible.
        If mobilization takes weeks, months and even years in the case of
    Special Operations Forces, how could effective demobilization occur in
    a week? Put another way, if a deep-sea diver doesn't decompress from a
    dive properly and surfaces too quickly, they are at risk of getting
    very sick or even dying.
        Soldiers emerging from the pressures of combat are no less at risk.
        Being able to provide veterans a continuum of support once they are
    back in their own communities could make a world of difference. Working
    proactively with soldiers before leaving the military would make an
    even bigger difference. Imagine transitioning into civilian with a life
    vision, career path and coherent treatment plan for visible and
    invisible wounds? I was told this kind of shift in resource allocation
    would require an Act of Congress.
        The Veterans Mental Health Care Improvement Act named after my
    brother is a huge step in the right direction. Treatment was too
    fragmented and too late to save my brother's life, but his experience
    enabled him to become an articulate champion for what could help other
    veterans facing similar mental health challenges in the future.
        This bill is in complete alignment with John Scott's beliefs and
    efforts. It embraces a broader range of treatment and therapy options.
    It supports research to identify what really works. It promotes more
    practitioners trained in mental health care. It advocates for
    collaboration between the VA and DOD. In short, this act will move us
    away from a reactive and piecemeal approach toward a proactive and
    evidence-based continuum of support. Isn't this what we owe the men and
    women who have served our country with their minds, bodies and souls?

        Thank you.
                                     ______

     Prepared Statement of Matt Kuntz, J.D., Executive Director, National
                    Alliance on Mental Illness, NAMI Montana
                                i. introduction
        Chairman Isakson, Ranking Member Tester and distinguished Members
    of the Committee, On behalf of NAMI Montana, and NAMI, the National
    Alliance on Mental Illness, I would like to extend our gratitude for
    the opportunity to share with you our views and recommendations
    regarding ``Harnessing the Power of Community: Leveraging Veteran
    Networks to Tackle Suicide.'' NAMI Montana and the entire NAMI
    community applauds the Committee's dedication in addressing the
    critical issues around veterans' suicide. NAMI is the Nation's largest
    grassroots mental health organization dedicated to building better
    lives for the millions of Americans affected by mental illness. NAMI
    advocates for access to services, treatment, support and research, and
    is steadfast in its commitment to raising awareness and building a
    community of hope for all of those in need.
        NAMI Montana is also a member of the Coalition to Heal Invisible
    Wounds (Coalition). The Coalition was founded in February 2017 to
    connect leading public and private scientific investigators of new PTSD
    and Traumatic Brain Injury (TBI) treatments with policymakers working
    to improve care for veterans. Coalition members support innovators at
    all stages of the therapy development lifecycle, from initial research
    to late-stage clinical trials. The Coalition aims to spur strategic
    Federal institution support to create better treatment and care for
    veterans suffering from PTSD and TBI.
        I am the Director of the Center for Mental Health Research and
    Recovery (CMHRR) at Montana State University. While the CMHRR does have
    statewide suicide prevention research, none of that research funding
    presents a conflict with this testimony. I have also been appointed to
    the Creating Options for Veterans' Expedited Recovery (COVER)
    Commission. This testimony does not reflect the views of Montana State
    University, the Montana University System, or the COVER Commission.
                              ii. recommendations
    A. The Veterans Administration should develop a telehealth resource to
            deliver Suicide Assessment and Follow-up Engagement: Veteran
            Emergency Treatment (SAFE VET) to emergency rooms throughout
            the country.
        In 2008, the Blue Ribbon Panel on Veteran Suicide recommended the
    development and implementation of an Emergency Department (ED)-based
    intervention for suicidal Veterans who are discharged from the ED VA
    leadership responded to this recommendation and developed a clinical
    demonstration project: Suicide Assessment and Follow-up Engagement:
    Veteran Emergency Treatment (SAFE VET) project.\1\ This program was
    specifically designed to address the issue of the ``dearth of
    empirically supported brief intervention strategies to address this
    problem in health care settings generally and particularly in emergency
    departments (EDs), where many suicidal patients present for care.'' \2\
    ---------------------------------------------------------------------------
        \1\ Knox, K., L., Stanley, B., Currier, G., Brenner, L., Holloway,
    M., & Brown, G.K. (2012). An emergency department based brief
    intervention for Veterans at risk for suicide (SAFE VET). American
    Journal of Public Health. 102 suppl(1): S33-7, 2012
        \2\ Stanley, Barbara, et al. ``Comparison of the safety planning
    intervention with follow-up vs usual care of suicidal patients treated
    in the emergency department.'' JAMA psychiatry 75.9 (2018): 894-900.
    ---------------------------------------------------------------------------
        In September 2018, JAMA Psychiatry published the results of a
    large-scale cohort comparison study to determine whether the SAFE VET
    intervention was associated with reduced suicidal behavior and improved
    outpatient treatment engagement in the 6 months following discharge, an
    established high-risk period.\3\ The study found that SAFE VET was
    associated with 45% fewer suicidal behaviors, approximately halving the
    odds of suicidal behavior over 6 months (odds ratio, 0.56; 95% CI,
    0.33-0.95, P = .03). Additionally, veterans that received the SAFE VET
    intervention had more than double the odds of attending at least 1
    outpatient mental health visit (odds ratio, 2.06; 95% CI, 1.57-2.71;
    P < .001).
    ---------------------------------------------------------------------------
        \3\ Id.
    ---------------------------------------------------------------------------
        A study published in the Archives of Suicide Research analyzed
    medical staff perceptions of the SAFE VET intervention.\4\ Almost all
    staff perceived that SAFE VET was helpful in connecting veterans'
    follow-up services. A slight majority of staff believed SAFE VET
    increased the safety of participating veterans. The study found that
    medical staff members also benefited from the implementation of SAFE
    VET, because their comfort discharging Veterans at some suicide risk
    increased.\5\
    ---------------------------------------------------------------------------
        \4\ Chesin, Megan S., et al. ``Staff views of an emergency
    department intervention using safety planning and structured follow-up
    with suicidal veterans.'' Archives of suicide research 21.1 (2017):
    127-137.
        \5\ Id.
    ---------------------------------------------------------------------------
        The SAFE VET program is ready for a broader scale intervention. The
    logistics of providing the intervention in person to veterans in
    emergency rooms across the country are likely infeasible. However, the
    Suicide Safety Plan portion of SAFE VET could be delivered via
    telehealth networks to participating emergency rooms, with the follow-
    up conversations being administered telephonically.\6\
    ---------------------------------------------------------------------------
        \6\ In person discussion between Matt Kuntz of NAMI Montana and Dr.
    Barbara Stanley Ph.D., one of the SAFE VET program developers. Columbia
    University. April 18, 2019.
    ---------------------------------------------------------------------------
        The VA has a strong expertise in delivering telehealth care. The
    agency is in an excellent position to be able to deliver this critical
    intervention across the country.
    B. The Veterans Administration and the National Institute of Mental
            Health need more funding to develop research-proven suicide
            prevention initiatives.
        In June 2017, Psychiatric Services published ``Suicide Risk
    Assessment and Prevention: A Systematic Review Focusing on Veterans.''
    \7\ This research was funded by the Quality Enhancement Research
    Initiative, Office of Research and Development, Veterans Health
    Administration (VHA), U.S. Department of Veterans Affairs.
    ---------------------------------------------------------------------------
        \7\ Nelson, Heidi D., et al. ``Suicide risk assessment and
    prevention: a systematic review focusing on veterans.'' Psychiatric
    services 68.10 (2017): 1003-1015.
    ---------------------------------------------------------------------------
        The systematic review's authors sought to update evidence of the
    accuracy of methods to identify individuals at increased risk of
    suicide and the effectiveness and adverse effects of health care
    interventions relevant to U.S. veteran and military populations in
    reducing suicide and suicide attempts.\8\ While the study did have some
    exclusions such as interventions involving medication, it can be seen
    as a broad view of the current state of the science for this critical
    issue.
    ---------------------------------------------------------------------------
        \8\ Id.
    ---------------------------------------------------------------------------
        The conclusions of the systematic review were bleak:

              Risk assessment methods have been shown to be sensitive
            predictors of subsequent suicide and suicide attempts, but the
            frequency of false positives limits their clinical utility.
            Future research should continue to refine these methods and
            examine clinical applications. Studies of suicide prevention
            interventions provide inconclusive evidence to support their
            use, and additional RCTs of promising individual therapies and
            site-randomized population-level interventions are needed.\9\
    ---------------------------------------------------------------------------
        \9\ Nelson, Heidi D., et al. ``Suicide risk assessment and
    prevention: a systematic review focusing on veterans.'' Psychiatric
    services 68.10 (2017): 1003-1015.

        The author's statement that further research is needed is mirrored
    by 2014 article in Psychiatry, ``Suicide Among Soldiers: A Review of
    Psychosocial Risk and Protective Factors.'' \10\ That research behind
    that article was funded by Department of the Army, the U.S. Department
    of Health and Human Services, National Institutes of Health, National
    Institute of Mental Health (NIH/NIMH). That article's authors concluded
    that, ``Moving forward, the prevention of suicide requires additional
    research aimed at: (a) better describing when, where, and among whom
    suicidal behavior occurs, (b) using exploratory studies to discover new
    risk and protective factors, (c) developing new methods of predicting
    suicidal behavior that synthesize information about modifiable risk and
    protective factors from multiple domains, and (d) understanding the
    mechanisms and pathways through which suicidal behavior develops.''
    \11\
    ---------------------------------------------------------------------------
        \10\ Nock, Matthew K., et al. ``Suicide among soldiers: a review of
    psychosocial risk and protective factors.'' Psychiatry: Interpersonal &
    Biological Processes 76.2 (2013): 97-125.
        \11\ Id.
    ---------------------------------------------------------------------------
    C. Expand the VA's existing Precision Mental Health program as
            described in the bipartisan Commander John Scott Hannon
            Veterans Mental Health Care Improvement Act.
        According to the authors of ``Suicide Among Soldiers: A Review of
    Psychosocial Risk and Protective Factors,'' ``The fact that the vast
    majority of suicides occur among people with a current mental disorder
    makes this risk factor a prime target for screening and prevention
    efforts.'' \12\
    ---------------------------------------------------------------------------
        \12\ Id.
    ---------------------------------------------------------------------------
        However, the state of the science in the screening, diagnosis and
    treatment of mental health conditions is in flux. A strong analysis of
    this issue is given by Dr. Thomas Insel MD, et al. in the paper
    introducing the National Institute of Mental Health's Research Domain
    Criteria effort. At the time of this article was published, Dr. Insel
    was the Director of the National Institute of Mental Health.

              Current versions of the DSM and ICD have facilitated reliable
            clinical diagnosis and research. However, problems have
            increasingly been documented over the past several years, both
            in clinical and research arenas. Diagnostic categories based on
            clinical consensus fail to align with findings emerging from
            clinical neuroscience and genetics. The boundaries of these
            categories have not been predictive of treatment response. And,
            perhaps most important, these categories, based upon presenting
            signs and symptoms, may not capture fundamental underlying
            mechanisms of dysfunction. One consequence has been to slow the
            development of new treatments targeted to underlying
            pathophysiological mechanisms.

              History shows that predictable problems arise with early,
            descriptive diagnostic systems designed without an accurate
            understanding of pathophysiology. Throughout medicine,
            disorders once considered unitary based on clinical
            presentation have been shown to be heterogeneous by laboratory
            tests--e.g., destruction of islet cells versus insulin
            resistance in distinct forms of diabetes mellitus. From
            infectious diseases to subtypes of cancer, we routinely use
            biomarkers to direct distinct treatments. Conversely, history
            also shows that syndromes appearing clinically distinct may
            result from the same etiology, as in the diverse clinical
            presentations following syphilis or a range of streptococcus-
            related disorders.\13\
    ---------------------------------------------------------------------------
        \13\ Insel, Thomas, et al. ``Research domain criteria (RDoC):
    toward a new classification framework for research on mental
    disorders.'' (2010): 748-751.

        The critical nature of this issue to the VA's services is one of
    both issue severity (veteran suicide) and scope. According to the VA's
    Office of Research and Development, ``More than 1.8 million Veterans
    received specialized mental health care from VA in fiscal year 2015.''
    \14\
    ---------------------------------------------------------------------------
        \14\ Office of Research & Development website. Department of
    Veterans Affairs. Accessed on June 19, 2019. https://
    www.research.va.gov/topics/mental_health.cfm
    ---------------------------------------------------------------------------
        Therefore, the VA serves almost 2 million veterans a year in a
    treatment system based upon mental health diagnosis categorization that
    the former Director of the National Institute of Mental Health has
    deemed not to be ``predictive of treatment response.'' \15\ (emphasis
    added)
    ---------------------------------------------------------------------------
        \15\ Insel, Thomas, et al. ``Research domain criteria (RDoC):
    toward a new classification framework for research on mental
    disorders.'' (2010): 748-751.
    ---------------------------------------------------------------------------
        The VA's Precision Mental Health Program led by Amit Etkin, M.D.,
    Ph.D. of the Palo Alto VA is tackling some of the most critical
    questions about how to improve the diagnosis and treatment of
    psychiatric conditions. The program recently published the results of
    its groundbreaking study, ``Using FMRI Connectivity to Define a
    Treatment-Resistant Form of Post-Traumatic Stress Disorder.'' \16\ That
    research ``We found that a subgroup of patients with PTSD from two
    independent cohorts displayed both aberrant functional connectivity
    within the ventral attention network (VAN) as revealed by functional
    magnetic resonance imaging (f MRI) neuroimaging and impaired verbal
    memory on a word list learning task. This combined phenotype was not
    associated with differences in symptoms or comorbidities, but
    nonetheless could be used to predict a poor response to psychotherapy,
    the best-validated treatment for PTSD.'' \17\
    ---------------------------------------------------------------------------
        \16\ Etkin, Amit, et al. ``Using f MRI connectivity to define a
    treatment-resistant form of Post Traumatic Stress Disorder.'' Science
    translational medicine 11.486 (2019): eaal3236.
        \17\ Id.
    ---------------------------------------------------------------------------
        The VA's Precision Mental Health program is making real headway in
    identifying the scientific tools to improve care for veterans' brain
    health treatment. There is also room to add additional partners for the
    program. For example, the ``Establishing Moderators and Biosignatures
    of Antidepressant Response for Clinical Care for Depression (EMBARC)''
    has made significant strides in their analysis of depression.\18\ That
    effort and related efforts by Dr. Madhukar Trivedi's team at the
    University of Texas Southwestern have identified potential
    biosignatures involving inflammation,\19\ blood,\20\ \21\ and advanced
    imaging.\22\
    ---------------------------------------------------------------------------
        \18\ National Institute of Health, National Library of Medicine,
    ClinicalTrials.gov website. Accessed on June 19, 2018. https://
    clinicaltrials.gov/ct2/5show/NCT01407094
        \19\ Jha, Manish, and Madhukar Trivedi. ``Personalized
    antidepressant selection and pathway to novel treatments: clinical
    utility of targeting inflammation.'' International journal of molecular
    sciences 19.1 (2018): 233.
        \20\ Czysz, Andrew H., et al. ``Can targeted metabolomics predict
    depression recovery? Results from the CO-MED trial.'' Translational
    psychiatry 9.1 (2019): 11.
        \21\ Furman, Jennifer L., et al. ``Adiponectin moderates
    antidepressant treatment outcome in the combining medications to
    enhance depression outcomes randomized clinical trial.'' Personalized
    medicine in psychiatry 9 (2018): 1-7.
        \22\ Cooper, Crystal M., et al. ``Cerebral blood perfusion predicts
    response to sertraline versus placebo for major depressive disorder in
    the EMBARC trial.'' EClinicalMedicine (2019).
    ---------------------------------------------------------------------------
    D. The VA needs to continue to work on its suicide prevention messaging
            to ensure that it carries the overall point that suicide is not
            a rational brain response to adverse experiences
                1. There is significant danger of having suicide prevention
                        models be lost in the weeds of this complex and
                        evolving science.
        The circularities and similarities between mental illness symptoms
    and suicide risk factors make it incredibly difficult to determine
    after a suicide if someone would actually have the right number and
    type of symptoms that they would have been diagnosed with a mental
    illness. This makes it difficult to determine how to interpret
    unresolved question that arises from the statistic that ``50% of
    veterans who completed suicide had received a mental health diagnosis
    before their death.'' \23\
    ---------------------------------------------------------------------------
        \23\ Dr. Keita Franklin Ph.D. presentation to COVER Committee on
    January 30, 2019.
    ---------------------------------------------------------------------------
        What about other 50%? How many of them would have had the right
    symptom cluster to have been diagnosed with a mental illness? Would the
    numbers agree with what used to be a general acknowledgment that ``over
    90% of those who committed suicide had a psychiatric diagnosis at the
    time of death?'' \24\ Is it lower? Is it potentially even much lower?
    Is it possible to even come close to the right number and how relevant
    is the symptom cluster possible mental illness diagnoses question
    anyway.
    ---------------------------------------------------------------------------
        \24\ Bertolote, Jose Manoel, and Alexandra Fleischmann. ``Suicide
    and psychiatric diagnosis: a worldwide perspective.'' World Psychiatry
    1.3 (2002): 181.
    ---------------------------------------------------------------------------
        Dr. Jerry Reed Ph.D. of the Suicide Prevention Resource Center
    spoke to the issue. ``We certainly need to learn more about the
    relationship between mental illness and suicidal behaviors. I welcome
    any research and dialog that will help clarify this association. But
    from a prevention standpoint, we should not let the ``90 percent''
    figure limit our pursuit of solutions or prevention opportunities.''
    \25\
    ---------------------------------------------------------------------------
        \25\ http://www.sprc.org/news/90-percent
    ---------------------------------------------------------------------------
        NAMI Montana fully agrees with Dr. Reed and we believe that the VA
    and other partners are following his advice of not letting this debate
    limit the ``pursuit of solutions or prevention opportunities.''
    However, there is a need for an overall model to communicate to
    veterans, family members, and others how to prevent suicide and why
    certain strategies work.
        In NAMI Montana's opinion, any effective suicide prevention model
    must be based on the irrationality of suicide while incorporating both
    susceptibility for suicidality and the impact of stressful situations.
                2. NAMI Montana recommends using that the VA use the
                        Stress-Diathesis Model as a foundation in its
                        suicide prevention messaging.
        As an organization immersed in suicide prevention policy, in a
    state that regularly has the country's highest suicide rate, NAMI
    Montana has considered a number of different tools for helping explain
    the complex realities of suicide, suicide prevention, and treatment for
    suicidal behavior. We ground our message in the Stress Diathesis Model.
    As described in an article in Lancet Psychiatry, ``The stress-diathesis
    model posits that suicide is the result of an interaction between
    state-dependent (environmental) stressors and a trait-like diathesis or
    susceptibility to suicidal behavior, independent of psychiatric
    disorders.'' \26\
    ---------------------------------------------------------------------------
        \26\ Van Heeringen, Kees, and J. John Mann. ``The neurobiology of
    suicide.'' The Lancet Psychiatry 1.1 (2014): 63-72.
    ---------------------------------------------------------------------------
        The article ``Suicide as a Public Health Burden'' goes into more
    depth:

              In this model, diathesis describes the development of risk,
            defined by conditions that create an enduring vulnerability to
            be suicidal. Stress refers to triggering environmental (and
            contextual) factors that promote acute risk and the breakdown
            of protective factors among those already vulnerable. The
            development of suicidal behavior is the result of an
            interaction between stressors and a susceptibility to suicidal
            behavior (diathesis). A typical stressor includes the acute
            worsening of a psychiatric condition, but often an acute
            psychosocial crisis seems to be the most proximate stressor or
            ``the straw that broke the camel's back'' leading to suicidal
            behavior. Pessimism and aggression/impulsivity are components
            of the diathesis for suicidal behavior. Sex, religion,
            familial/genetic factors, childhood experiences, and various
            other factors influence the diathesis stress model. The model
            posits that suicide is the result of an interaction between
            state-dependent (environmental) stressors a trait-like
            diathesis or susceptibility to suicide behavior, independent of
            psychiatric disorder. Stressors, such as life events and
            psychiatric disorders, are important risk factors for suicide,
            but the diathesis concept explains why only a few of these
            individuals exposed to these stressors will take their own
            life. Early-life adversity and epigenetic mechanisms seem to be
            related to causal mechanism for diathesis.\27\
    ---------------------------------------------------------------------------
        \27\ Wilcox, Holly C., et al. ``Suicide as a Public Health
    Burden.'' Public Mental Health (2019): 207.

        This model has held up for years for the variety of suicide factor
    data that has arisen in both military and veteran populations. It is
    easily grasped by a wide variety of populations, from families affected
    by suicide, clinicians, and policymakers. Other suicide factors can be
    added to the diathesis or stress categories. The model also has a
    strong basis in neurobiology which renders it less susceptible to
    changes in the process of diagnosis and treatment of psychiatric
    conditions.\28\
    ---------------------------------------------------------------------------
        \28\ Van Heeringen, Kees, and J. John Mann. ``The neurobiology of
    suicide.'' The Lancet Psychiatry 1.1 (2014): 63-72.
    ---------------------------------------------------------------------------
        This model also explains other conditions that generally stem from
    malfunctions in neuron communications of the brain, such as depression,
    bipolar disorder, schizophrenia, substance abuse, etc. are substantial
    risk factors for suicide. These conditions can be activated without
    trauma experience and are critical to understanding why some veterans
    are in danger of committing suicide even if they have not been in
    combat.
    E. Ensure that all veterans who in the VHA system have access to
            effective care for treatment-resistant depression.
        The VA/DOD Major Depressive Disorder (MDD) Clinical Practice
    Guidelines (VA/DOD Guidelines) state that, ``Military personnel are
    prone to depression, at least partially as a result of exposure to
    traumatic experiences, including witnessing combat and separation from
    family during deployment or military trainings.'' \29\ \30\ The VA/DOD
    guidelines highlighted data from the Army Study to Assess Risk and
    Resilience in Servicemembers (Army STARRS) as an example.
    ---------------------------------------------------------------------------
        \29\ VA/DOD Major Depressive Disorder Clinical Practice Guidelines,
    Version 3.0-2016. Available at https://www.healthquality.va.gov/
    guidelines/MH/mdd/VADODMDDCPGFINAL82916.pdf. Citing Depression and the
    military. March 29, 2012; http://www.healthline.com/health/depression/
    military-service#1.
        \30\ Id. Citing Hoge CW, Auchterlonie JL, Milliken CS. Mental
    health problems, use of mental health services, and attrition from
    military service after returning from deployment to Iraq or
    Afghanistan. JAMA. Mar 1 2006;295(9):1023-1032.
    ---------------------------------------------------------------------------
        Army STARRS described the 30-day prevalence of MDD as 4.8% compared
    to less than 1%--five times higher--among a civilian comparison
    group.\31\ In fiscal year 2015, among Veterans served by the Veterans
    Health Administration (VHA), the documented prevalence of any
    depression (including depression not otherwise specified) was 19.8%
    while the documented prevalence of MDD only was 6.5%.\32\
    ---------------------------------------------------------------------------
        \31\ Id. Citing Kessler RC, Heeringa SG, Stein MB, et al. Thirty-
    day prevalence of DSM-IV mental disorders among nondeployed soldiers in
    the US Army: Results from the Army study to assess risk and resilience
    in servicemembers (Army STARRS). JAMA Psychiatry. 2014;71(5):504-513.
        \32\ Id. Citing Veterans Health Administration Mental Health
    Services. Preliminary findings regarding prevalence and incidence of
    major depressive Disorder (MDD), non-MDD depression diagnoses, and any
    depression diagnosis in FY 2015 among Veterans. Veterans Health
    Administration Mental Health Services; 2015
    ---------------------------------------------------------------------------
        The VA's ability to effectively serve veterans with depression is
    hampered by the current state of the science to diagnose and treat
    depression. As described by the Depression Task Force, ``An estimated
    50% of depressed patients are inadequately treated by available
    interventions. Even with an eventual recovery, many patients require a
    trial and error approach, as there are no reliable guidelines to match
    patients to optimal treatments and many patients develop treatment
    resistance over time. This situation derives from the heterogeneity of
    depression and the lack of biomarkers for stratification by distinct
    depression subtypes.'' \33\ Other estimates of the prevalence of
    treatment-resistant depression range from 30% \34\ to 50% \35\. A
    recent study in the United Kingdom found treatment-resistant depression
    rates of 55%.\36\
    ---------------------------------------------------------------------------
        \33\ Akil, Huda, et al. ``Treatment resistant depression: a multi-
    scale, systems biology approach.'' Neuroscience & Biobehavioral Reviews
    84 (2018): 272-288.
        \34\ Rush AJ, Trivedi MH, Wisniewski SR, Nierenberg AA, Stewart JW,
    Warden D, et al. Acute and longer-term outcomes in depressed
    outpatients requiring one or several treatment steps: a STAR*D report.
    Am J Psychiatry 2006;163:1905-17. 10.1176/appi.ajp.163.11.1905.
        \35\ Souery DA, Oswald P, Massat I, Bailer U, Bollen J,
    Demyttenaere K, et al. Clinical factors associated with treatment
    resistance in major depressive disorder: results from a European
    Multicenter study. J Clin Psychiatry 2007;68:1062-70. 10.4088/
    JCP.v68n0713.
        \36\ Wiles N, Thomas L, Abel A, et al. Clinical effectiveness and
    cost-effectiveness of cognitive behavioural therapy as an adjunct to
    pharmacotherapy for treatment-resistant depression in primary care: the
    CoBalT randomised controlled trial. Southampton (UK): NIHR Journals
    Library; 2014 May. (Health Technology Assessment, No. 18.31.) Chapter
    8, The prevalence of treatment-resistant depression in primary care.
    Available from: https://www.ncbi.nlm.nih.gov/books/NBK261988/
    ---------------------------------------------------------------------------
        The Depression Task Force saw hope in the future, ``Recent advances
    in methodologies to study genetic and epigenetic mechanisms, as well as
    the functioning of precise brain microcircuits, prompt new optimism for
    our ability to parse the broad, heterogeneous syndrome of human
    depression into biologically-defined subtypes and to generate more
    effective and rapidly-acting treatments based on a knowledge of disease
    etiology and pathophysiology and circuit dynamics.'' \37\
    ---------------------------------------------------------------------------
        \37\ Akil, Huda, et al. ``Treatment resistant depression: a multi-
    scale, systems biology approach.'' Neuroscience & Biobehavioral Reviews
    84 (2018): 272-288.
    ---------------------------------------------------------------------------
        However, the possibility of future scientific advancements does not
    relieve the current burden that the VA bears to provide adequate care
    options for veterans with treatment-resistant depression. The VA/DOD
    Major Depressive Disorder (MDD) Clinical Practice Guidelines have the
    following recommendations for veterans with treatment resistant
    depression.\38\
    ---------------------------------------------------------------------------
        \38\ VA/DOD Major Depressive Disorder Clinical Practice Guidelines,
    Version 3.0-2016. Available at https://www.healthquality.va.gov/
    guidelines/MH/mdd/VADODMDDCPGFINAL82916.pdf

         ``For patients with treatment resistant MDD who had at
    least two adequate pharmacotherapy trials, we recommend offering
    monoamine oxidase inhibitors (MAOIs) or tricyclic antidepressants
    (TCAs) along with patient education about safety and side effect
    profiles of these medications.'' \39\
    ---------------------------------------------------------------------------
        \39\ Id. at 19.
    ---------------------------------------------------------------------------
         ``We recommend offering electroconvulsive therapy (ECT)
    with or without psychotherapy in patients with severe MDD and any of
    the following conditions:'' \40\
    ---------------------------------------------------------------------------
        \40\ Id. at 20.

              - Catatonia
              - Psychotic depression
              - Severe suicidality
              - A history of a good response to ECT
              - Need for rapid, definitive treatment response on either
            medical or psychiatric grounds
              - Risks of other treatments outweigh the risks of ECT (i.e.,
            co-occurring medical conditions make ECT the safest treatment
            alternative)
              - A history of a poor response to multiple antidepressants
              - Intolerable side effects to all classes of antidepressant
            medications (e.g., seizures, hyponatremia, severe anxiety)
              - Patient preference
              - Pregnancy

         ``We suggest offering treatment with repetitive
    transcranial magnetic stimulation (rTMS) for treatment during a major
    depressive episode in patients with treatment-resistant MDD.'' \41\
    ---------------------------------------------------------------------------
        \41\ VA/DOD Major Depressive Disorder Clinical Practice Guidelines,
    Version 3.0-2016. Available at https://www.healthquality.va.gov/
    guidelines/MH/mdd/VADODMDDCPGFINAL82916.pdf at 20.

        NAMI Montana believes that the VA must make all of these treatment
    modalities available to veterans that need them. Treatment-resistant
    depression is such a major component of the veterans' patient
    population that there is no excuse for not making the service available
    either within the VA or through contracts with outside treatment
    providers. While the VA does appear to be offering these services as
    some of its flagship facilities, our perception is that the VA does not
    offer them consistently across its facilities--particularly in rural
    states like Montana.
                                iii. conclusion
        Thank you again for the opportunity to testify in front of this
    honorable Committee. Your attention to this issue means a lot to me,
    our entire NAMI organization, veterans and their families. We look
    forward to working with you to save the lives of America's injured
    heroes.
                                     ______

                  Prepared Statement of Team Red, White & Blue
        Military service assimilates individuals into a socially cohesive
    force to address dangerous and traumatic situations that have no
    counterpart in civilian life. Upon leaving active duty, many veterans
    experience a ``reverse culture shock'' when trying to reintegrate into
    civilian institutions and cultivate supportive social networks. Poor
    social reintegration is associated with greater morbidity and premature
    mortality in part due to the adoption of risky health behaviors, social
    isolation, and inadequate engagement in health care services. Team Red,
    White & Blue (Team RWB) was created to help veterans establish health-
    enriching social connections with communities through the consistent
    provision of inclusive and locally tailored physical, social, and
    service activities. We offer programming in over 200 cities, and are
    committed to tackling these issues through local engagement with
    veterans and their surrounding community members.
        With roughly 18 million veterans living in communities nationwide
    today, and 250,000 veterans leaving active duty this year to join them,
    we have a significant opportunity to positively impact their lives.
    They face isolation, lack of physical fitness, and lack of purpose.
    Additionally, as highlighted last year by Deputy Assistant Secretary of
    Defense Smith, the military-civilian divide has never been greater and
    is a threat to the viability and sustainability of the all-volunteer
    force.
        We know that quality social relationships are a critical protective
    factor, not only to combat loneliness, but for maintaining overall
    health, happiness, and an `enriched' life.\1\ \2\ Evidence reveals
    targeted activities that focus on engagement and positive social
    relationships can improve overall well-being and reduce depression
    symptoms. To that end, we've worked with veteran thought leaders and
    academic partners to develop a theory-based framework for veteran
    health--the Enrichment Equation, with three core constructs: health,
    people, and purpose.
    ---------------------------------------------------------------------------
        \1\ Holt-Lunstad J, Smith TB, Layton JB. Social relationships and
    mortality risk: a meta-analytic review. Plos Med. 2010;7(7):e1000316.
        \2\ Uchino BN. Social support and health: a review of physiological
    processes potentially underlying links to disease outcomes. J Behav
    Med. 2006;29(4):377-387.
    ---------------------------------------------------------------------------
        There is no silver bullet to ending suicide in veterans, and while
    much research has been done on this topic, there still do not exist
    widely agreed upon and validated factors which could be used for
    intervention.
        There are, however, predictive factors which may be important
    targets for future suicide prevention efforts in veterans such as:
    suicidal intent, attempt history, suicide ideation, PTSD symptoms,
    alcohol use disorder (AUD) symptoms, and depression,\3\ and much
    promise exists in facilitating a healthy reintegration process for
    veterans such that these predictive factors can be avoided or treated
    pre-crisis.
    ---------------------------------------------------------------------------
        \3\ A longitudinal study of risk factors for suicide attempts among
    Operation Enduring Freedom and Operation Iraqi Freedom veterans
    ---------------------------------------------------------------------------
        We believe the health-enriching social connections we provide with
    our programs help to achieve Team RWB's long-term goal of preventing
    future health problems among at-risk veterans by ``funneling'' or
    linking veterans to other people and resources before the onset of
    serious health problems emerge.
         team rwb's efforts to reduce suicide in the veteran community
        It should be noted that Team RWB's mission and programs are not
    designed specifically to reduce veteran suicide. Rather, they are
    focused on prevention by enriching veterans' lives through increasing
    health, people and purpose as detailed above and thus facilitating
    effective reintegration. Nor does the organization track individual
    member referrals of members to suicide intervention and/or mental
    health treatment.
        However, given the academic work referenced above to develop our
    ``Enrichment Equation'' and our history of community-based operations,
    we believe Team RWB is able to contribute in a meaningful manner on
    this topic.
        Through its programs, Team RWB provides regular community
    engagement combined with inclusive membership participation to help
    create an environment for health-promoting social networks developed
    through peer-to-peer veteran engagement and broad civilian support.
        These social networks begin supporting health using physical
    activity as a low cost, low barrier mechanism to maintain these
    networks. In addition to its use in maintaining social networks,
    regular physical activity is an evidence-based behavior that positively
    affects subjective and psychological well-being, including management
    of depressive and anxiety symptoms and recovery from alcohol and
    substance use disorders.\4\ \5\ \6\ \7\ \8\
    ---------------------------------------------------------------------------
        \4\ Whitworth JW, Ciccolo JT. Exercise and Post Traumatic Stress
    Disorder in military veterans: a systematic review. Mil Med.
    2016;181(9):953-960.
        \5\ Conn VS. Depressive symptom outcomes of physical activity
    interventions: meta-analysis findings. Ann Behav Med. 2010;39(2):128-
    138.
        \6\ Edwards MK, Loprinzi PD. The association between sedentary
    behavior and cognitive function among older adults may be attenuated
    with adequate physical activity. J Phys Act Health. 2017;14(1):52-58.
        \7\ Vallance JK, Eurich DT, Lavallee CM, Johnson ST. Physical
    activity and health-related quality of life among older men: an
    examination of current physical activity recommendations. Prev Med.
    2012;54(3-4):234-236.
        \8\ Linke SE, Ussher M. Exercise-based treatments for substance use
    disorders: evidence, theory, and practicality. Am J Drug Alcohol Abuse.
    2015;41(1):7-15.
    ---------------------------------------------------------------------------
        However, it is not just the positive effects on health supported by
    physical activity that is achieved through the use of these social
    networks. Through Team RWB's networks, veterans become more willing to
    self-identify and address reintegration challenges and/or physical or
    mental health issues.
        These networks help to achieve Team RWB's long-term goal of
    preventing future health problems among at-risk veterans by
    ``funneling'' or linking veterans to other people and resources before
    the onset of serious health problems emerge.
        While not explicitly designed to reduce veteran suicide, we believe
    that the prevention of future health problems for veterans through the
    adoption of physical activity and strong social connections at the
    local level is vital. We acknowledge the difficulty in measuring
    effectiveness in long term ``non-events'' in veterans health, but
    believe that a long term, prevention-based approach is a critical
    component to the challenge of veteran suicide.
     detail factors team rwb has identified that put a veteran at risk for
                               suicidal ideation
        Following on from the above section, Team RWB does not engage in
    academic efforts to specifically identify predictive factors for risk
    of veteran suicide. However, starting in 2014, a Team RWB-led research
    team worked to develop the Enriched Life Scale (ELS)--a 40-item scale
    to assess enrichment on the key domains of health, relationships, and
    purpose.\9\ The ELS does not screen for predictive factors of veteran
    suicide, but it can be used to measure physical health, mental health,
    supportive relationships, sense of purpose, and engaged citizenship in
    veteran and civilian samples for research or clinical purposes. This is
    important to the factors detailed below.
    ---------------------------------------------------------------------------
        \9\ Caroline M Angel, Mahlet A Woldetsadik, Nicholas J Armstrong,
    Brandon B Young, Rachel K Linsner, Rosalinda V Maury, John M Pinter.
    The Enriched Life Scale (ELS): Development, exploratory factor
    analysis, and preliminary construct validity for U.S. military veteran
    and civilian samples. Translational Behavioral Medicine, iby109,
    https://doi.org/10.1093/tbm/iby109
    ---------------------------------------------------------------------------
        It is known that physical, mental, and emotional health issues are
    often comorbid and diminish the quality of life in veterans.\10\ \11\
    ---------------------------------------------------------------------------
        \10\ Spelman JF, Hunt SC, Seal KH, Burgo-Black AL. Post deployment
    care for returning combat veterans. J Gen Intern Med. 2012;27(9):1200-
    1209.
        \11\ Taylor BC, Hagel EM, Carlson KF, et al. Prevalence and costs
    of co-occurring Traumatic Brain Injury with and without psychiatric
    disturbance and pain among Afghanistan and Iraq War Veteran V.A. users.
    Med Care. 2012;50(4):342-346.
    ---------------------------------------------------------------------------
        One key factor that applies in this instance relates specifically
    to the reintegration and/or transition process and the behavior of
    veterans as they navigate this transition.
        In the years immediately following military discharge, veterans
    experience significant decreases in meeting recommended physical
    activity levels,\12\ increased nicotine and alcohol use,\13\ and rapid
    weight gain \14\ such that within a couple years following military
    discharge, 75%-84% of OEF/OIF veterans are considered overweight or
    obese.\15\ \16\
    ---------------------------------------------------------------------------
        \12\ Littman AJ, Jacobson IG, Boyko EJ, Smith TC. Changes in
    meeting physical activity guidelines after discharge from the military.
    J Phys Act Health. 2015;12(5):666-674.
        \13\ Widome R, Laska MN, Gulden A, Fu SS, Lust K. Health risk
    behaviors of Afghanistan and Iraq war veterans attending college. Am J
    Health Promot. 2011;26(2):101-108.
        \14\ Littman AJ, Jacobson IG, Boyko EJ, Powell TM, Smith TC;
    Millennium Cohort Study Team. Weight change following US military
    service. Int J Obes (Lond). 2013;37(2):244-253.
        \15\ Maguen S, Madden E, Cohen B, et al. The relationship between
    body mass index and mental health among Iraq and Afghanistan veterans.
    J Gen Intern Med. 2013;28(suppl 2):S563-S570.
        \16\ Rosenberger PH, Ning Y, Brandt C, Allore H, Haskell S. BMI
    trajectory groups in veterans of the Iraq and Afghanistan wars. Prev
    Med. 2011;53(3):149-154.
    ---------------------------------------------------------------------------
        Thus, veterans are significantly affected by obesity and related
    cardiovascular conditions \17\ \18\ that are derived from the adoption
    of unhealthy lifestyle habits as they navigate the reintegration
    process.
    ---------------------------------------------------------------------------
        \17\ Fryar CD, Herrick K, Afful J, Ogden CL. Cardiovascular disease
    risk factors among male veterans, U.S., 2009-2012. Am J Prev Med.
    2016;50(1):101-105.
        \18\ Nelson KM. The burden of obesity among a national probability
    sample of veterans. J Gen Intern Med. 2006;21(9):915-919.
    ---------------------------------------------------------------------------
        However, they are also affected by other conditions that are
    related to their military service such as musculoskeletal injury with
    chronic pain,\19\ \20\ sleep disturbance,\21\ and Traumatic Brain
    Injury.\22\
    ---------------------------------------------------------------------------
        \19\ Spelman JF, Hunt SC, Seal KH, Burgo-Black AL. Post deployment
    care for returning combat veterans. J Gen Intern Med. 2012;27(9):1200-
    1209.
        \20\ Helmer DA, Chandler HK, Quigley KS, Blatt M, Teichman R, Lange
    G. Chronic widespread pain, mental health, and physical role function
    in OEF/OIF veterans. Pain Med. 2009;10(7):1174-1182.
        \21\ Seelig AD, Jacobson IG, Smith B, et al.; Millennium Cohort
    Study Team. Sleep patterns before, during, and after deployment to Iraq
    and Afghanistan. Sleep. 2010;33(12):1615-1622.
        \22\ Taylor BC, Hagel EM, Carlson KF, et al. Prevalence and costs
    of co-occurring Traumatic Brain Injury with and without psychiatric
    disturbance and pain among Afghanistan and Iraq War Veteran V.A. users.
    Med Care. 2012;50(4):342-346.
    ---------------------------------------------------------------------------
        As these issues are often comorbid, however, they do not just
    affect the physical health of veterans--they are often related to
    mental health conditions such as depression, post-traumatic stress, and
    alcohol misuse, which, as referenced above, are conditions that show
    promise as strong predictive factors for suicidality.
        The challenge of coping with comorbid mental and physical health
    symptoms can also be an impediment to physical activity among
    veterans,\23\ \24\ which can further perpetuate the aforementioned
    health problems and create a vicious cycle.
    ---------------------------------------------------------------------------
        \23\ Hall KS, Hoerster KD, Yancy WS Jr. Post-traumatic stress
    disorder, physical activity, and eating behaviors. Epidemiol Rev.
    2015;37:103-115.
        \24\ Hoerster KD, Jakupcak M, McFall M, Unutzer J, Nelson KM.
    Mental health and somatic symptom severity are associated with reduced
    physical activity among US Iraq and Afghanistan veterans. Prev Med.
    2012;55(5):450-452.
    ---------------------------------------------------------------------------
        Physical activity and strong social connection in veterans are two
    important protective factors contributing to overall well-being, and
    may be important in veterans avoiding the conditions listed above, or
    for seeking treatment for those conditions, some of which have been
    identified as predictive factors for veteran suicide.
     team rwb's ideas on how communities can collect standardized data on
         best practices for community based suicide prevention efforts
        The collection of standardized data on community based suicide
    prevention efforts is inherently difficult, for several reasons listed
    below and others beyond this list:

         The widely varied nature of the organizations taking part
    in these efforts, from small non-profits to large health care systems.
         Referrals that routinely happen between organizations,
    thus creating data in multiple locations.
         The privacy requirements that exist, to include the Health
    Insurance Portability and Accountability Act of 1996 (HIPAA).
         The inherent difficulty is measuring suicide prevention.

        That being said, we do believe there are some important steps that
    can be taken at the community level that will improve overall data
    collection efforts and standardization.
        An important step is for organizations to utilize valid and
    reliable instruments for data collection, especially as it relates to
    wellbeing. Though well intentioned, there are still many organizations
    that utilize self-created surveys and measures to attempt to understand
    the wellbeing of their members. Though the intent is laudable, it
    creates a concluded and potentially inaccurate system of data across
    the nation.
        Another critical step is for organizations to put steps in place to
    ensure a feedback loop exists in their data collection processes. As
    much as possible, put systems in place to follow-up and verify the
    accuracy of the data which is collected.
        Though not directly related to standardization of data collection
    efforts across the country, we also believe there are several issues of
    note that relate to these community based efforts on data collection.
        We believe it is important that organizations do not use
    instruments that will diagnose mental health disorders, if the
    organization does not have the resources available to provide adequate
    care or efficiently make referrals. Organizations should measure that
    which they are designed to affect, and there is an inherent risk for
    all parties involved to screen for mental health conditions, but not
    act on the results.
        Also, we believe organizations should take great care when
    collecting data, and avoid using language typically associated with
    post-traumatic stress or other diagnostic criteria that could
    potentially evoke stigmatizing feelings or shame and would be
    counterproductive to assessing wellbeing. If this is done, it's
    important to make individuals aware of resources that are available to
    them in case of need.
        In closing, we are grateful for the opportunity to provide a
    written testimony for this hearing. Veteran suicide is an issue of
    critical importance to our country, and we at Team RWB are glad to be
    able to provide our perspective on this topic.

        [The included report ``2017 Enriched Life Scale Manuscript'' can be
    found at: https://academic.oup.com/tbm/article/10/1/278/5257713]
                                     ______

                 Prepared Statement of Wounded Warrior Project
        Chairman Isakson, Ranking Member Tester, and distinguished Members
    of the Committee on Veterans' Affairs: Thank you for inviting Wounded
    Warrior Project (WWP) to submit this statement for the record of
    today's hearing to explore how community-based support networks can be
    leveraged to help prevent veteran suicide. We appreciate the
    Committee's interest in learning more about the work these networks are
    doing to support veterans and their families, and we are grateful for
    the opportunity to offer our perspective on how new and existing
    initiatives and collaborations across the public, private, and non-
    profit sectors can help our collective effort to improve veteran mental
    health and wellness.
        Wounded Warrior Project's mission is to honor and empower wounded
    warriors. Through community partnerships and free direct programming,
    WWP is filling gaps in government services that reflect the risks and
    sacrifices that our most recent generation of veterans faced while in
    service. Over the course of our 15-year history, we have grown to
    become an organization of nearly 700 employees in more than 25
    locations around the world, delivering over a dozen direct-service
    programs to warriors and families in need. Our partnerships with like-
    minded organizations are augmenting these programs, enhancing our
    advocacy efforts, and fostering a culture of collaboration to better
    meet the needs of the wounded, ill, and injured veterans we serve.
             mental health & understanding the population we serve
        Wounded Warrior Project strives to be as effective and efficient as
    possible and we recognize that we must be willing to adapt our programs
    and approaches to meet the evolving needs and unique challenges facing
    the warriors and caregivers we serve. To learn more about their
    physical, social, economic, and mental health needs, WWP has conducted
    the Nation's largest and most comprehensive survey of post-9/11
    veterans who have sustained both physical and hidden injuries while
    serving the Nation. Since its first edition in 2010, this annual survey
    has helped us identify trends and needs among registered warriors, to
    compare their outcomes with those of other military and veteran
    populations, and to measure the impact of continual programmatic
    engagement--all to determine how we can better serve veterans,
    servicemembers, and their families.
        For the fourth year in a row, WWP's Alumni survey revealed that
    Post Traumatic Stress Disorder (PTSD) was the most frequently reported
    health problem from service (78.2%), followed closely by depression
    (70.3%), anxiety (68.7%), and sleep problems (75.4%), which are often
    linked to mental health challenges. Completed by over 33,000 warriors
    in 2018, WWP's Alumni survey contains a significant amount of data to
    help our organization better serve veterans and others in their support
    networks. This data guides our analysis of current programming, helps
    us identify partners who best complement our mission, and informs our
    advocacy before Congress. In addition to the points above, several data
    points can help frame the issue before the Committee today:

         Self-assessments reflect poor health: Overall, almost half
    of warriors report their health as being excellent, very good, or good,
    but unfortunately, the other half (50.9%) consider their health to be
    only fair or poor.
         Poor health affects social activities: Over 40% reported
    that their current health impacts normal social activities with their
    family, friends, and others all of the time or most of the time.
         Poor health affects employment: Their decreased health
    also impacts their employment outlook as warriors cite mental health
    issues, difficulty being around others, and not being physically
    capable as the top three barriers to finding employment.
         Warriors have a good support system as they deal with
    challenges: More than 80% of warriors said there are people in their
    lives that they can depend on to help them when they really need it.
    These family members and caregivers continue to make major sacrifices
    while supporting the recovery of their warriors.
         Desire for social engagement: Over half of warriors
    (55.8%) have participated in at least one WWP activity within the past
    year, with Warrior Engagement Events and Family Inclusive Events having
    the highest participation rates. These events are extremely important
    to warriors because they provide an opportunity for warriors to
    interact with other veterans that share similar experiences and
    circumstances. Of the many resources and tools provided to warriors
    with needs, including health care provided by the Department of
    Veterans Affairs (VA) and prescription medications, interacting and
    talking with other veterans remains a top three resource for helping
    them to address their mental health concerns. These interactions, along
    with the many other benefits provided by the WWP programs and services,
    are vital to the rehabilitation and recovery of warriors as they seek
    to improve their current health, employment, and financial status

        While no single point of data can capture the needs and appropriate
    responses for the warriors who look to WWP for support, the figures
    above begin to tell a narrative that reinforces our organization's
    belief that suicide prevention must move beyond the healthcare/crisis
    management model toward an integrated and comprehensive public health
    approach focused on resilience and prevention. A multi-disciplinary
    approach to treatment--whether clinical, community-focused, or a
    combination--is required.
                     factors that lead a veteran to crisis
        Given the prevalence of mental health challenges among the warriors
    we serve through direct services and partnerships, mental health
    programs are WWP's largest programmatic investment--in 2018, WWP spent
    $63.4 million on our mental health programs. Based on our experience as
    a program provider and a partner to others in the community who are
    addressing veteran mental health in a variety of ways, WWP can attest
    to what we know--and what we have learned from others--about the
    individual, relational, and societal factors that can lead a veteran to
    crisis.
        The Department of Veterans Affairs has identified several risk
    factors in its National Strategy for Preventing Veteran Suicide that
    should be guideposts for the community. VA appropriately states that a
    prior suicide attempt, mental health status, availability of lethal
    means, and stressful life events are characteristics associated with a
    greater likelihood of suicidal behavior. Stated differently, it is a
    combination of factors that can lead to a crisis. Pre-existing
    psychiatric conditions, like depression and/or PTSD, are risk factors,
    but in addition there may be significant life stressors related to
    occupational functioning, relationships, the ability to live
    independently, or chronic medical conditions that a veteran has
    difficulty managing. Chronic conditions such as pain, sleep
    difficulties, and/or financial problems can wear down resolve. Sudden
    psychosocial changes such as a deterioration or dissolution of a
    relationship, sudden change in family dynamics (i.e., child custody) or
    job loss may all play a role in psychological crisis--especially when
    they occur suddenly and exceed the veteran's ability to cope.
        Fortunately, our community has a growing understanding of
    protective factors that can help mitigate stressors. Access to mental
    health care, positive coping skills, and social connectedness are
    similarly addressed in VA's National Strategy for Preventing Veteran
    Suicide as being characteristics associated with a lesser likelihood of
    suicidal behaviors. As WWP has testified previously, mental health
    treatment works, but every individual has unique needs, and there is no
    one-size-fits-all solution.
        Suicide prevention cannot just be about saving someone's life when
    they are in crisis; it must be about creating a life worth living. Our
    end goal is continual engagement until the warrior is far enough in
    their recovery to ``live our logo'' (i.e., help carry a fellow
    warrior). Although WWP has over a dozen free programs and services for
    veterans, two in particular are addressing risk factors--social
    isolation and poor physical health--through nontraditional methods that
    are improving overall health and wellbeing, and helping insulate
    veterans from reaching a crisis point.
    In-Focus: WWP's Alumni Program & Combating Isolation
        Whether because of psychological (``invisible wounds'') or physical
    (``visible wounds'') trauma or a combination of both, every warrior who
    registers with WWP is provided with a unique path of individual and
    collective recovery that he or she can pursue through our direct
    services and other support networks. While there is no predetermined
    path for each warrior registering with WWP, a warrior's first
    engagement with our organization is often through our Alumni Program.
    While in the military, many servicemembers form bonds with one another
    that are as strong as family ties. WWP helps re-form those
    relationships by providing warriors opportunities to connect with one
    another through community events and veteran support groups housed
    within this program. WWP also provides easy access to local and
    national resources through outreach efforts and with the help of
    partners like The Travis Manion Foundation, The Mission Continues, Team
    Red White & Blue, Team Rubicon, and over 30 other funded partner
    organizations. Though most events are warrior-focused, WWP also hosts a
    variety of family-based activities.
        While engagements may range from recreational activities and
    sporting events to professional development opportunities and community
    service projects, the Alumni Program was formed with an appreciation
    for the fact that a desire for post-service camaraderie is what often
    brings veterans to our organization. In this context, our Alumni
    Program focuses on engagement and connection and not simply the
    activity or event itself. We diversify our connection-focused offerings
    in regions to attract a wide variety of warriors and families, and it
    is through these events that they develop a relationship with the
    organization and trust WWP to help resolve more challenging and
    personal obstacles in their rehabilitation and recovery. Our
    organization averages more than 11 engagements like this every day.
        Everything WWP does, including initial or ongoing participation for
    warriors in the Alumni Program, is focused on creating a life worth
    living with a purpose, thereby creating a protective fabric in the
    battle against veteran suicide. The Alumni Program's value becomes
    clearer when we conceptualize WWP ``membership'' and engagement as a
    possible first step in recovery for those seeking or in need of help.
    Obstacles to seeking mental health care support may be difficult to
    overcome, especially when amplified by stigmatizing messages. In many
    ways, these obstacles can seem monumental to overcome to veterans and
    serve to further isolate those who may already feel marginalized. A
    possible first step to overcome those hurdles is engagement with
    peers.\1\ During such peer engagement warriors may be exposed to peer
    testimonies that can, in turn, serve to break some barriers to seeking
    mental health care such as stigma. Engagements may also provide a
    specific strategy and action items that can assist the veteran in
    feeling empowered as they traverse a system that may feel complicated
    and foreign. WWP programs provide veterans with a specific path toward
    care and engagement in order to simplify their navigation in seeking
    care. Such paths may lead to career fulfillment, financial security,
    physical wellness, and other protective factors against suicide.
    Warriors may attend an engagement event to spend time with fellow
    veterans but may leave with newly acquired psychoeducational
    information and new friendships that empower them to take an additional
    step in their recovery.\2\
    ---------------------------------------------------------------------------
        \1\ Being part of and engaging in a greater community improves
    motivation, health and happiness (Hall, 2014)
        \2\ When individuals feel connected to others, they are less
    isolated and as a result may come to the realization that they are not
    alone in their suffering or that others may have experienced similar
    challenges (Hall, 2014).
    ---------------------------------------------------------------------------
        Alongside the Alumni Program, WWP-sponsored Peer Support Groups are
    led by, and designed for, warriors who want to empower their
    counterparts with disclosure of personal challenges and how those
    challenges were overcome. This can create a new sense of belonging and
    normalize psychological symptoms and conditions. Peer Support Groups,
    which can be found in communities across the country, lead to new
    friendships, provide a renewed sense of community, strengthen bonds
    through shared experiences, and introduce new solutions to challenges.
    WWP trains Peer Support Group leaders to facilitate productive
    discussions and maintain a safe, judgment-free environment for
    warriors. These groups not only serve as ``force multipliers'' for our
    organization but also assist WWP with identifying individuals in
    crisis.
        Meaningful relationships are vital to the success of warriors'
    transitions back into civilian life, and suicide is best combated
    through preventive measures such as providing mental health programs,
    connection opportunities, and pathways to build confidence and a sense
    of purpose.\3\ We must be proactive when engaging warriors and showing
    them how their lives matter in their homes and communities.\4\
    Offerings like WWP's Alumni Program and Peer Support Groups provide
    avenues to recurring engagement and a way to stay connected prior to a
    crisis.
    ---------------------------------------------------------------------------
        \3\ Psychological distress (i.e., depression) has been correlated
    with stronger negative reactions to social interactions, which may lead
    to further isolation (e.g., Gotlib, Kash, et al., 2004; Mogg & Bradley,
    2005).
        \4\ Interpersonal interactions can have a strong impact upon one's
    cognitions, emotions, and behaviors (Baumeister & Leary, 1995).
    ---------------------------------------------------------------------------
    In-Focus: Physical Health and Wellbeing
        Consistency with physical activity has proven to have a myriad of
    benefits to include improved mood, short and long-term memory,
    mobility, decisionmaking, and self-esteem, while lessening symptoms of
    anxiety, stress, depression, use of medications, and pain. The impacts
    are so pronounced and validated that mental health professionals often
    prescribe daily exercise in conjunction with other treatment
    modalities. There is no shortage of outdoor experiential activities
    such as surfing, rock climbing, and mountain biking targeted for
    veterans afflicted with PTSD. For these reasons, WWP offers its own
    programs and unites with others, including VA, to provide and promote
    physical health and wellness opportunities.
         Adaptive Sports: WWP will be supporting the VA's Summer
    Sports Clinic as the primary sponsor in San Diego this September, a
    weeklong experience offering veterans the opportunity to engage in
    instruction with cycling, surfing, kayaking, sailing, and adaptive
    CrossFit. Adaptive sports programming has long been used to reengage a
    veteran with a sense of community, team, spirited competition, and a
    sense of pride. WWP's adaptive sports team aims to expose veterans to a
    variety of sports, while also connecting them to resources in their
    community to continue regular play. This focus on long-term
    involvement, support, and accountability is critical as episodic
    experiences will only provide short term impacts to mental health.
         Social Community and Confidence: Soldier Ride is an
    adaptive cycling program that allows veterans to ride alongside fellow
    injured servicemembers and reclaim their confidence and mental
    fortitude in a supportive environment. Cycling offers a low-impact
    opportunity to reengage with physical activity and experience the
    improvements in mood created by exercise and a positive social network.
    Mountain biking and the ride modalities of ski and snowboard are
    devoted to improving a participant's skill, while enhancing focus,
    confidence, and self-esteem. The additional value of exposure to nature
    has shown a strong correlation to mood enhancement. Ride groups develop
    social networks that provide long-lasting camaraderie, motivation, and
    a shoulder to lean on when needed.
         Coaching and Ongoing Support: WWP's Physical Health and
    Wellness program engages veterans in a 90-day coaching experience that
    commences with four days of intensive instruction for fitness,
    nutrition, mindfulness, and sleep. Through the SMART Goals process,
    warriors identify their purpose, and why a healthy lifestyle is
    important to them. Biweekly check ins with their coach ensure adherence
    to goals, adjustments when necessary, and a mechanism of support that
    improves accountability. While many seek out this variety of
    programming for physical outcomes, they are pleasantly surprised at the
    immediacy of improvement to mental wellbeing. Collaboration with the
    VA's Whole Health initiative affords veterans additional resources,
    ongoing support, and a more impactful treatment strategy with their
    primary care team.

        As these programs and engagements illustrate, WWP embraces a
    holistic approach to overall wellbeing. Even though our mental health
    services represent our largest programming spend, we continue to build
    and invest in other programs that complement our mental health
    offerings and even serves as a bridge to more direct mental health
    engagements. Warriors most often reach out to WWP for help accessing VA
    benefits, but once they have registered and become more familiar with
    our other services, mental health programs emerge as the top internal
    referral destination. As such, we encourage the Committee to take a
    wide and comprehensive view of what helps veterans not just survive but
    thrive in their communities.
                 approaching suicide prevention as a community
        Conceptualizing a community approach to suicide prevention should
    reflect another key insight from VA's National Strategy for Preventing
    Veteran Suicide--that not all veterans have the same risk for suicide.
    Prevention strategies are most effective when considered alongside the
    risk factors they are addressing. VA and the National Academy of
    Medicine illustrate prevention strategies as falling into three levels
    (universal, selective, and indicated) that match risk, and community
    actors can and should follow this model to tailor programs to meet the
    needs of all veterans, some veterans, or relatively few individual
    veterans. Similarly, it cannot be overstated that although risk
    variables can be identified, the depth and breadth of their impact may
    be individualized to that person.
        In this context, WWP can attest that there is a huge collective
    effort underway to decrease suicide among veterans. VA alone has an
    organized national strategy comprising primary, secondary, and tertiary
    prevention approaches, and mandating a trained Suicide Prevention
    Coordinator at every VA medical center. The Center for Disease Control
    (CDC) has published comprehensive recommendations aimed at preventing
    all suicides (not making a particular distinction between veterans and
    non-veterans), including changes to economic policy, social and
    educational programs, and mental health services nationwide. Approaches
    from VA and CDC should soon become more aligned with other Federal
    agencies following the recent launch of the President's Roadmap to
    Empower Veterans and End the National Tragedy of Suicide (PREVENTS)
    task force.
        In the private and non-profit sectors, several networks have been
    developed to meet the mental health needs of veterans in their own
    communities over the past several years. These networks include WWP's
    Warrior Care Network, the Cohen Veterans Network, and the Headstrong
    Project among others. Each of these organizations provide direct
    clinical care to veterans at various locations around the U.S., and
    suicide prevention is an implicit aim (although the central mission is
    more one of overall mental health and well-being). Meanwhile,
    coalitions like the Bush Institute's Warrior Wellness Alliance are
    focused on convening organizations with limited individual reach in
    order to build collective input for wider application, extend impact to
    a broader population, and optimize the support and services available
    to veterans and their families.
        As an example, WWP is proud to offer programs to more than 130,000
    registered veterans and servicemembers; however, this population is
    just a fragment of post-9/11 warriors who may need help. Since
    September 11, 2001, more than 2.7 million brave men and women have been
    deployed to protect our Nation's freedom and according to the National
    Center for PTSD, more than 500,000 servicemembers have been diagnosed
    PTSD as a result of traumatic war-time experiences (e.g. combat, motor
    vehicle accidents, military sexual trauma). For these reasons, WWP
    joined the Warrior Wellness Alliance in order to amplify the reach of
    empowerment for post-9/11 warriors. The member organizations that
    comprise the alliance come together to discuss innovative ways to reach
    warriors and meet their needs. This passionate group is tasked with not
    only devising innovative ways to meet current warrior needs, but
    addressing potential future needs to come as the population continues
    to age and conditions worsen.
        As the greater community becomes more aligned, it currently stands
    that a component of all suicide prevention strategies is efficient
    access to effective interventions for the various factors that
    correlate to increased suicidality of which mental health is one.
    Mental health access needs to be available through varied settings and
    providers as people at risk of suicide are unlikely to persist in
    navigating the complex mental health system. By providing a community
    of providers through VA, the Department of Defense, and civilian
    providers, we can establish ``no wrong door'' for accessing effective
    interventions.
    In-Focus: State, Local, and Social Media Collaboration (Universal
            Strategy)
        Veterans struggling with mental health issues like PTSD,
    depression, and anxiety may find themselves on a path to self-
    destructive coping behavior and isolation. These barriers to seeking
    care are enhanced by stigma that still surrounds mental health
    treatment. While many in the community are familiar with facts and
    figures around suicide, the truth is that the actual numbers are
    illusive at best, given for example premature deaths from high risk-
    taking behavior, which one could conceptualize as being suicidal in
    nature.
        A critical step is getting organizations across the country to
    engage and extend a much-needed dialog regarding suicide. For the last
    three years WWP has coordinated a Facebook Suicide Awareness Live
    event, during suicide awareness month (September). We have partnered
    with subject matter experts from the VA, DOD and Bush Institute. The
    event encompasses panel discussions describing warning signs, stigma,
    strategies for discussing suicide prevention as well as veteran
    experiences. A panel of veterans discuss how their challenges and
    experiences led to their engagement with programs at WWP, VA and DOD.
    In 2018, our broadcast reached over 139,000 individuals, and we hope to
    reach even more in 2019.
        As WWP increases its exposure through presentations at various
    platforms to various audiences (i.e., conferences), we are increasingly
    viewed as a community resource and are invited to continue our
    engagement in this much-needed discussion. For instance, WWP has been
    invited to present multiple times at Governors and Mayors Challenges
    and the VA/DOD Suicide Awareness Conferences. These presentations have
    led to additional meetings to at the state level. For instance, WWP is
    scheduled to meet in Austin with the Texas Governor's challenge team to
    discuss partnership and collaboration between Texas Governor's
    Challenge to Prevent Veteran Suicide and WWP.
    In-Focus: WWP's Warrior Care Network & Partnering with VA (Selective
            Strategy)
        Within WWP's Continuum of Mental Health Support programming,
    warriors needing intensive treatment for moderate to severe PTSD can
    take part in the Warrior Care Network. This innovative program is a
    partnership between WWP and four national academic medical centers
    (AMCs): Massachusetts General Hospital, Emory Healthcare, Rush
    University Medical Center, and UCLA Health. Warrior Care Network
    delivers specialized clinical services through innovative two- and
    three-week intensive outpatient programs that integrate evidence-based
    psychological and pharmacological treatments, rehabilitative medicine,
    wellness, nutrition, mindfulness training, and family support with the
    goal of helping warriors survive and thrive.
        Through these two- to three-week cohort-style programs,
    participating warriors receive more than 70 direct clinical treatment
    hours (e.g. cognitive processing therapy, cognitive behavioral therapy,
    and prolonged exposure therapy) as well as additional supportive
    intervention hours (e.g. yoga, equine therapy). This is the equivalent
    of an entire year's worth of therapy in two to three weeks. Warrior
    Care Network providers and therapy protocols are having exceptional
    results resulting in significant reductions in PTSD and depression
    symptoms that translate into increased function and participation in
    life. Eighty-three percent of patients arrive with severe to moderate
    PTSD and leave with symptoms in the minimum range, and the program is
    seeing similar results with depression. The completion rate for
    patients is greater than 90 percent--forty points higher than the
    national average. Through WCN, veterans receive world-class care from
    their providers while building relationships with each other that offer
    the potential for long-term peer support. Warriors report greater than
    95 percent satisfaction rates--agreeing that they would tell their
    friends about the experience. This greatly helps in de-stigmatizing the
    act of seeking mental health care.
        Each AMC also has specific programming for caregivers and family
    members at some point during the intensive outpatient program,
    including family weekend retreats, psychoeducation, or telehealth
    communications. For example, UCLA's Operation Mend PTSD track includes
    three weeks for both veterans and caregivers to go through treatment
    and psychoeducation sessions. This provides caregivers with clinical
    outlets, as well as in-depth knowledge of PTSD symptoms, effects, and
    the recovery process. Family and caregiver support is extremely
    important to WWP, and our Warrior Care Network includes support for
    these groups to ensure they are fully informed on their warrior's
    therapy protocol and are poised to support their warrior's long term
    mental health care.
        Providing warriors with best in class care that combines clinical
    and complementary treatment is still only part of the Warrior Care
    Network's holistic approach to care. While AMCs provide veteran-centric
    comprehensive care, aggregate data, share best practices, and
    coordinate care in an unprecedented manner, a Memorandum of Agreement
    (MOA) between WWP and VA has been structured to further expand the
    continuum of care for the veterans we treat. In February 2016, VA
    signed this MOA with WWP and the Warrior Care Network to provide
    collaboration of care between the Warrior Care Network and VA hospitals
    nationwide. VA provided four part-time employees at each AMC to act as
    liaisons between each AMC and VA, spending 1.5 days per week at their
    respective sites to facilitate coordination of care and to meet with
    patients, families, and care teams. Each VA liaison facilitates
    national referrals throughout the VA system as indicated for mental
    health or other needs, but also provides group briefings about VA
    programs and services, and individual consultations to learn more about
    each patient's needs. Because of the immense impact recognized by all
    network partners, in November 2018, that MOA was renewed with a growing
    commitment from VA--VA created four full-time billets for liaisons at
    each AMC to enhance their contribution to the partnership. All told,
    this first-of-its-kind collaboration with VA is critical for safe
    patient care and enables successful discharge planning.
        As the Committee considers ways to improve accessibility of mental
    health care and to increase collaboration between VA and community
    providers, it is important to remember that clinical referrals most
    often occur between healthcare providers at the individual level. To
    the extent that external, innovative models of care like the Warrior
    Care Network and other such organizations may be more beneficial to an
    individual veteran, education could be provided at the system level and
    filter down to the clinics and providers from which referrals are most
    likely to originate. A coordinated information campaign to inform
    healthcare providers would be helpful in increasing the likelihood of
    veterans accessing available resources, particularly as VA's new
    Veterans Community Care Program continues to take shape and build
    networks of care that are responsive to the medical needs of our
    Nation's veterans.
                  creating a model for community collaboration
        There is an old proverb, ``If you want to go fast, go alone; but if
    you want to go far, go together.'' WWP knows no one organization can
    fully meet veterans' needs. To this end, we proudly partner with other
    organizations to help our Nation's wounded warriors. Since 2012, WWP
    has granted $88 million to 165 other veteran and military service
    organizations. In FY 2018 alone, we invested nearly $15 million in
    additional impact through grants to 34 partner organizations in support
    of our warriors and their families. These efforts reflect the value
    that comes with working with others to harness subject matter
    expertise, reach a greater number of injured veterans, and provide a
    more comprehensive network of support.
        As a community of service organizations, we each focus on
    complementary initiatives across missions (sometimes, generations) and
    together we are forging partnerships, providing cross-referrals and
    providing a stronger, expanded network of support. When assessing
    potential partnerships, WWP evaluates existing and potential partners
    based on how a program complements WWP by:

         Filling a gap in WWP direct services by providing a
    program or service WWP does not offer;
         Augmenting WWP direct services by doubling down on
    services that are in high demand;
         Amplifying messaging around issues affecting post-9/11
    wounded/ill/injured veterans, caregivers, and their families;
         Building relationships and collaboration with
    organizations serving veterans and families;
         Growing small organizations with potential that can have
    the ability to scale and offer innovative programming.

        Although no WWP partnerships specifically address suicide
    prevention with indicated strategies, several are addressing risk
    factors or promoting protective factors. As the Committee considers
    ways to leverage current community networks, the following illustrative
    examples may provide helpful inspiration drawn from ways WWP has helped
    develop networks of its own for the benefit of warriors and those who
    support them.

         Tragedy Assistance Program for Survivors (TAPS): In
    coordination with WWP's mental health programming team, a new 2019
    grant will support two Intensive Clinical Programs conducted in
    partnership with Home Base at Massachusetts General Hospital for
    survivors who experienced severe trauma after witnessing their loved
    one's suicide or experiencing the postmortem discovery of their loved
    one's body. In order to help inform WWP's suicide prevention
    programming we will learn what activities and crises lead up to a
    warrior's suicide.
         Boulder Crest: In coordination with WWP's mind team, the
    grant will support 4 Warrior PATHH (Progressive and Alternative
    Training for Healing Heroes) Retreats, an 18-month nonclinical program,
    designed to cultivate and facilitate Posttraumatic Growth amongst those
    struggling with PTSD and/or combat stress, that begins with a 7-day
    combat stress recovery retreat for warriors.
         Combined Arms: WWP funding supports Community Integration
    for warriors and their families in Houston, TX. In this veteran-dense
    area (300,000+ veterans), warriors and families are linked to local and
    national resources via a connection hub that provides assistance with
    employment, finances, homelessness, volunteerism, and health & physical
    activities. The availability of these resources empowers veterans to
    live fulfilling lives and stay connected in their community. More than
    50 organizations and agencies have joined their collaborative.
         The Mission Continues (TMC): Funding has supported
    expansion and development of community Service Platoons across the
    country and the community service Fellowship Program, which is now the
    Service Leadership Corps. TMC has grown to 84 active service platoons
    with 48 of those platoon leaders being WWP Alumni. TMC now has a total
    network of 55,009 (31,720 veterans/military members/23,289 non-
    veterans).

        Pursuing partnerships like those listed above has helped WWP form a
    unique perspective among veteran service organizations. While we
    continue to make the largest impact on individual lives through our own
    programs and services, we can help other organizations do the same
    through grants and partnerships. Like WWP, many are learning more about
    the military and veteran populations they serve through sharing best
    practices, cross collaboration, and increased interaction with the
    community. Various organizations have even channeled that experience
    into advocacy. As the Committee considers legislation to allow VA to
    continue along a similar path with more organizations, WWP can
    confidently attest to the value of taking a community-wide approach to
    addressing the full spectrum of challenges veterans and their families
    face.
        Last, it is important for the Committee to know that our approach
    to grants and partnerships has evolved over time and currently reflects
    WWP's engagement in leading research in the military-veteran community.
    Together with the Henry Jackson Foundation (HJF), and partners from the
    public and private sectors, WWP has funded a longitudinal study of
    transitioning veterans to better understand the components of well-
    being and the factors necessary for ensuring a healthy military-to-
    civilian transition. This study--The Veterans Metrics Initiative--
    follows a cohort of veterans over the first three years of their
    transition from military to civilian life. Six comprehensive surveys
    are being administered at six-month intervals (Waves 1-6) over the
    course of the three-year period. Each survey assessment is recording
    participant well-being across four domains: health (mental and
    physical), vocation (education and career), finances, and social
    relationships. Participants also identify transition assistance
    programs they used, if any. Following each assessment, the research
    team is identifying changes in well-being across various demographic
    groups, analyzing transition assistance programs identified to distill
    them into their common components, and examining links between common
    program components used and well-being outcomes. The TVMI study
    suggests that there are four components of well-being: Social
    Relationships; Health; Finances; and Vocation. WWP's investments for
    direct services and programming are considered and categorized on this
    evidence-based criteria, and we engage WWP's metrics team to measure
    our collective work and outcomes.
           additional recommendations for policy change and oversight
        In addition to efforts to facilitate more effective and efficient
    collaboration between VA and veteran networks, the Committee should
    consider the following recommendations that have potential to boost new
    and ongoing efforts on initiatives in the community.
        First, the Committee should maintain oversight of VA MISSION Act-
    authorized permission to use value-based reimbursement models to
    enhance mental health care quality. Section 101(i) of the VA MISSION
    Act allows VA to incorporate value-based reimbursement principles to
    promote the provision of high-quality care, and this permission can and
    should be used to help encourage innovative models in physical and
    mental health treatment. While the health care industry has embraced
    bundled payment approaches to address episodes of care for hip surgery,
    diabetes, stroke, cancer treatment, and others, VA lags behind. The
    expanded migration of this practice to mental health would allow VA to
    be a pioneer in an area where veterans are catastrophically suffering
    and drive the wider mental health care industry toward better quality
    and more cost-effective outcomes. Whether care is ultimately provided
    at VA or with a community-based provider, policies like this can
    ultimately serve to increase the volume of providers and the quality of
    care they are providing.
        Similarly, Congress should take steps to embrace innovation in care
    delivery and payments. Section 152 of the MISSION Act authorized--and
    VA has since established--a Center for Innovation for Care and Payment
    to develop new, innovative approaches to testing payment and service
    delivery models to reduce expenditures while preserving or enhancing
    the quality of and access to care furnished by VA. As the steward of
    taxpayer dollars dedicated to the health and well-being of veterans,
    Congress has a vested interest in tracking the developments of this
    center and encouraging action and partnership with the private sector
    on successful, scalable models of both care and payment.
        Last, WWP encourages the Committee to dedicate resources for
    biomarker research. Specifically, WWP recommends that emphasis be
    placed on biomarkers for PTSD, TBI, anxiety, and depression--challenges
    that face a significant portion of warriors who reach out to WWP for
    help. Private sector initiatives are already underway, including work
    being performed and funded by Cohen Veteran Bioscience (CVB) to fast-
    track the development of diagnostic tests and personalized therapeutics
    for the millions of veterans and civilians who suffer the devastating
    effects of trauma to the brain. Recent research published in Science
    Translational Medicine and funded in part by CVB, identifies a PTSD
    brain imaging biomarker.\5\ This biomarker is important because it may
    help determine which people with PTSD will respond to PTSD first-line
    treatment of behavioral therapy, and which individuals with PTSD who
    don't respond to first-line treatment but may respond to other options.
    This personalized approach will help connect people to the right PTSD
    treatment sooner. WWP supports continued research and collaboration
    into biomarkers for mental health and Traumatic Brain Injury treatment.
    VA would be an integral partner to work already being done in the
    community.
    ---------------------------------------------------------------------------
        \5\ Amit Ekin et al. ``Using fMRI connectivity to define a
    treatment-resistant form of Post Traumatic Stress Disorder.'' Sci.
    Transl. Med. 11, eaal3236 (2019).
    ---------------------------------------------------------------------------
                                   conclusion
        Wounded Warrior Project thanks the Senate Committee on Veterans'
    Affairs, its distinguished members, and all who have contributed to the
    policy discussions surrounding today's discussion about veteran suicide
    and the power of veteran networks to address this challenge. We share a
    sacred obligation to serve our Nation's veterans, and WWP appreciates
    the Committee's effort to identify and address the issues that
    challenge our ability to carry out that obligation as effectively as
    possible. We are thankful for the invitation to submit this statement
    for record and stand ready to assist when needed on these issues and
    any others that may arise.

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