    [House Hearing, 119 Congress]
    [From the U.S. Government Publishing Office]

                       ANSWERING THE CALL: EXAMINING VA'S
                             MENTAL HEALTH POLICIES

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

                                    HEARING

                                   BEFORE THE

                            SUBCOMMITTEE ON OVERSIGHT AND
                                  INVESTIGATIONS

                                     OF THE

                         COMMITTEE ON VETERANS' AFFAIRS

                         U.S. HOUSE OF REPRESENTATIVES

                        ONE HUNDRED NINETEENTH CONGRESS

                                 FIRST SESSION

                                   __________

                           WEDNESDAY, APRIL 30, 2025

                                   __________

                               Serial No. 119-18

                                   __________

           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
    61-151                    WASHINGTON : 2025

    -----------------------------------------------------------------------------------

                         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           CHRIS PAPPAS, New Hampshire
    MARIANNETTE MILLER-MEEKS, Iowa       SHEILA CHERFILUS-MCCORMICK,
    GREGORY F. MURPHY, North Carolina        Florida
    DERRICK VAN ORDEN, Wisconsin         MORGAN MCGARVEY, Kentucky
    MORGAN LUTTRELL, Texas               DELIA RAMIREZ, Illinois
    JUAN CISCOMANI, Arizona              NIKKI BUDZINSKI, Illinois
    KEITH SELF, Texas                    TIMOTHY M. KENNEDY, New York
    JEN KIGGANS, Virginia                MAXINE DEXTER, Oregon
    ABE HAMADEH, Arizona                 HERB CONAWAY, New Jersey
    KIMBERLYN KING-HINDS, Northern       KELLY MORRISON, Minnesota
        Mariana Islands
    TOM BARRETT, Michigan

                           Jon Clark, Staff Director
                      Matt Reel, Democratic Staff Director

                  SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS

                       JEN KIGGANS, Virginia, Chairwoman

    AUMUA AMATA COLEMAN RADEWAGEN,       DELIA RAMIREZ, Illinois, Ranking
        American Samoa                       Member
    JUAN CISCOMANI, Arizona              TIMOTHY M. KENNEDY, New York
    KEITH SELF, Texas                    HERB CONAWAY, New Jersey

    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

                                  ----------

                           WEDNESDAY, APRIL 30, 2025

                                                                       Page

                               OPENING STATEMENTS

    The Honorable Jen Kiggans, Chairwoman............................     1
    The Honorable Delia Ramirez, Ranking Member......................     2

                                   WITNESSES
                                    Panel I

    Dr. Ilse Wiechers, Deputy Executive Director, Office of Mental
      Health, Veterans Health Administration, U.S. Department of
      Veterans Affairs...............................................     4

            Accompanied by:

        Dr. Anthony Stazzone, Chief Medical Officer, Veterans
            Integrated Service Network 9, Veterans Health
            Administration, U.S. Department of Veterans Affairs

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

                                    APPENDIX
                        Prepared Statements Of Witnesses

    Dr. Ilse Wiechers Prepared Statement.............................    23
    Dr. Julie Kroviak, MD Prepared Statement.........................    27

                           Statements For The Record

    NeuroFlow Prepared Statement.....................................    43
    American Psychological Association Services, Inc. Prepared
      Statement......................................................    46
    Documents for the Record Submitted by The Honorable Delia
      Ramirez, U.S. House of Representatives, (IL-3).................    49

           ANSWERING THE CALL: EXAMINING VA'S MENTAL HEALTH POLICIES

                                  ----------

                           WEDNESDAY, APRIL 30, 2025

                 Subcommittee on Oversight and
                                Investigations,
                        Committee on Veterans' Affairs,
                                 U.S. House of Representatives,
                                                        Washington, DC.
        The subcommittee met, pursuant to notice, at 10:06 a.m., in
    room 360, Cannon House Office Building, Hon. Jen Kiggans
    [chairwoman of the subcommittee] presiding.
        Present: Representatives Kiggans, Ramirez, and Kennedy.

              OPENING STATEMENT OF JEN KIGGANS, CHAIRWOMAN

        Ms. Kiggans. Good morning, everyone. The subcommittee will
    come to order.
        I would like to welcome our witnesses, my fellow members,
    and the audience to this hearing of the Subcommittee on
    Oversight Investigations. Today we will dig deeper into U.S.
    Department of Veterans Affairs' (VA) mental health policies to
    gain insight into the processes and quality of care decisions
    regarding veterans' mental healthcare. From speaking with
    veterans in my district, it is clear that we have a lot of
    ground to cover to fix the mental health crisis in the veteran
    community.
        Of the concerns I hear most from veterans is how long it
    takes to schedule their appointments for mental health
    treatments. Delay in mental healthcare in the age of telehealth
    is well within our ability to address. Veterans deserve timely
    care.
        Despite the VA investing billions into Post-Traumatic
    Stress Disorder (PTSD) treatment, suicide prevention, and
    alternative approaches to mental health, we continue to lose
    too many veterans to suicide. One veteran suicide is too many.
    In 2022, 6,407 veterans died by suicide. That is 17 veterans a
    day. Unfortunately, it does not stop there. An additional 20
    veterans died by self-injury mortality, which generally means
    overdose. I have heard horror stories from constituents who
    have been prescribed pain medication and told to take more when
    they feel bad and less when they feel better. As a provider, I
    would not feel comfortable for prescribing two medications that
    might interact with one another without first consulting a
    psychiatrist. This is unacceptable.
        It is impossible to cover every detail of every case, but
    we know that we are losing veterans. Despite a seemingly
    endless amount of resources spent, these numbers have failed to
    substantially decline. One veteran's suicide, again, is too
    many.
        These men and women volunteer to serve their country in a
    variety of roles throughout our armed services. They have
    answered the call to serve. As a veteran and a nurse
    practitioner, it is alarming that we have allowed VA to fail to
    move the needle for this long. We must do better. We have tried
    to throw more money at the problem; the VA's budget has risen
    479 percent since 2001. Yet, despite a shrinking veteran
    population, the veteran suicide rate has remained virtually
    stagnant. Unfortunately, the VA's own numbers have only shown
    that they are doing less with more.
        This is not a question of spending more taxpayer dollars,
    but getting veterans what they need when they need it. Making
    progress means that we must take a closer look into the VA's
    bureaucracy and improve our oversight of the processes and
    policies that determine the quality of veteran mental
    healthcare. Suicide prevention and veteran mental health are
    bipartisan issues. Losing these veterans impacts red states and
    blue states.
        I hope this hearing will yield results to important
    questions about VA mental healthcare. How are these policies
    developed? What steps has the VA taken to adjust this approach?
    How does the VA use science and data to improve veteran care?
    Most importantly, how can the VA better serve the veteran?
        The answers that we hear today will inform our next steps
    to address these urgent issues. Veterans should not have to
    wait for mental healthcare and it is our bipartisan
    responsibility to ensure the VA has up-to-date policies and is
    enforcing these policies to ensure no veterans slip through the
    cracks. Again, this is a bipartisan issue and we cannot let
    politics stand in the way of making progress.
        There was spirited conversation during our last full
    committee hearing on the VA's workforce reform efforts--that
    the impact of VA's workforce reform efforts would have on
    delivering mental healthcare to veterans. The Secretary has
    addressed this misinformation and, let me reiterate, no
    mission-critical employees, including those at the Veterans
    Crisis Line, have been terminated from the VA.
        I am committed to ensuring that the VA works for veterans
    and their caregivers with a functioning, quality workforce.
    That being said, I look forward to hearing from our witnesses.
        I now recognize our Ranking Member Ramirez for her opening
    comments.

           OPENING STATEMENT OF DELIA RAMIREZ, RANKING MEMBER

        Ms. Ramirez. Thank you, Chair Kiggans.
        For many years I worked at a homeless shelter where I saw
    case of veterans confronting alone, without anyone to turn to,
    mental health challenges. Imagine, after wearing a uniform and
    serving our Nation, these veterans were dealing in silence with
    the pain of PTSD, depression, substance abuse, and the risk of
    self-harm. I am really glad that today we are having this
    hearing to truly discuss the necessity of adequate mental
    health and suicide prevention screening for veterans.
        The topic of today's hearing really gets to the crux of why
    VA and this committee specifically exist. Our responsibility is
    to ensure that when veterans need help they are connected to
    the clinicians who can provide the care and the services that
    they need so that no veteran has to confront these challenges
    alone. That is why we cannot have a complete conversation about
    mental health and suicide screening at the VA if we are
    unwilling to also address the cuts to personnel and the
    resources the agency and the work environment clinicians are
    currently operating in. We have to look at the entire picture.
        You see, the mental health and well-being of veterans does
    not exist in a vacuum, especially when upwards of 30 percent of
    the impacted workforce are veterans themselves. The Musk-Trump
    fueled uncertainty and the chaos being created for veterans and
    VA staff impact the mental health and the well-being of
    veterans. We are hearing directly from veterans who are worried
    about losing their VA care because of the Musk-Trump cuts. We
    know veterans have lost their jobs across the Federal
    Government and are now facing the trauma of unemployment due to
    this administration. Research shows that unemployment and job
    loss puts individuals at increased risk of suicide.
        Let me tell you, being someone that ran a homeless shelter,
    who saw veterans who were unemployed, who had no housing
    security, I can attest to this. It is really clear to me that
    we cannot have a conversation about adequate screening without
    also discussing adequate staffing across the VA enterprise. We
    cannot talk about adequate intervention without talking about
    adequate investment.
        Psychiatrists, psychologists, primary care physicians, and
    medical support assistance have long been on the VA Inspector
    General's severe occupational staffing shortage list. It is
    easy to see how shortages of these positions, which directly
    coordinate and provide mental healthcare to veterans, would
    affect VA's ability to adequately screen veterans for suicide.
    We had a talk about the work environment in which clinicians
    are now forced to provide mental health screenings and
    treatment.
        Since Department of Government Efficiency (DOGE) and
    Trump's April 15 Return to Office order that left facilities
    scrambling to find space for physicians, we have heard report
    after report from providers who are conducting telehealth
    appointments in compromised conditions, from open spaces to
    closets to even showers. I can tell you, as someone who served
    as the executive director of a social service organization that
    served people experiencing trauma and struggling with suicidal
    ideation, a shower is not the appropriate place to have these
    conversations. Providers are worried about the privacy of
    veterans, about the comfort of the veteran in disclosing their
    needs, and about having delicate conversations in unfit
    environments, and they have every single right to be worried.
    It is unacceptable that clinicians are taking their screenings
    in a closet.
        Sadly, a VA spokesperson dismissed the concerns about
    veteran privacy as nonsensical, saying that the VA will make
    accommodations as needed so employees have enough space to work
    and comply with industry standards for privacy. We are hearing
    directly from clinicians that those accommodations are just not
    happening.
        Hypocrisy is a word I feel like I am using a lot these
    days. My colleagues do not act concerned about the mental
    health of veterans, while ignoring the mental health toll that
    the Musk-Trump agenda is taking on them and cheering that
    agenda on from the halls of Congress.
        I will close with this. I believe we have an obligation to
    ensure that every single veteran access the care they need and
    they earned. Secretary Collins and President Trump have turned
    their back on LGBTQ+ veterans by shutting the VA's door to
    gender-affirming care, which in many cases includes mental
    healthcare. That, too, is unacceptable.
        If we want to talk about threats to veterans' mental
    health, we have to have an honest conversation about one of the
    biggest threats, and that is the Trump administration. Through
    their actions, they are creating the kind of anxiety, the
    uncertainty, the trauma, and stress that directly and
    negatively impact veterans' mental health, their well-being,
    and their care. With that, I look forward to this hearing, to
    truly forgetting about R and D and putting our veterans first.
    That also requires the veterans that are part of the workforce
    that protects our veterans.
        With that, Chairwoman, I yield back.
        Ms. Kiggans. Thank you, Ranking Member Ramirez.
        I will now recognize our witnesses on our first panel
    testifying before us today. We have Dr. Wiechers, deputy
    executive director of the Office of Mental Health of the
    Veterans Health Administration (VHA), the Department of Veteran
    Affairs. She is accompanied by Dr. Anthony Stazzone, the chief
    medical officer of Veterans Integrated Service Network (VISN) 9
    at the Veterans Health Administration, Department of Veterans
    Affairs. We also have Dr. Julie Kroviak, acting assistant
    inspector general for the Office of Healthcare Inspections of
    the Office of the Inspector General.
        All the witnesses, please stand and raise their right hand.
        [Witnesses sworn.]
        Ms. Kiggans. Thank you. You may be seated. Thank you. Let
    the record reflect that the witnesses answered in the
    affirmative.
        Dr. Wiechers, you are now recognized for 5 minutes to
    provide VA's testimony.

                       STATEMENT OF ILSE WIECHERS

        Dr. Wiechers. Good morning, Chairwoman Kiggans, Ranking
    Member Ramirez, and distinguished members of the subcommittee.
    I am honored to speak on behalf of the Department of Veterans
    Affairs about our work in providing high-quality mental
    healthcare for our veterans. My name is Ilse Wiechers and it
    has been my honor to serve the past 3 years as the deputy
    executive director of the Veterans Health Administration Office
    of Mental Health. Joining me today is Dr. Anthony Stazzone,
    chief medical officer of the VA MidSouth Healthcare Network.
        I have had the privilege of working with and caring for
    veterans as a practicing board-certified adult and geriatric
    psychiatrist for the past 15 years. VA's Mission to Care for
    our veterans drives us to improve daily. Veterans face unique
    mental health challenges, including higher rates of PTSD,
    depression, and substance use disorders, all of which
    significantly elevate their risk of suicide. Currently, 17.6
    veterans die by suicide every day, reflecting a grave public
    health crisis that impacts communities nationwide.
        While many veterans are successful and fully integrate back
    into society, some experience invisible wounds of war.
    Conditions like PTSD, depression, and substance use disorder,
    combined with the challenges of life after military service
    contribute to an elevated risk of suicide. In response, VA has
    developed a broad continuum of mental health services to ensure
    veterans receive the help they need. This includes crisis
    intervention, same-day access for urgent needs, outpatient,
    residential, and inpatient care across VA medical centers,
    community-based outpatient clinics, vet centers, the 24/7
    Veterans Crisis Line, and a nationwide network of suicide
    prevention coordinators, or SPCs.
        VA's Mental Health Services are designed to be accessible,
    evidence-based, and recovery-oriented. We emphasize early
    intervention, continuous support, and seamless integration of
    mental health into overall healthcare. Most veterans utilizing
    VA services report positive experiences and satisfaction,
    appreciating the availability of essential services, the
    privacy of medical records, ease of access, and the
    professionalism and courtesy of our VA staff.
        In 2018, VA published the National Strategy for Preventing
    Veteran Suicide, emphasizing a public health approach to
    suicide prevention. This combines community prevention and
    clinical intervention actions to directly serve veterans. Our
    commitment to preventing veteran suicide is integrated
    throughout all mental health programs and supported by enhanced
    staff education and suicide prevention.
        The Secretary has made preventing veteran suicide a top
    priority for VA. VA leadership is closely examining all current
    suicide prevention efforts and we are committed to challenging
    the status quo in order to find new and better ways of helping
    veterans. We cannot continue approaches that have failed to
    produce meaningful improvements despite substantial resource
    investments. Recent reports by the Office of Inspector General
    (OIG) have highlighted VA's efficiencies in VA's mental
    healthcare intake process and adherence to suicide risk
    identification screening. These findings underscore the need to
    strengthen initiatives and ensure high-quality care.
        VA has implemented a standardized suicide risk screening
    and assessment process known as the Suicide Risk Identification
    Strategy, or RISK ID. Completed annually for all veterans
    receiving VA care, this process includes a primary screening
    using a standardized questionnaire and a comprehensive suicide
    risk evaluation for any positive screen. This determines the
    severity of suicide risk and helps develop a risk mitigation
    plan. To ensure adherence, VHA issued a memorandum requiring
    all Veterans Integrated Service Networks to implement RISK ID
    requirements by April 7, 2025. In Fiscal Year 2024, VA
    completed over 2.6 suicide risk screenings.
        To stay at the forefront of suicide prevention VA
    continually updates clinical guidelines and training programs.
    In 2024, VA and U.S. Department of Defense (DOD) released a new
    Joint Clinical Practice Guideline for the assessment and
    management of patients at risk for suicide. Additionally, all
    VHA staff must complete suicide prevention training. VA has
    also implemented specialty training for SPCs and mental health
    clinicians on topics like lethal means safety counseling,
    ensuring high-quality care for at-risk veterans.
        VA is taking decisive action to transform the Department's
    mental healthcare system for veterans. The path forward
    requires VA to embrace innovation, accountability, and proven
    practices across every facet of its operations. Meaningful
    change requires collaboration within VA and with partners
    across government, private healthcare, and veteran
    organizations. This whole of society approach is essential to
    reach veterans wherever they may be. The oversight from this
    committee strengthens VA's work and helps ensure our focus
    remains on what matters most: providing veterans the
    exceptional care they have earned.
        The VA looks forward to continuing to work with this
    committee and we look forward to answering any questions you
    may have. Thank you.

        [The Prepared Statement Of Ilse Wiechers Appears In The
    Appendix]

        Ms. Kiggans. Thank you, Dr. Wiechers.
        Dr. Kroviak, you are now recognized for 5 minutes to
    provide your testimony.

                       STATEMENT OF JULIE KROVIAK

        Dr. Kroviak. Thank you, Chairwoman Kiggans, Ranking Member
    Ramirez. I am grateful for this opportunity to discuss the
    OIG's independent oversight of VA's and mental health services.
        The OIG recognizes that meeting the complex needs of
    veterans requiring mental healthcare comes with extraordinary
    challenges. The Office of Healthcare Inspections routinely
    assesses VHA's services and how well they address those
    challenges. Our clinical teams regularly make recommendations
    to improve VA's delivery of healthcare through reviews of
    mental health and suicide prevention programs, inpatient mental
    health units, reports of harm to patients at individual medical
    centers, as well as inspections of vet centers. OIG
    recommendations for corrective action are based on identified
    deficiencies and noncompliance with VA policies and established
    standards of care.
        As my written statement details, deficiencies can be
    grouped into three steps stages of suicide risk reduction
    interventions, with the first focused on screening and
    assessing veterans' risk. A December 2024 OIG review of VHA's
    suicide risk compliance found that in Fiscal Year 2023, the
    annual adherence rate was just 55 percent. Interviews revealed
    that the reasons for noncompliance included staff feeling
    uncomfortable with initiating screening and lack of clarity who
    should be overseeing staff compliance. A tragic example of a
    failure to properly assess a veteran was documented in an OIG
    report that found a veteran's crisis line responder did not
    fully assess a caller's alcohol impairment and access to lethal
    means. Shortly after the call, the veteran died by suicide.
        The second stage of risk reduction is the effective
    management of acute care needed after a veteran's suicide
    attempt or ideation. In two separate 2024 hotline reports, our
    teams found noncompliance with mandates to remove belongings
    from a patient that could be used in a suicide attempt and with
    requirements for staff's one-to-one observation for a patient
    with suicidal ideation. In both instances, the veterans
    attempted suicide during their hospitalization and, tragically,
    one died.
        Our mental health inspection teams consistently review the
    environment and care practices of VHA's Acute Inpatient Mental
    Health Units, repeatedly finding lapses in preparing patients
    for discharge. Because the highest risk for suicide occurs
    within the first 30 days after hospitalization, VHA staff
    should unfailingly carry out activities such as pre-discharge
    screening, determinations of access to lethal means, and a
    suicide prevention safety plan to confirm that a hospital
    discharge is appropriate and safe for each patient.
        Third, while the tragedy of a veteran's suicide can
    overwhelm survivors and healthcare teams, lessons learned can
    and must support efforts to reduce future suicides. Our work
    has identified numerous delays and deficiencies in important
    internal VA reviews after a veteran completes suicide,
    including root cause analyses, peer reviews, institutional
    disclosures, and family interviews. Such delays not only impede
    improvements, but also deprive loved ones of important grief
    management resources.
        The last report in my statement was published just last
    month on the role of VISN chief mental health officers. Across
    these 18 regional networks, the chief mental health officers
    reported they lack clarity about their role and the authority
    to effectively address staff noncompliance. In effect, VHA's
    governance structure may contribute to problems with
    performance and hinder opportunities for processing
    improvements.
        There will never be a single solution to the devastating
    problem of veteran suicide. Still, we must continue to work
    toward saving every life. That means not losing sight of what
    needs to happen today and every day: providing wraparound
    services that treat known risk factors for suicide, from
    prevention, such as anxiety and depression management,
    substance use disorder interventions, PTSD and military sexual
    trauma treatments, and grief counseling. VHA providers must
    meet veterans where they are and be ready to effectively
    intervene during their greatest moments of need. The OIG is
    committed to conducting oversight to ensure all veterans have
    access to the high-quality and compassionate care they need and
    deserve.
        Madam Chair, this concludes my statement. I would be happy
    to take any questions.

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

        Ms. Kiggans. Thank you, Dr. Kroviak. We will now move to
    questions and I yield myself for 5 minutes.
        I just wanted to start with you. You spoke a little bit,
    Dr. Kroviak, about staff noncompliance and about the VISN
    mental health chiefs being kind of frustrated with their
    ability to understand what their role is. Could you expand on
    that just a little bit, because I know we have talked about
    that in different parts of this committee, and what that looks
    like?
        Dr. Kroviak. Yes, I think there is this poorly defined or
    lack of clarity in what these critical leaders' roles should be
    in place of to being a consultative arm. We just repeatedly
    find that when we are in a facility, if there is an issue
    brought up, and we go to the VISN to understand their knowledge
    of interventions, they either were not aware or felt they could
    not intervene because that was not in their authority to do so.
        Ms. Kiggans. Would it be helpful to clarify that authority?
        Dr. Kroviak. We think so. We very much think so. The one
    report on the chief mental health officer is one example. We
    published other individual hotlines where we really tried to
    get that message across, that it was concerning that the
    facility was undergoing such trauma and the VISN either did not
    know about it or did not effectively intervene or monitor the
    events that were occurring.
        Ms. Kiggans. The monitoring is there, but just the
    enforcement of what to do once they identify a problem, what
    they can--what is the next step they can take?
        Dr. Kroviak. Yes, it becomes unacceptable for this regional
    source of expertise to just serve in a consultative role,
    waiting to hear about an issue, and we have repeatedly
    identified that in the reports.
        Ms. Kiggans. Thank you. Thank you very much for clarifying
    that. Then we have all heard the saying if you have seen one
    VA, you have seen one VA. My concern here is that all VA
    facilities operating off agencywide standardized policies for
    mental health. How is it that interpretation and adherence to
    VA's mental health policies varies so much between VISNs and
    facilities? Either Dr. Wiechers any of you can answer.
        Dr. Wiechers. Thank you for the question. We do have
    national standards and policies in place for mental health and
    for suicide prevention. The question of why is there variation,
    there are several possible causes for that.
        One could be that our policy needs to be better clarified
    and written more clearly. That is something that I take
    personally to heart and that I am working with my team as we
    constantly review and update our policies to ensure that we
    have clear language.
        The other could be about ensuring that there is clear
    training to help educate the field staff and our colleagues at
    the VISN level about that. We work hard to ensure we have those
    trainings available and that they are consistent across the
    system. We work closely, also, with our VISN partners and our
    facility leaders with open communication. We have regular
    meetings with our VISN chief mental health officers every week.
    Then the VISNs, and I will let Dr. Stazzone say more about the
    communication that they have regularly between facility
    leadership and VISN leadership.
        I think it is a matter of ensuring we have clear policies
    with standard trainings and clear lines of communication. We
    are working on all of those things, thanks to the OIG providing
    us some opportunities in areas where we may have gaps to focus
    on.
        Ms. Kiggans. Could that clarification include role
    clarification at the VISN level, what Dr. Kroviak was just
    talking about?
        Dr. Wiechers. Yes. I am pleased to report that Office of
    Mental Health has already drafted a functional statement and
    roles and responsibilities with our partners in the VISN chief
    mental health officer role. We look forward to having that role
    clarity for everybody across the system in each of the VISNs
    very soon.
        Ms. Kiggans. Thank you. Thank you.
        Dr. Stazzone, do you have anything to add?
        Dr. Stazzone. No. I appreciate Dr. Wiechers' comments and,
    as she said, at the VISN level our role is to make sure we have
    the policies from Office of Mental Health and Office of Suicide
    Prevention. We meet regularly with them as well as in the VISN
    we have regular huddles, and also meetings regularly with the
    facility leadership to make sure those things are going
    forward.
        I think it is important that there is some standardization
    and understanding authorities across the network. As any
    healthcare network, you need to have standard processes and
    policies to follow through and our goal is to make sure those
    are being followed through to the front lines. Healthcare is a
    very complex system and trying to make sure we have the right
    processes in place to follow the policies, to make sure our
    frontline staff can do the right things and follow through with
    those is critically important. Communication across the network
    also up to central office and down all the way to facilities is
    key. I will speak with VISN 9, we try to do that as much as
    possible. Our chief medical health officer reports directly to
    me.
        Ms. Kiggans. I am just curious about the communication
    flow. I know in my district in Hampton Roads, Virginia, has one
    of the largest veteran populations and just practicing in
    primary care there, and I know we have many patients who would
    receive some level of care at the VA because it entailed great
    services that they enjoyed: cheap hearing aids, eyeglasses,
    medications, this type of thing. Then they would come to
    receive community care from different civilian providers.
        One of my biggest frustrations was just trying to get
    patient notes and documents related to my patients, especially
    on the mental healthcare side, which I know there is certain
    privacy issues with mental health. Even from the civilian
    provider side it was challenging to get notes and an accurate
    prescribing record, which I thought was perhaps most important,
    too.
        How does the VA work with community providers to make sure
    that information is shared so providers are making informed
    decisions about a veteran's especially mental healthcare?
        Dr. Wiechers. Thank you for that question. The office at
    oversees Community Care works with our third-party
    administrators in helping manage the network of providers in
    the community, and working together to get that information
    back is a key area that we need to focus on and I am sure for
    the reasons that you have mentioned, because that continuity of
    care and that information is really valuable for the providers
    back at VA to understand what is happening in the community.
        Ms. Kiggans. Is there a person that goes behind and is
    doing that personal follow up, too, with the veteran ensuring
    that once they have left the office--just talking about
    continuity of care again, that that pace I feel like is where
    we lose people a lot of times, especially when we get them in
    the door. We them seen, we have a plan of care, we start a new
    medication or have a follow-up visit. Who goes behind and makes
    sure that, on the compliance side, that that is actually
    happening. Is there a process in place for that?
        Dr. Wiechers. I will have to take that back so that I can
    make sure I get the most up-to-date information about it.
        Ms. Kiggans. I have always been a proponent, just on the
    personal side of it, using home health nurse, especially. I
    mean, there is a lot of benefit to a visitor, too, in people's
    homes. We have tried to mandate that or make that--it is hard.
    We do not have home health providers either, but I just think
    that piece or what are we doing with that continuity of care
    piece, because they go home and I mentioned in my opening
    statements just about veterans who are taking multiple psych
    meds.
        I know you all understand what that interaction piece looks
    like. It frustrates me when I have surviving family members
    that will show me bags of medication that they do not know what
    this is. It was a combination of things that they would, again,
    take more if they felt worse and less if they felt better.
    There was some disconnect between when these medications--a lot
    of disconnect between when these medications were prescribed,
    how they got to be lumped together, you know. Then it just goes
    back to the communication flow, which is a source of
    frustration for me
        Again, on the civilian provider side, I think an, you know,
    electronic health record may be a helpful thing. We will keep
    working through that. Just that communication piece, that
    follow-up piece, that continuity and care piece, along with
    moral clarification and all the other things that I know you
    all are focused on in talking about, that piece is just
    important to me personally.
        My time has expired. I will yield to my ranking member.
        Ms. Ramirez. Thank you, Chair. I want to thank you all for
    being here again. Really appreciate it.
        Dr. Wiechers, I want to specially thank you for being here
    today. Behind me in a moment you will see are the instructions
    that accompanied a rubric VA supervisors were required to fill
    out justifying why their employees should not be subject to the
    agency's planned reduction in force, or what we call the RIF.
    Supervisors, who are clinicians themselves and who manage
    employees providing mental healthcare, were obligated to fill
    out this rubric. As I look at it, having been a manager myself,
    I find it absurd that the VA could measure mental health
    providers' value and justification through these very limited
    scales.
        Dr. Wiechers, these instructions require supervisors to
    provide one to two sentences explaining their special skills,
    their competencies, and their institutional knowledge for Their
    positions. How would you fill out this for a mental health
    provider and the support staff the provider relies on?
        Dr. Wiechers. Thank you for that question. I cannot really
    speak to a hypothetical. I would have to have an example of a
    specific individual provider to be able to answer the question.
    I am just seeing the information that you are providing now in
    terms of the details. I would respectfully like to take that
    back and would be happy to take any specific questions you have
    and report back afterwards.
        Ms. Ramirez. Thank you for that. Let me just be clear, Dr.
    Wiechers, this was provided to supervisors already, so this
    rubric is already available and I am concerned that you would
    not have seen it prior. Let me ask you this. Do you think one
    to two sentences fully capture a provider or their support
    staff importance to the mental health and well-being of
    veterans?
        Dr. Wiechers. I think that our mental health providers are
    invaluable resources to our veterans. Obviously the work that
    they do is complex and is something that is hard to capture in
    one to two sentences. Nonetheless, I can appreciate the need to
    have a rubric to make decisions.
        Ms. Ramirez. Following up on that, the rubric is there.
    Supervisors have to take time to fill this out. Can you explain
    to me why supervisors, many of whom are clinicians themselves,
    were required to take time away from patient care to fill out
    this rubric?
        Let me add a little more. Some providers reported they had
    to fill this out for over 300 employees, this rubric, and
    spending some time trying to figure out how in one sentence at
    most, they could be able to explain the negative service impact
    of letting that staff person go. I just do not understand.
        Tell me, do you think it is a good use of a clinician's
    time to perform administrative tasks that justify the critical
    nature of their employees' jobs instead of using their time to
    provide mental healthcare for veterans?
        Dr. Wiechers. I think putting veterans first is the most
    important thing that any one of our employees does. Putting the
    ongoing and sustaining mission and the work that we do is what
    is most important.
        Ms. Ramirez. I agree, Dr. Wiechers. We are also here to
    discuss ways that VA can better screen veterans to ensure that
    no veteran dies by suicide. I have another follow-up question
    for you. Will the VA provide gender-affirming care if it saves
    a veteran from suicide?
        Dr. Wiechers. The Department has made changes to a
    provision of hormone therapy related to transgender patients,
    but those who have been receiving that service and continue to,
    as well as servicemembers who are transitioning into veteran
    status who are eligible for VHA healthcare. All of our mental
    health services and preventive health services remain available
    for all veterans who are eligible for VHA care.
        Ms. Ramirez. What you are saying, Dr. Wiechers, is that the
    VA will provide that gender-affirming care if it saves a
    veteran from suicide?
        Dr. Wiechers. I am saying that the VA is providing services
    based on the new policy and that mental health services and
    preventive medical services remain available to all eligible
    veterans.
        Ms. Ramirez. Okay. Well, let me pivot for a second here. I
    know my time is up soon.
        Dr. Kroviak, what are the top five clinical severe
    occupational staffing shortages the Inspector General
    identified last year?
        Dr. Kroviak. Offhand I do not know the top five, but I do
    believe the top ones were nurses, physicians, mental health, in
    particular, psychologists, and psychiatrists.
        Ms. Ramirez. Got it. Since I only have 15 seconds, Dr.
    Wiechers, are you aware of the VA barring staff in the field
    for performing their assigned duties to do veteran outreach
    within their community? Yes or no?
        Dr. Wiechers. I am not personally aware of that. If you
    have examples, please share and I would be happy to look at it.
        Ms. Ramirez. Okay. Just to wrap up, just to put on record,
    in Chicago, we know that the VA staff are told to no longer go
    out to the ward offices to do veteran outreach. I guess my last
    question to you is, do you agree that meeting veterans where
    they are is a central component to suicide prevention?
        Dr. Wiechers. Yes.
        Ms. Ramirez. Thank you. With that I yield back.
        Ms. Kiggans. Thank you. We are going to do another round of
    questions. I just have a couple more since we have a little bit
    of time.
        Dr. Wiechers, could you please explain what policies the VA
    has reviewed since January to ensure better communication and
    procedures for servicemembers transitioning to VA care? I know
    we had a change of administration. We have a new VA Secretary.
    What improvements have been made to care coordination between
    the DOD and VA? What do you feel like we should be focused on
    moving forward?
        Dr. Wiechers. Thank you for that question, ma'am. The VA is
    working closely with our partners in DOD on transitioning
    servicemembers. That is work that is been ongoing for some time
    and continues to this day. I think ensuring seamless transition
    from servicemember to veteran status is important. In
    particular, ensuring that we have continuity of mental
    healthcare, especially for those who may be receiving
    medications or therapy, treatment as servicemembers, and
    ensuring that we get them transitioned as smoothly as possible
    to receiving those services at VA.
        Ms. Kiggans. Is that happening? Is that happening where
    there is a flawless transition or a seamless transition with
    charting and records?
        Dr. Wiechers. We are working to ensure that it happens
    smoothly for everyone. We have lots of folks working together
    with out colleagues in DOD to help ensure that that is taking
    place.
        Ms. Kiggans. Okay. Tell us what you need and what we can be
    helpful with to make that happen. I think that transition piece
    is critical and challenging in so many ways, but I think with
    the mental healthcare case we should prioritize that and we owe
    that to our veterans, especially now.
        Can you talk to me, Dr. Kroviak, about just staffing?
    Staffing. Do you feel like there are issues with staffing
    shortages? There is a lot of talk, a lot of misinformation, a
    lot of fear mongering. I do not believe that.
        Then, also, could you talk to me a little bit about your
    use of advanced practice nurses and if you feel like they are
    being best utilized in the mental health environment?
        Dr. Kroviak. In terms of staffing, you are right. We have
    not seen the Secretary's plan for what the actual final
    staffing cuts or decreases in staff will be, but we report
    annually on clinical staffing shortages. That is a
    congressionally mandated report. We are doing our work on that
    now and that will be published probably by the end of the
    summer. Those are perceptions at each individual facility level
    as to what the most critical clinical and nonclinical shortages
    are.
        A reminder that it is so important the staff member that
    meets with the patient, but in that arrangement there are
    multiple backstage staff who are coordinating so many
    activities to ensure the effectiveness of that meeting between
    the provider and the patient.
        The work we do on our cyclical reviews, hotlines,
    nationals, we will capture when there are staffing concerns. We
    might go in for an allegation specific to substandard care and
    find out that the staff are reporting ineffective staff, too
    few staff, prolonged vacancies. Our work will continue to ask
    those questions, and we will absolutely report the findings.
        Then your question about nurse practitioners, we have not
    looked specifically at their use or barriers to using them more
    so in mental health arena, but we know they are used across the
    system. With the shortages of providers within VA and without,
    I cannot imagine that there is not an increased need to
    encourage their participation in that care.
        Ms. Kiggans. Yes, and they are a great source of, if I
    might add, of being able to fill those gaps in care. Please
    make sure we are utilizing all of our advanced practice nurses
    as well. Hampton VA, which is the VA facility near my district,
    a lot of challenges we are working through, but when I have had
    the opportunity to visit and on the mental healthcare side, I
    think they do a great job and I hear great things about that
    piece. There are some other pieces we could work to do better,
    but I am thankful for that and I hope that all VA facilities
    are prioritizing that care. I know it takes a team. This is not
    just a provider. That is an important piece and making sure our
    providers are supported is important, too, when we think about
    staffing. That is good.
        Providing that reassurance, and I know Secretary Collins
    has done a good job throughout the country really. He has been
    down to Hampton Roads, but other places as well, just
    reassuring people that we are focused on staffing. We have
    picked up the phone, make sure we are focused. We are going to
    be protective of the actual provider piece, the nurses, the
    physicians, the allied heart health partners, who touch our
    patients. Just, again, providing that reassurance piece I think
    is important.
        I wanted to have each of you, if you do not mind, talk
    about just alternative treatments for mental health. I think
    that everyone responds differently and we need to meet the
    veteran where they are at. We have done some discussions in
    this committee talking about alternative treatments from
    psychedelics to Electroconvulsive Therapy (ECT) to different--
    you know, there are a variety of treatments out there.
        Can each of you respond just about how you feel that is
    going in the VA? Is there room for improvement? I feel like we
    need to do more and probably quicker about, again, meeting the
    veteran where they are at, what do they respond to? but I am
    just curious as to your opinions.
        Dr. Wiechers. Thank you for that question. The VA has been
    growing its use of what we call the somatic treatments. Those
    are things like ECT, transcranial magnetic stimulation,
    ketamine infusions, and intranasal S ketamine. Over the last 5
    to 7 years we have seen growth and expansion across the system.
    Could we do more? Yes. We continue to try to expand access to
    those, both in direct care and also through referral to
    community providers.
        We have, as I know you are aware, we have announced an
    Request for Application (RFA) for funding of psychedelic
    research and that is something that continues moving forward at
    VA. We also have studies ongoing for stellate ganglion block,
    excuse me, and other kind of emerging therapies as well. I
    think we are doing a lot in the research space and the
    innovation space. Then in terms of our existing standards of
    care for difficult to treat depression or other types of mental
    health conditions that fail to respond to initial courses of
    treatment, we have a menu of options available to veterans and
    we are working on expanding access to those.
        Ms. Kiggans. Good. Thank you.
        Dr. Stazzone. Thank you, Madam Chair. As Dr. Wiechers said,
    we look at evidence-based therapies to make sure we are doing
    the right things for the veterans that has been proved
    effective. There is lots of research in the VA as well. I will
    say our geriatric research centers also have research into
    dementia and psychosis as well for mental illness in geriatric
    populations, which is important.
        At this time, treatment-resistant depression, I will speak
    for VISN 9. We are try to implement three modalities of
    treatment, ECT, transcranial magnetic stimulation, and ketamine
    infusion, at all of our sites. All veterans have access to the
    most up-to-date and evidence-based treatments. I know there is
    much research going on, as Dr. Wiechers already spoke about,
    and as those new studies come forward with possibilities, you
    know, we will adapt those with evidence-based treatment.
        Dr. Kroviak. I will say from an oversight perspective
    nobody does mental healthcare like VA. They are absolutely
    pioneers in this field, and we are very encouraged by the
    previous, ongoing, and forward-looking research that continues.
    I hate to say it, but we look forward to doing oversight work.
        Ms. Kiggans. Yes, and I appreciate you are just always
    working to expand the treatment options for veterans and on the
    geriatric side, too. I mean, I think that is a whole other
    discussion probably for a whole other committee. I feel like
    there is not enough focus on that. Our veterans are older
    adults usually and geriatrics is technically over the age of
    65. That is a large, probably, percentage of our veteran
    population. I know at the Hampton VA, we had one geriatrician
    on staff and that was not enough and she had some great nurses
    working with her. Focus on that piece and thank you.
        I think we could always have more when we talk about
    studying dementia as a cognitive impairment. That was my
    specialty as a geriatric nurse practitioner. But I just in my
    perfect world, yes, we have a whole other section of the VA
    that focuses on geriatrics. We talk a lot about mental health
    and another just personal passion project of mine, but on the
    geriatric side we do not have advocates for older adults and
    their specific needs for the patient and for their families and
    caregivers. We will table that for now, but look forward to
    future discussions about taking care of our older adults.
        With that, I will move to my ranking member if she has any
    last questions.
        Ms. Ramirez. Thank you. I just want to follow up.
        Dr. Wiechers, as the chair mentioned in her opening,
    overdoses claim too many veterans' lives. Do you think that
    Narcan saves lives?
        Dr. Wiechers. Yes.
        Ms. Ramirez. Will the Trump administration cuts to Narcan
    funding lead to more overdose deaths, including veteran deaths?
        Dr. Wiechers. I cannot speak to hypotheticals.
        Ms. Ramirez. You do agree that Narcan saves lives and we
    should have adequate funding to be able to continue to provide
    it?
        Dr. Wiechers. I agree that Narcan saves lives and the VA's
    overdose education and naloxone distribution program has been
    award-winning and has saved many veteran lives.
        Ms. Ramirez. All right. Well, let me shift here then for a
    second to talk more about it. Can you please describe the
    partnership between the Substance Abuse and Mental Health
    Service Administration, or what we call SAMHSA, and the VA?
    Follow up with the second part of it. How does that partnership
    improve mental health treatment and support services for
    veterans?
        Dr. Wiechers. What I can speak to is the partnership that I
    personally have been engaged with colleagues at SAMHSA in as it
    relates to ongoing work in our development of strategic plans
    for psychedelic treatments. I believe that our partnership is
    strong and the connection between our two agencies helps both
    SAMHSA and our veterans at VA.
        Ms. Ramirez. Are you concerned that cuts at SAMHSA will
    affect the VA's ability to provide services to veterans
    suffering from substance abuse disorder and other mental health
    challenges?
        Dr. Wiechers. I believe that the VA will continue to
    provide high-quality access to substance use disorder drug
    treatments and for mental health treatments for its veterans.
        Ms. Ramirez. Okay. Let us get a little bit more into that.
    I want to know how you are going to do that. How will the VA
    fill in the gaps if SAMHSA is gutted?
        Dr. Wiechers. I will have to wait and see. Again, I cannot
    provide response to hypotheticals. We will adapt and ensure
    that all of our veterans continue to have access to Substance
    Use Disorder (SUD) treatment and mental healthcare.
        Ms. Ramirez. Yes, but, Dr. Wiechers, I hear you say that
    you cannot work on hypotheticals. You should be planning. As
    you are already hearing, there is going to be cuts to
    particular programming. For me, if we are having real
    conversations about ensuring that veterans have the resources
    they need, then you should already be planning on coordinating
    what you are going to do to fill those gaps. You are telling me
    that you will be prepared to be able to ensure that veterans
    continue to get the resource they need. It is hard for me to
    hear you say you are prepared to ensure that we continue to
    provide the resources, we have the partnerships we have, but
    you are not doing any planning.
        I think that is part of the challenge that we have seen,
    particularly in this committee, is that there is no adequate
    planning or even real strategic consideration when we are
    talking about letting staff go. We really have to be asking
    ourselves, when we are making these major decisions and shifts
    and changes, what will the impact, in fact, be for our veterans
    and what are we doing in advance to ensure that the veterans
    that we say that we serve are not impacted by it? I have to say
    that as you say that, it is really difficult for me because you
    can keep saying I cannot really plan a rhetorical, but if you
    are not actually planning for things you already know that are
    coming, then that is a concern for me, especially as we know
    how critical the work of this committee is in oversight.
        Let me come back to something real quick that I started
    talking about at the end and, with that, I will yield back to
    the chair. I mentioned to you that the VA is barring staff in
    the field from performing their assigned duties to do veteran
    outreach within their community in a number of locations. We
    have invited the VA to come to some of the outreach events that
    we do, particularly around housing, healthcare, and other
    resources. I submitted a letter March 6, asking why this is
    happening. You said you were not aware that this was happening.
    I want to make sure that on the record I know that I submitted
    a letter over a month ago and I have not received the response.
    I wonder if, by any chance, do you know that a letter was sent
    and if you know there is an update on when I can expect a
    response?
        Dr. Wiechers. Thank you for the question. I will take that
    back and we will get into it for an answer as to when you can
    expect your response.
        Ms. Ramirez. Thank you. Appreciate that.
        With that, I yield back to the chair.
        Ms. Kiggans. Thank you. I have no further questions.
        Ranking Member Ramirez, do you have any closing remarks?
        Oh, I am sorry. Well, we have a new member just joining us,
    so we will recognize Congressman Kennedy for 5 minutes and then
    we will close.
        Mr. Kennedy. Thank you very much. Thank you all for being
    here today, for your service to this country, for your
    testimony.
        Before entering public service, I served as an occupational
    therapist. My work focused on helping people navigate the
    challenges of daily life and understanding that health is not
    just about physical recovery, but it is also about mental and
    emotional well-being. I saw firsthand how addressing mental
    health is just as critical as treating physical conditions.
    Without quality mental healthcare, true healing is incomplete.
    Our veterans deserve no less, as we know.
        I am deeply concerned that VA's and mental health services
    are not meeting the rising demands of veterans. Because of
    reckless cuts by this administration, instead of much-needed
    investment in our bravest, veterans are facing long wait times,
    workforce shortages, and barriers to accessing a full range of
    services that they need. If we are truly committed to honoring
    our veterans' service and sacrifice that they have made, we
    have to ensure quality, timely mental health support at the
    gold standard level of care alongside their physical care.
        With that, I have a few questions. You know, first and
    foremost, the VA and this administration are now forcing
    employees, many of whom were hired as remote workers, to return
    to office. Dr. Wiechers, was the VA aware of the space
    constraints for mental health providers before ordering them to
    work in the office?
        Dr. Wiechers. Thank you for the question, sir. We have a
    process in place to review at each of the local facilities the
    space available before any Return to Office orders are
    submitted to employees to return. The space available is being
    considered as we return people to office.
        Mr. Kennedy. Is the agency concerned about the Health
    Insurance Portability and Accountability Act (HIPAA) violations
    as providers of reported staff overhearing sessions and the
    lack of privacy after being placed in congregate settings?
        Dr. Wiechers. All of our facilities and providers are held
    to the highest legal and ethical standards related to privacy
    and we have processes in place. Should people be concerned that
    the space they have available is not suitable for privacy
    concerns for the care that they are providing, we have
    processes at each of the facilities that allow other those
    staff to report those concerns so that they can be addressed
    and ensure that privacy of our veterans is held sacred, as it
    should be.
        Mr. Kennedy. Thank you. Dr. Wiechers, on March 4th it was
    announced that the VA planned to eliminate over 80,000 jobs,
    which would certainly include mental health providers.
    Thankfully, that directive is now on hold. Since the VA is
    already facing a shortage of mental health providers, how does
    the Department plan provide responsive mental health services
    in light of these cuts? Were you consulted before the
    announcement of these cuts?
        Dr. Wiechers. Thank you for the question, sir. There are
    30,000 frontline provider and staff positions that are exempt
    from the hiring freeze and other actions. Included on the list
    of those 300,000 staff providers are all of our different types
    of mental health providers. Psychologists, psychiatrists,
    social workers, marriage and family therapists, Licensed
    Professional Mental Health Counselor (LPMHCs), peers, all of
    those folks and our frontline mental health providers are on
    the exemption list.
        Mr. Kennedy. Is there hiring taking place right now?
        Dr. Wiechers. There is hiring taking place right now. I
    believe Dr. Stazzone can speak explicitly about VISN 9.
        Dr. Stazzone. Thank you, Dr. Wiechers. Thank you,
    Congressman. Yes. As Dr. Wiechers said, 300,000 positions were
    exempted from the hiring freeze. There is ongoing hiring for
    those positions. In VISN 9 we have a dashboard for workforce
    management that list the vacancies. We follow through with
    those and continue recruitments for all the frontline positions
    that are exempted.
        Mr. Kennedy. While there is hiring that is taking place,
    are these folks being onboarded?
        Dr. Stazzone. Yes, Congressman.
        Mr. Kennedy. Can you commit to sending this committee data
    on the number of employees and occupations that have been
    onboarded since January of this year?
        Dr. Stazzone. Yes, I will take that back Congressman for
    all employees. I can only speak to VISN 9, but there is a
    dashboard from workforce management. I believe they can get you
    those numbers.
        Mr. Kennedy. I think it is vitally important that we have
    that data. It is one thing to make an argument that there are
    exemptions while there are tens of thousands of potential cuts
    and we need to know what those exemptions are, where they are.
    If there is an argument that there is hiring that is taking
    place, we need to know if those people are actually being hired
    and onboarded and put to work rather than just put into a
    process and not to be brought onboard. It is very important
    information. We would appreciate you bringing that to us.
        Madam Chair, I yield back.
        Ms. Kiggans. Thank you. Now we will move to our closing.
        Ranking Member Ramirez, do you have any closing remarks?
        Ms. Ramirez. Thank you, Chair. I want to ask as we are
    wrapping up unanimous consent and to a few of news articles
    related to veterans' mental health into the record: from
    Reuters, on democracy, the New York Times, NPR, The Hill,
    Military.com, and NBC News.
        Ms. Kiggans. So ordered.
        Ms. Ramirez. Thank you. I would also like to ask for
    unanimous consent to enter six testimonials from veterans whose
    mental health is being affected by the cuts to the VA workforce
    and their ability to receive care.
        Ms. Kiggans. So ordered.
        Ms. Ramirez. Thank you. I want to end by reminding my
    colleagues that in order to honor our veterans' service with
    action we must defend and protect their access to mental health
    services. That starts by making sure that mental health
    providers are available.
        I look forward to our work and the follow ups we will get
    from the witnesses today. Thank you.
        With that, I yield back.
        Ms. Kiggans. Thank you. For my closing remarks I just want
    to thank the witnesses for coming in to testify today. We have
    gained better insight into the VA's mental health policies, the
    effectiveness of the services they provide to veterans, and how
    you are working to improve these processes. Thank you very much
    for clarifying about the mental health providers and partners
    that are exempt from the cuts and hiring freezes.
        We have said this time and time again, straight from the
    Secretary's mouth, thank you very much for your presence here
    today and to clarify that. We will continue to clarify that and
    to remind our veterans that mental healthcare and their health
    care in general remains a priority. I have personally picked up
    the phone multiple times to ensure that these positions are not
    being cut so I can provide some personal validation to them as
    well. Thank you very much for putting that on the record.
        We all know that while the VA has worked hard to provide
    support for mental health challenges, our veterans continue to
    struggle. We also know that providers are working hard. I
    wanted to say a special thank you to them because they are
    often an underappreciated group; our physicians, our nurses and
    all of our allied health partners and their staff who work so
    hard every single day.
        We cannot let fearmongering or partisan politics get in the
    way of achieving results for our veterans. It is one of the
    reasons I love working in the healthcare space. I feel like it
    should always be a nonpartisan issue. I think that we should
    work to hopefully remember that and hopefully we can get there.
        The VA must continue to prioritize a quality workforce that
    can deliver world-class mental health services and meet
    veterans where they are. We can no longer ask the veterans to
    navigate the VA's bureaucracy when what they need is help. I
    know we are all working hard and have the same objectives here.
    It is essential that we have our veterans' backs and we reform
    our approach to improve the policy and services that the VA
    provides to veterans.
        Thank you all so much for taking the time to be here today.
        I ask unanimous consent that all members should have 5
    legislative days in which to revise and extend their remarks
    and include any extraneous material.
        Hearing no objections, so ordered. This hearing is now
    adjourned.
        [Whereupon, at 11:03 a.m., the subcommittee was adjourned.]

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                             A  P  P  E  N  D  I  X

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                        Prepared Statements of Witnesses

                                  ----------

                      Prepared Statement of Ilse Wiechers

        Chairwoman Kiggans, Ranking Member Ramirez, and distinguished
    Members of the Subcommittee. Joining me today is Dr. Anthony Stazzone,
    Chief Medical Officer of the VA MidSouth Healthcare Network. It is an
    honor to be here on behalf of VA to discuss the critical work we are
    doing to ensure our Veterans receive the high-quality mental health
    care they deserve.

    Introduction

        Veterans face unique mental health challenges. While many Veterans
    are very successful and fully integrated back into society, some
    invisible wounds of war have manifested in conditions like
    posttraumatic stress disorder (PTSD), depression, and substance use
    disorders (SUD). These issues, combined with life transitions after
    military service, contribute to an elevated risk of suicide. In
    response, VA has developed a broad continuum of mental health services
    intended to ensure Veterans receive the help they need. This continuum
    ranges from crisis intervention and screening to same-day access for
    urgent mental health needs, as well as outpatient, residential, and
    inpatient care across the country. VA medical centers, community-based
    outpatient clinics, Vet Centers, the 24/7 Veterans Crisis Line, and a
    nationwide network of Suicide Prevention Coordinators (SPC) all serve
    as points of access.
        VA's mental health services are designed to be accessible,
    evidence-based, and recovery-oriented, ensuring that all Veterans
    receive the mental health support they need, regardless of where they
    access care. By emphasizing early intervention, continuous support, and
    the seamless integration of mental health into overall health care, VA
    is committed to enhancing the well-being and resilience of Veterans
    nationwide.
        Most Veterans who utilize VA health care services report positive
    experiences and satisfaction with VA mental health care, including the
    availability of essential services, the strong emphasis on the privacy
    and confidentiality of medical records, the ease of accessing VA mental
    health services, the expertise and professionalism of the mental health
    care staff, and the courtesy and respect demonstrated by the staff
    toward patients.
        In 2018, VA published the National Strategy for Preventing Veteran
    Suicide \1\ which emphasized the need to develop and implement of a
    public health approach to suicide prevention. The public health
    approach combines both community prevention and clinical intervention
    actions that directly serve Veterans. The National Strategy focuses on
    preventing suicide for all Veterans, as well as selective and indicated
    strategies for reaching Veterans at higher risk for suicide. VA Suicide
    Prevention has fueled ongoing work with our partners in the Department
    of Defense (DoD) to support transitioning Service members. VA's
    commitment to preventing Veteran suicide is also interwoven throughout
    all mental health treatment programs and bolstered by enhanced staff
    educational requirements in suicide prevention.\2\
    ---------------------------------------------------------------------------
        \1\ https://www.mentalhealth.va.gov/suicide_prevention/docs/Office-
    of-Mental-Health-and-Suicide-Prevention-National-Strategy-for-
    Preventing-Veterans-Suicide.pdf
        \2\ VHA Directive 1071, Mandatory Suicide Risk and Intervention
    Training, dated May 11, 2022.
    ---------------------------------------------------------------------------
        Let me be clear: the Secretary has made preventing Veteran suicide
    a top priority for VA. We face a sobering reality that demands
    acknowledgement: Since 2008, the number of Veterans who died by suicide
    each year has remained essentially unchanged at roughly 6,500 per year.
    Yet over that same period, VA spending on suicide prevention has
    increased by more than 11,000 percent, from $4.4 million per year in
    2008 to $522 million per year in 2022. In other words, VA spending on
    suicide prevention is now more than 100 times what it was in 2008, but
    we're getting the exact same results. This status quo is unacceptable.
        This new Administration and VA leadership are committed to
    challenging the status quo in order to find new and better ways of
    helping Veterans. We cannot continue approaches that have failed to
    produce meaningful improvements despite substantial resource
    investments.
        Recent reports by the Office of Inspector General (OIG) have
    highlighted deficiencies in VA's mental health care intake process and
    adherence to suicide risk identification screening guidance, among
    other issues. These findings underscore the urgent need for concerted
    efforts to address policy adherence and to strengthen our initiatives
    to provide high-quality health care to our Veterans. Despite these
    challenges, VA is committed to our mission: promoting, preserving, and
    restoring Veterans' health and well-being; empowering them to achieve
    their life goals; and to provide state-of-the-art mental health
    treatments. We are accelerating efforts to enhance access to care,
    whether delivered in VA facilities or through VA community care when
    eligible.
        This is not simply an organizational priority; it is VA's sacred
    obligation to those who served. The Secretary has established this as
    the standard by which the Department's effectiveness will be measured,
    and VA leadership will accept nothing less than transformative
    improvement in suicide prevention and mental health care.

    Suicide Risk Identification Strategy (Risk ID)

        VA staff play an important role in supporting the Department's top
    clinical priority to prevent Veteran suicide. VA has implemented a
    standardized suicide risk screening and assessment process, providing
    Veterans with a high standard of preventive care. This process, known
    as the Suicide Risk Identification Strategy, was introduced in May
    2018. As a population health effort, Risk ID is completed annually for
    all Veterans receiving VA care. Risk ID is also completed for Veterans
    receiving care in a VA emergency department and for Veterans seeking
    mental health services. Additional suicide screening occurs in certain
    health care settings, such as during intake at an outpatient mental
    health visit. Risk ID processes ensure that all VA health care systems
    are equipped to identify Veterans at risk for suicide and connect them
    to life-saving resources and interventions. Risk ID consists of a
    primary screen (using a standardized questionnaire such as the Columbia
    Suicide Severity Rating Scale), followed by a Comprehensive Suicide
    Risk Evaluation, a templated clinical assessment, for any patient who
    screens positive. The goal of the evaluation is to determine the
    Veteran's severity of suicide risk and collaboratively develop a plan
    for risk mitigation.
        VA is the largest health care system in the United States to
    implement universal screening for suicide risk, highlighting the
    Department's commitment to comprehensive suicide prevention. To ensure
    adherence to the Risk ID screening process, VHA issued a memorandum
    requiring all Veterans Integrated Service Networks (VISN) to confirm
    that facilities within each network have established procedures for
    implementing Risk ID requirements across clinical services. This
    attestation must align with each facility's standard operating
    procedures and conform to national policy and guidelines by April 7,
    2025.\3\ In Fiscal Year (FY) 2024, VA completed over 2.6 million
    suicide risk screenings.
    ---------------------------------------------------------------------------
        \3\ For Action: Suicide Risk Screening and Evaluation Requirements
    and Implementation Update (VIEWS 12521544)
    ---------------------------------------------------------------------------
        In addition to broad screening efforts, VA also wants all Veterans
    and former Service members to know that they can access emergent
    suicide care, no matter where they are. Under 38 U.S.C. Sec.  1720J, as
    added by section 201 of the Veterans Comprehensive Prevention, Access
    to Care, and Treatment (COMPACT) Act of 2020 (P.L. 116-214), any
    Veteran - whether enrolled in VA or not - and certain former Service
    members can go to a VA or non-VA facility to access emergent suicide
    care If you're a Veteran in crisis or concerned about one, contact the
    Veterans Crisis Line to receive, confidential support 24 hours a day, 7
    days a week. You don't have to be enrolled in VA benefits or health
    care to connect. To reach responders, Dial 988 then Press 1, chat
    online at VeteransCrisisLine.net/Chat, or text 838255.

    Enhanced Training and Clinical Guidance

        To stay at the forefront of suicide prevention, VA continually
    updates its clinical guidelines and training programs to support best
    practices. In 2024, VA and DoD released a new joint Clinical Practice
    Guideline (CPG) for the Assessment and Management of Patients at Risk
    for Suicide, which compiles evidence-based strategies for evaluation,
    safety planning, and treatment of suicidal individuals. VA providers
    are encouraged to familiarize themselves with this critical guidance.
    Additionally, all VHA health care staff must complete suicide
    prevention training. In recent years, VA has updated these trainings
    by, for example, creating improved education for all staff related to
    the steps to take to save Veterans lives, formerly known as ``Operation
    S.A.V.E.'' VA tracks and monitors these courses to ensure training
    compliance.
        Additionally, VA has implemented specialty training for SPCs and
    mental health clinicians on topics like lethal means safety counseling
    - such as how to talk with Veterans (and their families) about safely
    securing firearms or medications during a suicidal crisis. By
    institutionalizing such training and guidance, VA has worked to
    standardize the quality of care delivered to at-risk Veterans, no
    matter which facility they visit.
        Another enhancement to our suicide prevention infrastructure is
    assigning dedicated SPCs across all VA medical facilities. SPCs
    actively monitor Veterans flagged as high-risk, coordinate follow-up
    care, facilitate safety planning, and ensure compliance with suicide
    prevention protocols. Regular contacts from a dedicated suicide
    prevention team during a high-risk period may reduce the risk of new
    suicidal behavior over time. During times of personal or community
    crisis, the SPC program provides a model for addressing risks related
    to mental health and for recovery enhancement. A 2021 study showed that
    additional SPC contact reduced the odds, between 4-5 percent, of
    suicide attempt, suicidal behavior, and reactivation of high-risk
    status within the next year.\4\ Our enhanced safety planning practices
    now involve comprehensive, individualized safety plans collaboratively
    developed and documented clearly in electronic health records.
    ---------------------------------------------------------------------------
        \4\ Doran et al. (2021). Associations between veteran encounters
    with suicide prevention team and suicide-related outcomes. Suicide &
    Life-threatening Behavior.
    ---------------------------------------------------------------------------
        VA and DoD also have written CPGs for Bipolar Disorder, Management
    of First Episode Psychosis and Schizophrenia, Major Depressive
    Disorder, PTSD, and SUD. VA encourages mental health care providers to
    familiarize themselves with these guidelines.
        With regard to training staff in recommended therapy dissemination,
    VHA is a recognized leader in ensuring that staff are trained in VA/DoD
    CPG-recommended therapies. VHA has done this through the National
    Evidence-Based Psychotherapy and Psychosocial Interventions (EBP)
    Provider Training Program, which advances access to VA evidence-based
    mental health through the provision of high-quality, competency-based
    provider training in VA/DoD CPG-recommended evidence-based
    psychotherapies and psychosocial interventions. In Fiscal Year 2024,\5\
    the National EBP Provider Training Program included 14 training
    initiatives for depression, PTSD, SUD, insomnia, chronic pain, severe
    mental illness, and suicide risk management treatments. The program
    trained 2,781 VA mental health providers in 128 workshops and
    consultation trainings across the full range of mental health
    discipline professions and mental health work settings in Fiscal Year
    2024. The current VHA workforce has nearly 9,000 providers trained to
    competency, through the program.
    ---------------------------------------------------------------------------
        \5\ https://www.healthquality.va.gov/guidelines/MH/srb/VADoD-CPG-
    Suicide-Risk-Full-CPG-2024_Final_508.pdf
    ---------------------------------------------------------------------------
        All VHA mental health care staff are also mandated to complete
    training about Military Sexual Trauma and Prevention and Management of
    Disruptive Behavior. In recent years, the Office of Mental Health has
    provided staff with numerous additional trainings, for example,
    trainings on military cultural competence and trainings on how to treat
    Veterans with comorbid PTSD and SUD. In Fiscal Year 2024, the Office of
    Mental Health and Mental Illness Research Education and Clinical
    Centers provided over 1,000 training sessions to VA staff.

    Mental Health Policy and Governance

        As a program office, the Office of Mental Health provides policy
    and operational guidance for delivering mental health services across
    the continuum of care. The Office of Mental Health also provides
    ongoing monitoring and makes data available to aid VISNs and facilities
    in implementing mental health programming in accordance with policy and
    developing action plans to address non-compliance. VISNs are
    responsible for ensuring the implementation of such action plans,
    resolving implementation and compliance challenges in the VA medical
    facilities within the VISN and providing oversight of VISNs to ensure
    compliance with mental health directives and their effectiveness. The
    Office of Mental Health works closely to support such operational
    implementation efforts and develops and maintains dashboards that
    provide facilities and VISNs with easily accessible and regularly
    updated program performance information. Weekly forums between Office
    of Mental Health leaders and VISN Chief Mental Health Officers offer
    opportunities for compliance-related discussion and planning, as
    needed. To further support VISNs and facilities with their
    implementation efforts, the Office of Mental Health has National Mental
    Health Quality Improvement and Implementation Consultants, assigned to
    specific VISNs and facilities, who complete scheduled and for-cause
    site visits and are available to work closely with sites in developing
    action plans to address non-compliance and ensure those plans are
    informed by best practices and implementation science.

    Conclusion

        VA is taking decisive action to transform the department's mental
    health care system for Veterans. The path forward requires VA to
    embrace innovation, accountability, and proven practices across every
    facet of its operations.
        Meaningful change requires collaboration, within VA and with
    partners across government, private healthcare, and Veteran
    organizations. This whole-of-society approach is essential to reach
    Veterans wherever they may be. The oversight from the Committee
    strengthens VA's work and helps ensure our focus remains on what
    matters most: providing Veterans with the exceptional care they have
    earned. VA looks forward to continuing to work with this Committee and
    we look forward to answering any questions you may have.

                      Prepared Statement of Julie Kroviak
    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                           Statements for the Record

                                  ----------

                        Prepared Statement of NeuroFlow
    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    Prepared Statement of American Psychological Association Services, Inc.

        Chairperson Kiggans, Ranking Member Ramirez, and Distinguished
    Members of the Committee:

        American Psychological Association Services, Inc. (APASI) submits
    the following statement for the record in advance of the House Veterans
    Affairs Committee Oversight and Investigations Subcommittee hearing
    entitled Answering the Call: Examining VA's Mental Health Policies. We
    appreciate the Committee's willingness to examine challenges
    surrounding the critical delivery of mental health care for our
    Nation's veterans. Demand for VA mental health care has increased
    steadily over the past 20 years and continues to outpace other care
    within the VA. Meeting this demand while maintaining the VA's high
    level of clinical excellence is a priority.
        American Psychological Association and its companion organization
    APA Services, Inc. (APA/APASI) serve as the Nation's largest scientific
    and professional nonprofit organization representing the discipline and
    profession of psychology, as well as over 173,000 members and
    affiliates who are clinicians, researchers, educators, consultants, and
    students in psychological science. Psychologists and the profession
    have a rich history within the VA, serving veterans since World War II.
    As such, today we would like to address three policy areas important to
    the delivery of quality mental health care: maintaining clinical
    excellence and care coordination, protecting veteran privacy and
    confidentiality, and ensuring adequate mental health provider training
    and staffing.

    Maintaining Clinical Excellence and Care Coordination

        APASI is grateful that VA Secretary Collins is making preventing
    veteran suicide a top priority. Over many years, the VA has made
    tremendous strides in universal suicide prevention risk assessments and
    required training for providers of care on topics including but not
    limited to suicide prevention, lethal means safety, military culture,
    and military sexual trauma. The demand for mental health care is
    growing across our entire nation's health care system, also
    highlighting the unique role and mission within the VA to train much of
    our Nation's healthcare workforce.
        Increased investments in veteran suicide prevention have been
    impactful, and veteran outcomes are improved when interacting with the
    VA. The 2024 National Veteran Suicide Prevention Annual Report
    demonstrates the suicide rates for veterans receiving only VA care are
    50 percent lower than even those receiving all their care in the
    community care program. However, one veteran suicide death is one too
    many and now is not the time to let our foot off the gas on VA
    investments in mental health staffing, care coordination, and best
    practices that could be applied everywhere a veteran in crisis might
    receive care.
        As Congress reviews the VA's internal mental health policies, it is
    important to highlight that the VA continues to provide veterans with a
    gold standard of care in mental health treatment. Whether leading the
    way in post-traumatic stress disorder (PTSD) or requiring access to
    evidence-based psychotherapy, the VA maintains a high bar \1\ and
    consistently outperforms non-VA care in both quality of care and trust
    among veterans \2\,}\3\.
    ---------------------------------------------------------------------------
        \1\ https://www.mentalhealth.va.gov/providers/sud/docs/
    uniformserviceshandbook1160-01.pdf
        \2\ https://news.va.gov/press-room/va-outperform-non-va-facilities-
    cms-ratings/
        \3\ https://www.va.gov/initiatives/veteran-trust-in-va/
    ---------------------------------------------------------------------------
        Strong internal clinical standards, oversight by the VA Office of
    Inspector General (VA OIG) and other agencies, and the existence of
    reporting and compliance mechanisms within the VA all play a role in
    maintaining exceptional clinical excellence in mental health care. It
    is worth noting that such high clinical standards and oversight is
    lacking or nonexistent in VA community care. For example, the mandatory
    risk assessments and required trainings referenced above are optional
    in the community. APASI would like to see policies such as adoption of
    risk assessments and mandatory training applied regardless of site of
    service for the veteran and agrees with a recent Government
    Accountability Office report \4\ that stronger oversight of community
    care contracts is necessary to ensure high quality care.
    ---------------------------------------------------------------------------
        \4\ https://www.gao.gov/assets/gao-24-106390.pdf
    ---------------------------------------------------------------------------
        We encourage the Committee to support evidence-based treatments,
    measurement-based care, and the VA's critical role in care
    coordination, as each is so important to maintaining the high standards
    that are at the core of the VA's mental health program. Lessening care
    coordination and clinical standards does nothing to improve the health
    of America's veterans. We are concerned, for example, that the recently
    introduced Veterans' ACCESS Act, H.R. 740, which will allow access to
    outpatient private treatment without any VA authorization or referral,
    could adversely impact the quality of care. Care coordination and
    oversight ensures quality care for veterans. We are also concerned that
    this bill lessens the current VA facility requirement that mental
    health residential rehabilitation treatment programs (RRTPs) be
    accredited by both the Commission on Accreditation of Rehabilitation
    Facilities (CARF) and The Joint Commission to requiring only one of
    those accreditations. While improving access to care is critical and
    community care is a necessary complement to VA direct care, exacting
    standards for clinical excellence should be applied equally in each
    setting. Access to ``any'' care is not necessarily access to
    ``quality'' care.

    Ensuring Veteran Privacy and Confidentiality

        A recent issue of significant concern for us is ensuring veteran
    privacy and confidentiality when delivering mental health care within
    the VA. The recent policy change requiring most Federal employees to
    return to the office, including VA psychologists and other mental
    health care providers, is significantly impacting the delivery of
    confidential mental and behavioral health services. Many VA facilities
    lack sufficient private spaces to accommodate the influx of mental
    health providers who previously worked remotely. This has resulted in
    providers being asked to conduct sensitive therapy sessions in open
    office environments, cubicles, or shared spaces that fail to meet basic
    HIPAA confidentiality and privacy requirements for the delivery of
    mental health care services.
        The VA has long used telehealth to reach isolated, rural, and
    disabled veterans in need of mental health services and it further
    expanded access to telehealth services between 2020-2024 which allowed
    more mental health care providers to deliver care from private home
    offices. This enabled the VA to expand to meet a growing demand.
    Unfortunately, the return-to-office mandate undermines access and
    confidentiality essential to effective mental health care. This needs
    to be addressed as plans are put into effect. Without ensuring adequate
    space to absorb the return of mental health providers, those providers
    face the difficult choice between violating ethical and legal patient
    confidentiality requirements or suffering disciplinary action for non-
    compliance with return-to-office mandates.
        In light of these serious concerns regarding the timing and
    implementation of return-to-office mandates and other policies
    impacting delivery of mental health services, we encourage the
    Committee to consider waivers for all mental health providers that
    would return to a shared space until veteran privacy and access to care
    concerns are addressed. Our concerns currently center on several key
    issues:

          Ethical and practice standards: Both the APA Ethics Code
    and VA professional standards require that psychotherapy be conducted
    in private settings that protect patient confidentiality. In many
    facilities, the current implementation of return-to-office orders
    without adequate office space availability appears inconsistent with
    these requirements.

          Patient confidentiality and trust: A strong therapeutic
    relationship depends on confidentiality. Veterans dealing with
    sensitive mental health issues require assurance that their disclosures
    remain confidential. Conducting therapy in shared spaces fundamentally
    compromises this trust.

          HIPAA compliance risks: Arrangements in some facilities
    may violate HIPAA privacy and security requirements if patient
    information can be overheard in shared spaces. This not only presents
    individual providers with legal liability and ethics concerns but would
    also constitute a HIPAA violation by the Veterans Health Administration
    itself.

          Veteran care impact: These challenges threaten to disrupt
    ongoing care relationships and may deter veterans from seeking or
    continuing needed mental health treatment in their preferred setting.

          Workforce retention concerns: Reports indicate that some
    mental health professionals are considering resignation rather than
    practicing under conditions they view as unethical and below an
    acceptable standard of care. This could worsen existing staff shortages
    in VA mental health services.

        Many veterans experience trauma and sensitive mental health
    conditions. APASI supports long-standing policies that ensure the
    protection of patient confidentiality and privacy, including adequate
    physical space within VA facilities to provide private mental health
    services that prioritize patient needs.

    Ensuring Adequate Mental Health Provider Training and Staffing

        Finally, APASI continues to be concerned about adequate staffing to
    serve veterans of today and tomorrow. Psychology is again the number
    one clinical workforce shortage area within the VA, with 85 of 139
    facilities reporting psychology shortages \5\. The demand for mental
    health care continues to increase both within the VA and throughout our
    Nation's healthcare system. With well over 400,000 new PACT Act
    Veterans Health Administration (VHA) enrollees, and 754,000 new
    enrollees overall since August 2022, continued investment into the VA
    mental health workforce is more important than ever.
    ---------------------------------------------------------------------------
        \5\ https://www.vaoig.gov/sites/default/files/reports/2024-08/
    vaoig-24-00803-222.pdf
    ---------------------------------------------------------------------------
        The VA provides healthcare training, residencies, and fellowships
    to more than 120,000 trainees each year in over forty disciplines. Even
    today, 65 percent of all U.S. psychologists and 70 percent of
    physicians receive training in the VA. As Congress faces current
    Administration plans to reduce the size and scope of the VA, we ask
    that it not lose focus on one of VA's foundational missions dating back
    nearly 80 years--``To educate for VA and the Nation''. Our nation's
    veterans and every American depends on this critical health care
    workforce pipeline.
        Thank you again for your focus on mental health and the VA policies
    necessary for quality delivery of care. APASI stands ready to work with
    the Committee to ensure the best care for veterans.
        For more information, contact K. Conwell Smith, APA Deputy Chief
    for Military and Veteran Policy at csmith@apa.org or (301) 875-8923.

              Documents for the Record Submitted by Delia Ramirez
    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

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