[House Hearing, 119 Congress]
[From the U.S. Government Publishing Office]
ANSWERING THE CALL: EXAMINING VA'S
MENTAL HEALTH POLICIES
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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
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COMMITTEE ON VETERANS' AFFAIRS
MIKE BOST, Illinois, Chairman
AUMUA AMATA COLEMAN RADEWAGEN, MARK TAKANO, California, Ranking
American Samoa, Vice-Chairwoman Member
JACK BERGMAN, Michigan JULIA BROWNLEY, California
NANCY MACE, South Carolina 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
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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
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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.]
=======================================================================
A P P E N D I X
=======================================================================
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.
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\3\ For Action: Suicide Risk Screening and Evaluation Requirements
and Implementation Update (VIEWS 12521544)
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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.
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\4\ Doran et al. (2021). Associations between veteran encounters
with suicide prevention team and suicide-related outcomes. Suicide &
Life-threatening Behavior.
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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.
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\5\ https://www.healthquality.va.gov/guidelines/MH/srb/VADoD-CPG-
Suicide-Risk-Full-CPG-2024_Final_508.pdf
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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
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Statements for the Record
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Prepared Statement of NeuroFlow
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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\.
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\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/
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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.
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\4\ https://www.gao.gov/assets/gao-24-106390.pdf
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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.
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\5\ https://www.vaoig.gov/sites/default/files/reports/2024-08/
vaoig-24-00803-222.pdf
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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 [email protected] or (301) 875-8923.
Documents for the Record Submitted by Delia Ramirez
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