CONGRESSIONAL TESTIMONY OF HEARING ON
THE VETERANS'S AFFAIRS DEPARTMENT MENTAL HEALTH CARE SERVICES
BY PANEL OF EXPERTS FROM THE
U.S. DEPARTMENT OF VETERANS AFFAIRS
U.S. SENATE COMMITTEE ON VETERANS AFFAIRS
JULY 14, 2011
July 14, 2011
Good morning and welcome to today's hearing on how -- to examine how we can close the gaps in mental health care for our nation's veterans.
We all know that going to war has a profound impact on those who serve. And after more than eight years of war in which many of our troops have been called up for deployments again and again, it is very clear the fighting overseas has taken a tremendous toll and one that will be with us for years to come.
More than a third of veterans returning from Iraq and Afghanistan who have enrolled in V.A. care have post-traumatic stress disorder. An average of 18 veterans kill themselves every day. In fact, the difficult truth is that somewhere in this country, while we're holding this hearing today, it's likely that a veteran will take his or her life.
Last week, the president reversed a longstanding policy and started writing condolence letters to the family members of servicemembers who commit suicide in combat zones. This decision is one more acknowledgment of the very serious psychological wounds that have been created by the wars in Iraq and Afghanistan and an effort to reduce the stigma around the invisible wounds of war, but clearly much more needs to be done.
In the face of thousands of veterans committing suicide every year and many more struggling to deal with various mental health issues, it is critically important we do everything we can to make mental health care more accessible, timely, and impactful. In fact, according to data V.A. released just yesterday, more than 202,000 Iraq and Afghanistan veterans have been seen for potential PTSD at V.A. facilities through March 31st, 2011. This is an increase of 10,000 veterans from the last quarterly report.
Any veteran who needs mental health services must be able to get that care rapidly and as close to home as possible. Over the years, V.A. has made great strides in improving mental health services for veterans, but there are still many gaps.
As many of you know, just this past May, the 9th Circuit Court of Appeals issued an opinion that called attention to many of these gaps in mental health care for our veterans. And while that ruling has gotten the lion's share of attention, it is one of far too many warning signs.
Today, we will hear from the inspector general about ongoing problems with delays in receiving health care for those veterans suffering from the invisible wounds of war like PTSD. In one report, published just this week by the I.G., several mental health clinics at the Atlanta V.A. were found to have unacceptably high patient wait times. The report shows that facility managers were aware of long wait lists for mental health care, but were slow to respond to the problem.
The report also called into question the adequacy of V.A.'s performance measurements for mental health access time across the entire system. And as the I.G. noted, the V.A. only tracks the time it takes for new patients to get their first appointment. That means that since the V.A. is not tracking the timeliness of second or third or additional appointments, facilities can artificially inflate their compliance with mental health access times. That is unacceptable and it has to change.
In another report on veterans in residential mental health care, the I.G. found that an unacceptable number of veterans were not contacted by V.A. between the time they were accepted and the beginning of the program, and that staffing levels for mental health workers fell short of the V.A. guidelines.
GAO has also recently reported -- published a report on sexual assault complaints in V.A. mental health units that found many of these assaults were not reported to senior V.A. officials or the inspector general. V.A. clinicians also expressed concern about referring women veterans to inpatient mental health units because they didn't think the facilities had adequate safety measures in place to protect those women.
And just two weeks ago, the GAO issued a report that found the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury can't adequately account for tens of millions of dollars it spent to improve treatment for the invisible wounds of war. Taken together, these reports show very clearly there is significant work to do to improve mental health care outreach and treatment.
One way to fill these gaps and to overcome this -- is to overcome the stigma associated with mental health care and to eliminate the wait times s to provide primary and mental health care at the same visit. In the hearing today, we will hear from Providence Health and Services, which was recently recognized as one of the five most integrated health systems in the country, about how they have integrated mental health services into their medical home. I believe we need to look to Providence and those V.A. programs that work for guidance on making real progress.
Through its suicide hotline, V.A. has reached many veterans who might have otherwise taken their own lives. Each life saved is a tremendous victory and we should celebrate those with the V.A. But we also have to recognize these veterans who -- veterans who reached out to V.A. We want to hear about how the V.A. is reaching out to veterans, and how easy or hard it is for veterans to access the care they earned through their service to the country.
So we're going to hear today, despite the V.A.'s best efforts, veterans continue to experience problems when they reach out to the V.A. for mental health care. I've heard from veterans who walked into V.A. clinics and asked to be seen by a mental health provider, only to be told to call a 1-800 number. I've heard from V.A. doctors who have told me that V.A. doesn't have enough staff to take care of the mental health needs of veterans. And I have heard from veterans' families, who have seen first-hand what effects untreated mental illness can have on their family.
We are here today to see that that ends. I'm looking forward to hearing from all of our witnesses today and I hope it helps us to better understand these issues and to address them so that our veterans can receive the timely quality care they earned through their service.
With that opening statement, I do want to take a moment to publicly express my deepest condolences to my friend, Senator Burr, on the recent loss of his father. I know that Dr. David Burr was a Navy veteran who left Princeton to enlist back in 1942 and served in the Pacific theater in a frogman unit.
He served more than 25 years as a pastor in Winston-Salem. Senator Burr and I are both children of World War II veterans, so I know that his father's experience and example are what makes Senator Burr so dedicated to the veterans issues that come before this committee.
Senator Burr, all of our thoughts and prayers are with you and your -- your family at this difficult time and I appreciate you being here today.
With that, I will turn it over to Senator Burr for his opening statement.
Thank you, Madam Chairman, and good morning. And I can assure all that -- when you have the opportunity to -- to live to the age of 90, you haven't been cheated relative to the length of time on this Earth. And my dad was certainly blessed and is blessed today.
I want to particularly welcome today Mr. Williams, Sergeant Sawyer and his wife, Andrea. And I want to thank you for your willingness to come and to share your experiences first-hand with them. I know many of which are probably a little painful to recount.
As members of the committee, it's important that we have an opportunity to hear first-hand from veterans and their caregivers about their personal experiences in seeking the mental health services through the V.A.
Back in May, as the chairman said, the United States Court of Appeals for the 9th Circuit issued a scathing decision addressing delays in providing V.A. mental health care to our nation's veterans. While I don't intend to comment on the merits of the ongoing litigation, I do believe that it's worth our time to look into the issues raised in the case to ensure that veterans receive the care they deserve and have earned in a timely fashion.
As I've said before, early intervention offers the best hope for improvement and recovery from PTSD, depression, and substance abuse disorders.
Madam Chairman, it appears that early intervention continues to be challenging within V.A. According to the I.G. statement, even veterans who sought help and were accepted into the mental health program ended up waiting for the actual services. This is unconscionable.
This committee has worked aggressively over the years, through oversight hearings such as the one we're holding today, to improve the health care for our veterans and reduce the barriers preventing veterans and servicemembers from seeking mental health services.
For example, this is the third hearing in four years conducting oversight examining the gaps that exist in V.A.'s mental health care program. And yet, gauging from testimony we will hear from the first panel, there is still a tremendous amount of work that has to be done.
It's troublesome to learn of the issues both Mr. Williams and Mr. Sawyer encountered in seeking care from V.A. Both encountered problems finding someone in -- at V.A. to listen to what they needed, and more importantly, what they wanted from the standpoint of their treatment.
Their experiences lead me to ask: Where is the veteran in the Department of Veterans Affairs' policies? How does V.A. policy include the veteran when putting together a treatment plan?
I look forward to hearing V.A.'s testimony. I am particularly interested in learning how V.A. is working to address the issues raised by this first panel and the recommendations made by the inspector general.
I thank you, Madam Chairman.
Thank you very much.
Senator Begich, we'll turn to you for an opening statement.
Madam -- Madam Chair, because of limited time that I have here, I'll hold and really want to hear the testimony that the folks have. I have -- I do have a list of questions that I'll submit for the record and specifically about some work the V.A. is doing with regards to mental health services in Alaska and the coordination that's going on there.
So, I'll hold there with out -- especially around some of our hospital work with Providence Hospital. So I'll hold and want to hear their testimony.
Senator Brown, opening statement.
Thank you, Madam Chair.
Yes, same as Senator Begich, I'd like to hear the witness testimony. I appreciate you holding this. And I concur with Senator Burr, you know, where's the veteran -- you know, I hear these stories all the time and I'd like -- like some answers. So, thank you.
At this time, then, we will turn to welcome our first panel of witnesses. I very much appreciate all of you being here today and sharing your information.
We're going to hear first from Daniel Williams. He is a veteran representing the National Alliance for Mental Illness. Next, we will hear from Andrea Sawyer. She's a caregiver and a spouse, representing the Wounded Warrior Project. And I'd also like to welcome her husband, Loyd Sawyer who is here with us in the audience today. He is truly one of America's heroes and we want to thank him for his service and all of your family.
We will then hear from David Underriner with Providence Health and Services in Oregon. And finally, we'll -- we'll hear from Dr. David Daigh from the V.A.'s Office of Inspector General. He is accompanied today by Dr. Michael Shepherd.
So, Mr. Williams, with that, we will begin with you and thank you so much for joining us today.
Thank you, Madam Chairman, Ranking Member Burr, and members of the committee. On behalf of the National Alliance on Mental Illness, NAMI, thank you for inviting me to speak before you all today and give my testimony.
The V.A. Mental Health Program is a program that I've been in since 2007 from the time that I was put out of the service. Earlier this week, the national -- NAMI's national office subcommittee, my official -- oh, I'm sorry -- submitted my official statement for the record of this hearing. The statement contains additional information and comments about NAMI and our priorities and recommendations.
Madam Chairman, I was asked to appear at this hearing to tell you about the journey of my life since 2003 to 2004 -- I'm sorry, to 2007. In 2003 to 2004, I was in the Army. I served as a biochemist. I was deployed to Iraq in '03 -- was deployed with the 4th Infantry Division out of Fort Hood, Texas.
During that combat deployment, I suffered mental and physical injuries that will forever be part of my life. I was exposed to an improvised explosive device that injured my body, my brain and my mind. I received a traumatic brain injury, TBI. But I believe the most severe of my injury is the post-traumatic stress disorder, PTSD, an invisible injury that no one else can see, but -- but it haunts my every move.
From the moment I got injured until the time that I was honorably discharged, I received very little help from the Army or even acknowledgement of my mental health state. I went to the base clinic at Fort Hood, Texas, where I was told that I was having anxiety disorder and readjustment issues, but I would need to wait six months before I could get an appointment with a psychiatrist -- just an initial appointment to be looked at.
In the winter of 2004, after receiving no help or any hope of help, I attempted -- I attempted suicide by putting a .45 caliber pistol in my mouth while I was locked in the bathroom. My ex-wife begged me to let her in, but I wouldn't agree. She called the police. And when the police arrived, I argued with them. Then they kicked down the door and at that time I pulled the trigger.
By the grace of God, the weapon did not go off. The officer handcuffed me and put me in the seat in the back of his police car. One of the officers attempted to clear the weapon, but at that moment the weapon went off. That's the -- the same round that refused to kill me went off perfectly for him. Thankfully, no one was injured.
I was admitted to the psychiatric ward of the base hospital. I remained an inpatient for two weeks. At this time, I was diagnosed with readjustment anxiety disorder. But the physicians also acknowledged that I had PTSD. I was told by the doctors that the treatment record would be kept confidential and it was not.
It took me over a year to be able to be put out of the military service because of my mental illness. I was introduced to the DAV, the Department of Veterans Affairs, which handled my claims, taking me from the service to the -- to the V.A. I was never contacted by the V.A. -- only by the DAV.
When I first went to the V.A. Medical Center in Birmingham, Alabama, in 2007, I felt lost and had no guidance. With a brain -- the drain of PTSD, I wanted to give up and had just -- I had to wait for hours just to see a doctor. This was unacceptable not only to me, but to watch other veterans having the same issue.
And, honestly, the small little things were there that I couldn't handle -- the smells, the sights, the sounds, the crowds. These things made my condition worse. I had to relive this pain over and over every time I went to the V.A.
I recently went to the V.A. only two days ago and was told I could have my appointment rescheduled because I was coming here to speak and wasn't going to be able to make my appointment. My appointment was going to be put off for four months. That's not acceptable by any standard. And I'm sorry that not only I have to put -- go through this, but my fellow soldiers and servicemembers do.
There are many different issues that need to be changed in the V.A. system. Can this all be changed in one day? No, they can't. But they're -- they are the small things that need to be looked at that are very huge issues to us.
The time of care that we have for an appointment is very slow, to the point that it's almost -- it is a crawl. There needs to be more community services to be able to reach out to in the community to help the veteran through the process of the V.A. system because the V.A. system makes you want to give up and try something else.
Madam Chairman, the V.A. system has its flaws and it has its perks. There's an OIF-OEF transition team that handles my care; that helps me with my appointments; that does try to help me through these times. But it's not always successful not because of their efforts, because of the non-efforts on behalf of the V.A.
The V.A. has many resources open to them very freely, but yet they stay in close-knit with themselves and will not reach out to the local and national people that are out there and organizations that can help them make this a less difficult transition, not only from a soldier, but to a civilian again.
Servicemen and -women are taught to be soldiers through the service. We're not taught how to be civilians again. And once we're put out, we are left out to hang dry. I'm asking that this committee look at the possibility of having a peer movement in the V.A. facility; that the peers, a person like myself or others that have been through the same thing, that know the system, that know the people to talk to to help them through it because, otherwise, we're going to lose more than 16 people a day to suicides.
We've got to take action now and not tomorrow.
And I thank you, Madam Chairman. This concludes my statement. And I'll be pleased to answer any questions from other members of the committee.
Thank you very much, Mr. Williams, for your very compelling testimony and your courage to be here today and for all the work you do for others to make a difference in their lives. Thank you.
Chairman Murray, Ranking Member Burr, and members of the committee, my name is Andrea Sawyer, caregiver and spouse of U.S. Army Sergeant Loyd Sawyer, retired, and the mother of our two children.
Loyd served as an Army mortuary affairs soldier working first at Dover Port Mortuary with deceased servicemembers and later serving in the Balad Mortuary in Iraq where he processed countless civilian and military casualties. While there, he began exhibiting signs of severe mental distress.
Upon his return, I tried for 11 months to get him help. Ultimately, I sat in a room with an Army psychiatrist, watched Loyd pull a knife from his pocket and listened to him describe his plan of slitting his throat. Multiple episodes of hospitalization and intense outpatient treatment followed before he was permanently medically retired from the Army due to severe PTSD and major -- major depression.
Loyd immediately enrolled in care at the Richmond Polytrauma Center. In October 2008, he received 100 percent permanent total disability rating from the V.A. Given his urgent need for extensive help, we tried to get him into the PTSD clinic at Richmond, but the first available appointment required a two-month wait. When he was finally seen, we were told that the only thing available in the clinic would be a quarterly medication management session and a once-every- six-weeks therapy appointment.
Knowing that his depression was spiraling and his PTSD symptoms were worsening, we elected to use his TRICARE. He began treatment with a civilian counselor. He was able to see him once or twice week. But over the next eight months, I became increasingly concerned about the imminent possibility of suicide. Despite getting little help from our local V.A., but thanks very much to our federal recovery coordinator, Loyd was able to enroll in an inpatient PTSD program at the V.A. Medical Center in Martinsburg, West Virginia.
We had high hopes for this hospitalization, but it turned out to be a nightmare. The program delivered on none of its promises. His counselors and doctors there never coordinated with his local V.A. mental health clinician, his civilian counselor, or his federal recovery coordinator. He was placed on medication that made him physically and verbally aggressive despite having been taken off that same medication for the same reason while on active duty.
Over the course of this 90-day program, Loyd had fewer than five individual therapy sessions, and on returning home promptly discontinued all of his new medication, which was a step backward as he had been completely meds-compliant for the 18 months leading up to hospitalization.
In calling the Richmond PTSD clinic for help, I was told that it would be four weeks before they could see him. I tried to have his primary care physician intervene, but was told that I and his FRC were wasting the time of his primary care manager.
Eventually, again with help from our federal recovery coordinator, I was able to get Loyd an appointment within a week with a V.A. psychiatrist outside of the PTSD clinic. She suggested that he attend a weekly therapy group that met with a clinician inside the Richmond PTSD clinic. Feeling rather hopeless, he decided to try the therapy group and actually found great solace in being able to relate with others who were experiencing the same symptoms that he was.
Unfortunately, four months later and without consultation of the patient, the medical center staff announced that the V.A. was changing its treatment model and would be disbanding the group by year's end. For those wishing to continue in a group setting, the V.A. would be turning them over to an untested community-based program without a clinician.
Despite the veterans' petitioning to remain in a V.A. clinical program, their year-long effort has been unsuccessful except to temporarily keep a clinician. The 40-member group has withered to an average of five to seven because now, as a support group located off the V.A. campus, veterans cannot take sick leave to attend their meetings.
My husband is a veteran with well-documented severe chronic post- traumatic stress. We have all the advantages that should guarantee him good treatment: an excellent caring federal recovery coordinator, a 100 percent service-connected disability rating, a fabulous OIF case manager and the assistance of a super VSO.
If a veteran with all of these advantages cannot access timely, consistent, appropriate veteran-centered care in this system, what confidence can this committee have that any OIF veteran will have any greater success?
Loyd's experience is reflective of the challenges that the V.A. faces. A detailed V.A. directive identifies what mental health services should be available to all enrolled veterans who need them. But as the V.A. acknowledged in testifying before this committee, those directives are still not fully implemented some four years later.
V.A. reports its health care facilities have seen significant numbers of OEF-OIF veterans enrolling and screening positively for PTSD. A study of 50,000 of those vets with PTSD diagnoses found that fewer than 20 percent had a single mental health follow-up visit in the first year after diagnosis. V.A.'s own performance measures indicate that less than 11 percent of veterans are completing an evidence-based treatment program for PTSD.
There is a mental health crisis. V.A. cannot have a higher goal than helping these veterans recover from the mental scars of war. A Department of Veterans Affairs that routinely comes before this committee with a continuous list of mental health programs and initiatives is a department that is failing many of these warriors.
Wounded Warrior Project and I would like to work with this committee and the V.A. to close these gaps and to transform the V.A. mental health care system into one that is truly accessible and veteran-centered. My written statement includes many suggestions that would help the V.A. move towards achieving these goals.
And I'm happy to answer the questions of the committee. Thank you.
Mrs. Sawyer, thank you very much for sharing that story and for your tremendous courage, as well as those of your husband and your family, helping us understand what you're going through.
So thank you to both of you.
Mr. David Underriner, your testimony please?
Chairman Murray, Ranking Member Burr, and members of the committee, I really respect the -- the -- what the two -- Daniel and Andrea and Loyd have been going through. In -- in the context of what we do at Providence, and I'll go through it in my testimony, reflect the concern that we have in caring for individuals in our communities.
My name is Dave Underriner. I'm currently chief -- serving as chief executive, delivery systems, for the Oregon region of the Providence Health & Services. Providence Health & Services is a Catholic-sponsored, not-for-profit health care system serving communities across Oregon, Washington, Montana, California and Alaska. It was founded by Mother Joseph of the Sacred Heart in 1856 in Vancouver, Washington.
Providence Health & Services comprises 27 hospitals, more than 34 non-acute facilities, physician clinics, a health plan, a liberal arts university, a high school, approximately 50,000 employees and numerous other health, housing, and educational services.
I'm here today to describe the steps taken by Providence Health & Services in Oregon to improve clinical integration of behavioral health into our broader health care delivery system over the past 25 years, including our current work to fully incorporate behavioral health into the care provided through the patient-centered health home. We thank you for the opportunity to present today and share what we've learned over the past quarter century.
First, I'd like to provide some context as to why behavioral health is so important to Providence. Our mission calls us to provide high-quality, compassionate care to all people, with a special emphasis on serving the poor and vulnerable in our communities. Those dealing with mental health conditions are amongst the most vulnerable of those we serve, often suffering from physical challenges directly connected to an underlying behavioral health condition.
As such, Providence has striven for 150 years to ensure that people suffering from mental illness are able to access the care they need regardless of their circumstances. In fact, in 1861, the Sisters of Providence opened the first mental health facility in what was then the Washington territory. We believe effective behavioral health care is a key component of improving the health status of our communities. To that end, Providence developed a vision statement that guides our day-to-day operation and provides a road map for our strategic initiatives and planning.
Our vision for behavioral health is as follows. Providence Behavioral Health Services will be an advocate and leader in developing a patient-centered system of care for people with mental health and substance needs. The system of care will be evidence- based, focus on recovery and work in partnership with our community of providers, educators, consumers and families. This connected experience of care will achieve superior outcomes and patient satisfaction. That's what drives us.
This vision is pursued through a comprehensive organizational structure led by physician and administrative leadership focused on patient outcomes, population health, care coordination, patient satisfaction, strategic partnerships in the community, advocacy, clinical transformation and physician integration, research and education.
More than 25 years ago, as part of Providence's development of an integrated delivery system in Oregon, the decision was made to include behavioral health as a distinctive service-line program due to its importance as a clinical area of excellence. Providence Health & Services in Oregon has eight service lines, including heart and vascular, cancer, brain and spine, and behavioral health. Each of these service lines has defined leadership and strategic plans for delivery of service and programs in a coordinated, efficient, high- quality and cost-effective fashion.
This decision, perhaps more than any other, facilitated the integration of behavioral health services into the larger delivery system by elevating it as a key clinical program that requires overarching leadership and strategic focus. It also set forth the path towards full integration of behavioral health into our regional delivery system. And the decision led to a series of initiatives which are outlined in our written testimony.
I'd like today to focus on the patient-centered medical home. Consistent with our vision of a connected patient experience through a coordinated model of team-based behavioral health services, Providence in Oregon has set about to fully weave behavioral health into our patient-centered health home model for primary care.
This not only includes adding a behavioral health specialist in our primary care clinics, it also includes standardization of how we identify patients in need of assistance, development of clinical guidelines and creation of a team-based model of holistic care for patients served in those clinics.
This model involves the entire team in the primary care clinic, with the primary care provider in the oversight role in the management of the patient, both in terms of his medical or his or her medical and behavioral health needs. The Providence Medical Group has developed a tiered approach to the assessment and treatment that is both -- that is both standardized and flexible.
Specifically, the tiered approach in behavioral health includes the use of a patient behavioral health screening packet which focuses on using comprehensive diagnostic methods to identify specific behavioral health issues concerning the patient. A behavioral health care plan is developed and implemented and improvement is measured. If the patient requires a higher level of care, appropriate referrals are made within the community or within the system.
As -- as you can see, for the patient, the team approach provides for a comfortable, connected experience in which his or her whole person can be addressed in the clinic visit. The team knows them, cares for them and eases their way.
Despite the significant challenges resulting from lower reimbursement and inadequate numbers of mental health providers in the communities, we remain committed and steadfast in our commitment to behavioral health as a priority service line. Integrating behavioral health into the medical home model provides an important seamless point of access for patients, particularly those whose medical concerns are intertwined with a mental health condition.
We thank you for the opportunity to speak today. I'm happy to answer any questions that you may have.
Thank you very much for your testimony.
Madam Chairman, ranking member and members of the committee, it's an honor to be here to represent the work of the inspector general to you today.
I'd like to first thank Andrea and Daniel for the courage for the statements they made prior to me giving this testimony.
There are two gaps in the delivery of mental health care that I'd like to emphasize in my oral statement with you. The first has to do with what I would call coordination of care. We have looked at a number of cases over the years in detail and where veterans either committed suicide or had other untoward outcomes.
It's been almost a constant in those cases that at the level of the patient trying to get his care coordinated either between CBOCs, vet centers, and V.A. medical centers, but also between V.A.-owned facilities and civilian facilities. Veterans that we've looked at closely almost never get their care entirely from the V.A. They get it both from the community and from private practitioners.
And thirdly, the family of these veterans who are adults often feel left out at the end of the day when bad things have happened. So I think that -- that the coordination of care between the communities involved in these veterans is a very important issue. I think that the patient-aligned care teams, as I understand them, offers an opportunity and I hope will address this problem over time. So I -- I think that is a -- hopefully a good -- good way to begin to look at that problem.
The other gap that I'd like to talk about would be access to who I would call mental health specialists. And for me, that would be those psychiatrists, psychologists and -- in the -- in the V.A. system I would also include in that group pain management experts. And so many of our veterans return from war with physical disabilities, have substance use disorders and/or have pain syndromes that -- that are really quite complex to deal with.
When -- when we looked at residential rehab programs in the report we recently published, where V.A. had established staffing guidelines for physicians, P.A.s and nursing practitioners, they had in these programs 73 percent of the individuals they thought they should have. For psychiatrists, they had 68 percent; for psychologists, they had 49 percent; and for social workers, they had 65 percent.
In the recent report we published on Atlanta waiting times, one of the problems that complicated the issue in Atlanta, from our point of view, was that there was an inadequate mental health staffing at CBOCs, not that the V.A. didn't try to put mental health providers there, but they weren't there. And I think that diminished the flexibility of Atlanta to deal with the issues that they had.
So I guess I would make the point that when you have extremely complex patients presenting with very complex mental health conditions, I think they need to see rather quickly the captain of the team who -- who for me would be a psychiatrist or an experienced provider. And that individual then needs to lay out a plan that the rest of the team, the patient care aligned team and all the support staff can then follow.
So I'm less comfortable that the patient-aligned care team will directly get individuals to the specialist that they need to see. It -- it might do that, I'm just skeptical as to whether it will do that.
So I think given the staffing issues that we see, I think V.A. ought to consider in areas where there are a relative wealth of mental health providers, establishing arrangements with those providers that are beyond the fee basis arrangement; arrangements where a medical record can easily be shared, where the coordination of patients is easily -- easily seen and easily understood and a common -- common activity.
And where V.A. doesn't have primary care outposts, which is a large part of the country, and where the communities might be small enough that there really is not the demand for mental health providers, I think V.A. needs to sit down and talk with the local leaders, mental health providers, states, and see if they can't pool patients to create the demand and pool resources to provide the clinics that might then take care of those individuals where they live.
With that, I'd end my oral statement and Dr. Shepherd and I will be happy to answer questions. Thank you.
Thank you very much for your work on this.
And Dr. Daigh, let me start with you. As you mentioned, you heard the testimony. The stories that we've heard before the committee today are not unique. I hear them everywhere I go. And Congress has been listening to this. We have responded with the resources, with legislation, new programs. The I.G. has provided the oversight. Yet here we are and these stories are still here and they're relevant again today.
You mentioned a little bit in your testimony some things about coordination of care, those kinds of things. I heard you talk about Atlanta that they needed the clinicians, but it's not that they didn't try, I think you said, it's just that they weren't there.
Is that lack of people available to hire? Is it lack of resources? Is it lack of, you know, tell us what we need to be doing in order to make sure the V.A. has what it needs or to be telling the V.A. what it needs to do.
I think that there -- if -- from my understanding of the situation in Atlanta and looking at the data, there was a tremendous growth in the demand for mental health services over a relatively short period of time. I'm -- I'm not -- and -- and -- and some of the assumptions that they made about how they would provide care, their inpatient ward for example, they thought it would be functional and it wasn't.
So they had to adjust, and I think they could have made better decisions about how they adjusted. And our report says that we think they could have made better decisions about how they adjusted. But part of the problem is that if -- if you have prearranged relationships with universities or private practices or clinics of specialists that you know you need and you can easily call on them, as opposed to fee-basis where you say, "I can't meet your demand; here's a chit; go get care."
You have an organized way. The records are shared. They expect to see patients.
Which goes to the closed system that I think Mrs. Sawyer was referring to. Is that...
I think it's along the lines of -- I think it's along the lines of what she was saying where -- where she was able to go outside the system and get some help that was coordinated with it. But maybe not, I'm not sure (inaudible). . MURRAY: Mrs. Sawyer, tell -- tell me your experience.
We actually were not able to use the fee-basis system in the V.A. because my husband is medically retired. We have TRICARE and so we just simply chose to exercise the TRICARE benefit. It was not in conjunction with the V.A. Even requesting fee-basis at Richmond even for physical medical care is a labor-intensive process. It takes months. It's not easy to get done. It's really kind of a broken system.
So it -- even though there has been a directive that people should be able to use fee-basis care, in terms of waits, you still have to get it approved and it almost takes -- and pardon the pun -- an act of Congress to get it done.
Well, Mrs. Sawyer, in your testimony, let's talk about that, I mean you just told us time and time again that you were fighting everything to get appointments, to get attention. Dr. Daigh mentioned needing a captain of the team. Did you ever feel like there was a captain of the team?
Quite honestly, I feel like I'm the captain of the team. I feel that I monitor symptoms. I see the increase in symptoms, the decrease in -- in his quality of life. And at that time, I activate the chain as it is. I call the FRC. I call the clinic. I call the OIF case manager. I do everything that I can.
The problem is with the V.A. that we have found is time and time again I have gone in and said, "We are seeing this civilian counselor." I've said it to the neuropsychiatrist. I've said it to the person he was seeing in the PTSD clinic. I've said it to his OIF case manager. It's in his records, and yet again and again I get comments from the PTSD clinic, "We didn't know he was seeing any one else."
I'm sorry. You can Google it and find that he is seeing someone else. We haven't stayed quiet about it. We -- and we just can't get them -- I hand the number over. I ask them to call his counselor. I am his health care power of attorney. I also -- there's a flag on his chart. I'm supposed to coordinate his medical information because of a cognitive processing disorder. I constantly say, "Please call his counselor." And they don't.
This is a full-time 24/7 job?
Yes, ma'am. I gave up my job in order to keep him alive, that's what I had to do.
I hear that all the time. And -- and it has a huge impact on you, a tremendous amount of courage. And I think about all the men and women out there who don't have a Mrs. Sawyer as their -- their -- the captain of their team. So I appreciate what -- what you've been doing.
Mr. Williams, again thank you for your service and all of what you're talking about echoed in -- in many other stories as well.
You mentioned getting a hard time to get an appointment. I was curious from you whether any of the mental health care you received is offered after hours or on weekends. That's another thing I hear from a lot of people who are trying to have a job, do other things and can't get the care because of lack of after hours or weekend services.
Is that something that you've been able to access or see a need for?
There needs to be a larger amount of this care. Yes. The access -- the only access I have to this is the vet center, which is not communicating with the V.A.'s actual facility. This is a center where they do after hours counseling. They do marriage counseling. They're really not communicating, to be honest with you. They have no idea what's going on. They need to be more of it. It needs to be more advertised that there is this after hours care that can be used when, you know, you have -- you get off at 6 o'clock. Will they have sessions at 7 or 8 o'clock at night?
You know, the family members need this care, too. Because the family members have the same or gain the same PTSD or whatever the diagnosis may be, as the veteran does.
I know, as Ms. Sawyer said, she gave up her -- pretty much her life to take over to help her husband. And this is what happens not only to her, but I think just about every family either the spouse leaves or the spouse stands behind them.
And I know if it wasn't for the woman behind me, I would not have any care that I have today because she has given up her job, too, to take care of me. And there does need to be some more after hours. I know NAMI is trying -- or is partnering with the V.A. to do Family-to- Family. Family-to-Family is a program that helps the servicemember's family understand why they're doing the things they're doing; why they're trying to get an adrenaline rush; why they're doing these little quirks that may not make sense to the family.
This may be a rhetorical question, but it seems to me like -- that people like both of you know the system really well. Your families have really borne the burden of this silent disorder of post-traumatic stress disorder and PT -- and traumatic brain injury. We have a country that says they're there for our soldiers, but you alone have borne this.
Does the country understand PTSD? Do your neighbors and employers and people in the community know what you're going through? Do you feel pretty alone?
To be honest with you, I feel very alone. The only other people that understand is my family and when I say my "family," I mean my wife and other soldiers or other veterans. They're the only ones that understand the actual pain, the invisible pain that we live with every day. And it's very, very hard to try to express to the nation.
We get condolences. Thank you for your service. We hear that very often. But when was the last time somebody said, "All right, we need to make a change in the V.A. center; you need more services." That's the type thanks that I believe -- I take more to heart the action than I do words. Because like I said, it's not only suffering. I suffer from this mental illness of traumatic brain injury. My wife has to go through it. My kids have to go through it. So this is a never-ending cycle. My kids will have PTSD because of my actions.
And if we could put peers together, family members like Ms. Sawyer and my wife together more times, the support for one another, not only for themselves, but for us, it would be a stronger V.A. system. They've got to start looking at family-oriented stuff. It's such a just the veteran. And half the time, the veteran can't even get stuff done.
I mean, it literally takes my wife getting to the point of being arrested by V.A. police to be able to see my psychiatric doctor because people are sitting on the phones, talking on their cell phones during business hours, telling me to hold on a minute, and I'm having a crisis where I'm fixing to, honestly, have a breakdown.
And it takes people like these two women to have -- not every veteran has that. Not everyone is fortunate enough. And I think that needs to somehow be a mentorship to veterans that don't have the support system.
Mrs. Sawyer, do you want to add anything?
Truly, I don't feel that the community understands. We spend a lot of time at the V.A. Going to the V.A. is never just a go- for-an-hour-for-an-appointment. It's go, you sit, you have a 9 o'clock appointment and you might get seen by 11. And then the doctor says, "Oh, we're only running two hours late today; that means we're on time."
Then we sit for an hour. Sometimes it's not a good appointment. Then it takes hours for him to wind down. And we get home and the neighbors say, "What do you do all day?"
I talk to a lot of other caregivers who are in my situation. I've attempted to mentor some of the other caregivers because I do deal with -- I do have a lot of time to deal with caregivers with Wounded -- that I've met through Wounded Warrior Project who are at different stages in their recovery.
And I've been privileged that they trust me to call and ask, "OK, we're stuck. What do we do?" We need to build our own strong network outside of the V.A. and that's really what I use to survive. We have a community kind of all to ourselves. We've kind of been ostracized from the community.
I left at my job teaching. I had great scores, you know, for the be-all-to-end all tests at the end of the year that all teachers are judged by, whether we say they are or not. Great scores, but I had missed a lot of work. It was my fourth year, my tenure year. And it was Loyd's first year after he was retired. We were spending a lot of time at the V.A. which meant I was spending a lot of time out of the classroom. Then my principal came to me I had to choose between getting my husband better and teaching. So I left.
So no, the community does not understand.
Well, thank you very much for sharing that with us.
And Mr. Williams, I know your wife is sitting directly behind you. We want to thank her for being here as well and for all she does for you.
I have gone way over my time. Senator Burr, I apologize, but I felt what they had to say was extremely important for the committee. So I'll turn it over to you.
I was interested in your questions, and more importantly the answers. And of course, grateful as I am that all of you are on this panel, and I've got questions.
I'm going to forego all but one because quite honestly I don't want anything to stand in the way of the V.A. coming to that table while your testimony is fresh on their minds, and share with us where there is not a problem.
But I will ask you, Andrea. With the exception of your recovery officer, was there anybody in the V.A. that attempted to solve any of the problems that you had or went the extra mile to try to facilitate some type of remedy to the health challenge?
We actually have a fabulous OIF-OEF team that is a part of our V.A.. Our team at Richmond is wonderful. We have a patient advocate, a team leader and an OIF-OEF case manager social worker. They've since added a couple of people to the office. They -- one is -- two of them are OIF-OEF vets and the social worker is the wife of a vet.
It is truly personal to them and they take it personally. They have intervened countless times. I've watched my OIF-OEF case manager storm down and say, "You have 14 days to act from this referral. It's now day 30. What's your problem?" She really -- she has been my champion. I could not have done it. But we did not get introduced to that team until a year-and-a-half into the V.A. But once we were, they've been absolutely fabulous. They've done everything they can. The problem is that they file complaints and then they don't have the authority to act when nothing is done.
So they do -- I mean, you know, they literally, do everything that they can -- complain, march down there, attempt to hold people accountable to see what they can get done. But then when they can't get anything done, there is no remedy for the situation. And so it does necessitate me calling D.C.
The other thing that has been helpful for me personally as a family member, the Memphis V.A. did a pilot study a tele-health group for caregivers where there were 10 of us that all knew each other and so we asked to be in a special group. We were spread across the country. And they talked with us once a month on a group call and really tried to give us advice as a group and really just to help us heal and find resources within the system. The problem with that was it was a year pilot. And of course, our year has ended and we are back floundering on our own again.
So a lot of times I feel like the V.A. has some great things inside of it. But there is a time limit and when your time limit is done, it doesn't matter if your condition is done, they're done with you.
You've given us a number of avenues to look at from the standpoint of this committee and I am grateful to you for that.
I thank the chair.
Thank you, Madam Chair.
I kind of concur with Senator Burr. I am curious. I mean, the stories are not unlike the ones you've seen, Madam Chair, and others throughout the country.
In Massachusetts, we have very similar problems. They're working on them. We have -- with the Guard and Reserve, we have I think a better handle on it than the regular Army folks.
I just have one question, though, Dr. Daigh. The V.A. has increased the number of mental health staff by more than 6,800 and trained another 4,000 since last October. Yet, we continue to hear stories like this. You know, where do you think the breakdown is?
I'm going to be a little bit of a pessimist here. I think that people will try very hard. I'm not sure that all these stories will ever end. I think there will always be disappointments in the delivery of care between patients, their needs and providers. So...
But this seems just so egregious...
I understand that.
... the stories.
I understand that. I'm not disagreeing at all.
And I think -- I think that the limit that I would see is that I think there is sort of finite number of practitioners out there. And when you're in a city where there are mental health resources outside of what the V.A. owns, I think that an arrangement with those groups that are able to see veterans through a contracted or a regular-occurring use would make it easier for the access issues that I think are at the heart of much of what people are talking about to be addressed where people can then see the experts they need to see.
So is there a breakdown that we need -- that we can help with? For example, I am in the military still and I understand that there is always, you know, rules and regulations. Is there a breakdown where you're not able to go and seek those outside entities? And is this something that we need to tweak and fix to make that easier?
I would defer to experts...
... I would defer to experts on contracting. But my message to you is I don't think fee-basis, which is in my view a blow- off valve for a temporary increase in demand that you can't meet with the resources you have, is working. And I think a more concerted effort to build relationships within the communities where they exist would alleviate some of what we hear here.
And the other piece, I think, I do hope that the patient-aligned care teams are better able to deal with the coordination both within V.A. and without V.A. So, that would be my view as to what we need to consider.
Great. I'll just defer to the next panel.
Senator Murray, if I may?
I guess, Senator Brown, what I would like to say about those hiring numbers with the 7,500 new staff. I heard Dr. Daigh say in a hearing on the House side a couple of weeks ago that not all of that new staff are actually clinicians. They're techs -- so they're not all people who are are available to actually treat patients. Some of them are support staff.
The other thing that I've seen in my experience at the V.A. is a lot of people are hired on as only part-time clinicians and the rest of the time they're doing admin or research. They aren't boots on the ground 100 percent of the time. And quite frankly, we have a crisis. They need to be there treating.
They don't -- I am not saying that research isn't needed and isn't necessary. But at this point, we need people seeing patients.
I'm sure maybe there is an opportunity for you to inquire like what are the actual boots on the ground numbers? So we understand who is working part-time, who's working full-time, how many people are they seeing. What's the breakdown? So, we can get a better handle on that sort of thing.
I think we'll have that opportunity with the next panel. So, we'll definitely follow up.
Mr. Williams, would you like to share a comment?
Yes, ma'am, I'd like to make one more statement. Two things. A better way to see veterans not only with the crisis of not having a lot of doctors and also covering rural areas would be tele- medication. I don't think that's an avenue that's been seriously looked at that would help a lot.
And two, you can -- right now, it's hard to change things if there's a hiring freeze for the -- for the V.A. system. And you can hire peers or veterans that are making great progress in their recovery. I'm not saying we're lesser pay for the same thing you can spend on a psychiatrist or psychologist, when we can work together as a team to make a lot better pace to save lives.
All right. I do have additional questions I'm going to submit for the record, particularly for Mr. Underriner and Dr. Daigh. I want to thank all of you for your testimony today. And I concur with Senator Burr. I think it's important for us to get the V.A. up here. They just heard your testimony. We want to hear their response.
So again thank you to each and every one of you for being here today and your continued input to this committee is extremely valuable.
With that, I do want to call our second panel up for their testimony, and we'll pause for just a minute in order to change seats here. While they're getting seated, I will go ahead and introduce the second panel.
We are pleased to have Mr. William Schoenhard, deputy undersecretary for health for operations and management at the Department of Veterans Affairs. Mr. Schoenhard is accompanied today by Dr. George Arana, assistant deputy undersecretary for clinical operations.
Dr. Zeiss, acting deputy chief patient care services officer for mental health, and Dr. Schohn, acting director for mental health operations.
Dr. Schoenhard -- Mr. Schoenhard, I believe you are going to testify for the panel today. So if you would proceed please.
Before I begin, I would like to thank Mrs. Sawyer, Mr. Williams for their testimony. I, for one, as a veteran was very moved by their testimony. I talked to them briefly during this exchange and would very much like to personally follow up with them and learn more of their story and what we can learn.
But to these people who serve our country, whether they have served in uniform or as spouses of those who have served, their service is appreciated. And I want to express regret for any difficulty that they've had and pledge to get better.
We have since 2005 addressed a number of gaps in mental health. Thanks to the support of the Congress with budget enhancements, as has already been mentioned, a number of staff have been hired. We have put together a comprehensive mental health strategic plan and a landmark uniform mental health services handbook that was developed in 2008.
As Madam Chairman acknowledged, with the wars our volume of patients served has increased significantly. In 2005, we served 905,000 veterans for mental health services. In fiscal '10, that had risen to 1.25 million. If you consider the number served in mental health in our integrated setting in primary care, the number in fiscal '10 was 1.9 million, and so there is a great, great need.
Suicides are obviously of tremendous concern to all of us. One suicide is one too many. A crisis line was established in July of 2007. To show you the importance of this, over 400,000 calls have been received on that crisis line since it was initiated, with over 15,000 rescues. There's a great need.
Suicide prevention coordinators are now in every of our facilities. We have teams that work in our larger ones to be able to work with our rural and other clinics and CBOCs.
One of the advances this year under Dr. Petzel's leadership, our undersecretary for health, is a reorganization, and that's represented here in this panel where a number of clinical leaders have been added to operations and management where I sit. And we have, I think -- particularly blessed to have a psychiatrist as the assistant deputy, Dr. Arana, who is next to me.
And with the addition of Dr. Schohn, who has been in mental health operations working to deploy our universal -- excuse me -- our uniform mental health handbook, we have more boots on the ground in operations to have consistent deployment monitoring and improvements as we go forward.
It is extremely important that mental health be integrated into primary care, if for no other reason than the worry that many fellow veterans of mine have, and that is a stigma around accessing mental health services. And so I know the committee has already received testimony regarding the development of patient-aligned care teams in the effort to integrate better the captain of the ship and the team to be able to forge coordinated care. I could not agree more with Dr. Daigh from my private sector experience or in V.A. so far that improved coordination is needed.
We have made progress. In 2008, 77,000 veterans were treated in primary care settings for mental health. That rose to 155,000 in 2010, but much more is needed as we go forward. Earlier testimony spoke to vet centers. This is another important element of care for veterans because some veterans may be reticent to access traditional VHA services. These vet centers, that will number some 300 in 2011,and include 39 rural vet centers, 70 mobile clinics, are important in terms of outreach.
They provide professional readjustment counseling, counseling for those who have suffered military sexual trauma, and they provide bereavement counseling for families whose servicemembers have lost their lives while on active duty. In fiscal '10, we served 191,000 veterans in these vet centers, with about 1.2 million visits.
It's important also to understand that while there were 120,000 referrals from vet centers to our facilities for mental health, 39 percent of those who are seen in vet centers do not access traditional VHA services. And so that is another source of outreach to those who for whatever reason may be reluctant to access traditional services, particularly of my era, the Vietnam-era veteran.
Let me just conclude by saying there is no more important work we could be about than the provision of mental health services. I've seen first-hand as a veteran on deployment during wartime the impact of extended deployment. Mental health is integral to the quality of care and the quality of life for our veterans.
I come with 34 years of private sector experience. This is the most mission-driven organization I've ever been part of. I came, too, from a Catholic system. But this is an area where one suicide is one too many, and we can do better and we will do better. And learning from people like Mrs. Sawyer and Mr. Williams today is an important activity for us.
And I would again thank the committee for its focus, its leadership, its support of our efforts, and be happy to answer any questions.
Thank you very much.
Doctor Zeiss, I wanted to ask you. I noticed that you were shaking your head during Mr. Williams' and Mrs. Sawyer's testimony. Do you have anything you want to say to them?
I respect and really appreciate what they say. And I am shaking my head only in the sense of listening and trying to incorporate and understand the issues that they're raising for us.
I think you've been here longer than anybody on this panel within the V.A. system. And you have made some great strides, and I know you're writing the policies. Do you think these facilities are listening to what you're telling them to do?
I think that there has been tremendous progress in all of the facilities, but inconsistent. And I very much support the reorganization that Mr. Schoenhard was just describing. I think that we've come to a much clearer delineation of what policy offices like the Office of Mental Health Services can -- can do and can accomplish. And to be able to work in a much more interwoven fashion with operations and management is going to be very powerful, I believe.
Dr. Schohn and I work very closely together in terms of looking not only at how policies are being implemented, but I think the other part of the question is: Are we in central office listening to the facilities? And are we learning from them about the challenges they're having in implementing policies? And how do we do a much more coordinated job of coming up with guidance for the field that really can be implemented in a consistent way throughout? And I think this organization is going to be very, very helpful.
Mr. Schoenhard, we heard from the I.G. that Atlanta was not prepared to handle the influx of new veterans who needed mental help. And this isn't the beginning of this war. It's been going on for a very long time. We've been talking on this committee for a very long time about PTSD and TBI and the invisible wounds of war, and the high number of soldiers coming back who need this access. How could it be that the V.A. wasn't prepared for this?
Madam Chairman, that's a tremendously important question. In Atlanta, and it's true of VISN seven where Atlanta is part -- this is one of our fastest-growing areas for veteran enrollment. We have there about 7 to 8 percent increase.
We concur with the I.G., and I have talked with Mr. Clark who is the director there. We were not as quick as we should have been. And we're going to learn from this, and we're taking this report not just for Atlanta, but for other facilities, particularly in high-growth areas.
Where do we need to improve the process that occurred in VISN seven that I think was delaying to secure additional funding from the VISN in order to absorb that growth? And that's -- every opportunity we have to learn from this and especially apply those lessons across is important.
And I don't know if Dr. Arana may want to elaborate on that a little bit or Dr. Schohn because I'm looking to them for help with this.
Madam Chairman, before I make my comment, I'd like to thank Mr. Williams and Mrs. Williams, Mrs. Sawyer and Mr. Sawyer for being here. I've been a practicing psychiatrist for over 30 years. Their stories are just unacceptable in terms of practice.
I've been in the V.A. system for over 28 years. I know we can do better. I've treated hundreds of PTSD patients. And so I'm very sorry that you've had the experience you had. I'm sure hopeful that we can be able to make that better in the next few months and the next few years.
To the point of the reorganization, over the past four months, we've realigned in the V.A., particularly in terms of operations. And one of the key areas that we have realigned to is mental health. The idea of the realignment is to have more clinical muscle in operations so that we can better implement the policies that Dr. Zeiss has developed over the past few years, and the plan is very much to do that in an aggressive way.
Our hope is to get out to the facilities in a very regular way, in fact, much the way the I.G. does with on-the-ground visits with experts who know the business, who know how to ask the questions, who know how to find out where the gaps are. And our hope is to deploy this effort very strongly over the next six to eight months and hope to come back and tell you about our progress with that.
Well, as you've heard, the wait times and the appointments have a huge impact not only on the veteran, but on their entire family and the stress that they're going through which is adding to the problem that these people face in their own lives and, you know, to all of us who want to make sure they've got the resources.
And I know we don't even know the scope of all of this from the V.A. itself because they're only measuring the wait times for the first-time mental visit. We're not seeing what the second time, the third time, and I know that's what both of our witnesses before were talking about. It isn't just the first appointment. It's when you call yesterday and you're told, well, because you're going to be at this hearing it's going to be four months before you get in. Unacceptable.
How are we or you -- how are you empowering managers to be more flexible with their money, to do what they need to do to make sure that that's not what veterans hear on the first, second and third or hundredth time that they call?
Madam Chair, I'm going to ask Dr. Schohn perhaps to add to this, if it's OK. But what I would begin with is that the performance measurement we have for new patients is important, and we already heard testimony this morning that in this case a new patient presenting was not served in a timely fashion. And while that's necessary, I don't believe it's sufficient.
The performance measures that we work with facilities on and understand their difficulties with is an evolving methodology. And I think from the Atlanta I.G. report and from other indications we have, we need to look at what support needs to be given to being able to ensure that timely appointments are made for existing patients as well.
We do measure that, but what I am hopeful for in terms of the deployment of the uniform -- or the uniform mental health handbook is that all of this is laid out there for existing and new patients. And what we need to do is get better deployment, do the site visits, as you infer in your question; understand what, if any, barriers exist; what difficulties the facilities are having; the clinicians are having. What are the root causes of any gaps in that care? And address those, whether they be staffing, facility or...
Are you doing that or are you just identifying that as a problem?
Yes, we -- we are doing that. And if I could ask Dr. Schohn to elaborate further.
Yes, and then I need to turn it over to Senator Burr, so if you can answer quickly.
OK. Yeah. We're in the process of developing a comprehensive monitoring system that looks at all of the issues of the implementation rates, really combining the data all into one place so that we can red flag quickly based on our available data.
By the same token, we are also looking to develop new data based on our site visits that might give more accurate reflection of what's really going on in the facilities. And finally, we're going to be...
When -- when will you see that? How long does it take to collect all this data?
We hope to have the full package in place by the end of the year. We are looking at pieces of the data right now so that we can, again, begin to address this as it comes up. But we hope to have the full package available by the end of the year.
And then you'll have to analyze it and then go back...
No, no. We will -- no, no -- it will be put together as an analysis that we can work with the...
My question is: Does everybody have to wait another year?
No. No, we will be working on this, as I said, concurrently with putting the information...
So if you're seeing information come in...
We're acting on it.
... that second, third, fourth visits are taking longer, can you do something immediately about that?
Yes, we can.
Mr. Schoenhard, how do you define "timely" for a veteran with a gun in his mouth?
So is that the directive that comes out of the central office to all individuals at all locations that would come in contact for the first time with a veteran with mental health needs?
Well, we do have a requirement that those who present with serious issues -- and I might ask Dr. Zeiss to elaborate on this -- be seen within 24 hours.
But to your question specifically, a veteran with a gun in his or her mouth, our expectation would be immediate help starting with whatever would be available on the crisis line and any other intervention that could be provided.
Does the V.A. have written access standards for behavioral health care for both urgent care and routine care?
Yes, sir, we do.
And what are those?
Could you elaborate, Dr. Zeiss?
We do for urgent care require an appointment within 24 hours and 14 days for other new patients.
But you may want to elaborate on that.
There are a number of components. I'll try to lay it out, but we can also give you some additional information later. We do have very clear directives about having mental health providers in emergency departments where many of these issues might come up, having 23-hour observation beds in those emergency departments.
We also have requirements, as Mr. Schoenhard said, that if there's a referral for a new individual who has not been seen in mental health in the last two years, they require contact within 24 hours.
So Dr. Zeiss, where's our problem? Is our problem that the V.A. really doesn't put these directives out? Is the problem that the VISNs really don't read the directives that you put out and don't share it with the facilities? Is the problem that the individuals that comprise the medical staff at the facilities believe that the guidelines that come from the central office aren't enforceable?
Let me just ask this. Has anybody involved in the mental health delivery of care around the country in the V.A. been fired because of some of the issues that have risen from veterans like two that we heard today?
And Mr. Schoenhard, I've got to tell you, your opening statement, I've heard it before. I just hadn't heard it from you. So now that we've gotten that out of the way, the purpose of this committee is hopefully to partner with the V.A. to solve the problem.
And we keep going back to the things that are in place. If you only take one thing away from this, please understand: it does not work. There are gaps. There are holes. There are veterans that are falling through the cracks with mental health problems that I don't think went undetected.
I think it lacked a professional on the other end who works for the V.A. that really didn't give a damn whether they got the care in a timely fashion or not. So I fear that your definition of "timely" and the frontlines definition of "timely" is extremely different. Yours is genuine and theirs is whenever I have time to deal with it, versus the human face on the other end of a phone.
I've complained to the secretary before. If the relationship between the V.A. and the veterans is going to change, it starts with hiring somebody that answers the phone and makes appointments that actually cares about whether the appointment is made or not. Because when you get that bad taste in a veteran's mouth to begin with, no matter where you navigate through the system, the fact is that's always going to stick in your craw that the first person you talked to really could care less who you were or what your problem was.
Now, let me ask Dr. Zeiss. You've stated that the central office continually updates guidelines. I think I'm paraphrasing, but I think that's what you said. As we update those, shouldn't it eliminate some of the things we constantly hear?
That is certainly our goal and that is the intent of any guideline we develop is because we have seen a problem or have been asked by the field for more clear guidance. The guidance is developed and disseminated.
And I will again say what I did before. I think that this new organization, so that we in policy now have a clear team to turn to who will be working directly with the network directors is a tremendously positive step.
My time has expired, and I will have some written questions for -- for the panel.
I'll just make this statement, because it is highlighted in every hearing that we have on mental health. And it's how well the suicide prevention hotline works, and I applauded that when it was added. I think it's absolutely a necessity.
But I want to suggest to you that the ultimate prevention of suicide is to supply the treatment in the timely fashion that our veterans need. To walk away and feel good because somebody can pick up the phone when they want to kill themselves, I'm worried about the ones that never pick up the phone. I'm worried about the ones that naturally we aren't going to affect the outcome of what they intend to do.
And the only assured way that we can make sure that we minimize the number of people that call that line is to make sure that in fact the service we provide is effective. So as we hear about the numbers increasing of the hotline, understand with as many hearings as I've been in and with all of the new programs that I hear we're going to start, with an increasing number who call the hotline, it tells me that everything that we're trying really isn't working for the ones who need it the most.
And as long as we've got veterans who come before the committee and tell us the horror stories, it's the responsibility of this committee to remind you that everything that we've got in place is not perfect. We've got a lot of work to do.
And I might say, just for the record, this year it's $5.7 billion to mental health; 2012, it's $6.1 billion to mental health. Trust me, if you look at the last nine years in the V.A., if increasing funding solved the problems, this would be the model of government. But the challenges exist in every area of the V.A. and they're not limited by how much money we've been willing to pump into the program.
I thank you, Madam Chair.
Thank you very much, Senator Burr, for your passionate statement.
And the only thing I would add, and I share everything he said, is that the V.A. is the receiver of all this and ends up having to deal with it. We have to go back to the Department of Defense and the military itself and make sure that we are doing the right thing for our servicemen and -women while they're on the ground to make sure that they know where to go, so we don't get into some of the gaps that we hear that end up in the laps of this committee as well.
Thank you, Madam Chair.
You know, just to reflect and add onto what you said, yes, there needs to be a top-to-bottom review from the minute the soldier is getting out to determining what their status is, how they are mentally and physically. And I know we do a pretty good job on that, depending on what branch of service you're in, depending on whether you're Guard, Reserve, active Army.
I'm going to tell you what, you know, like I said, I've been here only a year-and-a-half and I've heard these stories more than any other committee -- any other committee that we've had. These are the most consistent stories I've heard is the complete breakdown between the soldier when they get out, when they're in such desperate straits that they would think of taking their own life. I -- I don't understand where the breakdown is.
And you say -- and I know that you're in a tough situation. I understand that. But when you're dealing with people's lives, you know, the response rate needs to be perfect because every lack of perfection equals a death.
I mean, bottom line. And interesting -- there was a comment on one of our video links, video treatment, audio -- to have a video treatment for some of these areas that are kind of, you know, the boonies, so to speak, you -- you -- it makes sense if they can get to a facility and at least speak to somebody.
I'm finding from everything that's been told to me, and I'm still serving. I'm 32 years in. I deal with this regularly and it's just having a warm body on the other end, just a smile, a handshake, a hug to say, "Hey, we care," and being able to help you right now.
But you know, to have the cold calculating statement of, "Oh, yeah, it's four months, sorry," they don't really give a crap. That's where the breakdown is. There's a complete lack of trust between the veteran and the department. And as a result, there is so much desperation right now in this area.
I don't know what you have to do to shift assets and resources and bodies and whatever, but you've got to get a handle on this stuff because you're going to be back here every month, every week, answering to us. And the amount of money that's being set forth to the department to solve these problems, it needs to be fixed. And it's going to take draconian efforts and herculean efforts, I should say, on your part to send the message out that this is unacceptable. These stories are unacceptable.
And that being said, you know, my question is, if the V.A. is placing an emphasis on recovery-based models, then why only 4 percent of its patients referred to vocational rehabilitation services? I'm curious as to why that's such a low number.
Senator, before I answer that, could I just say to your very, very important point regarding transition from active duty or Reserve or Guard service, there is a lot of collaboration. I was in a meeting over at the Pentagon this week working this issue between DOD and V.A. and this is an area where we need to continue to work together to improve.
Then how do these people then come to us? It's been years. It's not like, you know, you could Google them and find out. How did it take them, you know, screaming with M.P.s breaking down doors to come to this point? I mean, if that's the case, that there's all this amazing coordination, everything is great, great, great. I love Washington. Everything's great here.
But outside, it's not and people are hurting.
So how do you -- how do you get there?
Well, in my view, it is what we are working on in terms of OEF-OIF reach -- outreach. It is the warm hand-off between active duty...
It's not only a hand-off. It's a continuation.
It's not the hand-off. The hand-off -- you can give them a box of candy and flowers and a big hug. The hand-off is great, boy, what a great experience.
It's not -- that's not where the breakdown is. The breakdown is from the hand-off to the actual treatment.
That follow-up, that's the problem.
And that's how I intend -- what I'm saying is that we -- we get visibility of these folks, that there is not that kind of delay and that we have, for those who have served this country, particularly in multiple deployments in the current wars, an excellent transition going forward. And that requires -- I mean is in place right now, unprecedented cooperation and work, but it's an area where we are focused and we are going to continue to improve.
As it relates to the vocational rehabilitation, if I could yield to Dr. Zeiss or Dr. Schohn as they -- that may be a question we would have to take for the record, sir.
Yeah, I'm going to -- I have a whole lot of questions for the record. But, you know, I'm concerned and I'll just tell you where my head is at. I'm concerned about the process for follow-up consultation. What are the procedures and standards in place to contact the individuals who have been discharged, but are still at risk?
And the fact that the testimony we heard, they were even allowed to, like, go home. It just mystifies me. And you know, how was the V.A. going to improve its coordination in partnership with local community organizations? And really, just to have everybody in the ballgame. Everyone has some -- some -- some skin in the game.
Listen, I know -- I know this hasn't been just your problem. I understand that. And I'm not just going to come and throw bombs. That's why the chairwoman is having this hearing because I've often said, if -- if it's -- if there's a problem and you need help, we need to know about it.
Where's the breakdown? You're getting the money. Is it regulatory help you need? Is it -- are there roadblocks that you're -- you're seeing that we can kind of push the doors open a little bit? Is it the administration needs to do something? Is it we in Congress? What is it?
Because all I hear are these stories and stories, "Oh, yeah, we're working on it. We're working -- kind of we're working on it." It's like OK, it's 10 years now. We've known about this for at least seven. So where are we?
Well, sir, I think we're going to have greater visibility with these site visits and talking to clinicians in a more focused way than we've had before, and talking with veterans and talking with other providers. And we certainly will bring -- and brief the Congress on any barriers that we need your help.
Thank you. And I'll submit some questions for the record, Madam Chair. Thank you.
Following up on -- on Senator Brown, Mr. Schoenhard, I'd like you to go back to each one of the VISNs to survey the clinicians on the ground that are dealing with these wait lists that we're hearing about and report back to this committee on your findings.
I think it's really imperative that we hear it directly from the V.A.'s mental health care providers who are on the frontlines treating our veterans. We need to know if the providers -- not the administrators, but the providers -- think that they have sufficient resources to manage the waiting lists that they have.
So I would like you to commit to doing that for this committee.
We -- we will do that, Madam Chairman.
OK. I -- I have a couple more questions that -- that I want to do. I will have some of them submitted for the record.
But, Mr. Schoenhard, while you're here I wanted to ask you about this issue of sexual assaults. I was very troubled by the GAO's recent report on sexual assaults. They started this work because clinicians were not referring female patients -- veterans to inpatient PTS treatment because of safety concerns.
And I'm paraphrasing, but the GAO found that clinicians were concerned about the safety of women veterans in residential mental health programs. Part of this was that a program housed both women veterans and male veterans who had committed sexual crimes in the past. Clinicians expressed concerns about inadequate safety precautions in place to protect those women that were admitted to the unit.
Now, I'm shocked that this would happen at even one medical center. It is entirely unacceptable. And I'm afraid that there may be other places in the V.A. that this could be true as well.
So I want to know this morning what you are doing to correct that problem at this unnamed medical center, and what you're doing to make sure this is not happening anywhere else in the system.
I'm going to ask Dr. Arana to add to this, but let me begin.
This report from GAO had eight recommendations that we fully concur with; four that had to do with prevention -- which gets to your question, Madam Chairman -- and four which had to do with reporting. Just as with the case of suicide, one sexual assault, one instance where someone feels victimized is one too many. We take this report extremely seriously.
The undersecretary for health, Dr. Petzel, has chartered a work group chaired by Dr. Arana and Dr. Patty Hayes, who is the chief consultant for women's services at V.A. We wanted both operational and program leadership to address these recommendations, particularly having to do with prevention. And there are a series of findings that are coming out of the committee, out of the work group that are due July 15. We have been in touch with the facility that was addressed.
And again, as I mentioned earlier in my testimony, when we have a report like we did in this case of sexual assault, where they visited five of our facilities, what is it that we learned from that that we apply system-wide, not just to answer compliance with that?
And -- and, Dr. Arana, if you could please give some update on your work.
Madam Chairwoman, what -- what we're doing is essentially taking the GAO report and have extracted six major areas that we're going to pursue. One of the criticisms was we don't have a clear definition for "sexual assault." That we have done.
We don't have a definition?
A clear definition for all of V.A. for sexual assault. There's -- GAO has a definition. CDC has a definition. So the V.A. has...
You talk to any of the women and they can define it for you.
So the V.A. has -- has used the definition that the GAO used. And we're going to go forward with that definition as the definition for the V.A.
We are also re-looking at our -- our databases and our report structures. Right now, they are imperfect. That was pointed out by the GAO. The plan is to have police reports and management reports basically integrated and -- and have 100 percent coincidence, so that we know that -- that they agree with each other. That we're also doing right now.
The other thing is we're doing behavioral surveillance education. We're working -- we're partnering with DOD. They have a very strong program with this. And the hope is to learn from them about how to educate all staff and all patients and all visitors at our health care centers and also all our care areas about vigilance and -- and prevention.
And the fourth point is what we call "technical surveillance," which goes to cameras, panic buttons, locks on doors, adequate staffing of police. So we are looking at those four areas aggressively and hoping to be able to report back here and tell you about progress.
OK, look, I -- I have to tell you. In terms of sexual assault, I am deeply concerned about this. This has been a hidden problem coming home from our veterans for far too long.
Part of the work that I've done in this committee is to put in place a new focus on women's veterans so that all of our facilities have a place for women to go to. I've been out looking at many of the women's facilities, talking to the caregivers on the ground. A high number, much higher than I thought, are reporting military sexual trauma.
Definition or not, we cannot leave this as a hidden problem or something we're looking at and report back a year from now and hear these same things are going on. We have to all take this as a serious issue. Bring it out into the light and deal with it. And these kinds of reports to me are very, very troublesome, and I'm angry about it.
So I -- I don't want this to be a report back to this committee months from now. I want to know immediately what's being done -- immediately what's being done to make sure this is not happening to anybody.
And Madam Chairman, if I could just clarify as it relates to the definition. That had to do with the reporting.
Anytime anyone -- visitor, patient, employee -- anyone feels that they've been victimized in some way, that is where we need a report. We need immediate follow-up and -- and we need intervention.
And that needs to be system-wide in the V.A.
Yes. Yes, ma'am.
I have a number of questions I want -- we've run out of time, and I'm going to submit them for the record. I do -- do want to know about the peer -- the use of veterans' peers in particular. We heard that from our veterans today. I'd like you to get back to this committee on what you're doing on that.
The wait times, as you heard from this committee, is a huge concern. V.A. reported that 95 percent of the veterans seeking mental health were seen within 14 days. That is not what we're hearing on the ground. So, again, that's going to be an issue we want to follow up on and several others.
You're -- you're hearing the frustration from the members of this committee. You're all wonderful people. I know you work hard every day. I know you work with people who care. But I have to tell you, this war has been going on a long time. There are not surprises about the number of people out there suffering from PTSD and TBI.
We, as a country, cannot allow this to be a report or a report- back or to have it be hidden in a corner. We have to bring it out in the open. If we need more resources, if we need, you know, America to stand up taller, if we need more clinicians' boots on the ground, we need to know that because this committee is going to make sure that we don't continue to hear these stories year after year.
We need your help to find out the real answers to this so we can have the right policies and resources in place. That's why you're hearing the passion from this committee.
With that, we -- we have run out of time this morning. And I do want to thank all of our witnesses for being here today to share their views and experiences. Some steps have been taken. This -- this committee knows that. And we appreciate what the V.A. has been doing. But it is very clear a lot more needs to be done. And it's really crucial that we have the resources, we have the personnel in the right places.
As Senator Burr has reminded us time and time again, that first person who answers the phone has to be responsive because that is how our veterans feel that they are treated. So it goes across the board.
And with that, I look forward to working with the V.A. in the months ahead to address these issues and appreciate again all of you being here.
Thank you very much, and this hearing is adjourned.
List of Panel Members and Witnesses PANEL MEMBERS:
SEN. PATTY MURRAY, D-WASH. CHAIRWOMAN
SEN. DANIEL K. AKAKA, D-HAWAII
SEN. JOHN D. ROCKEFELLER IV, D-W.VA.
SEN. SHERROD BROWN, D-OHIO
SEN. JIM WEBB, D-VA.
SEN. JON TESTER, D-MONT.
SEN. MARK BEGICH, D-ALASKA
SEN. BERNARD SANDERS, I-VT.
SEN. RICHARD M. BURR, R-N.C. RANKING MEMBER
SEN. JOHNNY ISAKSON, R-GA.
SEN. ROGER WICKER, R-MISS.
SEN. MIKE JOHANNS, R-NEB.
SEN. SCOTT P. BROWN, R-MASS.
SEN. JERRY MORAN, R-KAN.
SEN. JOHN BOOZMAN, R-ARK.
DANIEL WILLIAMS, NATIONAL ALLIANCE ON MENTAL ILLNESS, AND FORMER ARMY RANGER
ANDREA SAWYER, CAREGIVER AND SPOUSE OF U.S. ARMY SGT. LOYD SAWYER
JOHN D. DAIGH, JR., ASSISTANT V.A. INSPECTOR GENERAL FOR HEALTH CARE
DAVID THOMAS UNDERRINER, CHIEF EXECUTIVE, DELIVERY SYSTEM, OREGON REGION, PROVIDENCE HEALTH & SERVICES
WILLIAM SCHOENHARD, DEPUTY V.A. UNDERSECRETARY FOR HEALTH FOR OPERATIONS AND MANAGEMENT IN THE VETERANS HEALTH ADMINISTRATION (VHA)
GEORGE ARANA, ACTING ASSISTANT DEPUTY V.A. UNDERSECRETARY FOR CLINICAL OPERATIONS AND MANAGEMENT IN THE VHA
ANTONETTE ZEISS, ACTING DEPUTY CHIEF PATIENT CARE SERVICES OFFICER FOR MENTAL HEALTH FOR THE VHA
MARY SCHOHN, ACTING DIRECTOR OF MENTAL HEALTH OPERATIONS FOR THE VHA