[House Hearing, 118 Congress]
[From the U.S. Government Publishing Office]
DIAL 988 + 1 EXAMINING THE OPERATIONS
OF THE VETERANS CRISIS LINE
=======================================================================
HEARING
before the
SUBCOMMITTEE ON HEALTH
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED EIGHTEENTH CONGRESS
SECOND SESSION
__________
WEDNESDAY, SEPTEMBER 18, 2024
__________
Serial No. 118-81
__________
Printed for the use of the Committee on Veterans' Affairs
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Available via http://govinfo.gov
______
U.S. GOVERNMENT PUBLISHING OFFICE
57-943 WASHINGTON : 2026
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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WEDNESDAY, SEPTEMBER 18, 2024
Page
OPENING STATEMENTS
The Honorable Jen Kiggans, Acting Chairwoman..................... 1
The Honorable Greg Landsman, Acting Ranking Member............... 2
WITNESSES
Panel I
Dr. Matthew Miller, Executive Director, Office of Suicide
Prevention, Veterans Health Administration, U.S. Department of
Veterans Affairs............................................... 4
Accompanied by:
Dr. Christopher Watson, Executive Director, Veterans Crisis
Line, Office of Suicide Prevention, Veterans Health
Administration, U.S. Department of Veterans Affairs
Mr. Brad Mills, Deputy Director, Unified Communications
Operations, Connectivity & Collaboration Services, Office
of Information & Technology
Dr. Julie Kroviak, MD, Principal Deputy Assistant Inspector
General for Healthcare Inspections, U.S. Department of Veterans
Affairs, Office of the Inspector General....................... 5
APPENDIX
Prepared Statements Of Witnesses
Dr. Matthew Miller Prepared Statement............................ 23
Dr. Julie Kroviak, MD Prepared Statement......................... 26
Statements For The Record
Questions for the Record Submitted by The Honorable Mariannette
Miller-Meeks, U.S. House of Representatives, (IA-01)........... 33
Response to Questions for the Record Submitted by U.S. Department
of Veterans Affairs............................................ 35
Response to Questions for the Record Submitted by Office of the
Inspector General.............................................. 40
American Foundation for Suicide Prevention Prepared Statement.... 41
Disabled American Veterans Prepared Statement.................... 44
Statement for the Record Submitted by Dr. Matthew Miller......... 47
DIAL 988 + 1 EXAMINING THE OPERATIONS
OF THE VETERANS CRISIS LINE
----------
WEDNESDAY, SEPTEMBER 18, 2024
Subcommittee on Health,
Committee on Veterans' Affairs,
U.S. House of Representatives,
Washington, DC.
The subcommittee met, pursuant to notice, at 2:45 p.m., in
room 360, Cannon House Office Building, Hon. Jen Kiggans
[acting chairwoman of the subcommittee] presiding.
Present: Representatives Kiggans, Radewagen, Van Orden,
Brownley, Landsman, and Budzinski.
OPENING STATEMENT OF JEN KIGGANS, ACTING CHAIRWOMAN
Ms. Kiggans. We will now get right into our oversight
hearing today on the Veterans Crisis Line (VCL).
Before we dive into the substance of today's hearing, I
would be remiss if I did not acknowledge that we are in the
middle of Suicide Prevention Awareness Month.
We are losing on average 17 veterans a day to suicide. Too
many veterans and active-duty servicemembers live with the
invisible wounds of their service. We must continue to work to
break the stigma surrounding mental health and get veterans and
servicemembers the support they may need.
There should be no wrong door when it comes to mental
health and Post-Traumatic Stress Disorder (PTSD) is treatable.
The U.S. Department of Veterans Affairs (VA) has an incredibly
large mental health and suicide prevention budget and a wide
range of programs to provide services and treatment to
veterans. We must ensure these programs are reaching veterans
where they live.
One of these community-based partnership programs would be
reauthorized through H.R. 9438, the No Wrong Door for Veteran
Act, a bill Chairwoman Miller-Meeks recently introduced.
There is no one size fits all approach to mental
healthcare, and as House Republicans and this subcommittee have
made clear this Congress is on VA to ensure every veteran has
access to the mental health care they have earned.
This brings us to today's oversight hearing on one of VA's
suicide prevention tools, the Veterans Crisis Line. The
Department of Veterans Affairs established the Veterans Crisis
Line in 2007 as a 24/7 resource to provide confidential help to
veterans and their loved ones in need of support.
In 2022, the National Suicide and Crisis Lifeline
transitioned from the standard 10-digit phone number to the
more recognizable 3-digit number, 988. To reach the Veterans
Crisis Line, callers can now dial 988 and press 1. The line is
accessible through call, text, or chat.
The intent of this shift was to make the phone number for
the Lifeline easier to remember and more accessible for people
who need immediate crisis support. For VA, this meant an
increase in callers and the need for a more robust operation.
In the 4-years since the launch of 988, the Veterans Crisis
Line has answered over 1.8 million calls. While VA maintains a
high call volume and a short average speed to answer time, I
find the number of notifications to Congress involving outages
and intermittent access issues concerning.
In the past year, we have been notified at least 6
different times about issues with the Veterans Crisis Line
which have impacted almost 700 callers. I have heard from
veterans in my own district about communication issues between
the caller and crisis line staff.
I am interested to hear from VA today about their
adjustments and operations since 988 was implemented as well as
how they are ensuring that veterans always have access to the
Veterans Crisis Line.
We will also hear from VA Office of Inspector General (OIG)
regarding their review of the preparation and response of the
Veterans Crisis Line team on the implementation off 988 press
1. One veteran lost to suicide is one too many.
I appreciate the work VA has done, but VA needs to be held
accountable for ensuring that their Veterans Crisis Line is
always accessible for all callers, especially given the year-
after-year increases in VA's mental health budget.
To all the veterans and their loved ones listening today,
if you need confidential support please reach out. Your life
matters and we need you here.
I now recognize Ranking Member Landsman for his opening
remarks.
OPENING STATEMENT OF GREG LANDSMAN, ACTING RANKING MEMBER
Mr. Landsman. Well thank you, Chairwoman, and thank you to
our VA witnesses for being here today. As you have noted this
is a timely topic as this month is Suicide Prevention Month. We
are just coming out of Suicide Prevention Week.
I would like to take this opportunity acknowledge the
important conversations like the one that we are going to have
today as we work to reduce the stigma and barriers for seeking
help and let veterans know that support is out there if and
when you need it, and as the Chairwoman said, you matter a
great deal.
Any veteran lost to suicide is 1 loss too many. We are all
committed to working with our partners in this room today and
beyond to raise awareness and prevent veteran health, veteran
deaths by suicide.
988 is a crucial lifeline in our toolkit against suicide.
Every call to 988 and to the Veterans Crisis Line is an
opportunity to save a life. Every interaction has the highest
stakes for the life and safety of veterans and their families.
Because of this, it is critical that the Veterans Crisis Line
responders, supervisors, and support staff are prepared to
answer every call and text and provide the best support in
response to contacts.
That is why it is so important to take every interaction as
a learning opportunity and identify what could be done better,
which we will do here today.
The Veteran Crisis Line was able to work collaboratively
with the VA's Office of Suicide Prevention and the Office of
Information Technology to execute a smooth transition to the
new and easy to remember 988 press 1 number. This includes
responding nimbly when outside venders notified VA that they
would not be able to provide services any more, to find a way
to provide those in-house.
The crisis line also hired aggressively in anticipation of
increased call volume with the new member and were more than
prepared with additional staff, as VCL works to define its
staffing including through ensuring it gets back to an
appropriate supervisor to responder ratio, we stand ready to
support and give the VA the resources it needs.
This includes ensuring that the VCL staff are aware of the
resources available to them is a very difficult job and the
importance of their work cannot be overstated.
When the worst happens VCL must make sure its responders
know about and feel empowered to make use of the postvention
services available to them.
Since the transition from the previous 1-800 number to 988,
VA has been very transparent with the committee about the
minimal outages that have occurred. VA has worked diligently to
mitigate any missed connections, track down veterans who were
disconnected and make sure their needs were met.
We will continue to monitor Veteran Crisis Line operations
and the VA's applications of lessons learned to ensure we are
providing--preventing, excuse me--tragedies as much as humanly
possible.
The VCL remains a crucial component of suicide prevention
efforts at the VA, the president, and this committee. I look
forward to hearing from the VA about the important work of the
VCL and the OIG on its oversight work in ways VCL can improve.
Thank you and I yield back.
Ms. Kiggans. I would now like to introduce the witnesses.
Testifying before us today we have Dr. Matthew Miller, the
executive director of the VA's Office of Suicide Prevention.
Dr. Miller is accompanied by Dr. Christopher Watson, the
executive director of the Veterans Crisis Line. Dr. Brad Mills,
the deputy director for Unified Communications in the Office of
Information Technology. We also have Dr. Julie Kroviak,
principal deputy assistant Inspector General (IG) for
Healthcare Inspections for VA's Office of Inspector General.
Dr. Miller, you are now recognized for 5 minutes to deliver
your opening statement.
STATEMENT OF MATTHEW MILLER
Dr. Miller. Good afternoon Chairwoman Kiggans, Ranking
Member Landsman, and distinguished members of the committee.
Thank you for your thoughtful opening remarks and accurate.
Thank you for the opportunity today to discuss the Veterans
Crisis Line on this 77th birthday of the United States Air
Force.
Accompanying me today as you mentioned is Dr. Christopher
Watson, Executive Director of the VCL, and Mr. Brad Mills with
our partners in the Office of Information and Technology.
September as you both mentioned is Suicide Prevention
Month. Everyone has a role to play in preventing suicide and
there is continued hope. I want to thank this committee for its
support and continued collaboration. This critical relationship
is reflected in the resources that Congress has consistently
secured for the VA.
In 2007, the VCL started with 14 trained crisis responders
working out of a call center in Canandaigua, New York. Now more
than 1,000 crisis responders are available to any veteran,
service member, or their loved ones 24 hours a day, 7 days a
week, 365 days a year through call, text, or chat.
The VCL crisis responders continue connections after the
call, chat, or text by offering veterans a referral to over 470
local Suicide Prevention Coordinators (SPC) available in each
VA medical center across the country.
We know that over 80 percent of veterans who accept a
referral to Veterans Health Administration (VHA) care after
calling the VCL for suicidal thoughts report the VCL played a
significant role in stopping them from acting on those
thoughts.
The VCL continues to advance its services and operations
through the National Suicidal Hotline Designation Act of 2020,
VCL simplified access to crisis services to launch 988 in July
2022, VCL partnered with Substance Abuse and Mental Health
Services Administration (SAMHSA) and U.S. Department of Health
and Human Services (HHS) as well as the 988 Suicide and Crisis
Lifeline along with numerous phone carriers.
Upon the 2-year anniversary of 988 launch the VCL has
successfully adapted to a 22 percent increase in calls per day,
a 77 percent increase in text per day and a 27.5 percent
increase in chats per day. This means that more veterans are
getting the support they need from caring, qualified responders
during times of crisis.
Beyond meeting demand, however, quality matters. VCL is
fully accredited by three organizations specializing in crisis
call center operations. The American Association of
Suicidology, the Commission on Accreditation of Rehabilitation
Facilities (CARF), and the International Customer Management
Institute.
In its most recent accreditation visit CARF awarded VCL a
full 3-year re-accreditation for achieving zero findings across
all domains including governance in call and quality. We were
called a model crisis call center.
Amidst 988 press 1 implementation, we have experienced
limited-service interruptions impacting veterans. Although less
than the previous year, VCL has experienced 12 notable outages
or service interruptions, 80 percent resulting from external
issues. These outages varied in scope and impact, however, none
of them incapacitated VCL services.
Our commitment to modernization and improvement is critical
to ensuring VCL can promptly respond when interruptions do
arise. Overall, 988 has been successful. We know that we are
saving veterans' lives. Two published studies recently have
found veteran callers were over 5 times more likely to have
less distress and less suicide ideation at the end of the call
compared to the beginning, were 11 times more likely to have
reduced suicidal urgency at the end of the call than the
beginning.
Before I close I want to acknowledge the 2023 OIG report of
a patient's death by suicide following contact with the VCL in
2021. From the painful lenses of retrospective review, I would
like to share that we have closed 8 of the recommendations, 2
are concluding and 1 has been submitted to OIG for closure. It
is our earnest desire and responsibility to apply wisdom gained
to strengthen processes for veterans.
Madam Chair, this concludes my remarks. My colleagues and I
are prepared to address any questions.
[The Prepared Statement Of Matthew Miller Appears In The
Appendix]
Ms. Kiggans. Thank you, Dr. Miller. Dr. Kroviak, you are
now recognized for 5 minutes to deliver your opening statement.
STATEMENT OF JULIE KROVIAK
Dr. Kroviak. Thank you, Chairwoman Kiggans and Ranking
Member Landsman, and subcommittee members.
September is Suicide Prevention Awareness Month and I am
grateful for opportunities such as this hearing that bring
greater attention to an issue that continues to devastate
individuals, families and communities, veteran suicide. In that
VA's number one clinical priority is reducing the rate of
veteran suicide, the OIG provides oversight of the many
clinical and other support services aimed at treating veterans
at risk for suicide, as well as reviewing the care provided to
those veterans in acute crisis.
For example, our proactive reviews of Vet Centers have
evaluated the compliance of Vet Center staff coordinating
mental health care with VHA clinical staff when a client is
deemed high risk for suicide. We have also developed a new
cyclical review that assesses the environments and quality of
care provided to those veterans in need of acute mental health
in-patient treatment.
We look forward to briefing your staff next week before
this first report publishes. Through several hotline reports,
we have reviewed the quality of services provided by VCL
responders to veterans in crisis. There is almost no service
that VA provides that carries the same high level of risk and
urgency than the services provided by VCL responders to a
veteran in an immediate mental health crisis.
Veterans, their families, and caregivers rely on this
crisis intervention service, and its role in reducing veteran
suicide cannot be overstated.
My written testimony details several failures of VCL staff
in providing high quality interventions to veterans in crisis,
failures that contributed to very tragic outcomes. Deficiencies
included incomplete risk assessments, missed opportunities to
initiate rescues, and misleading documentation of the
interactions with veterans.
These deficiencies do not define VCL services but they do
point out serious gaps in VCL's quality assurance processes.
These gaps are barriers to quality crisis interventions in that
they undermine leaders' abilities to ensure accountability and
continuous process improvement.
Our most recent report reviewed VA's 2022 implementation of
the National Suicide Prevention Hotline three-digit dialing
code. Overall, our team found that VCL leaders provided their
staff with the necessary equipment and technical support, and
they significantly increased responder staffing to meet an
anticipated increase in calls.
We were also encouraged by VCL leaders' quality data
collection and analysis practices. We did find opportunity for
VCL leaders and supervisors to be more supportive of frontline
staff by assuring awareness and access to postvention
resources. As with any crisis intervention service, the demands
and expectations of responders are significant, and they must
have access to resources that support their well-being and
resilience.
The most recent veteran suicide statistics are dismal and
must serve as a reminder that more must be done to engage
veterans in the care they need and ensure that that care is
delivered consistently and to the highest standards. We
recognize and appreciate the tireless efforts of dedicated VHA
staff including VCL responders who do just that every day.
The OIG remains committed to conducting impactful oversight
work aimed at further strengthening all VHA suicide prevention
programs and services.
This concludes my statement and I would be happy to answer
any questions you or members of the subcommittee may have.
[The Prepared Statement Of Julie Kroviak Appears In The
Appendix]
Ms. Kiggans. Thank you, Dr. Kroviak. We will now proceed to
questioning. I will now recognize myself for 5 minutes for
questions.
Dr. Miller, what is the process for identifying the
location of a veteran if they are not willing to provide that
information or are calling from a location that is not the same
as their phone's area code?
Dr. Miller. Thank you for the question. I think first
things first. An important aspect of Veterans Crisis Line
services is allowing veterans to interact with us anonymously
if they so choose. Therefore, we want to be very careful how
much we pursue information from the veterans, unless it is
absolutely necessary to provide them with the highest quality
care.
There are situations where perhaps in an emergency dispatch
we may need the veteran's location. About 5 to 6 percent of our
overall call volume includes a need for emergency dispatch. In
such a case we ask the veteran for their identifying
information and we ask for their location.
If the veteran is not able to provide that information or
chooses not to provide that information we have options that we
can engage to try to locate that veteran based upon a number of
variables. Again, that is a last resort and only in emergency
situations.
Ms. Kiggans. Thank you. Dr. Miller, the OIG's recent report
highlighted concerns that not all Veteran Crisis Line staff
were aware of postvention services. The responders may deal
with incredible emotional and triggering calls. How is the VA
ensuring that responders have the support and resources
available to them?
Dr. Miller. Great question. We appreciate your attention to
the well-being of our crisis responders. This is an area that
we have been working assiduously on. Dr. Watson, I defer to you
for specifics.
Dr. Watson. Yes, thank you for that question. I believe the
online survey was approximately in May 2023. Since that time up
to the current state we have provided postvention resources. We
have had all of our staff take training on that and the only
ones that have not been involved are anyone who is on extended
leave.
We have an employee assistance program and we have sessions
involved there. We provide yoga, meditation, stretching, other
types of things to help our callers unwind so that they will be
most proficient in providing the best services for our callers.
Ms. Kiggans. What is the attrition rate for the veteran,
Veteran Crisis Line responders?
Dr. Miller. You are referring to the turnover rate perhaps?
Ms. Kiggans. Yes. Yes, sir.
Dr. Miller. Okay. The turnover rate by industry standards
is rather low. It averages around 15 percent overall. We also
note that in our turnover you may have turnover from a
responder to a supervisor or to a workflow coordinator, which
we consider advancement and growth and a positive indicator.
Ms. Kiggans. Along those same lines just asking about the
staffing, are you fully fielded? Do you have enough employees?
Are you at 100 percent for your workforce?
Dr. Miller. We feel that from a staffing perspective we are
in a very good place right now visa vie our demand.
Some key indicators of that, we mentioned the 2023 OIG
report from a 2021 situation.
The heart of that situation was a responder working
overtime. With our hiring what we have been able to do is we
have been able to decrease overtime by greater than 25 percent.
We have been able to decrease the time that responders are in
concurrent chats and text messaging as well, so that they can
focus on the veteran in front of them whether it be chat, text,
or phone.
Ms. Kiggans. Thank you. Thank you very much. Dr. Kroviak,
why are silent monitors important for the oversight and quality
review of Veteran Crisis Line responders?
Dr. Kroviak. We very much feel that it is such an important
quality assurance process to have real time understanding of
the quality of interventions that are provided and then from
there, supervisors can make decisions about whether their staff
need more support, more training, retraining, or long term
tracking and trending how performance would influence
allocating resources differently and training and retraining
programs.
Ms. Kiggans. Thank you. Also Dr. Kroviak, in your testimony
you state there are a concerns about leadership accountability
and the handling of errors or performance deficiencies by VCL
staff. What recommendations has the IG made to improve VCL
leadership practices to ensure greater accountability and
adherence to high reliability organization principles?
Dr. Kroviak. Yes, we have multiple recommendations
throughout the reports I cited in my written testimony aimed at
just that, of strengthening the quality assurance program to
ensure that the leaders have an understanding of the
performance and act accordingly in that area of accountability.
Ms. Kiggans. Do you believe VCL leadership is taking
appropriate steps to implement these recommendations?
Dr. Kroviak. We do. They have been very responsive to the
recommendations that we have made.
Ms. Kiggans. Thank you. I will yield and I will now
recognize Ranking Member Brownley for any questions she may
have.
Ms. Brownley. Thank you, Madam Chair. Thank you to the
panel I apologize. I was late. I was in another committee
hearing voting. Anyway, I wanted to ask Dr. Watson, can you
speak to the extent to which VCL is offering culturally
competent training for staffers particularly as they are
preparing to interact with the LGBTQ+ community as well as
women, actually?
Dr. Watson. Thank you so much for that question. That is
very, very important to us and we have training for our LGBTQ+
population as part of an annual training. We also have training
for women veterans. We have training for veterans who are
living with military sexual trauma, so there is a 3-hour
training for new employees.
These are concerns that are very important to us and we
also have a resource SharePoint available for resources for our
special populations.
Ms. Brownley. Thank you. Have you been in your position
overseeing this from before COVID to currently after COVID?
Dr. Watson. Thank you for the question. I have not. I was
sworn in in April of this year?
Ms. Brownley. Okay. One of my questions is really around
these are very sensitive, delicate, trying, sometimes
heartbreaking jobs that people are doing, obviously very
critically important and I am just wondering, you know, when I
read through the testimony and staff report, I was feeling very
much like how is this, you know, how is this optimal where
people are working remotely and not working together to sort of
support each other?
I guess since COVID everybody started to work remotely and
stayed that way and I presume the decision was made to stay
that way because they felt as though that was optimal. I am
just wondering do you think it is optimal? You know, my gut
reaction seems to be, I am not so sure that is optimal.
Dr. Watson. Thank you for the question. We do feel like
that is, this is optimal for the organization to have
responders across the country. They are connected for our
virtual meetings. We have a tier huddle system that helps them
to remain connected not only on providing the best metrics for
the services that they provide to caller but it also keeps them
connected as sub-workgroups so we think this is something that
is effective.
Ms. Brownley. Those are meetings that are not, they are
meetings kind of across the country, not divided up by Veterans
Integrated Service Networks (VISN) or anything like that, these
virtual meetings that you are talking about?
Dr. Watson. Right. These are virtual, daily huddle meetings
where we look at the events of the previous day.
Ms. Brownley. This is for everyone working on a crisis line
across the country?
Dr. Watson. Correct.
Ms. Brownley. Okay. How do you know that they are getting
the support that they, that they need when you are talking to I
guess thousands of people during these meeting?
Dr. Watson. Great question again. We really depend on
regular feedback from our employees on whether the meetings are
helpful, are we addressing and answering the right questions
for them, and providing the support? It is something that we
consider continuous process improvement.
Ms. Brownley. Dr. Kroviak, did you, I mean is this an issue
that you got some sense of in terms of talking to the staffers
who are doing this?
Dr. Kroviak. In our most recent report with the 988
conversion, we did find an issue with challenges actually
related to hiring supervisors for onsite work.
Ms. Brownley. Yes.
Dr. Kroviak. It is almost the opposite of what you are
suggesting in that by offering remote position, VA was more
able to attract the talent that they needed in that supervisory
role to correct the ratios that we found so concerning between
supervisor and responders. It was not a finding in that work.
Ms. Brownley. I mean most of the people that you are hiring
are being trained or are coming in with experience whether they
are psychologists or whatever----
Dr. Kroviak. We are not doing the hiring. I would have to
defer the hiring criteria to Dr. Miller----
Ms. Brownley. Okay. In terms of your----
Dr. Kroviak. It is not specific----
Ms. Brownley [continuing]. conversation everybody was, that
you are saying and I read that in the staff report that it was
easier to hire quality people for a remote job then it was to
come in house.
Dr. Kroviak. From our work that was at the supervisor
level, they found it challenging to recruit supervisors for
the----
Ms. Brownley. I see.
Dr. Kroviak [continuing]. in place position as opposed to
the virtual positions.
Ms. Brownley. Okay. All right. I just--anyway I think, I
think you have answered my question in terms of another
question I had to making sure that, you know, VA employees are
getting the postvention services that are available to them and
making sure that everyone is knowledgeable and aware I think
from the OIG report there was some issue around that that was
not getting out.
I think it is critically important that those services are
there immediately just as thought it is critical important that
we answer the phone immediately and serve those veterans who
are in trauma immediately but we need to help the people who
are helping others and making sure that they have the supports
that they need when they need them. Thank you. I yield back.
Ms. Kiggans. Thank you Ranking Member Brownley. The Chair
now recognizes Mrs. Radewagen for 5 minutes.
Ms. Radewagen. Thank you, Madam Chair. I want to thank the
Ranking Member for holding this hearing. I also want to welcome
the panel. Thank you for being here today.
Dr. Miller, we have heard that there is a working group to
discuss the geo-routing issues for crisis line calls. Has VA
identified solutions to geographically locating veterans in
crisis?
Dr. Miller. Thanks for the question. You are well aware
then that this week SAMHSA announced the pilot implementation
of geo-routing, geolocation services. I think that this is
really important for 988 overall. It is going to help 988 to
link callers to more localized and the most localized crisis
call centers and in terms resources to address their needs.
Within the VA the geolocation services for the purpose of
providing localized care are less of a presenting issue with
our callers and our daily operations. As a national call
center, we link each caller to the most local facility and
suicide prevention coordinator therein.
Again, we are averaging about 15 to 17 percent of all phone
calls result in a voluntary SPC referral from the veteran.
Ms. Radewagen. When the decision was made to hire more
responders, Dr. Miller, why did VA fail to ensure that the
appropriate number of supervisors were simultaneously hired?
Dr. Miller. Well I think--I do not think it was a failure
to be honest with you from my perspective. I think it was a
developmental issue and occurred over a period of time where
phase 1 necessarily involved hiring qualified responders, phase
2 then required building up the supervisor cadre.
I will also note that the 1 to 10 ratio is a ratio that we
developed and stated as a target. It is not based in anything
that is policy. It is a goal. We are currently at a ratio of 1
to 8. We think that we are at the right place with that largely
because 98 percent of responders right now are monitored every
month by their supervisor.
Ms. Radewagen. From the congressional notifications, Dr.
Miller, we have received about outages and intermittent access
issues, approximately 675 callers have been impacted. What is
VA's procedure to connect with these dropped calls, texts, or
chats?
Dr. Miller. Yes, it is really important that we follow up.
We are one of the few crisis calls centers who engages follow
up for dropped or abandoned calls. We have developed, I think a
pretty thorough Standard Operating Procedure (SOP) for that.
Dr. Watson, would you like to share more about the SOP?
Dr. Watson. Yes and thank you for the question. We provide
at a minimum three calls across three different shifts to
callers that we need to reconnect with and do outreach to. The
percentages of those that we have reached is 74 percent.
The ones that we have not reached are due to numbers not
being correct or inoperable and/or the caller has already
reached back to us so we have already made a connection. This
is something that we take very seriously in terms of making
sure that the experience and any type of disruption is
addressed properly.
Ms. Radewagen. Thank you, Madam Chairwoman. I yield back
the balance of my time.
Ms. Kiggans. Thank you, Ms. Radewagen. The chair now
recognizes Ms. Budzinski for 5 minutes.
Ms. Budzinski. Thank you, Madam Chair and thank you Ranking
Member. Thank you for bringing us together to talk about this
important issue surrounding 988, the veterans crisis hotline.
As my colleagues have really already pointed out, the
veterans crisis line has been instrumental in reducing veteran
suicides. This has been one of the most important tools to
reach veterans in distress and it is especially important that
we are reaching our veterans living in more rural areas, which
tend to be harder to contact.
According by the study by the American Association of
Suicidology, rural vets have had a 22 percent higher risk of
dying by suicide than their urban counterparts. These
disturbing disparities--these are disturbing disparities but I
believe that the veterans crisis hotline can help us reduce
these numbers for all veterans including our rural vets.
My question is really for Dr. Miller, how is the Veteran
Crisis Line coordinating with local law enforcement to respond
to calls especially in rural areas where resources may already
be thin?
Dr. Miller. Thank you for the question. You are 100 percent
correct that rural or highly rural veterans represent a higher
statistical risk for suicide. Rural veterans also
disproportionately die secondary to firearm self inflicted
wounds.
We work closely as needed with local law enforcement
particularly in rural areas. We offer resources and training
for law enforcement. We are also engaged in law enforcement
communities of practice to talk about safe and effective ways
to intervene when engaging in an emergency dispatch with a
veteran.
Ms. Budzinski. Can you see any improvements that you might
identify that could be made just to strengthen the connection
and response in rural areas?
Dr. Miller. I think there is always opportunities for
improvement. I think one area that I have in mind most
immediately is the more that we can respond using broader
response teams and not just law enforcement, so response teams
that also consist of trained social workers, peers, and peer
support specialists, I think that that is going to improve the
experience and outcomes for everyone involved.
Ms. Budzinski. Okay. Thank you. In that similar, in a
similar vein, I am wondering about the safe continuity of care
and ensuring a seamless transition of also veterans' health
records when they use the Veteran Crisis Line.
Dr. Miller, again, how is the VA planning to improve
coordination in sharing of information regarding the outcomes
of calls into the Veteran Crisis Line and the VA facilities
that may be providing care to that veteran, particularly to
ensure the patient's electronic health record is updated in a
timely manner?
Dr. Miller. We walk a really fine line there to be
completely honest with you. The fine line that we walk is
veterans and service members call us because they believe we
are safe. They call us because they believe it is confidential
and if so, and if they so choose it is anonymous. Therefore,
our documentation system is separate from the VA health record.
However, it has interoperability and linkages through the
suicide prevention coordinators. Something that we have been
careful to do is ensure that we are continually updating
policy, practices, standard operating procedures for
communicating information in VCLs system to information in VA
care records through the suicide prevention coordinators.
Ms. Budzinski. Okay. Well, thank you. I just want to really
close by saying a big thank you to the VA and the staff of the
Veteran Crisis Line for providing this important tool and
really what a difference it is making in communities and for
our nations veterans. I just want to say a sincere thank you.
Thank you. I yield the balance of my time.
Ms. Kiggans. Thank you. The Chair now recognizes Mr. Van
Orden for 5 minutes.
Mr. Van Orden. Thank you Madam Chair. Dr. Watson, what
percentage of these folks are working for--wait, let me start
this over. Who is answering the phone?
Dr. Watson. Thank you for the question. The crisis
responders.
Mr. Van Orden. Yes, who is that?
Dr. Watson. These are staff that are across the country.
Mr. Van Orden. Okay. They are who? They are veterans, they
are psychologists, they are nurse practitioners?
Dr. Watson. Anyone who has a social science background
could be a crisis responder. They could be any of the above.
Mr. Van Orden. A social scientist from Cleveland that has
never spoken to a veteran in person could answer the phone and
try to talk someone off a ledge, is that right?
Dr. Watson. (No verbal response.)
Mr. Van Orden. The answer is yes. Okay. What percentage of
these social scientists are working from home?
Dr. Watson. Anyone who is on--the crisis responder is
working from home.
Mr. Van Orden. 100 percent of your staff, the social
scientists that are answering the phone that may or may not
ever actually seen a veteran in person, every, the 100 percent
are working from home. Is that right?
Dr. Watson. That is correct.
Mr. Van Orden. Okay. How much do they get paid?
Dr. Watson. I do not have that information. I can take that
for the record.
Mr. Van Orden. Yes, let us do that. How many of the vets
that call 988 go on to commit suicide?
Dr. Miller. I will be happy to take that, if that is okay--
--
Mr. Van Orden. It is, Dr. Miller.
Dr. Miller [continuing]. with you, sir? The veterans, the
veterans who contact the Veteran Crisis Line have a higher rate
of suicide and risk of suicide. The good news----
Mr. Van Orden. Whoa. Hold on a second.
Dr. Miller [continuing]. in the higher rate----
Mr. Van Orden. Stop, stop, stop. You are telling me a
higher percentage of veterans that contact the Veteran suicide
line and talk to a social scientist that has never seen a
veteran in their life in person have a higher rate of suicides,
is that correct?
Dr. Miller. Within 12 months of that call, yes, sir, that
is correct. They have about 10 and a half times higher risk.
However, I will also note that in the last 2 years of available
data we have significantly reduced the suicide rate.
Mr. Van Orden. Sure, if it is 10 and a half times higher
rate of suicide for people to contact you as of 2 years ago,
what was it 3 years ago?
Dr. Miller. Three years ago it was 10 and a half times,
sir.
Mr. Van Orden. What is now?
Dr. Miller. It, there is been a 30 percent reduction in
suicides----
Mr. Van Orden. Sir, I am a retired enlisted guy. Can you do
the math for me on that? Like what percentage is that?
Dr. Miller. I am percentage related to what, sir?
Mr. Van Orden. It is 10 and a half times greater. Okay. We
are----
Dr. Miller. There have been 284 less veterans suicide
deaths in the Veteran Crisis Line population----
Mr. Van Orden. Roger that. Okay, Okay.
Dr. Miller [continuing]. for 2020 through----
Mr. Van Orden. I have limited time. I got you. I want all
of this on paper. Did you think that Zoom school, online
learning during the COVID buffoonery was optimal?
Dr. Miller. I believe----
Mr. Van Orden. Do you think the educational outcomes for
children that did Zoom school that they are on power with their
colleagues that went to in-person school?
Dr. Miller. That is not an area I have studied, sir.
Mr. Van Orden. The answer is hell no. Is it more important
that a veteran does not commit suicide or that your staff gets
to work from home?
Dr. Miller. It is most important that the veteran does not
commit suicide.
Mr. Van Orden. Okay. If we are paying you to find social
scientists people that can have no contact with the human
veteran ever and they are sitting on their couch how do you
know they are working?
Dr. Miller. We----
Mr. Van Orden. How do you know that?
Dr. Miller. We have indications of their productivity. We
have indications of----
Mr. Van Orden. Sir, their productivity----
Dr. Miller [continuing]. the phone calls they are----
Mr. Van Orden.--is a 10 and a half times higher veteran
suicide rate than someone that does not talk to them.
Dr. Miller. I would also say that their productivity is 284
saves lives----
Mr. Van Orden. That is fantastic but that is a horrible,
horrible way to justify this, Doctor. If 10 and a half times
more veterans commit suicide than that talk to you that do not,
could not we reasonably say that more veterans would not commit
suicide if you did not exist?
Dr. Miller. What we can reasonably say is that----
Mr. Van Orden. That is, you are literally sitting next to
Dr. Watson, so if we could do a little Sherlock Holmes stuff
here, deductive reasoning, the answer appears to be yes. So,
this----
Dr. Miller. I disagree with you.
Mr. Van Orden. This--well you can disagree all you want,
Doctor.
Dr. Miller. Thank you.
Mr. Van Orden. You can. What I am telling you is this is
not working. You actually may be contributing to the problem.
With that I yield back.
Dr. Miller. I think we have data that tells it is working
and is effective. Thank you.
Ms. Kiggans. I just had a couple staffing questions out of
curiosity. If in 1 day how many calls might a--and assuming it
is is like an 8-hours shift. I do not know how you have your
shifts set up, but how many calls might one provider receive in
a day or in a work shift?
Dr. Watson. I do not have that particular answer. Thank you
for the question--for one crisis responder. We do receive about
2,500 calls per day on average. Some days more, some days less.
Ms. Kiggans. Okay. That is nationwide?
Dr. Watson. Correct.
Ms. Kiggans. Okay.
Dr. Miller. I also believe that the number of calls
answered can vary by day. For example, Monday tends to be our
highest volume call day.
The number of calls answered by one responder on a Monday
would probably be different from the numbers that same
responder on a Tuesday. It is higher in the fall than it is in
the winter. There is some seasonality to it as well.
On average, you are looking at a responder with an average
handle time of 43 to 45 minutes per call. Across shift, you are
looking at around an average of probably five calls on a
particular busy day.
Ms. Kiggans. Okay. Now how many, how many responders do you
have working every, in 1 day?
Dr. Miller. That depends on the day. That depends on the
time of year and that depends on the shift. We use forecasting
to predict call volume per ever 15 minutes and then we staff
accordingly and then we staff for a 15 to 20 percent surge just
in case there is a surprise in the numbers so that we are
available.
Ms. Kiggans. I am assuming things like holidays, you have
sufficient staff for?
Dr. Miller. We do. What we have actually learned though is
it is not the holiday that is busy. It is the day after the
holiday that tends to be more busy, particularly the Monday
following a holiday, so we staff accordingly.
Ms. Kiggans. If that crisis line provider deems that the
veteran who is calling needs immediate care, do they have any
problem getting them to be seen at the closest facility be that
a veteran hospital or even civilian health care? Can they
always make that connection for them?
Dr. Miller. Yes. Well as we mentioned we always use the
connection with the suicide prevention coordinators about 17
percent of calls result in that referral. The suicide
prevention coordinators follow up accordingly.
That was actually one focus of a recent OIG review making
sure that we are synching and coordinating with SPCs at the
local level to ensure that they are following up timely on
veteran referrals through the VCL and that recommendation was
closed.
Ms. Kiggans. Okay. Good. Thank you. My last question, have
you ever--I have been to different crisis centers and one
recently was a housing crisis line and they had all the people
in one room in cubicles answering the phone. Has that ever been
done in person or has it always been done remotely, the people
answering the phones?
Dr. Miller. It is, so since it originated in 2007 in
Canandaigua, New York, that was actually the Canandaigua VA in
New York, we maximized the market within Canandaigua. We
expanded to Atlanta. We maximized the market in Atlanta. We
expanded to Topeka, Kansas. That is about the approximate time
that COVID hit.
Ms. Kiggans. Has there been any discussion about bringing,
going back to an in-person setting?
Dr. Miller. We are open to whatever works best for veterans
and provides the highest amount of access and quality of
services. That is a window that I think should always be open
and in consideration if it is best for the mission.
Ms. Kiggans. Thank you very much. Ranking Member Brownley,
did you have any further questions?
Ms. Brownley. Yes, just a follow up on that. I have I think
sort of similar concerns about is working remotely have the
support systems in place. It just seems to me if people are
working together and particularly people who are onboarding and
who are new can listen to an experienced person and how they
speak.
I am just, you know, there seems to be in my mind, I mean
again I have no data behind this and no science behind it at
all, but my gut just sort of says, gee it seems like it would
be better if people were together as opposed to, you know,
working alone in their homes.
I mean do you have, you said, well we should be open to it.
I mean do you have an opinion of what is the better model that
is going to best serve our veterans and making sure that the
good staffers who are doing this work are taken care of as
well?
Dr. Miller. I do not think that we would have been able to
hire as quickly as we have in the last 2 years if we did not
have remote as an option. I also know that it was very possible
that at any moment the Veteran Crisis Line service could have
been wiped out by a responder walking in COVID positive to a
call center and then spreading that and us not having service
capability.
I will tell you as well, I went to Canandaigua a couple of
weeks ago and I just said, I am here. Come if you want to talk
and my schedule was full in talking to responders. One thing
they said, they missed the water cooler. They missed talking to
each other. They miss that connection. They were offering me a
myriad of ideas of ways that we could improve upon the water
cooler connection.
I will also note that we have less staff-to-staff
complaints and concerns as well. There is a balance there that
we keep in mind. I think your sensitivities are accurate and
correct.
Ms. Brownley. Thank you for that. I was just wondering if
you wanted to respond to some of the questions that Mr. Van
Orden was asking, Van Orden was asking and it seemed as though
you had more to say and did not have a chance to say it. I just
wanted to give you that chance?
Dr. Miller. I think that--yes, thank you. I do have more to
say to that. Obviously, I believe that the Veteran Crisis Line
is highly effective. I think it is very meaningful to say that
the suicide rate for the Veteran Crisis Line caller population
reduced by 30 percent from 2019 to 2020, and then an addition
20 percent from 2019 to 2021. This converts to 500 lives, 500
individuals who are alive today if that decrease had not
occurred.
We are dealing with a significantly high-risk population. I
think that it is meaningful to day that veterans report that
they are 11 times less likely to engage in suicide behavior at
the end of the call than at the start of the call.
I also believe we have opportunities to learn and grow. We
are all interested in significantly decreasing, eliminating
veteran suicide and we have opportunities for improvement.
Ms. Brownley. Thank you for that. I think the point you
were trying to make or I thought made pretty clearly is that
when a veteran is calling the call center, or crisis center,
they are in major crisis, so they are, you know, heightened at
risk and of course we want to save every single life, but
sometimes it just does not work out that way and we lose some
veterans from it.
Not that if it was not there then we would have less
suicide or a less suicide rate. That does not, that does not
make any sense to me at all and I thought that is the point
that you were trying to make. Anyway, I appreciate, I
appreciate your comments on that and I will yield back.
Ms. Kiggans. Thank you. The chair now recognizes Mr. Van
Orden for 5 minutes.
Mr. Van Orden. I am much more blunt than my distinguished
colleague, Ms. Brownley, and you said that her sensitivities
appear to be accurate that if people could get together they
would perform at a higher level.
I was super, duper clear asking these questions. What is
the most important thing? What did you say then?
Dr. Miller. That they would report higher satisfaction with
work if they were able to be more connected interpersonally.
Mr. Van Orden. Okay, man. If you have a workforce that
enjoys going to work, enjoys their environment, are engaged and
can be held personally accountable directly through observation
could we just make the bold leap saying that they would perform
at a higher level?
Dr. Miller. We have a very satisfied workforce right now
according to all employees----
Mr. Van Orden. Okay. You are----
Dr. Miller [continuing]. who are----
Mr. Van Orden. At this point you are obfuscating. You said
that a veteran calls, they are 11 times less like to have
ideation or less likely want to commit suicide at the end of
the call from the beginning. Correct?
Dr. Miller. Correct.
Mr. Van Orden. Okay. Please help me put this together. If
someone is 11 times less likely to commit suicide at the end of
a phone call than they were from the beginning of the phone
call but they are 10 and a half times more likely to commit
suicide after they call you.
I mean those are--we can play back your testimony. That is
what you are saying. It does not make any sense. This is why I
am more blunt. With the Senior Chief Mike Day, I have had 21 of
my friends, Navy SEALs commit suicide, 21.
This sort of dancing around this stuff is not appropriate,
man. These numbers, if--you said someone is 11 times less
likely to sound like they want to kill themselves at the end of
a phone call but they are 10 and a half times more likely to
kill themselves after they talk to you that does not make any
sense, sir.
Dr. Miller. Within----
Mr. Van Orden. I am the longest serving enlisted member in
the military ever to be elected to Congress. Rocks are heavy,
trees are made of wood, gravity is real, this does not make
sense.
Dr. Miller. Within 12 months, sir.
Mr. Van Orden. Well----
Dr. Miller. There is a big----
Mr. Van Orden. Sir, does it matter if someone kills
themselves within 12 months or 13 months or 15 months. They are
still dead.
Dr. Miller. That is correct. What it does matter is in
terms of the effectiveness of the Veteran Crisis Line services.
When the individual immediately gets off the phone with us the
individual is less likely to be dead. In 12 months, that
follows the individual is still high risk for suicide which is
likely----
Mr. Van Orden. Sir, I am in that patient category. I know
what the hell I am talking about. I did not read this in a
book. That is why you got these social scientists never talk to
a veteran. They need to be talking to people like me and they
need to be talking to people like Matthew Brennan, my staffer.
He is also in that group.
It is just we are doing something wrong and we can do it
better. I am not in any way shape or form impugning your guys
intention at all. I get all my healthcare through the VA or
through the VA system with Community Care. I know what you are
trying to do.
Sir, I am just saying that, you know, come let us reason
together because that is not what we are doing here. She has
brought up some exceptionally great points and we are just not
addressing them.
If we say that we think people are going to be more
productive when they are at the office by sitting on a couch
because everybody here has done a Zoom call and they are doing
17 things at the same time. You know what I mean?
They are not 100 percent focused on that phone call. I do
not care who you are. You cannot do. You have distractions.
That is true and you know that.
If the people need to focus their attention because Mrs.
Kiggans is sitting next to her holding me accountable, knowing
that I am focused on my job then that is what we need to do.
Like we just, we just need to do that. If your priority, and I
believe it is, sir, is that we have, we are always going to,
she is, Ms. Brownley is correct, we can only get to functional
zero for suicide unfortunately. You are absolutely correct,
ma'am. People are going to commit suicide unfortunately.
If we are not doing everything we possibly can to get
functionally, to functional zero then we are not doing our
jobs. That is what I am saying. These gobbledygook of numbers
just do not make sense. If it cannot make sense to me, like I
am the lowest common dominator, dude, and these things have to
make sense to me and they do not.
I have 9 seconds and with that I want to compliment you. I
do. Compliment you on your, on your efforts but I am not
complimenting you on your outcomes. With that I yield.
Ms. Kiggans. Thank you. I just have one last question in
closing. Is there any follow up that is done with the people
that do call and reach out? Does anyone check back in with them
in a few weeks or months?
Dr. Miller. Absolutely, over the last few years we have
developed a peer support outreach call center where we have
hired 100 percent veterans who are certified in peer support
and they engage then in call back. We call it our beyond the
call work.
What we found that that has been very successful and well
received. We have also engaged caring contacts which is monthly
written outreach to veteran callers. We have heard feedback
from them that that is greatly appreciate and effective as
well.
Ms. Kiggans. That is good. Just to close the lid on the in-
person and I know COVID through debate and I know COVID had
thrown everyone for a loop.
We had an in-person roundtable meeting with mental health
providers in my district on Saturday morning it was interesting
to get a group of about 12 of them together, civilian providers
from all different backgrounds but to listen to them talk to
each other and compare notes and I was there, it was a
listening session for me.
To listen to how much they learn from each other, just
having them in that room for about a 2-hour period and I think
there is a lot of benefit as Ms. Brownley mentioned.
I note hiring is challenging. There is not enough mental
health care providers from the social work side to the, you
know, the nurse practitioner or whatever side you are
approaching it from but and so to have them, you know, be
centered at our, at our VA medical--I think it is doable and I
am glad to hear you did it in the past but I think it is, I
think it, I think all of us here would agree it is something we
would like to probably see explored a little more.
I would like to thank everyone for their participation in
today's hearing and for the productive conversation. I would
like to reiterate to all the veterans and their loved ones out
there to please reach out if you need help. You can reach the
Veteran Crisis Line by dialing 988 plus 1 or connecting through
a chat or text for confidential help.
The complete written statements of today's witnesses will
be entered into the hearing records. I ask unanimous consent
that all members have 5 legislative days to revise and extend
their remarks and include extraneous material. Hearing no
objection, so ordered.
I thank the members and the witnesses for their attendance
and participation today. This hearing is now adjourned.
[Whereupon, at 3:57 p.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 Matthew Miller
Good afternoon, Chairwoman Miller-Meeks, Ranking Member Brownley,
and distinguished Members of the Subcommittee. Thank you for the
opportunity today to discuss the Veterans Crisis Line (VCL).
Accompanying me today are Dr. Christopher Watson, Executive Director,
VCL, and Mr. Brad Mills, Director Unified Communications, Operations -
Deputy Connectivity & Collaboration Services, Office of Information and
Technology (OIT).
In 2021, 47,646 adult Americans died by suicide. Of those, 6,392
were Veterans. These numbers are more than statistics--they reflect
individual lives prematurely ended, and they continue to be grieved by
family members, loved ones, and the Nation as a whole. More work
remains to amplify Veteran suicide prevention efforts alongside each of
you at the National, State, and local levels.
Suicide is a complex problem with a multifaceted interweaving of
individual and contextual factors. In addition to the individual-level
risk factors associated with suicide, we must look at external factors
such as social determinants of health. Exposure to trauma, sense of
hopelessness, chronic pain, insomnia, isolation/loneliness,
relationship strain, and the death of a loved one are examples of
individual factors outside the specific frame of mental health that may
play a role in suicide. Social determinants of health such as
inadequate access to care, poverty, limited affordable housing, lack of
educational opportunities and even macrolevel factors such as war,
famine, and global health inequities contribute to suicide risk. With
no single predictor, there is no single solution, and we must be
comprehensive in our approach to prevent Veteran suicide.
Every death by suicide is a tragedy, and we will not relent in our
efforts to end Veteran suicide. We know that suicide is preventable. It
is a national public health issue that affects people from all walks of
life, not just Veterans. Eliminating Veteran suicide is a top VA
priority, and we continue to work diligently across the Department and
with Federal, tribal, State, and local governments to advance a public
health approach to suicide prevention. The National Strategy for
Preventing Veteran Suicide 2018-2028 is VA's suicide prevention
strategy, and it fully aligns with the President's 2021 National
Strategy for Reducing Military and Veteran Suicide. More specifically,
VA's suicide prevention strategy takes a comprehensive, cross-sector,
evidence-informed public health approach with focal areas in improving
lethal means safety; enhancing crisis care, and care transition;
increasing access to effective care; addressing upstream risk and
protective factors; and enhancing research coordination, data sharing,
and program evaluation efforts.
VA's public health approach requires a focus on evidence-informed
clinical and community initiatives. This means maximizing prevention
efforts that cut across all sectors in which Veterans may interact and
collaborate with Veterans Service Organizations (VSO), State and local
leaders, medical professionals, criminal justice officials, private
employers, and many other partners. VA's public health strategy
combines collaborations with communities to implement tailored, local
prevention plans while also focusing on evidence-based clinical
strategies for intervention.
Overview
VCL is a national call center with trained responders available to
any Veteran, Service member, or their loved ones 24 hours a day, 7 days
a week, and 365 days a year. Launched in 2007, VCL started with 14
trained responders working out of a call center in Canandaigua, New
York. VCL partnered with the Substance Abuse and Mental Health Services
Administration (SAMHSA) of the Department of Health and Human Services
(HHS) and the 988 Suicide and Crisis Lifeline to establish 988 in July
2022. VA made it easier than ever before for Veterans to reach VCL, by
dialing 988 and pressing 1. Upon the 2-year anniversary of 988, VCL has
noted a 22.7 percent increase in calls per day, 76.7 percent increase
in texts per day, and 27.5 percent increase in chats per day since the
launch of 988. This means that more Veterans than ever are getting the
support they need from caring, qualified responders during times of
crisis.
VCL is a critical component of the Nation's largest Integrated
Suicide Prevention Network. VCL links to 476 Suicide Prevention
Coordinators at every VA medical center for local follow up within 1
business day of calling VCL. VCL also provides additional services
``Beyond the Call.'' VCL expanded its critical crisis intervention work
to help Veterans continue to feel supported and engaged by implementing
Caring Letters in June 2020. Since then, VCL has mailed over 2.3
million letters to more than 310,000 Veterans. This evidence-based
intervention has been found to reduce the rate of suicide death,
attempts, and ideation (Reger, et al. 2019). In 2021, VCL launched the
Peer Support Outreach Call (PSOC) Center, providing outreach by
certified peer specialists, who are also Veterans, to support hope and
recovery-oriented services after the initial call to VCL. Together,
Caring Letters and PSOC provide additional support of expansion of
services as part of the unified efforts for 988 implementation.
While VCL operations continued to expand with 988 implementation,
so did the program evaluation efforts to assess VCL effectiveness. The
VCL program evaluation efforts resulted in a study that found Veteran
callers who use VHA services: (1) were over five times more likely to
have less distress at the end of the call than at the beginning; (2)
were almost 5 times more likely to have less suicidal ideation at the
end of the call than at the beginning; and (3) were 11 times more
likely to have reduced suicidal urgency at the end of the call than the
beginning (Britton et al., 2022). Further, another study reported among
Veterans who had suicidal thoughts who called VCL, 82.6 percent
reported that using VCL played a role in stopping them from acting on
those thoughts (Johnson, 2021).
VCL has received tremendous support to implement 988 press 1. This
includes being approved for 460 new full-time employees (FTE) in March
2021 and an additional 1,073 new FTEs in January 2022--bringing VCL's
authorized FTEs to 2,568. VCL received a budget increase of $141
million in Fiscal Year (FY) 2022, bringing VCL's total budget to $255
million. VCL's Fiscal Year 2024 budget has increased by another $45
million, for a total budget of $300 million. Through this support, VCL
has increased onboard FTEs from 877 in February 2021 to 1,955 as of
August 25, 2024--a gain of 1,078 FTEs. This includes an increase in
Crisis Responders from 541 in February 2021 to 1,084 as of August 2024,
growing by 543 FTEs. VCL has worked extensively with OIT to make
enhancements to technological infrastructure and to implement an
internal backup call center. These enhancements are designed to ensure
VCL can provide crisis support to Veterans, Service Members, and their
loved ones 24 hours a day, 7 days a week, and 365 days a year.
Additionally, VCL began a comprehensive modernization effort in
November 2021. This effort provides a resilient, hardened, secure, and
responsive VCL system. The scope of the modernization includes all
components of VCL, including support procedures and contracts,
hardware, and software. To ensure strong support, the effort is co-
sponsored by executive leadership from VCL and OIT. The effort began by
stabilizing support for existing components of VCL's product suite.
Implemented improvements, including implementation of the Session
Initiation Protocol in the telephony environment, 24 hours a day, 7
days a week, and 365 days a year support contract for the Customer
Relationship Module (CRM), full integration with VA's Enterprise
Service Desk and monitoring systems, and designating VCL as a critical
bedrock system. After this initial work, the effort proceeded to a top-
down evaluation of the current State, and with joint agreement from VCL
and OIT, is now in the implementation phase in several areas; the VCL
improved chat solution went live in August 2024, the newly developed
cloud CRM solution is planned to go live by the end of 2024, and the
telephony contact center solution will go live in calendar year 2025,
after extensive training and testing of the solution.
Recent Veteran Suicide Prevention Laws
Enactment of new laws has helped fuel forward advancements in
Veteran suicide prevention. Notably, the National Suicide Hotline
Designation Act of 2020 (P.L. 116-172) established a national three-
digit emergency number, 988, to simplify access to crisis services.
This law reduced barriers to accessing care during times of crisis. In
preparation for the anticipated increases in call volume, VCL completed
extensive work with an external consultant in six major lanes of effort
to ensure a successful deployment and operations. These preparations
focused on crisis operations, business operations, quality assurance
and training, resource management, information technology and
innovation, and communications. As part of these efforts, VCL expanded
staffing to support call, chat, and text services. Business operations
were strengthened to streamline the onboarding and new employee
orientation processes to support significant hiring initiatives, and to
implement a new wellness section to support employee whole health.
Quality assurance and training were augmented through additional staff
to provide silent monitoring and training programs. The information
technology and innovation section expanded to provide 24 hours a day, 7
days a week coverage and strengthen collaboration with OIT. Finally,
detailed communication plans were implemented to share information
widely and proactively regarding the transition to three-digit dial to
reach VCL. Internal partnerships within VA were instrumental to
resource VCL, provide employees with the necessary equipment to do
their jobs, and communicate key changes to Veterans Integrated Service
Networks, facilities, and other program offices. VCL also leveraged
external collaborative efforts in preparation, including with SAMHSA,
the Federal Communications Commission, and other Federal agencies.
Another law that has impacted VCL is the Support the Resilience of
Our Nation's Great (STRONG) Veterans Act of 2022 (P.L. 117-328, Div.
V), which contains more than two dozen sections that bolster VA's
efforts to support Veterans' mental health and equitable access to VA's
life-saving resources. The STRONG Act requires VA to update training
for VA's workforce and VCL staff, implement pilot programs, expand
access to mental health care, conduct analysis and research, and
provide outreach to Veterans regarding mental health resources.
The STRONG Act aligns with VA's priority of preventing Veteran
suicide and connecting Veterans with the best care through the
expansion of culturally competent mental health and suicide prevention
services to traditionally underserved Veterans and increased staffing
to mental health disciplines. VA has already implemented the
requirements of 14 of the 27 substantive sections contained in the law.
Title II of the STRONG Act directed VCL to improve training and quality
management and to conduct two pilot programs. It also required VA to
solicit feedback from VSOs on how to conduct outreach to Veterans,
members of the Armed Forces, and their families on the transition to
988 as the new suicide and mental health crisis line. VA has
implemented supervisory silent monitoring for Crisis Responders to
ensure consistent, high-quality services are provided, and it has
updated numerous standard operating procedures to clarify procedures
and guidelines for supporting Veterans and Service members in crisis.
Quality Assurance and Training
VCL has a robust quality assurance and training program. Since
February 2021, this program has grown from 54 FTEs to 111 FTEs as of
August 2024, an increase of 57 FTEs. In addition to the increase in
quality staff, VCL is closely tracking and monitoring supervisor-to-
staff ratios. Since October 2023, VCL ensured a ratio of one Crisis
Response Supervisor for every 10 frontline Crisis Responders and has
also ensured there is at least one Supervisory Social Services
Assistant (SSA) for every 10 frontline SSAs. As of August 2024, VCL had
a supervisor-to-frontline staffing ratio of one to eight for both
Crisis Responders and SSAs. Through these initiatives, VCL completes
regular silent monitoring for all Crisis Responders. This includes
having silent monitors complete at least one silent monitor for each
Crisis Responder every 2 weeks for 80 percent of Responders. In
addition, Crisis Response Supervisors complete two silent monitors for
all their direct reports monthly. These reviews are essential for
maintaining and validating quality assurance.
VCL conducts quality assurance practices and staff trainings to
ensure continued quality services and well-trained staff amidst the 988
implementation. VCL is fully accredited by three organizations: the
American Association of Suicidology, the Commission on Accreditation of
Rehabilitation Facilities (CARF), and the International Customer
Management Institute. In its most recent accreditation visit, CARF
awarded VCL a full 3-year re-accreditation for achieving zero findings
during Fiscal Year 2024. Only 1 percent of organizations achieve this
level of compliance across the Nation. CARF also commended VA for the
comprehensive training provided to VCL staff.
VCL Outages
Thus far in Fiscal Year 2024, VCL experienced 12 notable outages--
10 resulting from external vendor or carrier issues and 2 related to
internal VA equipment. A outage is defined as a Critical Priority
Incident that is a technical event that meaningfully impacts VCL's
ability to deliver critical services. These outages varied in scope and
impact. Some were limited to carrier issues in specific geographical
locations, some were intermittent outages, and others impacted
individual components of VCL's overall application suite. VA's
significant commitment to VCL OIT modernization and improvements noted
as part of 988 preparation are critical pieces of ensuring VCL can
promptly respond when outages do arise. In the case of an outage, VCL
follows detailed, standardized protocols to reach out to all impacted
numbers. This includes attempting to contact each number at least three
different times, during different times of the day, and over the course
of several days. If a VCL Crisis Responder is unable to connect with
the individual or leave a voicemail after these attempts, available
records will be reviewed to determine possible next steps, such as
continued outreach or engaging with a Veteran's assigned VA facility.
Only after these efforts have concluded will VCL consider resolving the
case.
As this Subcommittee is aware, OIT briefed staff from the Senate
Committee on Veterans' Affairs on June 27, 2024, regarding intermittent
access issues related to the 988 press 1 service. We informed the staff
at that time, and reiterate today, that the incident was due to
external factors unrelated to VA technology. Specifically, the issue
stemmed from a technical problem at a phone carrier's facility, which
was beyond VCL's control. Similar issues have occurred subsequently
with other major carriers. In response to these incidents, VA worked
closely with HHS, experts within VA, and the relevant phone carriers.
We took swift action to mitigate the impact, including posting alerts
on VA's websites and social media platforms to ensure that Veterans
were informed of alternative ways to reach VCL.
VA takes any outage that may prevent Veterans from accessing the
care they need, when they need it, very seriously. As outlined in the
August 22, 2024, VA Office of Inspector General (OIG) report titled
Veterans Crisis Line Implementation of 988 Press 1 Preparation and
Leaders' Response (OIG Report No. 23-00925-227), VCL ``did not
encounter technology concerns related to 988 press 1 implementation.
VCL leaders in conjunction with OIT leaders assessed, planned for, and
implemented technology changes related to 988 press 1.'' \1\
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\1\ https://www.vaoig.gov/sites/default/files/reports/2024-08/
vaoig-23-00925-227r.pdf.
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Of the 1,410 frontline staff who received the survey, 1,037 (73.5
percent) reported having the equipment and technical support required
to perform their critical work.\2\ OIG reviewed 100 percent of the
responses and made no recommendations for OIT to remediate issues,
reinforcing the effectiveness of our efforts in this area. Despite this
positive report, VA continues to take any reported outages seriously.
VCL and OIT work closely with our service providers and others to
remediate issues quickly and provide Veterans in crisis with timely
notifications and alternative access options.
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\2\ Veterans Crisis Line Implementation of 988 Press 1; Preparation
and Leaders' Response (vaoig.gov)
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Conclusion
We appreciate the Committee's continued support and collaboration
in this shared mission. Madam Chair, this concludes my statement. My
colleagues and I are ready to answer any questions you and the
Subcommittee may have.
Prepared Statement of Julie Kroviak
Chairwoman Miller-Meeks, Ranking Member Brownley, and Subcommittee
Members, thank you for the opportunity to discuss the Office of
Inspector General's (OIG) oversight of the Veterans Crisis Line (VCL).
The OIG's Office of Healthcare Inspections routinely reports on the
quality of services provided across the Veterans Health Administration
(VHA) and on risks to patient safety. There is almost no service that
VA provides that carries the same high level of risk and urgency than
the services provided by VCL responders to a veteran in immediate
mental health crisis. While not clinicians, responders are expected to
engage callers through active listening, motivational interviewing,
problem solving, and safety planning. Responders assess each caller's
level of risk for harm and implement appropriate action to stabilize a
crisis as quickly as possible. Stabilization efforts can involve
significant coordination between VCL staff, emergency personnel, and
VHA clinicians while maintaining open communication with the veteran in
crisis. Not unlike interventions delivered in a hospital or outpatient
setting, this coordination can involve a complex interchange of
assessment and administrative activities that must always be precise.
Veterans, their families, and caregivers rely on this crisis
intervention service. Its role in reducing the risk of veteran suicide
cannot be overstated.
A September 2023 OIG report, A Patient's Suicide Following Veterans
Crisis Line Mismanagement and Deficient Follow-Up Actions by the
Veterans Crisis Line and Audie L. Murphy Memorial Veterans Hospital in
San Antonio, Texas, details a devastating incident in which a veteran
died by suicide less than an hour after interacting with a VCL
responder.\1\
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\1\ VA OIG, A Patient's Suicide Following Veterans Crisis Line
Mismanagement and Deficient Follow-Up Actions by the Veterans Crisis
Line and Audie L. Murphy Memorial Veterans Hospital in San Antonio,
Texas, September 14, 2023. The OIG identified numerous issues in the
care and services delivered by both the VCL and the Audie L. Murphy
Memorial Veterans Hospital where the veteran was a patient. Given the
focus of this hearing, and the number of issues identified in the
report, this statement will focus on the VCL.
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The veteran, in their mid-thirties, was a VHA patient and had prior
documented reports of suicidal thoughts and behavior over the span of
almost 3 years. In early 2021, the veteran initiated a text contact
with a responder at 10:14 p.m. The veteran described a plan for suicide
involving use of firearms and hanging themselves from a rafter in the
shed from where they were texting. The summary of the text exchange
recorded in the veteran's electronic health record noted that the
veteran and VCL responder established a safety plan that included
involving a family member, distancing from and securing identified
lethal means, taking medications as prescribed, and calling medical
providers the following day.\2\ The responder documented that the text
exchange ended without incident at 11:29 p.m., and the required consult
(referral) was placed for the facility's suicide prevention coordinator
(SPC). In the following days, the facility SPC documented several
unsuccessful attempts to reach the veteran and the family member
involved in the safety plan. The SPC initiated a welfare check with the
local sheriff's office and was informed that the veteran hanged
themselves in the shed the same evening of the VCL text exchange.
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\2\ Lethal means refers to objects, including weapons and
substances, that may be used for self-harm.
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The OIG independently obtained the actual text exchange from the
veteran's family member. After careful review, the oversight team
determined that not only did the responder's documentation of the texts
inaccurately summarize the exchange, but the responder also did not
offer critical support and intervention to this veteran who was clearly
in crisis. The OIG found that the responder did not assess and address
risk and consider immediate rescue efforts, failed to understand the
veteran's access to identified lethal means and alcohol use, and
neglected to access the support of an onsite family member. These
failures collectively contributed to the tragic outcome for this
veteran and their family. The healthcare inspection also revealed that
VCL leaders failed to conduct a thorough and comprehensive review after
being made aware of the veteran's death by suicide. The missed
opportunities detailed in the September 2023 report resulted from
critical deficiencies of a single responder, as well as leaders not
holding their staff and themselves accountable for falling short of
their mission.
This statement highlights themes and identifies improvements that
can be made to better ensure consistency in high-quality crisis
interventions. The findings of serious deficiencies in the selected
reports highlighted below do not reflect the quality of care that VHA
leaders and staff provide every day to veterans across the system;
however, dismissing these findings as one-offs or an isolated system
breakdown, impedes a thoughtful analysis and the broad application of
lessons learned.
COORDINATING CARE FOR VETERANS IN CRISIS DEPENDS ON ACCURATE RISK
ASSESSMENTS BY VCL STAFF
The OIG recognizes the extreme pressure responders face in meeting
the immediate needs of a veteran in crisis in a setting where there is
no room for error. All VCL interactions do not demand the same level of
resource coordination and intervention as those described in the
reports highlighted in this testimony, but each must be initiated with
an understanding of the immediate risk. It is essential that these risk
assessments include reviewing the veteran's access to lethal means,
considering other risk factors such as alcohol and other substance use,
as well as identifying and including individuals who can offer
immediate support to the veteran. Without such an assessment, a
responder cannot make time-sensitive decisions aimed at stabilizing the
crisis and initiating appropriate supportive efforts.
Lethal Means Assessments Must Be Immediate and Thorough
The time between contemplation of suicide and an attempt can be
minutes, and failing to immediately and accurately assess such risk can
be fatal for the veteran. After the OIG independently obtained and
reviewed the text transcript discussed earlier between the veteran who
received care at the Audie L. Murphy Memorial Veterans Hospital and the
VCL responder, it was clear that the responder did not address the
veteran's admission that they had ``tested'' the hanging apparatus in
the shed and described ``feeling everything fade.'' Despite that
admission, the responder inaccurately documented in the record that the
veteran ``had not put any plans in to action'' and more aggressive
rescue efforts were not considered.
An OIG report published in April 2021 found similar failings.
Despite the caller informing the responder that they had a firearm in
hand and ``will shoot anyone that comes into [the] apartment,'' the
responder did not adequately engage in mitigating the immediate threat,
assess homicidal ideation, or conduct a safety plan with the caller.\3\
Shortly after the call ended, the veteran shot and killed a family
member.
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\3\ VA OIG, Insufficient Veterans Crisis Line Management of Two
Callers with Homicidal Ideation, and an Inadequate Primary Care
Assessment at the Montana VA Health Care System in Fort Harrison, April
15, 2021.
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Alcohol and Other Drugs Must Be Considered in Every Assessment
In the September 2023 OIG report related to the veteran's suicide
by hanging, the responder failed to inquire about the veteran's current
alcohol use although the veteran had texted thoughts of getting ``drunk
enough to get it over with.'' Alcohol use is a recognized risk factor
for suicide as it can impact judgment and reasoning and, during an
acute crisis, can influence a responder's assessment of risk and a
commensurate response. Based on a postmortem sample, the veteran likely
had a blood alcohol level between 0.06 and .13 during the text
exchange, suggesting that the veteran may have had impaired judgment
and reasoning due to alcohol use. In Deficiencies in the Veterans
Crisis Line Response to a Veteran Caller Who Died (a 2020 report), the
OIG found similar concerns when a responder failed to consider the
increased risk when a veteran described consuming a significant amount
of alcohol prior to initiating the call, and hours later died from
combined acute intoxication with alcohol and other prescription and
nonprescription medications.\4\
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\4\ VA OIG, Deficiencies in the Veterans Crisis Line Response to a
Veteran Caller Who Died, November 17. 2020. All recommendations from
this report have been closed, following VHA's provision of information
responsive to the recommendations.
Including Trusted Family Members and Friends during Crisis
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Management Can Improve Intervention Outcomes
VCL guidance promotes inclusion of individuals identified by
callers who can help support safety planning, especially when lethal
means are accessible. Yet, the September 2023 report detailed further
evidence of failures to meet the veteran's needs during their crisis
when the text exchange showed the veteran willingly allowed the
responder to call or text an identified supportive family member in the
house just feet away from the shed where the veteran was located. When
asked during an OIG interview why that family member was not notified
of the crisis, the responder stated, ``we don't involve [family
members],'' a response that was inconsistent with the VCL's guidance.
The family member told the OIG of being unaware that the veteran had
contacted the VCL but acknowledged receiving a text from the veteran
during the same time period requesting that the firearms in the house
be secured. The family member also reported that the patient's prior
suicide attempts involved firearms, and if the information had been
provided that the patient was considering hanging as a means, they
could have intervened differently.
CONSISTENT, HIGH-QUALITY CRISIS INTERVENTIONS REQUIRE SUPERVISORY
OVERSIGHT AND A STRUCTURED QUALITY MANAGEMENT PROGRAM
No healthcare system is perfect, and VHA is no exception. Since
2019, VHA has committed to becoming a high reliability organization
(HRO), an initiative with a goal of zero patient harm with leadership
that reflects a commitment to building and nurturing a culture of
safety that relies on evidence-based tools to continuously evaluate and
improve the safety and efficacy of processes.\5\ The OIG has reported
on the progress of individual medical facilities in implementing HRO
principles and has attributed multiple findings in OIG reports to
leaders failing to uphold these principles.\6\ A crucial aspect to
successfully implementing HRO principles is using protocols to drive
process improvements. Contrary to this, the OIG has consistently found
major gaps in assessing and addressing the quality of VCL responders'
performance.
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\5\ VHA National Center for Patient Safety, VHA's HRO Journey
Officially Begins, accessed September 5, 2024.
\6\ See, for example, VA OIG, Care Concerns and Deficiencies in
Facility Leaders' and Staff's Responses Following a Medical Emergency
at the Carl T. Hayden VA Medical Center in Phoenix, Arizona, July 2,
2024; VA OIG, Leaders at the VA Eastern Colorado Health Care System in
Aurora Created an Environment That Undermined the Culture of Safety,
June 24, 2024.
Silent Call-Monitoring Can Be an Effective Quality Management
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Tool When Used Consistently
In 2016, VCL leaders initiated silent monitoring of responders'
calls. Silent monitors are specialists trained to listen to active
calls, assess them for risk, and provide coaching on identified areas
for responder improvement immediately following monitored calls. The
goal was to have one monitoring for 80 percent of responders at least
every 2 weeks. Despite this established quality review framework, the
OIG's April 2021 report on the veteran that shot a family member found
that VCL leaders failed to ensure that sufficient silent monitored
calls were conducted for all staff. The lapses in oversight contributed
to the tragic outcomes described in that report. As a result, the OIG
recommended the VCL evaluate the percentage of completed silent
monitored calls and establish benchmarks for individual staff
requirements. That recommendation has since been closed as implemented.
However, the September 2023 report found additional, previously
unidentified gaps in the VCL's silent monitoring program. The VCL
responder at issue was, in fact, a trained silent monitor working
overtime shifts in the role of a responder. The OIG found there was no
silent monitoring for any of their contacts as a responder from January
2019 through the day the oversight team requested this information in
early February 2022. In an interview, the VCL's director of quality and
training reported that there was no process to conduct silent monitored
contacts for staff performing responder duties for overtime. After the
OIG provided VCL leaders with the transcript of the text messages in
March 2022, the leaders assigned staff to complete a retrospective
silent monitoring of the same responder's interactions with seven
individuals who contacted the VCL from October 16, 2020, through
October 26, 2021. The reviewers noted the responder's inadequate
performance in assessing caller risk, collaborative problem solving,
involving a third party to address immediate access to lethal means,
and in clearly and accurately documenting interactions with callers.
The OIG recommendation, now closed after VHA provided sufficient
documentary evidence of implementation, asked the VCL to strengthen the
quality management oversight of staff who provide crisis management
services, including overtime coverage.
Delays in Establishing Processes for Retaining Text Messages
Prevented Effective Quality Management of Crisis Interventions
Individuals may contact the VCL via telephone, text message, or
web-based chat. The September 2023 report found that despite the VCL
launching text-messaging services in November 2011, a retention process
for those text exchanges did not occur until May 2022, months after the
OIG initiated the healthcare inspection detailed in the report, and
over a decade after introducing the text-messaging option. The OIG
determined the lack of text retention processes prevented leaders from
conducting comprehensive quality assurance reviews of text-messaging
contacts, relying instead on the responder's summary of each text
encounter.
Leaders' failure to ensure a robust text contact management quality
assurance review program limited supervisory oversight that could
identify performance deficiencies and enable corrective actions.
Although VCL leaders described a multiyear process to resolve
information technology issues for text-message retention as a barrier
to implementation, during this healthcare inspection, VCL leaders
adopted an immediate interim solution that allowed responders to simply
copy and paste text transcripts into the record, thereby addressing an
OIG recommendation to ensure text retention and quality reviews.
Timely Root Cause Analyses Must Be Completed to Improve
Deficiencies
Across VHA, a fundamental tool used by quality and safety teams to
evaluate an adverse event is a root cause analysis (RCA). The RCA is
conducted by a multidisciplinary team of experts, including the
organization's leaders, focused on understanding how an error or a
close call occurred and how to prevent the situation from recurring.
Specific to the VCL, its leaders established a patient safety risk
manager position in 2018 and initiated an RCA program the following
year. The VCL's standard operating procedure instructs that, upon
notification of a VCL contact's death by suicide, the risk manager
determines the need for an RCA. In the April 2021 report related to the
shooting, the OIG noted that the VCL did not conduct a timely RCA
because of confusion surrounding how best to review the responder's
inadequate performance.
During interviews for the September 2023 report regarding the
veteran's suicide by hanging, VCL's director of quality and training
reported that despite an issue brief informing leaders of the completed
suicide indicating an RCA would be ``chartered,'' once VCL leaders
learned the interactions with the deceased veteran occurred through
text exchange and were therefore not recorded, VCL leaders determined
an RCA would not be feasible. However, 11 months after the event, which
was 3 weeks after the OIG notified VCL of the healthcare inspection,
and before giving them the complete text transcript, the VCL's
executive director stated that ``we saw additional points related to
systemic concerns'' that warranted an RCA. The OIG concluded that VCL
leaders' failure to conduct a timely review of the veteran's contact
contributed to a delay in the identification of systemic and
performance deficiencies and implementation of corrective actions.\7\
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\7\ VCL's director of quality and training reported that RCAs were
discontinued and replaced with a minimum requirement of an annual
analysis of reports on critical incidents and near misses submitted
through the VCL Reporting Hub since August 2021. The VCL Reporting Hub
is a web-based system that centralizes reporting and allows staff to
input data and to generate reports and notification messages.
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LEADERS MUST HOLD THEMSELVES AND STAFF ACCOUNTABLE FOLLOWING ERRORS
The grief of a family and other loved ones who lose a veteran to
suicide is overwhelming and can have a deep effect on the care teams
that work every day to prevent such occurrences. OIG teams repeatedly
find dedicated VHA professionals that go above and beyond their duty to
provide high-risk veterans with the resources and interventions they
need. The OIG also recognizes these professionals require significant
support and sensitivity when, despite those efforts, a veteran
completes suicide.
However, the OIG expects that leaders recognize boundaries between
the efforts to support their staff and actions that may compromise the
integrity of an independent review.
After the OIG scheduled interviews with VCL staff for the 2023
report, the OIG found that the director of quality and training instant
messaged the subject responder stating that the ``main points are to
only answer the question asked - don't volunteer anything extra.''
Further, this director offered the responder suggestions about the
content of the upcoming OIG interview, including ``They will ask you
about the interaction and likely about related policies and
procedures,'' and ``I think they are going to be interested in the fact
that you're an [silent monitor] who was working as a [responder].''
Additional communication between the VCL leader and responder
suggested messaging failed to prioritize the deceased veteran and the
value of reviewing the events to improve the safety and efficacy of
crisis interventions for future veteran callers. Other instant messages
stated, ``I have confidence that the Veteran couldn't have received
better'' and ``I wish I could have protected you from this.'' The OIG
made several recommendations addressing the concerning conduct by VCL
leaders, one of which remains open at this time as not fully
implemented. When leaders do not hold their staff accountable and
intentionally compromise the integrity of any OIG work being conducted
to improve services provided to veterans, functioning as a high
reliability organization becomes an impossible goal.
SENSITIVITY AND RESPONSIVENESS TO TRAGIC OUTCOMES MUST BE ENGRAINED IN
POLICY AND STRICTLY ADHERED TO BY ALL STAFF
VA has a unique and important obligation to the families and other
survivors of the veterans it serves. The intent behind appointment
reminders and ``caring letter'' correspondence specifically aimed at
engaging and supporting veterans who have received treatment for a
suicide attempt or suicidal ideation is noble. Yet, extreme sensitivity
must be practiced to ensure such outreach does not exacerbate grief or
retraumatize families of the deceased. Caring letters are an evidence-
based suicide prevention intervention that involves sending periodic
messages with simple expressions of care and concern to veterans who
use VA health care and contact the VCL, usually for a 12-to 24-month
period.\8\
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\8\ ``Memorandum of Understanding Between VA Quality Enhancement
Research Initiative (QUERI) And Veteran Crisis Line,'' July 30, 2019.
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During reviews for the September 2023 report, the OIG found that
facility staff continued to leave messages on the veteran's phone and
sent caring letters to their home. Because VCL leaders failed to
develop procedures that would have ensured the Caring Letters Program
received notification of the veteran's death, and facility leaders did
not ensure timely placement of the alert noting the veteran had died in
the patient electronic health record, the bereaved family's grief was
repeatedly exacerbated for months after the veteran's suicide. The OIG
recommended the VCL take actions to strengthen processes to make
certain that caring letters are not sent following a veteran's death.
The recommendation is now closed.
VHA IMPLEMENTED THE VCL ``988 PRESS 1'' THREE-DIGIT DIALING CODE
Most recently, the OIG reviewed how the VCL prepared for the 2022
implementation of the National Suicide Prevention Hotline three-digit
dialing code ``988 press 1.'' \9\ The report focused on VCL responder
and supervisor staffing and training, including ``postvention'' support
awareness; information technology equipment and support; and quality
metrics data and oversight.\10\
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\9\ VA OIG, Veterans Crisis Line Implementation of 988 Press 1
Preparation and Leaders' Response, August 22, 2024. This phone number
was established by the Federal Communications Commission designating
988 as a national suicide prevention hotline number. On July 16, 2022,
callers were able to contact the VCL by using 988 press 1. National
Suicide Hotline Designation Act of 2020, Pub. L. No. 116-172, 134 Stat.
832 (2020), codified at 47 U.S.C. Sec. 251 (2023). After the act was
signed into law, the name of the hotline was changed from the National
Suicide Prevention Hotline to the 988 Suicide and Crisis Lifeline.
There were two recommendations included in this report. The first OIG
request for an update on the status of the implementation of the
recommendations will be on or about November 22, 2024.
\10\ A postvention is an ``intervention conducted after a suicide,
largely taking the form of support for the bereaved.'' This process
allows for the emotional release necessary for ``those who have endured
a traumatic occurrence.'' VCL S-ACT-311-2009, Veterans Crisis Line
Standard Operating Procedure for Postvention, August 2020. The OIG did
not examine the content or utilization of the postvention resources.
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VCL leaders, in conjunction with Office of Information and
Technology officials, assessed, planned for, and implemented technology
changes related to the three-digit call option. The OIG found that the
VCL did not encounter technology concerns. An OIG survey distributed to
frontline staff reflected positive feedback regarding technology
equipment and support, with 89 percent of survey respondents reporting
having the necessary equipment and 83.2 percent reporting having the
necessary technical support.
Because VCL leaders may have overestimated an increase in call
volume, they aggressively hired responders. Such aggressive hiring
ultimately decreased the ratio of supervisors to responders. To provide
adequate performance assessments and training, the OIG recommended that
VCL leaders provide an appropriate ratio of supervisors to frontline
staff.
The OIG survey also asked frontline staff whether they were aware
of postvention resources. These resources, provided by VHA, are
available to frontline staff and supervisors because of their exposure
to potentially traumatic experiences. Approximately 72 percent of
frontline staff who responded were aware of postvention services, and
72 percent of frontline staff responded feeling supported by their
supervisors to access postvention resources. Because the OIG was
concerned that frontline staff's awareness and feelings of support from
supervisors to use postvention resources was not closer to 100 percent,
the OIG recommended that the VCL director ensure supervisors and staff
are aware of the postvention resources.
The OIG was encouraged by findings related to quality data
collection and analysis by VCL leaders. Quality metrics data were
reported monthly to VCL leaders and included call volume, timeliness to
answer calls, average time per call, number of dispatches of emergency
services for individuals at risk of imminent harm, number of staff
cleared for independent work, and the interactive quality of the call
through silent monitoring. The silent monitoring goal of an assessment
at least once every 2 weeks for 80 percent of the crisis responders
improved from August 14 to December 17, 2022, to achieve that goal.
CONCLUSION
September is recognized as Suicide Prevention Month to raise
awareness of the suicide crisis and heighten efforts to engage with
individuals who are at risk for suicide. For VA, this is a daily
commitment. The OIG has witnessed thousands of dedicated VA staff
educating veterans and their families while treating those who are at
risk for suicide. The dismal statistics of completed veteran suicides
do not diminish those efforts and must not be used to suggest such
efforts are ineffective or futile. When veterans engage with VHA, they
should expect that the care delivered will be compassionate, safe, and
effective. We must hold all leaders accountable for meeting these
expectations. The findings and recommendations in the reports
highlighted in this testimony should be used by VA leaders to
continuously test whether their operations are free from OIG-identified
deficiencies and provide safe and high-quality services. The OIG will
continue to oversee and spotlight areas in which VHA and the VCL can
take action to improve their operations to meet the needs of all
veterans, especially those at risk for suicide.
Madam Chair, this concludes my statement. I would be happy to
answer any questions you or members of the subcommittee may have.
Statements for the Record
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Questions for the Record Submitted by Mariannette Miller-Meeks
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Response to Questions for the Record Submitted by U.S. Department of
Veterans Affairs
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Response to Questions for the Record Submitted by Office of the
Inspector General
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Prepared Statement of American Foundation for Suicide Prevention
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Prepared Statement of Disabled American Veterans
Chairwoman Miller-Meeks, Ranking Member Brownley and Members of the
Subcommittee:
Thank you for inviting DAV (Disabled American Veterans) to submit
testimony for the record of your hearing titled, ``Dial 988+1:
Examining the Operations of the Veterans Crisis Line.''
The Veterans Crisis Line (VCL) is a confidential toll-free hotline,
online chat, and text messaging service that provides 24/7 crisis
intervention services. Launched in 2007, it is free and available to
all veterans, including those not enrolled in the Department of
Veterans Affairs (VA) Veterans Health Administration (VHA) system. The
VCL can be accessed through the national 988 Suicide & Crisis Lifeline,
which transitioned to the 3-digit 9-8-8 number in July 2022. As of
April 2024, the VCL has responded to more than 7.7 million calls,
941,000 chats, 377,000 texts, and has referred more than 1.5 million
veterans to VHA suicide prevention coordinators.
Awareness and Accessibility
Despite efforts to promote the VCL, many veterans are still unaware
of its existence or how to access it. VA has implemented several
campaigns to raise awareness about the crisis line, but reaching all
veterans, especially those in remote or underserved areas, remains a
challenge. Ensuring that all veterans are informed about and can easily
access this critical service is crucial. DAV supports this effort by
providing all DAV benefits advocates with suicide prevention training
while amplifying VA's message through media and broadcasts of the VCL,
988 press 1.
Although DAV has made efforts to raise awareness of the VCL within
the veteran community and among the general public, it is crucial to
emphasize a holistic community approach to connect with veterans who
are currently disengaged from VA health care and benefits, not involved
with veterans' service organizations, or those who typically do not
self-identify as veterans such as women veterans.
In addition, some catastrophically disabled veterans experience
challenges while contacting the VCL. Challenges can arise from physical
limitations that make tasks like dialing and holding a phone, speaking
clearly, and accessing technology difficult. Certain mental health
conditions, post-deployment challenges and traumatic brain injuries can
cause veterans to have limited stamina, patience, and increased stress,
which can exacerbate their conditions and is the opposite desired
effect/outcome during a stressful period when reaching out for help.
These challenges can indeed make it difficult for them to get the help
they need. We offer a few potential solutions for consideration that
could help address these issues:
Voice-Activated Technology: Utilizing voice-activated
systems can assist veterans who have physical limitations. This
technology can allow them to make calls or send messages without
needing to physically handle a device.
Dedicated Support for Mental Health and TBI: Specialized
training for crisis line staff to understand and manage the unique
needs of veterans with mental health challenges and traumatic brain
injuries could improve the quality of support provided.
Stress-Reduction Techniques: Incorporating stress-
reduction techniques and tools within the crisis line's protocol could
help veterans communicate more effectively. This might include guided
breathing exercises or calming prompts before they begin to explain
their situation.
Accessibility Features: Ensuring that the crisis line's
technology is compatible with various assistive devices, especially for
blind or visually impaired veterans could make it easier to use the
service.
Outreach and Education: Increasing awareness about the
available resources and how to use them can empower veterans to seek
help more confidently. This could include instructional videos or step-
by-step guides tailored to their needs.
Many rural and tribal veterans live in remote areas, making it
difficult to access general and specialized medical services. Reaching
rural and tribal veterans with information about the VCL can be
challenging. Long travel distances to VA facilities and limited local
health care options can hinder timely support. Broadband internet
access is often limited in rural and tribal areas, which can affect the
ability to use online chat or telehealth services provided by the VCL.
Lack of reliable transportation can also be a significant barrier,
especially for those who need to travel long distances to reach VA
services. Tribal veterans may also face additional challenges due to
cultural differences and a lack of culturally sensitive care.
Rural veterans often face higher rates of poverty and food
insecurity, which can exacerbate mental health issues and make it
harder to seek help. The VA's Office of Rural Health and other
initiatives must continue to work to bridge these gaps and improve
access to care for rural and tribal veterans. Addressing these
challenges requires a multifaceted approach, but with the right
strategies in place, VA can make the VCL more accessible and effective
for all veterans.
Efforts to address these challenges must include consideration of
expanding telehealth services, improving outreach and education, and
ensuring that VCL responders receive cultural sensitivity training.
Ensuring that VCL responders are trained to understand and respect
these differences is crucial. Tailored outreach efforts are needed to
ensure these veterans are aware of the services available to them.
Call Volume and Wait Times
Transitioning to the shortened 988 number led to increased call
volumes, sometimes resulting in longer wait times for some callers.
This highlights the need for adequate staffing and resources to manage
the higher demand for these critical services.
Each year, the VCL manages a substantial number of calls. In 2023
alone, the VCL received over one million calls. During the holidays and
certain other periods, the crisis line experiences a surge in calls. In
Fiscal Year 2023, there was an 18 percent increase of calls over the
previous year, resulting in veterans experiencing longer wait times
than usual. Additionally, there was a 25 percent rise in chats and a 73
percent increase in texts compared to the previous year.
One key goal of the VCL has been to answer 90 percent of calls
within 30 seconds, but maintaining this standard has proven challenging
for the Department. According to one Government Accounting Office (GAO)
report (GAO-17-545T), the VCL experienced a series of technical issues
and did not consistently meet its target response time, falling short
of the objective of answering 90 percent of calls within the specified
timeframe.
During VCL outages or increased wait times, we recommend veterans
are automatically directed to other crisis lines, such as the National
Suicide Prevention Lifeline at 1-800-273-TALK (1-800-273-8255), which
also provides support for veterans.
To handle the higher call volume, the VCL must increase staffing
levels. This should include hiring more responders and providing
additional training to ensure that they can confidently handle a
variety of crisis situations. Additionally, the VCL could consider
working with community-based organizations and affiliates to provide
additional support and resources to veterans in crisis could
potentially help to alleviate some of the pressure on the VCL.
Training and Resources
The VCL has been plagued with staffing and training issues, which
correlate with veterans' safety and their very lives. Ensuring that all
responders are adequately trained in crisis intervention and military
culture is essential.
In a September 2023 report, the Office of Inspector General (OIG)
determined that a responder inadequately assessed suicide risk and
alcohol use for a patient who died by suicide within the hour after VCL
text contact. The OIG found that the responder failed to establish an
effective safety plan, involve a family member, confirm lethal means
access reduction, and consider a transfer from text to a telephone
call. The OIG further noted that VCL leaders failed to provide adequate
oversight and quality assurance. Finally, the OIG report highlighted
delays and inadequate administrative responses by VCL and facility
staff following the patient's death, including failure to update the
patient's electronic health record and delays in implementing the
Behavioral Health Autopsy Program.
While VCL leaders increased the hiring of frontline staff, the
number of supervisors hired did not maintain the previously established
supervisor-to-staff ratio of approximately 1 to 10. At the time of the
review, the ratio had increased to one supervisor responsible for
approximately 20 responders. Due to the significantly increased volume
of calls, we concur with the OIG that the VCL increase the number of
supervisors to meet the recommended 1 to 10 ratios of supervisor to
responders to ensure quality of services, timely oversight, and
accountability.
DAV also recommends ongoing efforts continue to improve training
and resources for responders, including more comprehensive training to
include postvention resources for frontline staff.
Technical Issues
VA acknowledged there were technical glitches and issues with
routing calls correctly, especially during the initial rollout. Despite
these challenges, the 988 Veterans Crisis Line remains a vital resource
for veterans in crisis, providing confidential support 24/7.
In May 2024, the VCL faced intermittent access issues. Out of 505
affected callers, at least one outreach attempt was made for 433 calls,
and VCL resolved the needs of 188 callers. However, many callers in
crisis may have had unresolved issues. Implementing advanced technology
solutions to manage call routing and reduce wait time must be a
priority. This includes improving the infrastructure to handle higher
call volumes and ensuring that calls are answered promptly by
implementing advance call routing, improve online chat and text
services, improve Artificial Intelligence (AI), ensure VCL has
integrated telehealth services and strengthen VCL IT staff to manage
its own contracts and to ensure all necessary technology and equipment
are available and functioning properly.
Madam Chairwoman, to mitigate these risks, it is crucial that the
VCL has sufficient resources, staffing, robust contingency plans,
including backup systems and partnerships with community organizations
to provide alternative support options to those individuals who have
bravely sacrificed for our freedom, to prevent suicide. When a veteran
who is in crisis and feeling desperate, reaches out for help, they
should be met with timely, knowledgeable and supportive response.
This concludes my testimony and we thank you for the opportunity to
provide our comments.
Statement for the Record Submitted by Matthew Miller
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