[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

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                                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




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                     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
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    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\
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    \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).
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                               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.
      

                                  [all]