Transcripts For CSPAN2 Veterans Health Administration Officials Testify On Suicide Prevention 20160513

[inaudible conversations] committee will come to order. Good morning, everybody. Thank you for being with the committee for todays oversight hearing entitled combating the crisis evaluating efforts to prevent veteran suicide. As the hearing title suggests, we are here this morning to discuss the ongoing veteran suicide crisis that, according to the latest Data Available from the department of Veterans Affairs, finds 22 veterans a day dying at their own hands. Im disappointed that the v. A. Was not able to release updated veteran suicide statistics at this time for this hearing. I understand that the center for Disease Control finally provided National Data to v. A. In the middle of march. Considering the critical interest in updated veteran suicide data, i cant emphasize enough the need for v. A. To pursue their analysis with a sense of urgency. Its my fervent hope that the new data will show a reduction in the rate of veteran suicides as a result of the investments we have made in v. A. Mental health care and Suicide Prevention. Regardless, im hopeful that v. A. s Witnesses Today will be able to provide some more recent insights into the numbers of veteran suicides and to shed some light on whether the efforts dedicated to this crisis are, indeed, making any impact. I recognize the challenges that v. A. And, indeed, the American Health care system as a whole faces in preventing suicides. The rates of suicides have risen significantly over the past 15 years for almost every single demographic. Except for veterans. And i think that is due in large part to the hard work that v. A. Health care providers do every day to extend helping hands to those most in need. But that is not to imply that the current rate is in any way acceptable. I continue to be concerned that, again, according to the latest data from v. A. That is admittedly dated, the number of veterans dying by suicide has not fallen despite significant increases in budget, in staff and programming for v. A. Mental health care and a number of targeted veteran Suicide Prevention initiatives. Its not enough for veteran suicide rates to remain stable. Our work will not be over until veteran suicide rates are eliminated. There are many reasons a person may choose to take their own life, and there are many opportunities along the way for someone with to for someone to step in and intervene. V. A. Should certainly be proud that veteran suicide rates have not risen along with rates in the general population, but theres clearly a deadly disconnect between the Many Services and supports that v. A. Offers and the veterans that most need our help. Care, particularly for someone that is contemplating suicide, is not one size fits all. And while suicide undoubtedly is a Mental Health issue, it is also much more than that. Eliminating veteran suicide altogether will take a comprehensive approach to insure that those most at risk have not only the care they need, but also a job, a purpose and a system of support in place to help carry them through their struggles. Therefore, v. A. Must adopt a Suicide Prevention strategying that recognizes the need for Wraparound Services that treats patientses as individuals and em bases patients as individuals and embraces complementary and alternative approaches to care where appropriate. Furthermore, v. A. Needs to better integrate a veteran and family perspective that incorporates the Lessons Learned from those who have been on the front lines of the fight against suicide and offer a personal perspective and a message of hope to those that are still struggling today. Last year the clay hunt Suicide Prevention for American Veterans, or s. A. V. E. Act, was signed into law. This law was named after a brave 28yearold marine, clay hunt, who returned from battle against our enemies in iraq and afghanistan but who, in 2011, lost his personal battle to the demons he brought home with him from those conflicts. The law included a number of provisions that i believe will help connect veterans in crisis with the care that they both need both in v. A. And in their communities, that will provide valuable information about what programs are working for veterans in crisis and assist v. A. In recruiting high quality Mental Health professionals to treat veteran patients. Fully implementing the clay hunt s. A. V. E. Act should be v. A. s highest priority. I look forward to discussing the departments progress to date and hearing about how the implementation of that important legislation is helping v. A. s efforts to prevent suicide among our nations veterans. In clays memory and in the memory of the countless other veterans who have lost their lives to suicide, we have to do better. With that, i yield to the Ranking Member, ms. Brown, for an Opening Statement that she may have. Thank you, mr. Chairman, for calling this hearing today. Strong oversight of the department Suicide Prevention Program Remains a priority of this committee. We are all aware of the oftencited statistics of 22 veterans a day committing suicide. We also know that v. A. Reports in 2014 that there is a decreased rate of suicide among users of the veterans Health Care System with Mental Health conditions. The question becomes how can we insure ready access to safe, quality Mental Health services for veterans in need of care. I hope that the v. A. Witness here today will be able to update us on those numbers as much of the country was not included in previous estimates. The last subject that concerns me relates to the new my v. A. 12 breakthrough priorities. I understand that addressing the suicide problem is not one of those. Increased iss to Health Care Access to health care, improving comprehensive exams, continuing to reduce homelessness and transforming the supply chains are all on the list. But specifically reducing suicide is not included. Given that suicide nationally is considered by some to be a Public Health problem, i believe v. A. Should include Suicide Prevention as number one my v. A. Priorities. I look forward to v. A. Testimony on this and where Suicide Prevention fits into the 12 priorities. I still believe that Suicide Prevention should be one priority of their own. Top priority. Mr. Chairman, this hearing also examine and implement the clay hunt Suicide Prevention for American Veterans act passed in the early days of 114th congress. This law focused the nation on this terrible epidemic affecting veterans. This law requires that the secretary of Veterans Affairs and the secretary of defense to arrange for an outside evaluation of their Mental Health care and Suicide Prevention. It also requires any Service Member being discharged to have their case reviewed for any evidence of posttraumatic stress disorder or trauma, brain injury or military sexual trauma. We have been at war for over 14 years. There are many veterans out there who do not engage the v. A. Care system for purposes of Mental Health treatment. Todays discussion should include how v. A. Is going to reach out to these veterans, and i definitely want to say that one of the major problems and i thank the v. A. For having the conference on Suicide Prevention that i was able to attend but one of the points that was pointed out that many of the veterans even though we have 22 a day, only three of them are involved in the system. And many of them are are getting on veterans who when they returned home wasnt received properly. So we immediate to figure out how we need to figure out how were going to reach out to these veterans and include them in the system and, with that, mr. Chairman, i yield back the balance of my time. Thank you very much, ms. Brown. With us this morning is ms. Jackie maffucci, joy ilen, thomas berger, the executive director of the Veterans Health council for the Vietnam Veterans of america and kim ruocco, the chief external Relations Officer for Suicide Prevention and postprevention for the Tragedy Assistance Program for survivors. And were also joined by dr. Maureen mccarthy, v. A. s assistant deputy undersecretary for health, for Patient Care Services who is accompanied by dr. Harold kudler, v. A. s chief consultant for Mental Health services, and dr. Caitlin thompson, v. A. s National Director for Suicide Prevention. Thank you all for being here today to testify before our committee. Dr. Maffucci, you are recognized for five minutes. Thank you. Chairman miller, Ranking Member brown and Committee Members, on behalf of iava, thank you for the opportunity to share our views on this critical issue. In 2014 iava launched the campaign to combat suicide, a result of our members continually identifying Mental Health and suicide as the number one issue facing post9 11 vets. This campaign centers around the principle that timely access to high quality Mental Health care is critical in the fight to combat suicide. The signing of the clay hunt s. A. R. S. A. V. E. Act was an important first step. We thank congress for passing legislation and the v. A. For their commitment to fully implement the law. We knew it would take time, and were pleased that weve been included in the process. Were committed to working with the v. A. , congress and our vso partners to progress both the s. A. V. E. Act and i new initiatives that are certain to follow. Personally, ive been working on this issue for about eight years, and never in that time have i seen a movement around this issue so strong or a collective will so unified than in this last year. The conversations are moving to action, and its our responsibility to make sure that this continues. So today id like to focus on four specific areas critical to progress; access to care, interdisciplinary approach to care, supporting those most at risk and the importance of research. In iavas annual member survey, over 80 of members reported seeking care. This is an increase from our last survey. They continue to emphasize the role of the family and friends with over 75 who reported having a loved one suggest they seek help and, as a result, getting that help. For those in care, three of four of our members are using the v. A. This year we saw over 75 of those using v. A. Mental Health Services report little to no scheduling challenges, which is up 10 from last year and comparable with those using a nonv. A. Clinician. The same number were also satisfied with that care. But with more Health Seekers comes more demand, and its critical to insure that the v. A. Is properly resourced to provide high quality care. Efforts are underway with the administration to bolster the v. A. Work force, recruiting medical students and improving curricula, but thats not enough. Beyond the challenge of a clinician shortage is the difficult task of hiring and retaining talent in the v. A. The federal hiring process is confusing and lengthy, at times deterring or rejecting qualified candidates. It must be made easier. The v. A. Needs to fully understand why staff are leaving. They need to know how best to attract and retain talent and to use updated staffing models and Realtime Data to establish where the need is. Climate surveys are showing that, in large part, v. A. s losing staff because of noncompetitive salaries and low morale. We all play a role at the v. A. We often forget to praise the dedicated staff who support v. A. s mission, some of whom are iava members. Our members have shared stories of the great work and dedication of these staff, relaying how these individualings saved their lives or cared for them in some of their hardest moments. We all must do our part to help celebrate what makes the v. A. Good while also focusing on how to make it better. Finally, we need to insure that high quality care exists outside v. A. Just under 40 of the veteran population actually seeks care at v. A. , which means the Current Community care work force needs to be equipped to help veterans and their families. Its not even common practice to ask a military person their history. This has got to change. But beyond asking about military histories, Community Care doctors need to know how best to provide treatment once they have the answer, and the v. A. And its academic partners are best equipped to lead this effort. Its not just about Mental Health care, in february we called upon the secretary to elevate the v. A. Suicide Prevention Office and were pleased that that call was answered. While Mental Health is a major aspect of Suicide Prevention, its not the only aspect. There are social factors that impact this as well. For the v. A. Suicide Prevention Office to truly take a Public Health approach to decreasing suicide, it must have impact wherever veterans and their dependents go. Within the v. A. , this has to include vba. So we ask congress to insure that the office, the Suicide Prevention office, is fully resourced through a line item on the budget so that it can be certain to carry out its critical mission. Weve also been focused on veterans with bad paper. This is a community thats been identified at high risk for suicide and homelessness. We can do something about this. Iava urges passage of the fairness for veterans act as part of the solution, but we also know that we, together, need to come up with a comprehensive solution with congress, dod and v. A. We simply dont know enough yet, and this is where the Research Piece comes in. We know that suicide impacts seniors disproportionately, but we dont know why. We know that women vets have a high rate of suicide but dont understand how best to intervene. This is why iava supports the female veteran Suicide Prevention act. We know that the post9 11 generation is showing an increased risk but are just starting to understand the risk factors to impact interventions. More research and evaluation is critical to developing these interventions. We simply cannot solve what we dont understand. The v. A. Has a wealth of research and a wealth of data, and they need to call upon academics to partner with them. And so were asking the v. A. To open up their data and invite academics to help be their army to look at this data and help us find the solutions. All veterans deserve the very best our nation can offer. We look forward to working with congress and the administration to address these very real challenges with informed solutions. Thank you. Thank you very much, doctor. Ms. Ilem, youre recognized for five minutes. Thank you, mr. Chairman. We appreciate the opportunity to testify as well on this important issue. Over the past decade, v. A. Has enhanced and promoted a comprehensive set of Mental Health Services Including integration of Mental Health into primary care and a goal of improving access, minimizing barriers and reducing stigma. Research shows Early Intervention and timely access to Mental Health care are key to improving quality of life, promoting recovery, obviating longterm Health Consequences and minimizing the disabling effects of Mental Illness and the risk of suicide. In recent years v. A. s Mental Health programs and Suicide Prevention efforts have been both praised and criticized. Outside sources have described the scope, depth and breadth hofstras multivariant Mental Health approaches as superior to care in the private sector. Data shows v. A. Users have a lower rate than veterans not using the v. A. Health care system, as youve noted. However, there have been documented issues with access in the past over prescribing of medications and serious failures for some veterans. Along with a call to action to do more to prevent suicide in this population. In our opinion, v. A. Has two major challenges. One, to insure it meets the diverse needs of an increasing number of veterans, enrolled veterans who need specialized Mental Health services and, two, how to effectively outreach to veterans who are not using v. A. But are in crisis or need of help. Younger veterans indicate they prefer a variety of nontraditional therapies over medication such as webpaced life coaching, yoga, meditation and acupuncture. While v. A. Is steadily increasing the availability of these nonmedical approaches, there is still variability of access to complementary and alternative services across the system. This past weekend dav, along with a group of communitybased organizations, sponsored a spartan weekend for ill and injured veterans centered on the promise that they would not take their own lives without reaching out to someone for help. The event reached 1. 8 million facebook and other social media users and resulted in a number of veterans reaching out for help for the first time. We believe these types of Community Events will be essential for connecting nonv. A. Users to the Mental Health services they need. Another challenge v. A. Faces is how to insure veterans with warrelated Mental Health issues get quality care in the community through the Choice Program. While dav prefers v. A. To be the provider of specialized Mental Health services whenever possible, immediate access to care is the most critical factor for a veteran in an emotional crisis. This group can particularly benefit from v. A. s peertopeer program, its expertise in treating ptsb and tbi. As well as the Wraparound Services and other postdeployment transition challenges they often face. If a veteran with Mental Health issues needs to access care in the community, we urge v. A. To routinely follow up with the veteran to insure the patient is receiving quality and effective care from a provider with expertise in treating veterans with warrelated or sexual trauma. Another area we recommend v. A. Put focus on is crisis management. When a veteran is experiencing a Mental Health crisis and asking for help, there must be ready access for Mental Health services. We are pleased in that regard that v. A. Has been working to improve training and services through its crisis line and pilot new programs for peer specialists who have been found to be very effective in helping to coach veterans into care and keeping them in care. Another area we urge focus on is Women Veterans. According to v. A. The suicide rate is six times higher for Women Veterans compared to civilian women. Increased suicide rates are also reported among women who have experienced military sexual trauma. However, it is encouraging to learn that Women Veterans who use v. A. Health services were 75 less likely to buy to die by suicide than Women Veterans who did not use v. A. This data suggests that v. A. s Mental Health programs for women including Suicide Prevention efforts are showing promise and positive results and that a concerted focus on this subgroup of veterans should be continued. We do, however, suggest that there be improved access for Women Veterans to specialize inpatient and residential Mental Health programs to insure recovery and effective reintegration. V. A. Must insure all of it Mental Health programs meet the unique needs of women including safety and privacy concerns. In closing, we urge v. A. To continue its training and partnerships with the Community Providers, improving its Mental Health programs and research on Suicide Prevention and to find innovative ways to engage all veterans who need specialized Mental Health services. We also ask congress to do their participant as well, providing part as well, providing v. A. With resources to address their recruitment challenges, staffing issues and ongoing research. Its our hope that as a community we can Work Together to insure that any veteran who needs help can get it. Mr. Chairman, that concludes my statement. Thank you. Thank you. Dr. Berger, welcome, and you are recognized for five minutes. Thank you, chairman miller, Ranking Member brown and distinguished members of the house Veterans Affairs committee. Vietnam veterans of America Thanks you for the opportunity to present our testimony regarding the department of Veterans Affairs efforts to reduce suicide among veteran population. The timing of this hvac hearing is particularly important. As some of you may have read the recent National Center for Health Statistics report that found that suicides in the United States has surged to the highest levels in nearly 30 years. With increases in every age group except for older adults in the age group both men and women over the age of 75. The overall suicide rate has risen by 24 from 1999 to 2014 according to that report, and the increases were so widespread that they lifted the nations suicide rate to 13 per 100,000 people, the highest since 1986. Theres absolutely no doubt that this country is in the midst of a Public Health crisis with suicide, and nowhere is that any more true than in the Veterans Community as we learned back in february 2013 with the v. A. s report on veterans who die by suicide. In particular, that report painted a shocking portrait of whats happening amongst our older vets, my cohort and those who served before me. Because almost threequarters of the veterans who commit suicide, based on that report, are age 50 or older according to that report. And even though suicides become a major focus for the military over the last decade, most research by the pentagon and the Veterans Affairs department is focused on men who account for more than 90 of the nations 22 million former troops. Little has been done or focused on female veteran suicide until recently. According to an l. A. Times article in july 2015 and, by the way, i have to apologize, my written testimony says july 2016. I cant read into the future, and i need to get my autocorrect fixed on my machine. Anyway, the suicide rates are highest among young female veterans for women ages 1829. Veterans kill themselves at nearly 12 times the rate of nonveterans. And according to that same times article, amongst that cohort that was looked at, the suicide rate of female veterans closely approximate that of male counterparts. In effect, women vets at 28. 7 per 100,000 versus 32. 1 per 100,000 male vets. But we also cant forget, as the chairman has alluded, that its from that 2013 report that the figure of 22 veteran suicides bear day is calculated per day is calculated. This number is suspect because of the data only representing numbers reported from 21 states from 1999 through 2011 and did not include states with massive veteran communities like california and texas which didnt report their suicides to the v. A. At time. Therefore, v. A. Calls for an updated veteran suicide report that includes data from all 50 states and u. S. Territories. And also we strongly suggest that v. A. Mental Health Services develop a nationwide strategy to particularly address the problem of suicides amongst our older veterans. Obviously, im speaking on behalf of our vietnam veteran era. Group. At the same time, we understand its very challenging to determine an exact number of suicides. But weve got to overcome the barriers, identify and overcome the barriers that prevent our Service Members from seeking the help that they need and that they deserve. Very va is heartened vva is heartened in particular by the efforts made since february 2016, including those efforts mentioned by dr. Maffucci earlier. While these initiatives are laudable, vva also believes strongly they cannot be fully successful without a significant increase in the recruitment, hiring and retention hofstra Mental Health staff retention of v. A. Mental health staff especially for our rural veterans. And this committee is in a position that can insure that our veterans and their families are given access to the resources and programs necessary to stem the tide of veteran suicide. Once again, on behalf of vvas national officers, bode and general board and general membership, thank you more your leadership and holding this important meeting, and ill be glad to answer any questions. Thank you. Ms. Ruocco, youre recognized. Chairman miller, Ranking Member brown and other distinguished members of the Veterans Affairs committee, the Tragedy Assistance Program for survivors thank thanks you for e opportunity to share stories of surviving members of veterans who have died by suicide. These families are honored to have a voice in this process, and they gain healing from the thought that this testimony in remembrance of their loved one may, in fact, save a life. My name is kim ruocco, and i work with Suicide Prevention and postvention for the group. I joined together with Bonnie Carroll to build a comprehensive, tierbased support program for all those grieving deaths of an active duty Service Member. Our ultimate goal is to help these families of the fallen to rebuild their lives. Taps presently has over 7,000 suicide survivors from the military and 700 survivors of military murdersuicide. For the purpose of todays suicide, ive gathered sorry, testimony, ive gathered information from Family Members who have recently lost a veteran to suicide. Survivors of military suicide hold a wealth of information on the multiple factors that lead up to this kind of death. They are on the front lines of a Service Member or veterans battle with pts, tbi, mental hillness, moral injury and the multiple stressors associated with military life. They are witness to the challenges of stigma and the barriers to care for those who are suffering. Survivors of veteran suicide loss can provide us with a picture of potential impact of challenges within the v. A. System. Todays testimony is a summary of information gathered from these families. The first common theme was barriers to care. It is important to note that in each case that i have highlighted, the veteran was not in ongoing, consistent, edbased evidencebased treatment at the v. A. In most cases the veterans struggled to get the care they needed in a timely fashion. In some cases, the veteran himself or herself was the first barrier to good care because of their cultural beliefs, their stigma regarding Mental Health. This reluctance to share the true story, fear that they would not be believed or insistence that they need to push through and suck it up in combination with institutional barriers can become a perfect storm for those veterans that are suffering. Families of these veterans struggled to help their loved one and often became frustrated or overwhelmed with navigating the system. Many of them expressed frustration with the lack of their involvement in the assessment and treatment of their loved one. They claim that part of the veteran culture is not to complain or admit to emotional and billion pain and to downplay how serious their issues are. Families feel strongly if they were present for intakes and evaluations, they would have had a more accurate treatment plan. Most families state it was difficult to get the veteran to go and agree to get help, and when they did go, it was usually during a crisis period, and there was long waits or inability to see someone at that time or a misunderstanding of their struggles during this diagnosis. The second theme that was throughout all of our families conversations was the quest for peer support. In each case the family tells taps that the veteran only wanted to talk to someone else who had been there. The veteran had a lot of shame and guilt about the symptoms they were feeling and thought these symptoms were a weakness in them and not an illness. This false belief became a barrier to getting timely, appropriate treatment. Tier support could be used to build trust and eventually leads to an understanding that their symptoms are real and valid and that there is treatment that works. Peers serve as a beacon of hope that those who are struggling can offer a road map to navigating the system. So here are recommendations based on our findings. We have to increase the number of Mental Health providers that are trained in evidencebased, best practices for treatments of these injuries and illness at each contact a veteran should be able to get appropriate Mental Health care in a timely manner x this is especially true in crisis points like e. R. S, Outpatient Clinics and primary care. Two, the families would love to develop advocacy and information groups that can offer support and guidance for those who are supporting a veteran so they can get answers. Number three, develop an avenue for Family Members to call for professional advice and get guidance on symptoms treatment and how to get their loved one into care. Four, make peer support specialists a line item. Peer support is an invaluable tool and a reciprocal relationship that adds value to all involved. It can be used to reach out to these veterans where they are and build a bridge towards treatment and help them stay in treatment. And finally, five, increase incentives for and streamline process for peers to become Mental Health professionals. In the case of veterans, personal experience adds a level of trust and credibility that greatly increases the probability of a veteran seeking treatment and staying in treatment. Thank you so much for listening to us today. We have many families that came and would like their stories heard, and we have those available the you if youd like to hear hem in the future. Them in the future. Thank you very much. Thank you very much for your testimony. Dr. Mccarthy, youre recognized for five minutes. Good morning, chairman miller, Ranking Member brown and members of the committee. Thank you for the opportunity to discuss the effectiveness of the department of veteran affairs Mental Health programs and our efforts in preventing veteran suicide. I am accompanied by dr. Harold kudler and dr. Caitlin thompson, National Director for Suicide Prevention. V. A. Has developed the largest integrated Suicide Prevention program in the country. We have over 800 dedicated and passionate employees including Suicide Prevention coordinators, Veterans Crisis line staff, epidemiologists and researchers who spend each day preventing suicide, caring for veterans. Our strategy enhances veterans access to Quality Health care and implements upstream programs designed to help veterans before they consider suicide. Veterans who reach out for help must receive that help when and where they need it in a way that makes sense for each of them. We do have a good story to tell today, one in which we wish to share hope and progress, in which we want all veterans to know that v. A. Is here to help. But the rest of the story is we still have work to do. Were pleased to share our progress and the opinions of others outside hofstra about the quality of our efforts. On february 2nd, we hosted a summit to bring together veterans families, other federal agencies, community partners, service organizations, subject matter experts, members of this committee and some other key partners to enhance our work on Suicide Prevention. Powerful for so many attendees were the stories shared by veterans and their families. These stories truly resonated with us. Just as we dont prevent sudden cardiac death only when its happening, we know that suicided prevention does not necessarily begin with our crisis line or other interventions when suicide is imminent. Our efforts are about hope, finding reasons for living, leading a high quality life and developing strong, meaningful relationships. Engaging veterans in v. A. Care and, in particular, in our whole system of care is a key part of prevention. Addressing their job concerns, substance abuse, homelessness, financial concerns, general medical health and, of course, Mental Health are all important steps in preventing suicide. The call to action generated multiple recommendations and initiatives to strengthen v. A. s approach to Suicide Prevention. For example, a Pilot Project is underway to evaluate risk intervention strategies based on data that predict who would be at risk for suicide before these individuals reach a crisis. V. A. Continues to actively monitor suiciderelated behaviors through our Suicide Prevention applications network. Were working to develop a dashboard that will allow us to identify possible clusters of suiciderelated behaviors and to trigger meaningful responses or interventions. V. A. Remains committed to insuring the safety of veterans, especially when they are in crisis. We do have universal access for 24 7 Emergency Care through our Emergency Departments and by v. A. s veteran crisis line. The Program Continues to save lives and link veterans with effective, ongoing Mental Health services on a daily basis. Preventing suicide also requires access to Mental Health care as our partners on the panel have noted. Between 2005 and 2015, the number of veterans who received v. A. Mental health care grew by 80 , a rate of increase more than three times that of the overall growth hofstra users. Growth of v. A. Users. This reflects v. A. s efforts to engage veterans to our system and stimulate access to Health Services. We remain committed to eliminating the stigma associated with receiving Mental Health care. In 2007 we rolled out integrated Mental Health services in Primary Care Clinics which allow veterans to receive warm handoffs present in the Primary Care Clinic on that same day. V. A. Has also moved to patient9centered Community Care, a centralized contracting mechanism and has implemented the Choice Program. We are addressing efforts we are addressing access through our efforts such as extended hours to help increase capacity and the hiring of over 900 peer specialists while expanding their role into primary care settings. We partner with more than 150 Mental Health obviously organizations around Suicide Prevention. We recognize that we cannot do this alone, and we continue to adopt and prioritize develop and prioritize these partnerships. We are aware that some veterans are at an even greater risk of suicide. We have individual and groupspecific interventions tailored to help these high risk veterans. Of course, any risk for any veteran is one we must continue to address. V. A. Has taken steps to implement each of the requirements of the clay hunt Suicide Prevention for american for veterans act including our call to action. V. A. Has contracted with an independent third party to conduct evaluation of Mental Health and Suicide Prevention programs. We are collecting selfreport outcome data from veterans newly receiving Mental Health care. Were working towards release of a web site that provides easily Accessible Information about all the Mental Health services for veterans. Currently, the v. A. Facility tool is available on v. A. s home page. It includes contact and resource or information for a variety of Mental Health programs. Mr. Chairman, the crisis of suicide among veterans mobilizes us to continuing and expanding upon the work we have done. We remain focused on providing the highest quality of care for our veterans while trying to understand more about precursors of suicide among veterans. We appreciate the support of congress, those at this table and all partners in our mission, and we will be happy to respond to any questions you may have. Thank you. Thank you very much, doctor. Could you you talked about having contracted a review of your Suicide Prevention programs and other outreach efforts. When, when do you expect to receive the final product from that review . So the contract is with the enterprise resource performance incorporated. They have started their work. I think we are due to give you a report by august about whats happening with the report, but in two years their review will be complete. So its a twoyear program, but we can get a report hopefully in august . Yes, sir. Okay. When were on our summer work period. Well happily do it whenevers convenient. As soon as possible. Thank you. Can you also talk to us about the vacancies that exist, what your current vacancy rate is right now in health care. And then i think its important for the committee to know and to understand whats the, whats the total time that it takes from recruitment all the way through to bringing a Mental Health provider onboard right now at the v. A. . I have to say im not the person that knows the exact number of days it takes for recruitment. I can tell you the process and that it does likely take several months. When asked about the actual vacancy rate of psychiatrists, and i believe we testified were at about 236. We out of, out of how many . 236 out of harold, do you know the number of psychiatrists we have . I have it in my notes somewhere. Its about, i believe its about 800. About 800. And as we continue to hire and expand, some moved around, and then we had vacancies. Theres turnover in Mental Health. The psychologists, theres a lower rate of vacancy go ahead and talk about the process of recruitment going all the way through to bringing somebody on board. So typically theres advertisement, people apply, often through usa jobs the applicants are reviewed, interviews are conducted. Theres a credentialing process that takes, thats sensitive to how quickly information is imported into the credentialing process. Its usually a minimum of two weeks, but it can take up to a month or two depending on the delays. Weve worked to streamline helping providers get the information they need in there relatively quickly. After that an offer is made and a start date is given. I do not have the average time, and id be happy to get back with you on that. Okay. And we talked a little bit about the clay hunt yes, sir. Suicide prevention act. And according to the figures that i have, because of the Enrollment Period being extended, there have been almost a thousand veterans that have been enrolled into the v. A. Health care system. What have you learned from those roughly 995 individuals in regards to your outreach to them and, you know, what can be done to provide more information about current programs . Thank you, sir. The question really is not just what we learn from them, but also other veterans as well that have chosen not to come and see us. What we learned also as part of the call to action part of the clay hunt implementation was people want us to make it easy for veterans who are leaving the military to enroll in v. A. Health care. So we have worked with dod, and we have work that were currently ongoing with our Health Eligibility office to decrease barriers to help every person leaving the military have a health plan when they leave. Weve done that especially already for people that have been engaged in Mental Health care, but now this is for all of them, to have a Health Care Plan when they leave. And so what were looking at is not automatic enrollment, but essentially close to that so that if they havent chosen or indicated another Health Care System, we would like to decrease any bureaucracy or any barriers for them receiving health care and get them enrolled in v. A. Very quickly. What are the Biggest Barriers youve heard they feel like they have to overcome to get into the system . On some level theres a sense that some veterans do not understand that theyre entitled to care. And for our vets who are post9 11 who are leaving, theres that fiveyear eligibility window. There really should be no barrier. We have treated Women Veterans who said literally in a clinic i didnt know i was eligible for of services. And so we have to change our messaging to be more welcoming to all of our veterans. We, as much as we try, we have people at outreach events. Our Suicide Prevention coordinators do five outreach events a month. We go the welcome home and Yellow Ribbon ceremonies and so forth, but something is not happening where people are understanding theyre eligible, or else theyre choosing not to come. Thank you. Ms. Brown . Go with the committee, so ill be the last. Whos the first [inaudible] thank you, mr. Chairman. Mr. Chairman, i want to thank all the witnesses for your testimony. I also want to make a pitch to you, mr. Chairman. Mr. Coffman held a wonderful reception for a group of people from colorado that did a wonderful video in which youre partly featured. And i hope that we can do something to encourage the committee as a committee to take the time to view that. It goes very deep into the topic of pts, and i hope that you might with encouragement do that. Why dont we do this . Ill spring for the pizza [laughter] and well have a showing of that here in the Committee Room in the very near future. I havent seen it, but i understand its its very good, very powerful. It is long, but i think itll give Committee Members other ideas that we need to follow and follow through on. With well, the director Stephane Tubbs is a very impassioned advocate. Well, it certainly i intend to show it at events in my district. Its a very bipartisan, very bipartisan video. Anyway, my i have some questions for i believe its the v. A. About taps. I understand that taps has a, is a big sporter of peerbased counseling. You recommended in testimony that peer support specialists should be a line item in the budget. What do you recommend that v. A. Do better with regard to their Peer Support Program . Well, i know theres about 900 out there now, but there needs to be more. We need more money to get that program built bigger and to have them everywhere because what our families told us is that they had a lot of trouble getting their veteran to the v. A. They had a lot of misconceptions about what would happen there. They dont understand treatment. They are afraid of treatment, theyre afraid of being overdrugged. And so they would not go to the v. A. Until they were in crisis. And then its very difficult to get immediate Mental Health care when youre in crisis where wed rather have them in the system before the crisis getting treatment. So these peer specialists have done everything from going and finding a homeless veteran to bringing them to the v. A. And getting them into the system, to getting them housing, to sticking with them and to describing what treatment is to saying i went there, i had the same symptoms, i went there and im better. So they can really be a bridge for all of this, because i think one of the Biggest Challenges is not getting, not getting you are our veterans who are suffering into good, evidencebased treatment for the things that theyre suffering with from these wars. And all of my cases are ones who fell through the crackings. They all died by suicide. Every one of them that i talked to had tried to go to the v. A. , had tried little places but they didnt go until they were in crisis, and then it was very difficult to get the treatment they want when theyre already in crisis and so many things that already interfeared with their lives. Interfered with their lives. Dr. Berger, i think its misleading to say that, generalizing and say 900 peer support persons have been hired. It makes it seem like theyre all in Mental Health when thats not true, okay . So i think we need some answers about how many peer support people do we actually have in Mental Health. Is there a response to that question. So the number that we quoted are primarily Mental Health or part of the integration program. So theyre linked to being the ones that reach out and encourage the veteran to receive care. Do we need, do we need to fund this more . Do we need to fund more . How much more do we need to fund it . Is that for me, sir . [inaudible] theres two pieces, right . Theres the peer support specialists and the training, but then theres also an avenue for peers to become Mental Health providers, right . Thats two separate things. So having peers, veterans when have been there, getting the training in the system is a win win for both because were taking those veterans who had this experience and were able to do good and save other veterans. So were talking about peer support specialists to go out in the community and get them into the v. A. , and were talking about a streamline of getting peers, veterans, trained in Mental Health to be counselors. Two separate pieces. Okay. My question is there adequate funding, and if not, how much more do we need . I dont have that, but wed be happy to get back with you on that amount. Please. Thank you. Thank you. Could i just clarify the number of vacancies . Im sorry, chairman miller. We currently have 5,500 onboard psychologists and 3,200 job board psychiatrists in v. A. And so when i talked about 236 vacancies, its 236 out of 3,203. Okay. Mr. Land born, youre recognized. Thank you, mr. Chairman, for having this important hearing today. Mr. Lamborn. Dr. Mccarthy, the bill that we passed, the clay hunt act, requires the v. A. To collaborate with nonprofit Mental Health obviouslies to do three things; to improve the efficiency of Suicide Prevention efforts, to assist other nonprofit organizations to do a better job and to collaborate with these nonprofit organizations. What is the v. A. Doing and how are these collaborative efforts coming along . So i did mention before our call to action summit that happened in february. Thats one piece of it. We really brought a lot of people together not for us to tell them, but for them to tell us what we really need to be doing, what we need to keep doing, what we need to do better, what we should do differently. More than that, we sponsor community Mental Health summits around the country, and this is our fourth year of doing it. Each Medical Center sponsors a summit in which information is shared bidirectionally. Our Homeless Outreach folks have done that, and Mental Health has been doing that. Weve learned and weve shared. And its been extremely productive for the collaboration one other thing weve been doing is actually working with partners in a community who provide care. We realize that especially as part of choice, there are veterans that are out there receiving Mental Health care, and we want them to have a warm, welcome reception in the Community Just like we want for them to have that at v. A. Weve developed in partnership with dod a military competence training for providers. Its, it provides up to eight hours of continuing medal call education medical education free for Community Providers or internally for people to be able to understand the language and about taking a military history. Weve also lobbied to have a cpt code added for taking a military history which is part of a reimbursement mechanism in the private sector so that people will be encouraged and financially rewarded for doing that. Okay, thank you. Dr. Berger, id like to can you a question about research, and i think we all agree there needs to be more research. You said about 70 of veteran suicides are people of the among males, is people of the age 50 and older. And according to your chart, 85 of male veteran suicides are age 40 or older. Welk sir so my question is, my question is when lets say vietnam era veterans who served 40 to 50 yearses ago between 65 and 75, 1965 and 1975, tell us about the connection between that service and a suicide at the anal of 70 or something age of 70 or Something Like that. And i understand probably every suicide is for unique and personal reasons. But what, what does Research Tell Us about the connection there . Well, certainly excuse me, sir. There are risk factors that all veterans share. Theres no denying it. But at the same time, as we age there may be additional risk factors added to the pool. For example, in the case of our older vets it may involve insurance, Health Insurance kinds of things if theyre not enrolled in the v. A. In particular. There may be family issues that surface at that time. The structure in our lives changes. But at the same time, im not aware of any focussier on to Logical Research on these different aged cohorts in which risk factors may be important at particular points in time. Okay. Thank you. And i appreciate the work of every one of you on the panel. Our hearts go out to those who have committed suicide at whatever age. And so thank you for your preventative work. Mr. Chairman, i yield back. Thank you, mr. Lamborn. Ms. Brownley, youre recognized. Thank you, mr. Chairman. And i wanted to thank dr. Maffucci for bringing up the female veteran Suicide Prevention act, and i am encouraging all of you to help many supporting in supporting this bill. We have a companion bill in the senate, and i certainly would like to see this particular piece of legislation, see it through, because i think the focus although dr. Berger talked about, i believe you talked about an increase in being able to treat Women Veterans, i think its really critically important that the v. A. Is the expert, the absolute expert in this issue around suicide. And particularly looking at best practices for both our male and female veterans. Because i do think a female experience on a battlefield can be very different from a mans experience. So thank you for that. I also, you know, wanted to talk a little bit about the outreach. And i know that we have a Transitional Program to have a warm handoff when our veterans leave the service from the dod to the v. A. , and i think that thats positive. Im curious to know how well thats going and what it looks like. But i think we have to actually dig back further. In other words, you know, it seems to me we should have medical professionals on the battlefield there. I think in terms of outreach with Family Members, i think we need to, for a veteran who is sent to the battlefield who is potentialling going to experience potentially going to experience trauma, the Family Member should be trained and prepared on their reentry back. Family members need to know. And when we talk about older veterans, which for the first time today im aware that the suicide rate amongst older veterans are going up, you know, weve got to figure out some kind of outreach in those cases as well. But i do think that, i think, you know, we train our men and women to go to the battlefield and be prepared to save their physicality and their physical health, but we also need to prepare them to survive their Mental Health as well. And so i think we have to go further back starting really at the beginning so that people are knowledgeable and aware, and even the veteran can be aware of their own behaviors and help themselves. So i guess, you know, the question that i would like to answer or to get some answers from is, you know, really how this handoff situation from the dod to the v. A. Is really working, how do these handoffs take place . What are they looking like . And are we collecting some data on that to figure out if this kind of warm handoff is actually working . I open it up to anyone. [inaudible] ill jump right in here at least from the perspective of what i know about it. You know, vva has stayed away from using the term seamless transition, because there is no such thing. I would only point out we have many, many cases where the transfer, quite frankly, theres no other way to say it is screwed up, and it ends in the result focusing on todays topic in a veterans suicide. For example, im sure youve all heard theres at least two or three cases in the last year or so of vets who were prescribed certain kinds of medication in dod for their Mental Health challenges. They get to the outside, those records werent forwarded to the v. A. , or there was some kind of barrier or what have you. The v. A. Gives a diagnosis, puts them on perhaps another complete set of Mental Health medications, and they cant cope, and they take their own lives. Dr. Mccarthy, do you have any responses in terms of that response and how you believe the program is working and if what dr. Berger is saying is true, how do we rectify that. So id be happy to respond to medication parts, and ill turn it over to dr. Thompson about the medication part. We have had an opportunity to look very closely in our crossagency partnerships about this particular transition time and medications. And we have made it now so that all psychiatric and pain meds that would be prescribed in dod could be prescribed in v. A. , and it is our expectation that those meds, the medications would continue seamlessly. However, the expectation is that the provider would do a safety review. So if, for instance, there are multiple drugs of the same class and too many, that at that point they could be adjusted. But the expectation clearly is that this go well. Weve started, weve done two sets of chart reviews actually looking at specifically transitioning veterans of a thousand veterans that we checked, i believe the number was 20 that had a medication change that was not what we expected it to be. Thats 20 too many. And so we provided feedback to those providers who made that change. And weve also increased our Education Program specifically about meds. But id like caitlin to talk about the transition program. Well, my time has run out, but maybe we can follow up. I yield back, mr. Chairman. Thank you. Dr. Roe. Ill yield my time to answer the question. Ah, thank you, sir. So we also have whats called the intransition program which is a coaching model so that Service Members who are, who have difficulties with Mental Health are given a coach while theyre still in service who then help them and make sure that they have that transition point across to the v. A. But we really take all of this extremely seriously especially because we know and for older veterans, but also for others that those veterans who are going through transition in any way are at very high vulnerability for suicide risk. Thank you. I want to start by, first of all, thank the v. A. I think you all have, i think you do have the largest comprehensive Mental Health program in the United States, and its not perfect, but its certainly better than it was seven years ago when i first got here, seven and a half years ago. Theres no question the focus that the congress has given and the v. A. Has given has improved things. One of the things thats hard to do in suicide, first of all, as a practicing physician is to identify those people who are at risk. Its a silent demon that you carry around, you dont share with anyone. I think one of the things weve learned today is that when patients, veterans do get boo care at the v. A. , their suicide rate goes down. I think we have figured that out. Number two, i think weve also learned that the hiring process at the v. A. Is ridiculously long and should be shortened for not just Mental Health, but other providers of health care. Thats got to be shortened. Ive hired multiple physicians in my career, and it doesnt take that long. Its not that hard to do to do your background checks and so fort, find out what you need. I think the other thing that has been brought up and what is confusing about this is when you look at the data and i think the cohorts of people are different. For instance, us guys, vietnam era guys, thats a different cohort than the younger veterans that are leaving. When you look at the suicide data among, from 2001 to 7, nondeployed veterans had suicide rates higher than deployed veterans which is confusing for us. The fact that i mean, why does that happen . I think more research is important, and i think one of the things we have to do, family and friends, there is no question. I looked at data years ago when i was in practice that showed somebody went to psychiatry had a higher risk of suicide than talking to their best buddy. Having a good friend to talk to, i think you need to expand this program where you can touch a buddy that was in the service. Those of us who have served have a different look of things, a view of the world and so forth. And when you have somebody thats put their overalls on just like you have, it makes a big difference. And i think thats a program that works, and it should be expanded. The other thing i want to encourage you to do at v. A. And outside the v. A. Is get good data, because without that, you cant make the right decisions. You just cannot. And you cant group us all into one big group. Were youve got to look at different cohorts, female, younger veterans and older veterans like i am. So ill stop there and make anyone make a comment. So maybe i could mention the Data Analysis thats going on right now because were excited about this. This is very different from what we did in the past where we had to get data from the states, and some states gave us data and some did not. We have worked with cdc and with dod and have requested data on everybody that had been in the military or the v. A. Between 1979 and 2015. And so we sent multiple discs with data that could be matched with the cdc data for suicide. And its come back to us, its very i raw. It involves a lot of individual checking and so fort. We sho wanted the data to share at the hearing, we dont. We were told it would be analyzed by the middle of the summer, but were really excited because this is not statespecific, and it crosses ages, sexes and all those other kinds of risk factors that we really want to be able to identify. And we want to make that Data Available to our academic partners in a transparent way so others can help us understand two things that were said, and dr. Berger pointed it out, this 22. Well, that is probably not correct because if you look, it was 21 states. Yet thats quoted all the time. Thats why we need accurate data. And in the u. S. , were 50th in the world in suicide. And im proud of the fact that were really pawning out because it all comes down to one person. It doesnt matter when youre the one patient out there, the one veteran or civilian thats contemplating taking their life. Its preventable. Its just like opioid addiction and death. Those are preventable deaths if we pay attention. I yield back. Thank you very much. Ms. Custer. Thank you very much, mr. Chair. And thank you, dr. Roe, for setting up my comments on the opioids, because as i sit and listen and, by the way, this is one of the best panels ive heard since weve been here but as i sit and listen, excuse me, there are so many corollaries. Im a cochair of the Bipartisan Congressional Task force on, to combat the heroin epidemic. And we now have over 80 bipartisan members, and were passing 15 bills this week, and i want to commend my colleagues on both sides of the aisle. And jackie who hour sky for her work on veterans. We passed yesterday the promise act. But theres so many corollaries. And many of the same people. Four out of five heroin users have a cooccurring Mental Health disorder. Often undiagnosed and untreated. But i wanted to speak to you particularly, ms. Ruocco, im sorry. First of all, my condolences for your loss, but thank you for your courage. And a big part of this is a about stigma. Its about Meantal Health generally and the stigma around Mental Health. One piece i want to convey to you is we want to help you to be a leader on addressing stigma and particularly for veterans. In New Hampshire im very proud of a new program that we have thats called ask the question, and were using this across the state. This is way beyond the veteran community. This is our entire health care community, Mental Health community, every person that comes in contact with anyone who comes before them to ask the question did you ever serve. My father was a world war ii pilot, spent he was shot down, he was a p. O. W. For six months. No one ever asked him this question. Right. He never talked about it until he was well into his 70s, and it was only when my boys growing up started asking him all the questions, what was the plane like . What happened to you . What do you mean . What happened after you hit the ground, you know . Tell this story. So im curious about this peer support because this is what one of my communities has just started for heroin use. Yeah. And it turns out that incredible psychological bond of someone whos been before you. And if you could talk more about how can we help you to grow that program. And then just generally for any of the witnesses, how can any of us here help with the stigma and the support . And then just lastly, really want to commend a candidate and i dont mean this to be partisan. To be honest, i dont even know his party. But this is in yesterdays politico. One candidates risky bet talking about his ptsd. Hes running in delaware. And hes a veteran. And it is a risky bet. But the courage for you as a Family Member to come forward and for others to come forward, i think, is critical. Well, thank you so much. Im from massachusetts, so im aware of that campaign, and its a great campaign. And we actually have all been speaking together, caitlin and i Work Together a lot on messaging with the department of defense. And one thing weve really talked about is this is a need for all of us as a whole to change the messaging around the v. A. And around suicide. Good. You know, that number 22 thats been going around, we had a suicide in the veteran population about five months ago who left a suicide note, and in the suicide note said im going to be one of the 22 today, why should i even try . So having the negative messages out there that its an epidemic, that theres 22 dying a day is increasing hopelessness in our veteran population and the feeling of helplessness and the feeling that treatment doesnt work. It is the biggest barrier to them getting real, good treatment with the demons that theyre bringing with us from, you know, unresolved Early Childhood trauma and additional combatrelated issues. So i think we need a campaign where were all speaking with one voice about the people that are getting treatment that treatment works, that more people are getting treatment and surviving than are dying by suicide. So that we can get those veterans out there really thinking, you know what . Theres others that have gone through this, theyve survived it, and theyre doing well. Because we have amazing veterans in our communities that are doing unbelievable work. And we have peerbased programs all over the country like red white and blue and team rubicon that are pulling these veterans together or providing hope and are real beacons of who these veterans really are. Theyre loyal and theyre senator and theyre dead smart, and theyre dedicated. Weve got to start a campaign that looks at that and talks about that and stop focusing on the fact of how many have died. Weve raised the awareness. We know its a problem. Lets get in forums like this and fix the problem but at the same time get a message going out there that treatment works and it doesnt have to be that way. So i think well, my time is up. Im sorry, well have to come back on another round. I would just say i saw the other night on television this invictus thats going on this week with the sports. Yes. So powerful, the hidden wounds of war. And this is part of what were going through in the addiction community, anonymity has been such a big part of this. Yes. Which is important for treatment. Yes. But for those on the other side to come out and start to tell their story is so to powerful. So powerful. So thank you. Thank you. Thank you very much. Dr. Benishek, youre recognized. Thank you, mr. Chairman. I, too, would like to thank you all for being here this morning. I just want to follow up on something with dr. Mccarthy thats been bugging me since ive been around here. I dont know, i mean, is it emblematic of whats going on . Is it a sign of the sincerity of the v. A. , but i have an issue with when you call the v. A. Hospital and theres an automated message that says dial 1 for the pharmacy, dial 2 for the Outpatient Clinic, dial 3 for o. R. , but if you have a Mental Health crisis, please hang up and dial a tendigit number, okay . This is a pet peeve of mine, all right . And ive been working on this not only in my district. They fixed that, all right . Because ive been on it all the time. But as of this morning in michigan, the Iron Mountain v. A. And the sag nau v. A. Have fixed it, but theres still three Medical Centers in michigan that you have to hang up and dial an 800 number. Now, i brought this up in committee a long time ago, and im asking why this is not fixed. They said, oh, itll all be fixed in six months. That was more than six months ago. And id like to know why we cant just fix this right now. Why does this change take so long . So you agree it should be fixed, right . Oh, sir, absolutely. I have good news. [laughter] there are 12 v. A. S where you can press 1 and get directly connected from the medical twelve. Twelve. To the crisis line. Thats what im telling you, thats not very many. Hawaii and a few other places which is great in terms of the technology. Its not all of them, and it should be all of them, and that is clearly in the works you see, this is why i bring this up, okay . Because, to me, this is something that should be just fixed automatically without taking a year to do it. All right . So here we are talking about Mental Health crisis, all right . And you cant do this. You understand what im saying . Weve got all kinds of huge problems to solve, and they dont dealing with Mental Health patients, and you cant fix this . It is outrageous. I mean, im amazed by this. I mean, it hurts me. Because this is, these are blocking and tackling. This is solving the individual problems that veterans have when calling. This is a crucial thing. I mean, ive had individuals talk to me about this very problem, you know . And they try to kill themselves in the parking lot of the v. A. Because they couldnt get help. It so what im trying to tell you with my comment be here is that this is a blocking, tackling, minor thing that these are the kinds of things that youve got to fix every day and not take a year to do it. So youre telling me that theres only 12 places in the country that that is actually occurring out of the hundreds of v. A. Facilities around . Its my understanding it was 12 the last time i checked. Is there somebody within the v. A. Thats resisting this change that youre aware of . Oh, no. We have a rather old phone system, and we have a number of challenges with it. Dont im not youve got the dial 1 for the pharmacy, it connects to the pharmacy just fine. Okay. You know what i mean . Do so dont blame it on the phone system. Heres the other thing i want to know. When you dial this crisis line, i mean, a lot of people end up dialing the crisis line because thats the only place they can get a person. So what is the process for triaging the person calling the crisis line whos just desperately trying to talk to somebody at the v. A. . Let me let dr. Thompson take that call because shes worked there. Thank you, sir. These are such important points, and i do want to by the end of the summer, all of the v. A. S will have rolled out the press 7 so that those press 7 numbers get to the Veterans Crisis line. The reason that they have to the pilot it is because they have to know how many people will be available at the crisis line as they roll this out, otherwise there wont be enough people to answer so right now youre saying the 800 number theres nobody there . Im sorry, sir . No, sir. Your answer makes me suggest that youre not rolling it out because you dont have people behind the scenes to no, we have to pilot things in order to understand what the rollouts going to be. But i assure you that by the end of the summer all of the v. A. S will be rolled out. That was what you said last year. This is, this has taken longer than we had thought we personally tested it. What about the question i just asked . Yes, sir. When people, and i worked on the crisis line for five years. When people call crisis line, there is a set of questions to insure that the person isnt at immediate risk and they need somebody right away which happens 3040 times a day where somebody needs that immediate help because theyre in the process of dying by suicide. They cant, they cant commit to being safe. So how many questions is it . Its, i mean, it varies as far as there are certainly, like, a few questions that are how long does it take . Important for a suicide, a suicide Risk Assessment. How long does it take . To do a suicide Risk Assessment . On the phone, yeah. The immediate question is are you safe right now really. And thats an immediate question. And then there needs to be developed a rapport with the person who is calling. So many of the people that call this is the first right. Okay. Im out of time. Thank you. Ill be glad to give you some more if you need it. And im happy to keep answering the question, but well, unfortunately, i dont know your answers are what hes looking for. I mean, to talk about a silly pilot on something as serious as this is just ridiculous. Mr. Orourke. Thank you, mr. Chairman. And, mr. Chairman, id like to begin by thank you for bringing muchneeded attention and focus and accountability to this issue. I cant think of a more important issue for us to be working on, and i think that reflected in your leadership, and i would just is that we continue to keep pressure and the focus and our commitment to provide the resources and the oversight necessary to make progress on this issue. And i think to a person, we are all there with you and the Ranking Member to maintain this as a priority. And i want to thank everyone whos part of the panel today from the v. A. And from the advocate community for your help and focus, the information that youre bringing to this so that we can make better decisions, so that we can hold ourselves and the v. A. Accountable for making improvements. And i want to echo the Ranking Members suggestion that through you, dr. Mccarthy, this goes to the secretary. He has 12 wonderful priorities for transformation of the v. A. Not one of them is specific to reducing veteran suicide. And i authored a letter that the Ranking Member, republicans and democrats signed asking for just that. Id hate to have to do that legislatively. I think thats something that the secretary could do and should do, and well ask him through you to do just that. Until it is a stated priority, were not going to see the changes that we need to see. Were not going to prioritize prevention, were not going to move from pilot programs to full implementation of necessary interventions. I just believe in that wholeheartedly. And it needs to happen. And if we need to get the veterans advocate Community Behind that to create the political pressure and will to do that, then is so be it. Then so be it. But lets not have to do that. One of the questions i have is whether if, well just use 22 as our baseline statistic,22 veterans a day taking their lives. If 17 of those are not accessing v. A. Care and if we believe that if they were to have accessed v. A. Care the outcomes would have been better, dr. Mccarthy, is the v. A. Ready today in terms of capacity, number of providers, space, other considerations to see those 17 veterans . Thats a very thoughtful question. You know, what weve tried to do with the 17 is find other ways to have us reach out them. And so we have this suite of mobile applications, weve worked on helping providers treat them and so forth. Space is a challenge. So let me ask you this because i was really looking for a yes or a no, and it sounds like the answer is no. I wont put words in your mouth if the answer is, in fact, yes. Tell me. But the answer, it sounds like, is no. What i want to know, and you may not be able to answer it today, so ill take it for the record, i want to know what it will take to be able to see each one of those 17 veterans in terms of resources, in terms of planning, in terms of new facilities, in terms of agreements with Community Providers to take some of the pressure off the v. A. For what i would call noncore priorities. Arthritis is incredibly important to provide care for, so is diabetes, so is the flu. But if theres a Community Provider that could see veterans for those issues so we could focus our hiring, resources and care for, as dr. Roe said, an eminently preventable condition, then we should do that. We can prevent the loss of life. I cant they of anything think of anything more important for the v. A. To do. So my question for you and through you to the secretary, and i think each of us wants to see the answer, what will it take to see each of those 17 veterans . Now, it sounds like were going to have an updated number this summer. Yes. So if the number is 25 and only 4 of those 25, we want to know what the other 21 are going to do. Would you mind providing a full, detailed, accurate, honest answer to every member of this committee . Id be happy to do my best to get that answer to you, sir. You know, i took it when you asked me the question, do we have the capacity internally, and we do not have that capacity internally. When you mention Community Providers, we do have a network of Community Providers, but were not up to speed with 100 percent of them in that position so, yes, well take your question, and i promise you well give you the answer to the best of our ability. Thank you. I yield back. Thank you. Mr. Huelskamp. Thank you, mr. Chairman. I appreciate the opportunity to follow my colleague, mr. Orourke, who has done tremendous work on this, bringing it to the attention of the committee and recognizing the difficulties in his area which are not just there, but thank you. I want to follow up a little bit more on those questions you mentioned the network of Community Providers. Can you describe how the Choice Program has worked in terms of Mental Health care and meeting the needs of rural areas like mine and elsewhere across the country . So let me start with the Choice Program. I can talk about the Community Care that was provided and the number of appointments that have been provided by choice. Im going to speak in somewhat round numbers, but in the, in fiscal year 13 we had 16, over 16,000 appointments in the community. In fiscal year 14, 24,000. Fiscal year 15 we had 31,000 in the community and over 3. 4 thousand through choice. The Choice Program has grown. This year we have over 18,000 so so the Choice Program is growing, and were grateful for that. And i know our veterans are. And the numbers on choice, are those do you know which those are based on waiting too long versus distance requirements . That, sir, i do not know. Okay. I do not know. And do you have a general figure on the waiting time for those that and how do you calculate that in this particular situation . To rethind how we talk about wait times and to do that in a veterancentric way. He said really the only important measure of wait time is the veterans satisfaction with how quickly theyve been seen. And so that is the direction were moving toward in calculating how were doing with access. We have an online kind of or a kiosk means, im sorry, in which well assess veterans each day as theyre in our system and did they get the care they needed when they felt they needed it. And a similar question, we have what we use is the shep survey and other Health Care Systems ask the same question as part of the cap survey, but that question is was the care available to you when you needed it. And that really is how we need to think about access in a set irancentric way. We want to be transparent, sir, and we just feel like as weve gone through all the descriptions of create date, desired date, you know, all those, all those other descriptors, weve managed to confuse a lot of people. And really the most important person we want to satisfy is the veteran well, in this situation, its certainly not like other items in health care. Were dealing with suicide. Yes, sir. Obviously, a very serious matter. Im not saying the others are not, but so what is the number . I heard the long description how difficult. If you call and push 7, and youre one of the lucky 12 v. A. S, you dont have to dial the crisis hotline, how long does it take where for you to sa Mental Health care provider . And do you not have that number, or tell us. So, first of all, if you press 7 or you call the crisis line, that gets you to the crisis line where an assessment is made, is this an urgent situation just as was asked before. If the veteran is in urgent need and the veteran calls or comes to the Medical Center, our expectation is that that veteran is seen that day. Okay. They come to our emergency room, theyre seen. That day. An urgent need is seen that day. However, if they come to a place like a communitybased Outpatient Clinic and its, you know, after hours or something and the clinic is closed, we need to understand urgency there. Our expectation is that the Medical Center, the parent Medical Center has an emergency room where that person could be seen. Urgent, same day. But what if youre 200 miles away . So then if youre working through the crisis line, the expectation is that the crisis line assists you with getting the care you need, reaching out either to the Medical Center or to some, the Suicide Prevention coordinators in the Medical Center to arrange for that care. Urgent, the expectation but, again, and these are limited circumstances. But in rural areas i dont think you have the network in my area that you certainly have elsewhere. What do they do and im just curious, its individual as each oz of these probably is, you call the hotline, you say its an urgent situation, what do you do next . So caitlin, who has worked this hotline, will explain this. Yeah, certainly. This happens all the time. So you get that emergency person immediately to that person. If the v. A. Is 200 miles away, theyre going to immediately go to the closest facility, and all of that is coordinated with, between the crisis line and the local officials. Local officials sorry to dig boo this, but unless the Choice Program is working well, that which in some cases its not, youre just going to call when would you call . Who would you call . I think were talking about a couple of different things. But in terms of an imminent situation, someone says i am feeling suicidal, the Veterans Crisis line will get them to whoever is available at that moment, the closest person. And then they can coordinate that care afterwards. And i appreciate im sorry, mr. Chairman. Rural areas, and this is not just with veterans. Wheres the network . Id be curious in the state of kansas and elsewhere, show me who you would call because i doubt that you have a network up that you could pick up the phone and say i know how to call out in the middle of western kansas. And, again, were 200, 300 miles away and every other candidate expected to drive. If we could have some follow up in my particular area what do they do, because im hearing from veterans, folks who are active duty as well what do they do. Yep. And the phones not working in these emergency situations. And longterm as well, what do you to do after that . Exactly. What do you do two months later and youre in because thats yep, and thats the crux of Suicide Prevention. Ill look forward to thank you, mr. Chairman. I apologize. Thank you. Ms. Rice. Youre recognized. Thank you, mr. Chairman. Im going to direct this question to ms. Mccarthy. I have heard from many veterans who separated from the military with whats called an other than than honorable, right, discharge. We all know that, that was their designation. And these veterans were often the ones who are the most difficult to reach out to because depending on the discharge, they are not able to access many v. A. Services like health care, housing or employment help. Test test test test test test test underutilized and how can we expand them if they are being, if there is that demand there . Because they certainly are not just for those with that paper but with families as well. Their criteria is much more broad than the v. A. , and they can do a lot more. Ms. Ruocco, if i could just make a comment. I applaud you. I would imagine how i difficult it must be for you to get past what must have been enormous anger and to be able to deal with that and be sitting here and be such an advocate. I was at an event last night with an Organization Called penn fed, and theyport, obviously support, obviously, our veterans, but also last night one of the caregivers for a veteran was given an award or, and it was the mother of a Service Member who was severely wounded in his service. And i think its time that we, you know, maybe focus on help to caregivers as well because it is an enormous population that we ask a lot of, and you sacrifice an enormous amount, and i thank you very much. Thank you, mr. Chairman. Well, thank you for that. Thank you very much. Mr. Coffman, youre recognized. Mr. Chairman, appreciate the comments of congresswoman rice on this important issue of veterans being discharged under other than honorable conditions and being denied is access to Mental Health care from the v. A. Combat veterans with multiple tours of duty who, i think, in a very unfair way for particularly the United States army to conduct a reduction in force through signaling out singling out combat veterans who might have some disciplinary issues, often times we believe related to posttraumatic stress disorder and are discharged without any access to v. A. Mental health care is a recipe for problems in and of itself. So this legislation, and i know many of the members here, mr. Orourke, mr. Zeldin and others are cosponsoring this legislation. But we absolutely need to get that done. I want to the thank iava for being really a catalyst on this very important issue. Let me just pivot to i have a real concern that weve had testimony before this committee before concerning, concerning a drugcentric therapy. Form of treatment, modality of treatment. In fact, we had testimony of a veterans suicide where one, where i think a former Service Member was given a cocktail of drugs in response to treatment and then moved, relocated. The prescriptions ran out, was unable to navigate the bureaucracy to get those prescriptions refilled. And given the powerful nature of some of those drugs, took his own life. And then i think weve had testimony as well. In fact, i was with congressman lamborn in his district in Colorado Springs where we had testimony from parents of a marine who had served tours of duty, i think, in iraq and afghanistan, had left the service, went to the v. A. For Mental Health care. They gave him a very powerful drug that part of the directions on the drug were it required constant monitoring. He was not monitored. He subsequently took his life. And so i just think that this reliance on these very powerful drugs is a shortcut to treatment by the v. A. And i think its costing veteran lives. And i want you to respond to that. So, you know, im not prepared to talk about individual situations sure. But id be happy to talk about our expectation. When we had learned about some of these problems with people moving, weve made it really clear the expectation is that the meds continue. And that any barriers to that be broken down so that the meds would continue. So we appreciate that having been brought to our attention, and it is certainly our hope and our expectation that that particular problem is not occurring at this time. As far as treatments go, the evidencebased treatments for ptsd in particular include a cognitive behavioral therapy, prolongs exposure therapies prolonged exposure therapies, all therapies that do not involve medications. And its really important that the right kinds of treatments are used. As a provider, a psychiatrist who has treated veterans with ptsd, i know that often this despair and the frustration and the impatience that you see when you talk to a veteran leads you to think ive got to do something. And i think that leads to people at times making choices about meds that today might not otherwise make. Let me try this, let me try that, you know . There is no single pill thats a cure for well, it becomes a bill to get up in the morning, a pill to go to bed at night, and i think it has a very adverse cumulative effect. Let me just also mention i think its been brought, i think its been raised by this panel about the say can is in the v. A. In terms of vacancies in the v. A. In terms of Meantal Health providers. We had a very good round table with the leadership in this room not that long ago, and one thing that was interesting that was raised in that was how difficult it is for somebody who wants a job in the v. A. To navigate how long it takes to get is accepted by the v. A. And how long it takes to get placed by the v. A. And how significant the attrition rate is by those who start the process and those who simply cant afford to finish the process. And so its been raised that it was a function of compensation. I contend that its part of this bureaucracy that needs to be cleaned up. Mr. Chairman, i yield back. Thank you. Mr. Walz, youre recognized. Thank you, mr. Chairman. And thank you to all of you for being here. And to the v. A. , thank you on the clay hunt bill is near and dear to many in this room. I appreciate the v. A. s not just approaching to fulfill the letter of the law, but the spirit of the law. And for that you should be thanked, and im grateful. Also i think the things that have been spoken by my colleagues talking about veteran health care in a vacuum outside of health care in general is the wrong way to go about this. We know the v. A. Cant fix alone and certainly the veteran and the families cant fix it alone. That gives us the opportunity to find new ways to partner, to deliver care, to use best practices. And i will echo what mr. Orourke, the chairman and Ranking Member all said. Its obvious you have elevated this to the highest level. I think v. A. In general has to. When we see a list of 12 priorities, my suggestion is this better be near the top. And in that i ask the question, i think were asking weve been tracking this very closely, this legislation. My question though is it seem like the coordination might be something. And, dr. Mccarthy, i dont question it, i just wonder. I ask you is do we need to elevate the v. A. Suicide Prevention Office to the office of the secretary . Is that the first step we need to do on this just so that coordination is tighter . So thank you for that question. We are in the process of reorganizing the Suicide Prevention office and raising it higher in the organization right now and increasing the number of staff as well as the resources. When we talked about elevating it, at one point we did talk about a separate line item in the budget would effectively elevate it as well. But in any case, what we very much mow is that it needs know is that it needs to report higher in the organization. Dod has elevated it to the level of the secretary. Im not sure thats what were going to do. Dr. Caitlin thompson is our Suicide Prevention coordinator, and we are having her report directly through the undersecretary for health. And i think thats an important place given that in that position she will have the opportunity to reach across the aisle to vba and effectively parenter in with dod. Well, i certainly dont want us to interfere down to that level, but i do want everyone to know that dr. Thompson, i would like you to open up your office door to the secretary on this one if thats what it takes to do. A wonderful job when we get them in. Thats what many of the members are focused on. New york times reported on clay hunts unit itself, and the National Guard were seeing clusters. Weve got to get better at these clusters went theyre happening, and i know thats all tough stuff. All of you look at this from a coordinated, broader perspective, but there have been several mentions of groups that have been trying to get that coordination. I would humbly request that. These are folks ive worked with. Evidencebased results on this, and the question that mr. Huelskamp brought up, theres a head strong group up in new york you may be familiar with working with cornell university, they partier with the san diego v. A. , and they say theyre fabulous about saying we cant handle awe these, you guys need to handle them. Theyre getting almost immediate care. Its incredibly cost efficient, and theyre out there. So that was our vision of the clay hunt. That was the vision of where these groups are at. And i know dr. Roe brought in the center stone people that operate in the tennessee and indiana area. So i ask all of you, these are out there. Theyre doing it. Certainly what works for veterans is what works. We have to be evidencebased, we have to be costconscious. But the purpose of the clay hunt bill was get that peertopeer, get that out in the community. Do you feel its happening . You mention the games, we hear names, we hear team rubicon. I think that model is a working one. We fully agree, and we do reach out. We are partnering with our folks at the table here often and in addition with partners in the community. So, yes. I would say that theres some really Amazing Things happening all over the country amazing. Like in massachusetts, the Home Base Program which is taking in, educating, giving free treatment, and theres vets for warriors, peerbased 24 7 callins, those people are verging those gaps. Youre right, really give them some funding i think it goes back into the v. A. Is the medical home of the coordinating center with dr. Thompson, but using those groups almost rapidly and seamlessly. Both dr. Maffucci and i in february called for a strengthening of that coordination and, in fact, okay . Dr. Carolyn clancy was named cochair of the National Alliance for Suicide Prevention. Okay in and as a member of the executive committee, there could be some stronger efforts by our v. A. Partners in pushing that message out because theyve got all those connections with some of the groups, most of the groups that you mentioned. Theyre building networks. I know my times over. I just think theres a golden opportunity here, and its not a critique on this. I think this is moving in a direction that many of us wanted to see, this seamless use, the building the networks. We can streamline the hiring, all that, thats not going to make all the difference. I thank you. Thanks, chairman. Mr. Zeldin, youre recognized. Well, thank you, mr. Chairman. Dr. Mccarthy, so i served four years on active duty. Ive been in the reserves since 2007. Ive lost more people ive known in the service due to ptsd than i have in combat. And its impacted my home county pretty hard. I represent suffolk county. We not only have the highest veterans population of any county in the state, were second highest of any county in the country. And there was some conversation earlier pretty much many your Opening Statements in your Opening Statements, you were getting at peer support. And i just want to get an idea of what kind of a model you may be considering if not doing already as far as peer support groups. So id like to turn to dr. Kudler to describe this. Thank you. V. A. Has been hiring and training peer support specialists. The 990 or so we have doesnt include about a hundred global war on terrorism outreach workers at the vet centers around the country. And we train them to run groups, to be in waiting rooms, to look for people who are agitated and in some places in Emergency Departments, for instance, at the phoenix v. A. Now has a peer support person in the e. D. To kind of hang out and wait for people who maybe might want to walk out before their wait time ends. And we are training them to do therapy, were tray training to help them with support work. And by the way, we also have a lot of peer volunteers who work for us in veterans justice outreach, working with people involved in the criminal Justice System that end up funneling down into the nations largest Mental Health system, our prisons and jails. And v. A. Has become an incredibly active partner in reaching that population largely through peers. And i do understand that your peer specialists do a lot, and as more so so than i would have list, obviously, because youre intimately familiar. I do understand your peer specialists do a lot of that. Im getting feedback that there arent as many peer support groups that, as necessary. I think youre right. And i think v. A. Can be in many ways the hub that can help generate more peer support. The clay hunt act asked us to partner with Community Peer organizations where they existed, and we are doing that and trying to enlarge on what clay hunt asked for. I think we could be doing more. We developed a peer support Specialist Training that i think we could be sharing with other groups, and i think particularly for guard and reserve. Ive been to suffolk county, im from queens. But i worked with military members and reserve units there, and i think that peer support could be key in working yeah. Peer supports important. In suffolk county, we are over one of a dozen counties in new york state. We have a program well put 8, 10, 12 veterans in one room because people feel isolated and alone, they dont realize that someone around the block is going through what theyre going through. People at work may not understand, friends dont understand. So its very important to create that peer group setting. Also a lot of people may live at a distance from a v. A. Hospital, so having support groups out in the community is incredibly important. One of the things that i have noticed while serving on this committee, we have had many representatives from the v. A. Come before this committee. This is my first term in congress. Ive only been able to experience this a little over a year. A lot of the Opening Statements that we hear from the v. A. Representatives are telling the committee about everything that is working to create this picture of the v. A. As if its perfect. And we all know its not. And what was stated by dr. Mccarthy was i want to be transparent. Quote, want to be transparent. And what we hear from our constituents with regard to veteran crisis line, calling a patient advocate and getting a voicemail, in some cases not getting a callback, the denver v. A. Hospital construction project, last year there was a last minute bailout where, obviously, the fiscal situation could have been brought to this committees attention earlier. A backlog of appeals where a backlog of claims is reduced just creating a backlog of appeals. We hear constituents with individual cases where their ducks are lined up, paperworks in order and theyre still waiting. We read the usa today report a few weeks ago where supervisors are instructing employees to falsify wait time lists. I would just one observation from one freshman member of this particular committee, i think in the effort of wanting to be transparent, it would be very helpful if when you are coming to the committee right out of the gate youre telling us what needs to be fixed as opposed to this committee having to pull it out of you. I yield back. Mr. Mcnerney . Well, i thank the chairman. This is a difficult and humbling subject, so i tread on it carefully. Im going to ask, im going to direct most of my questions to you, dr. Maffucci, but i ask anyone else on the panel to jump in they have answers. Dr if they have answers. Dr. Maffucci, you referred to the clay hunt s. A. V. E. Act as a step in the right direction. What specifically in that law is working that we can expand upon . So i also alluded to in my testimony this year has really been the foundation. We have been, the communitys been included in conversations with v. A. About how do we do this right. Because its one thing to do it, but its and our intention was always not to just get a law passed, it was to make sure that it was implemented correctly. So i think, certainly, going through the evaluations process. I previously worked in the pentagon, worked for dod, and i was on the army Suicide Prevention task force for about two and a half years, and the army went through this. And it took them a good three or four years to kind of process, figure out how to go through evaluating their Mental Health programs. Its something thats not done within the Mental Health world. There are no standards that are required. There are no metrics that are standardized. And so it makes these kinds of Program Evaluations really challenging. But our vision for the clay hunt s. A. V. E. Act was to ask the v. A. To step up and set those standards and work with dod to do that, because dod has the same requirements. So im really, were really excited about the evaluationings piece. Evaluations piece. Certainly with the Loan Repayment Program for psychiatrists, we were hoping that that wouldnt, would get, would get implemented more quickly. I understand theres been some challenges with changing the law, basically, to allow that. But i think that, too, noting that one of the challenges to v. A. Hiring is the low salis, the more that salaries, the more that the v. A. Can provide those incentives and match the private sector, if you will, the more competitive they can be to bring in those professionals. So that was another piece were really excited about. And then, certainly, the partnerships. Up until recently, up until this secretary mcdonald came into leadership at v. A. , partnerships was not a word that the v. A. Uttered. And so that in and of itself over the last two years is immense. And we hope to see that term and the implementation of what that term is really working to make sure that those partnerships expand in a really innovative way. Weve seen a lot of really positive interaction between v. A. , iava, the others at this table. Its going to take time. And, unfortunately, thats just the way it is. But i think we all feel, if i can speak for the others on the panel, we all feel that were moving in the right direction, that the momentums there, the motivations there. Theres a different energy, and were doing this. Like i said in my testimony, weve stopped talking about, were actually doing things. Well, one of the things, the buzzwords these days is evidencebased. Of course, suicide, its very difficult to get sort of trials or anything like that. But data sharing can be extremely important not only in this issue, but with regard to posttraumatic stress and traumatic brain injuries. What are the obstacles were facing with regard to data sharing in anyone on the panel. So one of the challenges which as a taxpayer doesnt make sense to me that most of the data thats paid for with taxpayer dollars is not shared. This is actually, i believe i heard dr. Shell kin commit the v. A. To opening up the v. A. s vaults and insuring they figure out how to make sure that the data that the v. A. Holds is shared across the research community. These are dollars that the taxpayers have already put forward to get that research, to get that data, and i can i promise you that there are other researchers out there that are just chomping at the bit to get at it and to help and to do their part. Are the hipaa laws part of the i think thats part of the concern, is the hipaa, and how do you balance needing to know certain information with also protecting the patients identity. So so thats certainly a challenge. But i would also say in my own personal opinion i think there is hipaa is often called upon as, like, the scary elephant in the room, right . When people want to, when people are worried about data sharing for whatever reason, often hipaa is the primary reason put forward. And the law itself often gets interpreted wrong. Mr. Chairman, perhaps we could assemble a group of experts to decide how to use data sharing and not violate hipaa intent. Absolutely. Great, great idea. I yield back. I appreciate it. Ms. [inaudible] do you have any comments . Thank you, mr. Chairman. First of all, all of this information has been tremendously useful, and i want to thank you all for being here today. I also wanted to associate myself with ms. Coffman and mr. Coffman and ms. Rices concerns about the Honorable Discharge veterans. Do you think that the va does a sufficient job to supporting the Family Members are veterans who died by suicide and if not, how can the va improve in that area . There are all of these problems that the veterans are going through the same thing. And actually in the past, as far as this goes they were on active duty. And we are working with an understanding and so they provided very comprehensive care and we have peer support and also we are connecting them to trauma support, counseling any kind of benefits issues, anything like that. So we are moving in a direction where we are doing better about that. What we hear from the families is that they would like to be more involved before there is a debt. Because they feel like they are at home struggling with veterans that are very sick and there is a real need for the va to work closely with family, we are working with people that can guide them and support them through the process. Thank you, doctor abraham. Thank you, you are recognized. This is a most important hearing. I thank you. When i was fortunate enough to be a part of this. We were told the first day that 22 veterans committed suicide and if they could get into the va system we can certainly could certainly reduce that. We hear these the same numbers today. And come on, we have to do better than this. And so we need more planning. And you guys at the table right now, a pen and a pencil. In about two hours you can come up with a plan and you know how to fix this. And i know that this probably goes above the level of implementation and the movement. But we are dealing with this every day and i have physicians better in my district and in my state. [inaudible] and these are positions that are with the medical boards, they graduated from wellknown universities and that is all you need. And we are bringing these people in and getting these people help in the community. They mentioned that they are still talking to each other and if they duplicate this, from one doctor to another, or if they have medicine that is an interaction, you have Serious Problems very quickly. But the chairman made a comment of why this program has been talking about this phone system. You know the secretary and you know that the individuals have the ability to move manpower. So why do you need to study this and why do we need this pilot program. Lets try something. Because what we have tried since i have been here has not been like this. And we are dealing with peoples lives every day. So the frustration, we need to quit talking and we need to do something productive here. The individual mention the families and i would say that we have talked about hipaa. If you cant share whats i suppose the where, and when that veteran comes in, i understand hipaa compliance. I also understand what it takes to put that on the form. I understand that when that veteran comes in, hipaa can limit information, 90 times out of a 100 they are going to say put them on the list. And we know that they are more intelligent than i am. And we understand that family is the first person in the first unit that recognizes when this veteran is in a bind. These are the ones that can reach out. And we have got to incorporate them. You guys have got to get them in the va system so that they can help and when they do see this they can call and just comments, again, i will take any comments that you have. Thank you for bringing that up. That is really important. All of these families told me that they wish they wouldve had the same treatment. And they have incentive support psychiatrists. They do not do other treatments for ptsd. So we have to get the providers to give the treatment that these guys need to. These men and women that are coming back with these types of injuries. And that is part of it as well. Doctor berger, do you have any comments . I think that my colleague is right on with it. And i also want to say that their effort needs to be more of a national ordination. This is a national Public Health problem and we can focus on that. What is important is that the va needs to take a leadership role in this and the court made it. They have practices, they have standards and etc. Do it. I know that it is going to burden the shop, and doctor mccarthys shop, lets find the money. Lets do it. Doctor lindstrom. Thank you, mr. Chairman. I appreciate you being here today. And we talked about that number 22 which we have had that over and over again. With that limited psychology background which is an undergraduate degree, negativity over and over again is not helping in this situation, creating awareness which was very much needed. And i hope we take a turn in the other direction. Not only with the va but the public in general. And i also found it intriguing and hopeful that as more people get into care, the rate drops. That is the bottom line. Another interesting point that it is not really just being deployed, it is a nonemployee in which you just mentioned as we have had this weighed on my mind all the time. Just in this neighborhood where i grew up, uppermiddleclass, the three families that had suicide, they went to good schools. The things that you would think would be the underlying factors. It is not just in the military. The military can lead on this with the opportunity to do that. But this is more than that. You mentioned the hipaa restrictions and the doctor who is a navy veteran, psychologist, he has a very good situation, i encourage you to take a look at it from the standpoint of being able to engage the family more readily and i think that that will help us not only at the va and also in the society. And you dont see many suicides taking place in theaters. They happen after. My feeling is that you are engaged and you have a purpose. And i think that when that purpose and we are seeing that you were not in combat. Now we are starting to get it. And is it important that we get people involved and that is probably the case on the civilian side as well. I would love love for you to weigh in on those thoughts. I still appreciate what you said. We need to approach it in the same way that we prevent Heart Disease and it doesnt start with that crisis line and it doesnt start in that urgent situation. Sometimes it does. But we really need to take a step ahead of time. An increasing awareness is important and making it a discussable issue is also important. Because what comes from the stigma is a big piece of it. We agree with you and we are happy to work with you. We have partnered with the federal agencies with cms and so forth to address this because of the national crisis. But it is veterans as well. Just yesterday at the Invictus Games which was mentioned earlier, they have changed the direction. Prince harry also made a video about this. The idea is to develop basic Mental Health literacy for all americans. And they dont know where to go when they have a Mental Health problem and they dont know if they should be speaking about this. And so we are partnering to create a National Rollout of a Mental Health producer which we believe will help this with future generations and all americans. [inaudible] family connections as well as veteran connections not just in the va but also having a program that works so well out into the community as well and it that is other locations so that they can bring them in. [inaudible] and if they dont understand the treatment, you have lost at the beginning. We know that the sense of purpose and sense of belonging is protected and suicide is one of the big losses that the military had. And within the communities this is really important. And obviously i can mentor this fallen comrade. Isnt that right . And this is where we keep them connecting with one another. With connecting them, we see people becoming at risk. But they are connected to other people and it is a place where other people noticed it. And so building those kinds of things all over the country will help support what the va is doing. Prevention is always wonderful if you can do it. And i think that we are getting some signs with what will work. You have art he heard my comments about the va taking a leadership role. In a larger sense and maybe it shows my scientific nerdiness, you cannot manage what you do not measure. A number of people passing through the program does not tell you whether the Program Works or not. From our own member survey, our members, 80 , over 80 have told us that they received transitioning challenges in the top three challenges that have been identified, number one is loss of identity or purpose. We actually know from our survey that from those that took part, 65 will not have a job when they left the military. And so jobs often give us purpose, careers give us purpose. Finally, the third one is Mental Health concerns. We do know within our population some of the pieces are within our membership, some of the pieces that are challenged with in transition and the Peer Support Program, getting individuals connected and while they are still on base. And that includes dod, to allow these programs. In one of the things that they have not provided and i dont believe they have done so from my inquiries is how that is being utilized. And what does that look like. And that will be really important and so have is that work with the organizations here before they leave them in the institution. Thank you, my time is expired. Thank you so much. The final questions from the Ranking Member, mr. Browns. Thank you. Thank you, it is very educational. I want to answer some questions that i didnt really give the answers to. The first is i think that is wonderful but it should be when we tackle homelessness, when we were able to engage the community and the va took the lead, we brought that down. And i think that we can do the same with leadership. And so the Veterans Crisis hotline has come under scrutiny and it has been realigned and i felt that they were on the right track. And Everybody Knows that they do an excellent job. They know that they should do this and all of this, the peertopeer and then the training of the va is different from peertopeer and to me it is in the community and they do an excellent job. I have not heard enough of that with the female veterans. I have had several with them, and we have come up with the womens Veterans Memorial that we do every year, but they are not educated with what services are available. I dont understand why the women get such a fall out. They dont know what services are available and they dont really use them as a part of the system. So we really need to do some work in that area and we do want to hear about the Vietnam Veterans because when i went to this conference that is the one area that stood out. Saying that the Vietnam Veterans are one of the highest groups committing suicide. Because when they came back and so we need some special reach out. So the last thing that i want to mention is that we would like to give scholarships in that area. And to give them not just this but social work in other areas. And of course, to get the systems, maybe you need a doctor. But some of us may need the entry level to be referred to a doctor. So with that, i want to hear from everybody. I will start on the sand and then we will keep going. We have gotten very loud and clear the message about the 12 priorities. So we thank you for communicating that very effectively. We agreed that the crisis line has been reorganized. And we are really pleased that therell be a total of 343 responders. I definitely feel like that is moving in the right direction and the lines of that group is right in place. We thank you for celebrating and we are very celebrated about this and we are very happy to be key partners. We need to do better. We need to have a welcoming environment. We have heard from them what sometimes is perceived is less than welcoming. We need to fix what that is. In addition, we welcome all the help in getting the word out about the va being there for them. We have a Communications Campaign and we have done a lot with images to improve them. We are also looking at how inclusive we are in treatment programs and Research Studies and everything else. And so the vietnam vets, as they rolled out the celebration, we have been awarding a number of veterans welcome home medals recognizing 50 years of service including some of our own employees who continued in ways that i have never seen. We would like to say welcome home to them as a nation. We do that individually, but to have that 50 Year Anniversary be a reason to do it is a really important thing. We agree about college and scholarships and i will pass this on to the rest of the panel. One thing that i hear from the families all the time is that they worry how their loved one dies, that it will kind of be what people focus on and they forget how they lived. Many of the families and in my testimony, there are stories of the families. They went into the military and they were healthy and strong and did several tours. It wasnt until after they had that exposure and had drinking and other issues. That got them less than Honorable Discharges and other things. So we really have to look at what are we asking these human beings to do. Lets provide them the kind of Mental Health care that they deserved. Deserve. After all of these exposures. And another challenge is that vet centers are doing really well for our Family Members. But you have to go to the combat zone. This is another faulty situation. If we know in the active duty, 50 of the people that died of suicide have never been in combat. They are struggling with other things and they may have been held back from combat because of their struggles. They are not eligible for this care. So we have the people that do not fit in to those things as well. Thank you. Thank you, congresswoman. Your comments related to the vietnam vets. Back in march, the secretary issued the va, and she publicly announced issues dealing with suicide. And one of those quoted the va. And that includes that they need to work on Suicide Prevention. They need to, as i said earlier, to develop a nationwide strategy to address the issues of suicide among our older veterans. There are many risk factors that we share. What is it that sets us apart and makes us take our lives more frequently according to the 2013 data. Hearings have been held, bills have been introduced. [inaudible] in regard to Women Veterans, once you get them into the va, they are doing much better and that includes how do you get those from other military errors. It resolves in a much higher rate than being part of the system and that includes Women Veterans that have felt neglected and isolated. We have been preparing to rollout the campaign focused on Women Veterans. And apparently we have had meetings, some of our Women Veterans are members as well as the survey that was set out beyond membership. Really to trying to understand what the challenges are, for myself, my first question was, are the challenges that Women Veterans facing different from their compatriots, or are they the same, and if they are the same, what do we do if they are different . And i think that one of the women that i spoke with summit of the best. And the Women Veterans are having challenges finding resources. A few things from the survey findings, and from those conversations that i wanted to share. The Women Veterans are self identifying. They are proud to be veterans. But they are also tired of the fact that they are veterans to the nation at large. Being challenged when they come out, they have told people that they are veterans. They are having a look of disbelief were questions. This is a cultural change first and foremost. It is the nation. We all need to recognize that women are growing in the forces, they are growing and the veteran community. They are serving right next to the men as well. On the on the topic of your support. That is something that our survey showed that women want other women and a Peer Support Program. You know, just understanding to what degree are we a part of this. Are we making sure that these are available . This is something that we are going to keep working on. It is critical within the va and also outside of the va to create that network of peer support so that women can find other women, share their stories and know that they are not alone. And the Research Piece is critical. And across the federal agencies, there is not a requirement to look at programs and look at gender analyses and age analyses and some of the other covariates that occur when you want to understand the programs. It is past time that the federal agencies at large start to recognize that it is not just about that big picture. We have to start understanding the populations within the population at large. Thank you very much. Thank you to our panelists for being here today. All members have five days to revise and extend their remarks. With that, this hearing is adjourned. [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations] [inaudible conversations]