[House Hearing, 118 Congress]
[From the U.S. Government Publishing Office]
SSG FOX SUICIDE PREVENTION GRANTS:
SAVING VETERANS' LIVES
THROUGH COMMUNITY CONNECTION
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HEARING
before the
SUBCOMMITTEE ON HEALTH
OF THE
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED EIGHTEENTH CONGRESS
FIRST SESSION
__________
TUESDAY, DECEMBER 12, 2023
__________
Serial No. 118-44
__________
Printed for the use of the Committee on Veterans' Affairs
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Available via http://govinfo.gov
__________
U.S. GOVERNMENT PUBLISHING OFFICE
54-525 WASHINGTON : 2024
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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
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TUESDAY, DECEMBER 12, 2023
Page
OPENING STATEMENTS
The Honorable Mariannette Miller-Meeks, Chairwoman............... 1
The Honorable Julia Brownley, Ranking Member..................... 2
WITNESSES
Dr. Erica Scavella, MD, Assistant Undersecretary for Health for
Clinical Services, Veterans Health Administration, U.S.
Department of Veterans Affairs................................. 4
Accompanied by:
Dr. Todd Burnett, Psy.D., Senior Consultant for Operations,
Suicide Prevention Program, Veterans Health
Administration, U.S. Department of Veterans Affairs
Ms. Missy Meyer, Director of Community Integration, America's
Warrior Partnership............................................ 6
Mr. Ken Falke, Chairman/Founder, Boulder Crest Foundation........ 7
Ms. Joyce King, Project Director, SSG Fox Veterans Suicide
Prevention Program, Sheppard Pratt............................. 9
APPENDIX
Prepared Statements Of Witnesses
Dr. Erica Scavella, MD, Prepared Statement....................... 31
Ms. Missy Meyer Prepared Statement............................... 35
Mr. Ken Falke Prepared Statement................................. 38
Ms. Joyce King Prepared Statement................................ 45
Statements For The Record
Swords to Plowshares............................................. 49
Wounded Warrior Project.......................................... 53
D'Aniello Institute for Veterans and Military Families (IVMF) at
Syracuse University............................................ 54
SSG FOX SUICIDE PREVENTION GRANTS: SAVING VETERANS' LIVES
THROUGH COMMUNITY CONNECTION
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TUESDAY, DECEMBER 12, 2023
U.S. House of Representatives,
Subcommittee on Health,
Committee on Veterans' Affairs,
Washington, D.C.
The subcommittee met, pursuant to notice, at 10:31 a.m., in
room 360, Cannon House Office Building, Hon. Mariannette
Miller-Meeks [chairwoman of the subcommittee] presiding.
Present: Representatives Miller-Meeks, Radewagen, Bergman,
Murphy, Van Orden, Luttrell, Kiggans, Brownley, Deluzio, and
Landsman.
OPENING STATEMENT OF MARIANNETTE MILLER-MEEKS, CHAIRWOMAN
Ms. Miller-Meeks. Good morning. The Subcommittee on Health
will come to order. It is a sad reality that roughly 17
veterans, on average, are losing their lives to suicide every
single day. One death alone from suicide is one too many. It is
a sobering reality, and the loss of just one veteran has a
profound ripple effect on their fellow veterans, their
families, and their communities. Like most of my colleagues
across this dais, one of my top priorities on this committee is
to decrease the number of veteran suicides. As we have examined
this year through multiple hearings, there are many factors
that come into play when a veteran loses hope. As we have also
examined, there should be no limits on what we can examine as
potential solutions.
As a 24-year Army veteran, I have seen unique challenges
that many of my fellow Service members and veterans face, both
in service and as they adjust to living back in their
communities. It is imperative that we continue to work on
solutions, such as the Staff Sergeant Parker Gordon Fox Suicide
Prevention Grant program to give veterans and their family
members the support that they so desperately need and deserve,
and that support is available wherever they live.
Over 60 percent of veterans who died by suicide in 2021
were not seen in Veterans Health Administration (VHA) in 2020
or 2021, and over 50 percent had received neither VHA nor
Veterans Benefits Administration (VBA) services. In order to
reach all veterans, we must continue to expand our work in the
community. Fox Grants assist veterans and their families by
providing veteran based outreach, veteran suicide prevention
services, connections to the VA, and additional community
resources, with the focus on reducing the number of veteran
suicides. Throughout this process, veterans and their families
are provided assistance on how to connect with VA clinical or
nonclinical help if eligible.
According to the VA's just released Annual Suicide
Prevention Report, through June 2023, grantee organizations
reached more than 10,000 veterans and their families in need.
Coordinated assessments by these organizations identified
approximately 130 imminent risk veterans and resulted in 800
nonemergency referrals and approximately 1,800 social service
referrals to address drivers of risk such as homelessness,
unemployment, income supports, and legal services. These are
not just numbers; these are veterans' lives.
The committee recently sent out a request for information
to grantees of the program and received an overwhelming amount
of positive feedback. As we look to the future of this grant
program, I am eager to better understand what can be done to
address any process challenges and expand on any potential
opportunities. I would like to thank the VA for their
commitment in providing aggressive technical assistance to
grantees through various forums and working groups. The program
office responsible for implementing this pilot embraced this
mission, and we look forward to continued dialog with them as
we move forward.
Thank you all for being here, and I look forward to hearing
the perspectives from our witnesses on this important program,
especially now as we continue to struggle with the stubborn
suicide rate among veterans. With that, I yield to Ranking
Member Brownley for her opening statement.
OPENING STATEMENT OF JULIA BROWNLEY, RANKING MEMBER
Ms. Brownley. Thank you, Chairwoman Miller-Meeks. Today's
hearing will focus on one of the most complex topics and
biggest challenges our subcommittee faces, and that is suicide
amongst our Nation's veterans. At the outset, if anyone
listening today is struggling with thoughts of suicide, or if
you know a veteran or service member who is in crisis, please
reach out to the Veterans Crisis Line. Simply dial 988 and
press 1. You can also send a text message to 838255 or go to
veteranscrisisline.net for an online chat. You will reach
trained responders who are ready to help.
Last month, the Department of Veterans Affairs released its
2023 National Veteran Suicide Prevention Annual Report, which
provided data on suicide mortality among veterans and
nonveteran U.S. adults over 2 decades from 2001 through 2021.
Sadly, the overall number of suicides among veterans rose
between 2020 and 2021. Women veterans were among the most
heavily impacted subpopulations in 2021, as there was a 24.1
percent increase in the age adjusted suicide rate for women
veterans, compared to 6.3 percent among male veterans.
Any life lost to suicide is a tragedy, and this committee
continues to examine all possible suicide prevention strategies
and ways to increase veterans' access to quality mental
healthcare. Over the past several years, Congress has passed
more than 40 veterans mental health bills through standalone
and omnibus legislation. These include the Commander John Scott
Hannon Veterans Mental Health Care Improvement Act, the
Veterans Comprehensive Prevention, Access to Care and Treatment
(COMPACT) Act, and the Support the Resiliency of our Nation's
Great Veterans (STRONG) Act. These bills contained dozens of
provisions that aim to increase veterans' access to mental
health care, strengthen VA's suicide prevention programs,
bolster VA's research and mental health workforce training,
establish pilots to examine complementary and integrative
approaches, and improve the transition from active duty to
veteran status.
One such pilot program was the Staff Sergeant Parker Gordon
Fox Suicide Prevention Grant Program. It was created in 2020
under the Hannon Act. It took some time for VA to stand up this
program and publish the necessary regulations. In September
2022, VA awarded the first round of grants to 80 organizations
in 43 states, the District of Columbia, and American Samoa. The
second round of grants was awarded about 3 months ago, with 77
of the original grantees receiving grants again, along with
three new grantees. These are now grantees in 43 states,
Washington, DC, Guam, and American Samoa.
The goal of the Fox Grant Program is not to expand access
to direct clinical care, rather it is to partner with
organizations that provide services to address some of the
upstream factors that can contribute to veteran suicide risk.
Such factors include housing instability, employment
instability, legal trouble, lack of social support and
engagement, and unstable interpersonal relationships. The
primary population Congress aims to reach through the Fox Grant
program is the approximately 60 percent of veterans dying by
suicide each year who have had no recent engagement with VA
healthcare.
I hope to hear more today about how grantees are putting
Fox Grant funds to use, and hopefully we will hear some success
stories about veterans whose lives may have been saved by this
program. I will acknowledge that it will be some time before
the potential benefits of this program will show up in VA's
annual suicide prevention report, as each report published
reflects data from 2 years earlier. However, before we consider
reauthorizing the Fox Grant Program, the subcommittee needs to
know more about the impact that the funds have had and see some
clear measures of success.
In accordance with the Hannon Act, within 18 months of
awarding the first Fox grants, that is, by March 19, 2024, VA
is required to provide an interim report to the House and
Senate Veterans Committees about the effectiveness of the Fox
Grant Program. Perhaps today's hearing can provide a preview of
VA's findings. I look forward to a robust discussion.
Madam Chairwoman, before I yield back, I wanted to take a
moment to recognize the service of the Republican Staff
Director of the Health Subcommittee, Ms. Christine Hill, who I
understand will be retiring soon. Back in early 2020, about 6
weeks before the pandemic, Christine and I had an opportunity
to travel with several other committee Staff to South Dakota
and North Dakota, where we visited the Cheyenne River Sioux
Indian Reservation and Standing Rock Sioux Indian Reservation.
We had a lot of fun and learned a lot.
We learned a lot on the trip about veterans' barriers to
healthcare, housing, and transportation, and we also got to
know each other a little better as we traversed several hundred
miles through Indian country. Counting her 20 years in the Air
Force after graduating from the academy, some time working in
the Senate and at the VA, and most recently, her 10 years with
the committee, Christine has spent over 36 of her career in
Federal service. We are sorry to lose her wealth of experience
and institutional knowledge, but Christine, your retirement is
very well deserved, and I wish you all the very best in your
third chapter. Thank you for your service to your fellow
veterans and to our Nation. With that, Chairwoman Miller-Meeks,
I yield back.
Ms. Miller-Meeks. Thank you, Ranking Member Brownley. I am
going to say ditto and save any comments for later. I would
like to introduce our witnesses on our panel today. Joining us
today Dr. Erica Scavella, Assistant Under Secretary for Health
and Clinical Services, Department of Veterans Affairs, Todd
Burnett, Senior Consultant for Operations, Suicide Prevention,
Department of Veterans Affairs, Psy.D. in Psychology, Missy
Meyer, Director of Community Integration, American Warriors
Partnership, Ken Falke, Chairman/Founder, Boulder Crest
Foundation, and Joyce King, Project Director, Staff Sergeant
Fox Veteran Suicide Prevention Program, Sheppard Pratt. Dr.
Scavella, you are now recognized for 5 minutes to deliver your
opening statement on the VA.
STATEMENT OF ERICA SCAVELLA
Dr. Scavella. Thank you. Good morning, Chairwoman Miller-
Meeks, Ranking Member Brownley, and distinguished members of
the subcommittee. Thank you for the opportunity today to
discuss the Staff Sergeant Parker Gordon Fox Suicide Prevention
Grant Program. Accompanying me today is Dr. Todd Burnett, our
senior consultant for operations within the Suicide Prevention
Program.
The grant program honors veteran SSG Parker Gordon Fox, who
served in the Army and joined the Army in 2014. Unfortunately,
he died by suicide in July 2021--2020, excuse me. The grant
program, authorized by Section 201 of the Hannon Act,
represents an important step in leveraging community networks
and expertise in veteran suicide prevention efforts beyond what
we can do within VA. The grant program complements VA's 10-year
national strategy for preventing veteran suicide. It supports
and aligns with the priority goals and the White House's
strategy for reducing military and veteran suicide.
Given the multiple factors that may lead to suicide death,
preventing suicide requires a comprehensive public health
approach. What this means in practical terms is that VA must
harness the full breadth of the Federal Government in close
partnership with States, Territories, Tribes, and local
governments, as well as collaboration with industry, academia,
communities, community-based organizations, families, and
individuals to prevent veteran suicide.
I am proud to report that the grant program is providing
resources toward community-based prevention efforts to meet the
needs of veterans, their families, and other eligible
individuals through outreach, suicide prevention services, and
connection to VA and community resources.
The impact of this program has been meaningful. I would
like to share two stories that illustrate just how this program
has affected those who have sacrificed for our Nation. The
first is a young woman who was pregnant, she was a veteran, and
she fled from a domestic violence situation and engaged a
grantee for services. She was enrolled in prenatal care and
other healthcare supports at VA. She is quoted as saying, ``I
could not have survived without your help.''
Another example is a Marine Corps veteran who presented to
a grantee with suicidal thoughts seeking help for combat
related trauma. After getting linked to help, he confided that
he had been engaged in steps toward ending his own life, and
had he not contacted the grantee, that would have happened. He
says that the services saved his life.
VA has collected and received many more examples like
these. These engagements within grantee communities are
critical interventions needed across the Nation to prevent
veteran suicide. As of October 31, 2023, grantees have
completed approximately 20,000 outreach contacts and engaged
over 3,500 participants. The grant program facilitates
engagement within clinical mental health care, but it is unique
in that most services that are provided are actually not
clinical.
As the Nation continues to recognize, as we as physicians
recognize, as we as healthcare community recognize, research
evidence confirms that the social determinants of health are
drivers of suicide risk. The grant program takes a bold step to
acknowledge and meet the need for suicide prevention
interventions outside of clinical care. The grant program is
proudly in its second year. Beyond the formal evaluation
process, we are implementing solutions for lessons learned in
real time to improve the grantee and participant experience.
Just last week, VA convened its fourth two-day technical
assistance meeting in Orlando, Florida, with over 150 grantee
representatives present. Attendees received tailored technical
assistance as well as the opportunities to connect with grantee
peers.
In conclusion, we are grateful for the enactment of the
Hannon Act and other laws that have helped to fuel advancement
in veteran suicide prevention. The grant program is one tool
that VA has rolled out in its public health approach to veteran
suicide prevention. We need everyone at the table. We need
everyone working in the same direction. This requires both
moving away from the belief that suicide prevention rests
solely on the shoulders of our mental health providers and
moves us further toward engaging within and outside of clinical
healthcare organizations and delivery systems to decrease both
the individual and societal risks of suicide.
Suicide is preventable, and each of us has a role to play.
This is our mission, and we are so thankful that you are with
us along this journey. This concludes my testimony. My
colleague and I are prepared to answer your questions.
[The Prepared Statement Of Erica Scavella Appears In The
Appendix]
Ms. Miller-Meeks. Thank you, Dr. Scavella. Ms. Meyer, you
are now recognized for 5 minutes to deliver your opening
statement.
STATEMENT OF MISSY MEYER
Ms. Meyer. Chairwoman Miller-Meeks, Ranking Member
Brownley, members of the subcommittee, thank you so much for
your invitation to testify today regarding the Staff Sergeant
Parker Gordon Fox Suicide Prevention Grant. America's Warrior
Partnership is a proud recipient of the Fox Grant, and we
utilize a unique upstream community integration model to
accomplish the goals set forth by this grant to work with
communities to prevent suicide.
I would like to share a story. On November 13, a post-9/11
Army veteran called our national network with an active plan to
end his own life. He had moved from Florida--from New York to
Florida after a divorce, and he was facing bankruptcy. He was
in crisis. He was not happy with his care he received from the
VA in New York. He was tired of taking all the pills he said
that were prescribed for both his Post-Traumatic Stress
Disorder (PTSD) and bipolar disorders. He had an appointment
the following morning for a medical evaluation with the Fort
Myers, VA. This gentleman, we wanted to get a referral for
mental health the next morning. He was in agreement with that.
I reached out to the local suicide prevention coordinator there
in Fort Myers and was unable to get a call back. I left a
message that we had an actively suicidal veteran that needed
care and that call has still not been returned. However, we
were able to connect with the 988 crisis line and get that
veteran the support that he needs. We are still working with
him and walking with him for as long as he will let us.
American Warriors Partnership (AWP) network staff worked
hard to connect that veteran with the services that he needed
and we are so thankful for the 988 crisis line being available
to us. While he states he loved his girlfriend too much to take
his own life, he certainly needed the support we were able to
offer.
Our goal is to improve the quality of life for veterans and
to end veteran suicide by empowering local communities to serve
them proactively and holistically before a crisis. In September
2022, outreach began with the Fox Grant and by March 2023, AWP
began enrolling Fox participants. Since that time, AWP has
completed intakes and suicide risk assessments for 1,057
warriors via the Columbia-Suicide Severity Rating Scale, as
required by the VA. One hundred eighty-five of those men and
women indicated some level of suicide risk. This means over 17
percent of that 1,057 had some level of suicidal ideation.
Once AWP knows a veteran or service member is experiencing
some level of suicidality, we must find them local and national
resources. In an acute suicidal crisis, as I said, that results
in a call to the crisis line and a referral to other local
counseling centers. However, there is no expedited care for Fox
participants. There is no special number or special
intervention to serve those people immediately. This is one of
the major shortcomings of the Fox program. There is no program.
It is a transaction. It needs to be relational, not a VA
sponsored phone call for assessments with no plan or
infrastructure on the backend connecting to services. The Fox
Grant Program needs to have follow up available for veterans in
need and making sure that that infrastructure is in place and
not having veterans disclosing these thoughts with no services
available to them.
Following the intake and suicide risk assessment, we create
a holistic service plan. If the veteran is willing, we conduct
additional assessments for the participant. There are nine
different assessments and questionnaires required for the
participant to be enrolled. Several assessments have ended with
an additional call to the 988 crisis line. Once the participant
has received referrals and has been connected to support, we
are required to then readminister the baseline assessments. We
have only had 6 of our 180 Fox participants complete that
entire process, and both Staff and veterans describe the
assessments as both repetitive and exhausting.
To eliminate redundancy, the psychosocial, Interpersonal
Support Evaluation List-12 (ISEL-12), and General Self-Efficacy
(GSE) assessments could be removed or combined and shortened
with other assessments. We already know that depression,
isolation, and financial hardships are risks for suicide. How
does continually assessing known stressors better our
prevention model?
In addition, the amount of data gathered is significant.
AWP has submitted thousands of forms to account for outreach
efforts and Fox Grant requirements, necessitating the hiring of
additional administrative staff to handle the load. We are in
year two of the grant's lifecycle, and the data collection tool
was made available to AWP just yesterday. We have not tested
that system to see how it will work from here on.
Finally, there is no clear measure of success for the Fox
Program. Is it a number or an outcome? Does success come with
potential increase in funding, and are those organizations
unable to meet their metrics held to account, removed, or
reduced? There is no bigger picture on how all this data will
impact VA policy to improve the lives of our veterans. Thank
you, subcommittee members, for the opportunity to testify
today.
[The Prepared Statement Of Missy Meyer Appears In The
Appendix]
Ms. Miller-Meeks. Thank you, Ms. Meyer. Mr. Falke, you are
now recognized for 5 minutes to deliver your opening statement.
STATEMENT OF KEN FALKE
Mr. Falke. Good morning. I want to begin by thanking this
committee for its essential and hugely impactful work on behalf
of our Nation's veterans and their families. Chairwoman Miller-
Meeks and Ranking Member Brownley, thank you for your
leadership and the opportunity to speak to the subcommittee
regarding the Staff Sergeant Fox Suicide Prevention Grant
Program. I also want to thank Representatives Bergman and
Houlahan, who as veterans themselves took the lead on the
creation of this legislation with the assistance of so many
others.
I served in the U.S. Navy for 21 years as a Special
Operations bomb disposal specialist. Since my retirement in
2002, I have become an advocate for my brothers and sisters. A
major driver of my work is the nearly unspeakable truth that
since 9/11, we have lost more members of the bomb disposal
community to suicide than we did on the battlefields. This
truth is nearly unspeakable because the work that my community
does on the battlefield is considered to be the world's most
dangerous job. Sadly, this epidemic is not limited to the bomb
disposal community.
In response to these challenges, my wife Julia and I
founded two nonprofit organizations, the Explosive Ordnance
Disposal (EOD) Warrior Foundation in 2004 and Boulder Crest
Foundation in 2010. Since then, our organizations have served
over 100,000 program participants. Boulder Crest Virginia is
the Nation's first privately funded wellness center dedicated
to combat veterans and their families. Our vision was to create
a place and programs where combat veterans could transform
their struggles into strength and growth.
Broadly speaking, our Nation's mental health system is not
focused on accomplishing this goal. The mental health system is
nearly exclusively focused on one thing when it comes to
clients and patients, and that is managing and mitigating
symptoms associated with times of struggle, often through a
combination of medication and talk therapy. This approach is
not working for far too many people, something made evident by
the highly distressing statistics around veterans mental health
and suicide.
In 1995, Dr. Richard Tedeschi coined a term posttraumatic
growth to describe how people reported growth in areas of their
lives in the aftermath of traumatic events. In 2014, we
partnered with Dr. Tedeschi in the development and delivery of
our Warrior Progressive and Alternative Training for Helping
Heroes (PATHH) program. Warrior PATHH is the first training
program ever designed to enable our Nation's combat veterans to
transform deep struggle into profound strength and lifelong
post-traumatic growth. It is a 90-day program,
nonpharmacological, peer delivered, and delivered at nine
permanent locations in the United States and through two mobile
training teams for a total of 11 Warrior PATHH programs per
month. In short, we have developed a program that achieved the
vision set forth to ensure that veterans could be as productive
at home as they were on the battlefield and live extraordinary
lives filled with passion, purpose, growth, connection, and
service.
In 2022, Boulder Crest was one of the 80 organizations
awarded a grant from Staff Sergeant Fox Suicide Prevention
Program. Our grant's for $725,000, which only covers the
delivery of 12 Warrior PATHHs and the administration and
reporting functions required by the grant. Boulder Crest and
our partners have delivered over 465 Warrior PATHH programs to
over 3,000 students. Across the more than 10 clinically
validated measurement tools that we use to measure the impact
of Warrior PATHH to include those required by the Fox Grant
program, participants report experiencing symptom reduction and
improved growth more than any other program.
The establishment of the SSG Fox Grant Program is a
realization of something I have long believed was necessary and
that is a true public-private partnership based on the goals of
ensuring at-risk veterans do not fall through the cracks and
the identification of innovative and effective programs that
are effectively and sustainably addressing the suicide epidemic
amongst veterans.
In light of the ongoing conversations with the VA and the
data from the VA funded Warrior PATHH participants, we propose
five key recommendations to enhance the program. The first one
is to remove the funding caps. Today, only 24 of the 132
annually delivered Warrior PATHH programs are funded under this
grant. Revise the eligibility criteria. We need to rethink the
use of the Columbia-Suicide Scale, primarily because we often
see the Patient Health Questionnarire-9 (PHQ-9), which is a
depression scale, scores out of sync with the Columbia scale.
As you know, depression is a leading cause of suicide.
We need to broaden the veteran eligibility. My personal
belief is that all veterans should be eligible for this
program, regardless of the score on a test that is only taken
for one day. Number four, we need to include traumatic brain
injury (TBI) centers. We need to expand the eligibility to
include leading privately funded clinical TBI centers. TBI is a
significant risk for veteran suicide and needs to be treated
clinically.
Finally, we believe that we need to expand the
collaborative partnership between the VA. We believe that the
more people that understand post traumatic growth, the better
chance they will learn to thrive in the aftermath of trauma and
help others do so. I believe these steps are vital to our
united mission to support our veterans' well-being and reduce
the veteran suicide epidemic. My team and I are committed to
being active contributing partners in this mission. I am deeply
thankful for the opportunity to address you today and look
forward to any questions.
[The Prepared Statement Of Ken Falke Appears In The
Appendix]
Ms. Miller-Meeks. Thank you, Mr. Falke. Ms. King, you are
now recognized for 5 minutes to deliver your opening statement.
STATEMENT OF JOYCE KING
Ms. King. I would like to begin by thanking the committee
for this transformational work on behalf of our Nation's
veterans and their families. I applaud Chairwoman Miller-Meeks
and Ranking Chair Member Brownley for their leadership, and I
greatly appreciate the opportunity to speak to the subcommittee
regarding the Staff Sergeant Fox Suicide Prevention Grant
Program.
My name is Joyce King. I serve as the director of the Staff
Sergeant Fox Suicide Prevention Grant Program at Sheppard
Pratt. I am a board-certified mental health therapist and
substance abuse counselor as well as a 16-year Air Force
veteran with more than 25 years of mental health, substance
use, and social services experience. Sheppard Pratt is the
Nation's largest private, nonprofit provider of mental health,
substance use, developmental disability, special education, and
social services in the country. We provide specialized services
for veterans, including supportive services for veteran
families, SSVF, Homeless Veteran Reintegration program, HVRP,
and clinically intensive grant per diem transitional housing.
Many of these programs are funded by the U.S. Department of
Veterans Affairs.
Collectively, Sheppard Pratt's veteran services assists
approximately 1,200 homeless veterans every year in urban,
rural, and suburban communities across Maryland and in select
counties in West Virginia. Many of our staff are veterans,
including some staffs who were previous clients. The dedication
and commitment of our team drives our impact. We have helped
over 5,235 homeless veteran and veterans' families to obtain
permanent housing. Our HVRP program helps homeless veterans to
obtain employment with an average wage of just under $20 an
hour.
In 2022, the VA released a Staff Sergeant Fox Grant notice
of funding opportunity. Its deep focus on community connection,
well-being, and suicide prevention responded to a clear gap in
the community-based services for veterans. Accordingly, we
jumped at the opportunity to better serve our veteran
community. The application process was well organized and
transparent with significant flexibility and approach provided
by the VA. The staff of the VA deserve credit for designing and
implementing a disciplined, efficient application process.
Sheppard Pratt was honored to be awarded the Staff Sergeant
Fox Grant in September 2022. Our implementation strategy
combines a comprehensive and holistic strategy set selected
based on the best available evidence for the greatest potential
to prevent suicide among veterans across Maryland. We leverage
current programming in relationships with veterans that are
high risk yet disengaged with the VA in mental health care.
Peer support is a critical component of our Staff Sergeant Fox
implementation strategy. Through this new funding, we have
trained veterans with lived experiences related to suicide and
mental health.
Our peer support specialists work directly with the
veterans and their families to promote connectedness, provide
holistic case management, and reduce risk factors associated
with suicide. In addition, case managers help veterans with a
range of health, housing, employment, and other needs. As the
Staff Sergeant Fox Grant Program was only recently launched,
our data is preliminary, but suggestive. During enrollment, 95
percent of our veteran clients indicate a need for mental
health services, 75 require connection or reconnection to the
VA services and supports, 65 percent report benefits
challenges, 60 percent request peer support and connection, and
another 60 percent report health, housing, employment, and
other challenges best addressed through case management.
The need, therefore, is clear. The impact of the Staff
Sergeant Fox Grant Program is best demonstrated through
stories. I would like to share a story of one of the
participants. I will call her Alice. Alice's story illustrates
the power of the Staff Sergeant Fox Grant Program as well as
the way in which community-based veteran services, including
SSVF and HVRP, combine to prevent suicide and promote well-
being more generally. Alice is a 48-year-old single veteran,
single female Navy veteran with a history of post-traumatic
stress disorder and traumatic brain injury.
Alice recently experienced two traumatic events. In 2022,
she was laid off. To make ends meet, she moved in with her
sister. In 2023, her sister passed away unexpectedly. With the
loss of both her job and her sister, she fell behind on her
rent. She had to make a choice between paying her rent or
buying food. In September 2023, she called Sheppard Pratt. Our
Staff Sergeant Fox Program team collaborated with SSVF to help
Alice find a more affordable housing option. To help Alice gain
employment, our Staff Sergeant Fox and HVRP teams worked
together to provide Alice with both a computer and
technological training. Alice dedicated herself to her job
search. Within a month of her calling Sheppard Pratt, she had a
new job in the IT field.
While Alice was working to obtain a new job and housing,
she was simultaneously grieving the loss of her sister. The
Staff Sergeant Fox peer support specialists were instrumental
in modeling healthy and effective coping strategies. Today,
Alice is working, living stably in safe housing and in a
healthy home. She shared the impact of Staff Sergeant Fox in
her exit survey. ``I can say for sure that the program and all
of the team went above and beyond my expectation. I honestly
never felt like I was alone during the process. In fact, the
opposite almost. I literally felt like a team was assigned to
me for different stages and aspects. I could not be more
grateful.''
Alice's comments about the Staff Sergeant Fox program are
echoed by other participants. John Woodard, a former Marine,
similarly was struggling with PTSD, a job loss, and eviction
when he connected with the Staff Sergeant Fox program. John
tells his story better than I can. He said, ``Sheppard's
veteran services got me and my family out of a situation that I
was in before where I was not appreciated and was not being
supported for my mental illness. Now I am in a better location
with my family, with a peaceful mind instead of a crime
infested area where I could hardly sleep because of fear and
hyper vigilance. I would like to thank the veteran services
programs for coming to my rescue. I have been using this time
to heal and to get help with my PTSD.''
[The Prepared Statement Of Joyce King Appears In The
Appendix]
Ms. Miller-Meeks. Thank you, Mrs. King. We appreciate your
testimony. We will now proceed to questioning. I will defer my
questions to the end. I now recognize Ranking Member Brownley
for any questions she may have.
Ms. Brownley. Thank you, Madam Chair. Dr. Scavella, I
wanted to ask you with regards to metrics and what the VA uses
as metrics to measure the success of these grants.
Dr. Scavella. Thank you for the question, Ms. Brownley. As
you heard from our fellow witnesses, there are a number of
metrics that we do use to assess how our veterans are doing.
There are some that are required, some that are taking place
later on in the process. I am going to ask Dr. Burnett to add
the details on which ones are required at the beginning and
which ones we conduct during the course of the care.
Dr. Burnett. Thank you. There are three primary areas that
we use to evaluate success of this program, the first being
reduction in suicide risk factors. The second, of course, being
perceptions of well-being. Hannon 201 requires that we make
assessments not only of immediate suicide risk, but also
overall well being to push the interventions as upstream as
possible to prevent the escalation of people who are feeling
suicidal. Third, is the connection to veterans who are most at
risk and currently unconnected to services.
Ms. Brownley. Certainly the first one is important. All
three are important. In my opinion, the two and three are a
little bit harder to actually assess and put into a metric.
What about, I mean, one of the other objectives of this grant
program is helping veterans who are not enrolled to enroll in
VA healthcare. Is that something that you measure? Also, one of
the other objectives of the program was to reach out to the
approximately 60 percent of veterans who have had no connection
to the VA at all. Are those metrics that you will be
collecting?
Dr. Burnett. Yes. We will provide information on both of
those things to you in the interim report that is coming to you
in the spring.
Ms. Brownley. Okay. Can you speak to in the VA's testimony,
they talked about the number of organizations and the amount of
money that has been awarded so far. If you break that down on a
per veteran basis, it is pretty expensive. Do you have any way
to explain why the cost per veteran of this grant program seems
to be so high?
Dr. Burnett. Thank you for that question. It is not
unexpected in the first year of this pilot program, as these
grantees are establishing their services. The first half of
last year, they were really getting their programs up. They
were not required to begin seeing veterans until January 2023.
What you have seen is that trend increase pretty dramatically.
As of December, for example, we had approximately 100 veterans
that were participating in the program, and by October 31, we
had 3,500. You had just around 120 outreach events in December,
and that reached 20,000 by the end of the year. We expect that
trajectory to continue into the second year here. That does
help give some context to why that cost was so disproportionate
at the beginning of the year as they ramped services.
Ms. Brownley. Thank you. Mr. Falke, I think in your
testimony, I think it was you who mentioned that it does not
cover all the costs. Am I quoting you correctly?
Mr. Falke. I think in my written testimony, I talked about
the cost. The Warrior PATHH program, it is a cohort-based
program of eight veterans per program, and we deliver 11 of
those programs a month. Only two of them are funded.
Ms. Brownley. Two of them?
Mr. Falke. Two of them are funded by the grant. The rest of
it is all funded philanthropically through private donations. I
would love to see it expand and cover all of them, you know,
assuming that Warrior PATHH is, in fact, identified by the VA
as one of the critical programs to solve this problem.
Ms. Brownley. Thank you for that. I want to thank all the
grantees who are here for the work that you do for our Nation's
veterans. We appreciate it very, very much.
I wanted to also ask, as I mentioned in my opening
statement, that the age adjusted suicide rate among women
veterans has increased significantly in 2021. If any of the
grantees can speak to that and wondering if any of your
organizations are specifically targeting programming toward
women veterans.
Mr. Falke. We run, our Warrior PATHH programs are run as
male and female cohorts. Initially, we were doing, if you take
Boulder Crest Virginia, we were running 12 programs a year, two
of those were for women veterans, 10 for male, which is a
little disproportionate to the amount of women who serve versus
men. I think it is 90/10, and we were doing 80/20.
In the last 3 years, we have had to increase the number of
female programs because of the demand. That is kind of how we
respond as a small nonprofit is based on the demand. We will
transform one of the male cohorts into a female cohort. With
the network we have created around the United States, 11
programs now delivering it, we are at about 27 percent of the
veterans who go through our program is female.
Ms. Brownley. I know my time is up, but I would love to
follow up with you and talk in greater detail about some of the
differences between men, women, et cetera. It seems that there
is a lot of good information in there. Thank you. I yield back.
Ms. Miller-Meeks. Thank you Ranking Member Brownley. The
chair now recognizes Representative Bergman for 5 minutes.
Mr. Bergman. Thank you, Madam Chair. You know, when you
turn on the evening news, they start with good evening, and
then for the next 27 minutes, they tell you why it is not. Then
for the last 3 minutes, they give you good feeling stories so
to come back and take the abuse the next night.
We are going to flip that on its backside. A couple of
years back, Chairman Bost and I had the honor of visiting
Boulder Crest Virginia. We are grateful, Mr. Falke, for your
selfless efforts to serve so many in the mil vet community.
Twenty-two years naval service, followed by the creation of two
nonprofits that have served more than 100,000 folks is an
incredible achievement and one you should be proud of.
What we saw at Boulder Crest was, quite simply, visionary.
In your testimony, you mentioned that traditional mental health
is focused on one thing only, ``managing and mitigating the
symptoms associated with times of struggle often through a
combination of medication and talk therapy.'' If I were to
appoint you as the new mental health tsar at VA, do you think
you could spend that $16.5 billion in a more focused manner? I
know you stated a lot of it in your comments, but if there are
a couple of things you would like to share with us here,
because we are still in the good news phase of my 5 minutes.
Mr. Falke. Do you have any harder questions, sir? I served
in the Navy 21 years. I was in the government contracting
business for 10. I have been through this contracting process.
I will say hands down, this VA process has probably been the
smoothest thing I have ever seen. I am not just saying that
because I am here. It has really been a great process, how the
grant was rolled out, how the outreach programs work, the
partnerships in Orlando.
You are right. I think, you know, I tell people all the
time, I have raised $200 million in the last 20 years for
veteran causes, nearly $200 million. I have been shot at. I
have disarmed bombs in the middle of the night. I have jumped
out of airplanes, been diving in deep, dark waters. There is
nothing harder than raising money.
One of my frustrations with the VA, and I have been fairly
outspoken, three of the last four secretaries have been to
Boulder Crest Virginia. Bob McDonald is on our honorary board.
One of the problems that I have seen, and we were instrumental,
I think, in part of the lobbying efforts around this grant, is
that there is not real good community partnerships, and there
does not seem to be a sense of urgency that I saw in the
Pentagon.
Mr. Bergman. I am going to cut you right there.
Mr. Falke. Yes, sir.
Mr. Bergman. You just made the key phrase that in my 7
years here on Veterans' Affairs, the idea of when--by the way,
thank you. We have had countless testimonies here where we have
asked the VA, how will you get a sense of urgency behind your
efforts? You know, Dr. Scavella, there is growing frustration
on both sides of the aisle because the news does not get
better. We are still, even though we may have a dip from year
to year, the overall rise is still unacceptable.
Put bleakly, over $150 billion has been spent since 9/11 on
this issue. When you look at the ratio of suicide in the
community, it has only gone up, never down. In fact, in
comparison to the general population, it only continues to get
worse, not better despite significant resources spent.
You know, in the 116th Congress, I, along with some of my
colleagues, worked very hard because we had grown frustrated
with the VA's lack of progress over time on this. Could you
outline the VA's specific objectives to reduce veteran suicide
over the next 5 years going forward, ideally broken down by
year? What achievable metrics will you use to measure success?
You have only got 20 seconds to do that. If you would like to
take it for the record, I would really like to see a timeline,
however you want to put it, because no results is just that, no
results. We need to put the money where we are going to get the
results for our veterans. With that, I yield back.
Madam Chairwoman, may I have 30 seconds to say that to our
Christine, you know, in naval terms, you have served honorably
and fair winds and following seas we will see in the future.
Ms. Miller-Meeks. So recognized. Is that it is better to
ask for forgiveness than ask for permission? Dr. Scavella, if
you will, please follow up with the question from
Representative Bergman and send in that response, which would
have taken much longer than 20 seconds. I, too, would like to
see that data. If you could submit that in writing to the
subcommittee, that would be greatly appreciated. The chair now
recognizes representative Deluzio for 5 minutes.
Mr. Deluzio. Thank you, Madam Chair, and good morning,
everyone, and thank you for your commitment to helping solve a
crisis in our veterans community.
Dr. Burnett, I will start with you to follow up a bit on
what Ranking Member Brownley was asking about the report that
this committee and our counterparts in the Senate will see.
What is most useful from where I sit is understanding are
grantees effective and are they effective relative to VA? On
the cost question, I heard you answer part that, you know, is
this a cost effective, are we seeing cost effective performance
again relative to VA? My first question on reducing suicide
risk factors, do you plan to report to us that success or
failure relative to how VA is doing here?
Dr. Burnett. Preliminary indications are very good. 73
percent of the people who have started and completed this
program have seen an improvement in well-being or reported an
improvement in well-being, which is a good first year start for
this.
Mr. Deluzio. Let me dig in a bit there then. Do you have
that same data and have that same metric for those who are
seeing care within the VA? Will you be reporting that data
about grantees and/or VA to us in the report?
Dr. Burnett. Keep in mind, many of these, so 80 percent----
Mr. Deluzio. Some are not eligible.
Dr. Burnett. Well, so you have 7,000 support
recommendations or referrals that were submitted. Almost half
of those are for nonemergency mental health care and 80 percent
of those are coming to VA for services. When you look at
emergency services, so when they are screened, as we talked
about the screeners earlier, more than 300 are identified at
the time of that screening as being at high immediate risk. 78
percent of those are going to the VA or vet centers for care.
About 22 percent are going to the community or other
organizations. We can provide you with that information.
Mr. Deluzio. You get the thrust of what I am interested in
seeing there.
Dr. Burnett. Yes, of course.
Mr. Deluzio. Similarly, I heard the explanation on some of
the high costs----
Dr. Burnett. Yes.
Mr. Deluzio [continuing]. per veteran. It will still be
useful from where I sit to see how the financial performance is
relative to what, you know, a similar cost per care metric is
within VA.
Dr. Burnett. Of course, understood. We evaluate that as a
part of our business operations process in reviewing all
grantees.
Mr. Deluzio. Good. This could be either Dr. Burnett or Dr.
Scavella, the grant recipient in my district and region,
Veterans Leadership Program, they run the PA Serves Care
Coordination Network across the Commonwealth. We say
Commonwealth in Pennsylvania. They have a good relationship
with the Pittsburgh VA. I have, you know, seen that
coordination. I have seen the referrals that pass through both
directions. I would like to know if VA is assessing and whether
we have a way to assess whether that is happening elsewhere and
if you have tools in place or you need different ones to
encourage that kind of coordination for other grant recipients.
Dr. Scavella. Yes. Thank you for that question. When our
veterans are engaging with any of the grantees, they are
required to try to get them in for services with us. That is
one way we are doing that structurally as part of the program,
part of the procedures. As far as data related to how many have
actually done that and how many are engaged, we can get that
information, and that is something that we are very interested
in because we are trying to tackle that 60 percent, you know,
group of veterans who are not enrolled engaged with us.
Mr. Deluzio. Yes. I think it is another way for us to
assess whether this is successful or not is to see that level
of coordination reported to us. I would encourage you to
include it as well. Madam Chair, I yield back.
Ms. Miller-Meeks. Thank you, Representative Deluzio. The
chair now recognizes Representative Van Orden for 5 minutes.
Mr. Van Orden. Thank you, Madam Chair. Just to go over a
couple of numbers here, $16.5 billion requested last year, $150
billion since 9/11 applied to this problem set, and we have an
increase in veteran suicide. As an enlisted guy who does not
have the highfalutin degrees and whatnot, to me that is just
abject failure. How much of this money have you guys given to
faith-based programs? I am talking to you, ma'am.
Dr. Scavella. I am going to defer to my colleague. I do not
know the answer to that question.
Mr. Van Orden. Very well. Dr. Burnett.
Dr. Burnett. Nineteen percent of our current grantees
report providing are faith-based service offerings, sir.
Mr. Van Orden. Okay. I would like a list of those, please.
Dr. Burnett. Mm-hmm.
Mr. Van Orden. Are you familiar with the program called
Mighty Oaks Foundation?
Dr. Burnett. Yes, sir.
Mr. Van Orden. Do you know what their success rate is?
Dr. Burnett. Not off the top of my head.
Mr. Van Orden. They have treated approximately 5,000
veterans, two of which have committed suicide. That smokes any
of your programs you got going on. I have some very basic
questions here. You guys are failing. I am not going to
sugarcoat anything. You are failing. You are failing my
brothers and sisters. The master chief is not. Ms. King, you
are not. Ma'am, sorry, I took my glasses off. I cannot read
your name right now. Yes, you know who I am talking to. Anyway,
you guys are doing God's work. I know you guys are trying, but
you are just not pulling it off at all.
If I understand this program correctly, you guys are
failing completely. We are now giving you money to give to
people that are succeeding. Is that right? I mean, that is what
this is, right? We are cutting you checks through the
chairwoman to give you money to give to people whose programs
are succeeding. Did I miss something? I mean, that is what we
are doing, right? The very basic question is, why does your
office exist? It is like an incredibly expensive middleman?
What can we do differently?
My colleague Mr. Luttrell has got some language in for
psychedelic treatments. I do not particularly agree with it
completely. However, it works. Faith-based programs work. We
have got to do something different. You have to do something
fundamentally different because your treatment modalities are
failing. With Senior Chief Mike Day, I have had 21 of my Navy
Sea, Air, and Land (SEAL) friends commit suicide to date. I
will guarantee you there are going to be more.
This is a statement. You guys need to do something
different. If that means we hack half your staff and take those
salaries and benefits and give it to those three people, then
that is what we need to do. It is not about me. It is not about
you. It is not about your job. It is not about your career. It
is not about an agency. It is about saving our brothers' and
sisters' lives.
Ms. Meyer, I want to thank you. Master Chief, thank you
very much. Ms. King, thank you for your efforts. I appreciate
it. I understand you are trying but it is not working. From our
previous line of work, that means you got to go. With that I
yield back.
Ms. Miller-Meeks. Thank you, Representative Van Orden. The
chair now recognizes Representative Landsman for 5 minutes.
Mr. Landsman. Thank you, Madam Chair. Thank you all for
being here and working on what is one of the most significant
crises that we face as a country and getting at the question of
what is working, what is not working, and where we go from
here. Several members and I, in a bipartisan fashion, kicked
off last week a What Works Caucus to help us as lawmakers and
the administration do a better job at ensuring legislation,
programming is evidence-based, that we are using data to not
just see what is working, but getting better, continuous
improvement. This is for everyone across the board. What are we
measuring now? What are the inputs, outputs that you think are
most important? What should we be measuring? You know, what is
the best way forward for us to track this as a committee,
because getting this right is so hugely important. I will just
turn it over and maybe go right to left, left to right. In any
event, what are the most important measures in your mind? Are
we tracking them? How do we make sure that this committee has
visibility into that and can be as helpful as possible?
Dr. Scavella. Yes, thank you for that question. One of the
main things we are tracking is going to be the looking at the
number of the suicides. Not only has it risen within the
Department of Veterans Affairs and our patients, but in the
community as well. We want to keep track of all those instances
that have been successfully avoided. We will be documenting and
reviewing that data, and we will continue to do that.
Also, you know, we know that this is a complicated problem.
One of the concerns is that how do we make sure that we are
looking at things that are not purely clinical? This program
has been impactful and visionary in the fact that it is not
only looking at clinical services, but also looking at
community services, faith-based organizations that are helping
us, as well as other innovations. That is really where we are
pushing the needle into territory that is new. That is what I
would offer. I will turn it over to Dr. Burnett.
Dr. Burnett. Thank you for that question. Two things in
particular. Are we reaching the right people, and are we making
a difference for them? Your question earlier was about how do
we know we are reaching women veterans, or American Indian,
Alaskan Native veterans, or veterans 35 to 54? Those are three
populations that you saw significant increases in the 2021
report. 23 percent of the participants in this program are
women, 40 percent are veterans or individuals who are 35 to 54,
and about 10 percent are American Indian, Alaskan Native, Asian
American, Pacific Islander, Native Hawaiian veterans.
More than that, and the information you will see is what is
the risk at the time that they are coming into this program?
About 70 percent of each of those groups are coming into these
programs as identified as being at high risk or moderate risk
for suicide. Then what is the impact when they leave this
program? Did we make a difference? Now, I shared with you about
73 percent of those so far. We are just in our first year, so
we do not have all the information we are going to have, but
that is the information we need to be presenting to you and
making decisions based on what works and how we know it works.
Mr. Landsman. I have got a minute left, so maybe we could
circle back or you could submit to the committee what measures
that you all are using. Maybe you already have done that. I
just wanted to say, as we think about this, and this may end up
being something we work on as a committee. In Cincinnati, where
I am from, we have one of the best children's hospitals in the
country, and they will tell you that they got to be in the top
two or three because they focused entirely on this idea of
getting better, being the best at getting better, and using
data and continuous improvement to provide the greatest
possible care. With something so complicated as this, something
so important as this reducing veteran suicide, I would love to
see us do more, especially with this grant program, to ensure
that every dollar is going to the highest impact program
possible. Thank you. I yield back.
Ms. Miller-Meeks. Thank you, Representative Landsman. The
chair now recognizes Representative Luttrell for 5 minutes.
Mr. Luttrell. Thank you, Madam Chairman. Veteran suicides,
we have been parked on 6,000-plus veterans for about 20 years
now. That is a fair assessment, correct? Anybody say yes
because that is the number. You should be screaming, that one,
which is 6,000 way too many. Dr. Scavella, you, previous just
said we are moving into kind of a more innovative approach on
how to address these things. Now, when people read these
numbers, they see the number.
Dr. Scavella. Yes, sir.
Mr. Luttrell. I am a researcher by trade before I showed up
to this place. You guys are researchers, too. We know the
underlying factors. We do. For 20 years, we have known the
underlying factors. Is that a fair assessment?
Dr. Scavella. Yes.
Mr. Luttrell. Why is it 20 years later, we are just now
moving to an innovative approach? All right. I say this on just
about every single committee I sit in front of the VA is I
cannot imagine the rucksack that you are carrying every single
day. You two sitting right there. It is unforgivable. It is.
You should be the two people in this room that go to bed every
night and get up every morning sick to your stomach because we
have 6,000-plus veterans dying every year. It is not a fun job.
I understand that.
You have these three organizations that are pushing the
envelope as best they can. If they did not exist, imagine what
those numbers would be. To my colleague to my right here and he
stated those faith-based and the organizations, they grow. I
think there are more veteran service organizations in America
than any other organizations possible, 40,000 or 400,000. It is
crazy numbers.
When the VA grants these nonprofits or for profits money,
does the information that they gather annually come back to the
VA and does the VA share that with other organizations so they
can tailor their processes to be similar or to grow? Either one
of you too.
Dr. Scavella. Sure. I will start and then I will pass it on
to Dr. Burnett. One of the important factors with this is that
we are not being prescriptive to the T for every single
program. We are allowing the programs to innovate and to set
forth programs that they think will impact the actual community
that they are taking care of.
Mr. Luttrell. Does VA have a portal or an enclave of every
single one of the facilities that exists? What is the
turnaround time from a call to the VA hotline to Mr. Falke's
organization?
Dr. Scavella. Yes. If someone is calling a hotline, they
are getting an answer on that call. That is not being called
back. That is an actual answer. With regards to the reporting,
our teams are getting regular engagement and information back
from the organizations that are participating in the program on
a monthly basis. Then we are also there for any technical
questions and things like that that may arise. Is there
anything I have missed, Dr. Burnett?
Dr. Burnett. No, I think you captured it and I think what
you are getting at is the foundation of a public health
approach to suicide prevention, which is a big part of the
difficulty.
Mr. Luttrell. The VA should be leading the charge on that.
You should not be able to walk across the United States and you
should be able to ask somebody who is leading the charge on
suicides in America? The first words out of the mouth should be
the VA. That does not happen.
Congress, I dare say this committee, subcommittee and
committee would most likely give you as much rope as you needed
to go out and take this from 6,000 to zero. I think what we are
waiting on is for those, you individuals, to come to us and
say, we hit 6,000 this year. I am going to promise that will
not be the number next year. I have not heard that yet all
year.
Dr. Scavella. I did not hear a question there, but I do
want to comment on your statement.
Mr. Luttrell. That was more of a statement----
Dr. Scavella. Yes.
Mr. Luttrell [continuing]. but you can respond, if you
would like.
Dr. Scavella. I just want to just emphasize that this is
our top clinical priority, our top priority, period, and that
we are committed to this work.
Mr. Luttrell. How long have you been in this position?
Dr. Scavella. I have been in this position since 2020.
Mr. Luttrell. Okay.
Dr. Scavella. 2021, excuse me, sorry. I have been with the
VA for my entire career as a physician. I have been committed
to taking care of veterans from the time I became a physician.
This is very important to us. We have gotten to this place
because we have looked at the data and seen that despite all of
our efforts, we do have a large component, 60 percent, who are
not engaged with VA at all. We are trying to find ways to get
to them to make sure that we are taking care of them as well.
Mr. Luttrell. That is a perfect point. I will close with
this statement but thank you. I do not think we are catching it
early enough. By the time those broken bodies and brains show
up to these organizations, the round is downrange. I would like
to hear, after what the VA working by, with, and through
Department of Defense (DoD) is doing to catch the members as
they leave our services so we can get in front of it.
Statistically, there have got to be numbers out there that say
these problem sets, these characteristics, these mannerisms,
will inevitably lead to. We are Artificial Intelligence (AI)
based. There has got to be a way we can figure this out. I
would like for a follow up, if we could get those numbers and
know exactly how the VA is working with the DoD to decrease
these numbers. I yield back, Madam Chair.
Ms. Miller-Meeks. Thank you, Representative Luttrell. To
correct for the record, when I thanked Mrs. Brownley, I meant
to thank Representative Landsman. Thank you, Representative
Landsman. I now recognize Dr. Murphy for 5 minutes.
Mr. Murphy. Thank you, Madam Chairman. Apologize, this is
one of those ping pong days, as we all know so very well. Thank
you all for coming. This is an important, obviously, purpose,
really, of our VA subcommittee. I do not know if there is
anything necessarily greater, because these lives lost are
tragedies that are absolutely, in my opinion, preventable.
I am very fortunate. About a 10th of my district, actually,
one in 10 constituents, is a veteran. Camp Lejeune, Cherry
Point, several other places are well within my district. It is
one of the largest constituencies and the fabric, really, of
eastern North Carolina. I cherish our veterans, and whenever I
am ever driving anywhere, if I am stopping off for gas or
something, I always give somebody a challenge coin because it
is just a small thing that we can do to always help our
veterans.
That said, I feel like we are failing these individuals,
and I am going to pick up a little bit where Mr. Luttrell
stepped. If we are not starting this from day one, day one
being the day before they leave the service, we are failing our
veterans. I have the Veterans Bridge Home in my district and
the Bunkham Asheville Buncombe Community Christian Ministry.
These agencies do a great job. We need to really, in my
opinion, start this from day one. The fact that we cannot touch
these folks is a big deal.
Hyperbaric oxygen is a big deal for me. I think it has
changed lives. We have had hearings on psychedelic medicine,
which is innovative and interesting. There are a lot of
research studies going now on mitochondrial injury, on whether
how that can produce suicide.
I just wonder if I could ask, and we theorize a little bit
as we are encroaching now, literally a wheel formation in
medicine and in technology with artificial intelligence. Where
does the VA see that as being able to help our veterans,
because so many times, I have been a physician now for 35
years, I am able to buildupon my experience to help take care
of patients. With AI, we are going to be able to take care to
use the knowledge base essentially instantaneously of millions,
if not billions or trillions of experiences. How are we going
to be able to use that to help prevent veteran suicide?
Dr. Scavella. Yes. Thank you for that question. As I am
sure you are aware of, we are in the middle of a tech sprint
where we are asking companies who have innovations that can
help us to take care of our veterans, to give those proposals
to us so that we can put things into place to make changes in
how we are delivering care. We see artificial intelligence, as
well as the entire spectrum of those technologies, as
potentially instrumental and impactful in what we are doing for
our veterans.
Mr. Murphy. How does that process look like? What is the
timeline?
Dr. Scavella. I am not sure when the tech sprints close,
when we get all the proposals back, but they are ongoing
currently.
Mr. Murphy. Do you expect to have to come back and ask for
further funding, or is there funding within the VA to do that?
Dr. Scavella. I cannot answer that question. I would have
to talk to the finance team about that.
Mr. Murphy. Okay.
Dr. Scavella. I am not sure.
Mr. Murphy. This is a critical issue. Despite the number
being taken down statistically and really just by
administrative change, being taken down from the number being
taken from 22 to 17, it is still the same number. It is still
the same number. I think it is, you know, a ruse on the
American people that we all of a sudden dropped five suicide
deaths per day. That is not really true.
I applaud you all for what you are doing. This is critical.
This is the life changing element that not only touches one
lives, but it touches so many other lives. We cannot get caught
in the bureaucratic nonsense either of outside the VA or within
the VA. It is one life at a time. Thank you. With that, Ms.
Chairman, I will yield back.
Ms. Miller-Meeks. Thank you, Mr. Murphy. The chair now
recognizes Representative Kiggans for 5 minutes.
Ms. Kiggans. Thank you, Madam Chair. Thank you all for all
your work you are doing here. I do not need to restate some of
the, just the statistics, and we all say that one veteran
suicide is too many. I know that many of you mentioned just
some of the assessments that I think, Ms. Meyer, you mentioned
that only six of 180 of the assessments were complete.
Just reading the list of requirements of all the different
scales and assessments you have to complete, I know we can get
bogged down in some of these screenings, especially things
like, I quickly reviewed the Columbia-Suicide Severity Rating
Scale and can understand it. I am a nurse practitioner at a
primary care, so really assessing patients mental health, I
understand the importance of the scales, but there is a job
that we are trying to do. Getting bogged down in that type of
scales, it just seems like we have expanded government yet
again and the requirements for you all.
There is, I think, a discussion we had about, do we really
need all of those scales, because, you know, pretty quick, if
you are dealing with somebody who is in trouble and who is not.
One of the things that is not listed on these scales that I am
interested in just from talking to veterans in my district and
understanding depression and suicide, is, are we ensuring, and
I guess this is a question maybe for Dr. Scavella or Dr.
Burnett, but ensuring that we are looking at their med lists
and what these guys are taking? I know that you talked about
talk therapy and all the other components and the scales and
everything else, but there is so much that chemical imbalance,
and I have seen firsthand time and time again, when we
administer medication to these patients, and most of them carry
black box warnings about the risk, increased risk of
suicidality. I have seen it like, night and day, like flipping
a switch. I usually would have my patients come back a week or
two after we start a new medication. Are you feeling better?
Are you feeling worse? Do we need to change course? Are we
looking at that, too? Is that one of the assessments that we
are doing? I do not feel like we have talked about that a lot.
Dr. Scavella. Yes. Thank you for that question. One of the
things we do at every visit is medication reconciliation. We
are looking at the medications they are on. We are also
questioning whether or not they need to remain on something
they may have been on for a while. Can we reduce the strength?
Can we reduce the frequency? Can we discontinue it altogether?
Those are questions that our clinicians are asking at every
visit. Looking at potential side effects from medications that
they are currently taking, yes, that is something that is
included. We do not just have our clinicians who are involved,
but we have a group of clinical pharmacists who are also part
of the care team who are also doing that look to assist our
clinicians with those assessments and those reviews.
Ms. Kiggans. Is that being done in some of our other care
organizations? That the rest of you guys just not leaving out
that medication component. I have heard even from Special
Forces guys that say, we got a bag of medications. Their
spouses would say, we found this bag of drugs. We do not know
what it is. We do not know what it does, but this was given to
them by their team doctor. Just making sure we are having those
frank conversations about what medications you are ingesting.
Do you know what they are for? Do you know what they are
called? What side effects they carry. Are we looking at that
from the other side, too?
Ms. Meyer. That is not something that we are currently
assessing. We do not employ any clinical staff.
Ms. King. As a clinician, that is something that I look at,
and our staff are trained to look at as well, because it is
instrumental in determining risk factors associated with
veteran suicides.
Ms. Kiggans. How about you, Mr. Falke.
Mr. Falke. We do look at medication as part of the intake
summary, and it has been amazing to me. We had a colonel in one
of our programs, a retired colonel who was on 34 different
medications. It has been super disappointing to me. I think I
know how it goes. I am a patient of the VA as well, so I know
how it goes. You just get one drug after another and you start
to store them up and take them. We do look at it very closely.
Ms. Kiggans. In my perfect world, I shorten this assessment
list that you guys are required, and I would put in a
medication assessment by a clinical provider who can understand
those interactions and some of those side effects profiles.
Thank you for that.
Let us see also for Dr. Scavella and Dr. Burnett, for just
continuity of care, I feel like is a really important piece
that I feel like when we have our initial assessments, it is a
team effort by some of our other care organizations. Is the VA
doing a good job with that continuity of care piece, because
that is where we lose people. We get them either inpatient or
these initial assessments, but then we lose them. Can you talk
to me a little bit about what that looks like?
Dr. Scavella. Yes. Care coordination is really important.
We reach out both internally and externally when our veterans
may receive care outside of our actual system to make sure that
we have all the information, that we can do the proper follow
up. Also, if it is vice versa, they are leaving us to go
somewhere else to do the same thing. Is there anything you
would like to add, Dr. Burnett?
Ms. Kiggans. Do your other care organizations provide
continuity of care pieces as long as needed?
Mr. Falke. One of the things that we have really talked to
the VA about is how do we get our, most of the people that come
to us do not go to the VA. What we want to do is make sure that
they get over there. That is really what we believe. I believe
that we make our participants better patients. That is one of
the things that happens, is you lose agency and you start to
believe things, and that is why you take drugs that maybe you
do not need. To put a patient who has been through our program
into the VA with better agency and to be a better patient, I
think it really creates a win-win for this program because it
is going both ways.
Ms. Kiggans. Very much so. It cannot be overstated. I am
out of time but thank you very much for all that you do.
Ms. Miller-Meeks. Thank you, Representative Kiggans. The
chair now recognizes Representative Radewagen for 5 minutes.
Ms. Radewagen. Thank you, Chairwoman Miller-Meeks and
Ranking Member Brownley, for holding this hearing today. Thank
you to all of the witnesses for your testimony. Dr. Scavella,
how does the VA address organizations that are unable to meet
established metrics of success within the Fox Grant Program?
Are there accountability measures in place such as removal or
reduction of funding?
Dr. Scavella. I will start and I will pass on to Dr.
Burnett eventually. We are still early in our process, so we do
a lot of engagement in the support of the organizations who
have applied to be part of our program, who are grantees. If we
see something that is not going quite as expected as planned,
we want to support those organizations to try to get them into
compliance, but we do have a regular follow up with them. Dr.
Burnett?
Dr. Burnett. Yes. I would echo that. Most of these grantee
sites are yet to complete a first full year of running their
services, and so we are still evaluating those outcomes. Of
course, we do operational oversight and business operation
oversight to make sure that they are spending those funds
appropriately, that they are using those funds for eligible
veterans and partnerships that are within the scope of the
legislation. As we get that information back, we will be happy
to share that with you in the interim report that we will
provide in the spring.
Ms. Radewagen. Thank you. Dr. Scavella, how much
flexibility do grantees have in using their funds? If, for
whatever reason, the original grantee found themselves at risk
of failing to execute the grant, could an otherwise qualified
third party be designated to receive the grant so that funding
remains within the target community?
Dr. Scavella. That is a great question. I am actually going
to look to my expert, Dr. Burnett, for this one.
Dr. Burnett. Yes. If a grantee, if I understood your
question correctly, if the grantee is underperforming or is
unable to execute appropriate funding, can that funding be
reallocated to another? There are a couple of answers there.
Grantee site, of course, we want to promote innovation, and if
they ask to change the scope of their grant to provide
different services, they always have the ability to request a
change in the scope of their services, which we will support
them with. If they are unable to provide those services or
something happens at their facility, we will then pivot those
funds to others to cover the veterans in that area the Notice
of Funding Opportunity process.
Ms. Radewagen. All right. Well, that is it, Madam
Chairwoman. I yield back the balance of my time. Thank you.
Ms. Miller-Meeks. Well, thank you very much. I now yield
myself 5 minutes. The advantage of being the chair is that you
have to stay during the entire hearing, and so you get to
listen to the questions and the answers by all of the Members
of Congress. I am going to toss out what I thought were the
questions that I was going to ask, and I am going to try to hit
on some of the points made by our members. First and foremost,
let me just say that I know that my colleagues, all of them
here on the Health Subcommittee and on the Veterans Affairs
Committee, are extraordinarily interested in this topic and
want to see the number of veterans suicide and the brain health
of veterans improve. They want to see the numbers decrease.
They want to see brain health increase. I know that that, too,
is the VA's priority and their mission.
I am going to first say thank you for all of those efforts.
However, we know that the number of veterans suicide remains
high. It has not dropped. In the spirit of innovation, I think
what we are trying to say to you is it should not be Members of
Congress coming up and touring in their districts or elsewhere,
innovative programs coming back, talking to the VA, and/or
passing legislation to force the VA to do something that if
this is your priority, please, I ask you to go outside of the
box and find those programs and those entities that are doing
that work in concert with you, whether or not they are being
given a grant by the VA. Incorporate those, bring those to us.
Let us know that you really are thinking about how to best
address this issue.
One of the things that we have heard today is the nine
different assessments. As a physician and a veteran, I
understand what the VA is trying to do. The VA is trying to
standardize the entry process so that you have the data and
metrics that members have asked you for so that we can assess
the effectiveness of the program, and you are trying to apply
the same standards done within the VA institution to these
outlying organizations. I get it. I understand it. I do not
fault you for that. Those assessments are not working.
What we hear from our veterans in our district is I go to
the VA, even if I am trying to make an appointment on the
phone, I am asked all these questions. They do not have
anything to do with what I am doing. Perhaps I would say one of
the things, Dr. Scavella and Dr. Burnett, you can take from
this hearing is tailor that, narrow it, find out what it is
that you need to do in order to have metrics and data for
effectiveness, but tailor it for our communities.
Number two, the cost of medication. We are not figuring in,
in the cost of all these programs. Dr. Scavella, how much is
the VA spending per year on mental health and suicide
prevention, all dollars?
Dr. Scavella. I would have to get that information to you.
Ms. Miller-Meeks. Please get that information to us. In
this, if you have an individual who goes to Missy Meyer's
program or goes to Ken Falke's program, or Joyce King gets
someone to a program, or English River Outfitters in my
district, or Heroes with Horses in Wyoming, if they go to one
of those programs and they are on four or five medications and
they are taken off, what is the cost of those medications,
because that is also in the cost of success if an individual is
off medications. I do not disagree with what Representative
Kiggans, or Representative Luttrell said, or Ken Falke said. As
a physician, I can tell you, and having worked with this and
worked in the VA, someone comes in, they are prescribed a
medication, they have a side effect or something else. Part of
the medication's working, but something else has happened, they
are prescribed another medication. We are not treating people
holistically.
I am just going to make a comment from one of my
colleagues, the reason you have the assessments that you do is
that we need to know that we are treating people the same
severity, the same support groups, the same attempts at care,
whether they are within the VA or outside of the VA. Saying
that x number of people went into this program and only x
number of people committed suicide does not really tell you the
data. It is anecdotal. What you are trying to do is get real
data. You are attempting to apply structure and standardization
to this program to validate and determine effectiveness.
We need to do better. That is what we are saying. We need
to do better. We need to lower the rates of suicide. We have
not seen that through the VA. I am going to also say that I
actually support these programs. I have toured these programs.
I have seen whether they are faith-based, non faith-based. We
know that there is an individual, a holistic patient, and this
includes the suicide risk and TBI, which should be included.
This is a program that I think that we are all willing to
support and see continue. It is really just in its infancy,
even though it is three years. We would like to see the VA take
greater steps, get more grants out there, simplify the
assessment and the data so that we can determine effectiveness.
With that, I thank you, and I yield back. Does Ranking
Member Brownley, would you like to make any closing remarks,
seeing no other representatives here to ask questions?
Ms. Brownley. Thank you, Madam Chair. I just want to say
that this is an important hearing. The topic is obviously
important and complex. This is not an easy issue. I think that
this particular grant program has great opportunities to be
wildly successful. It could be wildly a failure as well if we
are not doing the proper oversight.
I feel as though the VA's role in terms of working with
these grantees across the country is really to intervene with
all of these grantees in a positive way to kind of check in to
see how are you doing? Where are your metrics? What is driving
your practices here? Maybe we need to adjust to get to where we
are trying to get to. I just think that we have to approach
this in a business model, if you will. That is very much a data
driven, continuous improvement model, that every single
grantee, you know, that we are funding is really focused in
that way and knows that they have to be data driven. They have
to be continually improving their program.
I do not know whether the VA even has that capability to be
overseeing all of these grantees across the country. I know you
are there to provide a service for grantees who need and want
your assistance and help, but I am not sure that you are
closely, closely following each and every one of these
grantees.
That is what I think, if we do something like that, I think
we can be wildly successful in this. I do not think the VA is
going to solve this problem by itself, that we need the help of
experts across the country to help us in this endeavor to help
to solve this problem. We have got to be able to do it. I am
not saying that we are doing it in a willy nilly way, but we
have really got to approach it in a very serious business model
and for it to succeed.
I think the grantees here are grantees that we can look to
that have been successful and can help others. We have got to
really approach this, I think, in a very data driven way. I
worry that we are not going to be collecting all of the data
points that we should be collecting. With that, I yield.
Ms. Miller-Meeks. Thank you, Ranking Member Brownley. I
realize that in my question, I did not have a lot of questions
that I asked, but I think that you understand the suggestions
that I am making. In addition to the data that Representative
Brownley and others suggested acquiring about medications,
about sex, we also should be--and when you provide us the
information, looking at active duty, National Guard, and
Reserve broken down, i.e., members that are leaving active-duty
military and transitioning, have a different transition out of
the service than members of the National Guard or the Reserve
who are deployed for a set period of time and then go back to a
community. How they integrate back into their community.
I would like to thank everyone for their participation in
today's hearing and for the productive conversation, and I
appreciate everyone's focus on such, it really is a critically
important topic and also all of your dedication to decreasing
the number of veterans suicide. It is important to me and my
colleagues on both sides of the aisle that all veterans seeking
help receive it in a timely manner. It is our responsibility,
this committee, the VA, and our communities, to lift veterans
at risk out of isolation, get them out of trouble, treat them
as whole people within a family and a community, not just a VA
hospital community, and we get them the care that can save
their lives.
If you are a veteran watching this right now who needs
help, please know that help is available to you anytime by
calling 988 and pressing 1 or texting 838255 or visiting
veteranscrisisline.net.
I would also like to just say, if I can, I have to pull
this up on my phone, so I apologize for the delay. You have
already heard this from Ranking Member Brownley. As a closing
note, I want to take a moment to recognize our outstanding
Staff Director, Christine Hill, who will be retiring at the end
of this year and over 30 years of Federal service. I have not
worked with her as long as Ranking Member Brownley has, but in
the 3 years I have been on the Veterans Committee and the
Health Subcommittee, she has just been outstanding. For her
time here, from her time in the Air Force, to her work here as
a Staff Director of the Health Subcommittee, Christine's life
has been about service.
I am grateful to have been able to work closely with her on
the Health Subcommittee this year. While she will be sorely
missed, we wish her the very best in retirement and know that
she will continue to serve. Thank you so much, Christine.
The complete record of statements of today's witnesses will
be entered into the hearing record. I ask unanimous consent
that all members have 5 legislative days to revise and extend
their remarks to include extraneous material. Hearing no
objections, so ordered. I thank the members and the witnesses
for their attendance and participation today. This hearing is
now adjourned.
[Whereupon, at 11:58 a.m., the subcommittee was adjourned.]
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A P P E N D I X
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Prepared Statements of Witnesses
----------
Prepared Statement of Erica Scavella
Good morning, Chairwoman Miller-Meeks, Ranking Member Brownley, and
distinguished members of the Subcommittee. Thank you for the
opportunity today to discuss the Department of Veterans Affairs' (VA)
implementation of the Staff Sergeant Parker Gordon Fox Suicide
Prevention Grant Program (SSG Fox SPGP). Accompanying me today is Dr.
Todd Burnett, Senior Consultant for Operations, Suicide Prevention
Program.
The SSG Fox SPGP honors Veteran Parker Gordon Fox who joined the
Army in 2014. He died by suicide on July 21, 2020. His obituary \1\
notes his legacy of ``loyalty, thoughtfulness, joy, compassion, and
deep friendships.'' Section 201 of the Commander John Scott Hannon
Veterans Mental Health Care Improvement Act of 2019 (P.L. 116-171; the
Hannon Act) authorized this Program, which assists VA in implementing a
public health approach that blends community-based prevention with
evidence-based clinical strategies through community efforts, bringing
personalized support and care to Veterans. The SSG Fox SPGP represents
an important step in leveraging community networks and expertise in
Veteran suicide prevention efforts beyond VA's systems.
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\1\ https://www.dignitymemorial.com/obituaries/johnson-city-tn/
parker-fox-9282651.
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The SSG Fox SPGP enables VA to provide resources toward community-
based suicide prevention efforts to meet the needs of Veterans and
other eligible individuals, including their families, through outreach,
suicide prevention services, and connection to VA and community
resources. The impact of this Program has been meaningful. For
instance, the following two examples are a brief sample of the
incredible work SSG Fox SPGP grantees are rendering:
A young, pregnant Veteran fled from a domestic violence
situation and engaged in services provided by a grantee who helped her
enroll in prenatal care at VA as well as other health care and mental
health supports. She stated: ``I could not have survived without your
help.''
A Marine Corps Veteran presented to Boulder Crest
Foundation, a grantee in Virginia, with suicidal thoughts and was
seeking help for combat-related trauma. After getting connected to
help, he confided that he had been engaged in preparatory behaviors to
end his life prior to getting connected, and that the services he
received saved his life.
VA has collected and received many more examples: lifesaving
engagements through the Healing Warriors Program in Colorado to the
Warrior Wellness Program, meeting the needs of Choctaw Nation of
Oklahoma Veterans, and the Aleutian Pribilof Islands Association in
Alaska, as well as many more. The engagements within grantee
communities are part of the critical community-based interventions
needed across the Nation to prevent Veteran suicide.
Congress authorized $174 million to be appropriated for fiscal
years (FY) 2021 through 2025 to carry out the SSG Fox SPGP.
Organizations can apply for grants worth up to $750,000 and may apply
to renew awards from year to year throughout the length of the program.
Grants are awarded to organizations that provide or coordinate suicide
prevention services for eligible individuals at risk of suicide and
their families, including but not limited to:
Outreach to identify those at risk of suicide;
Case management and peer support services;
Baseline mental health screening for suicide risk and
behavioral health conditions;
Assistance in obtaining VA and public benefits;
Assistance with emergent needs (e.g., personal financial
planning, child care); and
Non-traditional \2\ and innovative approaches and
practices.
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\2\ Nontraditional and innovative services that were included in
grants funded include Adaptive Performance, Art Therapy, Creative Arts,
Equine Therapy, Family Support Circles, Food Security, Healing Touch
Therapy, Mindfulness, Moral Injury Education, Music Therapy, Native:
Risking Connections (Hawaiian), Native: Alaska Native Cultural Health
and Resilience Gathering, Outdoor Recreation, Recreation Therapy,
Resilience Strength Training, Service Dogs, Warrior PATHH, Water
Sports, and Yoga.
VA first awarded grants in September 2022, to 80 awardees in 43
states, Washington, DC, and American Samoa. In March 2023, VA prepared
for the second round of grant awards by publishing a Notice of Funding
Opportunity (NOFO) for renewal grants and new organizations to apply.
The application period opened March 2, 2023, and closed May 19, 2023.
On September 20, 2023, VA announced the award list for FY 2023 grants
totaling more than $52 million to 80 community-based organizations;
this included 77 current grantees and 3 new grantees in 43 states, the
District of Columbia, Guam, and American Samoa. Twenty-one grantees
serve tribal lands including Navajo Nation, Cherokee Nation, Choctaw
Nation, Alaskan Native tribes, and others. Funding decisions prioritize
the distribution of grants to rural communities, tribal lands,
territories of the United States, medically underserved areas, areas
with a high number or percentage of minority Veterans or women Veterans
and areas with a high number or percentage of calls to the Veterans
Crisis Line.
As of September 30, 2023, grantees have completed over 20,000
outreach contacts and engaged 3,500 participants. Grantees have
successfully intervened for many who are on a pathway to risk, as the
program takes an upstream approach to reach Veterans with some, but not
necessarily acute, risk for suicide. The SSG Fox SPGP facilitates
engagement with (and reduces barriers to) clinical mental health care
but is unique in that most services are non-clinical. As the Nation
continues to recognize, and as research evidence confirms,\3\ social
determinants of health (e.g., economic hardship, unemployment, barriers
to health care) are drivers of suicide risk; the SSG Fox SPGP takes a
critical step to acknowledge and meet the need for suicide prevention
services beyond just the clinical mental health continuum.
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\3\ U.S. Department of Veterans Affairs. (2023). 2023 National
Veteran Suicide Prevention Annual Report. https://
www.mentalhealth.va.gov/docs/data-sheets/2023/2023-National-Veteran-
Suicide-Prevention-Annual-Report-FINAL-508.pdf.
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The grants are a core aspect of VA's 10-year National Strategy for
Preventing Veteran Suicide. The SSG Fox SPGP also supports and aligns
with the priority goals and cross-cutting implementation principles in
the White House's strategy on Reducing Military and Veteran Suicide.
Given the multiple factors that may lead to suicide death, preventing
suicide requires a comprehensive public health approach that harnesses
the full breadth of the Federal Government in close coordination with
states, territories, tribes, and local governments, as well as
collaboration with industry, academia, communities, community-based
organizations, families, and individuals. Reducing suicide requires a
long-term strategic vision and commitment designed to create and
implement systemic changes in how we support Service members, Veterans,
and their families across the full continuum of risk and wellness.
The SSG Fox SPGP is uniquely positioned to help tailor resources to
meet the needs of diverse Veterans in their communities, while also
building community capacity to deliver suicide prevention services. The
strength of the SSG Fox SPGP is that it allows for different approaches
to fit diverse community needs and to reach those individuals at risk
of suicide who choose not to receive care at VA. The program also
engages families, which is critical to reaching and serving those at
risk.
Eligibility Requirements
Eligibility requirements are set forth by law through the Hannon
Act. Eligible individuals are persons defined in section 201(q) of the
Hannon Act who are at risk of suicide. For purposes of SSG Fox SPGP,
risk of suicide means exposure to, or the existence of, any of the
following factors, to any degree, that increase the risk for suicidal
ideation and/or behaviors:
1. Health risk factors, including mental health challenges,
substance use disorder, serious or chronic health conditions or
pain, and traumatic brain injury.
2. Environmental risk factors, including prolonged stress,
stressful life events, unemployment, homelessness, recent loss,
and legal or financial challenges.
3. Historical risk factors, including previous suicide
attempts, family history of suicide, and history of abuse,
neglect, or trauma, including military sexual trauma.\4\
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\4\ 38 C.F.R. 78.10(b).
Grantees use non-clinical tools to assess these areas to determine
the degree of risk of suicide for eligible individuals and the drivers
of stress to focus support recommendations to facilitate the
individual's (and family's) well-being. To assist grantees in
determining risk of suicide (and thus an individual's eligibility for
suicide prevention services), VA provides grantees with a Columbia
Suicide Severity Rating Scale screening tool, which is a brief,
evidence-based form that can be administered quickly by responders with
no formal mental health training and applied in a wide range of
settings for adults to detect the presence of suicide risk.\5\ VA has
ensured that grantees are provided this tool before providing or
coordinating suicide prevention services under the Program and have
access to publicly available training materials to support their use of
this tool.
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\5\ Posner, K., Brent, D., Lucas, C., Gould, M., Stanley, B.,
Brown, G., Fisher, P., Zelazny, J., Burke, A., Oquendo, M., & Others.
(2008). Columbia-suicide severity rating scale (C-SSRS). New York, NY:
Columbia University Medical Center.
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Grant Program Evaluation
The SSG Fox SPGP evaluation plan has two components:
The VA grant management program is evaluated using a
formative evaluation design to collect mixed methods data on
program-level impact using the Reach, Effectiveness, Adoption,
Implementation, Maintenance (RE-AIM) framework.\6\
---------------------------------------------------------------------------
\6\ Fetters, M.D., Curry, L.A., & Creswell, J.W. (2013). Achieving
integration in mixed methods designs-principles and practices. Health
services research, 48(6 Pt 2), 2134-2156. https://doi.org/10.1111/1475-
6773.12117.
The evaluation of the grantees uses a summative
evaluation design with standardized outcome measures for
community-based programs using a longitudinal and pre-and post-
test survey methodology.\7\
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\7\ Stone, D.M., Holland, K.M., Bartholow, B., Crosby, A.E., Davis,
S., and Wilkins, N. (2017). Preventing suicide: A technical package of
policies, programs, and practices. Atlanta, GA: National Center for
Injury Prevention and Control, Centers for Disease Control and
Prevention.
The reporting requirements in 38 C.F.R. Sec. 78.145 were designed
to provide VA with the information required to assess the outcomes
associated with grantee programs. Ultimately, evaluations of
effectiveness are measured by one goal - reducing the number of
Veterans at risk of suicide, which we evaluate through expectations
laid out in every grant agreement, including but not limited to
services provided, at-risk populations reached, and pre-and post-
service surveys. Our data collection specifically evaluates the effects
of SSG Fox SPGP engagement on Veterans' financial stability, mental
health status, well-being, suicide risk, social support, treatment
engagement, and service utilization.
Evaluation activities include demographic and geospatial analysis
to ensure we are positioned to engage the broadest possible range of
at-risk Veteran subpopulations. We will provide an overview of our
outcomes to date in the interim 18-month report and final report.\8\
These reports will include information on population engagements
overall and by specific at-risk groupings (such as the number of
American Indian/Alaska Native, women, minority, LGBTQ, Asian American,
Native Hawaiian and Pacific Islander, rural, or other target population
members engaged), the services provided to Veterans, active-duty
Service members, or family members; assessed risk pre-and post-
services, and the type of services. VA launched an online data
collection tool in November 2023 to give grantees the ability to submit
real-time information on the services they are providing. This allows
VA and grantees to identify where service demands are expanding, the
types of services needed, and where supports are needed to overcome
barriers to engagement. The program is also positioned to identify,
share, and scale emerging best practices for community-based suicide
prevention.
---------------------------------------------------------------------------
\8\ Beginning not later 18 months after the date of the first grant
award (September 19, 2022), VA must provide an interim report to the
Committees on Veterans' Affairs regarding the provision of community-
based grants to eligible entities through the SSG Fox SPGP.
Additionally, VA is required to submit a final report no later than 3
years from the date of first award and annually thereafter for each
year in which the program is in effect (P.L. 116-171, section 201(k)).
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Operation of the SSG Fox SPGP
VA's collaborations with grantees are designed to facilitate
eligible individuals' engagement in care, wherever, whenever, and
however needed to reduce the risk of suicide. To ensure oversight of
grants implementation, VA grants are subject to Federal laws,
regulations, and VA policies. SSG Fox SPGP and grantees must comply
with section 201 of the Hannon Act, VA's regulations (38 C.F.R. Part
78), other applicable VA policies, and the grant agreement. To support
grantees with implementing their programs, VA offers guidance and
technical assistance on key elements of the Program and best practice
sharing. This supports grantees in optimizing efficiencies and resource
stewardship to maximum benefits to eligible individuals and their
families. VA guidance and technical assistance includes the following:
The SSG Fox SPGP Program Guide, which was initially
issued October 2022 and was updated and distributed in July 2023;
Recurring onsite technical assistance events for all
grantees;
Monthly technical assistance webinars; and
Monthly Grant Manager meetings, weekly data technical
assistance, and 1:1 Grant Manager support services.
Prior to providing SSG Fox SPGP assistance to a participant,
grantees enter into a written agreement between their agency and each
participant. This agreement describes the grantee's SSG Fox SPGP
services and any conditions or restrictions on the receipt of suicide
prevention services by the participant. Agreements do not require
sobriety, income limits, participation in suicide prevention services,
or other unnecessary requirements as a condition of assistance to the
extent practicable. Grantees work in coordination with the local VA
medical center (VAMC), particularly around referral and linkage to
VAMCs for clinical mental health assessment and services. The grantee
must facilitate referral to an appropriate alternative, except in
emergent situations. If all clinical mental health care is declined,
individuals may still receive SSG Fox SPGP services, and grantees
follow their policies and procedures for ongoing risk assessment and
referral discussions.
A critical goal of the SSG Fox SPGP is to ensure the safety of all
participants and grantee and community staff. Grantees are required to
develop a comprehensive plan to maintain the safety of participants and
staff and the confidentiality of the Program's participants and their
records. In developing such a plan, VA requires that grantees complete
the following:
Establish goals and objectives that reduce and eliminate
accidents, injuries, and illnesses related to administering suicide
prevention services to participants;
Develop plans and procedures for evaluating the safety
program's effectiveness, both at the grantee service location office
and in the field;
Develop priorities for remedying the identified factors
that cause accidents, injuries, and illnesses;
Ensure that participant records are secured with all such
information password-protected;
Ensure that all staff, students, and volunteers receive
initial and annual training on how to respond to and report critical
incidents; and
Develop a clear written procedure for following up on any
incidents that may occur to ensure that the Program evaluates how they
responded and to ensure any party involved was connected to any
services needed.
VA conducts reviews of grantee programs that include an assessment
of policies and procedures.
Conclusion
VA is grateful for Congressional support in advancing Veteran
suicide prevention. The SSG Fox SPGP is just one tool that VA has
rolled out in its public health approach to Veteran suicide prevention.
We need everyone at the table and working in the same direction. This
requires both moving away from a belief that suicide is solely a mental
health problem and moving toward engaging within and outside of
clinical health care delivery systems to decrease both individual and
societal risk factors for suicide. Suicide is preventable, and each of
us has a role to play in this mission. The public health approach
reminds us that we each can and do make a difference. This concludes my
testimony. My colleague and I are prepared to respond to any questions
you may have.
______
Prepared Statement of Missy Meyer
Chairwoman Miller-Meeks, Ranking Member Brownley, and other
honorable members of the Subcommittee
Thank you for the honor to testify before the House Veterans
Affairs Subcommittee on Health. The issue of Fox Grants and ending
veteran suicide means a lot to me personally, and my colleagues at
America's Warrior Partnership (AWP).
The SSG Fox Suicide Prevention Grant, from the original idea and
inception in this Committee, had a singular goal: find veterans in the
community that are in need and help them.
While Congress has been very thoughtful and deliberate in crafting
the law and providing generous funding, it is a big program that is
still working through growing pains and in need of minor reforms and
fixes to ensure it can meet the intended goal.
As a Fox Grant recipient that has done extensive work in the
community, the process for how the grant was awarded was complex, time
consuming, and met with repeated delays by the VA.
However, in September 2022, America's Warrior Partnership (AWP)
began conducting outreach utilizing Fox Grant funds. This outreach is
targeted at all veterans in each of our five communities across the
country in alignment with AWP's upstream Community Integration (CI)
Model. The idea behind CI is to find veterans that are not engaged in
services and may have no connection to resources. This includes both
veterans typically considered ``at risk'' which the Fox Grant has
identified as primary candidates for outreach as well as community
leaders, professionals, volunteers, etc. that may not currently need
services or believe they do not qualify for benefits. Our mission is to
partner with communities to prevent veteran suicide. Our programs
accomplish this by starting at the community level and understanding
the unique situations of veterans and their families. We connect local
veteran-serving organizations with the appropriate resources, services,
and partners that they need to support veterans, their families, and
caregivers at every stage of veterans' lives. Our ultimate goal at AWP
is to improve the quality of life for veterans and to end veteran
suicide by empowering local communities to serve them proactively and
holistically before a crisis occurs.
In March 2023, AWP was able to begin fully assessing and enrolling
active service members, veterans, veteran spouses and caregivers in the
SSG Parker Gordon Fox Suicide Prevention Grant Program. Since that
time, AWP has completed intakes and suicide risk assessments, as
required by the VA, via the Psycho-Social Assessment and Columbia-
Suicide Severity Risk Scale for 1,057 warriors. 185 of those men and
women have indicated some level of suicide risk. This means over 17
percent of those 1,057 veterans had suicidal ideations ranging from
wishing they could fall asleep and not wake up to having active
thoughts of taking their own life with a plan and an intention to act
on that plan and/or having made a previous attempt to end their own
life.
Once AWP knows a veteran or service member is in crisis, we must
find them local mental health resources. In a crisis, this is achieved
with a call to the ``988'' crisis line and a referral to their local
counseling center. Veterans who do not wish to work with the VA are
referred to community based mental health resources. There is no
expedited care for Fox participants, there is no special number or
intervention to get them services immediately.
As an example, on November 13th a veteran called AWP's ``The
Network'' with an active plan to take his own life. He was
disillusioned with his care at the VA in New York but had an
appointment with the Fort Meyers VA for a medical appointment the
following morning. He was ``tired of taking so many pills for my PTSD
and Bi-Polar that the VA doctors keep giving me.'' I called the Fort
Meyers, FL Suicide Prevention Coordinator as required by the Fox Grant.
I left several messages including the information that we had an
actively suicidal individual that needed services. AWP was hoping to
coordinate a mental health referral while the vet was in the VA for his
other appointment. This call has still not been returned. The Network
was able to connect with the 988 hotline and continued working with the
veteran. He stated that he loved his girlfriend too much to kill
himself, and we are still talking with him today to help improve his
quality of life.
This is one of the major shortcomings of the SSG Fox Suicide
Prevention Grant Program. There is no ``program.'' It is a transaction.
It is a VA-sponsored phone call and assessment with no plan on the
backend for care, or funding for connected services. As stated before,
AWP's mission is to assist veterans and end veteran suicide. We would
serve these warriors exactly the same way even without Fox funding.
However, these assessed veterans are not offered expedited care or a
same day appointment for a mental health evaluation.
The next step in the Fox Grant, following the intake and suicide
risk assessment, is to create a holistic service plan based around the
veteran's needs and wants. We set goals and connect each veteran to
various services as needed. Then AWP is mandated to conduct a series of
additional assessments with each participant. There are nine forms over
all that must be complete for the participant to be enrolled. The
Veteran (or Veteran Family Member) Intake Form, Columbia-Suicide
Severity Rating Scale, Psycho-Social, Socio-Economic Status, Personal
Health Questionnaire, Participant Communication Confirmation Form,
General Self-Efficacy Scale, Interpersonal Support Evaluation and
Warwick-Edinburgh Mental Well-Being Scale. In addition, there is a
service attendance form, referral form and various others that are
submitted monthly or as needed.
The Columbia Scale has been a life saving measure since AWP
integrated the questions into every warrior intake. This allows us to
take a veteran reaching out for rental assistance and ensure they do
not need immediate mental health support as well. In my opinion, this
is the biggest success of the Fox Grant. All grantees are required to
``ask the question.'' This gives our veterans the opportunity to
express any ideations to someone they have already connected with.
Once the participant has received support and been connected to
referrals, AWP is required to readminister the baseline assessments:
PHQ-9, ISEL-12, GSE, SES and Warwick. AWP has only successfully
completed both sets of assessments with 6 of our 180 Fox Eligible
participants largely due to lack of engagement.
In addition, the program itself needs metrics and accountability.
There is no clear measure of success for the Fox Grant program. The
grantee has key performance indicators set forth in their grant
agreement, but the Fox Program overall has no measurable indicator of
success other than individual improvement that is supported solely by
individual organizations. How will we use this data once we have it?
What will the VA do differently with the knowledge from these
assessments? We already know that depression, isolation and financial
stressors are risks for suicide. How does continually assessing known
stressors better our prevention model?
With this in mind, there are several recommendations below that may
be good to focus on during upcoming discussions about changes and fixes
to the program.
First, AWP is often asked about the Fox Program and what it
entails. The honest answer is this program is a data gathering mission
that gives the veteran the opportunity to share their feelings and
experiences to help the VA improve future prevention measures. Yet
there is no direct benefit to the veteran, and it may even be a
detriment. These assessments ask people that are actively in crisis to
elaborate on feelings of isolation, depression, and lack of resources
with no licensed mental health professional present to assist in
debriefing that individual. Many VA staff members have no idea what the
Fox Grant is or why grantees are calling asking for assistance with a
``Fox Participant.'' At the Fox Grantee Conference this past week there
were several grantees that noted having an issue connecting with their
local Suicide Prevention Coordinators. There needs to be more education
that extends to frontline staff on the Fox Grant and what to do with
those enrolled.
The Fox Grant program cannot be transactional. It needs to have
follow-up programs available for veterans in need. Calling and asking
for information, with no infrastructure to assist, is defeating for
many veterans opening up to Fox Grant recipient organizations in hopes
of getting help. Several assessments ended with an additional call to
the 988 Crisis line. There needs to be a better plan for how to help
these individuals. Again, these participants receive no preferential or
expedited care for their time and efforts.
Next - the assessments need to be refined and slimmed down to
eliminate redundancy. The Psycho-Social asks participants that have
already indicated some level of suicide about suicide risk factors. The
ISEL-12 and GSE ask questions already addressed in our holistic intake
as far as support and self-efficacy. All three of these assessments
could be done away with, as there are certainly similar assessments
conducted as soon as the veteran enters the VA, or other resources, for
mental health assistance.
Both AWP staff and clients describe the assessments as repetitive
and exhausting. The amount of data gathered is significant. AWP has
submitted thousands of forms to account for both outreach efforts to
find veterans not connected with resources and complete Fox mandated
forms. Every AWP outreach event requires its own form submitted in a
PDF form via email. The massive amount of paperwork has resulted in AWP
having to hire additional administrative staff to handle the data entry
load. We are in year two of the grant's life cycle, and the Data
Collection Tool is not yet available to AWP to lighten the load of
saving and emailing individual PDFs by the dozens every month.
Finally, the VA needs to fully detail and expand their measures of
success. Is it a number or outcome? Does success come with a potential
increase in funding? And are those organizations that are unable to
meet those metrics held to account and removed, or reduced?
Organizations like AWP take this very seriously and believe the Fox
Grant can be incredibly helpful for outreach to veterans that are
otherwise not in the VA system. Accordingly, we want this program to be
successful, and it takes metrics and accountability to determine that
success.
Metrics and goals with accountability build trust with veterans as
well, but only if it fits the overarching aim of the program itself.
Recently, during our in-person Fox Grant conference, VA staff outlined
program goals: reduce suicide risk, improve mental health status and
improve well-being of participants. However, the issue remains: there
is no bigger picture on how the data grantees spend hours compiling and
reporting will impact VA policy.
Members of the Subcommittee, thank you again for the opportunity to
testify today. We look forward to our continued work together and would
like to thank each of you for all your hard work and dedication to
those who served in our nation's armed forces.
______
Prepared Statement of Ken Falke
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Prepared Statement of Joyce King
Introduction
I would like to begin by thanking the Committee for its
transformational work on behalf of our nation's Veterans and their
families. I applaud Chairwoman Miller-Meeks and Ranking Member Brownley
for their leadership, and I greatly appreciate the opportunity to speak
to the Subcommittee regarding the Staff Sergeant Fox Suicide Prevention
Grant Program.
My name is Joyce King, and I serve as director of the SSG Fox
Suicide Prevention Grant program at Sheppard Pratt. I am a Board-
certified mental health therapist and substance abuse counselor, as
well as a military Veteran with more than 25 years of mental health,
substance use, and social services experience.
Sheppard Pratt is the Nation's largest private, nonprofit provider
of mental health, substance use, developmental disability, special
education, and social services in the country. We provide specialized
services for Veterans including Supportive Services for Veteran
Families (SSVF), Homeless Veteran Reintegration Program (HVRP), and
clinically intensive Grant Per Diem (GPD) transitional housing. Many of
these programs are funded by the U.S. Department of Veterans Affairs
(VA).
Collectively, Sheppard Pratt's Veterans services assist
approximately 1,250 homeless veterans every year in urban, rural, and
suburban communities across Maryland and in selected West Virginia
counties. Many of our staff are Veterans, including some staff who were
previously clients. The dedication and commitment of our team drives
our impact: We have helped over 5,235 homeless Veteran and Veteran
family members to obtain permanent housing. Our HVRP program helps
homeless Veterans to obtain employment with an average wage of just
under $20 per hour.
Joining the SSG Fox Program
In 2022, the VA released the SSG Fox Grant Notice of Funding
Opportunity. Its deep focus on community connection, well-being, and
suicide prevention responded to a clear gap in community-based services
for Veterans. Accordingly, we jumped at the opportunity to better serve
our Veteran community.
The application process was well-organized and transparent, with
significant flexibility in approach provided by the VA. The staff at
the VA deserve credit for designing and implementing a disciplined,
efficient application process.
Sheppard Pratt was honored to be awarded a SSG Fox Grant on
September 19, 2022. Our implementation strategy combines comprehensive
and holistic strategies selected based on the best available evidence
for the greatest potential to prevent suicide among veterans across
Maryland. We leverage current programming and relationships with
veterans that are at high-risk yet disengaged with VA and mental health
care.
Peer support is a critical component of our SSG Fox implementation
strategy. Through this new funding, we have trained Veterans with lived
experiences related to suicide and mental health. Our peer support
specialists work directly with Veterans and their family members to
promote connectedness, provide holistic case management, and reduce
risk factors for suicide. In addition, case managers help Veterans with
a range of health, housing, employment, and other needs.
As the SSG Fox Grant program was only recently launched, our data
are preliminary but suggestive. During enrollment, 95 percent of
Veteran clients indicated need for mental health services; 75 percent
required reconnection to the VA for services and supports; 65 percent
reported benefits challenges; 60 percent requested peer support and
connection; and 60 percent reported health, housing, employment, or
other challenges best addressed through case management.
The need, therefore, is clear.
The Impact of the SSG Fox Program
The impact of the SSG Fox Grant program is best demonstrated
through stories. I would like to share the story of one participant:
I'll call her Alice. Alice's story illustrates the power of the SSG Fox
Grant program, as well as the way in which community-based Veterans
services - including SSVF and HVRP - combine to prevent suicide and
promote well-being more generally.
Alice is a 48-year-old single female Navy Veteran, with a history
of Post-Traumatic Stress Disorder (PTSD) and Traumatic Brain Injury
(TBI).\1\
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\1\ Some details have been altered to protect confidentiality.
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Alice recently experienced two traumatic events. In 2022, she was
laid off. To make ends meet, she moved in with her sister. In 2023, her
sister passed away unexpectedly. With the loss of both her job and her
sister, she fell behind on her rent. Alice had to choose between paying
for her rent or buying food.
In September 2023, she called Sheppard Pratt. Our SSG Fox program
team collaborated with SSVF to help Alice find a more affordable
housing option. To help Alice gain employment, our SSG Fox and HVRP
teams worked together to provide Alice with both a computer and
technology training. And Alice dedicated herself to her job search.
Within a month of her calling Sheppard Pratt, she had a new job in the
IT field.
While Alice was working to obtain a new job and housing, she was
simultaneously grieving her sister's death. The SSG Fox peer support
specialist was instrumental in modeling healthy and effective coping
strategies.
Today, Alice is working and living stably in a safe, healthy home.
She shared the impact of SSG Fox in her exit survey: ``I can say for
sure that the program and ALL of the team went above and beyond my
expectations. I honestly never felt like I was alone during the
process. In fact, the opposite almost, I literally felt like a team was
assigned to me for different stages and aspects. I couldn't be more
(sic) greatful.''
Alice's comments about the SSG Fox program are echoed by other
participants.
John Woodard, a former Marine, similarly was struggling with PTSD,
a job loss, and eviction when he connected with the SSG Fox program.
John tells his story better than I could. He said, ``Sheppard's
Veterans Services got me and my family out of a situation that I was in
before where I was not appreciated, and I was not being supported for
my mental illness. Now I am in a better location with my family with a
peaceful mind, instead of in a crime-infested area where I could hardly
sleep because of fear and hypervigilance. I would like to thank the
Veterans Services programs for coming to my rescue. I've been using
this time to heal and get help with my PTSD, and I've been going back
to school. Veterans Services made that possible.''
Mr. Woodard adds, ``I would like to say thank you for keeping your
word and coming through in my time of need. I wasn't getting any
support from anywhere and they came in and saved me, saved my whole
year. I was depressed, I was upset, I was thinking about suicide. And I
just want to say thank you.''
John has advice for Veterans across the Nation: ``To other vets who
are where I was, I would say you can't get discouraged. You can find a
way. Reach out for help when you need it. It takes a team, just like in
the military. [Sheppard Pratt's] Veterans Services was part of my
team.''
John is better able to articulate the value of the SSG Fox Grant
program than perhaps anyone.
Enhancing the Impact and Scale of the SSG Fox Program
As both our qualitative and quantitative data illustrate, the
strengths of the SSG Fox Grant program are undeniable: our team is
reaching Veterans who are at high-risk of suicide; the program is
connecting Veterans with critical resources that are both community-
based and VA-based; and this intervention is helping Veterans to
improve their well-being and strengthen protective factors against
suicide. Moreover, the VA has been responsive to community feedback and
supported the evolution of the program based on both the community
feedback and data analysis.
Like every new initiative, SSG Fox will need to evolve to achieve
greater impact - and further contribute to the end of Veteran suicides.
How, then, can we enhance the impact of SSG Fox? What lessons have
we learned thus far?
First, we must expand access to life-saving clinical behavioral
health services for SSG Fox participants. There are two primary
challenges that SSG Fox participants face when we connect them to
mental health and substance use treatment services.
While 95 percent of Veterans enrolled in our SSG Fox program have
requested mental health and other behavioral health services, we have
experienced delays in connecting Veterans to outpatient services at the
VA. We appreciate that the VA is working diligently to reduce wait
times and recognize that significant progress has been made. In the
meantime, we respectfully request a clear and direct path for high-risk
SSG Fox clients to VA mental health services.
Further, we respectfully request an improvement in rates for
community behavioral health service providers serving Veterans.
Sheppard Pratt is committed to providing behavioral health services
to Veterans, but current rates for both Tricare and Community Care
Network providers do not cover the cost of care. Raising rates to
reflect provider costs is critical to expanding community-based mental
health and substance use treatment services for Veterans across the
Nation.
Finally, I would like to recommend that we continue to invest in
the SSG Fox Grant Program, expanding its scale and reach over time.
Current funding restrictions limit our ability as providers to serve
Veterans in every community. Additional resources will allow us to
better engage Veterans across the nation, particularly Veterans who are
reluctant to seek support.
As John Woodard reminded us, ``it takes a team, just like in the
military.'' The SSG Fox Grant Program is an essential part of the team
working to prevent Veteran suicide across our Nation.
Conclusion
Thank you again for the opportunity to speak to the Subcommittee
regarding the Staff Sergeant Fox Suicide Prevention Grant Program. As a
veteran and a clinician, my gratitude is both professional and
personal.
About Sheppard Pratt
Sheppard Pratt is the nation's largest private, nonprofit provider
of mental health, substance use, developmental disability, special
education, and social services in the country. A nationwide resource,
Sheppard Pratt provides services across a comprehensive continuum of
care, spanning both hospital-and community-based resources. Since its
founding in 1853, Sheppard Pratt has been innovating the field through
research, best practice implementation, and a focus on improving the
quality of mental health care on a global level. Sheppard Pratt has
been consistently recognized as a top national psychiatric hospital by
U.S. News & World Report for nearly 30 years. Thanks to support from
the U.S. Department of Veterans Affairs and the U.S. Department of
Labor, Sheppard Pratt provides Supportive Services for Veteran
Families, Homeless Veteran Reintegration Program, Grant Per Diem
Clinically Intensive Transitional Housing, and SSG Fox Suicide
Prevention Services to veterans in Maryland and, for some services, in
West Virginia.
Statements for the Record
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Prepared Statement of Swords to Plowshares
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
Prepared Statement of Wounded Warrior Project
Chairwoman Miller-Meeks, Ranking Member Brownley, and distinguished
members of the Committee on Veterans' Affairs Subcommittee on Health -
thank you for inviting Wounded Warrior Project (WWP) to submit this
written statement for the record of today's hearing on the Staff
Sergeant Parker Gordon Fox Suicide Prevention Grant Program (SSG Fox
SPGP). We share your commitment to easing the pain of veterans who are
suffering from invisible wounds and appreciate the opportunity to offer
our perspective on potential congressional action to improve how the
U.S. Department of Veterans Affairs (VA) serves veterans through
innovative mental health programming like the SSG Fox SPGP.
For 20 years WWP has been committed to our mission to honor and
empower wounded warriors. In addition to our advocacy before Congress,
we offer more than a dozen direct service programs focused on
connection, independence, and wellness in every spectrum of a warrior's
life. These programs span mental, physical, and financial domains to
create a 360-degree model of care and support. This comprehensive
approach empowers warriors to create a life worth living and helps them
build resilience, coping skills, and peer connection. Our reach extends
to more than 200,000 veterans who are being served in various ways
across the United States.
In this context, assisting warriors with their mental health
challenges has consistently been our largest programming investment
over the past several years. In Fiscal Year 2022, WWP spent more than
$82 million in mental and brain health programs - an investment
consistent with the fact that more than 7 in 10 respondents to our 2022
Annual Warrior Survey self-reported at least one mental health
condition, and nearly the same amount (66.3 percent) reported visiting
a professional in the past 12 months to help with issues such as
stress, emotional, alcohol, drug, or family problems.\1\ Four WWP
programs - Warrior Care Network, WWP Talk, Project Odyssey, and Complex
Case Coordination - focus specifically on mental health; however,
programs that focus on physical health, financial wellness, and social
connection all play a critical role in improving quality of life and
mitigating against mental health stressors like loneliness, financial
insecurity, and chronic pain.
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\1\ WWP's 2022 Annual Warrior Survey can be viewed at https://
www.woundedwarriorproject.org/mission/annual-warrior-survey.
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Wounded Warrior Project has proudly delivered these life-changing
programs while also appreciating that a single organization cannot meet
the needs of post-9/11 veterans and their families alone. Collaboration
is at the core of all we do and serves as a critical driver of the
innovation, efficiency, and excellence we strive to reach. Since 2012,
WWP has supported 212 military and veteran-connected organizations
through grants. These targeted investments help to expand our reach,
diversify engagement opportunities, augment our programs and services,
and ultimately improve outcomes for all veterans and their families. In
FY 2021 alone, WWP grants to partner organizations extended our impact
to more than 36,000 veterans, caregivers, family members, and military-
connected children. These partnerships touched nearly every aspect of
veteran well-being, targeting issues like social connection, support
for the Special Operations community, brain health, family resiliency,
emergency financial assistance, transitional housing, and many more.
This background in partnership and program delivery was critical to
our advocacy in support of the historic Commander John Scott Hannon
Veterans Mental Health Care Improvement Act and its centerpiece now
known as the Staff Sergeant Parker Gordon Fox Suicide Prevention Grant
Program (P.L. 116-171 Sec. 201) (SSG Fox SPGP). The SSG Fox SPGP is a
three-year pilot program that will provide up to $174 million to
community-based organizations and state, local, and tribal governments
that provide suicide prevention services for veterans and their
families. Suicide prevention services have been broadly defined to
permit healthy interventions before veterans reach mental health crises
and allow for spending on activities like outreach, case management
services, peer support, and assistance in obtaining VA benefits. After
two funding cycles, VA has awarded $52.5 million in both 2023 and 2022
to 80 community-based organizations, with only three organizations
changing from year to year.\2\, \3\
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\2\ Fiscal Year 2022 SSG Fox SPGP Awards List, available at https:/
/www.mentalhealth.va.gov/docs/SSG-Fox-SPSG-FY-2022-Grant-Awards-List-
508.pdf.
\3\ Fiscal Year 2023 SSG Fox SPGP Awards List, available at https:/
/www.mentalhealth.va.gov/ssgfox-grants/docs/FY23-SSG-Fox-SPGP-Awardee-
List.pdf.
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While VA's metrics and impact for this program are in the earliest
stages of review, our perspective on the SSG Fox SPGP implementation to
date is largely anecdotal and based on our organizational experience.
We agree that no one organization - and no single agency - can fully
meet all veterans' needs. We recognize that empirically supported
mental health treatment works when it is available and when it is
pursued, but the best results will be found by embracing a public
health approach focused on increasing resilience and psychological
well-being and building an aggressive prevention strategy. WWP is not a
SSG Fox SPGP grantee, but we support and encourage others to
participate. In this context, we offer two important considerations for
the Subcommittee.
First, organizations that WWP has worked with have expressed
concern that the SSG Fox SPGP application and compliance requirements
can be onerous. Although expectations were clearly laid out by VA \4\,
some participants have shared with WWP that aligning a veteran's
eligibility with delivery of specific services can be challenging. A
veteran must meet definitions set out in Section 201(q)(4) of the
Hannon Act, which includes consideration of a myriad of health,
environmental, and historical risk factors for suicide. While
acknowledging these predispositions are important in early and direct
conversations about suicide, approaching such considerations without a
foundation of trust can sometimes discourage veterans from being honest
with their responses or willing to accept and engage in services.
Allowing some time to foster a relationship enables engagement in
difficult conversations that stem from place of care and compassion,
rather than obligation. Navigating discussions in such a way can foster
more immediate connection to services that mitigate their risk for
suicide and reduce emergent needs while also making the delivery of
those services ineligible for grant purposes. Others have noted that
the high volume of veteran assessments required can induce incentives
(like providing small gifts) for completion that may skew the quality
of data gathered and what practices are sound under the premises of the
grant. We encourage more investigation into how administrative
practices can better align with the intended purpose of connecting more
veterans with support.
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\4\ Funding Opportunity: Staff Sergeant Parker Gordon Fox Suicide
Prevention Grant Program, 87 Fed. Reg. 22630 (Apr. 15, 2022).
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Second, the provision of clinical care under this grant program -
generally not permitted beyond emergency treatment - should be more
grounded in practical considerations for delivering veterans evidence-
based mental health care. Currently, when grantees are treating
eligible individuals at risk of suicide or other mental or behavioral
health conditions, the grantee must refer that individual to VA for
follow-on care. If they do not, any care given is at the expense of the
grantee.\5\ However, some veterans are not comfortable receiving care
at VA for a variety of reasons. This puts the grantee in a difficult
situation where they are forced to stop providing care or provide care
at their own expense, something many programs may be unable to afford.
Additionally, if a grantee is a part of VA's Community Care Network,
they are still required to get additional VA authorization to provide a
veteran follow-up care. We would ask the Subcommittee to consider if
there are ways this process can be improved so that more veterans at
risk of suicide can be connected to care they know and trust as soon as
possible.
---------------------------------------------------------------------------
\5\ Id.
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As the Subcommittee continues its oversight of the SSG Fox SPGP,
WWP remains supportive of this critical new asset to assist veterans
and their families lead healthy and fulfilling lives. We appreciate the
support that Congress has provided both in authorizing this program and
continuing appropriations, and we are grateful for this opportunity to
provide our perspective on how this program can be improved over the
duration of the pilot period and beyond. WWP stands by as your partner
in meeting the needs of all who served - and all who support them. We
are thankful for the invitation to submit this statement for record and
stand ready to assist when needed on these issues and any others that
may arise.
______
Prepared Statement of D'Aniello Institute for Veterans and Military
Families (IVMF) at Syracuse University
Background
Successfully addressing and preventing veteran suicide requires a
comprehensive and holistic approach at the individual, community, and
policy levels. This collective approach must include addressing the
variety of upstream, non-medical drivers of mental health that
contribute to a veteran's overall health outcomes and risk of suicide.
Examples of non-medical drivers of health include socioeconomic status,
financial strain, housing stability, food security, and access to
reliable transportation. The complex nature and interactions of these
contributing factors present multiple opportunities to intervene when a
veteran is at risk of suicide. At each of these steps, community-based
organizations and government agencies have the chance to prevent
further deterioration of the veteran's health by providing resources to
meet the veteran's material and non-material needs. Due to their long-
standing presence and trusted partnerships, non-profit community-based
organizations (CBOs) are particularly well poised to intervene and
assist veterans who are at risk of suicide.
Established in 2020 with the passing of the Commander John Scott
Hannon Veterans Mental Health Care Improvement Act, the Staff Sergeant
Parker Gordon Fox Suicide Prevention Grant Program (SSG Fox SPGP) plays
a vital role in addressing the pressing issue of veteran suicide in the
United States. By providing funding to CBOs to address underlying
causes of veteran suicide in addition to facilitating referrals for
clinical care, the SSG Fox SPGP recognizes the complex nature of
factors leading to veteran suicide and takes meaningful action to
partner with and support communities in the prevention effort.
In September, the D'Aniello Institute for Veterans and Military
Families (IVMF) at Syracuse University hosted several events in
recognition of National Suicide Prevention Month at the National
Veterans Resource Center. In addition to local attendees, we invited
our community partners that are recipients of the SSG Fox SPGP to join
in person. During the gathering, we convened a roundtable where SSG Fox
SPGP grantees had the opportunity to share valuable insights on both
the program's successes and the challenges it faces. The feedback
provided in this document represents the collective viewpoints of
eleven grantees from across the country who actively engaged in this
discussion.
Eligibility
One topic the roundtable participants discussed related to
eligibility was restrictions based around level of risk. Participants
noted that these restrictions prevent them from potentially capturing
high-risk individuals who don't meet the administrative eligibility,
such as the 24-month requirement. The potential expansion of the SSG
Fox SPGP to support additional populations.
Participants also recognized instances where individuals scored
within an eligible range for some assessment metrics but fell short in
others, leading to disqualification from SSG Fox SPGP intervention. For
example, grantees noted that individuals who score high on psychosocial
assessments but not on the Columbia Suicide Severity Rating Scale (C-
SSRS) still present a potential risk and should be eligible. In a few
more dire cases, despite exploring other avenues to assist these
individuals, communities reported they had witnessed tragic outcomes,
including suicide. Our discussion emphasized that understanding the
motivations behind individuals declining assessments could lead to a
more comprehensive approach.
Grantees also highlighted constraints to eligibility regarding
covered services. They raised significant concerns about barriers to
entry into the SSG Fox SPGP, both in terms of outreach and getting to
the point of screening. Many individuals struggle with transportation,
as it isn't covered until a client becomes officially enrolled in the
program. Others are more responsive to initial outreach efforts that
are more social in nature, rather than focused specifically on mental
health. Providing veterans with material resources such as food and
transportation assistance simultaneously reduces risk factors and
builds trust with individuals in their communities.
Additionally, specific barriers were recognized as potentially
addressable by non-SSG Fox SPGP funding, such as the Supportive
Services for Veteran Families (SSVF) for housing. Still, these programs
may have their own entry challenges, and keeping track of different
federal funding sources for similar activities can be burdensome.
One other topic that arose was the idea of expanding populations
eligible for the program. These populations might include Reservists,
National Guard members, and even family members. For example, if a
veteran enrolled in SSG Fox SPGP dies by suicide, their spouse may
subsequently experience suicidal ideations. However, the program is
currently unable to provide the needed support.
Screening
In addition to the eligibility side of screening, a range of
crucial issues regarding screening tools and process emerged. While
supportive of the selected assessments in general, as noted above,
grantees want to eliminated situations where a veteran would be
automatically disqualified despite the potential risk still present.
This dilemma prompted discussions on how to make the screening process
more comfortable and conducive to open conversations, as well as
addressing its labor-intensive and formal nature. Suggestions included
actively seeking feedback from grantees to enhance comfort, promoting
organic and conversational interactions, involving non--clinicians in
the screening process, and exploring ways to distill necessary
information from more natural conversations.
One of our presenters in another session (Joe Geraci, PhD, Director
of the Transitioning Servicemember/Veteran and Suicide Prevention
Center at the VISN 2 MIRECC) shared a 17-question screener used by his
team, which includes the C-SSRS questions. Many participants seemed to
believe this screener would be a valuable asset, relative to the host
of other screeners currently part of SSG Fox SPGP.
Participants acknowledged that screenings are subjective and
contingent on a client's truthfulness, adding to the complexity of the
process. There's also a culture clash between current military culture
and openly discussing mental health. To overcome this hurdle, grantees
stressed the importance of finding effective ways to communicate in the
language of the service member and to reshape their perspective on
mental health. In light of these challenges, participants and our team
underscored the trusted standing that CBOs hold within their
communities, and how they play a critical role in engaging with
veterans and creating the space they need to obtain support and
assistance.
And last, while the Fox grantees' programs and interventions differ
from one another, the screening tools and eligibility criteria are
uniform. Many of the participants expressed interest in collaboration
and efforts to share resources more effectively, particularly when a
practice was working well in one community but not another.
VA Referrals & Process
The process of referring eligible individuals to the VA has
revealed both successful practices and areas necessitating improvement.
One success reported was direct collaboration between the VA and the
grantee, where they were able to work directly with the Suicide
Prevention Coordinator (SPC) to create procedures for enrollment. These
actions not only streamlined the referral process, but also enhanced
understanding of the VA's capacity to accommodate these referrals.
However, there have been notable challenges in the referral
process. Though well-intentioned, the Office of Mental Health and
Suicide Prevention has sometimes fallen short in ensuring local VA
Medical Centers (VAMCs) follow programmatic guidance and intent.
Successful collaboration with SPCs as described above was the
exception, and levels of support seem to vary highly from VAMC to VAMC.
Even where partnerships were strong, they were not stable in the event
of turnover.
Furthermore, VAMCs may not have the readiness to accommodate
referrals through this channel. Suicide Prevention teams, often
stretched thin, have cited capacity constraints. Another critical issue
is the absence of a specific code in the intake to identify SSG Fox
SPGP participants, leading to delays in care due to administrative
hurdles. There is also a need for improved tracking of clients'
treatment history across different systems to streamline the referral
process and ensure seamless coordination between the VA and CBOs.
Grantees also noted that the referral process would benefit from
being more bidirectional, particularly at the point where patients may
be discharged from VA care. Communities faced discrepancies in whether
their local VA was willing to take the appropriate steps to authorize
releases of information. They noted that the services they are able to
provide can often make an enormous difference to veterans' experiences
managing their mental health and day-to-day lives.
Overwhelmingly, our partners remained positive about the potential
of the SSG Fox SPGP. They believe that by continuing to buildupon the
partnerships with CBOs through the program, the VA can continue to
provide comprehensive care for veterans that aims to address root
causes of health and wellness that allow veterans to thrive.
Data Collection & Sharing
While grantees acknowledged ongoing improvements from the VA and
MITRE, data collection remains a challenge. One prominent issue
revolves around the lack of clarity on how the MITRE dashboard will
display important and relevant information. Grantees agreed it feels as
if they're sending data off without a clear sense of how it will be
shared or utilized. Participants also emphasized the necessity for more
immediate feedback and quicker turnaround on screening scoring. Others
suggested more flexibility in the required data forms, depending on any
changes that may come to screening process requirements.
We also noted other missed opportunities to capture meaningful
data. For example, while this program is in its early stages and
therefore still improving, it would be beneficial to track individuals
who score high on psychosocial assessments but zero on the C-SSRS
screening, those who screen positive but face administrative-caused
ineligibilities, and those who refuse assessments. There is also a
desire for more comprehensive data on those screened but not deemed
eligible, including insights into their circumstances. Participants
have expressed a perception of limited interest from the SSG Fox SPGP
data team regarding information on individuals who do not strictly meet
the eligibility criteria. Additionally, they expressed concern over the
omission in collecting information about why individuals withdraw from
the program. There was a strong willingness to collect and share this
type of information with the VA, if more data was available in return.
As a final point on data collection and reporting, grantees
conveyed the complexity with managing multiple federal grants that have
specific coverage and measurement requirements. There was wide
agreement that there is an opportunity to increase efficiency and
consider the ways in which data can be standardized and aligned
throughout the process of administering different programs.
In response to data challenges, programs have undertaken their own
tracking and documentation of program data to understand the broader
context better, integrate into their other operations more effectively,
and address the pain points described above. We know that robust and
accessible data is necessary to effectively address the underlying
causes of poor mental health and veteran suicide. Both the IVMF and our
partners strongly hope that data from SSG Fox SPGP is collected
thoughtfully, incorporated into meaningful analysis, and transparently
shared.
Conclusion
We thank the Committee for the opportunity to share these insights
and for its continued focus on the target and shared goal of preventing
veteran suicide. The SSG Fox SPGP provides the needed support to CBOs
to address upstream factors of mental health that contribute to a
veteran's risk of suicide. We look forward to seeing how veteran health
continues to improve with the incorporation of this feedback to
strengthen the SSG Fox SPGP and ensure its long-term viability and
sustainability.
[all]