Transcripts For CSPAN3 VA Secretary Shulkin Testifies On Veterans Suicide Prevention 20170928

Of time were going to go ahead and get started. Todays hearing is about the issue of suicide. As many people in the room know, this month in america is National Suicide Prevention Month across the country. Suicide is a terrible, terrible, terrible loss, and wasteful loss of life. And preventible loss of life. I think john will remember when we first came in as a committee three years ago, our first bill that we passed was the clay hunt Suicide Prevention bill. It passed this committee 990. And we asked the secretary and the other members of the v. A. Here today to give us any report they might have on the progress of the implementation in terms of clay hunt act. But its a very important act. In august of 2014, i held a hearing as a member of this committee. It was a field hearing on the issue of suicide. The reason i did was because in that year, the months leading up to august of 2014, georgia va hospital in decatur had three suicides, two on campus. Some from mishandling of available tools for suicide Like Pharmaceuticals and things of that nature. Others for a lack of awareness and many for a lack of capacity. And that was the real thing that concerned me. So we began working in the claremont hospital in atlanta to improve v. A. s response to suicide and to Mental Health issues. Suicide is a disease. And it is preventible. And there are many things we can do. And to set the example, our staff director did a great job of seeing to it that every member of the staff, majority and minority, has been through the s. A. V. E. Training for Suicide Prevention. S. A. V. E. Stands for signs are you thinking about committing suicide, which is a tough thing to address. But the key question to ask. Validate the veterans experience. And encourage treatment and expedite getting help. And i can tell you from what we learned in atlanta and have learned in the v. A. , timing is everything, as it is in health care and most things when someone is contemplating suicide, its not something you put off to an appointment on wednesday or to another day. Its something you deal with immediately and quickly and expedite the response to it. So i want to thank the staff for going through the training. And just like the heimlich maneuver has saved many a life in a restaurant when somebody was choking and somebody else knew how to apply that maneuver and they breathed their air passages. Just like cpr has helped people to who had untimely heart attacks. Just like cpr helped people who might have been drowning and they were brought back to life. Being aware of training necessary to save a life is critically important. And were going to see to it in our committee we promote this training throughout the v. A. And throughout the government to see to it that we are saving lives and helping people to recover and restore their life. I want to thank bob for his commitment to doing it on the staff and thank all the Staff Members for having done it and thank the members of the committee for their effort, as well. We have two panels today on the issue of suicide. Our first panel, mr. John day. Assistant Inspector General for health inspections. Second is craig brian. Dr. Craig brian, executive director, National Center for veterans studies, university of utah. And dr. Matthew kuntz. We appreciate all three of you being here today. Youll be allowed to give up to five minutes of testimony. We dont have a whistle that blows at the end of five minutes. But after ten, youll be in big trouble. So and you can all your statements will be printed for the record and be memorialized in the record by unanimous consent. Well start with you, dr. Day, and your testimony, and go down the list from there. Welcome. Thank you, chairman isaacson, Ranking Member tester, members of the committee. Its an honor to testify before you today on the subject of Suicide Prevention. This topic is important to mr. Missile and all of the staff at the oig. We work to ensure veterans receive the highest quality Mental Health care. We have reviewed in depth facts surrounding the death of many veterans who took their own lives. Often we find these veterans suffered the effects of chronic Mental Illness, and Substance Use disorder. In the aftermath of these deaths, we frequently hear from members of the veterans family, significant friends and v. A. Providers that they would have acted sooner or differently, only if they had known. After the Virginia Tech incident shootings, a serious review of the privacy laws that impact the disclosure of medical information was undertaken. My staff met with and talked with a number of the individuals who were involved in this review to determine if there were Lessons Learned that could be applied to v. A. Changes to law seemed too difficult to design. However, changes in practice that utilize advanced directives or similar devices may offer a way to improve communication at the critical point when a patient needs help the most. I think there is a chance to improve communication by expanding the situations under which these and similar devices are used. V. A. Has thoughtfully derived a model to predict who may suicide. The question is when would an atrisk veteran take action to harm themselves or harm others . When would intervention be most effective . Research using social media and other more timely data has shown promise in understanding the human emotional state, and therefore may assist in identifying when intervention for these atrisk individuals would be most successful. I think research and pilot studies in this has great potential. The testimony of others at this table point out that veterans, many veterans, do not obtain their care primarily from the va hospital system. And so an effort to reach those veterans who are at risk is most appropriate. And essential if we are to make a significant improvement in veterans suicide data. This concludes my oral testimony. And i would be pleased to answer your questions. Mr. Chairman, this Ranking Member and members of the committee. I appreciate the opportunity to appear here today to discuss recent advances in veteran Suicide Prevention. I will not read my written testimony in full, but will highlight a number of key points. In response to rising suicide rates, the v. A. Has adopted and implemented numerous measures intended to prevent suicide among veterans. These efforts have led to improved access to care and serves as an example of how an agency can aggressively advance the cause of Suicide Prevention. Several new studies reporting suiciderelated outcomes among military personnel and veterans have been published in just the past two years. While the most of these studies enrolled military personnel, their findings are applicable to the v. A. And veteran community as a whole. As summarized in the attachment to my testimony, all of the interventions reduce Suicidal Ideation. But only two are associated with significant reductions in suicidal behavior. Brief Cognitive Behavioral Therapy and Crisis Response planning which were found to reduce suicidal behavior by 66 . Its currently the only strategy shown to reduce behavior among those who served in the military. These treatments serve as a foundation for several studies currently under way in the v. A. , as well as in the d. O. D. These latest findings not only confirm that suicidal behavior can be prevented among military personnel and veterans, they also show us how to do it. If these studies tell us anything, its this. Some strategies work better than others. And simple things save lives. Tragically, few veterans are likely to receive these potentially lifesaving treatments for a number of reasons. Today i will focus on one particular barrier, inadequate training in Mental Health professionals. Two recurrent v. A. Studies highlight this issue. In these studies, researchers found that a key Suicide Prevention strategy used by the v. A. Was not associated with subsequent reductions in suicidal behavior, as was expected. The lack of effectiveness was attributed to poor quality implementation. Of note, v. A. Personnel often do not implement the procedure with sufficient reliability or specificity. Researchers from both studies concluded that the results pointed to insufficient training and that additional training could actually change this course. The problem of deficient training is not confined to the v. A. , though. Tragically, deficient training is endemic across our nations Mental Health professional Training System. The recent report from the American Association of suicidology highlights this issue. The Main Findings of that report are also summarized in the attachment to my testimony. As you can see, a shockingly low number of Mental Health Training Programs provide any education or training about suicide to its students. Furthermore, state licensing boards, the very bodies charged with protecting the Publics Health and safety from unqualified professionals, typically do not require any exams or demonstration of competency in suicide Risk Assessment or intervention. The implications of this report are disturbing. The vast majority of our nations Mental Health professionals are unprepared to effectively intervene with suicidal veterans. This has critical implications for all veterans, both within and outside the v. A. Weve long talked about the many barriers that stand in the way of a veteran receiving Mental Health treatment, and have invested heavily in removing those barriers. What unsettles me the most as a veteran is knowing that when a fellow veteran overcomes these barriers, he or she is unlikely to receive the treatments that are most likely to save their lives. The sobering and uncomfortable truth is that we have made it easier for veterans to obtain treatment that doesnt work, especially those veterans who receive services from nonv. A. Providers and their communities. If we want veterans to benefit from the most recent advances in Suicide Prevention research, we will need to ensure implementation is accompanied by a comprehensive and robust training program. Luckily, the past few years have also led to considerable advances in our understanding in the most effective ways of teaching these methods to others. Much of this knowledge has actually been obtained by the v. A. And their researchers. In order to reverse the trend of veteran suicide, we must therefore think boldly and must be willing to disrupt the status quo. We need to adopt the newest strategies that have garnered the most scientific support, even though they may depart from existing procedures. We need to invest more heavily in Training Clinicians to use these procedures, and create new initiatives to incentivize and support their implementation in clinical settings. These changes should not just target the v. A. And the d. O. D. , but all clinicians in all settings, as well as our universities and our Training Programs that are responsible for the readiness and preparedness of our Mental Health professionals. In conclusion, we are at a critical turning point for veteran Suicide Prevention. Answers are now clear and effective strategies have been identified. We must now take the steps needed to ensure these treatments and interventions are easily available to all veterans, both within the v. A. And in our communities. Thank you very much. We appreciate your testimony. Now from the great state of montana, the executive director of the National Alliance for Mental Illness in montana, mr. Kuntz. Mr. Kuntz . Yes, sir. Chairman isaacson, Ranking Member tester and distinguished members of the committee, on behalf of nami montana and nami, i would like to extend our gratitude to share our views and recommendations. We applaud the committees dedication in addressing the Critical Issues around veteran suicide. As someone who has personally lost a Family Member that was a veteran to ptsd, i just want to appreciate my sincere thanks. Montana has the highest suicide rate in the country with 68. 6 per 100,000. This is significantly higher than both the National Veterans suicide rate and the Western Region veteran suicide rate. As an organization thats immersed in Suicide Prevention, we think its very important that you have a framework to understand suicide. The model that we use is the die athesis stress model in which a combination of biological susceptibility and environmental factors then lead to malfunctioning neuron communications. Which develop into Suicidal Ideation behavior and other symptoms. Examples of the factors of biological susceptibility are genetics and physical trauma, examples of factors on the environmental side are emotional trauma, but on the positive, therapy and supportive family. Youll note that i will not be covering lethal means restriction, because i believe its incredibly hard to legislate that. But it is an important factor. Montana is a very rural state with an average of fewer than six persons per square mile. This creates unique challenges for our Health Care Providers, and we are deeply in need of more Mental Health providers. Ill move on to our recommendations. First, offer a Public Health intervention proven to reduce suicide during critical points of military and veteran experience. Nami montana was influential in bringing the youth aware Mental Health program to the united states, and we would like to offer it as a template of something thats proven to work in another population. It would be perfect to bring over to this one. Second recommendation, establish a clear policy goal to improve the diagnostic treatment system. The target that nami montana recommends to the committee is it asks the v. A. To work with the department of defense, the National Institute of Mental Health and private partners to identify and prepare two additional brain diagnostic measurements for clinical work in the v. A. By the fall of 2020. Our next recommendation is to develop a plan for treatmentresistant Mental Health conditions. Roughly a third of Mental Health conditions do not respond to traditional treatments. And this is a big issue, and its an issue thats not addressed in montana. The montana v. A. Has nothing in our state to address treatmentresistant depression. This is very personal to me, because i lost a dear friend that was a veteran in september 2015 to treatmentresistant depression. And to watch his options slowly slip away was one of the hardest things ive ever seen. Montana blue cross and blue shield supports tms treatment for treatmentresistant depression. I do not know why the montana v. A. Does not. Next recommendation, expand access to tele psychiatric re. And then make nonline Cognitive Behavioral Therapy available to all veterans. We also believe the v. A. Should expa expand automated suicide assessment scales. Develop a valid screening tool to determine which patients are at risk of developing side effects from cloz apeen. Develop Online Research directory for nonv. A. Resources. Create a more synergistic relationship between the v. A. And community Mental Health centers. There are over 1,300 Community Health Centers Across the country and we should be working with those to care for our veterans. Increase the v. A. s collaboration with outside researchers. And finally, establish a continuity of care pipeline for veterans directoly from the department of defense v. A. And Community Providers. Thank you again for the opportunity to testify in front of this honorable committee. Your attention to this issue means a lot to me. Our entire nami organization. And their families. Thank you. We appreciate your being here today. What im going to do is reserve my time, since we have three members that are here and different meetings take place. Im going straight to our members with questions and ill ask mine later when senator tester returns. Hes doing a presentation in another hearing and will be here in a little bit. Let me start off with john . Thank you very much, mr. Chairman. And thank you for holding such an important hearing. And, again, also to senator tester, i cant you know, think of anything thats more important to discuss. Certainly we all agree that this is a crisis. In arkansas, i think were number ten in suicide rate overall. Of that group, veterans represent about 8 of the population. But represent about 20 of the suicides. So we are a state that is like, you know, so much of the rest of the country. In fact, the rest of the country, period, that is experiencing significant problems. Dr. Brown, you mentioned the inadequacies of our nations Mental Health professional training. In fact, i was looking at the chart. 50 of psychologists, 25 of social workers, 2 to 6 of marriage counselors, 28 of psychiatrists. You know, only those have really received what we would call even the Old Fashioned training, perhaps, not to mention, you know, the work that you and others are doing, you know, in such a good way. Thats those are pretty staggering. How do we go about unless we have a metric out there, how do we go about solving that problem . I will admit that and also, as youre thinking about that, and the rest of you all can jump in, too. How do we, you know once we have the new research, once we perhaps get a metric, how do we get that, you know, not talked about, but actually instituted in a timely manner . Correct. So both very good questions. The first one i think is a much bigger question. Ill admit it. This is a huge issue that would probably require a concerted effort in redesigning or potentially really reengineering our education and Training System in professional practice of Mental Health. We would need to find ways to incentivize graduate Training Programs and medical schools to ensure that not only are they providing any amount of training, but that training is scientifically supported. And so this can be accomplished in a number of ways. Perhaps looking at grants and other federal incentives and initiatives to encourage certain types of curriculum, as well as training opportunities. But also i think partnering with and working alongside with various accreditation bodies to look at how do we determine whether or not an educational system is meeting minimum standards for the practice of Mental Health across these disciplines. If we kind of work with those organizations, i think we would be able to see some very dramatic shifts in curriculum. For your second question regarding dissemination and implementation, i think one of the challenges that many of us have as scientists is a scientists tend to be not good at communicating their ideas to nonscientists. And so many of us in the dissemination field have really talked about how do we find opportunities to have researchers and scientists work with Communications Experts on how to convey this information, not only to the general public, but also to other professionals, those who we want to target to be using these strategies, but we also need to target the consumer. So the consumer is educated and understands which treatments work best. So when they go to a Health Care Provider, they can ask the right questions, to determine if this is an individual who is likely to be able to help me. Yes, sir. Go ahead. Yes, sir. You know, one of the things that we found to be very important is getting the research to the states. Creating a pipeline to have those conversations. We had to start up a Research Center in montana to make that happen. Ask because of the way that the v. A. Structures are centralized, research, we probably will never have v. A. Research doing much in montana. But if that pipeline is adjusted, that gets those conversations started and gets people trained. The other thing that i would recommend is for the v. A. To make its treatment algorithms for veterans more widely available. I think that the transition to the cerner medical records is going to make that more i guess more possible. But, you know, get those treatment algorithms out to the field so people in nonv. A. Facilities can use them. Thank you. Very good. Is overmedication a problem . I would say my response is overmedication is broad. What we would see, for instance, a student of mine just finished her dissertation, were about ready to publish the results, founding there is about a larger than expected proportion of veterans who receive bens owe die as peens, despite being diagnosed with ptsd. Bens owe die as peens can actually interfere with effective treatment for ptsd. Oftentimes physicians and other prescribers rely on these, because firstline treatments have not worked and so theyre hoping to provide some kind of symptom relief. The unfortunate aspect of this, as my student found, in those cases, those veterans with ptsd who receive these are almost three times more likely to die by suicide. So theres another risk associated with contraindicated medications where i dont know if theyre overprescribed, but im not necessarily certain that in all cases veterans and their prescribers are aware of all of the risks and are able to weigh them with the benefits of those medications. Right. Thank you, mr. Chair. Thank you, senator. Senator bloomiumenthal who did t work in the last congress. Thanks, mr. Chairman. And thanks for your leadership on this important issue. I was indeed the lead Democratic Co sponsor on the clay hunt bill, along with senator john mccain on the republican side. And i believe that it was a start, but only a first step in this effort. And much more needs to be done. Obviously, there are steps that have been taken by the v. A. In furthering this effort, and i know well hear from dr. Schulkin later. But the more i learn about this problem, the more complex and challenging i think it is. Dr. Bryan, one of the very important statistics in your testimony is that the suicide rate among veterans who do not use v. A. Services increased by 39 between 2001 and 2014. Whereas the suicide rate among v. A. Users increased by only 9 . Put aside the exact numbers, what i am hearing again and again and again is that the suicide rates are increasing among veterans who lack access, either because of geographic or other difficulties in routine services. Or because they have received less than Honorable Discharges. And this has become a passion for me. Because there is a whole group of veterans who suffered from pts, often undiagnosed, were separated less than honorably, and have been cast out. And barred from using those services. And often feel stigmatized. And disengaged. Not only from the v. A. , but from society in general. And ive met with many of them, and ive worked with the department of defense on the review process. Which has been changed, as a result of leadership within the department of defense, commendably. But many of those veterans who were discharged less than honorably dont know about it. Dont know about the changes in policy. Dont know about the possibility of access to these services. So it is a a vicious cycle. A lethal cycle. Which can lead to suicide. So i guess my question to all of you, not only about the less than honorably discharged veterans, but Women Veterans who also perhaps do not readily access these services, and their suicide rates are increasing. Those segments of the veteran community whose suicide rates are increasing need to be reached. And my question to each of you is, do you see that phenomenon as real . Do you recognize it, and can you elaborate on it, and what are your recommendations for addressing it . Sir, i agree with you. I think the adequate treatment of Substance Abuse disorder and access to therapy and the adequate treatment of depression, as mr. Kuntz indicated, you know, to include pharmacologic treatment and maybe ect or other treatments available i think is critical. So if you cant get people to a competent provider, its a very difficult problem. So i agree with your statement. I have two thoughts in response. The first of which is, i think the what the statistics highlight is that the rates are going up. Even among v. A. Users. But its a much slower rate. And so the v. A. Is doing something good that is not happening for those who do not receive the services. And so a common question is, how do we get more veterans into the v. A. . And i think that is an important question. The other question, though, i think, we need to ask is, why are there not other adequate Services Available to veterans and their communities . And i think this this really came to a head for me several years ago. I dont know if youve read the New York Times article about the marine 27, who has had a very high suicide rate. And a lot of them did not have access to the v. A. And there is a lot of discussion about that. And i said, well, the implication of this is some veterans have access to really nothing. Or they have access to Community Providers who have little to no experience working with Service Members veterans. They dont know how to treat ptsd. They have never seen traumatic brain injury before, and the statistics i show you here, they have no experience with suicide risk. And so i think part of the solution will be how do we get more veterans into the v. A. , because as the rand report recently released highlighted, the quality of care in the v. A. For Mental Health exceeds that in the private sector. But for those who do not access v. A. Services, whether theyre because theyre not eligible or because they choose not to we have to keep that in mind. Some veterans choose not to. We need to make sure Quality Services are available to them. And what we have done in Salt Lake City kind of as a model of this is our center is on the University Utah campus, right across the street from the salt lake v. A. And what we say is, were not a competitor to the v. A. Were the augment. And so the v. A. Sometimes sends their patients to us for treatment, and there are some veterans in the community who cannot go to the v. A. , or are unwilling and they come to us. And we can sometimes connect them with the v. A. For other services and benefits that maybe they didnt know. And so i think we need to look at models like that on how Different Community agencies in the v. A. Can further strengthen working together to better meet the needs of all veterans. Thank you. Senator blumenthal, thank you for bringing up the less than honorable issue. That was something that came up in our family. Before my step brothers death. And its really big issue. Ill point out one of the ways it was solved in montana or improved was by adding a vet center to our community. And at the time the v. A. Had fought it, because they said that you already have a hospital, everybody that will go there, you know that would go to the vet center is already going to the hospital. And that turned out not to be true. And i think that part of it is when youre depressed or when you have ptsd, the first thing that you cant stomach is bureaucracy. And you just quit. You face bureaucracy, you face this red tape, and you give up. And the vet centers have less bureaucracy, the fqhcs have less bureaucracy. And in order to get in and start to play, and thats i think that that that thats part of whats not really shown in those statistics is the folks that give up. Because they look at the bureaucratic red tape, and say, i cant mentally take it. I just want to thank all of you for your testimony today. Obviously we have just scratched the surface of this topic. I hope that we can get the latest numbers on vet suicide rates, on the differences between v. A. Users and nonusers. I sponsored legislation with my colleague, senator blunt, to its called a veteran peer act, legislation that would establish peer specialists in patientaligned care teams within v. A. Medical centers to do this kind of outreach. The peertopeer relationship among vets i think is an effective way to enable more access. But the v. A. Has been doing better, and i commend dr. Schulkin and his team, and as i mentioned, well be hearing from him. But on all counts, the nation needs to do better. Thank you. Thank you, senator blumenthal. For the benefit of the members here, were going to take questions by order of appearance, alternating by party. And the next three questions will be senator hellerson, manchin, and senator sullivan. In that order. Mr. Chairman . Thank you. Youre welcome. Thank you for this hearing. I want to thank those that are witnesses for being with us today. And i want to especially thank senator tester. Because i know this is an issue thats important to him, and an issue that is important to montana. And it is unfortunate that montana leads us in this statistic. But nevada is right behind them. A question i ask myself is what makes montana and nevada unique. And mr. Kuntz, ill start with you as to why we see the stress in the areas of montana and nevada. Maybe a little more unique than the rest of the country. Senator heller, its a great question. And ill tell you that if i had the perfect answer for that, i would probably be making a lot more money. But i will tell you that just to see what is there is we do have higher access to lethal means in our state for the most part. When youre suicidal, the closer you are to committing suicide, i mean, is very real. We also have a lot of veterans per capita in our communities. And i think that thats important. One of the things thats a little bit different about our suicide trends, and i dont know if its the same for nevada, is we have more older veterans that are killing themselves. And i think theres National Trends saying that its younger. But if you look at montana, that age 30 to 65 white males is when were losing them. And maybe its just that we have a lot of people in that population group. But i think its a its also an issue of lack of care. We have no Psychiatric Residency Program in our state. And i know that a lot of nevada Rural Communities struggle, too. So i think its a its a number of different factors. And weve got to tackle them one at a time. I really do appreciate your comments. We had secretary schulkin in the state just a month or so ago, and he expressed his efforts, and to tackle this particular problem. We have hospitals, both north end and south end of the state. We have a number of clinics that have been opened recently, because of the efforts and the work of the secretary. And the v. A. And its appreciated. Let me ask you, mr. Bryan. They have a Resiliency Program in israel. Maybe weve already discussed this. Where they try to get this on the front end instead of the back end, where they actually train their soldiers, both male and females, of trying to avoid some of the stressful situations they may find themselves in, and train them for them. Are we doing the same thing here in our country . I would say in general, yes. In the sense that if you look at military training in general, a lot of it is designed to foster resiliency. How to endure difficult or diverse situations, perform under pressure, manage stress, et cetera. Where we have not had much success over the past decade or so is when we try to where in we bring in outside experts who then teach or train, sometimes trainers within the units are resiliency experts within the units who are then supposed to go and teach these skills within the unit. There are a number of barriers to that, but unfortunately, some of the research thats been done on some of the larger Resiliency Programs, such as soldier fitness have yielded no benefit. We have seen some promise, however, in other resiliency methods, one that has garnered the greatest promise so far, is one that was developed by the army called battle mind, one that was supposed to prevent, it wasnt large, but a small but noticeable degree amongst those who had the greatest and most intense levels of combat exposure while deployed. Which if you think about it is the ones who probably needed it the most, and the ones who had the highest level of trauma while deployed. So we have a couple of threads of evidence that suggest that certain approaches might help to reduce or prevent, or at least reduce the severity of ptsd. However, we have not been able to large scale implement and further study those different strategies. Is there any family training . Not just the veteran themselves, but actual family training so they can identify some of these issues prior and prepare to help that veteran . There are a number of programs that have been created, theres none that sort of rises above the top, where a lot of the family Training Programs, and the peer issue that you mentioned before, a lot of the programs tend to take, heres a bunch of signs and symptoms of this Health Condition and now refer someone to a Mental Health professional. But what we lack is, what do the Family Members do. So if a Family Member is struggling with ptsd and does not want to go to treatment or theres a twoweek wait, what are you supposed to do in the meantime, and we currently dont have any programs training that. And the new research, the Crisis Response as we mentioned before, this is something we have been teaching to Family Members, we have been teaching to family specialists, we have been teaching the nonhealth care related Family Members, who might recognize when they need help and also what to do about it and doing things that have been shown to reduce suicidal behavior. I would like to thank the senator in expressing his concerns on these particular issues because it does make a difference and we need to figure this out and make that kind of difference. Senator manchin . Thank you, chairman. My first question will be to mr. Kuntz, as you mentioned in your testimony, Community Health centers are a critical part of providing health care in rural areas, your state and my state are pretty rural. In your state for instance, Community Health centers treat almost 400,000 patients, thats almost 25 of our population, we have 166,000 veterans in our state. Im sure many of them got treatments there rather than traveling long distances to the vas, because they lived in the rural areas of West Virginia. I would just like to hear you speaking on the importance of Community Health centersprovidey have the expertise to do that . In trying to get the treatment as quickly as possible, without trying to build a whole other infrastructure to do it, if this community is available for it, Community Health centers. Thank you for your question. Its an amazing point. I tell you that we have our licensing board in the state of montana and we have lcsws who work at the lqhcs, psychologists here, this is the same level of staff, the training may be a little bit different, but the fqhcs or the Community Health centers are adding Mental Health care for all veterans. Can they be as adequate there as in the Community Health centers . Yes, the only thing theyre not good at is longterm care, so i think that shortterm turn around coverage, may be six sessions of counseling, until theyre transferred to the va, but if youre in a time crunch, that is exactly a place where i sent people. If youre struggling to get into the va, go to the fqhc. You have mentioned not adequate training not just among Va Health Care providers, but nationwide. So my question would be as this Committee Moves forward on efforts to be worked in nonva care, how can we better invest and incentivize better Mental Health care training, how we can increase Suicide Prevention . I think the easiest and most straight forward approach is invest in training workshops, however i will say that will likely have little impact. I have learned over the past decade, training thousands of Health Care Professionals, often times it is not enough for them to actually use the therapy in an effective way, one of the things we have learned from a lot of the vas efforts in educating, is that you have to provide ongoing support, you train people, you meet with them on a regular basis, you help them, you teach them how to overcome common barriers so as we look at treatment, were going to have to look at longterm support. And the second aspect of this is that we will have to look at our Health Care Education system. Another thing i have learned in doing this training of professionals at all legvels, i you teach a student how to do good medicine, they will go on the rest of their life providing good medicines, if you teach interventions, they start doing that for 10 or 20 years and its very difficult to get them to change back, when i really think of this question, its not only training the current labor force, but were also going to have to look at how do we change how we train and teach the future labor force. I have one more question, mr. Chairman, if i may. Dr. Dye, in your testimony, you brought up the concern about sharing information to coordinate better Mental Health between the provider and the veterans family. As it stands, more than half a million va patients are abusing opiates and va patients overdose on prescription pain medication have more than doubled the national average. And its a horrible problem in my state of West Virginia, as most states are dealing with this. While the va has made really significant improvements, i still believe in areas that these are critical areas we must work on. The vet connect act of 2017, which would stream like the Health Care Records between the va and Health Care Providers, because were giving more services outside the va, the bill requires the Veterans Health administration to comply with hipaa, but Community Advisors can make decisions based on the veterans hole l i medical treatment. And how the current law is undermining the quality of coordinated care and hurting our veterans . What do we need to do to change . I dont know if i can answer all of that. I think that give it a shot. I think that in the personal relationship between the team at the va whos providing care to a veteran, they often know who the significant individuals are in that providers life, not necessarily related members. So i think that coming up with mechanisms and va does currently use advanced directives but to use them more widely and more thoughtfully and consider how they can be used so that when people get in crisis, va providers can reach out and talk to significant individuals to try to bring that person back in. To the second point of sharing medical records across, i think that the data exchanges have to work in order for the va medical record to communicate with all those other medical records systems, so if there is among the vital points going forward, that is an extremely vital point. Im not advocating that there be some change to the privacy rules, im advocating that we be more creative in getting permission so that at the time a person is ill, a Larger Community can be brought into the discussion. Were going to need your help on that because we have had trouble getting past that. We have a bill called jesses law, a little girl 30 years of age who was addicted, she overdosed a couple of times then she died in the hospital. She died because when she went into the hospital, she explained that she was recovering addict and she had asked repeatedly, she says please notify my records, make sure that my records identify that they know im a recovering addict. The records were buried. It wasnt like if youre allergic to according to zo cortizone, and the Health Care Provider didnt see it and he prescribed her 30 oxycontins and she was dead by 3 00 in the morning. You might be the ones that will help us transition this thing and get this piece of legislation and gives you the chance to share that patients, within the professional rights that you can better serve them, and you need to speak out on that. Thank you senator manchin, senator montana is back. Are you ready for your questions now, senator tillis . First i want to thank senator tester because we have worked together over the past year or two getting in the department, we had a quick meeting or two with the doctor in our office and i appreciate your continued very valuable contribution to us keeping track of the transformation efforts within the va and im sorry that i was not here earlier to hear the testimony. Well start back on the medical record. Back in north carolina, i sat on the Electronic Health record board when we were trying to integrate medical Health Care Providers within the state and since im here and im on the Senate Armed Services committee, we were successful in getting a provision in the nda, that makes absolutely certain and i believe the department is glad that we did, the va, makes absolutely certain that we dont miss a step as we integrate the two medical record platforms that are going to be common platforms. Theres a lot more work to do, with over 120 instances of medical records in the va, we have got to first make sure that theres a good flow from the dod to the va, and weve got to make sure that we get that rite and then we have to go a step further in providing care. I think its critically important, there are ways to do it, we can address the privacy rules but we want to make absolutely certain that the c p comprehensive view of the veteran in their Health History is provided to everyone providing care at every level. Im kind of curious, about the work that we need ive got the state, the heart breaking statistics for the state of north carolina, but frankly theyre in some cases than the national average, which led me to respowonder to what extent w a correlation between the incidences of suicides in other states and the lack of va Resources Available to themmor oththemmor to where we have a large military footprint, you have a group of people that have a therapeutic value just by being around other veterans and then we have a brick and mortar facility. Is there any correlation between footprint and outcome to your knowledge. No, sir, the gentleman who compiled the data may be able to answer that question, but i dont have an answer. I think it could be important. And every one of our states are different. Thats why some of the performance of the va is different, its faced on a variety of factors and thats why i think it will be constructive in looincreasing o presence. I was curious if he brought up the issue that he and i share a concern with and it has to do with possibly bad paper and not tracking. What more should we do to go back and take a look at discharges other than honorable that if we had had a better understanding of what may have occurred during their service that could put them at a higher risk and actually could have resulted in paper that they shouldnt have been discharged with. Yes, he did raise that issue and this is i think an important issue not only for suicide, but also for a host of other social issues that are i think of high relevance, we have seen higher rates of homelessness, higher rates of criminal activity in that subgroup as well, other social problems and so i think if we address it here with Suicide Prevention, we actually probably would have a much larger impact in other social areas as well. Do you know of anything we should do, as we deal with the policy issues, there are two pieces to this. Prospectively going forward, how do we make sure at the point in time when were making a discharge decision, that were taking in factors, that particularly the individual impacts of war, that could have impacted that person that statistics show that a lot of the suicide were seeing are not in the current wars that were fighting, but theyre vietnam war and prior to that. So has there been much work done or any bright spots that you see that were going back and seeing in that veterans population and trying to help them try to clean up their record and making sure theyre getting the care they need to avoid a possible suicide . Senator, probably the best one that i have seen is the vet centers. Because if you have been in combat, they dont care what your paper work looks like, so there is a place where people can go and i think that the other policy statement is these Mental Health conditions lead to conduct that eventually can get you discharged and if you have been in combat, why is there a less than honorable . I dont know if we can scientifically say this didnt cause your behavior or didnt have some kind of effect. So my perspective, the tie goes to the runner. Ill take that at face value and it may be something that we should talk and i chair the Personnel Committee and committee for armed services. Even in the military, there are people who do things that are 3r0e79 f appropriate for disHonorable Discharge, and based on the circumstances that a soldier was expose to, that maybe the tie breaker is the nature of the environment that were exposed to and what you can reasonably expect as a medical practitioner and say this is maybe where the tie needs to go to the soldier. The other point that you need to look at, when you look at the soldier, there are two separate processes whereby a soldier is the medical services and they dont necessarily interface with each other and i cant speak for myself as a former military psychologist, sometimes there is confusion about who has precedent, because both issues are going on. Which one goes first, which one goes second, so it can create a lot of confusion and a lot of frustration for both the commanders and the Health Care Providers and the services and the veteran. So something we could look at going forward, how do we create a process where in these two separate tracks can be worked together a little bit more explicitly, and theres cross talk among these two stove pipes that isnts not happening, so it makes it easier to make a decision that would help reduce a lot of these conflicts and decision. Senator tester. Thank you mr. Chairman, and i wasnt even going to talk about this but since senator tim poli senator tillis is, the easiest thing is for the military to kick people out, the easiest thing to do is to it is incumbent on the military to do that. Its important. This is for either dr. Bryant or door daigh. Can you give me an idea of what percentage of veterans who attempted suicide were previously diagnosed with Mental Health issues . When you say attempted suicide, they died by suicide, or they made an unsuccessful attempt . I would they that somewhere around 70 give or take. 70 have already been diagnosed with a Mental Illness . Right, yes. Have we seen a correlation between combat exposure and suicide . We actually published a paper on this a couple of years ago and the answer is a little more complex to answer. So is there a relationship between deployment in general and suicide, no. Is there a correlation between exposure to certain types of combat related traumas, yes, killing and exposure to death, there was a small correlation. There has been some research that living at higher altitudes can impact suicide depression. Are you familiar with those studies and are they real . Yes, actually its a colleague of mine at the university of utah, Perry Renshaw is actually the leading scientist in that area. And theyre real . Absolutely. What seems to happen is at higher altitude, we have different oxygenation of metabolites in the bloodstream so it has to do with how our brain brains transmit neurotransmitters. Veterans are concerned about if you seek Mental Health care, theres a stigma attached that could have effects on their career, perception by family, friends, right down the line. Do you think were making the appropriate steps to reduce the stigma thats associated with Mental Illness . Have we made any progress in destigmatizing Mental Illness . I think we have made progress as a society. One thing i dont understand why we dont do enough of is really brag about how some of our best americans had posttraumatic stress disorder. When youre talking about abraham lincoln, why arent we saying, bless us, that that guy had bipolar disorder, or depression . I mean i think that some of our greatest leaders, were bringing Sergeant Major from delta force to congress in november and, i mean, people like that need to stand up and say, in some ways my condition helped me. But on those days where i struggle, you better be there to help me through. Right on. You talked about older veteran suicide. Can you give me, and this kind of goes back to the question that i just asked mr. Kuntz, can you give me an idea whether the newer generation of veterans are seeki inin inin inin inin ining readily . I dont know the data offhand, my sense is that there is a decreased likelihood of younger generations of veterans Access Services at the va. So its actually gotten worse . Thats what i understand, i could be wrong, but thats what i understand from some of my va colleagues. So if someone has a better understanding of the data than me. One of the things that i think is interesting, we were contacted by a veteran from sidn sidney, montana, thats in the southeastern part of montana, very rural, who noted that the va is unable or unwilling to include Family Members in the intervention process if a veteran is in crisis. I dont know if this is true or not. But if it is true, i think were making a big mistake. I would love to hear all of your opinions very briefly, because you know we only got about a minute left, 30 seconds. On what the va can do better to engage families. Well start with you mr. Daigh . I think that use of advanced directives or some other mechanism that allows providers to talk about otherwise prohibited information to families widely when there is a crisis would help that intervention process. Dr. , dr. Brant. I think theres two key things we can work with families on, and that is basic crisis management. So actually working with the family to train them so they can recognize correct. And this is something we have been doing in Salt Lake City, training Family Members on what to do, and the second related piece of that, teaching Family Members and bringing them involved in the Firearm Safety as pea s aspect. How do we work with families to increase safety within the household, even during times not crisis, because if we have a safer family to begin with, during a time of crisis, everyone in the household is safer overall. Do you have any idea how many suicides are committed by veterans with guns or some other way . A vast majority, close to 70 to 75 are through firearms. Senator tester, i think telling the families how to communicate with the va, because you can get around hipaa, i mean, you need to send us a letter, you need to send it to this portal, you can call us, we may not be able to tell you about the veteran, by if your veterans in trouble, this is how you communicate to us and this is the way that you do it in a way that well respond. We tell our families, you do written letters, to professionals, they start thinking about malpractice and pretty quick theyll get moving. But you have to train those families. And we have a family to family course, which helps train them in how to interact with the treatment system. Well, thank you all for your testimony. I have got i mean we could spend all day on this issue, truthfully and we could spend all week and maybe next month. But i want to thank you for what you guys are doing. Each one of you in your own rite, are doing some really good work and i think youre the key to be able to partner with folks like you. To really move this issue in a way where we have better outreach, we have better education, and we have better results. Thank you. Thank you, senator tester, well go to the second panel. So real quickly to this panel. Mr. Cankuntz, youve made refere to biological susceptibility it is test, is there a blood test that have markers that there may be a suicide . I absolutely wish there was, there is not a test now, but biological susceptibility is, its something thats also dependent son other it can factor into every other health care condition, theres not necessarily a biological susceptibility test for skin cancer either, but thats one of the things that we have asked the committee, is to ask the va for more biological indicators by the fall of 2020. And i think that even if its not specific of this test for that, there are things like computerized executive functioning, where we know if that executive functioning is getting worse, theres something going on in that brain, its not necessarily ptsd or depression, but there are tests that need to be brought forward and i hope they can be rolled in by the fall of 2020. The reason i ask the question is, when you listen to the system of all of you, theres more than one thing that pops out, theres not been sufficient training for prevention of suicide. Suicide prevention is the main focus of his leadership. The other thing is that people dont ask the right questions, dont and our timing is never very good. Response timing on Suicide Prevention ought to be immediate, not an appointment two weeks later coundown the ro. Thats why im so proud of all of our staff on the majority and might have been north safe have taken the save test. If we embrace the save program in the va, well have the direction of knowing what to do. 90 of the problem is solving the problem and 100 of the problem is identifying it. Everybody wishes there was a biological test. There are indicators, whether its skin cancer or whatever it might be. I apologize if these questions have already been asked. Dr. Daigh, how do you establish that if somebody guy dying fa drug overdose, is that considered a suicide, or is that considered a drug overdose. So in the course of our work, sir, we would rely with what the medical examiner said in their determination of all the relevant facts at the time the death occurred to state whether they thought it was an accidental death or an intentional death. So accidental in the sense that they are addicted to drugs, they took too much, they stopped breathing, that wouldnt necessarily be a suicide, that might be considered accidental overdose. We would record it that way, we would have that interpretation, and we would always wonder if were right. Mr. Bryan, you mentioned that, and again im just trying to understand. Clearly you cite the statistic that i think thats compared to the general population, not to an agegender based cohort. And im not sure its related to socioeconomic class or Disease Burden. People with more of a Disease Burden are more likely to commit suicide. Help deem logically, are they matched against a match cohort against the general population. And if they are not matched against a match cohort, what the excess rates relative to one who is matched . The statistics as i said was from the va report from last ye year. What about the sec. I was not involved in the analysis, i dont know what other variables they may have adjusted for. But age and gender . Age and gender are the most common when were looking at veteran and military suicide statist statistics. From my general knowledge, i dont know, is suicide more common among certain, clearly, suicide would be more common among people who are addicted. Thats clear, theyre addicted for a reason . But are there other kind of in the general population as a whole, are there certain things, yes, in this social strata its more common, or this Disease Burden its more common, im asking this from my knowledge. Right, yes, so if we look, for instance, like in the va report, they broke things down into different age groups, they looked at different diagnostic characteristics, perhaps if they looked at opiod abuse as well. And what were men versus women and what we tend to see is that on a whole, veterans have a higher rate of suicide regardless of the categories. But im asking in the general population. Mr. Kuntz . Senator kaz dicassidy, i cany speak well to montana, but since we have the highest suicide rates in the country, we created a montana suicide team that went through all the death certificates in the state, for exactly the reasons youre talking about, we cant solve it unless we know it. And interestingly enough the one demographic that we found was white males between 30 and 60. Let me stop you mr. Kuntz because theres a research out of princeton which says in the general population, white males to a lesser extent, white females in that demographic are dying. But it does relate to lower socioeconomic can class. Now your state has i think a higher rate of poverty than new jersey. So have you corrected that for economic status or not . Looking at the economic status, it will also say that most of our suicide are from people who are economically struggling and in particular people who have not a lot of education. Theyre very theyre less, like the higher you go up the education totem pole, the less likely you are to commit suicide in our state, although i will state that there are some other factors that weave into this because if you have depression, anxiety, popping people off the work, popping people off the education. Rich people shoot themselves too, i hate to say. Yes, sir. Im sure dr. Schultz can testify as to weather these va lower socioeconomic class, how closely do they match to this prince on the data, if you all know that, i i have ten more seconds and if not, ill wait for dr. Schultz. Thank you very much, doctor, senator tester . Yeah, i just i think that mr. Chairman, im done with this panel, while theyre setting up for the next panel, i would just like to make a quick statement if i could. I want to thank the panel for being here today, your testimony has been eye opening and helpful and well continue to focus on this this. Well switch the table around for our next panel. And while theyre doing that, i would like to give a quick statement. The Ranking Member is recognized. I would just like to say this discussion is very, very important today, it continues to be unacceptable, we have the number of suicide in our veteran population that we have. But make no mistake about it, its also a national epidemic, not specific to veterans, but were here to talk tot vabout veterans. And since the Committee Chairman has dropped the gavel on this hearing, six people have committed suicide in this country. Approximately 20 veterans commit suicide every day. And on average, and this is an important stat trystic to know, only six were enrolled in Va Health Care. We have to make sure that those folks have the Health Care Professionals on the ground within the va to get the help they need. Why is that important for this committee . If were going to get Health Care Professional on the ground in urban and rural areas, and i think theyre needed in both, we have to have more money, and i think its really an important issue moving forward. I think this last panel has showed it. So we need to fill those vacancies within the va, we need to make sure we fully leverage the assets like our va centers. We can talk about this and i think its important we talk about it and get the facts. But as matt kuntz knows, and i dont know if matt left or not, but i will tell you this guy not only talks the talk, he walks the walk. We need to follow his lead and make sure we follow up this Committee Hearing with action that actually does right by our veterans in this country, and by the way, if we do that, i think it helps the civilian population too. So thank you very much mr. Chairman. Thank you, senator, te test. We know suicide is the number one problem in your state and we know that the doctor has focused on Suicide Prevention, and in the absence of making a we work very hard in the first nine months of this year, the Ranking Member and i, and the entire committee to bring legislation to the floor that was sought by many of us and in some cases sought by the secretary to improve the va. We have changed the paradigm of the va, we have changed the headlines at the va, were very proud of that. One of the reasons we have done that is were united democrat and republican alike we have done that. But also the leadership is seizing the advantage we have been given. That wouldnt been possible thif that legislation had not passed, nor would it have been possible if the secretary had not taken that initiative. Thank you for taking advantage of the tools you have asked for and we have give on you on the veterans administration, theres a lot more tools in the bag, and were going to be there do support you, i just wanted to acknowledge publicly, thank you for your account bltd last week. The cabinet member for the veterans administration, to assist dr. Carol if necessary. Thats the way its supposed to be. Great. Great. Okay, no problem. Thank you mr. Chairman, and good morning senator kcassidy, senatr manchin, the best attendance award and so thank you for staying for the whole thing and i want to thank you mr. Chairman, i couldnt agree more with your comments. Im very proud of this committee, i think its the best committee in the senate that works together in a bipartisan way and working to really get things done and im proud to be working with you on that. And also thank you for having the first panel first because they got all the hard questions and i got to hear all the answers and that was terrific. But as you know, were here today and this is an important hearing, because our goal is to eliminate suicide. We want to do that through risk identification, we want to do it through effective treatments, education, outreach, research, and strategic partnerships, senator tester mentioned right before he left that our Research Shows that 20 veterans aday are dying through suicide and he did something by saying that there were six americans who died during the course of our hearing. I think about that every day, how many veterans are dying for us not being more effective at the way that were addressing this problem. We know veterans are at greater risk for suicide than americans. This is an american Public Health crisis, but for the veteran population, even more so. And we do know as has been said so many times this morning, that 14 of those 20 arent receiving care within the va system. We know from research that va care saves lives and we know that treatment works. So this is a matter of trying to get more people treated and what were trying to do is more aggressively than ever before to outreach to veterans that arent getting access to care. But we cant help those that we dont see, so this is where we are extending our help into the community to work with community partners. Were doing more to reach veterans than ever before, as secretary, i have authorized that we do start providing emergency Mental Health services to those that were other than honorably discharged and thats important. But we can do more with your help. We have asked every Medical Center this month to sign a suicide declaration pledge. Im pleased that you signed it this morning, mr. Chairman, along with the Ranking Member. And when i was out in nevada, senator heller also signed it with his Community Members so were doing that across the country, and thats a pledge of specific action steps that we want our members to take to help reduce suicide. We have developed the largest integrated suicide prevenation. Our goal is to hire 1,000 additional Mental Health professionals so we can even do more to grow that network. Our vet thans crisis line which we established in 2007, has answered more than 3 million calls and dispatched 84,000 emergency ambulances to help people who were in urgent need of help. Thats incredible. We have had 504,000 referrals to Suicide Prevention coordinators so were helping a lot of people through that. The Veterans Crisis line number, and i encourage everybody to keep this in their phone because you never know when youre going to get that 2 00 a. M. Call and you dont want to be looking for this. Is 18002738255. We have recently appointed seven weeks ago, dr. Matt miller to head up our Veterans Crisis line, this is the first time we have had a clinical psychologist in charge of the Veterans Crisis line, because this is clinical work and this is not just a call center. We have expanded teleMental Health, we have 11 teleMental Health regional hubs throughout the country. And in 2006 alone, we had 427,000 teleMental Health encounters, thats more than ever before. We have taken from our research interpri enterpris enterprises, a big data analytical up over the next year. And now we call them, and this is being done around the country, to outreach and see what we can do to proactively help, and not waiting until theres a suicide attempt. On september 15 of this month, we have we have continued to develop publicprivate partnerships, because va cant do it alone. This morning i was talking to the cohen network, but many of our vsos and other groups are here in the room today, are those partners that were working with. We continue to invest in two va center of Excellence Research initiatives to help us understand how to do interventions better and to take a Population Health approach towards reducing suicide. This month, as you have said, is Suicide Prevention month, thats our be there campaign, where were reaching out to make people aware, and try to decrease the stigma of Mental Illness. And with that today, i have brought with us our new psa announcement. And i just want you to listen to it for a second. And maybe youll realize whos helping us with that. It fabric of america, they are the toughest threads, they raised their hands, stepped forward and served. For each other, for you, and me. One of the first thing they learned was the code that every Service Member lives by. Leave no one behind. Now all of us need to live by it too. Because some veterans are being left behind. 20 of them fatake their own liv every day. Why . Its not simple. It never is. What matters is that were there for them. Just like they were there for us. A hand shake, a phone call, a simple gesture make a big difference to a veteran in crisis. Learn how to be there for a vet trat. And be there for veterans. Com. Honor the code. Be there. Leave no one behind. In the fabric of america. Were grateful to tom hanks for lending his credibility for his help in getting this message out. And youll begin to see this psa with a video starting in about 30 days. So despite all in progress were making, we still have more to do. And like you said, this is my number one priority, this is what were focusing on to make a difference. It wouldnt be a hearing if we didnt ask for your help. Those are three things that we could use your help on. We have to figure out a way to recruit more menl health professionals, and were not making the progress that i need to make in recruiting them. And secondly, we want you to be part of helping to spread the word in the be there campaign, thank you for signing the declaration, but you are well respected members of the senate and are very helpful in spreading that word for us. And we need more research. And there are no blood tests, the biomarkers, we need to be able to have Better Research to be able to make a difference. And the va has that capability with your support. I would be happy to take questions along with dr. Carol. Senator manchin youll be recognized first. Im so sorry i have a hard 11 30 with about 100 children here. But i wanted to ask a couple questions. I know that youre aware and there are more and more stories in the news about veteran suicide. The most alarming one is theyre doing it in parking lots, theyre coming to the va facilities and we just had one in clarksberg. It i dont know how to train security better and so forth. I dont know how to do it. Everything goes into lock down if its on the property. Its becoming more of an occurrence than we ever thought it would be. I dont know if youve taken steps. Believe me, were extremely aware of this, it is so painful to hear each of these stories. Youre right, that what were seeing is that people are coming on to va property. And we are doing a number of things. Part of these declarations, every one of our ten action s m steps, were training every one of our members in Suicide Prevention and what to do. And were establishing much that we have learninged in your homelessness program. Somebody whos at risk should know where and what to do and should have a spompbt to followthrough. What im concerned about and its alarming, people say its not well publicized, as you know, its becoming more and more, and what happens in small rural states such as West Virginia and the parking lot of the va, and we have an awful lot of veterans in your state. Im concerned about maybe this being taken inside the hospital. To where its more than just that person doing harm to themselves. Because they need help. I dont know how you secure that, are we securing the hospitals . Because we all have to come through to come on va property, we have to have a stop, a check point. Right. I dont know, but i would hope you would consider that, but i want to go to another question very quickly if i can. But im saying, please, to the highest element you can, im concerned. Y you talked about rural West Virginia, rural montana, this and that. We had a vacancy for a psychiatrist to oversee the Addiction Program in martinsberg, thats been posted since october 2016 and another vacancy just posted within the last five or six months and theres vacancies for menl health counselors. Can you tell me of the 649 people that have been hired, what is the ratio between rural area or urban . I think you have it right. Martin martinsberg is actually a success story. About a year and a half ago, i was really concerned about their staffing levels, they have done a great job of bringing people on. But in general, it is harder to recruit in rural areas, theres no doubt. Our urban areas, where there are more trainees and younger people are staying, thats where were establishing our 11 teleMental Health hubs to be able to support the rural areas. But this is where we want to see expanded graduate education in Mental Health programs. We use up all of our dollars that you give us to use, because its a very effective program. And you have asked us to do that more, but you didnt appropriate money for us, so were trying to find the additional dollars, that will be in july of 18. I have more questions, but i want to thank you all for the job you do. Thank you. I theyve got this right, were going to go to senator moran and then to senator murray and then to senator rounds and then to senator tester and ill finish up. Senator moran . Mr. Chairman, thank you very much, secretary, thank you for joining us this morning on a hugely significant and unfortunately so timely topic. First of all, i want to highlight the hearing that our appropriations Sub Committee had in political april on this topi want to remind you, senator and i understand senator murray has a finding for you on a followup commitment that was made in that hearing. It was committed by the va that we would get monthly reports in regard to your efforts, the departments effortses to comply with the Inspector Generals recommendations and failures at the va in regard to suicide and we have not received those reports on a monthly basis. Ill defr to senator murray, but i would join her in her request that what was promised would actually be followed through on. Let me then talk about another topic that senator tester and i have worked on, we have been trying for a long time and in fact in 2010, now seven years ago, gave the va the authority to hire marriage and family therapists and licensed professional Mental Health counselors. The results of that authority have not resulted in any significant hiring of either one of those professionals. I would guess that senator tester and i are interested in this reason for the scarcity of professionals generally. But especially as you are indicating in Rural Communities, and so, we have sought and have provided Congressional Authority for the va to hire, you indicate youre in the process of hiring 1,000 additional professionals, but i would tell you that after seven years, those two categories only account for 2 of the Mental Health workforce at the department of veterans affairs. Will you, senator tester and i and others have a letter to you in this regard, that was sent to you just a few days ago. But in there hiring, would you again commit to filling these positions with those professionals, something that has not happened, and if so, how many of those are going to be what was your prediction, that would fit an lpmhc and would you provide me with those numbers as you fill those positions and i assume that there will be a priority given in regard to places that are hard to recruit professionals. I also know that you have hiring authorities that are difficult. I dont know what your expedited hiring authorities are. What are they, do you currently what do you have at your disposal and do they apply to Mental Health professionals . What needs to happen to fix this problem . We have noticed so many times that the things that are having to be posted dont result in any kind of Quick Response or hiring at the va. We discussed this topic with dr. Stephanie davis who testified shes at the eastern part of our kansas division. She testified before our subcommittee in april, jobs were posted on usa jobs. Com. Where applications can linger for four or five months, people find other jobs in the meantime and it becomes even more impossible to recruit and retain. We know that positions sit vacant for months or even years while providers go through the process of the federal hiring mechanism. What can you do to get that process expedited. And then final, mr. Secretary, and i wanted to tell you that earlier this month at the fooek va, where i saw one of the pilot programs under clay hunt agent, its there called be connected, i was impressed as to what this is about as those having similar circumstances who have served this country, who are veterans themselves who have had ptsd and other problems, as the counselors who are those who are calling the numbers and i would be interested to know what the va is doing to support be connected and are there plans to expand that program elsewhere . A lot of questions and i will go quickly, first of all, on the issue that you talked about us not providing timely follow up and if senator murray is going to comment on that, too, look, that unacceptable, if we say were going to commit to something, our expectation is that we submit to it. So i appreciate you letting me know about it. I can assure you my staff will be knowing about that and we will do better and thats just not the way that i want the department run, so we will make sure that you get that. On the marriage and Mental Health counselors, i look forward to the letter. I am aware that we continue hear about vas strictness on our accreditation issue, this is strictly a training program. We are committed to bringing on marriage and family therapists, if dr. Carol has any specific information on numbers, i would defer to him in a second. On the issue of hiring, look, its the single most challenging thing that i know of in vva, it shouldnt be that hard to get people on board. In the act that we passed not too long ago, you gave direct hiring authority to Medical Center directors, that is really helpful to us, it allows us to skip over a lot of the red tape. I want that authority for all of our Critical Health professionals. I would urge us to Work Together on that. Its just too hard to get people hired into the va. So do you have the authority under the account. Act to do what you need to do . Only under Medical Center directors, so if we could work on expanding that, i would love to target it for Mental Health, but we have other health needs as well. So i would love towork with you on that, and on the be connected program, peer support is something were really committed to, we think this works, particularly for veterans who understand what they have gone through, thank you for your visit and thank you for mentioning that and thats something that were going full force on. Do you have plans for that program elsewhere . We already have over 1,100 peer support counselors and based on that model, we know its work, since the resident state of senator moran is kansas that the third Mental Health Hotline Center is set up in topeka, kansas, if im not mistaken. Youre correct. Were delighted to have you. Senator murray. Thank you so much for having this hearing. It really is such an important topic and i was able to listen to much of the first panel from my office in between meetings and it really was good. I appreciate it. Thank you for your testimony. Thank you for saying this is a number one priority, because it is. But i do remain deeply troubled by the igs findings from may 2017 that va is not complying with a number of policies including 18 of facilities not meeting their requirement for five out reach activities each month, 11 of high risk patients medical records did not have a Suicide Prevention safety plan. And for 20 of inpatients and 10 of outpatients no documentation the patient was provided a copy of the safety plan. There were several shortcomings in coordination of care for patients at high risk of suicide and critical improvements to follow up for high risk patients after discharge. 16 of nonclinical employees did not receive Suicide Prevention training and more than 45 of clinicians did not complete suicide training within the first 90 days. When it comes to Suicide Prevention policy, anything less than 100 isnt acceptable. When will all the igs recommendations be fully implemented . First of all, this is exactly why the ig is valuable, pointing this out. I have no other mechanism to get data that comprehensive. We have committed to addressing the ig concerns. The reason we have made Suicide Prevention our number one priority and made leadership sign off on the declaration is to fix those issues. Weve committed to training. So over this year look, 100 is the right goal, but i cant tell you exactly what date were going to reach that, but were going to be working really hard to get as close to that as possible as quickly as possible. The senator referred to the hearing at the va back in april, i asked for monthly updates until all the problems are resolved. Va has not done that and this is really unacceptable. I want a commitment to you today that we will get those updates starting right now. I think you have that commitment, yes. We intend to see that happen. Let me ask you about Women Veterans. This is something i asked about many times. I am really disturbed in the increase in suicide rate among our Women Veterans. Between 2001 and 2014 the rate of suicide for Women Veterans who do not use va care increased by 98 . Ive heard from Women Veterans many times that they dont think of themselves as veterans and i hear far too often from women who dont feel welcome at va facilities. They dont feel it is their place. It is a significant problem actually that the Rand Corporation testified in april as well. But this increase in suicide is the most important reason yet that i believe va has to redouble its efforts to reach out to women and get them into care. I wanted to ask you what are we doing to address that. Well, you gave a really important statistic, which is that over the last 15 years between 2001 and 2014 those women that did not receive care in the va, that the rate of suicide went up by an extraordinary number. You said 98 . Those that did use the va, we actually saw a decrease, a decrease in suicide rates over that 15 year period of 2. 6 . We know, particularly in this population and all veterans, getting care and access to care makes a difference and saves lives. The issue about making the va more welcoming to women is a critical issue. Its a cultural issue. We have worked hard to change the culture and environment. I speak about this all the time. Of course, we are absolutely, as this is our number one priority, committed to putting more resources into this. This is something we have to keep working on, because if a woman doesnt consider herself as a veteran, she doesnt think about going to the va. If she is not welcome at the va or doesnt feel that the veteran facility is welcoming to her, she wont go. If she has other issues, child care, work, its doubly hard. This is not an easy problem to solve but we really have to put hearts, minds, resources and as a country recognize Women Veterans. I agree. I feel very strongly about that. I just have a couple seconds left. I wanted to the i can ask about the vas reach initiative. Predictive models to identify veterans who may be at risk of suicide. I want you to tell us how that model works. Also, 14 of the 20 veterans who die by suicide do not come to the va for care. How does that work for folks not coming to the va . Quickly, that is a Big Data Analytic Research project. When i was under secretary, i said its time to stop researching it and start putting it into practice. Senator testers point about every day we delay theres going to be more deaths. So we have moved it into the clinical setting. Our Suicide Prevention coordinators get lists of veterans names in the highest 0. 1 risk of suicide. 80 higher risk than a person not on the list. They are proactively calling out saying, how are you doing, how can we help you and anything that you need help with and connects with them. And i meet with those people. Dr. Carroll has more contact, of course. Its making a difference. I dont have statistics. Are you working with local groups and providers and nonva agencies . No. We do not have that data. Because of limitation, they use va off medical electronic records. We have no way of identifying the 14 in the community. Thats a big issue for us. Yeah. I think expanding va access in Mental Health will save lives. Thats why i made the decision on other than Honorable Discharges to do that. We have a big hole here. One of the big holes is with the department of defense. What were working now with them and theyre being very cooperative is essentially an auto enrollment program, so nobody leaves active Service Without knowing where they can get their Mental Health care. I think thats going to be a big deal in eliminating the gap that we have. Thank you very much. Appreciate it. City of new york senator cassidy. Let me just echo others praises for the changes youve made in your reign to far. Anyway, thank you for that. I mentioned earlier with the earlier panel theres a professor of economics out of princeton, ill quote the article, rising morbidity among white, nonhispanic americans in the 21st century. Im trying to figure out is it a specific veterans phenomena or reflective within the va, but also throughout. Are you with me . Yeah, i am. So they find among this population that the increase for whites is largely accounted for by drug and alcohol poisoning, suicide, chronic Liver Disease and cirrhosis. Although all education groups say increases from suicide and poisoning, and i could go on. I guess what im trying to figure out is how much of this is unique for the v. A. Relative to this study as opposed to its just kind of what were seeing in society . Right, well, first of all, your questions before were excellent. We do not adjust by socioeconomic status because the way we collect the data off the National Data death index and from the cdc data and v. A. Data doesnt have a socioeconomic let me ask because as a physician when i used to practice, i would find that usually folks who were well to do didnt go to the v. A. For their health care. Our eligible doesnt allow unless theyre Service Connected. Even though the Service Connected who had more money, they preferred a different facility, for whatever reason. Do you know the mean socioeconomic class of your typical v. A. Attendee versus the general population . Yes. Yes. We are definitely more a safety net organization. By proxy, we can assume that you have a higher death rate among those being seen that that would probably reflect your overall population. Yeah. You know, my background is not helptology so im going to give you my best educated guess. There is a socioeconomic status component that i think youre identifying, but the veteran population is more than that. You wouldnt see as large a difference. I think its both in there. Again, if its merely reflective of the larger population, that is tragic, but the v. A. Represents the hope. Right. If it is no, being a veteran in the v. A. System is an additional risk factor, thats something to be identified and corrected. Well get that to our Health Services Research Team to see if we can do that. We published 75 articles on suicide and Suicide Prevention last year, and we have a good team on this that i think could maybe tease some of that out. Let me ask, my staff has given me but i have not yet comprehended it. A spread sheet thats been distributed, the Mental Health composite summery, fiscal year 2017, quarter 3. I have stats for louisiana. I know you have done that analysis. Is there a difference in suicide rates associated with different facilities . Again, hopefully correcting for that each population is the same but im assuming its a roughly homogeneous population. I have seen the analysis by state, not by facility. Dr. Carroll, have you seen that . No. The analysis is by state. The veteran population is not homogeneous from one state to the other, nor is the general population. There are state differences in the population, both at large and for veterans. I accept that. But probably broadly, louisiana is a higher africanamerican population, and some states have a higher hispanic. Theres going to be that broad demographic. But dr. Casey pointed out its among nonhispanic whites were seeing a bump in the general population. Have you done a very rough, as i was told on the previous panel, we have it for age and gender. I can see throwing race in there because its apparent. Do we have any sort of rough estimate on that. Those analyses are ongoing. It is part of the evaluation of the data. Let me ask as well because youre sending out this data, and thank you very much, looking at specific facilities. Im presuming that most vets, not all, but most vets have a facility of choice. Yes. Is your analysis going to include the rate of corrective for all these other factors, how each specific facility is doing . Senator murray pointed out were not getting 100 of these being passed out, but i suspect that would vary from facility to facility as well. Yeah. Yeah. I think the type of statistics that senator murray was talking about, about compliance with screening absolutely is done, not only at the facility level but by the specific provider. Oh, yes. You have Electronic Medical record data on that. The broader statistics which include the National Death index and other things may be harder to do by facility, but you could look by state. Absolutely. I think we need to know, is this a v. A. Issue or does it reflect broader society. Its a v. A. Issue, we need to give you tools. If its broader society, we need to do something more broadly. Does that make sense . Right. You do know about the difference between veterans who are getting care in the v. A. And not in the v. A. I saw that, and you want to correct for that, but you mentioned your safety net, and we suspect that, my suspicion is in some places youre serving as a safety net, and some in places theres inadequacy, which case we need to identify and address it. If you need tools, we have to give them to you. Thank you very much. I yield back. Thank you. And thanks, Ranking Member, for yielding. I want to follow up on senator murray and senator cassidy talked about the suicide report. I first thank you for being here and thanks to dr. Carroll, too. I dont really understand my state, 244 veterans took their lives and took their own lives in 2014. I want to talk about them and the thousands around the country. Im not really clear on why you would release that statebystate report on a friday afternoon at 5 00. Thats not really my question. I dont understand why you would do that. Talk to me about how you share this data statebystate, how you share it with veterans, with Medical Centers, with Community Providers, with academia who address what you call the national Public Health issue. Yeah. Weve this analysis, which was released on september 15th, friday, at 5 00, is really the first time that weve released that type of specific data. So were actively trying to get that out and to share it with the groups that you mentioned. There was no attempt to downplay this issue. If there was, it was a bad strategy because what were seeing is all around the country, that data getting out there and being picked up by the press, being discussed in forums. This is exactly what we want to have happen, and were actively disseminating it. If you dont know your data, i want every Medical Center director knowing what their number is, how many veterans they lost. You cant design as effective an intervention. That means not just a patient from that Medical Center. It means population. Never got into the v. A. System in franklin county. Thats the populations. Talk, new psa employees no vet behind. 14 of 20 vets who take their lives each day dont use v. A. Care. Talk to us about the reach vet initiative. What metrics you have in place to see how its working, what your what the process to get those 14 who then wont take their lives if they get v. A. Care, talk that through. Yeah. So the reach vet program is not for is not for those that arent using v. A. Its for those who are using v. A. That we know are at high risk. The 14 that arent using v. A. , thats where were beginning to start tackling it through other strategies. Letting other than honorable have emergency Mental Health is a strategy that will bring some of those 14 into the v. A. For others that arent eligible or choose not to go to the v. A. , were working with community partners, and were working with Veterans Service organizations. Were working with the churches and the synagogues to make sure that they understand that they have a responsibility in this. The psa message essentially is Suicide Prevention is everybodys business. And we need Family Members, friends, coworkers, to be able to identify people at risk to get them help, whether its at the v. A. Or outside the v. A. Thank you. Thank you, mr. Chairman. Thank you for your work on this issue. You heard a number of my questions earlier today. I did. About that difference between the veterans who have used the v. A. And the veterans who have not done so. I know you have been asked a number of questions about that issue so far. I want to focus on the less than Honorable Discharge group. Do you have any thoughts about how that cohort can be better accessed and how they can be encouraged to come forward, because i think that the knowledge about them is also lacking . Yeah. Well, quite frankly, i did what i could. It was one of the first things i did as secretary, just to use the authorities i had to offer emergency Mental Health services. I thought it was wrong that we were not providing access and were letting them out there, and they are at higher risk for suicide as Homeless Veterans are at higher risk. But i did as much as i can. Now, i actually need your help. This, were going to need legislative changes to allow us to offer other than honorable other than Honorable Discharge people to be able to access our full array of Mental Health and physical services. All that i was able to do is offer 90 days of emergency treatment. And then im trying to find them other places to get care, working in the community. Were going to do everything we can, but it is not the ideal approach. We could use your help in this, senator. Well, i would like to work with you. I have other questions. Sure. I would hope we can pursue this. As to all of the veterans who right now are, through no fault of their own, perhaps, not part of the v. A. Yeah. I know youve been asked about the clay hunt Suicide Prevention act. I would also like to follow up on that, particularly as to the funding that is necessary. The president has signed a number of measures dealing with veterans issues. Those pieces of legislation have been long in the works. And we have devoted a lot of time and attention to them. I hope that his apparent commitment to those issues will translate into funding, which is really the test. Its fine to wield a pen on measures that were started well before his presidency. Now its a test of his commitment. And i think that applies to issues like the Veterans Crisis line, the Suicide Prevention measure, and i would like to, again, ask you about Women Veterans. And what expanded or enhanced efforts you contemplate involving Women Veterans. Well, first of all, thank you for highlighting, i think, all of these issues that are important. The president s budget, the requested budget actually has increased funding for both Mental Health care and Womens Health care issues. Both critically important. So i think that he does share that commitment that you have to seeing us do better in these areas. Is that amount of money, in your view, sufficient . I was very pleased with the president s budget. I think that many of the issues that were dealing with werent Financial Issues solely, but in areas that we have to do better in, im not only seeking additional funds, as we saw in the president s budget, but im actually moving current budget funds into higher priority areas. And so i do think that we have sufficient resources this next year, should the president s budget get approved. I would be remissed if i didnt ask you about the west haven veterans facility. We have talked about it. It was built in the 1950s. Its out of date structurally. It needs more than just rehabilitation. It really needs rebuilding. And i wonder where it stands on the list of priorities and whether the president s budget is sufficient to cover the Capital Improvements there and elsewhere. As you know, you and i stood outside that building, and i think your assessment is generous. I trained at the west haven v. A. , and i dont think its changed too much since i was there. We are still undercapitalized in the v. A. We have a very old infrastructure. I think realistically, we can expect to take decades of essentially underfunding and fix it all at once. So we are putting more funds. We have requested more funds into the modernization of v. A. , i have announced i want to dispose of 1100 facilities that arent being utilized well by veterans to put back into facilities that are busy like the west haven v. A. I dont have a specific number of where the projects are, but certainly, i am going to support fixing the west haven v. A. And other facilities that arent modernized, and part of that is were going to have to redo our matrix on how we make capital decisions because right now, i will tell you, the number one weighted factor and where the money goes is the seismic improvements. While thats really important, im not going to say that thats not critical, youre not on a fault line. And it puts facilities like west haven at a disadvantage. Were going to be looking at that. I hope i can be generous in pushing west haven to a higher level on the list, as you noted. I was being generous. It has really changed little, if at all. There are some cosmetic improvements, but you well know the level of dissatisfaction that exists about it. And i would add that it is dissatisfaction with the structure and the capital facility not with the staff. I agree. I want to just give a shoutout to the very dedicated men and women who work for the v. A. In connecticut. And i have no authority to speak on behalf of veterans in connecticut, but generally, i have gone to high level of approval in satisfaction. So they deserve our thanks, and they work under conditions that should be better for them and for our veterans. Im sure they will appreciate both of those sentiments. And i would like to invite you to come visit, again, and be at that facility with me again. And i want to thank you for that. I do have a visit scheduled. Ill let you know. Okay. When that is so we can get there together. Wonderful, and i thank you, by the way, in the meantime for the work being done on the wifi internet connections, which is very important there and at v. A. Facilities around the country. Exactly. So, thank you. I want to add to your answer a second ago. If im wrong, i want you to tell me. As you go through your 1,100 evaluation of underutilized facilities to invest in places that need more help, youre going to consider rural locations, rural states, populations, things of that matter so north dakota and montana and things with a light population dont lose out on a statistic in terms of the availability of Clinic Association . What i announced is that, first of all, i share the sentiment that we dont want policy that discriminates against locations because the rural or because theyre not on seismic fault lines. But what i announced previously was that in the state home money distribution, that the rural areas were never getting from the bottom of the list, so i committed to relooking at those criteria because the state home grant moneys really were going only to very small numbers of states, essentially. But i do want to make sure that we are modernizing the facilities in an equal way across the country. I want the Ranking Member to make sure we knew were looking after our interests as well. Yeah. Senator tillis. Thank you. Senator tillis. Why youre such a good chair, mr. Chair. I was going to end with a capital project, but let me go to that because i think this is critically important. You have said that you believe, i believe the president has a real commitment to veterans and accelerating some things and frankly didnt move as quickly as i would have liked for them to have in the past couple of years. But i have the same view in my role in Senate Armed Services. Were always going to have fewer resources than you want. Right. And shame on any member of congress who advocates for moving something up ahead of line where the data doesnt say its the best way to provide care to the communities that need it. Im in north carolina. Im in a 50 urban, 50 rural state with over 1 million veterans. 10 of my population. If you told me montana is where the resources need to go to serve that population, thats where i want it to go. Along with that, when youre taking a look at optimizing capital projects, shame on any member who tries to come up with a statutory protection for something that you dont think is in the interest of supporting the veterans. I every once in a while call up a v. A. Facility the night before i happen to be in town. Want to stop by and see them. I said this is not a surprise visit. I just want to talk to you all. I stopped in one a year or so ago who said they made a proposal to consolidate two operations that were only about 40 minutes apart. Made total sense. They thought they could provide better care to the veterans by consolidating the resources and getting more leverage, but we had a member of Congress Stop that because it happened to affect 75 jobs in their district. Thats not the way we should think if were going to get out of the way and let you support veterans in a more appropriate manner. I need to make sure i have your commitment and any time you see us doing something thats at odds what is your best professional judgment is getting the resources to the communities who need it most and making optimal the resources that were given you, i want to know who that is because i think they should be held accountable. Now, on the Electronic Medical records. I want to go back to the questions i asked the first panel. Actually, i want to thank you for being here because i was rushing in and i mistakenly thought you were in the first panel, but it doesnt surprise me you and your team were here to hear that testimony. I thank you for that commitment. I like the decision that you made for the baseline system, because i think its an accelerator between dod and v. A. , but similar to the question i asked when you were here last, we know we got over 120 instances that have to be consolidated within v. A. , but even more importantly, we have nonv. A. Care providers out there, choice providers out there. I believe that as you get further into the Implementation Plan that we discussed in my office, that youre going to identify that you need other layers in the Technology Stack to make sure that we know how prescriptions are being dispensed, whether theres any dangerous interactions, other indicators you can use to make that a more productive experience for the provider and for the patient. And so have you gotten to a point now where youre thinking through how as youre looking at your implementation priorities and your broader transformation plan, the remainder of the stack, or we used to call it gluewear, or buying and configuring tools youre going to need to flesh out that Technology Stack . Weve gotten to essentially the principles that you have talked about, saying a system thats going to work into the future is going to have to have the components that frankly you have done a good job of outlining. We havent gotten to defining which specific tools they are yet and how were going to meet those needs, as we talked about the days of v. A. Being a Software Developer are over, and were going to be looking at off the shelf current technologies. But theres going to be a lot more definition on that. I think yesterday, we released to congress, to you, the 30day notice of an award of a contract. So we are keeping on the timeline that we talked about. Were marching forward. We have the principles. I have some updates to share with you on the strategic i. T. Plan, because i think we are making a lot of progress with that. We are going to announce that we will in this i. T. Conversion with obviously your support, we will be sunsetting 80 of the projects that were currently under development, so this will be i think not only the right thing for clinical care, but also the right thing for taxpayers. Thats great to hear. Im going to hold my time because i guess im the last member to speak. But we do have a number of questions for the record on Suicide Prevention issue. We are, i took note in the first panel, and i have asked my staff to get with the Senate Armed Services staff because i would like to have a Committee Hearing at the subcommittee level to talk about traumatic brain injury, ptsd, and things that were doing to do a better job of detecting and treating it, but i would like to add a second panel that then talks about the veterans who may actually first off, how do we track those who get an Honorable Discharge and make sure that were trying to anticipate or provide interventions for ones who may be at risk of suicide, and then for the ones who have other than Honorable Discharge, what are we doing to make their experience when they were in the military instructive to any decision about what category of discharge they get, and then finally, we have to come back to the v. A. And get your advice on how we do that for those who have already received that paper and they need care. And thank you for pushing the envelope. And i heard you loud and clear, its time for congress to give you more tools so you can provide more veterans with care. Thank you. Thank you, mr. Chair. Senator tillis, are you on the way out the door . Or do you have five minutes . I want to ask you a favor, i have to leave, and senator tester has questions he wants to ask and i dont want to cut him off. Yes, sir. I have one that i want to be sure is for the record. You adopt the same software being used by dod. Thats a huge step forward. Does that merger also allow you access to the same information dod has regarding the Wounded Warrior transition units . Yes. Our warriors when they leave the battlefield or leave deployment in battlefield areas, theyre asked questions on the computer, answer by computer. It doesnt have a statement. Theyre answering a computer question. There are questions that give indicators of where there may be somebody at risk for suicide. So you have Interoperable Software one day soon. Well also have interoperability access to that information. Is that correct . There is certainly some exceptions with dod. One of the things i just learned recently, i dont know if you know this, the coast guard doesnt have wasnt in their contract, so were going to have to figure out a way to be interoperable with them or get them into this. So theres some small exceptions and were working through those. Our relationship with dod is extremely cooperative on this project. I think were helping them in their implementation. Theyre certainly helping us. But those types of data sources are extremely valuable to us. Youre to be commended for that move. Were very proud of it. Im going to turn it over to the Ranking Member and ask senator tillis to adjourn the meeting. I appreciate your patience. Thank you, mr. Chairman. Thank you, mr. Chairman. I want to thank you fellows for being here as well as the first panel. I just want to touch on brak really quick because i think theres some opportunities to get rid of some facilities that arent being used. You would agree manpower and recruitment of manpower is a continuing challenge, wouldnt you . Absolutely. So i would just say, as we look for ways to save money and commonsense ways, what im really concerned of, and i know youre not a part of this. If you are, let me know. That they will come in and potentially, if we do it in congress or if you do it administratively, do a brakc, and they say montana, they havent had a doc in years. We say the vets arent using this and close it down. Same thing could be said for senator rounds of south dakota. If Something Like that were to happen, i guarantee there would be a bipartisan explosion on this committee, which wouldnt be a good thing. I just bring that to your attention. Im all for making sure that youre getting rid of properties you dont use anymore, and have outlived their usefulness and utilizing the dollars. Thats a Good Government thing and i applaud those efforts. When we get into the because im going to tell you, i know there are some people who want to do a fullblown brack, and im going to tell you some of the metrics arent going to speak well. Not because these arent good facilities, because they havent been staffed. I just want to bring that up. In your testimony, you said that Suicide Prevention was the top priority. Mmhmm. You also mentioned that v. A. Has integrated Mental Health services into the primary care at v. A. Centers and at cbox. Tell me what that means in montana. Well, what it means is that v. A. By far is leading the strategy across the country, where if youre in your primary care office, you dont have to say i am i have been given a number to go and to call for a Mental Health appointment and then go down the street to the Mental Health department. You get that Behavioral Health care as part of your primary care office experience. How are you going to i agree. Its about destigmatization. How are you going to do it when you have to have somebody there that knows the issue, right . You have to have the Mental Health professionals with your primary care people. Okay. Colocated. In a small population state like montana, were about 20 short right now. Yeah. I mean, the best laid plans without the people infrastructure blow it. It gets back to what you were saying. We have a manpower issue. Its not and its geographically distinct, particularly in areas that dont have a lot of medical schools and other places with untrained professionals. So senator moran talked about other opportunities out there that could get us besides psychiatrists and psychologists, other folks who could help. Is that proceeding . Is it proceeding well . And are we making some inroads . Im going to tell you that we have talked about a lot of metrics today, about what population is committing suicide and what altitude. We have to get our arms around the whole baby before we can even get to a point where were talking about well, look. No other Health System im aware of has Suicide Prevention coordinators. Thats a v. A. Strategy that i think is super effective. Were using peer support specialists in a way that no other Health System is using. And of course, were trying to hire traditional Mental Health professionals, licensed social workers, psychologists and psychiatrists. Do you have a comment on the marriage therapists and family therapists . Were encouraging strongly as we can facilities to hire them. That is part of their within their purview. The other thing were doing, to your question about primary care, Mental Health integration, is using teleMental Health. Using our teleMental Health system to provide providers in places where they may not be able to hire a Mental Health professional. Can you tell me, and cbox overall, do they all have tele Health Capabilities . Not all of them. We list them on our website, which ones do. Certainly, the rural ones will be much more likely to have it than you would have in new york city. Really . Right. But one of the cool things, i dont know if you have ever seen it, that just amazes me, you go into a primary care office in a Medical Center, and right there is a digital display that if the primary care doctor wants to dial in a psychologist or psychiatrist, they can do it right from their office and the patient is there. I dont see that in many places in the private sector. So thats that integration you were talking about. Thats good. I want to go back to manpower for just a second. Mmhmm. Earlier in the year, you testified that you were going to try to get 1,000 additional Mental Health providers this year. Mmhmm. Your testimony today says that you have hired over 600 new Mental Health care providers. Im not going to ask what the difference between additional and new are. But has there been a net increase in the number of v. A. Mental Health Clinicians . You just asked it, then. And the answer is no. The 623 is just keeping us even. We are not succeeding at that 1,000 new professionals. I need help in doing that. Doctor. Yes. What do we need to do . What we need to do is to, a, give us more direct hiring authority. Just like you did in the accountable act for my Medical Center directors. Make it easier for me to hire. And we talked about the fact that our recruitment and retention dollars were actually cut in half. That was shortsighted, quite frankly. We need the tools that the private sector has to be able to recruit the very best Health Care Professionals. If we are serious about tackling this, let us dont tie one of my hands behind my back. I want to be clear. Did we cut your Recruitment Retention dollars . To pay for the legislation, yes, sir. Yes. Keep going. So a competitive process so i can hire quicker. Yeah. Recruitment dollars . Recruitment dollars and the flexibility to be able to help expand training. Those are the three areas that would really make a difference. Look, theres a National Shortage here, so you know, i think we all worry about not just whats happening in v. A. But everywhere. These are all important strategies, particularly the training one. Yeah. Ill just make one side comment. You know this better than i do. Youre right, it is a national problem. But with veterans, we made a promise to them. Yes. So we cant have a bunch of excuses. We have to have more solutions. Right. Right. Appreciate you guys being here. Thank you. Thank you. On the last point, were about to adjourn. Im not going to ask other questions although i have them for the record. I remember this discussion within secretary mcdonald, i think there was a series of news stories that some of our members got tempted into amplifying that had to do with training and Retention Programs that you thought were critically important. And i think what we need to do is understand, if youre going to make this an attractive place for professionals to come to, then you better have professional development and a Retention Program similar to the private sector. And when you see some of the dollars that you were spending on training, im sure i could find something that was not a good idea, but i saw the numbers that the v. A. Was spending on a per employee basis, and it was pennies on the dollar compared to what i would have spent at a partner at price waterhouse. Youre never going to get to that ratio, but we have to not talk out of both sides of the mouth. On the one hand saying we need to give you recruiting, and then we want to micromanage how you spend it. I have never been the head of a Major Health Care system before. You have. Now youre the head of one of the biggest in the world. I trust you to make a decision about how you have therapists and doctors and technicians and other people you want to attract and have a Value Proposition so youre getting your fair share of the best resources out there in the private sector. Thats another one where when we hear us say one thing and do another thing here, please give me your commitment that youll say thats not a good idea. Thank you. Were going to adjourn the Committee Hearing. And were going to leave the record open for one week for additional questions. Thank the first panel for being here. Its always a pleasure to see the leadership from the v. A. This meeting is adjourned. Thank you. Health and Human Services secretary, tom price, today got a flu shot at the National Press club and called on all americans, over 6 months old to also get a flu shot. [ applause ] so, dr. Price, thank you very much for that good information and call to action. I would like him to know that we are particularly pleased that an Orthopedic Surgeon is working to prevent flu. Surgeons are very incisive and you are making incisive remarks. We thank sharon walsh from head start visiting nurse association. Right now administering the vaccine. There you go. [ applause ] thank you so much. Thank you. This weekend on American History tv on cspan 3, saturday at 8 00 p. M. Eastern, on lectures and history, university of virginia professor, Gary Gallagher on the legacy of the svl war. The loyal citizenry and africanamericans and confederates have different takes on the war as they went forward. They embraced versions of the war that suited their purposes. And sunday, at 10 00 a. M. , president bill clinton marking the 60th anniversary of the integration of little rock high school. I wanted to say, you did 60 years, take a victory lap, put on your dancing shoes, have a good time. But, instead, i have to say, you got to put on your marching boots. [ applause ] then, at 7 00 p. M. Eastern on oral histories, we continue our history on photo journalists with an interview with darrel heikes. The army was nip we were working, especially the white house to have the optimum lens in your hand and the maximum amount of film when ever something happens. Because somebody, in a split second could be there and you got it and the person standing next to you does or doesnt have it. At 9 00 p. M. Eastern, hamilton play write and actor captured the 2017 freedom award. When you are a theater kid, you make friends from different grades and social groups. You work hard to create something bigger. For the sake of making something great, you trust your passion and let it lead the way. Without humanities, i wouldnt be standing here. Without Alexander Hamilton and others that built this country, its probable few of us would be here either. American history tv, all weekend, every weekend only on cspan 3. Next week, here on cspan 3, former equifax ceo, Richard Smith testifying before the House Committee about the data breach at the Credit Reporting Agency he used to lead. The hearing is tuesday at 10 00 a. M. Eastern. You can see it live here on cspan 3, online at cspan. Org or the cspan radio app