[House Hearing, 118 Congress]
[From the U.S. Government Publishing Office]


     COMBATTING A CRISIS: PROVIDING VETERANS ACCESS TO LIFE-SAVING
                   SUBSTANCE ABUSE DISORDER TREATMENT

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

                                HEARING

                               BEFORE THE

                         SUBCOMMITTEE ON HEALTH

                                 OF THE

                     COMMITTEE ON VETERANS' AFFAIRS

                     U.S. HOUSE OF REPRESENTATIVES

                    ONE HUNDRED EIGHTEENTH CONGRESS

                             FIRST SESSION
                               __________

                        TUESDAY, APRIL 18, 2023
                               __________

                            Serial No. 118-9
                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
       
                  [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]       


                    Available via http://govinfo.gov
                    
                               __________

                    U.S. GOVERNMENT PUBLISHING OFFICE
                    
52-206                      WASHINGTON : 2023       


                     COMMITTEE ON VETERANS' AFFAIRS

                     MIKE BOST, Illinois, Chairman

AUMUA AMATA COLEMAN RADEWAGEN,       MARK TAKANO, California, Ranking 
    American Samoa, Vice-Chairwoman      Member
JACK BERGMAN, Michigan               JULIA BROWNLEY, California
NANCY MACE, South Carolina           MIKE LEVIN, California
MATTHEW M. ROSENDALE, SR., Montana   CHRIS PAPPAS, New Hampshire
MARIANNETTE MILLER-MEEKS, Iowa       FRANK J. MRVAN, Indiana
GREGORY F. MURPHY, North Carolina    SHEILA CHERFILUS-MCCORMICK, 
C. SCOTT FRANKLIN, Florida               Florida
DERRICK VAN ORDEN, Wisconsin         CHRISTOPHER R. DELUZIO, 
MORGAN LUTTRELL, Texas                   Pennsylvania
JUAN CISCOMANI, Arizona              MORGAN MCGARVEY, Kentucky
ELIJAH CRANE, Arizona                DELIA C. RAMIREZ, Illinois
KEITH SELF, Texas                    GREG LANDSMAN, Ohio
JENNIFER A. KIGGANS, Virginia        NIKKI BUDZINSKI, Illinois

                       Jon Clark, Staff Director
                  Matt Reel, Democratic Staff Director

                         SUBCOMMITTEE ON HEALTH

               MARIANNETTE MILLER-MEEKS, Iowa, Chairwoman

AUMUA AMATA COLEMAN RADEWAGEN,       JULIA BROWNLEY, California, 
    American Samoa                       Ranking Member
JACK BERGMAN, Michigan               MIKE LEVIN, California
GREGORY F. MURPHY, North Carolina    CHRISTOPHER R. DELUZIO, 
DERRICK VAN ORDEN, Wisconsin             Pennsylvania
MORGAN LUTTRELL, Texas               GREG LANDSMAN, Ohio
JENNIFER A. KIGGANS, Virginia        NIKKI BUDZINSKI, Illinois

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.
                         C  O  N  T  E  N  T  S

                              ----------                              

                        TUESDAY, APRIL 18, 2023

                                                                   Page

                           OPENING STATEMENTS

The Honorable Mariannette Miller-Meeks, Chairwoman...............     1
The Honorable Julia Brownley, Ranking Member.....................     3

                               WITNESSES
                                Panel 1

Dr. Tamara Campbell, MD, Executive Director, Office of Mental 
  Health and Suicide Prevention, Veterans Health Administration, 
  U.S. Department of Veterans Affairs............................     4

        Accompanied by:

    Dr. Sachin Yende, MD, Chief Medical Officer, Office of 
        Integrated Veteran Care, Veterans Health Administration, 
        U.S. Department of Veterans Affairs

Dr. Julie Kroviak, MD, Principal Deputy Assistant Inspector 
  General, Healthcare Inspections, Office of the Inspector 
  General, U.S. Department of Veterans Affairs...................     6

                                Panel 2

Mr. Daniel Elkins, Chief of Staff, The Independence Fund.........    18

Mrs. Jen Silva, Chief Program Officer, Wounded Warrior Project...    20

Mr. Thomas B. Sauer, Chief Executive Officer & Owner, Miramar 
  Health.........................................................    21

        Accompanied by:

    Mr. Brendan Dowling, Veteran Outreach, Miramar Health

                                APPENDIX
                    Prepared Statements Of Witnesses

Dr. Tamara Campbell, MD Prepared Statement.......................    33
Dr. Julie Kroviak, MD Prepared Statement.........................    39
Mr. Daniel Elkins Prepared Statement.............................    45
Mrs. Jen Silva Prepared Statement................................    63
Mr. Thomas B. Sauer Prepared Statement...........................    76
Mr. Brenden Dowling Prepared Statement...........................    77

                        Statement For The Record

Cohen Veterans Network...........................................    79

 
     COMBATTING A CRISIS: PROVIDING VETERANS ACCESS TO LIFE-SAVING 
                   SUBSTANCE ABUSE DISORDER TREATMENT

                              ----------                              


                        TUESDAY, APRIL 18, 2023

            U. S. House of Representatives,
                            Subcommittee on Health,
                            Committee on Veterans' Affairs,
                                                   Washington, D.C.
    The subcommittee met, pursuant to notice, at 10:20 a.m., in 
room 390, Cannon House Office Building, Hon. Mariannette 
Miller-Meeks [chairwoman of the subcommittee] presiding.
    Present: Representatives Miller-Meeks, Van Orden, Luttrell, 
Kiggans, Brownley, Budzinski, and Landsman.

   OPENING STATEMENT OF MARIANNETTE MILLER-MEEKS, CHAIRWOMAN

    Ms. Miller-Meeks. Good morning again. This oversight 
hearing for the Subcommittee on Health will now come to order. 
Our country has been experiencing a substance abuse and 
overdose epidemic, and we are seeing historic highs in overdose 
deaths and our Nation's veterans are not immune. One death from 
substance use disorder is one too many. It is a somber reality 
that many lives are taken by this treatable mental disorder. 
One hundred sixty-five million people in the United States 
alone struggle with drug and alcohol abuse, and over 100,600 
Americans died from drug overdose in 2021.
    As a 24-year veteran, I have seen the unique challenges 
that many of my fellow service members and veterans face. Among 
the veteran population, we have sadly seen a 53 percent 
increase in drug overdose mortality rates from 2010 to 2019. 
Four in 10 veterans struggle with illicit drug use, seven in 10 
struggle with alcohol use, and one out of eight struggles with 
both.
    This is an enormous obstacle that we need to address. Had 
the VA sent us testimony in a more timely manner, let me 
emphasize that, had the VA sent us testimony in a more timely 
manner, I would have liked to have addressed the initiatives 
they are talking about today. In spite of that, I would like to 
acknowledge the VA Mental Health Residential Rehabilitation 
Treatment Program, also called MHRRTP, that provides 
rehabilitative and clinical care to veterans that need 
intensive specialty treatment for mental health and substance 
use disorders. The MHRRTP continuum includes more than 70 
programs for the treatment of substance use disorder and more 
than 40 programs for the treatment of posttraumatic stress 
disorder, with the expectation that all programs provide 
integrated, concurrent treatment for co-occurring substance use 
disorder and mental health treatment needs.
    That being said, veterans through the Mission Act should be 
eligible to receive in and outpatient substance abuse treatment 
in the community when it is appropriate course of action.
    I am very concerned about how the VA has interpreted and 
differentiated between institutional and uninstitutional 
extended care. It is becoming increasingly clear that once 
again bureaucracy has overcome intent. VA continually repeats 
that there is no wrong door for veterans seeking substance 
abuse care. However, we will hear from our witnesses on the 
second panel that that is inaccurate and bureaucratic hyperbole 
with that statement.
    I would like to point out three instances where the VA has 
not embodied their no wrong door declaration. First, we have 
heard from a specific veteran who struggles with Post Traumatic 
Stress Disorder (PTSD) and alcohol abuse. After many attempts 
and 3 months of trying to receive care, this veteran was not 
able to get the help they needed. This was essentially a locked 
door. This veteran spoke with multiple congressional offices 
and with the VA central office. They were eventually referred 
to community care. However, it was rescinded as the VA ensured 
that this veteran could receive the care they need. This 
veteran still struggles with their sobriety today.
    Next is an example of the VA presenting no door to a 
veteran. As we will hear during our second panel, there was 
another instance where a veteran sought care in the community. 
However, VA noted that they could not refer this veteran to the 
community if a VA bed was available within 30 days. Veterans 
can and should not have to wait 30 days to receive care that 
they desperately need. The program attempting to assist this 
veteran was told that veterans must first go to a domiciliary, 
then grant per diem programs such as VA homeless shelter, and 
then to the Salvation Army. Then after all of these options 
have been exhausted, they could be referred into the community.
    That is a disgrace. As a state senator, I specifically 
introduced legislation to get rid of preauthorization for 
medicated assisted treatment. So, within immediate. To find 
that this is existing with our VA system is unacceptable.
    Finally, we have heard from a veteran who has struggled 
with PTSD, substance use disorder, and a history of traumatic 
brain injury. This specific veteran was searching for a 
residential program for substance use disorder at the VA. 
However, this veteran was denied because they did not have a 
history of seeking help through the VA. Because this veteran 
had not been to the VA since 2017, their record was closed and 
they were never contacted about receiving care. This appears to 
be a case where a veteran experienced a missing door. Luckily, 
a Veterans Service Organization (VSO) paid for a treatment 
program for this veteran.
    There is no excuse for any of the neglectful and harmful 
care that these veterans are experiencing and we need to hold 
the VA to a much higher standard. I am saddened and I am 
frustrated that this is how VA has been managing care for those 
who have selflessly served our country. Thank you all for being 
here and I look forward to our discussion on both panels to 
best identify ways to improve access. With that, I yield to 
Ranking Member Brownley for her opening statement.

      OPENING STATEMENT OF JULIA BROWNLEY, RANKING MEMBER

    Ms. Brownley. Thank you, Madam Chair, for holding this 
morning's important hearing. As of Fiscal Year 2022, more than 
550,000 veterans receiving VA healthcare, or about 8.5 percent 
of all veterans using VA healthcare services, had substance use 
disorder diagnoses. Often, veterans have turned to alcohol or 
drugs to try to relieve stress or symptoms of PTSD and other 
co-occurring mental health disorders. As a result, substance 
use disorder is a significant challenge among the veteran 
population. This challenge was only compounded by the COVID-19 
pandemic, which increased feelings of social isolation, 
anxiety, and depression, and caused many adults to start or 
increase their use of alcohol or drugs.
    At the same time, access to intensive residential treatment 
at VA and in the community declined as providers limited 
admissions and placed residents in single occupancy rooms in an 
effort to minimize the spread of COVID-19. I am perplexed by 
the two very different stories that were told in the written 
testimony of VA and the other witnesses we will hear from 
today. If we are to take VA at its word, veterans receive 
timely access to residential treatment, admission within 72 
hours for veterans requiring priority admissions, and within 30 
days for routine admission. The VA Office of the Inspector 
General, however, has found that VA ``faces significant 
challenges in meeting the needs of individuals with substance 
use disorders.''
    This finding is echoed in the testimony of our second panel 
of witnesses. I hope today's hearing will help us better 
understand the true state of veterans' access to residential 
treatment for substance use disorder. I do not doubt that there 
are instances where veterans would benefit from referral to 
residential treatment from community providers, particularly 
when there are excessive wait times for beds in VA programs, or 
when veterans can access timely care in the community closer to 
home. However, we must ensure that veterans receive high 
quality evidence-based care when they are sent to the 
community.
    I hope today's hearing will also shed some light on the 
extent to which VA ensures that the community providers to 
which it refers veterans meet clinical practice guidelines and 
accreditation standards for delivering such care. While we will 
focus much of our attention today on access to residential 
treatment, I hope we will also take some time to consider the 
full continuum of care, including the extent to which veterans 
are successfully transitioning from residential care to 
outpatient treatment and independent living.
    As the VA Office of Inspector General points out in its 
testimony, care coordination between VA and community providers 
is critically important for high-risk patients like those 
receiving treatment for substance use disorder. When patients 
receive care in the community, they are not always as easily 
able to access other VA benefits, such as housing and 
employment support as they would if receiving care at a VA 
facility.
    In 2019, I visited a truly impressive program operated by 
the VA Boston Healthcare system called the Women's Veterans 
Trust House, which provides excellent care, coordination, and 
continuity of care for women veterans who had completed 
residential treatment for substance use and posttraumatic 
stress. The typical stay is about 12 months, during which time 
women veterans participate in individual and group 
psychotherapy, compensated work therapy, and recreational 
community outings. Through this program, they are learning how 
to develop healthier coping mechanisms and constructive 
interpersonal relationships. Unfortunately, at the time I 
visited, the Trust House could accommodate just seven women at 
a time, and they were traveling from all over the country, 
first to participate in VA's residential treatment program and 
then this transitional program. Undoubtedly, more women 
veterans, indeed all veterans, would benefit from greater 
access to transitional programs like this.
    I hope that we can learn more today about the extent to 
which VA is trying to expand its capacity in this area as well. 
I have legislation that aims to do just that, and I hope 
today's hearing will help inform my planned reintroduction of 
the bill. Thank you again, Dr. Miller-Meeks, for organizing 
this important hearing and I yield back.
    Ms. Miller-Meeks. Thank you, Ranking Member Brownley. I 
would now like to introduce the witnesses. Joining us today 
from the Department of Veterans Affairs is Dr. Tamara Campbell, 
who is the executive director of the Office of Mental Health 
and Suicide Prevention (OMHSP). Accompanying Dr. Campbell today 
is Dr. Sachin Yende. I apologize for any mispronunciation. The 
chief medical officer in the Office of Integrated Care. We also 
have Dr. Julie Kroviak, the Principal Deputy Assistant 
Inspector General of Healthcare Inspections in the office of 
the Inspector General. Dr. Campbell, you are now recognized for 
5 minutes to deliver your opening statement.

                  STATEMENT OF TAMARA CAMPBELL

    Ms. Campbell. Good morning, Chairman Miller-Meeks, Ranking 
Member Brownley, and distinguished members of the subcommittee. 
Thank you for the opportunity to discuss VA's mental health, 
substance use disorder, residential rehabilitation treatment 
programs, and community care referrals. Accompanying me today, 
as mentioned, is Dr. Sachin Yende, Chief Medical Officer, 
Office of Integrated Veteran Care.
    Over the past decade, potent and dangerous drugs became 
more widely available and misused in the United States. In 
response to the rise in substance use morbidity and mortality, 
prevention and treatment efforts have been established. VA is 
making a positive difference in veterans' quality of life by 
enhancing motivation and building confidence in their treatment 
and recovery process. Veterans receiving treatment for their 
substance use disorder in VA are experiencing benefits in terms 
of their mental and physical health across many other aspects 
of their lives that impact social determinants of health. VA's 
mental health Residential Rehabilitation Treatments (RRTPs) are 
a critical component of VA's broader efforts to address the 
needs of veterans with substance use concerns.
    Mental health residential programs are institutional 
extended care and are not subject to designated access 
standards. They do, however, have access requirements that 
inform when consideration for referral to the community should 
occur. These access requirements are defined by Veterans Health 
Administration (VHA) Directive 1162.02 and more recently by 
implementation of the Comprehensive Prevention, Access to Care, 
and Treatment (COMPACT) Act for Crisis Residential Care.
    The ability to pay for community care mental health 
residential treatment has resulted in an increase in the number 
of programs available to veterans. From Fiscal Year 2021 to 
Fiscal Year 2022, referrals to the community increased from 
7,000 to 11,000 uniques, with expenditures exceeding 1.2 
billion since 2021. Concurrent with these increases, VHA has 
observed instances of community programs marketing directly to 
veterans and providers, resulting in confusion by veterans when 
informed of the availability of VHA to meet their needs. We 
believe the solution to this lies with increasing familiarity 
with the process and with VA's mental health residential 
resources, while also addressing concerning marketing practices 
when they are identified.
    Timely access to residential treatment has been a priority 
area of focus for VHA. This has been critical as the 
residential programs experienced significant reductions in 
capacity early in the pandemic. I am pleased to share that 
today MHRRTP capacity is rebounding, with wait times decreasing 
and census increasing.
    Recognizing a need to ensure access to this critical level 
of care, OMHSP worked collaboratively with the Office of 
Integrated Veteran Care to verify authority, to provide 
residential treatment in the community, and to provide a 
mechanism by which VHA could pay for such care. VHA policy 
requires that when a veteran is assessed as requiring 
residential treatment and the program is unable to meet the 
veterans' needs, an alternate treatment program must be 
offered. Alternate treatment may include treatment within VA or 
within the community. VA is thankful for the independent 
investigation of the Office of Inspector General in the review 
of the Domiciliary Substance Use Disorder (SUD) Treatment 
Program and residential community care referrals.
    The ability to refer to mental health residential treatment 
in the community is a relatively new process with the first 
Standard Episode of Care for the Mental Health Residential 
Treatment, released in October 2020, and updated in August 
2021. OMHSP worked collaboratively with Veterans Integrated 
Services Networks (VISNs) during this time to clarify 
requirements and expectations for when referrals for mental 
health residential care in the community may occur. These 
efforts have continued with targeted efforts to ensure 
awareness of requirements and processes for ensuring access to 
residential treatment in the community when indicated.
    In conclusion, we appreciate the committee's continued 
support and partnership in this shared mission. Nothing is more 
important to VA than supporting the health and well-being of 
our veterans and their families. This critical work is 
lifesaving, and my colleagues and I are now prepared to respond 
to any questions you may have. Thank you.

    [The Prepared Statement Of Tamara Campbell Appears In The 
Appendix]

    Mr. Luttrell. [Presiding] Thank you, Dr. Campbell. Dr. 
Kroviak, you are now recognized for 5 minutes to deliver your 
opening remarks.

                   STATEMENT OF JULIE KROVIAK

    Ms. Kroviak. Thank you. Ranking Member Brownley and 
subcommittee members, thank you for the opportunity to discuss 
the Office of Inspector General's (OIG's) oversight of VHA's 
substance use disorder treatment program. The OIG's Office of 
Healthcare Inspections reviews the quality and safety of 
healthcare provided across VHA and communicates the findings 
through public reports. We are unique in the IG community 
because of our ability to conduct this oversight. With over 250 
clinical staff, the majority having significant experience 
providing direct care to veterans, our reports can provide in-
depth clinical analyses and identify issues that impact 
healthcare delivery.
    Take our mental health team, staff with board-certified 
psychiatrists, psychologists, and licensed clinical social 
workers. They are proactive and vigilant in conducting 
oversight work that supports veterans in need of mental health 
treatment. We are in the last stages of developing a new 
cyclical review that will initially focus on VHA's inpatient 
mental health units. These units treat acutely ill psychiatric 
patients. And our teams have developed tools to evaluate the 
safety and efficacy of these settings to ensure veterans are 
receiving the high-quality care they need and deserve.
    Substance use disorders have devastating effects on 
veterans, their families, and caregivers, and often require 
intensive, multidisciplinary interventions to support a 
meaningful recovery. In addition, veterans with substance use 
disorders often have additional mental health diagnoses that 
can place them at higher risk for suicide. Given that VHA's top 
clinical priority is to reduce veteran suicide, evidence-based, 
substance use disorder treatment programs are critical to 
addressing these clinical needs.
    To meet the increasing demand for these services, VHA 
depends on community care. When VHA and community care 
providers are comanaging these patients, the coordination must 
be seamless and collaborative. The OIG has identified 
persistent administrative errors and communication failures 
among VHA, its third-party administrators, and community care 
providers, as well as between the care providers and their 
patients. These deficiencies challenge the efforts of VHA 
personnel to ensure that seamless experience for veterans.
    Many OIG reports have described the challenges and, most 
importantly, the risks when patients are referred to the 
community. These risks are amplified for patients with high-
risk mental health issues or complex disease. For example, my 
written statement details our January 2023 hotline inspection 
that substantiated the allegation that in 2020 and 2021, VA 
North Texas staff did not follow VHA policy requiring that 
patients be offered alternative options for care within VHA or 
the community when the wait time for a needed service exceeds 
30 days. This practice potentially delayed treatment for these 
veterans and has the long-term potential to fracture trust 
between patients and the healthcare system upon which they 
rely. We also determined that the VISN's chief mental health 
officer lacked authority to ensure staff adherence to these 
policies.
    We made five recommendations, with one specifically 
ensuring that staff comply with community care referral 
requirements and another recommending a review of the 
facility's management of community residential care referrals. 
All of these recommendations are open, and we will begin the 
follow-up process with VHA at the end of this month.
    While this report highlights issues with offering community 
care to veterans, it does not provide a complete picture of the 
concerns we have found when veterans are receiving community 
care. Our office has published reports related to community 
care detailing delays in diagnosis and treatment, lack of 
information sharing or miscommunication between providers, and 
significant quality of care concerns. While we recognize the 
importance of VHA staff consistently informing and offering 
veterans all options available to meet their care needs, 
ignoring that the current community care framework does not 
adequately address critical gaps in coordination will further 
increase risk to patients. We are piloting a new community care 
review that will provide data to support VHA's leaders' efforts 
to reduce these risks.
    The OIG will continue to provide meaningful oversight to 
support and improve the quality of healthcare provided to our 
Nation's veterans. We also recognize the need to enhance and 
adapt our work to best support this dynamic healthcare system. 
We remain grateful for the participation and cooperation of VHA 
staff across the country, and we commend their commitment to 
caring for those who have served. Members of the subcommittee, 
this concludes my statement. I would be happy to answer any 
questions you may have.

    [The Prepared Statement Of Julie Kroviak Appears In The 
Appendix]

    Mr. Luttrell. Thank you, Dr. Kroviak. We will now proceed 
to questioning. I now recognize the ranking member, Ranking 
Member Brownley, for any questions she may have.
    Ms. Brownley. Thank you, Mr. Chairman. The first question I 
have is to Dr. Campbell. I understand VA currently has two 
dedicated residential substance use disorder treatment programs 
for women veterans. Is that correct? Two?
    Ms. Campbell. I did not hear, I am sorry, the first part of 
the question.
    Ms. Brownley. I understand that VA currently has two 
dedicated residential substance use disorder treatment programs 
for women veterans. Is that true?
    Ms. Campbell. We have 13 programs across nine locations 
specializing in treatment for women at the residential level.
    Ms. Brownley. I had difficulty finding those. Where do I go 
to find those?
    Ms. Campbell. You can locate them on our website. They are 
in VISN 110, and I believe 17.
    Ms. Brownley. I understand that all of these are not 
substance use disorder treatment programs.
    Ms. Campbell. There is a mixture, and thank you for that 
question, of substance use disorder as well as PTSD. We 
understand that those diagnoses typically coexist, and so we 
ensure that our programs are treating both the PTSD and 
substance use at the same time.
    Ms. Brownley. Just to get back to my original question, 
there are currently two dedicated residential substance use 
disorder treatment programs for women veterans. True or false?
    Ms. Campbell. I would have to go back to get that exact 
number. What I have is 13 programs across nine locations, five 
programs that specifically focus, and two additional that are 
in for implementation for Fiscal Year 2024.
    Ms. Brownley. Okay. I also understand the Fiscal Year 2024 
budget request indicates the Department has two additional 
women-only residential programs in development. Is that 
correct?
    Ms. Campbell. Yes, ma'am, that is correct.
    Ms. Brownley. In what locations will they be?
    Ms. Campbell. I will have to get back about those 
locations.
    Ms. Brownley. How did you decide where the locations should 
go?
    Ms. Campbell. We are in the process now of making that 
determination.
    Ms. Brownley. Okay. In my opening comments, I talked about 
transitional programs and the continuity of care for our 
patients. Does the VA, you know, I know today we are focusing 
much more on intensive residential treatment, but wanted to 
know how many transitional programs across the VA do exist. I 
mentioned one in Boston.
    Ms. Campbell. Thank you for that question. I would have to 
get back with you about the specific numbers. In terms of 
transitional programs, we have compensated work therapy and 
community reentry programs within all of our domiciliary 
programming. Is that what you are referring to?
    Ms. Brownley. Yes, I mean, for those kinds of services. In 
a transitional, you know, in a transitional space environment, 
you know, where women would be co-located going through with 
these particular kinds of services offered to them. The one I 
referenced in Boston lasted for almost a year of transition. 
That is what I am looking for. Apparently we do not have the 
answers to that. I will have to wait until you can get back to 
me on several of these questions about numbers of residential 
treatments for women and the two additional women clinics, 
where they are and how they were decided upon in terms of 
location.
    My last question to Dr. Kroviak. In terms of veterans being 
referred to in the community, what are some of the hallmarks of 
quality residential substance use disorder treatment programs? 
How does coordinating this kind of care in the community differ 
from coordinating a medical procedure such as surgery?
    Ms. Kroviak. There are some accrediting bodies that are 
important to the residential programs, like are for Joint 
Commission. VA is required to ensure that when they are 
referring a patient to this type of treatment, that those 
facilities are certified by one of the two institutions as well 
as the state in which they are operating. In terms of 
referrals, the referral process is quite similar. You know, a 
patient can self-refer. Any provider can refer a patient when 
they are appropriate and engaged in that level of care.
    Ms. Brownley. Just this accreditation process or, you know, 
approval from these outside agencies and as far as you are 
concerned, the VA is adhering to those requirements?
    Ms. Kroviak. We have no concerns that VHA is not, meaning 
that we have not heard allegations on that front. Those are 
appropriate accrediting standards to ensure.
    Ms. Brownley. Thank you. I yield back, Mr. Chairman.
    Mr. Luttrell. Thank you, ranking member. The chair 
recognizes Congresswoman Kiggans.
    Ms. Kiggans. Thank you, Mr. Chair. Thank you committee 
members just for being here, our board members. Just a question 
about reimbursement for community care providers. We got to 
hear from them and just some of their struggles with why are 
they not accepting some of our patients that we are referring 
to. They had concerns about their reimbursement rates and about 
the time it was taking for them to be reimbursed. Can you tell 
how competitive we are when looking at community care compared 
to the VA system? Is the compensation competitive or do we look 
at that even when we are thinking about compensation?
    Mr. Yende. Thank you for that question, Congresswoman. In 
terms of processing claims in general, VA has been pretty good 
about processing clean claims. I believe over 95 percent of 
these clean claims are processed within 30 days. I do not have 
the exact numbers for RRTP programs, but we can get back to you 
if needed.
    In terms of a reimbursement, we follow Medicare rates in 
general, but there are lots of nuances about reimbursement. I 
believe we are competitive. If there are specific questions 
about a particular Current Procedural Terminology (CPT) code or 
those kind of details, we are happy to work offline and try to 
clarify those questions.
    Ms. Kiggans. It was just a comment that I have heard more 
than once about why they can not take VA or they do not want to 
contract with the VA because our reimbursement rates were not 
competitive for them. There is such a shortage of mental health 
providers in the community and throughout the country that, you 
know, I just want to make sure we are prioritizing staying 
competitive so that they are incentivized to be able to see our 
patients.
    I represent Hampton Roads and recently got to talk to and 
visit the Hampton VA, which is doing a great job. Their two 
complaints were that they wanted more space and they needed 
more people, which I think is kind of are universal complaints. 
Their mental health department, I think they are doing good 
work. Overall, I just want to say thank you, you know, to them. 
I know it is a hard job. I know that as a nurse practitioner, I 
know nurses especially have been asked to do a lot during the 
pandemic, especially in the mental health field and all 
providers. I want to thank them because they are doing good 
work out there.
    One of the things I hear about and that I am concerned 
about as well is when we have these great inpatient programs 
that we send our veterans to for substance abuse for any mental 
health as depression, anxiety, suicidal ideations, we stabilize 
them and have them there for however long it takes, and then we 
release them back to the community, back to their homes. That 
continuity of care piece, you guys talked about it a little 
bit, but, you know, we see it. I saw it, you know, in my 
practice. It is like we lose them to the community, right? How 
are we ensuring that when these patients are discharged, I am 
sure there is a discharge planner that makes sure they have a 
follow-up appointment, that make sure they go home with their 
meds. On the State House level, I know we were pushing for 
things like home health to actually visit the home because 
leaving the motivation just with this patient and they are 
already probably struggling, and their family, and a lot of 
questions, new side effects of medication, transportation 
issues, all those things.
    My desire was to have someone actually visit the home. 
There is so much benefit. We can get to see what that home 
environment looks like. That continuity of care piece, whatever 
that looks like, is it home health? What is the VA doing to 
just ensure that? Is it utilization of nurse managers, you 
know, to make sure that we are really thinking of all the 
issues that veterans struggle with once we get them stabilized 
so that we do not lose them to the community?
    Ms. Campbell. Thank you for that question. We do have full 
comprehensive continuum of care that includes, as we mentioned, 
inpatient, which is the most restrictive all the way to 
outpatient services, as well as leveraging our peer specialists 
and that provide a lot of coaching. The uniqueness about VA 
peer specialists is that they have a veteran lived experience 
and so they are able to rapidly build rapport with our 
veterans.
    We certainly are able to leverage telehealth services so 
that when the veteran reintegrates in the community and is 
competitively employed, we can utilize that service so they do 
not have to spend time away from a job that they have been 
newly employed to. Then we have multiple award-winning apps 
that can be downloaded for the veterans use. Thank you.
    Ms. Kiggans. They are utilizing those things. Someone is 
going behind them and making sure they are utilizing one of 
those great services.
    Ms. Campbell. Yes, we are.
    Ms. Kiggans. Thank you. Thank you, I yield back.
    Mr. Luttrell. Thank you. Congresswoman Budzinski, you are 
recognized for 5 minutes.
    Ms. Budzinski. Thank you, Mr. Chairman and thank you, 
ranking member. Thank you to the panel for being here today. I 
represent a predominantly rural district in Central and 
Southern Illinois. I just got back from a 2-week recess working 
at home in-district and heard from many of the veterans while I 
was in-district that are struggling still in accessing VA 
services, specifically in our rural areas. This is very 
concerning to me as the rate of veterans with substance use 
disorders continues to climb, especially post pandemic. Rural 
vets simply do not have the access to as many SUD treatment 
programs and facilities as they do in urban areas.
    My first question is really two-part and it is for Dr. 
Campbell. What are the steps the VA is taking to ensure rural 
veterans with substance use disorders are able to access high 
quality VA treatment programs? What is being done to address 
the infrastructure and access shortages for our rural vets?
    Ms. Campbell. Thank you for that question. We do realize 
that that is a challenge for our rural veterans. Whenever we 
can, we leverage our telehealth services. Sometimes we know 
that there could be bandwidth problems with that. Veterans are 
still able, certainly, to see individuals face to face as 
needed. The Office of Mental Health and Suicide Prevention has 
partnered with rural health and our clinical pharmacy service 
to help us leverage additional prescribers for medication 
assistant treatment for our veterans.
    Ms. Budzinski. Thank you. I wanted to add on to what 
Ranking Member Brownley had just asked about some of our women 
veterans in particular. As you know, the number of women in the 
military is increasing and women are the fastest growing 
demographic within the VHA. It is why within my district I am 
going to be specifically assembling a women's veterans council 
so I can hear specifically from the women veterans in the 
district because female veterans are experiencing many of the 
same problems as males.
    There is emerging evidence showing that women veterans may 
be more likely to experience substance use disorders than their 
male counterparts. This is due to additional factors for women 
veterans tending to experience such as higher chances of 
experiencing sexual assault, and harassment, rape, and intimate 
partner violence. Again, my question is for Dr. Campbell. The 
VA has acknowledged it needs to improve VA services for women 
veterans, but what are some specific steps that the VA is 
taking to improve and expand specialized care for women 
veterans experiencing substance use disorders?
    Ms. Campbell. Thank you again for that question. Wherever 
we can in terms of our full continuum of treatment, we are 
making sure that those individuals who are specialized to 
address women health needs are right in those clinics, such as 
the primary care mental health integration clinics, certainly 
on our residential treatment programming clinics. Then we are 
also ensuring that our women's advocacy is shored up that they 
have the time to devote to make sure that there is seamless 
flow of treatment for women within VA.
    Ms. Budzinski. Okay, thank you. Since I have a little bit 
more time, I am actually going to shift to residential 
rehabilitation treatments. To just note, you know, I understand 
some of the concerns my colleagues have voiced regarding access 
standards for residential SUD treatment, as this can lead to 
longer wait times and longer travel times for our vets, which I 
know we have been talking about. The ability to have all levels 
of SUD treatment available, including outpatient, residential, 
and hospital inpatient services is still strained for all 
veterans. However, more so again concerning for women veterans 
and for rural veterans.
    I also understand that we need to ensure our veterans have 
protections from fraudulent community providers who have taken 
advantage of vulnerable patients seeking treatment and who have 
prioritized profits over the safety of their patients. Veterans 
deserve, as I believe, high quality evidence-based care if they 
are sent to community providers for SUD treatment.
    Dr. Campbell, I know not all veterans have a substance 
use--require a substance use disorder residential treatment. 
For those who do, how can the VA help to ensure those veterans 
are able to access the intensive SUD care they need while also 
making sure they are protected from fraudulent providers or 
entities? Thank you.
    Ms. Campbell. Thank you again for that question. We are in 
the process of continuing to educate within our own 
organization, and certainly with the community, the standards 
that we expect in terms of particularly SUD treatment. We have 
completed regional conferences to make sure that our staff is 
aware of the policies as it pertains to community care, as well 
as holding quarterly meeting with our VSO stakeholders to make 
sure that they understand where our programs are and to listen 
and learn regarding the concerns they have.
    I wanted to mention another certainly concern of our women 
veterans is that they need to feel safe when they come to our 
facilities. Within our residential units, we have secured wings 
just for female veterans with closed circuit TV monitoring at 
exit entrances so that we can keep monitoring as closely as we 
can. Dr. Yende can----
    Mr. Yende. Just to add to Dr. Campbell's point, from a 
community care side, in addition to the accreditation 
requirements that Dr. Kroviak mentioned, we also have 
standardized processes where our Transition Patient Advocates 
(TPAs) are expected to review LEIE list. If a provider has 
engaged in fraudulent activities and that has been confirmed, 
they will be part of the List of Excluded Individuals and 
Entities (LEIE) list and they are expected to be excluded from 
that.
    Ms. Budzinski. Thank you. I think we are overtime. Thank 
you for your generosity, Madam Chair.
    Ms. Miller-Meeks. Thank you. The chair now recognizes 
Representative Luttrell for 5 minutes.
    Mr. Luttrell. Thank you, Madam Chairman. Dr. Campbell, I 
understand--I am going to go off what the ranking member asked. 
The VA currently has two dedicated residential substance use 
disorder treatment programs for women veterans. Then the 
question was asked, there are two additional residential 
programs in development. Where are they and are they admitting 
patients? How did the VA decide on these location programs 
because the budget itself is already out?
    I do respect and appreciate the weight that you have to 
carry, but we have to go back to our district. When these 
questions come from our constituents. The fact that you were 
not able to answer those questions in front of us today is 
disheartening, because now we have to go back and tell them 
that the VA does not know. You want to respond to that?
    Ms. Campbell. I would. Thank you again for that question. I 
certainly understand the responsibility that we all have to our 
veterans for these answers. I will certainly get that answer to 
you as quickly as I can regarding where the two additional 
programs will be located. The other programs that I mentioned 
specific to women are in VISN 110 and 17. I will check that, 
though, to make sure that that is accurate.
    Mr. Luttrell. Thank you, Doctor. I appreciate it. Dr. 
Kroviak, are you familiar with VHA Policy 1162.02 regarding 
mental health residential rehabilitation treatment programs?
    Ms. Kroviak. I am somewhat familiar. I certainly did not 
draft it, but I would be happy to take your question.
    Mr. Luttrell. What do you know about it? Give me the wave 
top.
    Ms. Kroviak. I am sorry?
    Mr. Luttrell. Can you give me what the wave top description 
is? The way you think that is?
    Ms. Kroviak. The referral time you mean?
    Mr. Luttrell. Well, I will just go this way. It states, the 
directive states that any veteran with a scheduled wait time of 
greater than 30 calendar days must be offered alternative 
residential treatments on another level of care to meet the 
veterans needs and preferences at the time of screening. Where 
did 30 days come from?
    Ms. Kroviak. That was legislated to my understanding.
    Mr. Luttrell. Do you think that that is a good----
    Ms. Kroviak. Oh, I am sorry. I might be confusing with the 
Mission Act. I think the 30 days was just a measurable metric 
developed to assess progress toward providing the care that was 
not available at the time of the referral.
    Mr. Luttrell. Given the issues that we see in suicide and 
substance abuse, the psychiatrists, and psychologists, and 
doctors in the VA still think 30 days is a reasonable 
timeframe?
    Ms. Kroviak. I would have to defer that question to VHA in 
terms of the 30-day standard of what their providers assume is 
appropriate.
    Mr. Luttrell. As the Inspector General, I would assume that 
you were digging into this problem.
    Ms. Kroviak. In terms of the 30-day standard, that was not 
established by the IG.
    Mr. Luttrell. No, I know.
    Ms. Kroviak. We just do oversight to hold----
    Mr. Luttrell. I guess my question----
    Ms. Kroviak [continuing]. VHA accountable.
    Mr. Luttrell [continuing]. is, do you think that that 
timeframe is too long?
    Ms. Kroviak. I think it depends on the diagnosis that you 
are describing. I think it is a clinical decision. I think 30 
days is somewhat arbitrary for a lot of these issues that 
veterans are referred for specialty care.
    Mr. Luttrell. Some do not like the Community Care Network. 
However, the intent of the new COMPACT Act is to provide 
immediate access to those services anytime, anywhere, largely 
expanding access to community care. What is the view of the VA 
on implementing the COMPACT Act? Is there any rulemaking to 
write directives and policy to implement the act itself?
    Ms. Campbell. Thank you for that question. COMPACT has been 
implemented, as you mentioned, that it allows the veteran to be 
treated for an acute suicide episode at any community facility 
or within VA. I will defer to Dr. Yende for more information on 
COMPACT.
    Mr. Yende. Congressman, implementation started in January 
of this year. Implementation of the COMPACT Act started in 
January of this year. To date, we have provided care for over 
11,000 veterans since the program started.
    Mr. Luttrell. Eleven thousand?
    Mr. Yende. Yes. This is both on the direct care side as 
well as on the community care side.
    Mr. Luttrell. Okay, final question. I am just going to 
throw this out to the three of you. Are any of you aware of a 
new VA community care policy or process and/or guidance within 
the last 10 months surrounding a mental health residential 
rehabilitation treatment program that restricts, inhibits, or 
deters community care referrals? I say that because I actually 
have verbal and written statements by VA employees that State 
that they are under this new policy.
    Mr. Yende. To our knowledge, Congressman, we have no 
policies that would restrict. If they meet criteria for 
referring the patient to alternative treatment facilities for 
RRTP programs, which includes community care, they should be 
referred in a timely manner.
    Mr. Luttrell. My time is up, ma'am. I would like to 
preserve the opportunity to submit additional questions.
    Ms. Miller-Meeks. So recognized. The chair now recognizes 
Representative Landsman for 5 minutes.
    Mr. Landsman. Thank you, Madam Chair, and thank you all for 
being here. My district, which includes the city of Cincinnati, 
Southwest Ohio, is home to a great VA. We offer, you know, some 
of the best veterans care in the country for PTSD, suicide 
prevention, and other mental health issues.
    When I have spent time with folks at the VA in Cincinnati, 
they talk a lot about the evidence-based programming, and it is 
really compelling. When it comes to specialty treatment for 
substance use disorder, veterans across the country are not 
getting the care they deserve. This may have already come up. I 
have seen statistics that suggest more than 550,000 veterans 
diagnosed with substance use disorder last year, of those, 62 
percent received outpatient treatment. Those numbers drop off 
drastically as the level of services increase. Less than 25 
percent received specialty care and even fewer received 
intensive care at 4 percent. You see, there is a drop off in 
terms of if a veteran needs additional treatment outside of the 
outpatient treatment.
    I have two questions. One has to do with, you know, do you 
have a sense as to the drop off? What you know, have you seen, 
is it staffing, is it other issues? Then the second has to do 
with a general question as it relates to all of the VA 
services. This is true for a lot of public services, nonprofit 
services, and that is that we really do struggle to get to 
folks who are not getting to us. You know, this is particularly 
true for veterans, particularly veterans who are just not 
coming in, you know, and have real issues.
    I have been pushing in these hearings for the kind of 
programming outreach that gets the VA to where folks are. I am 
curious what you think has worked, could work in terms of 
meeting veterans where they are, and connecting those who are 
currently disconnected. Two questions, one has to do with the 
drop off and the second outreach. Thank you.
    Ms. Campbell. Thank you, sir, for those questions. I will 
take the first question in terms of the dropout. The dropout 
may not necessarily mean that that veteran is not in some type 
of other care. I think what you were referring to is a drop off 
when it concerns more intense care, such as residential 
treatment. The veteran may still be involved in an outpatient 
treatment, may be involved with teleservices, and sometimes, 
for various reasons, the veteran has elected a later date to 
come into treatment. That decision regarding the level of care 
is always between that individual veteran patient and the 
provider that is helping with the medical disposition and 
clinical decisionmaking. We do realize, especially where 
community care is concerned, because SUD is such a specialized 
treatment, that it may not be available in every location where 
that veteran is.
    In terms of your second question regarding being able to 
touch veterans who are not already in our care, we are 
certainly hoping that the legislation that has been passed with 
COMPACT, allowing veterans to be treated wherever the need is 
without any cost to them will help with that. We have fantastic 
media campaigns, Don't Wait Reach Out, where we are utilizing 
veterans to help veterans understand what it is like to come 
into VA for care. Then certainly leveraging everywhere we can 
our peer support specialists who have that lived experience 
that can help us bring in care.
    Mr. Landsman. Thank you very much. I have additional 
questions if I can submit them. Thank you.
    Mr. Van Orden. Dr. Campbell, good afternoon. How long has 
your office been in existence? I know you have been there since 
2022, but how long has the Office of Mental Health and Suicide 
Prevention been in existence?
    Ms. Campbell. I am sorry, sir, I did not hear the entire.
    Mr. Van Orden. How long has the Office of Mental Health and 
Suicide Prevention been in existence?
    Ms. Campbell. Been getting?
    Mr. Van Orden. Been in existence?
    Ms. Campbell. Oh, been in existence. At least 34 years.
    Mr. Van Orden. Thirty-four years. Very well, thank you. How 
many people work for you?
    Ms. Campbell. I have about 140 people within my office.
    Mr. Van Orden. Got it, thank you. Do your reporting numbers 
reflect, for veteran suicide, do they reflect overdoses?
    Ms. Campbell. That is a separate report in terms of 
overdoses that we hope to be able to publish the end of June.
    Mr. Van Orden. In your opinion, Doctor, if someone kills 
themselves by overdose or gunshot wound, are they still dead?
    Ms. Campbell. They are still dead, sir.
    Mr. Van Orden. Okay. Do your metrics for veteran suicide 
include overdose?
    Ms. Campbell. The metrics that we reported recently on our 
annual report does not include overdose.
    Mr. Van Orden. Okay. That is a problem. What are your 
established metrics of success for your Office of Mental Health 
and Suicide Prevention?
    Ms. Campbell. We have various metrics depending on the 
service that we are looking at in terms of outcomes. We have 
hundreds of metrics that we use. It depends on specifically 
what you are asking about in terms of outcome.
    Mr. Van Orden. Do you think, and please take this as it is 
intended, Morgan and I have had multiple friends commit 
suicide. Over 21 now, for me personally. Veterans have 
committed suicide. Do your metrics include veterans that do not 
commit suicide? I know it is kind of hard to prove a negative. 
What I am wondering is, after 34 years of existence with over 
140 employees, if your office ceased to exist, would more 
veterans be alive tomorrow? I mean, is your office preventing 
veterans from committing suicide or not? Or are we just 
spending money and hiring people so that they can get together, 
come to these committee meetings, talk a bunch, submit reports, 
metrics that can not be defined? Are you moving the needle?
    Ms. Campbell. Sir, we do. Thank you for that question. I 
certainly can understand the frustration. This is a very 
complicated area. We are certainly ourselves saddened by any--
--
    Mr. Van Orden. Doctor, please----
    Ms. Campbell [continuing]. suicide.
    Mr. Van Orden.--I have a limited amount of time.
    Ms. Campbell. I do believe we are moving the needle on 
this. We have a full public health approach where suicide 
prevention is concerned. The field of mental health and 
psychology, psychiatry has evolved over the past 30 to 40 
years. As we continue to evolve, we are learning new things, 
new methods, new evidence-based approaches that we can use.
    Mr. Van Orden. Thank you. That leads to my next question. 
How many non-evidence-based treatment modalities do you guys 
support, specifically religious and faith-based programs 
similar to the incredibly successful Mighty Oaks Foundation? 
How many faith-based nonevidence programs are currently being 
administered by the Veterans Administration?
    Ms. Campbell. Thank you again for that question. Within VA, 
we certainly value scientifically based evidence-based 
programs. That does not mean, however, that we do not 
collaborate with our chaplain services that certainly help us 
with specifically the moral injury side of PTSD and other 
mental health disorders.
    Mr. Van Orden. Doctor, what I am hearing from you is that 
the Veterans Administration is not helping these wildly 
successful programs that can quantify, like, actually quantify 
the amount of veterans lives that they are saving because they 
are faith-based, which, according to you guys, are non-
evidence-based. Living veterans, that is evidence of a 
program's functioning.
    I just want to be real clear. You are telling me the 
Veterans Administration is not allowing non-evidence-based, 
specifically faith-based programs like the incredibly 
successful Mighty Oaks Warrior Foundation to function within 
your organization, even though they have proven to save 
thousands of veterans lives? Is that accurate?
    Ms. Campbell. Sir, we are certainly willing to sit down and 
have a conversation with this organization to see how we can 
partner with them.
    Mr. Van Orden. Thank you very much for your time, ma'am. 
With that, I yield back.
    Ms. Miller-Meeks. Thank you. The chair now recognizes 
herself for 5 minutes of questioning. The Independence Fund 
will testify that in the past 23 months, their case workers 
intervened for 110 veterans who ran into issues accessing 
complex mental health care and 59 of those required substance 
use care. In fact, in the last Congress, we passed a bill, the 
Brandon Act, because a veteran in my district went to the VA 
Center, was denied care, and 5 hours later committed suicide. 
Would you agree that these veterans, frustrated by access to 
critical care, would be at elevated risk for suicide? Dr. 
Campbell, yes or no, please?
    Ms. Campbell. Yes, I would agree that they are at high 
risk, and veterans at high risk certainly would be at high risk 
for suicide.
    Ms. Miller-Meeks. Dr. Yende.
    Mr. Yende. Yes, chair, Congresswoman.
    Ms. Miller-Meeks. Dr. Campbell, the committee has been made 
aware of a policy that was supposedly rolled out internally, as 
was mentioned, that required that if a VISN's Veterans 
Administration Medical Center (VAMC) could not meet the 30-day 
appointment availability window, it must confer with other VISN 
VAMCs for VA residential substance use disorder bed 
availability before leveraging community care in order to keep 
care in house. I certainly have experienced these complaints in 
my own district in Iowa. It was also reported that five VAMCs 
must be contacted to fulfill the directive. Can you either 
confirm or deny this policy?
    Ms. Campbell. There is no policy, Madam Chairwoman, denying 
veterans access to community care. The Standard Episode of 
Cares (SEOCs) regarding residential treatment were newly 
established. SEOCs is a standard episode of care for community 
care in October 2020. The process is somewhat new for us. We 
understand there are challenges in making sure that people are 
educated about the appropriate referrals to community care. We 
do not have a policy denying people community care access.
    Ms. Miller-Meeks. Would you call these veterans liars?
    Ms. Campbell. No, I would not call the veterans liars. What 
I would say is that we need to do a better job of educating our 
veterans, our staff, and the community about the appropriate 
procedures for referrals to community care.
    Ms. Miller-Meeks. Well, I can certainly say as both a 
physician who has taken care of veterans through the community 
care system, the Mission Act, and as a veteran myself, that it 
is unacceptable. When people report and come to the decision to 
obtain substance use disorder treatment, they should be 
addressed and acknowledged and get care immediately. This also 
goes for complex mental health. I can tell you the family of 
our veteran who committed suicide 5 hours after being at a VA 
hospital, would also agree with that.
    Dr. Campbell, we have heard of multiple instances where 
veterans have been approved for a community care referral, as I 
said, only to have that referral overruled by administrative or 
other senior staff. Can you explain why a decision for a 
specific course of medical care as determined between the 
veteran and their provider would be reversed by an official 
outside of their clinical chain? What recourse does the 
referring physician have when their clinical judgment is 
overruled? How are you going to address this deficit?
    Ms. Campbell. Thank you for that question. Each case, as we 
mentioned, is an individual case that is a decision between 
that provider and the patient or veteran. I am not aware of 
policies where decisions are being overturned. I will turn to 
Dr. Yende to see if he has more information regarding community 
care.
    Mr. Yende. Congresswoman, if the provider determines that 
the veteran should go to the community, then that decision 
should be followed through. Our policies do not require that 
that care should be provided in the VA in that instance. If 
there are instances, we are happy to look into it.
    Ms. Miller-Meeks. Let me just speak for the entire 
committee. We expect better of the VA medical care system. Our 
veterans deserve better. Through this oversight, you know, some 
of the comments that have been revealed are really astonishing. 
We hold oversight because what is occurring at the VA Medical 
Center and what is occurring in referrals for community care 
when veterans are in need, especially complex mental health and 
substance use disorder, needs to be addressed and addressed 
rapidly. We will continue to ask for both collaboration and 
verification, as we have said. What you have learned today 
should in fact put you on notice and on record.
    On behalf of the subcommittee, seeing that there are no 
other Representatives who wish to ask questions, I want to 
thank you for your testimony and for joining us today. You are 
now excused. We will wait for a moment as the second panel 
comes to the witness table.
    Welcome, everyone, and thank you for your participation 
today. On the second panel, we have Dr. Daniel Elkins, the 
chief of staff with the Independence Fund, Mrs. Jen Silva, 
chief program officer with the Wounded Warrior Project, Mr. 
Thomas Sauer, chief executive Officer and owner of Miramar 
Health. Accompanying Mr. Sauer is Mr. Brendan Dowling. Mr. 
Elkins, you are now recognized for 5 minutes to deliver your 
opening statement.

                   STATEMENT OF DANIEL ELKINS

    Mr. Elkins. Good morning Chairwoman Meeks, Ranking Member 
Brownley, and members of the subcommittee. On behalf of Sarah 
Verardo, Chief Executive Officer (CEO) of the Independence 
Fund, we would like to thank you for your kind invitation to 
provide testimony at today's hearing. As a currently serving 
Green Beret in the National Guard and the chief of staff of the 
Independence Fund, I have seen firsthand my brothers and 
sisters in desperate need be denied access to care, fall 
through the cracks of bureaucracy, and suffer alone with the 
wounds from war. It is this denial of access and subsequent 
isolation that often culminates in death by suicide, a death 
that could be prevented.
    This hearing could not be more timely as our casework staff 
have been receiving a significant number of inquiries 
nationwide who are experiencing frustration and hardship when 
seeking the most critical services for acute mental health 
conditions. The geographic dispersion and similarity of factors 
presented in many of the cases indicate that these cases are 
not merely anecdotal but may be indicators of a more widespread 
problem for mental health within the hospital network. We would 
like to thank VA's VSO liaisons for their support and 
assistance and help with these cases. However, there is work 
that needs to be done.
    In our written testimony, the Independence Fund has 
provided extensive case study examples of the inconsistencies 
currently present within VHA care. Each of these cases involves 
a veteran who was in acute need and required priority treatment 
for substance abuse disorder in PTSD. These veterans were 
denied access to care, even community care referrals, in direct 
conflict with the spirit. In some cases, incidents of the 
letter of the law of Mission Act. We have found that the 
Veterans Health Administration was unable to provide these 
veterans with proper continuity of care, failing to meet the 
most basic of industry standards.
    Indeed, it was not until October 2021 that the Independence 
Fund discovered that VHA does not consider the access standard 
authorities of Mission Act when veterans are seeking help for 
substance use disorders. Yes, you heard that correctly. 
Veterans do not have Mission Act's regulatory protections for 
wait times, travel distance when seeking treatment for 
substance use disorders as these treatments fall within VHA's 
residential rehabilitation treatment program.
    According to the VA, this program is instead under the 
authority of VHA Directive 1162, which requires that VA admit a 
veteran seeking inpatient residential care within 72 hours for 
priority patients, and no more than 30 days after a VA 
assessment for any patient needing residential care. Based on 
our experience, however, that is not unusual. It is not unusual 
for veterans to wait beyond this time limit. Furthermore, it 
has been our observation that even after those time limits are 
exceeded, VHA exercises latitude to further delay access to 
treatment when looking for an available bed in another VA 
facility, even if that facility is several states away.
    More troubling, the Independence Fund has found that some 
VHA administrators or senior clinical staff overrule referrals 
of care for the community, in spite of VA-appointed providers 
for the veteran. There have also been some cases where our 
casework team were told by an administrator that community care 
was not offered. At times, the administrative staff did not 
understand community care was even a lawful option. In certain 
circumstances, VA staff do not discuss community care options 
with the veteran without prompting or until a case worker 
inquires a VA administrator or patient advocate.
    It is important for us all to keep in mind that many 
veterans do not know their full care options and have already 
taken a monumental step in seeking help. More work needs to be 
done. In our written testimony, we offer six recommendations to 
the subcommittee on how to resolve these issues that create 
barriers to care for veterans seeking treatment for substance 
use disorder and PTSD and other conditions that are highly 
indicative of death by suicide. I will highlight what we 
believe should be the foremost priority for this subcommittee.
    We must ensure that all criteria for community care wait 
times, travel distance, and access standards under Mission Act 
govern VHA Directive 1162 or eliminate VHA Directive 1162 
entirely and defer to Mission Act's original authorities and 
intent to support all levels of specialty care, including 
rehabilitation services. Once this goal is achieved, it will 
substantially improve the quality, timeliness, and 
effectiveness of care for veterans in acute need of treatment 
for substance use disorder, whether that be in a VHA provider 
or community care provider.
    Thank you for this opportunity to share with you all the 
struggles of our Nation's heroes, and I look forward to 
answering any questions you may have.

    [The Prepared Statement Of Daniel Elkins Appears In The 
Appendix]

    Ms. Miller-Meeks. Thank you, Mr. Elkins. Ms. Silva, you are 
now recognized for 5 minutes to deliver your statement.

                     STATEMENT OF JEN SILVA

    Ms. Silva. Thank you, Chairwoman Miller-Meeks, Ranking 
Member Brownley, and the distinguished members of the Health 
Subcommittee for this opportunity to speak before you. Since 
our founding 20 years ago, Wounded Warrior Project has been 
helping post-911 wounded, ill, and injured veterans address 
their biggest challenges and reach their highest potential 
through impactful no cost programming and advocacy. Today, 
those two paths intersect to highlight how veterans who need 
inpatient care for mental health or substance use are not 
receiving access to the prompt and in some cases, lifesaving 
care that they need and deserve.
    The VA Mission Act was signed into law with broad support 
in the potential to provide veterans and their advocates with 
clear, useful, and timely information that could inform their 
health care decisions. In January 2019, VA published access 
standards that included limits on wait times and travel for 
mental health care. However, as time has passed, it has become 
clear that these access standards have a critical gap for 
veterans seeking care in inpatient programs, most specifically 
VA's mental health residential rehabilitation treatment 
programs, or their community-based equivalents.
    As discussed in our written statement, VA's Mission Act 
derived access standards do not extend to these crucial 
inpatient mental health programs. Instead, veterans and their 
advocates are left to interpret a VHA directive that we have 
discussed. In our experience, this directive provides little 
predictability about the course of their treatment and their 
options for care along the way. Unless Congress or VA act to 
address this policy gap, many of these veterans will continue 
to face obstacles in connecting to the care they need, placing 
them at heightened risk for negative outcomes the longer they 
wait.
    My remarks today are largely informed by Wounded Warrior 
Project's Complex Case Coordination Team, or C3. This team 
offers a high touch service to warriors with complex challenges 
that are often multifaceted and require urgent action. The team 
connects warriors to our internal support programs and to VA 
and community care treatment options, all with the goal of 
providing immediate assistance and case coordination.
    In just the last four years, our team has helped nearly 
1,200 warriors with complex cases navigate VA and community 
treatment options. However, our support simply cannot reach the 
scale required to assist all veterans who need this heightened 
level of care and intervention. The team's single biggest 
challenge since inception has been helping veterans access VA 
inpatient mental health care. The lack of a consistently 
applied access standard has essentially resulted in no true 
access standard for residential treatment. Local policy 
variations have resulted in unpredictable referral decisions. 
Wait times are not uniformly calculated and can be impacted by 
inconsistent policies about a veteran first having to complete 
significantly less intensive treatment options. Staffing 
challenges can also limit communication and bed availability. 
Alternative treatment options that would result in a community 
or even intra-VA referrals and faster access are not uniformly 
accepted by VA administrators.
    In totality, many veterans are not accessing the care they 
need when they are ready to receive it. Delays in finding 
appropriate care in a timely manner not only fails to 
capitalize on the veteran's desire to change their life 
circumstance, but in some cases causes further damage to their 
mental and physical health, declines in family and social 
relationships, and even involvement with the justice system. As 
illustrated in VA's most recent National Veterans Suicide 
Prevention Annual Report, substance use disorder continues to 
be a significant factor in veteran suicide. While the report 
showed overall reduction in the veteran suicide rate, 
subpopulations struggling with opioid, cocaine, cannabis, and 
stimulant disorders showed increased suicide rates.
    To mitigate the risks associated with inpatient care access 
and ensure consistent VA help throughout the enterprise, we 
believe that Mission Act access standards must apply to the 
delivery of inpatient mental and substance use disorder care. 
We want and we need the VA to be successful in this. Simply 
put, for us, VA is our most critical partner in connecting 
veterans to the inpatient care they need. In closing, I want to 
thank the subcommittee for this invitation to testify, and I 
welcome your questions.

    [The Prepared Statement Of Jen Silva Appears In The 
Appendix]

    Ms. Miller-Meeks. Thank you, Ms. Silva. Mr. Sauer, you are 
now recognized for 5 minutes to deliver your opening statement.

                   STATEMENT OF THOMAS SAUER

    Mr. Sauer. A broken record here, all right. Thank you very 
much. Chairman Miller-Meeks, Ranking Member Brownley, and 
members of the subcommittee, my name is Tom Sauer, and I am 
honored to testify before you today. I am a Navy and Marine 
Corps veteran, and for the better part of my life, I have been 
wearing the cloth of the Nation. I am a former listed Marine 
infantryman, a 2006 Naval Academy graduate, and a former Navy 
explosive ordinance disposal officer. Today, however, I am the 
owner and CEO of Miramar Health, a veteran-owned and operated 
community care provider for intensive substance use disorder 
and mental health treatment exclusively for America's veterans.
    Mental health and addiction treatment are deep passions of 
mine because depression and addiction killed my dad. Five days 
before I graduated from high school and 3 weeks before I 
shipped out for the Marines in 1999, a methamphetamine overdose 
took his life after decades of struggle, just like so many 
millions of Americans suffering from our country's disastrous 
mental health and addiction crisis. I would also like to point 
out that 4 days ago, my father-in-law died of addiction. He was 
an Air Force veteran.
    Thanks to recent legislation, thousands of veterans have 
enhanced access to lifesaving mental health care and addiction 
treatment within the VA's Community Care Network. We provided 
intensive, custom tailored, world class mental health and 
addiction treatment for nearly 250 veterans from a dozen VA 
medical centers across the western United States, typically for 
30, 60, sometimes 90-plus day stays. This treatment is for our 
veterans who are truly suffering, in crisis, and often near 
death from suicide or overdose resulting from this disastrous 
mental health and addiction crisis.
    In 3-1/2 years, we have grown from one small clinic with 
six employees to eight residential facilities and one large 
outpatient facility. These facilities are staffed by nearly 100 
phenomenal physicians, nurses, psychologists, therapists, 
medical technicians, case managers, and support staff, many of 
whom are veterans themselves. One is sitting right to my left 
as well. I could not be any prouder of them.
    I did not come all the way out here just to tell you all 
this, just so I could pat myself on the back, but rather to 
simply convey the sincerity of our intentions and to lay out 
how important this challenge is. Miramar believes in our 
partnership with the VA by bridging both capability and 
capacity gaps within certain VA medical centers and in being an 
advocate to veterans in need, all while providing them with the 
highest quality of care. In other words, we do not consider 
ourselves to be just another government contractor. We are 
partners and we are teammates with the VA, and we are here 
asking for your help to ensure our Nation's veterans receive 
the lifesaving care they need and deserve by helping us to 
strengthen that partnership.
    The overwhelming majority of frontline, boots on the ground 
VA personnel we directly interact with are fantastic, 
dedicated, lifesaving public servants. Some of these guys 
deserve medals and parades. There are many who deserve medals 
and parades. I am here to add today to advocate for veterans in 
need to be able to access care anywhere immediately and we can 
figure out that paperwork later.
    The current VA policy of 30 days to wait to find a bed in a 
given region does not meet the urgent level of this crisis. I 
think you have been hearing this before, a recurring theme. 
Specifically, we have encountered several occasions where, 
despite community care being available for a veteran in crisis, 
they are either put on a waiting list for up to 30 days before 
receiving care when they do not have 30 minutes without 
becoming a very real risk to suicide or overdose. Chairwoman 
Miller-Meeks, I think you have highlighted such a case. We have 
cases that can highlight that as well too.
    I have firsthand knowledge of these suicide and overdose 
deaths since I have owned Miramar, so I can understand the 
devastation this policy can cause. We believe this issue could 
rather be easily corrected through either through a legislative 
carve out for community care eligibility, as with urgent care, 
or when it comes to urgent care for community care, when it 
comes to mental health and addiction treatment. This could be 
done by clarifying ensuring the COMPACT Act is being 
implemented as intended and that veterans are aware of this 
option for receiving care.
    We urge you to seek to ensure that our veterans have access 
to care they need when they need it through the Community Care 
Network. We appreciate your consideration of this matter, and 
we are willing to work with you to address these issues to 
ensure that our guys and gals get the care they need so 
desperately. Thank you, Chair, and members of the subcommittee, 
each of you, your staffers, and the committee staff are 
champions for America's veterans. I am exceptionally grateful 
to you and to your commitment to serving them and that you are 
holding this important hearing today. In conclusion, thank you 
so much for addressing these issues, and I am more than happy 
to answer your questions.

    [The Prepared Statement Of Thomas Sauer Appears In The 
Appendix]

    Ms. Miller-Meeks. On behalf of all the committee, Mr. 
Sauer, our condolences on the loss of your father, and I thank 
you for your testimony. I will go last in the lineup of 
questions. I now recognize Ranking Member Brownley for any 
questions she may have.
    Ms. Brownley. Thank you, Madam Chair. Ms. Silva, I just 
wanted to stay on a theme of women veterans for a minute, and I 
know we are talking about access, so I was wondering if you 
could speak at all to your experiences in trying to get women 
veterans the gender specific care that they need programs, 
inpatient programs, and if you could speak to that within the 
VA and within the community.
    Ms. Silva. Well, thank you for the question. I believe the 
women specific care adds an element that complicates this 
already kind of urgent action approach to this. We have a very 
short window for care. If a veteran comes to us and needs 
that--we are talking, specifically mental health and substance 
use disorder--the co-occurring with either military sexual 
trauma makes them at a heightened risk, as we talked about in 
the previous panel for this.
    I have a vignette that I think is a pretty interesting one, 
where a female veteran was trying to get care for Military 
Sexual Trauma (MST) and substance use disorder, so co-
occurring, and the opportunities were not available. They were 
available in that Community Care Network area. Unfortunately, 
in this situation, the VA said it seemed too resort-like and 
were not able to get her into that care. They did not allow for 
that.
    What she did, but they did have an intra-VA option and she 
moved her entire family across a couple of states in order to 
get into that care. She was into VA care. I think in my 
experience, once they are in the care, so all those barriers of 
maybe females not being comfortable, once they are in there, it 
has been very productive and the outcomes are fantastic. We 
have got to work on--it does not have to be that difficult 
where you have got to move across states. Maybe it had to work 
in this situation. I think we can do better though.
    Ms. Brownley. Well, I think it is true for men as well as 
women, but I think for particularly women, I think you just 
highlighted one of the, I think, big obstacles to access, and 
that is a woman to get the proper resources and treatment that 
she needs, many times has to travel outside of her state in 
order to receive that within the VA. You know, what does a 
woman do with her family? All of that. It becomes a tremendous 
burden for them to, you know, to leave family, to leave 
responsibilities in order to get the appropriate treatment. I 
feel like we need to address some of those issues as well.
    As a consequence, we need more, I believe, more gender 
specific programs for women. I wonder if you could just comment 
a little bit. I know we are talking more about access, but just 
in terms of your experiences with getting referrals inpatient 
within the VA and within the community, can you speak to--it is 
my sense that when I have spoken to people, once they get into 
the VA and inpatient care, it is pretty good and the success is 
there. Can you talk a little bit about quality of care compared 
to, you know, inpatient VA versus community care? Can you give 
any kind of conclusions?
    Ms. Silva. Ma'am, I actually agree with what you said. Once 
they are into care, whether it is in the VA and in the 
community, it has been very positive overall. It is the 
connective tissue in order to get them into that care is 
lacking. They are willing oftentimes they have to go to a less 
intensive program before they are--even if the clinical 
decision is that they need this inpatient approach, it needs to 
be quick. That window of opportunity, especially when we are 
talking about these complex cases, most of them co-occurring or 
the substance use disorder it is a really short window. You 
have got to act as everyone would agree.
    You have to have that availability. There is a shortage, et 
cetera. If the community can provide that, then that is the 
best way to go, in my opinion, because ultimately the veteran 
has a positive experience. It is still a VA referral. I think 
from a customer perspective, it actually keeps your customer, 
if I can use that term, happy with the overall care, even if it 
is not within the VA Medical Center.
    I know within--back to the military sexual trauma or women 
specific care, we have found within our Warrior Care network, 
it is extremely important to many of the women that are served 
through our intensive outpatient program that they receive it 
outside of the VA or outside of maybe if they are still active 
duty. That is a gigantic barrier to care. If that is the best 
option for that female veteran, then let us do it. We have VA 
liaisons there that can get them back into VA care. It is 
really not outside. It is just the connective tissue is a 
really positive experience for that veteran.
    Ms. Brownley. Thank you. I yield back.
    Ms. Miller-Meeks. Thank you, Ranking Member Brownley. I now 
recognize Representative Luttrell for any questions he may 
have.
    Mr. Luttrell. Thank you all for your service to this 
country and your continued service to our veteran community. I 
really appreciate that. Sir, I am very sorry for your loss.
    Given the previous testimony on the previous panel's 
testimony, Mr. Sauer, can you just explain to us as a veteran 
why it is you do what you do today?
    Mr. Sauer. Well, thanks for the question, Mr. Luttrell. I 
found really no higher calling than helping fellow service 
members. That is what it comes down to. When it came down to 
all this. I realized that there is a bigger crisis, you know, 
especially you two gentlemen up there on the dais, that we 
probably lost more friends and colleagues to suicide and 
addiction than we did on the battlefields overseas. I saw this 
as an incredibly growing problem.
    The opportunity for a TriWest contract was presented. I did 
not know this was something that was even available. I like 
looked at this phenomenal opportunity that serves this growing 
dramatic public need. When one of my partners, who is my Naval 
Academy classmate, and I work with folks like Mr. Dowling here 
from the special operations community, like what a phenomenal 
group of people. Just to absolutely save lives.
    I can tell you right now that, you know, as a former Navy 
Explosive Ordnance Disposal (EOD) officer, I spent a long time 
in uniform, that the work that we are doing herein today is far 
more valuable and to the Nation, and to the country, and 
frankly, for the world at large than anything I ever did 
wearing the uniform.
    Mr. Luttrell. Congressman Van Orden brought up a very valid 
point. He said that the Suicide and Prevention Office in the VA 
has been in place for 34 years. My question that I did not get 
to ask then was has the suicide rate gone up in those 34 years? 
It has, absolutely. I think that lends itself to the efforts 
that this panel is making to protect our brothers and sisters 
in the veteran space.
    If there were one change that you could make that would 
increase veteran access to lifesaving substance abuse and 
mental health inpatient care, what would that be?
    Mr. Sauer. I think it is a pretty simple one right now is 
that to change that wait time from 30 days. When they do not 
have 30 minutes, ordinarily I would suggest 24 hours. You know 
what, to kind of be--to be a little understanding of the VA, 72 
hours, that is one business day. When a veteran shows up to 
their VA provider in a mental health or addiction crisis that 
the VA is, you know, their standard must be that they put that 
veteran into a bed, get them off the X, so to speak, because 
lots of--we do not know exactly that the severity of the need 
of care. Get them off the X and they have the opportunity to be 
in a residential treatment program, whether or not that is in 
an in-house VA facility. If those facilities are full, not 
available right away, then you get them into a community care 
facility within 72 hours, one business day, preferably 24, 
frankly.
    If we can do that right there, because obviously, one, we 
need to be able to ramp down the level of care as far as like 
if somebody has to wait 30 days, but then they can do 
telehealth, like that is ramping up the level of care. You need 
to get them off the X right away, get them into a highly 
intensive level of care, and then you can assess and start 
ramping down those levels of care. However, I would say that is 
what you got to do right there, just immediately get them off 
the X in that care, 72 hours. Yes, I think that is it right 
there. I mean, in a simple word, is not 30 days. You have got 
72 hours, whether it is in the VA or outside with community 
care.
    Mr. Luttrell. For us on the panel and having dealt with the 
VA at multiple levels, is it in your professional opinion that 
the referral process is failing at a lower level or at the 
higher leadership level, at the higher level?
    Mr. Sauer. Absolutely. It is not the social workers we deal 
with. I have encountered many who have told me, you know, over 
the phone, told people like Brendan over the phone as well, or 
even over email saying, this program looks fantastic. I would 
love to write you referral. You know, instead they would say, 
however, the residential rehabilitation care has a different 
Mission Act eligibility criteria than other specialty services 
and then they cite 1162.02. In that particular case, I took 
that particular veteran on scholarship. He was a retired 
Marine, spent a long--former infantryman--and we took him on 
scholarship. We also have a former Navy Seal who is in our 
facility today on scholarship as well, because he was denied 
care and denied access. We saw we had to do the right thing.
    We know when I speak to these social workers nearly every 
single time, they are the ones who say we would love to be able 
to refer them, but we can not. They will not let us.
    Mr. Luttrell. If you do not mind, I would like to circle 
the wagons and get those names and the positions they hold so I 
can address them directly. I yield back.
    Ms. Miller-Meeks. Thank you, Representative Luttrell. I now 
recognize Representative Van Orden for 5 minutes.
    Mr. Van Orden. Dr. Campbell, I see you in the back there. I 
want to thank you for staying here. Just so you are aware, I 
think Brendan, you are an enlisted guy, right? Yes, you did not 
go bad like, you did not go bad like Sauer?
    Mr. Dowling. Yes, I was.
    Mr. Van Orden. Yes, yes, noted. Ma'am, so as enlisted 
people, we need to make the rubber meet the road. Although 
those questions appear to be harsh, they are for a very 
specific reason so that we can quantify a problem and then move 
forward. Our purpose here, my sole legislative agenda as the 
chair of a Subcommittee for Veterans Economic Opportunity is to 
prevent veteran suicide. I thank you for staying here. I 
appreciate that greatly.
    What I have noticed, gentlemen and gentlewoman, is that the 
issue is not with the Veterans Administration in many cases. It 
is with the Department of Defense (DOD). What I would like to 
ask you specifically is what is your access to the Transition 
Assistance Program? We will just start with Mr. Elkins, the 
Green Beret.
    Mr. Elkins. Well, as an enlisted guy, it is always a 
pleasure to be in the company of other enlisted, as well.
    Mr. Van Orden. Okay. I did not realize that. I thought you 
went bad too. Go ahead.
    Mr. Elkins. Working with the Transition Assistance Program 
at many levels, having gone through it multiple times, we will 
have to go through it again in the next several months, as I am 
about to transition out of my role to deploy for the third time 
in the last several years. There is definitely gaps that need 
to be addressed.
    Mr. Van Orden. Let me ask you something specifically, does 
your organization have access to the Transition Assistance 
Program so that you can speak to active duty service member as 
an upstream solution to prevent them from committing suicide 
and having drug and alcohol addiction issues after they retire?
    Mr. Elkins. Yes.
    Mr. Van Orden. You do?
    Mr. Elkins. Yes.
    Mr. Elkins. Okay. Ma'am, Ms. Silva.
    Ms. Silva. No, we do not.
    Mr. Van Orden. You do not. Okay. Mr. Sauer.
    Mr. Sauer. No, sir, we are not. We are dealing usually 
directly with VAs, and by the time a veteran comes to us or we 
are made aware of a veteran that in need, that they have 
already gone down. They are already in a bad spot.
    Mr. Van Orden. Then, Brendan, what class were you in?
    Mr. Dowling. I was in Buds Class 242.
    Mr. Van Orden. New guy. Oh, with you? OK. When you went 
through the Transition Assistance Program, were you made aware 
of any of these external organizations that may help you bridge 
the gap from being active duty service member to becoming a 
productive veteran?
    Mr. Dowling. No, I was not. My Transition Assistance 
Program experience was unremarkable. I did not really pull 
anything from it----
    Mr. Van Orden. Okay.
    Mr. Dowling [continuing]. of use.
    Mr. Van Orden. Then just for everybody across the board, do 
you feel like you have access to the Department of Defense and 
ready access to the Veterans Administration on a coequal basis 
because we have to get upstream solutions. Do you guys have 
points of contact that you can call? Do you feel like the DoD 
is responsive to your guys' inquiries? If you needed to, can we 
help? If you do not, can we facilitate that for you so that we 
can start up here and then work our way to the veteran status?
    Mr. Elkins. We do have access. In some cases, it is very 
timely, and other times, we will use you and your office for 
assistance.
    Mr. Van Orden. Okay. That is absolutely open at any time. 
Ma'am?
    Ms. Silva. I would say we have developed, on the DoD side, 
we have developed relationships with different commands. We 
have heavy involvement in Alaska due to the increased suicide 
rates there, and we have been able to be part of that solution, 
working with the community there. And then different--it is 
very command-related. That is the difference, in my opinion, 
between DoD and VA. Most of the warriors that we serve are 
already on the veteran side of the equation, and so our bigger 
contacts are with the VA. We certainly would love more 
collaboration with the transition piece of DoD.
    Mr. Van Orden. Okay, excellent. Mr. Sauer.
    Mr. Sauer. Miramar is contracted with TriWest Healthcare 
Alliance, which, you know, currently has the sole contract with 
the Department of Veterans Affairs. We have no formal 
relationship with DoD. However, as you may be aware, TriWest 
Healthcare Alliance won the contract for Tricare West, so we 
will, beginning next year, it is my understanding we will be 
able to treat active duty and their families, which we look 
forward to. We are close to Camp Pendleton. There is a large 
population of active duty there, and we welcome the opportunity 
to strengthen those relationships for that transition.
    Mr. Van Orden. Okay. Hey, my time is expiring. I just want 
to tell you that my office is yours. I know that there is no 
one on this panel, Democrat or Republican, who is unwilling to 
step out to make sure that we can facilitate your organizations 
to work in conjunction with Dr. Campbell back there to help 
prevent veteran suicide. With that, God bless you, and thank 
you for your work very much. Ma'am, I yield back.
    Ms. Miller-Meeks. Thank you, Representative Van Orden. I 
thought about removing your time because I take offense as a 
former enlisted who became an officer.
    Mr. Sauer. Same here.
    Ms. Miller-Meeks. Ms. Silva, who is a West Point grad, that 
I did not go to the dark side when I got pinned my lieutenant 
bars. I now yield myself 5 minutes for questions.
    You know, this is a very sobering hearing in many ways. Let 
me just say that as a veteran and as an ophthalmologist and I 
did both care, active duty military. I did Veterans 
Administration care. I was an assistant professor in academic 
medicine and as well as private practice, and I was an 
ophthalmologist. Let me just say that when I would get calls 
from a patient for a red eye, I would see that patient that 
same day. That is a red eye. Nowhere near the gravity of what 
we are talking about now. That was my personal standard. It was 
not a standard imposed upon me by an insurance company, by the 
institution for which I worked, nor by Members of Congress.
    Mr. Elkins and Mr. Sauer, in both of your testimonies, you 
mentioned being made aware of a VA policy stating that the VA 
has 30 days to place a veteran with substance use into an 
inpatient mental health residential rehabilitation program when 
working cases for veterans in crisis. Can you explain further 
your experiences with the VA when policy is not adequately or 
inaccurately conveyed?
    Mr. Elkins. Thank you for that question. Thirty days is too 
long to ask a veteran to wait on the availability of an RRTP 
facility or care in the community. In a 30-day period, the risk 
of suicide or destabilization can drastically increase. We 
recommend a clinically sound, lesser number of days because 
PTSD in conjunction with SUD require swift intervention and 
services. Additionally, in some cases, veterans lack trust with 
the VA based on past experiences and the mere fact that you 
have to go through an RRTP facility first and fail and then 
afterwards go to the community care, needs to be addressed.
    Ms. Miller-Meeks. Thank you. Mr. Sauer, I will just kind of 
dovetail on that and then go to you. Both of you in your work 
with veterans, have you heard anything about a recent direction 
from the VAMC that if they can not meet the 30-day appointment 
availability, they have to confer with other VISNs. They have 
to try to get them into care at another location. Or that five 
VAMCs must be contacted to fulfill the directive. Have you all 
heard that?
    Mr. Sauer. Yes, we have. A matter of fact, Mr. Dowling, to 
my left is the one who directly dealt with that when after 
speaking with a VAMC therapist who was one who also managed 
many community care referrals or made the consults that would 
later become referrals. Brendan can definitely speak about it 
in more detail if you have questions. It was that if a VISN's 
VAMC--it went to effect on I think October 1 is what they were 
told. We were told this verbally. This was not in a writing or 
policy, that if a VISN's VAMC cannot meet the 30-day 
appointment availability window, it must confer with the other 
VISNs for bed availability before leveraging community care in 
order to keep the care ``in house.'' He further reported that 
five VAMCs must be contacted in order to fulfill the directive. 
He advised this new policy would highly impact referrals 
throughout the community. Is there something else you wanted to 
add, if I may? Is it is all right, to Mr. Dowling? It is Okay 
if not. Understood.
    Ms. Miller-Meeks. Have you experienced the same thing?
    Mr. Elkins. Yes, we have experienced the same thing in 
multiple cases over the last several months. As of January, we 
have seen a significant increase in the amount of cases we are 
seeing where there are unnecessary delays.
    Ms. Miller-Meeks. Thank you. It is surprising then that our 
bureaucracy has not heard the similar thing.
    Mr. Sauer, we often hear that the VA care is the best care 
because those who work at the VA understand the veteran. I am 
going to refer to a community organization I have in one of my 
largest cities in my district in Davenport, where an entirely 
volunteer veteran organization assisted a veteran who had not 
seen their family or come for any kind of care for 20 years, 
had not seen their family. The veteran showed up there to this 
total voluntary organization, no one taking a salary, and 
contacted his family for the first time in 20 years. How does 
your experience and the experience of your staff, such as those 
with Mr. Dowling's background, equip you to serve our Nation's 
veterans?
    Mr. Sauer. It is a big question, ma'am. I would say that we 
are incredibly honored for this opportunity to do this. I will 
say that there is nothing that is more rewarding. I know that 
when Brendan joined the team last year, he saw the mission we 
were doing. I mean, he can speak for himself on that one. Most 
certainly we go pretty far out of our way for a number of 
cases. We have taken, for what it is worth, as well, when we 
have cases where a veteran has for any number of reasons, but 
usually due to the reasons that we are here for which we are 
here today, they are unable to get care, we take them on 
scholarship.
    Now, I still have 100 employee--nearly 100 employees. I 
have to make payroll to keep the lights on. I can not do that 
continually, but I am happy to do that, you know, in certain 
situations. We have done that about seven or eight times that I 
can think of in the past year or two. We just do it because it 
is the right thing to do, that is it.
    Ms. Miller-Meeks. Thank you. I yield. Ranking Member 
Brownley, would you like to make any closing remarks since I 
see no other members here?
    Ms. Brownley. Yes. Thank you, Madam Chair. Really, thank 
you very much for having this hearing. It is very much an 
important hearing of which I still feel like we need to do even 
a deeper dive on it to really get down to the bottom of things. 
I really thank this panel for your testimony. This is one of 
these hearings where I wish we had panel two first and the VA 
second, because there is so much that you have raised that now 
I would like to ask the VA. I think there is clearly a 
disconnect between the VA's testimony and your testimony, and 
we need to get to the bottom of that. I have a feeling that 
some of the problem has to do with how VA really addresses 
access and how they account for access and missing some data 
points, perhaps.
    I do want to acknowledge that what I am hearing from panel 
two as well is that the quality of care within the VA once the 
veteran gets into the VA is very good. I want to, you know, 
applaud the VA for the quality care. The access piece and when 
we are talking about suicide and other kinds of things, that 
getting, you know, when someone is in crisis and they come to 
the VA or come to any of you, if there is not a bed, they still 
need to be in a room. They do not get to leave the hospital at 
that particular point. They are in the care of the VA. Never 
should a veteran walk out of that VA in crisis. I think clearly 
something has to be done here around these access points.
    Mr. Sauer, too, I want to congratulate you, too, on, you 
know, the quality of community care that you are providing in 
your area. We thank you for that. Again, my condolences to you 
with regards to your father. With that, I will yield back.
    Ms. Miller-Meeks. Thank you, Ranking Member Brownley. I 
would like to thank everyone for their participation in today's 
hearing and for their productive conversation. I would like to 
especially thank our most recent panel for submitting their 
witness testimony in a timely fashion so Members of Congress 
could read it.
    As a veteran, as a doctor, as a former director of the 
Department of Public Health, and someone who is very active in 
mental health and substance use disorder, it is one of my top 
priorities. I know the same goes for my colleagues on both 
sides of the aisle to take care of all veterans and to ensure 
that they have timely care, especially for those who are 
struggling with complex mental health issues and substance use 
disorder. No one here on this panel--witness up on the dais 
today has impugned the quality of care delivered at the VA. The 
most important metric, not hundreds of metrics, the most 
important metric of success is whether the suicide rate has 
gone down, and unfortunately, it has gone up. No veteran should 
be turned away when a decision is made to seek help.
    I look forward to working on these issues. I look forward 
to working with my colleagues on the other side of the aisle 
and many more with the department, stakeholders, and my 
colleagues on this subcommittee.
    The complete written statements of today's witnesses will 
be entered into the hearing record. Questions will be 
submitted, and we will ask that they be responded to in a 
timely fashion. I ask unanimous consent that all members have 5 
legislative days to revise and extend their remarks and include 
extraneous material. Hearing no objection, so ordered. This 
meeting is now adjourned.
    [Whereupon, at 12:03 p.m., the subcommittee was adjourned.]

 
      
      
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                         A  P  P  E  N  D  I  X

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                    Prepared Statement of Witnesses

                              ----------                              


                 Prepared Statement of Tamara Campbell

    Good morning, Chairman Miller-Meeks, Ranking Member Brownley and 
distinguished Members of the Subcommittee. Thank you for the 
opportunity today to discuss VA's substance use disorder treatment 
programs through Mental Health Residential Rehabilitation Treatment 
Programs (MH RRTP) and through community care referrals. Accompanying 
me today is Dr. Sachin Yende, Chief Medical Officer, Office of 
Integrated Veteran Care (IVC).
    Veterans are increasingly struggling with substance use disorders 
(SUD). From fiscal year (FY) 2018 to FY 2022, the number of Veterans 
diagnosed with a SUD and receiving treatment in the Veterans Health 
Administration (VHA) increased from 522,544 to 550,412. This increase 
also reflects an increase in Veterans with a diagnosis of alcohol use 
disorder receiving care in VHA which increased from 393,531 to 411,615 
over the same time period. Of the over 550,000 Veterans receiving care 
from VHA in FY 2022, or 8.5 percent of all patients who received care 
from VHA, received treatment for a substance use disorder. While the 
annual number of Veterans receiving treatment from VHA for opioid use 
disorder has stabilized at about 67,000 patients per year, a rising 
number of VA patients are receiving treatment for cannabis use disorder 
and amphetamine stimulant use disorder, which includes methamphetamine 
use disorder. The number of patients treated in VHA for amphetamine 
stimulant use disorder has climbed by almost 8 percent over the 
previous 5 years to more than 40,000 patients annually, while the 
number of patients treated in VHA for cannabis use disorder has 
increased by more than 12 percent to more than 139,000 patients 
annually. The number of Veterans who have been diagnosed with an 
alcohol use disorder over the same time period has increased by nearly 
5 percent. Together with each of you, VA is totally committed to 
providing a wide range of interventions that are supported by evidence 
to cater to the requirements of every Veteran.
    Care for Veterans who have co-occurring SUD and mental health 
issues is a crucial component of general health care. Because it has an 
integrated health care system, VA is in a unique position to meet the 
requirements of Veterans with SUD by offering assistance for co-
occurring medical, mental health, and psychosocial issues, including by 
providing supports for employment and housing. Due to the complexity of 
SUD, neither a single remedy nor solely clinical or VA interventions 
will suffice to solve address the issue. To reduce the burden of SUD in 
the veteran population, it is important to use broad-based national 
preventative and treatment strategies. To achieve its goals, VA uses 
both whole-of-Government and whole-of-Nation approaches. These are 
exemplified by VA's interagency collaborations. As an illustration, the 
Department of Defense (DoD) and VA collaborated to produce clinical 
practice guidelines for the management of substance use disorders. To 
meet the needs of Veterans with or at risk of substance use disorder, 
VA also collaborates closely with several other Departments and 
agencies, including the Departments of Health and Human Services, 
Energy, Justice, and Housing and Urban Development.
    Also, VA is incorporating Oak Ridge National Laboratory data into 
predictive models for targeted prevention programs so we can better 
identify Veterans with the greatest challenges to recovery and get them 
the additional support they need. Through collaborations with the 
Lawrence Berkeley, Los Alamos, and Sandia National Labs, VA is making 
better use of medical record information to identify high-risk VA 
patient populations. Through work with JJR Solutions in Dayton, Ohio, a 
service-disabled Veteran-owned small business, VA has found that 
provider education sessions on opioid safety practices lead to more 
effective treatment for Veterans in primary care and reduction in 
overdoses.

Overview of SUD Treatment at VA

    There has been an upsurge in morbidity and mortality from substance 
use disorders during the past 10 years or more as powerful and 
hazardous illicit drugs have become more widespread in the United 
States. Federal, State and community prevention and treatment efforts 
have been developed in response, particularly aimed at reducing 
overdose deaths and addressing the opioid epidemic.
    Within VA, patients with at-risk alcohol use or the SUDs of mild 
severity may be treated with evidence-based brief interventions and/or 
medical management in primary care or general mental health. For those 
with more severe disorders impairment, specialty SUD treatment programs 
provide intensive services including withdrawal management, evidence-
based psychosocial treatments, SUD medication, case management and 
relapse prevention provided in outpatient, intensive outpatient and 
residential settings of care. VA has developed services specifically 
focused on engagement in care for vulnerable Veteran populations. VA 
efforts include universal screening for at-risk alcohol use, urine drug 
screening for at-risk Veterans, the provision of peer support services, 
integration of SUD treatment within homeless programs, and 
collaboration with Veterans' courts and the work of our re-entry 
specialists to engage Veterans with SUD involved with the legal system.
    These efforts also have required close collaboration with other 
Federal partners in support of priorities defined by the Office of 
National Drug Control Policy (ONDCP). In alignment with ONDCP's 
National Drug Control Strategy, VA is working to expand access to 
evidence-based treatment for SUDs and enhancing evidence-based harm 
reduction efforts aimed at reducing overdose fatalities. VA offers a 
comprehensive continuum of specialty SUD services for Veterans. Our VA/
DoD Clinical Practice Guidelines,\1\ updated in fiscal year (FY) 2021, 
provide the foundation for evidence-based treatment within VA and have 
positioned VA to respond to emerging drug use trends. Current policy 
requires facilities provide access to a comprehensive continuum of SUD 
treatment services ranging from early intervention and harm reduction 
services through intensive outpatient and, when needed, residential or 
inpatient treatment for SUD. In addition, current policy requires 
facilities provide same day outpatient access for Veterans with 
emergent substance use treatment needs. This care may be provided in 
several settings including general mental health, primary care mental 
health integration clinics, and SUD specialty clinics. Core 
characteristics of SUD services include timely same day triage, a no 
wrong door approach, concurrent treatment for co-occurring needs and 
Veteran-centered and individualized treatment based on the needs and 
preferences of the Veteran.
---------------------------------------------------------------------------
    \1\ https://www.healthquality.va.gov/guidelines/MH/sud/.
---------------------------------------------------------------------------
    With national initiatives like Stepped Care for Opioid Use 
Disorder, Train the Trainer, and the Psychotropic Drug Safety 
Initiative, VA emphasizes access to evidence-based treatments for SUDs. 
These initiatives also aim to increase access to both evidence-based 
pharmacotherapies and evidence-based psychotherapies for substance use 
disorders. According to the National Survey on Drug Use and Health 
conducted by the Substance Abuse and Mental Health Services 
Administration, only 22 percent of the general population with opioid 
use disorder received medication for opioid use disorder in 2021. In 
calendar year 2022, VA more than doubles that rate, with over 47 
percent of patients with opioid use disorder receiving medications for 
opioid use disorder from VA within the last 12 months. Appropriate use 
of FDA-approved medications for opioid use disorder can lower the risk 
of illicit opioid use, overdose, suicide, and other mortalities.
    In 2022, VA provided psychosocial or behavioral therapy for SUD to 
almost 172,000 Veterans. VA is using national training initiatives to 
ensure that these treatments are as effective as possible, expanding 
access to highly evidence-based cognitive behavioral therapies and 
contingency management programs. Notably, contingency management is the 
most effective, evidence-based treatment for stimulant use disorder and 
has shown success in treating cannabis use disorder, two substance use 
disorders that are increasingly common in the VHA patient population. 
More than 6,200 Veterans have received contingency management treatment 
since 2011. Over 90 percent of the nearly 80,000 urine samples that 
those Veterans submitted tested negative for the target drugs, which 
are frequently stimulants and occasionally cannabis (THC). For Veterans 
with alcohol use disorder, VA offers both evidence-based medications as 
well as evidence-based psychotherapies separately or in combination 
depending on the shared decision-making between each Veteran and his/
her treatment provider.
    VA recognizes that not all Veterans with SUD will embrace 
abstinence among their recovery goals. Furthermore, SUD, like 
hypertension or diabetes, is a chronic, relapsing condition; even 
Veterans who are striving to abstain from substances may not always be 
consistently successful. Because any exposure to substances can be 
fatal for individuals with SUD, VA provides Veterans with evidence-
based interventions to protect them from harms, like overdose or 
infectious diseases like HIV and hepatitis, that could otherwise lead 
to their death. In just the past year, VHA equipped over 70,000 
Veterans with naloxone to reverse potentially fatal opioid overdoses. 
Furthermore, nearly 1 million naloxone prescriptions have been provided 
to Veterans since 2014, when we launched our Overdose Education and 
Naloxone Distribution (OEND) initiative. This initiative has led to 
more than 3,700 overdose reversals. As part of this effort, VA uses 
data-driven modeling to identify Veterans at high risk of overdose and 
conducts clinical case reviews to inform their customized treatment 
plans. Support from Congress has been critical for the success of VA's 
overdose prevention efforts with passage of the Jason Simcakoski 
Memorial and Promise Act allowing VA to provide naloxone at no cost to 
Veterans at risk for overdose.
    In support of its comprehensive approach to the treatment of SUD, 
VA has developed a wide array of substance use education programs in 
its efforts to expand SUD education and outreach. The programs are 
being implemented across the Department and can be classified as 
follows:

      Initiatives to educate primary care practitioners on the 
diagnosis and treatment of alcohol use disorders.

      Harm reduction approaches to reduce negative consequences 
of substance use including planned/developed mobile and internet-based 
treatment to expand VA's efforts related to SUD treatment, education, 
and outreach.

      Programs developed for Veterans and Veterans' families.

      Clinician training and consultation programs to improve 
their knowledge, skills, and abilities to treat Veterans with SUD.

      SUD training programs for trainees participating in 
clinical training with VA.

    In addition, VA is supporting SUD training for our future workforce 
and is implementing novel harm reduction approaches including the 
development of mobile and internet-based applications. Beginning with 
the President's Budget for fiscal year 2022, VA has requested support 
to directly respond to national priorities defined by ONDCP. The plan 
directly addressed the unique needs of Veterans with substance use 
concerns within the context of broader national priorities.
    VA honors Veterans' autonomy in determining their recovery goals, 
and our providers support them with evidence-based treatments and 
subject matter expertise. Consequently, VA is making a positive 
difference in Veterans' quality of life by building confidence in their 
treatment and helping motivate them in their recovery. Indeed, Veterans 
receiving treatment for their SUD in VA are experiencing benefits in 
terms of their mental and physical health and across many other aspects 
of their lives such as housing stability, employment, and improved 
interpersonal relationships (See DeMarce et al. for an example of such 
impact).\2\ These are the goals VA is pursuing. We want to help 
Veterans do more than just survive - we want to help them learn how to 
thrive.
---------------------------------------------------------------------------
    \2\ Josephine M. DeMarce, Maryann Gnys, Susan D. Raffa, Mandy 
Kumpula & Bradley E. Karlin (2021) Dissemination of cognitive 
behavioral therapy for substance use disorders in the Department of 
Veterans Affairs Health Care System: Description and evaluation of 
Veteran outcomes, Substance Abuse, 42:2, 168-174, DOI: 10.1080/
08897077.2019.1674238.

FY 2024 President's Budget Expands Access to Treatment for Substance 
---------------------------------------------------------------------------
Use Disorders (SUD)

    President Biden's FY 2024 Budget proposes continued support for 
initiatives started during FY 2022, with over 1,100 additional staff 
awarded enterprise-wide to help meet VA's SUD treatment priorities to 
include the following:

      Stepped Care to expand access to evidence-based treatment 
for SUD in settings outside specialty SUD Care;

      SUD Residential Treatment to reduce wait times and 
improve the quality of SUD care with expansion of staff and programs;

      SUD Telehealth to expand access to evidence-based SUD 
treatment via telehealth;

      Homeless Program SUD Treatment Coordinators to engage 
Veterans with SUD into VA SUD outpatient and residential services;

      Supported Employment Specialists to expand access to 
employment opportunities for Veterans in recovery; and

      SUD Peer Specialists to increase engagement and retention 
in evidence-based SUD treatment.

    As of March 7, 2023, over 55 percent of the more than 1,100 
positions have been filled or are in the final steps of the hiring 
process. VA continues to respond to emerging illicit drug threats to 
ensure the needs of Veterans experiencing substance use concerns are 
met. VA will establish program management leads for harm reduction and 
will work collaboratively to develop policy and national tools to 
support implementation of targeted harm reduction strategies throughout 
VHA addressing critical issues such as stigma and the need for 
technical assistance for the field to support implementation.

Mental Health Residential Rehabilitation Treatment Programs (MH RRTP)

    VA's MH RRTPs are a critical component of VA's broader efforts to 
address the needs of Veterans with substance use concerns. With origins 
that date back to the National Homes for Disabled Volunteer Soldiers, 
the Domiciliary Care programs have evolved over time to meet the 
changing needs of Veterans. Today, residential treatment for mental 
health and substance use concerns in VA is provided through Mental 
Health Residential Rehabilitation Treatment Programs (MH RRTP) located 
throughout the country. The MH RRTP continuum includes Domiciliary Care 
(SUD, Posttraumatic Stress Disorder (PTSD), General and Domiciliary 
Care for Homeless Veterans - DCHV) as well as Compensated Work Therapy-
Transitional Residence programs, which provide transitional housing for 
Veterans actively engaged in vocational rehabilitation and 
participating in either transitional work or supported employment. 
There are currently more than 250 MH RRTPs across 121 locations of care 
with more than 6,700 operational beds. This includes more than 70 
programs for the treatment of SUD and more than 40 programs for the 
treatment of PTSD with the expectation that all programs provide 
integrated, concurrent treatment for co-occurring SUD and mental health 
treatment needs (dual diagnosis services) as more than 90 percent of 
all Veterans served by the MH RRTPs have a SUD diagnosis.
    All Domiciliary Care programs within VHA provide 24/7 professional 
and peer support with comprehensive services addressing mental health, 
medical and psychosocial needs provided by an interdisciplinary team; 
these programs are accredited by The Joint Commission and the 
Commission on Accreditation of Rehabilitation Facilities. VHA Directive 
1162.02 defines expectations for clinical services within the programs 
with the Domiciliary SUD (DOM SUD) programs expected to adhere to the 
VA/DoD Clinical Practice Guidelines for the Management of SUD. Given 
the nature of the care provided in the residential programs, VA's MH 
RRTPs often are at the forefront in implementation of critical services 
for Veterans. For example, efforts to support implementation of OEND 
within VA have their origins with work that was started by the MH RRTPs 
in 2012, as part of the first Culture of Safety Stand Down, which was 
established in response to concerns about opioid overdose. At that 
time, only 11 percent of Veterans served by the MH RRTP received 
medications for opioid use disorder. During FY 2022, more than 40 
percent of Veterans received medications to treat opioid use disorder 
during their stay. Further, during FY 2023 to date, more than 70 
percent of Veterans with an opioid use disorder have received a 
prescription for naloxone \3\ during their MH RRTP stay. Several 
studies have demonstrated the impact of VA residential treatment.\4\ 
Studies completed within the SUD residential programs have shown 
sustained reductions in substance use and changes in other factors 
related to recovery (e.g., Blonigan & Macia, 2021; \5\ Boden & Moss, 
2009; \6\ Lash et al., 2007,\7\ 2013 \8\).
---------------------------------------------------------------------------
    \3\ We note that U.S. Food and Drug Administration (FDA) recently 
approved the first nonprescription naloxone product. See FDA Approves 
First Over-the-Counter Naloxone Nasal Spray, U.S. FOOD &DRUG ADMIN. 
(Mar. 29, 2023),
https://www.fda.gov/news-events/press-announcements/fda-approves-first-
over-counter-naloxone-nasal-spray#:?:text=Today percent2C percent20the 
percent20U.S. percent20Food percent20and,for percent20use 
percent20withoutpercent20a percent20prescription
    \4\ Smith, N. B., Sippel, L. M., Rozek, D. C., Spangler, P. T., 
Traber, D., Straud, C. L., Hoff, R., & Harpaz-Rotem, I. (2020). Courses 
of suicidal ideation among military veterans in residential treatment 
for posttraumatic stress disorder. Depression and anxiety, 37(3), 273-
284. https://doi.org/10.1002/da.22993 Holliday, R., Smith, N. B., 
Holder, N., Gross, G. M., Monteith, L. L., Maguen, S., Hoff, R. A., & 
Harpaz-Rotem, I. (2020). Comparing the effectiveness of VA residential 
PTSD treatment for veterans who do and do not report a history of MST: 
A national investigation. Journal of psychiatric research, 122, 42-47. 
https://doi.org/10.1016/j.jpsychires.2019.12.012 Cook, J. M., Schnurr, 
P. P., Simiola, V., Thompson, R., Hoff, R., & Harpaz-Rotem, I. (2019). 
Adoption by VA Residential Programs of Two Evidence-Based 
Psychotherapies for PTSD: Effect on Patient Outcomes. Psychiatric 
services (Washington, DC.), 70(7), 553-560. https://doi.org/10.1176/
appi.ps.201800338
    \5\ Blonigen, D. M., & Macia, K. S. (2021). Personality change 
during substance use disorder treatment is associated with improvements 
in abstinence self-efficacy post-treatment among U.S. military 
veterans. Journal of Substance Abuse Treatment, 120, 108187. https://
doi.org/10.1016/j.jsat.2020.108187
    \6\ Boden, M. T., & Moos, R. (2009). Dually diagnosed patients' 
responses to substance use disorder treatment. Journal of Substance 
Abuse Treatment, 37(4), 335-345. https://doi.org/10.1016/
j.jsat.2009.03.012
    \7\ Lash, S. J., Stephens, R. S., Burden, J. L., Grambow, S. C., 
DeMarce, J. M., Jones, M. E., Lozano, B. E., Jeffreys, A. S., Fearer, 
S. A., & Horner, R. D. (2007). Contracting, prompting, and reinforcing 
substance use disorder continuing care: A randomized clinical trial. 
Psychology of Addictive Behaviors, 21(3), 387 397. https://doi.org/
10.1037/0893-164X.21.3.387
    \8\ Lash, S. J., Burden, J. L., Parker, J. D., Stephens, R. S., 
Budney, A. J., Horner, R. D., Datta, S., Jeffreys, A. S., & Grambow, S. 
C. (2013). Contracting, prompting and reinforcing substance use 
disorder continuing care. Journal of Substance Abuse Treatment, 44(4), 
449-456. https://doi.org/10.1016/j.jsat.2012.09.008

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Access to Mental Health Residential Treatment within VHA

    VHA affirms the critical importance of timely access to residential 
treatment for mental health and substance use concerns and has taken 
steps to remove barriers to care. Veterans may self-refer or may be 
referred by their provider (internal or external to VHA) to mental 
health residential treatment. In accordance with nationally defined 
admission criteria, Veterans must be screened for appropriateness for 
admission with a decision provided within 7 business days. VHA's goal 
is to admit Veterans as quickly as possible, and the admission date 
should take into consideration the Veteran's preference. Timely access 
to residential treatment has been a priority area of focus for VHA with 
several efforts underway to ensure Veterans have access to residential 
treatment when clinically indicated. One such effort included 
development of a process to facilitate access to residential care in 
the community. Prior to the time of enactment of the VA MISSION Act of 
2018 (June 6, 2018), residential treatment in the community was not 
readily accessible, with a limited number of care providers and no 
direct pathway to authorize and pay for such treatment. When care did 
occur, it was provided either through inpatient programs for the 
treatment of substance use disorder or through contracts with community 
care providers. Recognizing a need to ensure access to this critical 
level of care, VA worked to verify authority to provide residential 
treatment in the community and to provide a mechanism to pay for such 
care. The Mental Health Residential standardized episode of care (SEOC) 
and the technical mechanism to place a consult for this care were 
released to VA medical centers in October 2020.
    VHA's formal guidance to facilities defined how and when referrals 
for residential care in the community should occur. This guidance was 
informed by VHA Directive 1162.02, which defines requirements for 
ensuring timely access to residential treatment. While the MH RRTPs are 
considered institutional extended care and not subject to the 
designated access standards established by VA at 38 CFR Sec.  17.4040, 
which can establish eligibility to elect to receive care in the 
community, access standards for MH RRTPs still do exist. VHA policy 
requires that when a Veteran is assessed as requiring residential 
treatment and the program is unable to meet the Veteran's needs (72 
hours for Veterans requiring priority admission and 30 days for 
Veterans assessed as appropriate for routine admission) an alternate 
treatment program must be offered. Alternate treatment may include 
another MH RRTP in the Veterans Integrated Service Network (VISN), a 
comparable program appropriate to meet the Veteran's needs (e.g., a 
homeless grant and per diem program) or referral for care in the 
community. The policy in question does not reflect a new policy 
requirement but rather was the first step to provide a clear 
expectation for provision of residential treatment within the community 
and a mechanism to facilitate access.
    Through the second quarter (Q2) of FY 2022, the average time 
between screening and admission for all Veterans admitted for 
residential treatment was 23 days, with half of Veterans admitted 
within 12 days of being screened for admission. For the DOM SUD 
programs the average time was 24 days, but with half of Veterans 
admitted within 9 days of being screened for admission. It is important 
to note that a small subset of Veterans request or require a later 
admission date (18 percent for DOM SUD programs during FY 2022). VHA is 
committed to ensuring timely access to care with a focus on moving 
toward same day/next day admission consistent with priorities defined 
by the National Drug Control Strategy. Through Q2 of FY 2023, 40 
percent of Veterans were admitted either directly from an inpatient 
mental health stay or within 1 day of screening.
    Further, since the publication of the MH Residential SEOC, the 
number of Veterans receiving residential care in the community has 
increased rapidly. During FY 2021, there were more than 7,000 referrals 
for mental health residential care in the community using the new SEOC, 
with that number increasing to roughly 11,000 unique referrals during 
FY 2022 and exceeding 6,800 to date during FY 2023. Expenditures for 
residential care in the community since 2021 have exceeded $1.2 
billion. By comparison, during FY 2022, VA's Domiciliary Care programs 
overall served more than 20,000 unique Veterans with the DOM SUD 
program serving more than 9,800 Veterans.
    Community care residential treatment programs are critical 
resources when a facility is unable to furnish residential treatment 
for a Veteran within the VISN. Facilities are actively working with 
community providers to ensure that when a Veteran is referred to a 
residential treatment program, the program meets quality standards and 
that there are clear processes for referral and for engagement in post-
discharge continuing care with VHA. Collaboration with community 
providers also has allowed VISNs to communicate about specific 
treatment needs where residential treatment options may be limited in 
VHA.
    Beyond ensuring that mechanisms exist to ensure Veterans have 
access to community residential treatment when applicable, VA is 
committed to addressing internal access challenges. The MH RRTPs were 
significantly impacted by the pandemic with many programs reducing 
capacity to ensure both Veteran and staff safety. VA began 
communicating on the importance of ensuring access to MH RRTP services 
as early as July 2020, with a focused effort to resume MH RRTP services 
and increase capacity initiated in February 2021. Since that time, VA's 
Office of Mental Health and Suicide Prevention (OMHSP) has been working 
collaboratively with the VISNs to increase capacity and reduce wait 
times with the average number of days between screening and admission 
approaching pre-pandemic levels. However, VHA recognizes the need to 
establish accelerated targets informed by Veteran feedback. Beginning 
in August 2022 and concluding in December 2022, VHA conducted regional 
meetings specifically focused on access to residential care emphasizing 
a goal of providing same day or next day admission when clinically 
indicated. Since the start of those conversations in August 2022, the 
average daily census has grown from around 3,300 Veterans to just over 
3,800 Veterans in March 2023.
    In addition to efforts to return MH RRTP capacity to pre-pandemic 
levels of operation, several new DOM SUD programs have recently been 
established or are under development and expected to open within the 
next few years. During FY 2022 and FY 2023 year to date, 55 DOM SUD 
beds have been established at 3 new locations of care with 14 
additional beds at 2 additional programs projected to open during FY 
2023.

Compliance with Community Care Referrals for Substance Abuse 
    Residential Treatment

    VA is grateful for the independent investigation of the Office of 
Inspector General (OIG) in the review of the DOM SUD treatment program 
and residential community care referrals.\9\ As noted in VHA's response 
in the OIG report, the ability to refer for mental health residential 
treatment in the community is a relatively new process with the first 
SEOC for mental health residential treatment released in October 2020 
and updated in August 2021. OMHSP worked collaboratively with VISNs 
during this time to clarify requirements and expectations for when 
referrals for mental health residential care in the community may 
occur. These efforts have continued with targeted efforts to ensure 
familiarity with access requirements and processes for ensuring access 
to residential treatment in the community when indicated.
---------------------------------------------------------------------------
    \9\ Department of Veterans Affairs Office of Inspector General. 
``Noncompliance with Community Care Referrals for Substance Abuse 
Residential Treatment at the VA North Texas Health Care System''. 
Report No. 21-03864-34. January 31, 2023.
---------------------------------------------------------------------------
    Specifically, in response to recommendations in the report, VA has 
taken several steps to ensure a clear understanding by all programs of 
access requirements and when referrals for mental health residential 
treatment in the community should be completed. Further, in response to 
the OIG report, VA has ensured clarification on the existing guidance 
regarding the role of the mental health treatment coordinator and 
expectations for engagement with the coordinator as part of the 
referral and admission process for Veterans requiring mental health 
residential treatment. Further, VA has several efforts currently 
underway to address access for MH RRTP services, with a workgroup 
convening to determine potential changes in national policy responsive 
to access challenges that have been communicated by stakeholders with 
the expectation that a formal plan and path forward would be finalized 
within 45 days of the workgroup convening. In addition, OMHSP is 
working to put in place a process that leverages existing monitoring 
efforts to inform procedures for notifying VISN leadership when there 
are concerns with conformance to national policy.

Implementation of Veterans COMPACT Act, Section 201

    The Veterans COMPACT Act created a new authority in 38 U.S.C. Sec.  
1720J for VA to provide emergent suicide care to eligible individuals 
in acute suicidal crisis at no cost both in VA and in the community. 
This authority increases access to care, including residential care, 
and is in full alignment with VA's National Strategy for Preventing 
Veteran Suicide.\10\ Building upon VA's comprehensive public health 
approach, this new emergency suicide care and treatment health care 
benefit enhances our ability to provide critical treatment for eligible 
individuals experiencing a suicidal crisis. Eligible individuals in 
suicidal crisis can go to any VA or community health care facility for 
emergent suicide care. VA is responsible for providing, paying for, or 
reimbursing for this care, depending on the setting it is provided in, 
and therefore, this care is provided to eligible individuals at no 
cost. Eligible individuals receiving emergent suicide care will also 
have the costs of ambulance transportation and related prescriptions 
covered. Emergent suicide care can be provided in multiple settings, 
including inpatient or crisis residential care for up to 30 days and 
crisis-related outpatient care for up to 90 days. The access standards 
for mental health residential treatment outside of an acute suicide 
crisis (72 hours for priority admission and 30 days for routine 
admission) would not apply. This health care benefit has the potential 
to increase access to acute suicide care to an additional 9 million 
unenrolled Veterans and reduce the number of Veteran suicides by 
offering immediate care when Veterans are most vulnerable.
---------------------------------------------------------------------------
    \10\ U.S. Department of Veterans Affairs. (2018). National Strategy 
for Preventing Veteran Suicide. http://www.mentalhealth.va.gov/
suicideprevention/docs/Office-of-Mental-Health-and-Suicide-Prevention-
National-Strategy-for-Preventing-Veterans-Suicide.pdf.
---------------------------------------------------------------------------
    On January 17, 2023, VA published an interim final rule outlining 
eligibility for emergent suicide care and immediately began providing 
this new benefit to eligible individuals. As part of implementation, VA 
developed a robust communications plan targeted toward eligible 
individuals, Veterans, and community providers. VA continues to 
aggressively address critical cross-platform information technology 
enhancements to ensure that multiple administrative and clinical 
systems work seamlessly together to ensure timely and efficient care at 
no cost. The Veterans Crisis Line serves a critical role in the 
coordination of life-saving resources, such as emergency dispatch for 
Veteran crisis care. VHA provided external resources for Veterans and 
providers, as well as internal resources and training for VA staff on 
section 201 of the COMPACT Act. We are committed to ongoing education 
and training efforts within VA and in the community as we deploy this 
new, life-affirming benefit in our ongoing suicide prevention efforts.

Conclusion

    We appreciate the Committee's continued support in this shared 
mission. Nothing is more important to VA than supporting the health and 
well-being of the Nation's Veterans and their families. VA has employed 
broad, evidence-based strategies to address the opioid epidemic, 
including patient and provider education, pain management and access to 
non-pharmacological modalities, risk mitigation strategies, and 
addiction treatment for Veterans with SUD. This critical work saves 
lives.
    My colleagues and I are prepared to respond to any questions you 
may have.
                                 ______
                                 

                  Prepared Statement of Julie Kroviak

    Chairwoman Miller-Meeks, Ranking Member Brownley, and Subcommittee 
Members, thank you for the opportunity to discuss the Office of 
Inspector General's (OIG) oversight of the Veterans Health 
Administration's (VHA) domiciliary substance use disorder treatment 
program. The OIG's Office of Healthcare Inspections reviews the quality 
and safety of health care provided across VHA and communicates the 
findings through a variety of public reports. These include results 
from hotline inspections, national reviews, comprehensive healthcare 
inspections, vet center inspections, and Veterans Integrated Service 
Network (VISN) reviews. For each of these reports, OIG clinical review 
teams provide recommendations for improving processes or further 
reducing risks to the veterans who entrust their health care to VHA.
    VHA faces significant challenges in meeting the needs of 
individuals with substance use disorders. The devastating effects on 
veterans, their families and caregivers, and communities cannot be 
overstated. Veterans with substance use disorders often have co-
occurring mental health issues that can place them at higher risk for 
suicide. Given that VHA's top clinical priority is to reduce veteran 
suicide, evidence-based substance use disorder treatment programs are 
imperative to addressing the clinical needs of these high-risk 
patients. When both VHA and community care providers are engaged in 
managing these patients, the coordination must be seamless and 
collaborative.
    This testimony focuses on OIG reports that have identified 
challenges with community care access and coordination for high-risk 
patients. The OIG believes the findings and recommendations should be 
considered by all VHA providers and leaders managing patients with 
complex mental health needs including substance use disorders.

NONCOMPLIANCE WITH COMMUNITY CARE REFERRALS FOR SUBSTANCE ABUSE 
RESIDENTIAL TREATMENT AT THE VA NORTH TEXAS HEALTH CARE SYSTEM

    In August 2021, the OIG hotline received allegations that staff for 
the domiciliary substance use disorder treatment program (DOM SUD) at 
the VA North Texas Health Care System (VA North Texas) placed patients 
on waitlists for two to three months and failed to offer non-VA 
community residential care referrals for substance use disorder 
treatment.\1\ The complainant also alleged that VA North Texas staff 
denied patients' requests for community residential care referrals, 
whereas patients from another VISN 17 facility, the Central Texas 
Veterans Health Care System (Central Texas VA), received community 
residential care treatment. During the course of the OIG staff's review 
of the allegations (including examining 15 VA North Texas DOM SUD 
consults (referrals) and electronic health records for 10 patients), 
the team identified additional concerns related to compliance with 
required scheduling procedures and the assignment of mental health 
treatment coordinators to patients awaiting admission. To understand 
the context for the resulting report's findings, it is important to 
consider VHA's program goals and requirements.
---------------------------------------------------------------------------
    \1\  VA OIG, Noncompliance with Community Care Referrals for 
Substance Abuse Residential Treatment at the VA North Texas Health Care 
System, January 31, 2023.

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Background

    Mental health residential rehabilitation treatment programs (MH 
RRTPs) provide 24-hour treatment and rehabilitative services to 
patients with a range of treatment needs and include domiciliary 
substance use disorder programs. MH RRTP is an umbrella term for the 
range of residential programs that provide treatment to patients 
experiencing homelessness, substance use disorders, posttraumatic 
stress disorder, as well as other medical and mental health conditions. 
To be eligible for an MH RRTP referral, veterans must need a higher 
level of care than an outpatient program but not be at imminent risk to 
themselves and others, and not meet criteria for a medical or acute 
mental health admission. VHA requires that each facility provide access 
to care at MH RRTPs through service agreements with other VA facilities 
or through referral to non-VA community residential care facilities.
    VA North Texas, part of VISN 17, includes a 40-bed DOM SUD at the 
Dallas VA Medical Center and a 69-bed DOM SUD at the Sam Rayburn 
Memorial Veterans Center in Bonham, Texas. The Central Texas VA is in 
Temple, Texas, and has a 169-bed general domiciliary that offers 
substance use disorder treatment as a ``track.''
    According to VHA's requirements, patients referred to MH RRTPs must 
be screened within seven business days by a team that includes a 
licensed mental health professional and a medical provider to determine 
whether admission is appropriate. If accepted, the patient must receive 
a tentative admission date and a point of contact at the MH RRTP.\2\ So 
VHA can track admission wait times, the patient must be added to the 
pending bed placement list.\3\ Since 2018, VHA has required staff to 
include information in the patient's electronic health record to 
improve tracking of program wait times and capacity.\4\
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    \2\ VHA Directive 1162.02, Mental Health Residential Rehabilitation 
Treatment Program, July 15, 2019. Tentative admission date refers to 
the MH RRTP staff's expected date of bed availability.
    \3\ VHA Directive 1002, Bed Management Solution for Tracking Beds 
and Patient Movement Within and Across VHA Facilities, November 28, 
2017.
    \4\ VHA Deputy Under Secretary for Health for Operations and 
Management (10N) memo, ``Mental Health Residential Rehabilitation 
Treatment Programs (MH RRTP) CPRS Note Templates Implementation,'' July 
30, 2018.

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Community Care Program Eligibility Criteria

    The John S. McCain III, Daniel K. Akaka, and Samuel R. Johnson VA 
Maintaining Internal Systems and Strengthening Integrated Outside 
Networks Act of 2018 (MISSION Act) mandated changes to VHA's community 
care program.\5\ Those changes led to VHA's Office of Community Care 
issuing implementation guidance stating that ``wait time and drive time 
access standards are only applicable to primary care, specialty care, 
and non-institutional extended care services.'' The guidance further 
said MH RRTPs ``are considered institutional extended care services'' 
and do not follow the same wait-time standards.\6\ When MH RRTP care is 
not available within VA facilities for an eligible patient who ``elects 
to receive care in the community,'' VHA will authorize community 
residential care. Further, for MH RRTP admission wait times greater 
than 30 calendar days, facility staff must offer the patient 
alternative care that addresses the patient's needs and preferences 
including a referral to community residential care or another VHA 
program. Additionally, facility staff should discuss outpatient care 
options with the patient while the patient awaits MH RRTP admission. It 
is important to note that the COVID-19 pandemic put additional stresses 
on VHA and that the Texas facilities were not alone in facing long wait 
times. In February 2021, VHA estimated that 3,500 patients nationally 
were pending admission with an average wait time of more than 150 days. 
At that time, VHA required MH RRTP staff to provide alternatives, 
including community residential care, if unable to admit patients 
within 30 days.\7\
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    \5\ MISSION Act, Pub. L. No. 115-182, 132 Stat. 1393 (2018).
    \6\ VHA Office of Community Care, ``Field Guidebook: Specialty 
Programs,'' updated November 3, 2021. The Office of Community Care 
determines a patient eligible for community mental health care when the 
wait time is greater than 20 days or the drive time is greater than 30 
minutes for a VHA outpatient mental health appointment.
    \7\ VHA Assistant Under Secretary for Health for Clinical Services 
memorandum, ``Ensuring Access to Residential Treatment for Veterans 
with Mental Health and Substance Use Disorders during the Pandemic,'' 
February 11, 2021.

VA North Texas DOM SUD Wait Times Exceeded Requirements and Staff 
---------------------------------------------------------------------------
Failed to Refer Patients to Community Residential Care as Required

    The OIG team reviewed 15 VA North Texas DOM SUD consults to 
determine admission wait times and evaluate whether staff offered 
community residential care. The team substantiated the allegation that 
VA North Texas staff placed patients on waitlists for two to three 
months and failed to offer community residential care referrals during 
most of fiscal years 2020 and 2021, inconsistent with VHA requirements. 
It is important to note that the OIG did not identify any adverse 
clinical outcomes due to the patients' delayed access to residential 
care.
    In March 2020, due to the pandemic, facility leaders restricted 
access to the Dallas DOM SUD to local veterans, in accordance with VHA 
guidance. The Dallas DOM SUD subsequently reopened to a broader group 
of patients but still with reduced capacity in September 2020. The 
Bonham DOM SUD remained open during the pandemic at reduced capacity 
until January 2022, when admissions were halted until June 2022 due to 
COVID-19 concerns. VHA data indicated that the Dallas and Bonham DOM 
SUDs' average wait time was 30 days or greater from the third quarter 
of fiscal year 2020 through the second quarter of fiscal year 2021, 
likely due to pandemic-related restrictions.
    Of the 10 North Texas patients' records the OIG reviewed, five had 
one DOM SUD consult placed and the other five had two consults placed 
during the review period, resulting in a total of 15 consults examined. 
Of the 15 consults, 13 were referrals to the Bonham DOM SUD and two 
were referrals to the Dallas DOM SUD. Seven consults were closed when 
the patient was admitted within 30 days, declined screening, or was not 
approved for admission. Among the eight remaining consults, two were 
closed when the patients declined admission and six resulted in 
patients waiting an average of 79 days before VA North Texas staff 
offered DOM SUD admission or removed the patient from the pending bed 
placement list. For seven of the eight consults, staff documented that 
the ``anticipated admission date exceeds 30 days; however, there is no 
available alternative to consider at this time.''
    The OIG determined that the VA North Texas chief for Patient 
Administration Services, who oversees community care, misinterpreted 
community care guidance and provided inaccurate information to VA North 
Texas leaders and staff. Specifically, the Office of Community Care's 
guidance states that community care wait time standards were not 
applicable to MH RRTP. Facility staff should have instead followed VHA 
policy requiring a patient with a schedule wait time of greater than 30 
days be offered alternative residential treatment or another level of 
care. Alternative residential treatment could include a referral to a 
community program, another program in the VISN, or another program in 
another VISN.\8\
---------------------------------------------------------------------------
    \8\ VHA Directive 1162.02.
---------------------------------------------------------------------------
    However, the Patient Administration Services chief told the OIG 
team during the review that MH RRTPs are ``excluded from the MISSION 
Act'' and not eligible for community care based on access standards--
reflecting an inaccurate understanding of the Act. In contrast, the 
national director of the MH RRTP reported that although drive time and 
wait time standards do not apply to DOM SUDs, community care referrals 
are expected when a patient is determined to require a residential 
level of care and VHA is unable to provide treatment within the 
required timeframe.
    In September 2020, the MH RRTP national program office released 
guidance that included instructions for community care referrals. In 
February 2021, VHA provided guidance that VISN chief mental health 
officers and facility leaders must ensure that patients who require a 
residential level of care are offered a VA MH RRTP bed or community 
residential care. VHA further required that each facility provide the 
operational status of MH RRTP beds and ``information on the 
availability of community based residential treatment options.'' \9\ 
VISN 17's response to the February 2021 guidance indicated that the 
Dallas and Bonham DOM SUDs were not making community residential care 
referrals.
---------------------------------------------------------------------------
    \9\ VHA Assistant Under Secretary for Health for Clinical Services 
memorandum.
---------------------------------------------------------------------------
    In December 2021, the OIG informed VISN 17 and VA North Texas 
leaders of staff's failure to comply with community residential care 
referral expectations and requested corrective action be taken to 
address staff education and potential patient treatment needs. VA North 
Texas leaders communicated referral requirements to Office of Community 
Care and Mental Health Services staff and reviewed all community 
residential care consults placed from October 1, 2019, through November 
30, 2021. Additionally, in response to the OIG's request, VA North 
Texas staff completed a clinical review to ensure appropriate follow-up 
for patients referred from October 1, 2019, through December 31, 2021, 
to the Dallas and Bonham DOM SUDs whose wait times were greater than 30 
days.
    The OIG made a total of five recommendations in this report.\10\ 
The first recommendation is for the VA North Texas director to ensure 
that staff provide alternative treatment options, including community 
care when MH RRTP admission wait times exceed 30 days. The second 
recommendation calls on the director to conduct a comprehensive review 
of the management of community residential care referrals. They 
concurred in principle with this recommendation. The remaining three 
recommendations are described below.
---------------------------------------------------------------------------
    \10\ The OIG considers all five recommendations currently open 
pending the submission of sufficient documentation that would support 
that adequate progress has been made on implementation to close them. 
The OIG requests updates on the status of all open recommendations 
every 90 days, which are then reflected on the recommendations 
dashboard found on the OIG website. For this report, the OIG will 
request the first update on or about May 1, 2023.

---------------------------------------------------------------------------
VA Central Texas Compliance

    In contrast to the VA North Texas's failures, the OIG's review of 
two patients referred to the Temple DOM SUD by VA North Texas staff 
indicated the VA Central Texas staff placed consults and scheduled 
patients in accordance with VHA policy. Further, VA Central Texas 
developed procedures for community residential care referrals when MH 
RRTP wait times were greater than 30 days.

Inadequate VISN Oversight

    The OIG determined that VISN 17 leaders did not ensure VA North 
Texas leaders' adherence to the national MH RRTP policy. According to 
the MH RRTP directive, each VISN mental health lead is responsible for 
ensuring that all VISN MH RRTPs collect data sufficient for oversight 
related to VHA policy implementation.\11\ Additionally, the national 
director of the MH RRTP confirmed the VISN has oversight responsibility 
to ensure eligible patients have access to a residential level of care, 
although there are not defined expectations related to community care 
utilization monitoring. The VISN 17 chief mental health officer 
provided guidance to VA North Texas leaders on three occasions in 2021 
regarding the use of community residential care. However, she reported 
that the VISN role did not have the authority to ensure policy 
adherence or ``direct oversight'' because ``oversight is at the local 
facility management level.'' The third report recommendation is for the 
under secretary for health to make certain that VISN leaders provide 
adequate oversight to ensure that access to care for MH RRTPs is 
provided consistent with VHA policy.
---------------------------------------------------------------------------
    \11\ VHA Directive 1162.02, Mental Health Residential 
Rehabilitation Treatment Program, July 15, 2019.

---------------------------------------------------------------------------
Bonham MH RRTP Nonadherence with VHA Scheduling Requirements

    During the inspection, the OIG team also identified that the Bonham 
MH RRTP standard operating procedure was inconsistent with VHA's 
minimum scheduling effort requirements, as it instructed schedulers to 
close a consult after three failed scheduling contact attempts rather 
than the four required. Since 2016, VHA has required providers to 
document a request for other services in the referred patient's 
electronic health record. The second attempt must use a different 
method of contact and can be completed the same day as the first 
attempt, while the third and fourth attempts must be on different days. 
To allow the patient time to respond, staff must wait a minimum of 14 
calendar days from the second contact attempt before determining the 
action on the consult request, such as closing the consult. 
Additionally, the Bonham MH RRTP staff were attempting to contact 
patients by phone and not using other modes of contact. Failure to 
adhere to VHA minimum scheduling requirements may hinder efficient 
patient scheduling and contribute to the barriers patients experience 
in accessing DOM SUD services. The fourth recommendation is for the VA 
North Texas director to ensure that Bonham MH RRTP scheduling 
procedures are consistent with VHA minimum scheduling effort 
requirements.

Mental Health Treatment Coordinator Assignment

    Finally, the OIG found that VA North Texas policy did not include 
information about the requirement for MH RRTP staff to assign a mental 
health treatment coordinator for patients awaiting admission to a 
residential program. Since 2012, VHA has required facility staff to 
assign a mental health treatment coordinator to patients who are 
receiving treatment in an outpatient mental health setting, have been 
admitted to an inpatient mental health setting, or are ``waiting to 
engage in a different level of care'' including an MH RRTP bed. 
However, in an interview, the national director for the MH RRTP 
acknowledged not having an assignment process for patients pending MH 
RRTP admission. This failure to develop a national-level process likely 
contributed to the VA North Texas MH RRTP leaders' lack of knowledge 
that the VA North Texas policy should address the identification and 
assignment of a mental health treatment coordinator for accepted 
patients awaiting admission. This lack of policy awareness may not only 
contribute to a coordinator not being assigned but can also diminish 
the likelihood of patients' engagement in outpatient care while 
awaiting admission. The fifth report recommendation relates to 
strengthening coordinator assignment procedures for patients waiting 
for an MH RRTP bed.

OTHER OIG REPORTS CITING CONCERNS WITH COMMUNITY CARE COORDINATION OF 
VETERANS WITH COMPLEX MENTAL HEALTH NEEDS

    Coordinating medical care between the VHA care system and community 
providers remains a challenge, particularly for managing patients with 
complex mental health needs. The OIG has identified persistent 
administrative and communication errors or failures among VHA, its 
third-party administrators, and community care providers, as well as 
between the care providers and their patients. These deficiencies 
challenge the considerable efforts of VHA personnel to ensure a 
seamless experience for veterans. Many OIG reports have described the 
frustrations and, most importantly, the risks associated with patients 
referred to the community. The following reports exemplify the 
consequences that poor care coordination contributes to for high-risk 
patients.
    In a report on the deficiencies found in the care and 
administrative processes for a patient who died by suicide, the review 
team found that administrative errors and confusion in the Phoenix VA 
health care facility's community referral process delayed specialized 
psychological testing for a veteran. The veteran died by suicide never 
having received the appropriate testing and resulting targeted 
treatment.\12\
---------------------------------------------------------------------------
    \12\ VA OIG, Deficiencies in Care and Administrative Processes for 
a Patient Who Died by Suicide, Phoenix VA Health Care System, Arizona, 
March 31, 2021.
---------------------------------------------------------------------------
    Another oversight report focused on a patient who ultimately died 
by suicide after not receiving several authorized community care 
counseling sessions. This was due to deficiencies in the coordination 
of the patient's care between the Memphis VA facility's community care 
staff, providers in the community, and the third-party 
administrator.\13\ In addition, the patient suffered from 
hyperthyroidism, a condition that can aggravate anxiety. The patient 
declined a referral to endocrinology at the facility, due to the 
distance from home, but was never offered a referral to the community.
---------------------------------------------------------------------------
    \13\ VA OIG, Deficiencies in Care, Care Coordination, and Facility 
Response to a Patient Who Died by Suicide, Memphis VA Medical Center in 
Tennessee, September 3, 2020.

---------------------------------------------------------------------------
CONCLUSION

    High-quality care demands that patients receive the necessary care 
provided by qualified clinicians in a timely manner. This is even more 
critical for individuals deemed to be at high risk due to their mental 
health and substance use conditions. The pandemic disrupted healthcare 
delivery in all settings, including addiction treatment, yet at the 
same time increased the demand for such interventions. VHA will 
continue to rely on community providers to deliver care when a 
veteran's needs cannot be met within VA's own facilities. The reports 
highlighted in this testimony call attention to the risks introduced 
when that care is not offered and even more concerning, when the care 
is not coordinated.
    Chairwoman Miller-Meeks, Ranking Member Brownley, and members of 
the Subcommittee, this concludes my statement. I would be happy to 
answer any questions you may have.
                                 ______
                                 

                  Prepared Statement of Daniel Elkins

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                    Prepared Statement of Jen Silva

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                   Prepared Statement of Thomas Sauer

    Chair Miller-Meeks, Ranking Member Brownley, and members of the 
Subcommittee:
    I am honored to testify before you today. My name is Tom Sauer, and 
I'm a Navy and Marine Corps Veteran, having spent the better part of my 
adult life wearing the cloth of our Nation. I'm a former enlisted 
Marine infantryman, a 2006 Naval Academy graduate, and a former Navy 
Explosive Ordnance Disposal officer. Today, however, I'm the owner and 
CEO of Miramar Health, a Veteran-owned and operated Community Care 
Provider for intensive substance use disorder (SUD) and mental health 
treatment, exclusively for America's Veterans.
    Mental health and addiction treatment are deep passions of mine, 
because depression and addiction killed my dad. Five days before I 
graduated from high school, and three weeks before I shipped out for 
the Marines in 1999, a methamphetamine overdose took his life after 
decades of struggle, just like so many millions of Americans suffering 
from our country's disastrous mental health and addiction crisis.
    Thanks to recent legislation, thousands of veterans have enhanced 
access to life-saving mental healthcare and addiction treatment within 
the VA's Community Care Network (CCN). We've provided intensive, 
custom-tailored, world-class mental health and addiction treatment for 
nearly 250 Veterans from a dozen VA Medical Centers across the Western 
United States, typically for 30, 60, and sometimes 90+ days. This 
treatment is for our veterans who are truly suffering, in crisis, and 
often near death from suicide or overdose resulting from America's 
disastrous mental health and addiction crisis.
    In three and a half years, we've grown from one small clinic with 
six employees, to eight residential facilities and one large outpatient 
facility. These facilities are staffed by nearly 100 phenomenal 
physicians, nurses, psychologists, therapists, medical technicians, 
case managers, and support staff, many of whom are Veterans themselves. 
I could not be any prouder of them.
    I didn't come all the way out here to tell you this just so I could 
pat myself on the back, but rather to simply convey the sincerity of 
our intentions and to lay out how important this challenge is. Miramar 
believes in our partnership with the VA by bridging both capability and 
capacity gaps within certain VAMCs and in being an advocate to Veterans 
in need, all while providing them with the highest quality care.
    In other words, we do not consider ourselves to be just another 
government contractor. We are partners and teammates with the VA, and 
we're here asking for your help to ensure our Nation's Veterans receive 
the lifesaving care they need and deserve by strengthening that 
partnership.
    The overwhelming majority of front-line, boots-on-the-ground VA 
personnel we directly interact with are fantastic, dedicated, and 
lifesaving public servants. There are many who, in my mind, deserve 
medals and parades for saving the lives of Veterans.
    I am here today to advocate for veterans in need to access care 
ANYWHERE, IMMEDIATELY, and we can figure out the paperwork later. The 
current VA policy of having 30 days to find a bed in a given region 
does not meet the URGENT LEVEL of this CRISIS.
    Specifically, we've encountered several occasions where, despite 
community care being available for a Veteran in crisis, they're either 
put onto waiting lists for up to 30 days before receiving care, when 
they don't have 30 minutes without becoming a very real risk to suicide 
or overdose. I have first-hand knowledge of these suicides and overdose 
deaths since I've owned Miramar, so I understand the devastation this 
policy can cause.
    We believe this issue could be rather easily corrected through a 
legislative carve-out for Community Care eligibility, as with Urgent 
Care, when it comes to urgent and emergency mental health and addiction 
treatment.
    This could be done by clarifying and ensuring the COMPACT Act is 
being implemented as intended and that Veterans are aware of this 
option for receiving care.
    We urge you to ensure that our veterans have access to the care 
they need when they need it through the Community Care Network.
    We appreciate your consideration of this matter, and we are willing 
to work with you to address these issues and ensure that our guys and 
gals get the care they so desperately need.
    Thank you, Chair and members of the Subcommittee. Each of you, your 
staffers, and the committee's staff are champions for America's 
Veterans, so I am exceptionally grateful to you and your commitment to 
serving them, and that you are holding this important hearing today.
    In conclusion, thank you for addressing the issues we raised today. 
Veterans' lives depend on it. Thank you again for the opportunity to 
appear, and I look forward to answering your questions.
                                 ______
                                 

                 Prepared Statement of Brendan Dowling

    Good morning, Chair Miller-Meeks, Ranking Member Brownley, and 
distinguished members of the subcommittee.
    My name is Brendan Dowling, and I am currently Miramar Health's 
Veteran Outreach Manager.
    I am formerly a Navy SEAL that served in multiple military 
campaigns for the Global War on Terror from 2001-2014. My service 
spanned across numerous deployments in multiple combat zones.
    Since last summer, I have had the pleasure of visiting over 141 VA 
facilities that provide medical, clinical, counseling, or VBA services 
to Veterans across the Western US.
    This includes 94 VHA facilities; 18 Medical Centers, 74 Community 
Based Outpatient Clinic's, and 35 Veteran Centers.
    I look forward to answering any questions you may have.

                        Statement for the Record

                              ----------                              


              Prepared Statement of Cohen Veterans Network

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


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