Transcripts For CSPAN2 VA Secretary Shulkin Testifies On Veterans Suicide Prevention 20170928

Order. Thank you for coming today especially the witnesses we have a number of witnesses available todays hearing is about the issue of suicide. As many people know this month in Americas National Suicide Prevention month across the country terrible wasteful loss of life they think john will remember when we first came in three years ago the first bill we passed was a Suicide Prevention bill that passed and if they could get any report they might have on the progress on the implementation in terms of automatic but its very important. I held a hearing at Georgia State university as a member of this committee. As they feel dishing hearing on the issue of suicide th suicidey redesigned it is in that year from leading up to august, 2014, the georgia principal hospital in claremont road i indicator hd three suicides, to oncampus and on the mishandling of available tools for suicide Like Pharmaceuticals and things of that nature and others were like awareness to improve the response to suicide and Mental Health issues. Suicide is a disease and it is preventable. Its been through the safe training for Suicide Prevention. It stands for suicide thinking should be recognized and asks the most important questions of all are you thinking about committing suicide which is a tough thing to address. To encourage treatment and expedite getting help and i can tell you from what we learned in atlanta and in the va, timing is everything as it is in healthcare. You expedite the response and just like the heimlich maneuver safely when somebody was choking and someone else knew how to apply it, just like it helps people that have on timely heart attacks and people that might be drowning more might have drowned and brought back to life, but being aware of the training that is necessary to save a life is critically important. We will see to it that we promote this throughout the va and throughout the government is to it that we are saving lives and helping people recover and restore their life and i want to thank you for your commitment to the Staff Members for having done it and think the members of the committee for their effort as well. We have two panels on the issue, first is the assistant Inspector General for Health Inspections and second days doctor craig bryant at the center for National Veteran studies university of utah and the executive director of the alliance for montana we place all three of you here today you will be allowed to give up to five minutes of testimony. After ten you will be in big trouble. All your statements will be printed for the record and withs episode we will start with you and go down the list from there. Thank you Ranking Member isakson and members of the committee is an honor to testify today on the subject of Suicide Prevention. This topic is important to mr. Russell and all of the staff. We work to ensure veterans of the highest quality Mental Health care. We have reviewed the facts surrounding the deaths of many veterans who took their own lives. Often we find a suffer the effects of chronic Mental Illness and Substance Use disorder. In the aftermath of these deaths, we frequently hear from members of the veteran family, significant friends in pa providers that they would have acted differently if only they had no. After the Virginia Tech incident it impacted the disclosure of medical information that was undertaken. My staff met with and talked with a number of individuals involved in this review. To determine if there were Lessons Learned that could be applied to the va. It seemed too difficult to design but the practices or similar devices may offer a way to improve communication at the critical point when the patient needs help the most. I think there is a chance to improve by expanding the situations under which these and similar devices are used. They thoughtfully derived the model and the question is when thwould an atrisk veteran take action to harm themselves or others. When word intervention be most effective . Research using social media and timely data has shown promise in understanding the human emotional state and therefore may assist in identifying when these atrisk individuals with the most successful. This has great potential. The testimony of others at the table point out that many veterans do not obtain their terror primarily from the va Hospital System and so an effort to reach those veterans who are at risk is most appropriate and essential if we are to make a significant improvement in veterans suicide data. This concludes my testimony and i would be pleased to answer your questions. Mr. Chairman and members of the committee i appreciate the opportunity to discuss advances in recent Suicide Prevention. I will not read in full that i will highlight a couple of key points. The response the va has adopted and implemented numerous measures intended to prevent suicides among veterans. These have led to improved access to care to serve as an example of how an agency can address the cause of Suicide Prevention. The studies reported that these outcomes among military personnel veterans for bush in the past years. Most of the studies in the murder military personnel are applicable to the veteran community as a whole. As summarized in the attachment, all of the interventions reduced suicide but only two are associated with significant reductions in suicidal behavior. The behavioral therapy and crisis respons response planninh are found to reduce the behavior by 60 to 76 . They are the only strategies shown scientifically to reduce suicidal behavior among those that have served in the military. The treatments now serve as a foundation for many studies underway in the va as well as the dod. These not only confirmed the suicidal behavior can be prevented among the military personnel and veterans and shows how to do it. If these studies tell us anything its that they work better than others and simple things save lives. Today will focu we focus on oner barrier. Two studies highlight this issue. The studys researchers found that a Suicide Prevention strategy used was not associated in subsequent reductions in suicidal behavior as expected. The training could actually change this course. The problem is not confined to the va. Tragically it is endemic across the nations Mental Health professional Training System. The recent report from the American Association highlights this issue. The Main Findings are also summarized in the attachment to the testimony. As you can see a shockingly low number of Mental Health Training Programs provide any education or training about this fight is too dense. They typically do not require exams were devastation of intervention. The majority of the Mental Health professionals are unprepared to effectively intervene with suicidal veterans. This has critical implications for all veterans cant both within and outside of the va. Weve long talked about the many barriers that stand in the way of a veteran receiving Mental Health treatment and have invested heavily in removing those barriers. What unsettles me the most as a veteran is knowing that when a federal fell in pcs these, sobering and uncomfortable truth is that weve made it easier for the veteran something treatment that doesnt work, especially those who receive services from non pa providers and their communities. If we want veterans to benefit we need to ensure implementation is accompanied by a comprehensive and Robust Training Program and the past few years also led to considerable advances in the most effective ways of teaching these methods to others. Much of this knowledge has been obtained by the va and the research. In order to reverse the trend of a Veterans Society must think bold and be willing to disrupt the status quo. We need to adopt the strategies that have gone with the most support even though they may depart from existing procedures. We need to invest more heavily in Training Clinicians to use these procedures and create new initiatives to incentivize and support their implementation in the critical settings. These should not just target that all clinicians in all settings as well as the universities and their Training Programs that are responsible for the readiness and preparedness of the mentalHealth Professionals. In conclusion, we are at a critical turning point for veteran Suicide Prevention. The answers are clear they have been identified and we must now take the steps needed to ensure the treatments and interventions are easily available to all veterans, both within the va and in our communities. Thank you very much. The appreciate your testimony. Now from the great state of montana. Distinguished members of the committee, on behalf i would like to extend our gratitude for the opportunity to share our views and recommendations. We applaud the committees dedication and addressing the Critical Issues around the veteran suicide as someone who personally lost a Family Member that was a veteran i just want to appreciate my sincere thanks. With 68. 6 per 100,000 visits significantly higher than the suicide rate in the western region. As an organization thats emerged in Suicide Prevention, we think it is very important that you have a framework to understand suicide and the model that we use a combination of biological susceptibility and environmental factors then lead to malfunctioning communications which develop into suicidal behaviors and other symptoms. Examples are the factors of biological susceptibility or genetics and trauma come examples on the environmental side are Emotional Trauma but on the positive, therapy and the support of family. Yofamily. Youll notyou will note that i e covered in lethal means restrictions because i believe that it is incredibly hard to legislate that, but it is an important factor. Montana is a rural state with an average of fewer persons files for this creates unique challenges for Health Care Providers and we are deeply in thneed of more Mental Health providers. Proven to reduce suicide during critical points of the military and veterans experience, montana was influential in bringing awareness and we would like to offer that as a template of something that is proven to work in another population. The second recommendation established a policy goal to improve the diagnostic system, the target that they recommend to the committee is that it hass the va to work with the department of defense, the National Institute of Mental Health, and private partners to identify and prepare to additional brain diagnostic measurements for clinical work in the va by the fall of 2020. The next recordation is to develop a plan for treatment resistant mental conditions. Roughly one third of Mental Health conditions do not respond to traditional treatments and this is a big issue that is not addressed in montana. They have nothing in our state to address treatment, this is personal to me because i lost a dear friend and who was a is a n in september 2015 to resist and to watch his options slowly slip away is one of the hardest things ive ever seen. Montana blue cross and blue shield supports treatment and i do not buy montana va does not. The next recommendation expands access to tell the psychiatry and then makes online behavioral therapy available to all veterans. We also believe that the va should expand the availability of automated suicide risk assessments to do that with a prize to create and update a medical screening tool to determine which patients are at risk of developing side effects from clozapine and develop a public facing Online Research directory for non va resources and create a more synergistic relationship between the va and community Mental Health centers over 1300 community Health Centers across the country, and we should be working with those to care for our veterans. Increase via collaboration with outside researchers and finally, establish a continuity of care pipeline for veterans directly from the department of defense to the kind of Community Providers. Thank you again for the opportunity to provide and your attention to this issue means a lot to me and the entire organization and their families. We appreciate your being here today and what im going to do is reserve my time since we have three members here and i will go straight to the members questions and ask mine later when senator tester returns. Let me start off with the gentleman from arkansas. Thank you mr. Chairman for holding such an important hearing and again also to senator tester i cant think of anything more important to discuss. We all agree that this is a crisis. In arkansas i think we are number ten in the suicide rate overall. Of that group, veterans represent about 8 of the population is represented up 20 of the suicide, so we are a state that is like so much of the rest of the country experiencing significant problems. You mentioned that with recent reports that highlight the inadequacies of the nations medical Health Profession training and in fact i was looking at the charge 15 of psychologists, 25 of social workers, marriage counselors, 28 of psychiatrists only those have received what he called even the oldfashioned training perhaps, not to mention the work that you and others are doing in such a good way. Those are pretty standard. How do we go about unless we have a metric out there how do we go about solving the problem as you are thinking about that and the rest of you can jump in. Once we have done the research and lead to perhaps get in the truck, how do we get that dot talked about but instituted in a timely manner . Good questions. First is a bigger question i will admit this is a huge issue that we are probably requiring in a concerted effort and redefining and reengineering of education and Training System and professional practice of Mental Health. We would need to find ways to incentivize into the initiatives to encourage certain types of curriculum and also partnering and working alongside various accreditation bodies to look at how do we determine. Many of us talk about how we find opportunities to have researchers and scientists work with Communications Experts only to the general public also to other professionals. Of those probabl that we want tt to be using these strategies but also the consumer, so the consumer is educated and understands which treatments work best. So when they go to a Healthcare Provider they can ask direct questions to determine if this is an individual that is likely to be able to help me. Yes sir, go ahead. One of the things we found to be important as getting the research to the states, creating a pipeline to have those conversations with the start of a Research Center in montana to make that happen because of the way that the structures are centralized in the research we probably will never have va research doing much in montana but if that pipeline is adjusted, that gets those conversations started and get people trained. The other thing i would recommend is for the va to make its treatment algorithms for veterans more widely available, i think that transition to the medical record is going to make that more possible. Get those treatment algorithms onto the field so people in the facilities can use them. Is overmedication a problem i would say my response on the overmedication is broad. What we would see for instance a student of mine just finished a dissertation about to publish the results with a larger than expected proportion of veterans that receive diazepam despite being diagnosed with depression and it is not effective treatment for ptsd. Often times, physicians and other prescribers rely on these because the previous treatments have not worked and so they are hoping to provide some kind of symptom relief. The unfortunate aspect is in those cases the veterans are almost three times as likely to die by suicide so theres another risk associated where i dont know if they are overprescribed but im not necessarily certain that in all cases that are intended to prescribers are aware of all the risks and are able to weigh them out with the benefits of those medications. Thank you mr. Chairman. Thank you senator. I would point out one of leaderof theleaders in that bilt book on that in the last congress. Thank you mr. Congress man. I was and hed believed democratic cosponsor along with senator john mccain on the republican side and believe that it was a start but only a first step in this effort and much more needs to be done. Obviously there are steps that have been taken in furthering this effort and i know people here from the doctor later. One of the very important statistics in your testimony is the suicide rate among veterans who do not use the services increased by 39 between 2001 and 2014 was among users increased bthe usersincreased bt aside the exact numbers but i am hearing again and again is that the suicide rates are increasing among because of the other difficulties in reaching these services often undiagnosed and separated less than honorably and have been cashed out and barred from using the services and often feel stigmatized and disengaged not only from the va but from the society in general. Ive met with many of them had worked with the department of defense on the review process which has been changed as a result of leadership commendably but many of those veterans who were discharged less than honorably, they dont know about the change in policy and access to the services, so it is a vicious cycle, a lethal cycle which can lead to suicide, so i guess my question to all of you not only about the less than honorably discharged veteran but when a in veterans who also perhaps do not readily access the services and their suicide rates are increasing, those segments of the veteran community whose suicide rates are increasing need to be reached and my question to each of you is do you see that phenomenon as real, do you recognize it and can you elaborate what your recommendations are for addressing . I agree with you. I think the adequate treatment of Substance Abuse disorder and access to therapy and the adequate treatment of depression as was indicated to include pharmacological treatment and maybe others that are available i think is critical, so if you cant get people to a competent provider it is a difficult problem so i would agree with your statement. Two thoughts in response. The first of which i think what the statistics highlight is the rates are going up but its a slower rate so if they are doing something good that is not happening for those who do not receive the services so a common question is how do we get more veterans into the va and i think that is an important question to the other question i think we need to ask is why are there not adequate Services Available to the veterans in the communities and i think this came a in froma super bowl years ago in the New York Times article about the marine who had a suicid suicides and a lot of them didnt have access to the va and theres a lot of discussion about that and i said the implication of this is some have access to nothing or they have access to Community Providers that have little to no experience working with servicemember veterans they dont know how to treat ptsd. Theyve never seen traumatic brain injury before and they have no experience with suicide risk and so i think part of the solution will be how do we get more veterans into the va because as the recently released the quality of care for Mental Health exceeds that in the private sector but for those who do not access, some veterans choose not to. The va sometimes sends their patients to us for treatment and there are some who cannot go to the va and come to us and we can sometimes connect them for other services and benefits. It is a big issue if i will point out that was solved in montana and improved by adding a data center to the community it at the time they thought it because they said you will already have a hospital. Everybody that would go to the centers are already going to the hospital and that turned out not to be true. I think part of it is when you are depressed and have ptsd the first thing is bureaucracy and you just quit. You face bureaucracy and face the red tape and if you give up, they have less bureaucracy. Thats part o of buddhism what n in the statistics a is the folks that give up they say i cant mentally take it. I hope that we can get the latest numbers on the suicide rate between the va users and the nonusers. I sponsored legislation with my colleague. We will be hearing from him but on all accounts, the nation needs to do better. Thank you. We are going to take question by appearance and the next three will be senator manchin and senator sullivan. Mr. Chairman, thank you. Thank you for this hearing. I want to thank those of the witnesses for being here today and especially senator tester because this is an issue that is important to montana and its important that they beat us in this statistics. The question that i continue to ask myself is what makes montana and nevada unique. I will start with you on yuv cds stress is maybe stresses may bee unique than the rest of the country. If i had the perfect answer for that i would probably be making a lot more money. But, i would tell you that just to see what is there we have higher access to the lethal means in our state for the most part when you are suicidal the closer you are to committing suicide is very real. We also have a lot of veterans per capita in our communities thats important. Important. Another thing that is different about the suicide trend and i dont know if it is the same for nevada, we have older veterans that are killing themselves and i think that theres National Trends saying its younger but if you look at montana aged 30 to 65 is when they were losing them and maybe it is just a way out. A lot of people in a population group. A lot of the communitys struggle so i think it is a number of different factors and weve got to tackle one at a time. We had him in the states just a month ago and he expressed his efforts to tackle this particular problem we have hospitals both the north south end of the state and a number of clinics that have been opened recently because of the efforts and the work of the secretary and the va. Let me ask you com, the resiliey program in israel where they try to get this on the front end instead of the back and where they treat the soldiers both male and female of trying to avoid some of the stressful situations they may find themselves in, are we doing the same thing here . I would say in general, yes if you look at military training in general, a lot of it is designed to foster resiliency and how to endure and managed stress etc. Where we have not had much success is where we try to develop new programs that take more of a classroom format where we bring in outside experts who then teach or train trainers within the units, resiliency experts who are then supposed to go and teach these concepts and skills and others in the unit. Thereve been a number of barriers to that with some of the research that has been done on the larger resiliency programs, such as the country as a soldier for this has yielded no benefit. We have seen some progress, however, in other methods. The one that garnered the greatest is the army called battle mind that was shown to prevent or reduce a small but noticeable degree among those that have the greatest and most intense levels of exposure while deployed which if you think about it makes sense where we found the defect were the ones who needed it the most and have the highest level of trot exposure. So we have a couple of evidences suggesting that they might help to reduce or prevent the severity. Theres a bunch of signs and conditions and now refer someone to a mentalhealt Mental Health, but what we lack is what do the Family Members do. So if they suffer from ptsd and do not want to go to treatment or there is a two week wait what are you supposed to do in the meantime if we didnt block out the programs training that. Now the new research i mentioned before this is something we have been teaching the Family Members and specialists. Weve been teaching them on Health Care Providers who are closest to the veterans in need and also what to do about it doing things that have been shown to prevent suicidal behavior and ptsd. Ive got to turn my microphone on first. My first question as you mentioned of that Committee Testimony at a critical part of providing health care in rural areas and in West Virginia for instance they treat almost 400,00400,000 patients thats at 25 of the population. And out of that, we have 166,000 veterans in the United States im sure many of them got treatments. They have the personnel and expertise to do that is. We have our licensing in the state of montana and those that work at the lcsw this is the same level of staff to training may be a little bit different. The only thing that they are not that good at is long ter this le so i think that shortterm turnaround coverage may be six sessions of counseling but if you are in a time crunch, that is exactly the place or if youre struggling you highlighted testimony on the Suicide Prevention methods on Mental Health professionals not just among the providers but nationwide. And we are using the non va care that we talked about. How can we get more people in the expertise and the prevention . I think it will require a multipronged approach into the easiest and most straightforward approach is to invest in training workshops. That will likely have limited impact for training thousands of Mental Health professionals it ends up getting the continuing education and the powerpoint slides. Often it is not enough for them to actually use the therapy in an effective way. One of the things we learned in the efforts and educating is you have to provide ongoing support. Train the people, supervise them come and meet with them on a regular basis, help them, teach them to overcome common barriers. So as we look at the training we have to look at this from more of a longterm support. I think the second aspect of this is we will have to look at our educational system. Another lesson i learned over the decade of doing this training with professionals at all levels is if you teach a student how to do good medicine, they spend the next 30 to 40 years of their life doing good medicine. If you teach a student to use unsupported and not scientificallybased intervention, they start doing that for ten or 20 years and it becomes very difficult to get them to change back. I have one more question mr. Chairman if i may. You brought up the requirements for the provider and extended family and im glad you pointed out that issue because as it stands, more than half a million patients are abusing opioids and overdosed on prescription pain medication and have more than double the national average. That is a horrible problem in my state of West Virginia as most states are dealing with this. While they made significant improvements, i still believe the areas must be worked on. I introduced the act of 2017 which would streamline Health Records between the va and Community Health providers since we are getting more services in the pa. The bill requires the administration to comply and ensures the Community Providers can make informed decisions based on the veterans holistic medical history so my question is can you elaborate on your findings as to why it is so important for the providers to have access to this behavioral Health Treatment information for the patients and how the current wall is undermining the quality. The personal relationship between the team at the va to tt provide care to a veteran who are the significant individuals in the providers life, not necessarily the related members, so i think that coming up with mechanisms that are currently used advanced directives more widely so when people get in a crisis they can reach out and talk to significant individuals. I think the data exchanges have to work for the va medical record. Im on the vital point Going Forward but is a vital point. Im not advocating that there be some change to the privacy rules. Im advocating that we be more creative in getting permission for that at the time a person is ill, a Larger Community can be brought into this discussion. Will. Make sure they identify i am a recovering addict. Well, there was no such record. It wasnt like you are allergic to cortisone or any of the other types of things that stand to mark dispensing and we had a long time getting through because patient privacy so especially with the veterans on the front line now you might be the ones that help us transition this thing and it gives you the chance to share that. You need to speak out on that one. Thank you mr. Chair. Go ahead, senator. First i want to thank senator tester we are getting together with the department and had a good meeting in our office. Since im here and im on the Senate Armed Services committee, we were successful getting a provision that makes absolutely certain, and i believe that the department is glad that we did. It makes absolutely certain we dont miss a step as we integrate the two medical pot is going to be common platforms. Theres still a lot more work to do. There is a good form for you to make sure we get that right into the next step with all the other providers that could be involved in providing veteran care. So, im glad you brought that up i think it is critically important. We need to push the envelope and we can address the privacy rules but we need to make absolutely certain that the comprehensive view of the better and in termsf their Health History is known to anybody that made care at any level. Its between the incidences of suicide in other states and the lack of the pa Resources Available to them. In other words in a state like North Carolina where we have such a large military footprint, you have a Natural Group of people that have a therapeutic value just by being around other veterans independently have the brick and mortar facilities. Is there any correlation between the throughput and outcomes . It could be instructive as we go through and look at how we are prioritizing and every one of the states are different. Thats why some of the performance is based on support networks. He brought up the issue that we shared concern with and it have to do with that paper and not tracking what more should we do to go back and take a look at the discharge is other than honorable that if we had a better understanding of what may have occurred during the service and actually could have resulted in the paper that they couldnt have been discharged with. This is important not only for suicide but for a host of other social issues that are of high relevance. We actually probably would have a sorrow to be the social impact in other areas as well. Are you aware of anything we should do as best practice is why we deal with policy issues how do we go back to the two pieces of this prospectively going over how do we make sure that at the point in time we are making a discharge decision that we are taking in the factors that could have affected that persons behavior. It shows a lot of the suicide we are seeing are not the current e current war that we are fighting and prior to that has there been much work done or any bright spot that you see we are going back to try to help them get the care they need to avoid a possible suicide. The best one i have seen oregon Veterans Centers because the other policy statement is these conditions needed to conduct that eventually can get you discharged and if you have been in combat, why is there a less than honorable . If we can scientifically say this didnt have some kind of an effect, so my perspective goes to the runner. I will take that at face value and something maybe we should talk about but look at it in a way there can be in the u. S. Military people who do things that are appropriate for disHonorable Discharge. Its a matter of how you get that right based on the circumstances a soldier was exposed to the nature of the environment they were exposed to and what you can expect as a medical practitioner that would say this is where it needs to go to the soldier. One other point i would add to that is when you look at the decisions there are different processes, the medical process and then the administrative and they do not provoke each other or interface with each other and i speak for myself as a military psychologist sometimes theres confusion about who has precedent because both issues are going on which one goes first in which the Second Circuit can create a look of confusion and frustration for everyone involved, so perhaps something Going Forward is how do we create a process where the parallel tracks may Work Together explicitly where theres cross talk among the two that right now isnt happening so it can be easier to make these decisions that would help reduce a lot of these conflicts have questions. Senator tester. The easiest thing is to get someone out if they have jamaican analysis without the combat changed them and i think that is the incumbent upon the military to do that. You both dont hav have to answr this, can you give me an idea what percentage of veterans have attempted suicide or were diagnosed with Mental Health issues . When you say attempted suicide were, i do know that statistics are available and i want to say it was around 70 , give or take. Have we seen a correlation thing the suicide . The answer is a little more complex so it is a relationship between deployment in general. Is there a correlation between exposure to certain traumas, y yes. Theres been Research Indicated higher altitudes. Are you familiar with those studies . A colleague of mine is the leading scientist in that area. What seems to happen is at higher altitude we have different oxygenation of the tablets in the bloodstream so it affects how the brain processes the narrow transmitters and how the brain in athens works. There is a stigma attached for family and friends to break down the line. Do you think we are taking the appropriate steps. I think weve made progress as a society. We brag about how some of our best americans have Mental Health conditions can have posttraumatic stress disorder. When you are talking about abraham lincoln, why dont we say bless us and i have bipolar disorder or depression. I think some of our greatest leaders were bringing the nature from delta force to congress in november and people like that need to stand up and say my condition helped me but on those days i struggled, you better be there to help me. You talked about older veteran suicide. Can you go back to the question i just asked whether the newer generation of veterans are seeking Mental Health care more readily than the older generation or is there no difference . Stanek i dont know the date offhand. There is a decreased likelihood. I could be wrong but that was my understanding from some of the colleagues so maybe someone else has a better understanding of the data. One of the things that i think is interesting we were contacted by a veteran who noted that they are unable or unwilling to include Family Members for the intervention process as the veterans in crisis. I dont know if this is true or not but i think we are making a big mistake. What can the va do better to engage families . You sai said the advanced direcs or another mechanism that allows providers to talk about otherwise prohibited information to the families quietly when therwidely whenthere is a crisin that intervention process there are two strategies we can work with on the basic Crisis Management how to talk to someone in a crisis and how to help them when they are struggling to identify solutions to the current problems and a second related piece of software for Family Members involved in the firearms safety aspect how do we work with families to increase the safety within the household and maybe even during times of thought a crisis if we have a favor house looke safer n with during a time of crisis everyone in the house would be safer overall. Do you have any statistics on how many are committed by guns versus others . Its close to 75 through firearms telling them how to communicate because you can get around it. You need to send us a letter to this portal, you can call us. This is how you communicate to us and how you do it in a way that will respond. Do written letters and they start thinking about malpractice and pretty quickly they will get moving. Thank you all for that testimo testimony. I want to thank you for what you are doing. [inaudible] we have better outreach and education. I have a couple of quick questions for the panel and then we can go to the second panel. You made reference to the biological susceptibility. Is that a test is there a biological test you can give for markers are indicators that there may be suicide . I absolutely wish that there were. The biological susceptibility is something that is also dependent on other. Theres not necessarily a test for skin cancer either but some people are more prone. Some of the things weve asked the committee is to ask the va for more biological indicators by the fall of 2020. And i think that even if its not a specific of this test for that, there are things like computerized executive functioning where we know if it is getting worse there is something going on its not necessarily ptsd or depression but they need to move forward and im hoping that they can be rolled in by the fall of 2020. When you listen to the testimony, we havent had enough good training in the va. Its the main focus of the leadership and people dont ask the right questions or report the right timing. Thats why im so proud of the staff have taken the course and now i understand how important is to look for the sciences i did ask the question are you considering suicide, but beating around the bush about it. We will simply have the awareness and protection of knowing what to do. We are better aware of things we need to look for and everybody wishes there was a biological test, but you are right to. Senator, did you have a question . These questions have already been asked and i would apologi apologize. How do you establish intent. Iif sony buys furniture blog. Koif somebody dies from a Drug Overdose . We would rely on what the medical examiner said in their determination of all the relevant facts at the time the death occurred to the states whether they thought it was an accidental death. So accidental in the sense that they are addicted to drugs and they took too much and stopped breathin breathing thatt necessarily be a suicide, that might be considered accidental overdose. We would record it that way and have that interpretation and we would always wonder if we were right. Im just trying to understand this. This. You cite a statistic that 30 increased rate of suicides among veterans, but im not sure i think that is compared to the general population of the genderbased cohort and going beyond that im not sure that its related to the class of the Disease Burden an with greater Disease Burden our more likely to commit suicide, so as we understand the statistics are they matched or is it the general population and if they are not matched against cohort, what are the excess rates relative to one that is matched . The statistic is from the report of last year. I dont know what other variables have been made and adjusted for. That age and gender. The most common adjustments we make in this suicide. In the general knowledge is it more common among certain people that have addictions that intuitive. Are there other breakups that you would match against the general population as a whole are there certain things yes it is more common in this Disease Burden is more common im asking you this for my knowledge. And interestingly enough one demographic that really jumped out with white males between 30 and 60 and that was. Let me stop you because theres research princeton which says in the general population wide nails in that demographic are dying but it does relate to lower socioeconomic class. Your state i think has a higher rate of poverty than new jersey. Have you corrected that for economic status are not . Looking at the economic status let me say most of our suicides are people who are economically struggling in particular people who have not a lot of education. The higher you go up the education totem pole the less likely you are to commit suicide in our state although i will say there are some other factors that we have been to this because if you have depression and anxiety. Rich people shoot themselves to i hate to say it. Im sure dr. Ludlow drive and will testify are these veterans atypically socioeconomic low class and i have 10 more seconds and if not i will ask the doctor shulkin. Thank you all and i yield back. Thank you very much. Senator tester. I think mr. Chairman i am done with this panel. While we are setting up for the next panel would like to make a statement if i could. I want to thank the panelists were being you today. Your testimony has been eyeopening and helpful and we will continue to focus on this and we thank you for your time today and we will switch the table around for next panel. While they are doing that. Thank you mr. Chairman. I would say it this discussion is very important today. It continues to be unacceptable that we have a number of suicides in ivana trump operation of we have that make no mistake about it this also national epidemic. Not specific to veterans that we are here to talk about veterans and in fact its the tenth leading cause of death in a season since the chairman dropped the gaveltogavel in of this hearing six people have committed suicide in this country. The eight data suggest 20 veterans commit suicide every day. On average and this is an important statistics for us to know only six were enrolled so what does that mean . We have to do a better job about reach and once we do that job about reach we have to make sure those folks have the Health Care Professionals on the ground within the va to get the help they need. Why is that important to this committee . If we are going to get Health Care Professionals on the ground in urban rural areas and i think we need them both is going to cost some money. We have to have more residency slots and we have to be more aggressive on this and i think its really an important issue moving forward. This last panel has showed it so we need to fill those vacancies within the va and we need to make sure we fully leverage the assets for va centers and we can talk about this and its importantly talk about it and get the facts and i dont know if matt left to knock on the first panel but i will tell you this guy not only talks the talk but walks the walk. We need to follow his lead and make sure we follow up with action that does veterans in this country and by the way if we do that i think it helps the civilian populations of thank you very much mr. Chair. Thank you senator tester. We appreciate your leadership on this entire issue of veteran suicide. We know its number one in your state and we want to do everything we can to make sure we are addressing it with the Veterans Administration and dr. Shulkin is focused on Suicide Prevention one of the key things was to focus on and i want to say thank you to dr. Shulkin. We worked hard in the first nine months of this year the Ranking Member and die in the entire committee to bring legislation to the floor. It was thought by many of us in some cases by the secretary. We have changed the paradigm and change the headline and we are very proud of that. One the recently done this committee has been United Democratic and republican alike but also because the va has shown leadership. I want to acknowledge last week, maybe this week was the first use of the accountability legislation and determination of the Senior Member of the staff of the Veterans Administration for lack of performance etc. Of performance etc. , etc. , etc. I would have been possible had that legislation passed by would have been impossible if we have the secretary so i want to on behalf of the Ranking Member myself thank you for taking the tanish of the tools you have asked for and we have given you. They are a lot more tools in the bag that youll need to use and we are going to help you. I want to acknowledge publicly, thank you for your initiative unaccountability last week. Without her there do dr. Shulkin and thats a way supposed to be. Thank you mr. Chairman and good morning senator cassidy and senator murray its nice to see you senator manchin thank you for staying through the whole thing and i want to thank you mr. Chairman for several things. First of all i think i couldnt agree more with your comments. Im proud of this committee. I think the Committee Works together in a bipartisan way and working to really get things done and proud to be working with you on that and also think for having the first panel 1 because we got all the hard questions and i got to hear all the answers and that was terrific. As you know we are here today at this important hearing because our goal is to eliminate suicide. We want to do that through Risk Identification and effective treatments, education, outreach, research and strategic partnerships. Senator tester mentioned before he left that our Research Shows that 20 veterans a day are dying through suicide and he did something by saying that there were six americans who died during the course of our hearing. I think about that every day, how many veterans are dying for us not being more effective than the way we are addressing this problem. We know veterans are at greater risk for suicide than americans. This is an american publichealth crisis and in the veteran population even more so and we do know as its been several times 14 of those 20 arent receiving care within the va system. We know from research that va care saves lives and we know the treatment works of this is a matter of trying to get more people treated and what we are trying to do this more aggressively than ever before our reach to veterans who are getting access to care. We cant help those that we dont see so this is where we are extending our help and to the community to work with Community Partners. We are doing more to reach veterans than ever before and as secretary i have authorized that reduced our providing emergency Mental Health services to those other than were not only discharge and thats important but we can do more with your help. We have asked everyone at the center this month to sign a suicide that ration pledge. Im pleased that you send it this morning mr. Chairman along with the Ranking Member and when i was out in nevada senator heller signed it with his community members. We are doing that across the country and thats a pledge of specific action of steps that we went leadership to take to be able to help reduce suicide. We have developed the largest integrated Suicide Prevention network in the country. Over 1100 professionals who are dedicated to Suicide Prevention including Suicide Prevention coordinators and other Mental Health professionals. Our goal to hire 1000 national Mental Health professionals so we need to do more in the growth and network. Our veterans which we established in 2007 is now answered more than 3 million calls and dispatch to 84,000 emergency ambulances to help people who were in urgent need of help. Thats incredible. We have had 504,000 referrals to Suicide Prevention coordinate or so we are helping a lot of people through that. The Veterans Crisis line number and i encourage everybody to keep this in their phone because you never know when you are going to get that 2 00 a. M. Colin you dont want to be looking for this. Its 18002738255. We have recently appointed, seven weeks ago doctored miller to head up our Veterans Crisis line. This is the first time we have had a clinical psychologist in charge of Veterans Crisis line. This is clinical work and this is not just a call center. We have expanded teleMental Health. We have 11 teleMental Health regional hubs throughout the country and in 2006 alone we had 427,000 teleMental Health and thats more than ever before. We have taken from our research a Big Data Analytics program that we call reach out that predicts who may be at their greatest risk for suicide up to 80 times the risk of suicide of a regular person and now we call them. This is being done around the country to outreach and proactively help and not waiting until theres a suicide attempt. On september eighth of this month the release to stay suicide data. Many of you have been referencing that data but we think thats going to help people with more effective intervention. We continue to develop privatepublic partnerships. This morning i was talking to the Veterans Network is one of those partnerships. Many of our vsos and other groups in iraq today are those partners we are working with. We continue to invest in two center of Excellence Research initiative to help us understand how to do interventions that are and take a Population Health approach towards reducing suicide. This month as you have said the Suicide Prevention month. Thats our campaign where we are reaching out to make people aware and try to decrease the stigma of Mental Illness. With that today i brought with this our new psa announcement and i just want you to listen to it for second. Hopefully you will recognize it. In the fabric of america they are the toughest threats, our bravest and most selfless. They raise their hands and step forward and have served for each other, for you and me. One of the first things they learned was the code that every servicemember lives by, leave no one behind. Now all of us need to live life to because some veterans are being left behind. 20 of them take their own lives every day. Why . Its not simple. It never is. What matters is that we are there for them just like they were there for us, and handshake, a phonecall, a simple gesture make a big difference to a veteran in crisis. Learn how to be there for a veteran and be there for veterans. Com. Honor the code, be there, leave no one behind. In the fabric of america,. We are grateful to tom hanks for lending his credibility to help us get this message out and youll begin to see this national psa with the video in about 30 days. Despite the progress we are making we still have so much more work to do and thats why as i said mr. Chairman this is my number one priority. We need your help and those are three things that we can use your help on. We have it figure out a way to them get mormon to help professionals and not just the va but the country at large to train. We need 1000 more and we are now making the progress we need to make in recruiting them. Secondly we want you to be part of helping us spread the word and be their campaign and thank you again for signing the declaration. You are as well respected members of the senate very help all to network with us in third we need more research in this. Many of you have identified the biomarkers. We need Better Research to be able to make a difference and va has that capability with your Additional Support so thank you for holding this today and id be glad to take any questions along with dr. Carol. Senator manchin you are recognized first. Mr. Chairman thank you. I wanted to ask a couple of questions of doctors shulkin. I know that you are aware and we hear more and more stories in the news about veteran suicide. Beer coming to the va facilities in doing that. I dont know what you can do to train your security and i just dont nod to do it but there is timing involved here and its becoming more occurrence than we ever thought it would be. Are there steps taken to the high enough level and notice as a country a problem run the country. We are extremely aware it so painful to hear the stories. You are right that what we are seeing is that people are coming on to be a property and we are doing a number of things. Part of these declarations that every one of our facility leadership are 10 actions and one of them is training to spike this committee. Every one of our Staff Members in Suicide Prevention on what to do and we are establishing much of what we learned in our homeless program. You do this through no wrong approach. If veteran who is at risk and somebody identifies them should know they have a responsibility to follow through. Soon i can ask a question or a quick . What im concerned about is this is not well publicized as you know. Its becoming more and more but it happened in the parking lot of the va. I am concerned about maybe this is being taken inside the hospital to where its more than just that person doing harm to themselves because they need help. I dont know how you secure the hospitals. We all have to come through to come on va property. We have to have a checkpoint. I dont know but i want to go to another question very quickly. Im just saying please do all that you can. You talked about Mental Health. We had a psychiatrist in clarksburg in january 2017. We had another vacancy for a psychiatrist in martinsburg since october of 2016 and another vacancy just posted within the last five or six months. Are you having a harder time and can you tell me of the 609, 649 people that have been hired what is the ratio between rural and urban because its probably easier to get someone and perhaps its more effort in that. Martinsburg believe it or not is a success story. A year and a half ago i was really concerned about the staffing levels. They have done a great job but in general it is harder to recruit in rural areas theres no doubt. Our urban areas where there are more trainees coming younger people are saying and thats where we are establishing our love and eleMental Health pubs that will support the rural areas but you know this is where we want to see expanded Education Programs in those rural areas. We use up all of our dollars that you allows to use and we would like to use more periods of very Effective Program in a clay hunt program you have asked us to do that more but did appropriate money for a soapy are trying to find the additional dollars. I have more questions but thank you all so much for the meeting. We are going to go to senator moran and then to senator murray senator tester and i will finish up. Mr. Chairman thank you very much and secretary thank you for joining us this morning on a significant and timely topic. First of all i want to highlight the hearing that our appropriations subcommittee had in april on this topic but i want to remind you mr. Secretary and i understand senator murray had a question for you about va follow through that was made on the hearing. It was submitted by the va that we would get monthly reports in regards to your efforts in the departments efforts to comply with the Inspector Generals recommendations and failures at the va in regard to suicide and we have not received those reports on a monthly basis. I will defer to senator murray that i would join her and her request that what was practiced practiced promised would be followed through on. Let me than talk about another topic that senator tester and i worked on. We have been trying for a long time and in fact in 2010, seven years ago the va gave the authority to hire marriage and family therapist and licensed professional Mental Health counselors. The results of that authority of not resulted in any significant hiring of either one of those professionals. Our guests senator tester and i are interested in the reason for the scarcity of professionals generally but especially as you are indicating in rural communities, and so we have sought and provided Congressional Authority for the va to hire. You indicate you are in the process of hiring a thousand additional professionals but i would tell you after seven years those two categories only account for 2 of the Mental Health workforce at the department of veterans affairs. Senator tester and i sent a letter to in this regard. It was sent to you just a few days ago but in this hiring, would you again commit to filling these positions with those professionals, something that has not happened and if so, how many of those and what would your prediction be within lpr mhc and could you provide me with those numbers as you fill those positions . I assume there will be a priority given with regards to places that are hard to recruit professionals. I also know that you have hiring authorities that are difficult. I dont know what youre expedited hiring authorities are what are they . What do you have at your disposal and do they apply to Mental Health professionals . What needs to happen to fix this problem . We have noticed so many times that the things that are posted dont result in any kind of Quick Response at the va. We discussed this topic with dr. Stefan davis who testified. She said the eastern part of our kansas he testified before subcommittee in april. Jobs are posted on usa jobs. Com where applications can linger for four or five months. People find other jobs in the meantime and it becomes more impossible to recruit and retain we know the positions are taken for months or years while providers go through the process of federal hiring mechanism. What can you do to get that process expedited and then finally mr. Secretary i want to tell you that i was just earlier this month at the phoenix va where i saw one of the pilot programs under the clay hunt acts. I was impressed as having those who have similar circumstances who have served our country who are vegans themselves and other problems as the counselors for those who are calling that number and i would be in just a knowing what the va is doing to support and are there plans to expand that program elsewhere . A lot of questions. Im going to go really quickly and those that go do an adequate job on i will followup. On the issue you talked about us not providing followup and senator murray will comment on that too but thats unacceptable. If we say we are going to commit to something my expectation is that we commit to it so i appreciate you letting me know about it. I can assure you my staff will know about that but we will do better and its not the way i want the department run runs that we will make sure you get that. On the marriage and Mental Health counselors, i look forward to the letter appeared unaware that we continually hear about the strictness on our accreditation issue. This is particularly a training issue. There are two accreditation programs. We are committed to bringing on marriage and family therapists. Dr. Carol has specific information on numbers or will defer to them. On the issue of hiring the single most challenging thing that i know of at the va, shouldnt be that hard to get people onboard accountability act that the chairman referred to that we passed not too long ago you gave direct hiring authority to Medical Center directors. That is really helpful to us and allows us to skip over a lot of the red tape. I want that authority for all of our critical Health Professions. I would urge us to Work Together on that. Its just too hard to get people hired into the va. Do you have the authority . Only under Medical Center directors so we can work on expanding that i would love to target it for Mental Health but we have other health needs as well. I would love to work with you on that and on the b. Connected program peer support is something that we are really committed to. We think this works particularly for veterans who understand what they have gone through so thank you for your visit and thats something we are going full force on. You have other plans for that program elsewhere . We have 1100 support counters and much of our model is based on that model. We know it works and the growth has continued to go up each year. We are delighted to have you. Senator murray. Chairman thank you so much for having this hearing. It is such an important topic and i was able to listen to much of the ers panel for my office between meetings and are really was good and i appreciate it. Dr. Shulkin thank you for being here and thank you for your testimony and thank you for saying its your number one priorities but i do remain deeply troubled by the findings from may 2017 at the va is not complying with a number of policies including 18 of facilities not meeting the requirements for outrage each month. 11 of highrisk patients medical records have not have a Suicide Prevention safety plan and 20 in patients and 10 about patients no documentation. There were several shortcomings in the record like ordination of care for patients with for a highrisk of suicide in critical followup for highrisk patients after discharge. 16 of nonclinical employees did not receive Suicide Prevention training and more than 45 of clinicians did not complete suicide Risk Management training in their first 90 days. When it comes to Suicide Prevention policy anything less than 100 is unacceptable so when will the organizations be fully implemented . First of all this is exactly why the ig is valuable. I have no other mechanism to get data that comprehensive so we have committed to addressing the ig concerns. The reason this we have made Suicide Prevention number one priority and made a leadership sign off on the decoration is we are committed to training so over this year 100 is the right goal but i cant tell you exactly what date we will reach that. We are going to be working very hard to get as close to that is possible and as quickly as possible. Senator miranda woods to the veteran suicide Hearing Committee in april i asked him for monthly updates and all the problems that the crisis line or resolve the va has not done that and thats really unacceptable. I want a commitment from you today to all of us that we will get those updates are in right now. You have that commitment, yes. C we intend to see that out. Let me ask about Women Veterans. I am really disturbed by the increase in suicide rates among our Women Veterans. Between 2001 and 2014 the raiders suicide by the Women Veterans who do not use care increased by 90 protect heard from Women Veterans many times that how they dont think of themselves as veterans and i hear far too often some dont feel welcome at our va facilities. It is a significant problem at the Rand Corporation testified in april as well. This increase in suicide is the most important reason yet that i believe va has to redouble its efforts to reach out to women and get them into care. I want to ask you what are we doing to address back . You gave a really important statistic which is that those over the last 15 years between 2001 and 2014 the women that did not receive care from the va that the rate of suicide went up by an extraordinary number. He said 90 . Those that did use the va we actually saw a decrease in suicide rates over the 15year period of 2. 6 so we know particularly in this population but for all veterans getting care and accessing care makes a difference and saves lives. The issue about making to be a more welcoming to women is a critical issue. Its a cultural issue and we have worked hard to create Womens Centers and to change the culture. I speak about this and i speak with Women Veterans all the time but of course we are absolutely and are number one priorities committed to doing much more and be more aggressive in putting resources into this. C this is something we have to keep working on because if a woman doesnt consider herself a veteran she wont go to the va. If she is not welcome at the va or doesnt feel the veterans facilities welcoming to her she wont go. She has other issues, childcare, work its doubly hard. This is not an easy problem to solve but we have to put hearts minds and research into it. I feel very strongly about that. I just have a couple of seconds left. I want to ask you about the vas initiative. Identifying veterans who may be of risk of suicide before it happens in i wanted to quickly tell us how that model works but also 14 of the 20 veterans who die each day by suicide did not come to the va for care that want to ask how does that work for folks who are not coming to the va . Quickly if the data Analytic Research project. I started researching and putting it into practice. Senator testers point about every day we delay there will be more deaths. We have moved into the clinical setting printer Suicide Prevention lists the veterans names that are the highest 0. 1 risk of suicide 80 times higher risk than a person who is not on the list and they practically are calling out every day and saying how are you doing and how can we potentially help you and anything you need help with in connecting with them. Dr. Carol has more contact. Are you working with local groups and providers and nonva agencies . We do not have that data. We have no way of identifying the 14 the community. Thats a big issue for us. I think expanding va access and Mental Health will save lives. Thats why it made the decision on Honorable Discharges to do that. We have a big hole here. One of the big holes is within the department of defense. What where working with now and they are being very cooperative is essentially an auto Enrollment Program so nobody leads at Service Without knowing where they can get their Mental Health care. I think thats going to be a big deal in eliminating the gap right now that we have. Thank you very much. Dr. Ludlow drive on again let me echo others praises for the changes you made. Thank you for that. I will quote the article raising mortality among white nonhispanic americans and nonhispanic americans in 21st 21st century and im trying to figure out as we are looking at the veterans phenomena or if it is reflective of the va but also throughout. Are you with me . They find in this population that the increase for whites is accounted for by increasing death rates from drug and alcohol poisoning suicide chronic Liver Disease and cirrhosis. I can go on. I guess what im trying to figure out is how much of this is unique to the va relative to the study as opposed to its just kind of what we see in society . First of all your questions before were excellent. We do not just by socioeconomic status because the way we collect the data out that National Data death index and from the cdc data. I find that usually folks who are more welltodo didnt go to the va for their health care. Are eligibility doesnt allow it. Even though the Service Connector had more money you referred a different facility for whatever reasons. You know the socioeconomic class of your typical va attendee versus the general population . We are more of a safety net organization. By proxy we can assume that you have a higher death rate of those things seemed that reflected the overall population my background is not hepatology but Health Services research. Im going to give you my best guess, educated guess. Theres a socioeconomic status component that i think you are identifying that the veteran population is more than that. You wouldnt see as large a difference i think its both. Is merely reflecting the Larger Population and that is tragic. If it is an additional risk factor is something to be identified and corrected. We publish 75 articles on suicide and Suicide Prevention last year and we have a good team on this. Let me ask, i have not yet comprehended a spreadsheet distributed to the Mental Health domain composite summary. I cant say i comprehend them but i know you have done that analysis. Is there a difference in suicide rates associated with different facilities again hopefully correcting for populations the same but i assume is roughly the homogeneous population. Ive seen the analysis by state. The analysis is by state and the veterans population is not homogeneous from one state to the other nor is the general population so their art differences in the population both atlarge and for veterans. I accept that but louisiana has a higher forget American Population some states have a higher hispanic. As dr. Casey pointed out its nonhispanic whites who have seen of jump in the rigor population. As i was told on the Previous Panel we have for age and gender and i threw a race in there because its pretty apparent. Do we have any rough estimate on that . Those analyses arent going so we looking at ethnicity and race as part of the ongoing data. You are sending out the state and thank you very much looking at specific facilities and im presuming most have a facility of choice. Is your analysis going to include these other factors and how each specific facilities doing tech Center Murray pointed out we are not getting 100 of these being passed out at i suspect that would vary from facility to facility. I think the type of statistics that senator murray was talking about our calm clients for screening. Not only is it done to facility level but the specific writer. You have to let tronic medical record data on that. The broader statistics which include the National Death index and other things may be harder to do at a facility. I think we need to know is that in the va issuer does it reflect Broader Society . If its a Broader Society when to do something more broadly. Does that make sense . We do know the difference between veterans getting care the va and. I saw that and you mentioned your safety net and my position is in some places you are certain theres a safety net and some cases theres an inadequacy in which we have to identify that and if you need tools we have to give them to you. Thank you very much and i yield back. Thank you and thank you the Ranking Member. Want to follow up on senator murray and senator cassidy talking about the suicide report and first i thank you for being here and thanks to dr. Carol two. My state 244 veterans took their lives in 2014. I want to talk about them and in the thousands around the country. Im not really clear why you would release that statebystate report at 5 00. Thats not really my question and i dont understand why you do that but talk to me about how you share this data statebystate and how you share with veterans, with Medical Centers with Community Providers and what you called the National Public health issue. We did this analysis which was released on september 15th friday at 5 00. It was really the first time was released to that specific data so we are actively trying to get that out and sure with the groups that you mentioned. There was no attempt to downplay this issue and if it was it was a bad strategy. What we are seeing is all around the country that data getting out there and being picked up by the press and thats exactly what want to have happen. We are actively disseminating it is to be dont know your data and to the point of senator cassidy and want every Medical Center director knowing what the number is. You cant design effective intervention. That means it never got into the va system in Franklin County you psa implores the country to leave no that behind. Talk to us if you would about the initiative and what metrics you have in place to see how its working, what the process to get those 14 who wont take their lives because they get va care, talk that through. The program is not for those that are accusing va. Its for those who are using va that we know are at highrisk. The 14 that are using va thats where we are beginning to start tackling it through other strategies leading others have emergency Mental Health. This tragedy that will bring support to the va and for others that arent eligible we are working with Community Partners and we are working with Veterans Service organizations, working with the churches and the synagogues to make sure that they understand that they have a responsibility. The messages Suicide Prevention is everybodys business and family Family Members france and coworkers to identify people at risk whether its the va are outside of the va. Thank you mr. Chairman. We thank you for your work on this issue and he heard a number of my questions earlier about that difference between the veterans who have used the va and the veterans who have not done so and i know you have been asked a number of questions on that issue so far. I want to focus on the less than Honorable Discharge group. You have any thoughts about that cohort and how it can be better accessed and how they can be encouraged to come forward. I think the knowledge is also lacking. Quite frankly i did what i could. It was one of the first things i did the secretary which is used to use the stories i have to offer emergency Mental Health services. I thought it was wrong that we were not providing access and we were letting them out there and they are higher risk for suicide as Homeless Veterans i believe are at higher risk. I did as much as i can. Now i actually need your help. We are going to need legislative changes to allow us to offer other than Honorable Discharge people to be able to access our full array of Mental Health and physical services. All i made able to do is offer 90 days of emergency treatment than im trying to find them other places to get care working in the community. We are going to do everything we can but it is not the ideal approach. We could use your help in this, senator. I would like to work with you i have a question as to all of the veterans right now through no fault of their own perhaps are not part of the va. I know you have been asked about the Suicide Prevention act and i would also like to follow up on that particularly as to the funding. The president has signed a number of measures dealing with veterans issues. Those pieces of legislation have been long and the work and we have devoted a lot of time and attention to them and i hope his apparent commitment to those issues will translate into funding which is really the test its fine to yield the pen on measures that were started well before his presidency and now its a test of his commitment. I think that applies to issues like the Veterans Crisis line and veterans Suicide Prevention center and i would like to again ask you about Women Veterans and what expanded or enhanced efforts to contemplate. First of all thank you for all these issues that are important. The president s budget requested budget has increased funding for both Mental Health care in Womens Health care issues, both critically important so i think he does share that commitment that you have two seeing us to better. Is that amount of money in your view sufficient . I was very pleased with the president s budget. I think many of the issues we are dealing with words Financial Issues solely like areas we have to do better in i am not only seeking additional funds essays on the president s budget but im also moving current budget into higher Priority Areas so i do think we have sufficient resources this next year should the president s budget get approved. I would be remiss if i didnt ask about the westhaven veteran facility paid you and i have talked about it. It was built in the 1950s. It needs more than just rehabilitation. It needs rebuilding and i wonder where it stands on the list of priorities and whether the president s budget is sufficient to cover the Capital Improvements there and elsewhere as you know you and i stood on the doping and i think your assessment is generous. I trained at the westhaven va and i dont think it has changed much since ive been there. We are still undercapitalized me of a very old of the structure but we cant expect to take decades of underfunding and fixx it all at once. We have requested more funds into the modernization of the va and i want to dispose of 1100 fellow silagys that are being utilized. I dont have any specific number of where the projects are but certainly i am going to support the westhaven va and other facilities that arent modernized and part of that is we are going to have to review our matrix on how we make usage of that. Right now i will tell you the number one weighted are and where the money goes is improvements and while that is really important and im not going to say that thats not critical, you are not on a fault line. It puts facilities like westhaven at this advantage so we will be looking at that. I hope it will be generous and pushing westhaven to a higher level. As you noted i was being generous and change the look at all. There were some cosmetics improvements that as you well know the level of dissatisfaction that exists about it and i would add that the satisfaction with the structure and capital facility, i want to give a shoutout to the very dedicated men and women who work for the va in connecticut and i have the authority to speak on behalf of veterans in connecticut the generally high level approval and satisfaction. They work under conditions that should be better for them and their veterans. Im sure they will appreciate that and i would like to invite you to come and visit again and be at that facility with me again. I want to thank you. I do have a busy schedule so i will let you know what we can do that and get together. And also worked in done on the wifi Internet Connection which is very important so thank you. I wanted to add to your answer as you go through your 1100 at valuations of underutilized facilities to rearrange her capital. You are going to consider rural states in population something for that matter. States that have a lights population dont lose out on the opportunity. What i announced is first of all i share the sentiment that we dont want policy that discriminates against locations because they are rural or not on seismic fault lines but what i announced previously was in the state home money distribution that the rural areas were never getting to the bottom of the list so i committed to relooking at those criteria because the state grant money really was going all made two very small numbers of states essentially bought i do want to make sure we are modernizing the facilities and an equal way across the country. Thank you. Senator tell us. I think its critically important and you said i believe the president has a real commitment to veterans and frankly didnt move as quickly as i would have liked for them to have in the past couple of years but i have the same view in my role as Senate Armed Services. Where i is going to have fewer resources than you want and shame on any member of congress who advocates for moving something ahead of the line read the data doesnt say its the best way to provide care to communities that need it. Im in North Carolina. Im in a 50 urban and 50 rural state with over a million veterans, timber semipopulation but if you told me montanas where the End Resources need to go to serve that population thats where want to go and along with that looking at the capitol projects. Shame on any member who tries to come up with the statutory protection for something that you dont think is in the interest or support of veterans. I every once in a while call up of va facility the night before i happened to be in town and want to stop and see them. This is not a surprise visit, just want to talk to you all. I stopped than one a year or so ago. They 40 minutes apart. They thought they would provide better care to the veterans by consolidating these resources. We have a member of congress to stop that because it happened to affect jobs in their district. We need to make sure night to make sure that i have a commitment every time you see us doing something that is at odds with the best professional judgment getting resources to the committees that make it the most in making a possible the resources are giving you, i want to know who that is. Now on Electronic Medical records. I want to get back to the questions i asked the first panel and i want to thank you for being here. I mistakenly thought you were in the first panel but it doesnt surprise me that you and your team were here did hear the testimony and i thank you for your commitment. I like the decision you made for the baseline system. Its an accelerator between dod. I asked you the question when you were here last we know we have 10020 but more important we have nonva care providers and we have choice providers out there. I believe as you get further into the Implementation Plan we discussed in my office you are going to identify other layers of technology to make sure we know how prescriptions are being dispensed and whether there are dangerous interactions and other indicators we can use to make that a more productive experience for the provider and the patient. Have you gotten to a point where you are thinking through as you are looking at here implementations priorities and the broader Transformation Plan the remainder of the clue where are the other custom efforts buying a configuring tools youll need to flesh out that . We have been to essentially the principles that you talked about. A system that worked in the future will have to components that frankly done a good job of outlining. We havent gotten to binding which specific tools and how we will meet those needs. We talked about the days of va being a Software Developer are over and we are going to look at technologies. There is going to be more definition on that. Yesterday we released to congress, to use 30day notice of an award of a contract so we are keeping on the timeline we talked about and we are marching forward. I have some updates to share with you on the strategic i. T. Plan because we are making a lot of progress with that. We are going to announce that we will in this i. T. Conversion with obviously your support they will be sun setting sun setting 80 of the projects currently under development so this whole not only be the right thing for Clinical Care but they right thing for taxpayers. Thats great to hear. I guess i am the last member but we do have a number of questions for the record on Suicide Prevention issues. We are the first panel and ive asked my staff to get that the Armed Services staff because i would like to have a Committee Hearing at the subcommittee level to talk about, dramatic at brain injury ptsd and things that we are doing to do a better job of detecting and treating it but id like to add the second panel that talked about the veterans who may, first off how do we get an Honorable Discharge to make sure we are trying to provide intervention for the risk of suicide and the ones who have other than Honorable Discharge what are we doing to make their experience when they were in the military destructive to any decision about what category discharge again and finally we have to come back to the va to get your advice. Thank you for pushing the envelope and i heard you loud and clear its time for congress to give you more tools. Thank you mr. Chairman. Senator tell us if you are on the way out the door you have five minutes. Senator tester has some questions that he wants to ask. I have i will one i want for the record. You adopt the same software used by dod. You have been committed for that it will allow you access to the same information that dod has regarding the warrior transition units. Our warriors when they leave the battlefield they are asked questions and doesnt have the statement too. There are questions that give indicators whether maybe somebody is at risk for suicide. You have Interoperable Software and you also have interoperability access to that type of information. Theres certainly some exceptions with dod. One of the things i learned recently that coast guard wasnt in their contract so we are going to have to figure out a way to be interoperable to them. There are some small exceptions and we are working through those. A relationship with dod is extremely cooperative on this project. We are helping them and they are certainly helping us but those types of data sources are extremely valuable to us. You are committed for the move and we are proud of it that im going to turn over to the Ranking Member. Thank you mr. Chairman. Thank you mr. Chairman and i want to thank you for being here as well as the first panel. I just want to touch on brac really quick because there is an opportunity for facilities that are being used and you would agree that manpower recruitment of manpower is continuing to be a challenge. Absolutely. I would say as we look two ways for save money what im really concerned about and i know you were not part of this and if you are let me know that they will come in potentially if we do it in congress or if you do it administrative lands a classico montano you walk in and say close it down. The same thing for senator rounds of south dakota and if Something Like that were to happen i guarantee there would be a bipartisan explosion of this committee which wouldnt be a good thing. I just bring that to your attention. Im all for making sure you are getting rid of properties you dont use anymore and have outlived their usefulness and utilizing the dollars and i applaud those efforts. When we i want to tell you another some people who want to do a fullblown bracket im going to tell you some of the metrics out there, not that these are good facilities that they are understaffed. I just want to bring that up. In your testimony you cited Suicide Prevention is the top priority. That knows the issue. You have to have the professionals with your primary care people. In a small population states like an montana, we are short right now so it is about the infrastructure. It gets back to what you are saying. We have a manpower issue and it geographically distinct, particularly in areas that dont have a lot of medical schools and other places that bring professionals. Besides psychiatrists and psychologists and other folks that can help. Is that preceding and is it proceeding while we talked to one of the tricks of suicide and what altitude and all this stuff. Weve got to get our arms around the whole thing before we can get to the point we are talking about. No other Health System i am aware of has Suicide Prevention coordinators. That is a strategy. We have peer support specialists in a way that no other system is using and of course, we are hiring. We are encouragingly as strongly as we can facilities to hire them and as a part of their purview the other thing we are doing about primary care and Mental Health integration is using the tele Mental Health to provide providers in places where they may not be able to to hide or a Mental Health professional. Ten q. Tell me, do they all have these Health Capabilities . No, we list on the website which ones do but certainly they will be more likely to have it than you would in new york city. Thats one of the cool things i dont know if youve ever seen it, that just amazes me. Youre going to a primary care office at the Medical Center, and right there is a digital display that if the primary care doctor wants to die you win a psychologist or psychiatrist that they can do it right there from their office. Earlier in the year, you testified that you were going to try to get thousand additional providers this year. Your testimony today says you hired over 600 new Mental Health care providers. Im not going to ask the difference between additional and new but has there been a net increase. The answer is no, the 623 is just keeping us even. We are not succeeding at that thousand new professionals. What we need to do is give more direct hiring Authority Just like you did in the doctors projectors to make it easier for me to hire. We talked about the fact that the recruitment and retention dollars would actually cut in half. That was shortsighted quite frankly. We need the tools that the private sector has to be able to recruit the best healthcare professionals. The areas that are tackling this, dont tie one of my hands behind my back. Did he take away the retention dollars . To pay for the legislation, yes, sir. So, a competitive process to hire quicker and the flexibility to appeal to help expand training, those are the three areas that would make a difference. There is a national shortage. Well worry about nowe all worrt whats happening in the va particularly the training one. You are right it is an actual problem. But the veterans, we made a problem to them so they can have a bunch of excuses, we need more solutions. Appreciate you guys being here. The last point we are about to adjourn although for the record i remember this discussion wit with the then secretary mcdonald. I think that there is a series of stories that have to do with training and Retention Programs that you thought were critically important and i think what we need to do is understand if you were going to make this an attractive place in the professionals to come to them you better have professional development in the Retention Program somewhere to the private sector. When you say some of the dollars you were spending im sure i could find something that was not a good idea, but i sold a number that the va was suspending and it was pennies on the dollar compared to provide would have spent. Now that youre going to get to that ratio and make sure we are not talking about both sides of our mouth to get the retention resources and then we went to micromanage how you go about spending it. Ive never been at the head of a major Health System before and now you are the head of one of the biggest in the world. I trust you to make a decision about how you have therapists and other people and how the Value Proposition so you get your share of the best resources. Theres another one when we hear one thing and do another thing, please give me your commitments that you will sa see that is noa good idea. We are going to adjourn the Committee Hearing at leave the record of him for one week for additional questions. I think the first panel for being here it is always a pleasure to see the leadership. The meeting is adjourned. [inaudible conversations] [inaudible conversations] wildfires in the west with a focus of an environment of Public Works Committee in the senate today. Vendors heard from for Risk Management experts on the impact of wildfires have had on the environment and the economy. From capitol hill, this is about one hour and 45 minutes