Transcripts For CSPAN3 Veterans And Spinal Cord Inuries 2017

Your other point was about really the Community Providers and the type of care they deliver. You might have practiced inside and outside the va. I am note going to paint everyone the same picture. It happens to us a lot. I think there are a ton of Community Providers that are delivering extra care. Hopefully strenten them so you dont need to provide. We can provide them in house, timely and state of the art. Thats what i mean for certain things like spinal cord injury we need to make sure they are there to support our patients. At the same time for things that we think are provided at high quality in the community and maybe dont require that expertise as much like a quick exam, a colonoscopy and how do we make sure they are in our network. I think its part of our job to educate and provide resources. We started pretty much a free training program. They can get free cme credits. We have a four Course Program on military cultural competency. They can go to a web site, get that certificate and get that. We also have a lot on opioids and oers. In some areas we are providing consul tative services. If theres a provider they can reach out to get that answered. We are not where we need to be there but i think thats going to as we start to really refine what that network looks like i hope that we have more and more providers that have completed those sort of trainings and are working with us in a collaborative manner. We want to reward and incentivize our providers to do that. Right now we are paying for volume. When you think about a lot of the health plans they might be incentivizing and minimizing the use of some care. Thats how they become a preferred status. We want the complete opposite. I want to mike sure that our providers that are delivering high quality care and i vesting and learning about veterans, they might need to get a little bit of a plus up in how we work with them contract yulely. Thats where we want to get to. We are definitely not there yet but i hope that over time youll start to see more of that. From the minneapolis va spinal cord center. Followup question regarding the home care. We havent had a problem with authorization for home care or agencies that have been contracted. The problem is work force. We can make referrals but the ase agencies dont have stuff. We what can the va do to improve the work force for home care, particularly for the highest need kind of patients that need daily or twice daily intensive home care . I think thats a great question. I dont know if i have the whole answer there but you bring up this very important point, which va is part of the fabric of the American Health care system tlchlt are certain macro forces that we also face. A lot of our stake holders may not know that. I always try to make clear whats a va issue. That work force issue an american medicine issue. We have such a derth of Mental Health care providers. It sounds like hoem health agencies, its probably not only the minneapolis va but maybe university of minnesota abdomen others experiencing that. We are asking to do something similar in the future where we would be able to cover the residency, very similar to what the Public Health service does or the dod does. I hope we can start to contribute some what to that issue by training and bringing them back to the shortage area. Many folks that complete the Residency Training tend to stay in that area. Hopefully they will continue serving veteran population and others. Thats a tough one. We need to be working with others in the american medicine spectrum to address that. So i would like to continue our home care discussion. Sure. Since thats a huge part of whats going on with choice. I am from the denver va. We are currently a spinal cord injury spoke site and by next year are supposed to be a hub site. What our Home Care Department has now done is gone to medicare criteria to authorize all home care. I will tell you that the majority of my spinal cord injury patients are not home bound. They are young, active, healthy men for the most part. They work full time in many cases. They require assistance in their home in order to be to be able to get up in the morning, get dressed, get out to work on time. That does not meet medicare criteria. So we have battled with our Home Care Department on making the exceptions for our final cord injury patients. If you go to medicaid they do not have the same home bound regierr requireme requirement. We are trying to work with them but like our college said recently, home care should not be a part of this provider network. It should be founded in a very separate way. It is utilized very differently. In my facility my department probably uses 90 of all health care authorized services because its longterm. So its not the short term you just had your hip replaced you need six to eight weeks of home care. So i think this needs to be looked at from a very different criteria on that community side. Sure. In addition to that one of my frustrations with home care, i never ever see the home care notes. When i ask for the home care notes my Home Care Department tells me they dont exist because the home care people are not required to send in their notes in between their 485s. I can get the 485 and see what they are supposed to be doing but i have no reasonable expectation to know that is being carried out from one 485 to the next. It would be nice if there was an expectation that like the Community Providers those agencies were required to submit those notes to us so we knew things were being carried out correctly. Until i started asking for the notes and by the way, he was being seen for swallowing issues which he did not have, but thats what the deck menation. We have four years of payments for a high level therapist that the patient didnt need and should never have been th authoriz authorized. But because we didnt have that followup its technically fraud. The patient didnt need that service but i have no way of documenting that. Neighally we havent set any sort of standards. One thing oil realizing is helpful is standard episodes of care. We do this for many especially for facilities that dont have a lot of specialty services. We try to create a package of Different Things that would be required for that. They need to do pt after. So i could see a standard episode for spinal cord or injuries. Specifically its different than the home care for after you had a surgery. I think theres a way to address that. We are rolling out a number of standard episodes over time. I think i would need your expertise to help us determine what would be appropriate. You might have more than one depending on different conditions. Once we put those into the they could be used across the different facilities. I think thats solvable. It varies from one place to another. In some locations they are authorizing a ton and others its a little bit. We can work on that. I think we keep going i was harping very strongly on that care coordination. It is so critical. Before a few months ago we couldnt it could be part of your outlook. We deployed that and now we are going to more broadly across this v anchts there should be nothing that stops you in getting those records. So maybe i can share with you a little bit about that. Denver is one of the sites that has some of those resources. We need to connect the dots there. The one gap thats exits is existing living. Im hopes to explore to provide assisted living ochgss for those that are ageing with spinal cord injury but dont have to choose between living at home and being institutionalized. We dont and you hit it on the head. When i think of the larger va benefits package we have nursing home care, home health care. I think thats something that is up for discussion. Theres a lot of things that come with that like pros and cons in terms of how you to be frank make sure you have resources to take care of that. We should definitely be thinking about that. Appreciate it. I would like to speak a little bit about the care corporation. When we are talking about Specialty Care and we dont do Clinical Care coordination, have you filled out communicated with the provider we are lacking the clinical piece that can navigate my va and so its clinical. When they feel they are doing a great job because we are beefing up the Clinical Care program its note meeting the needs of the veteran face to face. Im so glad you brought that up. It is a Clinical Care coordination model. One of the things that was very important to me, when i first came into the va to lead the office there was never a clinician. They were trance acting dollars back and forth. I think its a clinical program. Thats why im standing in front of you as a clinician thats leading this program. We are talking about coordinating care. We are talking about the local office of Community Care. If you dont have radiation oncology that is your program. Like anything else though theres a marriage between the business and the clinical. Some of the work we are doing is working to align the local office of Community Care under more clinicaltype leadership and we created what we called our operating model that has nurse ns there work wg primary care providers or the care team. I hope that it evolves you know, there are many good things. I hope we take the good things and evolve the care coordination model like that. Im so glad you brought that up. It is not we dont want it to be transactional. Its more of did you receive the records back from the doctor or who do you need to contact to let them know it came back. We are only in the early phases. Most have been business offices. We are working to try to change that. So we would welcome your ideas there. I think thats important. I would ask if you have any additional questions you can forward any questions and well get them to him and his staff. I prams you they are very responsive to what we request towards them. I think we owe him a round of applause for his time here. [ applause ] that is the car i got pulled out of. Maybe your patients talk about survival day or reborn day. Its kind of a day of a new awakening because you become a different person trying to hold onto that identity you were born with. 14 years on the anniversary of that date another significant thing happened. It was a day we lost a person who was very important to me, homer s. Thompson jr. When i got to d. C. I was the associate director. Theres an old say that success has many fathers but failure is an orphan. I attribute everything i have become in paralyzed vert rans of america to this one individual who i thought about long before i saw myself as a champion for veterans. He saw that potential. It wasnt necessarily what he said to me, it was how he carried himself as an advocate and as a champion. Do we have that picture yet . Who here knew homer townsend . If you didnt know him now missed out on a true treasure. We are talking about life and death literally in many cases. He became the person through his work and example in i wanted to most imulate in my new life. When we lost him on february 20th of last year, of 2016 it was a tough day for paralyzed veterans of america. I knew i would become executive director. The question became how do i do this . He did it so well and so effortlessly. She groomed a lot of people. Is carl back in here . Come on up here. That picture is one of the last pictures last took. We were all three associate directors and homer was sort of the god forth to all of us. They came to see him not because of any power or authority but because they trusted his wisdom and incite on things. When we lost him we being pva society lost a true treasure in who he was, but how we memorialized him became a question. How do we best recognize his contribution . One of the ways we do this is every year starting last year we had the Homer Thompson memorial lecture which youll get when im done speaking. The lecture is kicked off with a moment of recognition for not just somebody that is an advocate but a champion. And so while i have lana, carl and myself here thats gap. Theres somebody missing and the only way we can best fill that void is by finding someone who best embodies homers characteristics and bodies as a champion and pull them into this picture that we are going to take this morning. This is a person that i have known for quite a while. It was the consistency and ten nasty that distinguished this individual adds a champion for veterans, as a champion for people who will never have an opportunity to fight on their own behalf because they cant. So it requires somebody who is there, accessible, consistent and trust worthy. I want to recognize that individual. Im proud to give this award. Its called the lets see it. This year well recognize joel as a recipient. Joel is director of Field Services for the benefits department of paralyzed veterans of america. I wont get into his personal life but he is deeply invested. He was one of the people this isnt why he got the award, but he was one of the people that homer entrusted with his life. Homer went to boston. They took his life in his hands. When he landed he was a happy man. The one thing we talked about is what joe did. Thats what champions do. They bring comfort. It was the fact that homer trusted him so much. I think last year lana received the initial reward. It brings me great pleasure to do the same for joel. From the bottom of my heart i thank you for what you do for homer and for every veteran you touch. You really set a high bar. Im proud to give this award to you. [ applause ] [ applause ] im pretty overwhelmed. Im not really sure what to say. Its not just because of this award. I think a lot of us probably still have goose bumps from shermans presentation earlier. All i can keep seeing in my head is that running video and thinking about the things we take for granted every day something as simple as the inability to scratch our nose. Thats probably one of the most powerful and memorable presentations that i have seen. And it takes me back to something i taught to our staff all of the time about people think i talk funny and i dont mean my accent but i always use terms like we are privileged to work in such a noble profession. I dont think its true just for us but for everyone in this room. Theres times over the last couple of years that sherman has asked me do things. I know no matter what i have done or what i do throughout my career ill never be able to make the type of sacrifices that homer did or sherman for that matter. Thank you all very much for this honor. I dont think ill ever measure up to the people that came before me but im truly honored. Thank you. [ applause ]. Good morning. I wanted to welcome you all to the memorial. Im excited to be here. Im a psychologist at the san diego va. Its good to be here and have the presenters actually talk about something thats very important which is to talk about Suicide Prevention. Before we get started with that i wanted to also thank sherman for his talk this morning that personally left me with a visceral reaction to what its like to be a person who is spinal cord injured and bring us to the moment that people get injured and also bring us back to the context in which they Carry Forward with them in their own lives. I hope we can all remember that as we are working with patients as to what they all bring to the journey as well. Thank you again. It was wonderful. This morning we are going to have a presentation titled addressing Suicide Prevention. It is everyones responsibility. Im thrilled to see its everyones responsibility. We have three wonderful presenter presenters im excited to introduce you to. We have dr. Kaitlyn thompson who is National Director for office of Suicide Prevention. So welcome. [ applause ] thanks. I wanted to really thank the Program Committee for this opportunity. It really is a special privilege especially thankful that this is in memory of homer townsend. I really only got to know homer well in the last few months of his life unfortunately. I had seen him at meetings on a relatively super official basis. He wasnt in the best of health when i did get an opportunity to know him better. I can tell him every time i met him i came back feeling really energized and more passionate about what i was doing. Every time we got into this conversation, and some times we would have different perspectives on the issue you could tell how passionate he became and how energized he became. I really looked for ward to seeing him on a regular basis and realized it was ben official to both of us. He having worked for him several years before he moved up the ladder. I can tell you he is unique in terms of advocacy in supporting the spinal cord injury team. The other people i want to thank is my copresenters here. One thing is that he is executive director for Suicide Prevention. Kaitlyn was the National Director for Suicide Prevention and has now moved onto risk management. I forget the risk Program Evaluation in the private sector but working closely with veterans. I think part of the reason for doing this is because i had a lot of questions myself and i still do. And it was an opportunity to really pick their brains and also for them to share hair expertise with us. So we have no disclosures that are relevant with this. One of the reasons for doing this was because earlier this year for a few months i was temporarily serving spinal Cord Injury Program before he could take places, the permanent director. During that time there was one since dent where there was a very unfortunate tragic incident at a va facility. That triggered a lot of sort of thought processes within our own selves about what went wrong, what could we have done as a system . Could we have done Something Different . Could we have done Something Better . As part of that it really brought the focus to issues that there is really there is a very limited Community Providers<\/a> and the type of care they deliver. You might have practiced inside and outside the va. I am note going to paint everyone the same picture. It happens to us a lot. I think there are a ton of Community Providers<\/a> that are delivering extra care. Hopefully strenten them so you dont need to provide. We can provide them in house, timely and state of the art. Thats what i mean for certain things like spinal cord injury we need to make sure they are there to support our patients. At the same time for things that we think are provided at high quality in the community and maybe dont require that expertise as much like a quick exam, a colonoscopy and how do we make sure they are in our network. I think its part of our job to educate and provide resources. We started pretty much a free training program. They can get free cme credits. We have a four Course Program<\/a> on military cultural competency. They can go to a web site, get that certificate and get that. We also have a lot on opioids and oers. In some areas we are providing consul tative services. If theres a provider they can reach out to get that answered. We are not where we need to be there but i think thats going to as we start to really refine what that network looks like i hope that we have more and more providers that have completed those sort of trainings and are working with us in a collaborative manner. We want to reward and incentivize our providers to do that. Right now we are paying for volume. When you think about a lot of the health plans they might be incentivizing and minimizing the use of some care. Thats how they become a preferred status. We want the complete opposite. I want to mike sure that our providers that are delivering high quality care and i vesting and learning about veterans, they might need to get a little bit of a plus up in how we work with them contract yulely. Thats where we want to get to. We are definitely not there yet but i hope that over time youll start to see more of that. From the minneapolis va spinal cord center. Followup question regarding the home care. We havent had a problem with authorization for home care or agencies that have been contracted. The problem is work force. We can make referrals but the ase agencies dont have stuff. We what can the va do to improve the work force for home care, particularly for the highest need kind of patients that need daily or twice daily intensive home care . I think thats a great question. I dont know if i have the whole answer there but you bring up this very important point, which va is part of the fabric of the American Health<\/a> care system tlchlt are certain macro forces that we also face. A lot of our stake holders may not know that. I always try to make clear whats a va issue. That work force issue an american medicine issue. We have such a derth of Mental Health<\/a> care providers. It sounds like hoem health agencies, its probably not only the minneapolis va but maybe university of minnesota abdomen others experiencing that. We are asking to do something similar in the future where we would be able to cover the residency, very similar to what the Public Health<\/a> service does or the dod does. I hope we can start to contribute some what to that issue by training and bringing them back to the shortage area. Many folks that complete the Residency Training<\/a> tend to stay in that area. Hopefully they will continue serving veteran population and others. Thats a tough one. We need to be working with others in the american medicine spectrum to address that. So i would like to continue our home care discussion. Sure. Since thats a huge part of whats going on with choice. I am from the denver va. We are currently a spinal cord injury spoke site and by next year are supposed to be a hub site. What our Home Care Department<\/a> has now done is gone to medicare criteria to authorize all home care. I will tell you that the majority of my spinal cord injury patients are not home bound. They are young, active, healthy men for the most part. They work full time in many cases. They require assistance in their home in order to be to be able to get up in the morning, get dressed, get out to work on time. That does not meet medicare criteria. So we have battled with our Home Care Department<\/a> on making the exceptions for our final cord injury patients. If you go to medicaid they do not have the same home bound regierr requireme requirement. We are trying to work with them but like our college said recently, home care should not be a part of this provider network. It should be founded in a very separate way. It is utilized very differently. In my facility my department probably uses 90 of all health care authorized services because its longterm. So its not the short term you just had your hip replaced you need six to eight weeks of home care. So i think this needs to be looked at from a very different criteria on that community side. Sure. In addition to that one of my frustrations with home care, i never ever see the home care notes. When i ask for the home care notes my Home Care Department<\/a> tells me they dont exist because the home care people are not required to send in their notes in between their 485s. I can get the 485 and see what they are supposed to be doing but i have no reasonable expectation to know that is being carried out from one 485 to the next. It would be nice if there was an expectation that like the Community Providers<\/a> those agencies were required to submit those notes to us so we knew things were being carried out correctly. Until i started asking for the notes and by the way, he was being seen for swallowing issues which he did not have, but thats what the deck menation. We have four years of payments for a high level therapist that the patient didnt need and should never have been th authoriz authorized. But because we didnt have that followup its technically fraud. The patient didnt need that service but i have no way of documenting that. Neighally we havent set any sort of standards. One thing oil realizing is helpful is standard episodes of care. We do this for many especially for facilities that dont have a lot of specialty services. We try to create a package of Different Things<\/a> that would be required for that. They need to do pt after. So i could see a standard episode for spinal cord or injuries. Specifically its different than the home care for after you had a surgery. I think theres a way to address that. We are rolling out a number of standard episodes over time. I think i would need your expertise to help us determine what would be appropriate. You might have more than one depending on different conditions. Once we put those into the they could be used across the different facilities. I think thats solvable. It varies from one place to another. In some locations they are authorizing a ton and others its a little bit. We can work on that. I think we keep going i was harping very strongly on that care coordination. It is so critical. Before a few months ago we couldnt it could be part of your outlook. We deployed that and now we are going to more broadly across this v anchts there should be nothing that stops you in getting those records. So maybe i can share with you a little bit about that. Denver is one of the sites that has some of those resources. We need to connect the dots there. The one gap thats exits is existing living. Im hopes to explore to provide assisted living ochgss for those that are ageing with spinal cord injury but dont have to choose between living at home and being institutionalized. We dont and you hit it on the head. When i think of the larger va benefits package we have nursing home care, home health care. I think thats something that is up for discussion. Theres a lot of things that come with that like pros and cons in terms of how you to be frank make sure you have resources to take care of that. We should definitely be thinking about that. Appreciate it. I would like to speak a little bit about the care corporation. When we are talking about Specialty Care<\/a> and we dont do Clinical Care<\/a> coordination, have you filled out communicated with the provider we are lacking the clinical piece that can navigate my va and so its clinical. When they feel they are doing a great job because we are beefing up the Clinical Care<\/a> program its note meeting the needs of the veteran face to face. Im so glad you brought that up. It is a Clinical Care<\/a> coordination model. One of the things that was very important to me, when i first came into the va to lead the office there was never a clinician. They were trance acting dollars back and forth. I think its a clinical program. Thats why im standing in front of you as a clinician thats leading this program. We are talking about coordinating care. We are talking about the local office of Community Care<\/a>. If you dont have radiation oncology that is your program. Like anything else though theres a marriage between the business and the clinical. Some of the work we are doing is working to align the local office of Community Care<\/a> under more clinicaltype leadership and we created what we called our operating model that has nurse ns there work wg primary care providers or the care team. I hope that it evolves you know, there are many good things. I hope we take the good things and evolve the care coordination model like that. Im so glad you brought that up. It is not we dont want it to be transactional. Its more of did you receive the records back from the doctor or who do you need to contact to let them know it came back. We are only in the early phases. Most have been business offices. We are working to try to change that. So we would welcome your ideas there. I think thats important. I would ask if you have any additional questions you can forward any questions and well get them to him and his staff. I prams you they are very responsive to what we request towards them. I think we owe him a round of applause for his time here. [ applause ] that is the car i got pulled out of. Maybe your patients talk about survival day or reborn day. Its kind of a day of a new awakening because you become a different person trying to hold onto that identity you were born with. 14 years on the anniversary of that date another significant thing happened. It was a day we lost a person who was very important to me, homer s. Thompson jr. When i got to d. C. I was the associate director. Theres an old say that success has many fathers but failure is an orphan. I attribute everything i have become in paralyzed vert rans of america to this one individual who i thought about long before i saw myself as a champion for veterans. He saw that potential. It wasnt necessarily what he said to me, it was how he carried himself as an advocate and as a champion. Do we have that picture yet . Who here knew homer townsend . If you didnt know him now missed out on a true treasure. We are talking about life and death literally in many cases. He became the person through his work and example in i wanted to most imulate in my new life. When we lost him on february 20th of last year, of 2016 it was a tough day for paralyzed veterans of america. I knew i would become executive director. The question became how do i do this . He did it so well and so effortlessly. She groomed a lot of people. Is carl back in here . Come on up here. That picture is one of the last pictures last took. We were all three associate directors and homer was sort of the god forth to all of us. They came to see him not because of any power or authority but because they trusted his wisdom and incite on things. When we lost him we being pva society lost a true treasure in who he was, but how we memorialized him became a question. How do we best recognize his contribution . One of the ways we do this is every year starting last year we had the Homer Thompson<\/a> memorial lecture which youll get when im done speaking. The lecture is kicked off with a moment of recognition for not just somebody that is an advocate but a champion. And so while i have lana, carl and myself here thats gap. Theres somebody missing and the only way we can best fill that void is by finding someone who best embodies homers characteristics and bodies as a champion and pull them into this picture that we are going to take this morning. This is a person that i have known for quite a while. It was the consistency and ten nasty that distinguished this individual adds a champion for veterans, as a champion for people who will never have an opportunity to fight on their own behalf because they cant. So it requires somebody who is there, accessible, consistent and trust worthy. I want to recognize that individual. Im proud to give this award. Its called the lets see it. This year well recognize joel as a recipient. Joel is director of Field Services<\/a> for the benefits department of paralyzed veterans of america. I wont get into his personal life but he is deeply invested. He was one of the people this isnt why he got the award, but he was one of the people that homer entrusted with his life. Homer went to boston. They took his life in his hands. When he landed he was a happy man. The one thing we talked about is what joe did. Thats what champions do. They bring comfort. It was the fact that homer trusted him so much. I think last year lana received the initial reward. It brings me great pleasure to do the same for joel. From the bottom of my heart i thank you for what you do for homer and for every veteran you touch. You really set a high bar. Im proud to give this award to you. [ applause ] [ applause ] im pretty overwhelmed. Im not really sure what to say. Its not just because of this award. I think a lot of us probably still have goose bumps from shermans presentation earlier. All i can keep seeing in my head is that running video and thinking about the things we take for granted every day something as simple as the inability to scratch our nose. Thats probably one of the most powerful and memorable presentations that i have seen. And it takes me back to something i taught to our staff all of the time about people think i talk funny and i dont mean my accent but i always use terms like we are privileged to work in such a noble profession. I dont think its true just for us but for everyone in this room. Theres times over the last couple of years that sherman has asked me do things. I know no matter what i have done or what i do throughout my career ill never be able to make the type of sacrifices that homer did or sherman for that matter. Thank you all very much for this honor. I dont think ill ever measure up to the people that came before me but im truly honored. Thank you. [ applause ]. Good morning. I wanted to welcome you all to the memorial. Im excited to be here. Im a psychologist at the san diego va. Its good to be here and have the presenters actually talk about something thats very important which is to talk about Suicide Prevention<\/a>. Before we get started with that i wanted to also thank sherman for his talk this morning that personally left me with a visceral reaction to what its like to be a person who is spinal cord injured and bring us to the moment that people get injured and also bring us back to the context in which they Carry Forward<\/a> with them in their own lives. I hope we can all remember that as we are working with patients as to what they all bring to the journey as well. Thank you again. It was wonderful. This morning we are going to have a presentation titled addressing Suicide Prevention<\/a>. It is everyones responsibility. Im thrilled to see its everyones responsibility. We have three wonderful presenter presenters im excited to introduce you to. We have dr. Kaitlyn thompson who is National Director<\/a> for office of Suicide Prevention<\/a>. So welcome. [ applause ] thanks. I wanted to really thank the Program Committee<\/a> for this opportunity. It really is a special privilege especially thankful that this is in memory of homer townsend. I really only got to know homer well in the last few months of his life unfortunately. I had seen him at meetings on a relatively super official basis. He wasnt in the best of health when i did get an opportunity to know him better. I can tell him every time i met him i came back feeling really energized and more passionate about what i was doing. Every time we got into this conversation, and some times we would have different perspectives on the issue you could tell how passionate he became and how energized he became. I really looked for ward to seeing him on a regular basis and realized it was ben official to both of us. He having worked for him several years before he moved up the ladder. I can tell you he is unique in terms of advocacy in supporting the spinal cord injury team. The other people i want to thank is my copresenters here. One thing is that he is executive director for Suicide Prevention<\/a>. Kaitlyn was the National Director<\/a> for Suicide Prevention<\/a> and has now moved onto risk management. I forget the risk Program Evaluation<\/a> in the private sector but working closely with veterans. I think part of the reason for doing this is because i had a lot of questions myself and i still do. And it was an opportunity to really pick their brains and also for them to share hair expertise with us. So we have no disclosures that are relevant with this. One of the reasons for doing this was because earlier this year for a few months i was temporarily serving spinal Cord Injury Program<\/a> before he could take places, the permanent director. During that time there was one since dent where there was a very unfortunate tragic incident at a va facility. That triggered a lot of sort of thought processes within our own selves about what went wrong, what could we have done as a system . Could we have done Something Different<\/a> . Could we have done Something Better<\/a> . As part of that it really brought the focus to issues that there is really there is a very limited Evidence Base<\/a> for people with spinal cord injuries. I realized the va made a lot of strides in suicide presengs. There are opportunities to really apply that into our spinal cord injury practice. Also i think at the same time realize that a lot of us dont quite know what our role is in Suicide Prevention<\/a>. As jerry mentioned, it often falls to the Mental Health<\/a> provider but each of us has a very Important Role<\/a> to play in Suicide Prevention<\/a>. So these are the goals based on that background. And then the other thing that i think we realize, even though it would be good to apply the Evidence Base<\/a> that exists in the population theres unique considerations that are relevant to spinal cord injury practice that i hope we have a chance too talk about. David is going to talk a little bit about facts and figures related to spinal cord injuries. Thanks. Good morning everyone. It is a real privilege to be here with all of you today and to speak to you about something that is most important to us. I want to thank them for the opportunity to partner with them in this presentation today and to have the honor of being here for the townsend memorial lecture and of course to give a shout out to all of our veterans, all of the va employees and everyone else who is our partner in this important work. Suicide prevention, the health and well being of veterans is the most important thing to all of us who worked for the department of the Veterans Affairs<\/a> and to all of us as a nation. What we are going to do this morning is to begin by talking about some data zwrous kind of set the context for this really important work that we have to do that we are committed to do as a department and as a nation. Ill use to mouse. There we go. So suicide a Public Health<\/a> issue. I would say its a Public Health<\/a> crisis in the United States<\/a>. Between 2001 and 2014 the rate of suicide in the u. S. Civilian population increased by almost 24 . Currently death by suicide is the tenth leading cause of death in the United States<\/a>. This is not just anni issue for one segment. This is a Public Health<\/a> issue. This is a Public Health<\/a> crisis. Va is working with partners across the nation with the Substance Abuse<\/a> and Mental Health<\/a> services administration, the department of health and Human Services<\/a> with our dod partners, with all of the partners that he was talking about in the first presentation this morning. But this is something that we need to do together. As the title of our talk says, this is everyones business. This isnt just the responsibility for the folks who work in the Mental Health<\/a> clinic at the end of the hallway or for the Suicide Prevention<\/a> coordinator staff. This is everyones responsibility. We can all do something about it. Thats really the great news. Thats what i want to communicate with you this morning. She will talk about training we developed in va that can make people at ease in having the conversation with somebody to say, you know, you seem to be in a crisis. Have you been thinking about taking your own life and to have the confidence to say that and then to have the ability to say lets you know, i understand that. Lets see what we can do to figure out and get you help now, how we can get you into care. We can do something about this. We are not helpless and we are really trying to get that message out. Pardon my enthusiasm. I just had a start there. Theres a very poz ti thing that is coming out of our work in va and with our partners across preventing suicide and helping people reengage in their lives, in their wellness, whatever their situation may be. So with that let me come back and talk about data. Ill stay on track here. We have seen an increase in suicide. And the other thing i would note in va, on average there are roughly 6, maybe 7 million veterans who are enrolled. About 28 of those are engaged in Mental Health<\/a> care. There are roughly 22 million. Our commitment to prevent suicide is to all 22 million veterans. So thats why this is everybodys business because we are also committed to helping veterans and their families even if they arent typically engaged in Va Health Care<\/a> services. So the rates went up at a higher rate in females. As we look at the next slide between 2001 and 2014 the rate of suicide in u. S. Veterans increased by 31 . So slightly more than the overall population rate increase. Actually its probably significantly more but more than the u. S. Population. The rate increases substantially, 62. 4 . When we look at the overall data and talk about the rate per day this is something thats portrayed in the media. Far long time the rate that was in the media was 22 veterans on average die each day from suicide. Based on the 2014 data that rate is 20 veterans a day on average die from suicide. You can see thats decrease in the number of veteran suicides as a percentage of overall suicide in the United States<\/a> from 22 to 18 . This isnt really necessarily good news, however, because the number of veterans living in the United States<\/a> also decreased between 2001 and 2014 and 2010 and 2014. And so, you know, the daily number is 20. It is not a good news story. There is much more that we need to do. A couple of interesting and really important facts. We are committed to present it among every group of veterans that there is. Roughly two things are those over the age of 506789 it is a particular issue for veterans later in life. We also know it is the result of firearm injury. Wael talk more about gun safety later this morning. The latest slide is something abo among kafrmt and as you can see on this slide across the board the rate of ip crease for veterans who use Va Health Care<\/a> services went up but it went up significantly less than it did for veterans that do not receive care from va. So there is something what about we do in va. Theres something about that connection that is helpful. And so part of our mission is to really reach out and to engage veterans in va care or in whatever care that they want. We know that most veterans who died by suicide are not in va care. We want to get them connected to care in the community as he was talk about, to va care but we want to get them connected somewhere. They are not alone. There are Resources Available<\/a> to them. Well talk some more about that as we go forward. Im going to talk a little bit about suicide risk specifically after spinal cord injuries. So well talk about a patient. I would say the Case Scenario<\/a> is fictional. Its not a lot of what im saying did not truly happen to jason. This is jason and jason was a 27yearold veteran who left after returning to deployment in afghanistan. He was working part time as a handyman and thinking about enrolling in college. So jason had a couple of drinks after an argument. He was speeding on his way ohm and he was in a motorcycle accident. That is the scene of the accident. He had no finger movements and no movements below his neck or in the legs. Even in this you can see a section at the vertical level. So what is jasons risk for suicide . What do we really know about the literature that we could apply to jasons to addressing jasons suicide. We know that people with final cord injury are more likely to think about suicide, more likely to athe temp suicide there with there was a a lot of other studies generally indicate peek are more like tloi and that the location. As you know. People are predominant males. This is loolking at standard ieds portalty. As i said, they are also more likely to think about suicide and attempt suicide. This was a larger than i had thought at least. In 20 say they looked aa large number of shent they administered several questions of which it really talks about in the past two weeks. And 13 of their patients were across a spectrum of time since injury reported suicide across sectional analysis. 7 reported a lifetime suicide attempt. Now, this is one study. It is very high. Studies are largely conducted based on of People Living<\/a> with spinal cord injury. We dont know if the same thing translates to veterans with spinal cord injury. There really isnt a lot of good data on veterans with spinal cord injury. We dont know you know, as david mentioned, veterans in care of v. A. Actually might have a lesser suicide. We dont know if theres specific risks that apply to this population in addition to the usual risks that apply to individuals with spinal cord injury that may increase the risk. The va does have resource erurc factors that in some cases protect against suicide. But the at the is we hadata we is limited. I dont expect you to read this slide. Its a table i copied from 2017 article that just came out a couple of months ago. But basically its looking at it was a systemic review of seven or eight studies that have been published about epidemiological risk of suicide. And the bottom line is that suicide accounts for 410 of deaths after spinal cord injury based on the data. The one thing i would say is that this study this last one, the study in 2014 actually looked at data. They also stratified it in the decade of injury. And they found that there was actually a dekrecrease. It was still about 3. 5 to 4 times of death. But there was a decrease over the decades. In the 1990s, there seemed to have been a decrease in suicide, at least in that patient population. Part of the conjecture was perhaps there is a greater attention with the ada and greater resources, greater attention to community integration, that perhaps that has some bearing on the decrease in suicide risk. I think that then goes directly to some preventive factors well talk about. What do you know we know about the factors associated with suicide risk post sci . Just like in the general population, suicide does seem to be more prevalent in nonhispanic in the white race. Some studies have indicated more in males. Some dont really have a clear cut gender difference. And its hard to tell because the numbers are so small, especially for females with spinal cord injury. That gender and age data is also inconclusive, but it does seem to be more prevalent in nonhispanic whites. This is somewhat surprising. It does not troelt whrelate to might think is the most impaired individuals. In fact, several studies have corroborated that successful suicide is more common in people with paraplegia than it is in tetraplegia. One of the things that has been suggested is that perhaps people with tretettraplegia might have more isolation and less attention to these resources and daily interactions and that might be factoring in. There have been other kinds of things but this seems to be something that is corroborated in several studies. In terms of duration of injury and again, i think this focus on where the prevention efforts should be especially targeted, the first five to six years after injury seems to be the highest risk. In the study, years two to five it was highest risk for suicide with some increase also in year one in the more recent study. The suicide risk then decreased progressively and then significantly it reduced about 60 for people who survived ten or more years after injury. The greatest suicide risk is really in the first five to six years. Theres some suggestion again, this is very weak evidence, in terms of the mode of injury, that people who get hit by an object just passively are less likely to commit suicide than those who have an active enrollment in whatever cause of injury. But that is, again, weak data. Not surprisingly, depression, Substance Abuse<\/a>, including both drug and alcohol abuse, history of Mental Health<\/a> disorders such as schizophrenia and bipolar disorders and a history of past suicide attempts. This Mccollum Smith<\/a> study looked at meaning full environmental with rlower environmental rewars and a sense of lower control on those activities with suicidal ideation. In terms of methods of suicide, this also charlie, i think from san diego and Kevin Gerhardt<\/a> had done a studstudy. 50 , not unlike the u. S. Population in general of swieds after spinal cord injury, are related to gunshot wounds. Thats the best data we have followed by overdose, cutting, sufficie suffocation. In europe, by contrast this is a danish study that showed that overdose is the most common cause. Perhaps that has something to do with gun availability in the United States<\/a>. So im next going to pass it onto caitlyn. She and david will talk about specific issues related to myths and realities for suicide risk after spinal cord injury. Hi, everyone. Again, just want to reiterate what my colleagues have said. Its such a delight to be here today and a real honor. I want to dispel some myths in terms of our suicide Risk Assessment<\/a>. Theres one that asking about suicide may lead to someone taking his or her life. Theres a lot of fear about asking about suicide. And so one of the big fears is if i ask somebody if theyre feeling suicidal and i say, do you feel like you want to kill yourself, im going to put it into their head as an idea for them to then kill themselves. Theyre going to then kill themselves and its going to be my fault. That is a very widespread myth that i want to make sure youre all aware is not a reality. Reality is that if you ask somebody if theyre feeling suicidal or feeling like taking their own life, it in fact opens up this huge conversation for them. Weve heard this with so many survivors of suicide. That if somebody had just asked them, said, you know what im really concerned about you, are you feeling suicidal, that they would have opened up and talked about it. It shows that youre not scared. Youre not scared to talk about what are probably the most difficult feelings in somebodys life. Another fear that people have is if i ask somebody about suicide, if theyre feeling suicidal, my fear is that theyre going to say yes, i am feeling suicidal. And that is really scary. Because then what do you do. So im going to talk through some strategies that we can go through. But i first want to dispel some of these myths right now. There are talkers and there are doers. People say, well, some people will talk about it but they wont really do it. In fact, people who talk about suicide must be taken very seriously. So if you hear somebody its not like everybodys going to come up to you and say, hey, buddy, guess what, im feeling suicidal. But you have to think about the language that people use. It really is a wide spectrum. It might be somebody saying i just feel so tired all the time, i just dont know if i can go on. And so as youre continuing to talk with people and talk with each other, really recognize the fact that everybody has their own language and their own way of talking about how theyre doing. So be very, very aware of that. Because we know that about 80 of people who died by suicide gave some warning as to their intentions. We always hear those stories and we know those people perhaps who have died by suicide. And you say, they had everything going for them, what happened. Or, you know, they were so supported. They had young children. All of these things. And in fact, people who then look back and say, wait a second, there were some signs. Always trust yourself and make sure that you follow up if people are talking about feeling suicidal. Theres another myth if somebody really wanted to die by suicide, theres nothing you can do about it. And that is not true at all. Most people who are feeling suicidal can get better. Theres treatment. Its either going to the va, its going to a clinic, its reaching out and talking with somebody. And so knowing that you can get better is especially important, particularly if youre talking with somebody who might be in crisis. When youre talking with somebody and theyre suddenly talking with you about i do want to take my own life, its then saying to that person, listen, i am here with you. Im going to hold your hand through this and were going to get through this together. That can be so powerful for that person who can feel so alone and so helpless. Again, you know, this myth of theyre not really going to kill themselves. You know, they just made plans for a vacation. They just got a new job. They just, you know, retired from a horrible job and theyre going to move onto something. You know, they have all these plans theyve made. They have young children. The reality is that most people who feel suicidal and who eventually take their own life, their perspective is not good. There is this overwhelming sense, especially of hopelessness, of worthlessness. There is kind of this misperception that i am a burden on so many people. And so therefore whats the point. And so that idea of, oh, its nothing for me to worry about because of this, they know how much we love them. Which is very, very it doesnt feel that way for most people who eventually do die by suicide or who attempt suicide. I want to run through. Im going to do a very abbreviated version of what we call operation saver at the va. This is gate keeper training. There are a few different kinds of gate keeper training. The army has their own, different organizations have their own. Im going to talk through the vas gate keeper training. Its for everybody. Its for nonclinicians. Its for anybody who comes in contact with a vet eran or realy anybody else. It talks about the very specific and very easy ways that you can intervene with somebody who might be feeling suicidal. So s. A. V. E. Stands for what are the signs of suicidal thinking that we need to recognize, what is the most important question of all and how do you ask it, learning how to validate that veterans experience and verify their experience. And then the e. Is encouraging treatment and expediting getting them help. Very, very basic, really easy to get through. I also wonder how many people in the audience know who your local Suicide Prevention<\/a> coordinator is at your va . Awesome. Fantastic. Thats wonderful to hear. If you dont know who your local Suicide Prevention<\/a> coordinator at your va is, its very easy to find. Its at veteranscrisisline. Net. Its so important to collaborate with that spc as we call them. They are your local experts in Suicide Prevention<\/a> for veterans in your region. Any time youre concerned about a veteran or if you want to get this training, please please contact them. This is part of their job, is to provide this training, is to provide the support thats needed. Im giving you the very brief, abbreviated version of this. But you can get the one to two hour in person training for your local Suicide Prevention<\/a> coordinator really anywhere with your local chapters, pva anything. What are some of the signs of suicidal thinking . As i said before, hopelessness. That is really known to be the paramount risk factor for those who are feeling suicidal. Most people its a huge percentage of people who have survived suicide attempts, have said that hopelessness was one of their biggest factors, feeling tlifeel ing like theres no way out. Other things to watch out for, any change in behavior, any change in terms of anxiety or sleeping, feeling like theres no reason to live, any change in anger, engaging in risky activities without thinking, increasing alcohol or drug use or withdrawing from family and friends. Another thing thats really important to recognize is that suicide for anybody tends to happen when people are going through major transitions in their lives. Whether thats separating from the military, whether thats retiring, especially also when people are going through difficult relationship problems. We know from a lot of the studies that have been done at va, that the primary reason why people have been known to die by suicide is a relationship problem and also pain, physical pain. So those are especially important things to watch out for. Any sort of legal problems. Of course, we know just across the country, any time theres a recession or serious financial problems with somebody, the suicide rates go up. Thats known world wide in various countries. Greece recently had a real high rate of suicides because of their financial problems within their countries. Other things to just make sure that youre recognizing. There are a few things that require, of course, immediate attention. Thats when somebody is saying i really do want to kill myself. I am looking for ways to die. I am purchasing a weapon. Im stockpiling my medication. These are things that require immediate attention. Im talk about what to do with that mediaimmediate attention. Asking the most important question of all, are you feeling suicidal, are you thinking about killing yourself, are you thinking about taking your life. Lots of people also and this is very, very normal is that fear again of going straight to the question, that fear so theres a lot of people who say are you thinking about hurting yourself, which is okay, but still youre eventually going to have to get to that question anyway. And most people that we have talked with, again, its are you thinking about killing yourself, get right to the crux of it. It again shows youre not scared to talk about, again, what is probably the most difficult thing that somebodys going through. So there are some ways to ask it. I mean, a lot of people are very scared too, what if i then Say Something<\/a> wrong, what if i do something wrong. Really the only thing you could do wrong is say, well, yeah, maybe you should go through with it, which of course nobodys going to do, right . I mean, really, you just have to be that em papathic, human cari person and just continue the conversation. Another thing that we do it lessens our anxiety is asking the question. So you werent thinking of killing yourself, are you . Well, what is that saying to the person, right . Well, no, of course not. Theyre not going to answer you, well, yeah, i kind of am. You have to just be very out there, very up front and just ask the question. Ask it when you have some time. Dont wait until, oh, wait a second, i know we just finished our session or whatever, by the way. This is incredibly important, this conversation, as you all know. There isnt much that you can say thats wrong. Its just then continuing and validating that persons experience, which is where we go to the v. Its talki ing openly about it. Even though inside you might be freaking out, because you are right now with somebody whos saying theyre suicidal and that is just so scary. On the outside its being confident and talking with the person. As i said before, its just saying were going to get through this together. Youre going to be okay. Were going to get you some help and i am here with you. Not passing judgment. Are you kidding . Are you serious . You have young children. You just retired. You have so much to live for. The guilt is not going to work. It is being with that person in their experience and its walking through whatever theyre feeling at that time. And then what do you do . You encourage treatment and you expedite getting help. If somebody is at very high risk or imminent danger, you need to get them to the hospital. You need to call 911. We also, of course, have the Veterans Crisis<\/a> line, which is an extraordinary service. I know lots and lots of veterans are using it and lots of people use it too. We even have psychiatrists who call to say, i have a patient here and theyre feeling suicidal and im not sure what to do. And so its 18002738255. You press one, its 24 7. Extraordinary people, they will expedite getting the help that you need. You dont want to leave the veteran alone. You want to make sure theres a warm handoff to wherever youre going. You want to make sure that the veteran feels like you are with them, youre taking them to the emergency room, youre calling somebody and handing the phone directly to them. That way, you know, its you know that the veteran is going to be safe. And thats the end of my part. [ applause ]. She will be back because im going to ask her questions too. So lets get back to jason. So jason seems withdrawn. Hes quiet, hes not eating, hes not sleeping well, hes refusing to go to therapy. Just in the past couple of days he was told by his physician that he would never walk again. In the kind of family meeting that sherman talked about whether the question was asked and the answer was just a simple, no, youre not going to walk again. Hes getting over pneumonia, he has a suspected urinary tract infection. He said Something Like<\/a> what caitlyn just mentioned, i feel fatigued all the time, i dont know if i can go on like this. That is something that we often encounter in the patient population. How would you respond . And the second question is, what are some of the warning signs that would especially concern you about suicidal intent . We dont have a lot of time, but maybe take a minute or two and think about it and talk to the person sitting next to you, practice saying what caitlyn just mentioned, asking the question. Dont ask it in a negative manner. But ask the question. Because i know that i myself feel very uncomfortable asking that question. So maybe just start by asking that question and reflect on this for a minute. Everybody. Okay. I know you have a lot to say. Do you want another half minute or so . Maybe lets do that. And i guess the issue is and well come back to some of this conversation at the end, hopefully at the question and answer time. Some of you can come up and talk about what your thoughts are about this. Some of the questions that do come up that i think ive encountered myself and ive seen people on my team encounter, is how do you really distinguish between this time limited sort of distress that is natural, not for everybody. Everyone responds differently. People have different ways to respond to different events, including a spinal cord injury. But the time limited distress that we often encountered in people. We talked about this morning. The presentation by sherman was such a powerful portrayal of what he felt, what he heard at the time of his spinal cord injury. As you can imagine, there are different thoughts going on. That is something thats often encounter encountered. We get so used to that. Are we then able to see when someone truly needs to go one step further to ask that question about suicide risk. Should we be asking that for everybody in that situation. Thats something that well talk about, i think, a little bit. And caitlyn already mentioned asking the question is important if you feel that is an issue. Its also important to then bring up your concerns not just to keep it to yourself, because in some instances what happens is you may notice something, but youre a nursing assistant on a spinal cord injury unit. You think theres a whole team of people. Its really, im not sure if i should even bring this up. I know, at least at boston, our nurses feel free to go to our psychologists and say, hey, im concerned about this patient. Im hoping thats true in all your teams. The psychologists are always open to listen, but its up to us to make sure that if we are not quite sure what to do next that we go to a Mental Health<\/a> provider on our team. We, if needed, find the Suicide Prevention<\/a> coordinator or at least contact someone who might be able to. Its really important to do that. I think the other tension that we run into is if we feel that someone is possibly at a risk, at what point and what is the extent of and this is true of the attention that does occur, is maximizing safety is a priority versus excessive or unnecessary interference with autonomy. Thats always a concern. I think we have to default on the side of safety, but at the same time i think we need to be cognizant of the in fact people are there often for their initial rehabilitation when this scenario happened with jason. He was going to rehab. Yes, he was refusing some therapies. But then, if you truly think at what point would you then maybe have a one to one, maybe restrict visitors and at what point will you weigh the pros and cons of doing that. That goes to that second question we talked about and the signs that caitlyn talked about. What are the red flags . If someone really is communicating suicidal ideation, those are the kind of red flags that i think should alearn you where you do then need to err on the side of safety. How are you going to force treatment on someone who refuses to get treatment and maintaining the therapeutic relationship. I think one of the other things we ran into when the va responded to that particular incident we talked about is that we have really strong Mental Health<\/a> support as part of our spinal cord injury teams. We do provide ongoing, regular Mental Health<\/a> evaluation, assessment and treatment. But the issue really is, is there Something Else<\/a> we should be doing more consistently in terms of suicide Risk Assessment<\/a> and prevention. And that became apparent partly because there is not good evidenced based in the spinal cord injury population. We dont know what is the standard. There are no really wellestablish wellestablished standards of care for spinal cord injuries providers. If you are concerned, then its really important to ask the question. The other question that sometimes comes up and this came new that you know, after we had some discussions with the field about how to respond to those after that unfortunate incident happened. If you truly think someone is at imminent risk for taking their own life, what is the best setting for their treatment . Mostly the recommendation is in an inpatient psychiatry unit. We know that people with akutd spin acute spinal cord injury, that may not be the best setting. The s. C. I. Units are not locked units. It is a true tension in terms of what we experience. Maybe we can talk a little bit about your thoughts or experiences regarding that in the q a session. Im going to turn it over to david to talk about what is the summary of research and what the resources are within the va. Thanks. Im not going to spend a lot of time on this slide. This is a slide that really summarizes the body of research around Suicide Prevention<\/a> and whats important. I want to point to the fact that keeping people safe in the upper lefthand corner is one of the most Evidence Base<\/a>d things that we can do, whether were talking about gun safety. Were not talking about gun control, were talking about gun safety, particularly when people are at risk, talking about opioid safety, safety with medications, safety in the environment for someone who is acutely suicidal. The number one most evidenced based thing that we can do as well as asking about things like depression and doing it in primary care settings. Again, were not talking about what is traditionally considered a Mental Health<\/a> problem, but in the front line, whether its in primary care, if its in an s. C. I. Clinic. But in those kinds of settings those are the important places. I want to just make a comment that there are eight slides coming up. We dont have time we want to make sure we have time for questions here and have some conversation with you. Im going to go through them but very quickly. Before i do that, i want to go back to the save training that caitlyn was talking about. It is so important. Weve had at least two wonderful stories in the last few months from va Medical Center<\/a>s. In one case a staff member was walking across the campus thats on a lake. They saw somebody sitting on a park bench on the edge of the lake and said this doesnt look right. They went up and asked the question, are you thinking about suicide, are you thinking about taking your life today . And the person said yes. And they got that person into care. It was a random event. They could have just kept on walking. In another case just this past week a nurse on an inpatient unit noticed the patient had a change in their routine. And the nurse said this just isnt right and again had a conversation and there was a problem and the person opened up to that nurse and they got the patient into care. We know that va grounds keepers in the National Cemeteries<\/a> often come across people. The Canteen Service<\/a> workers across va are taking save training. It is now required for every va employee every year. It is really our commitment to be there for veterans and be there is our campaign that were rolling out in the month of september for Suicide Prevention<\/a> month. That is our commitment, to be there for veterans, to ask the question, to help them connect with the services that they need. To support you in that work, here are the slides. Caitlyn already mentioned the great work that is done 24 7, 365 at the Veterans Crisis<\/a> line. They also 2,000 calls on average every day, dispatch Emergency Services<\/a> 7580 times a day across the 24hour period. 18002738255, then press one. All of our Suicide Prevention<\/a> resources for va are on that website. It is wonderful. Please look at that. And including the list of Suicide Prevention<\/a> coordinators, we have over 400 Suicide Prevention<\/a> coordinators at every facility. If youre at a facility, if you havent partnered with your Suicide Prevention<\/a> coordinator, do that. Theyre the quarterback. Theyre not going to take care of every issue regarding Suicide Prevention<\/a>. We all need to do that. But theyre the quarterback and they can help you with that. Reach vet was a program we have launched in the fall of last year using all of the data we have in va to identify veterans who may be at risk for suicide based upon all of that data that may not have bubbled up to the surface clinically yet. Thats being pushed out to providers so providers can ask patients and review their care plan with them. Va has had a very Robust Program<\/a> on the gun safety. Its not about gun control. We have no idea who has gotten a gun lock from va, but we have distributed over 3 million gun locks through va. And they happen to have the Veterans Crisis<\/a> line number on them. We know just in that moment, interrupting someones, you know, moment of desperation, if the gun is locked, that saves lives. Going back to that research slide, that is one of the prominent findings in terms of Suicide Prevention<\/a> research. Gun locks make a difference. Theyre available free at every Medical Center<\/a> to anyone who wants them. Again, check with your Suicide Prevention<\/a> coordinator. Another website, make the connection. Hundreds of stories of veterans in their own words saying, yeah, i had a problem and i did something about it and im glad i did and my life is better. We can connect with each other as veterans. And you can tailor that to your particular situation. There are websites, again, for va. There are mobile apps in support of Suicide Prevention<\/a>. And finally Consultation Services<\/a> through the National Center<\/a> for ptsd. We have Community Provider<\/a> tool kits. Please look at that. I am david carroll. I would be happy to follow up with you at any time. So just getting back to jason, so weve talked about suicide risk in the acute setting. Its not just the severity of risks. Its risk temporally. Jason returned for routine follow up, hes medically stable, not overtly decreased. His pain is increasing and interfering with ability to take care of self and participating in the community. Hes voicing increasing concerns about being a burden to his family. The question is whom do we screen and what supintervention are appropriate at this point. I think i would like you to reflect on this and maybe talk about it during breaks and come up to caitlyn and david after this to ask their Expert Opinion<\/a> about how we could apply what theyve said to this particular scenario. This is something that we often encounter. We do know that some of the suicide literature talks about this issue of perceived burd burdensom burdensomeness. As well as looking at this issue of really thwarted belongingness where they feel they dont have a meaningful purpose. And i think the va that is one part that i think we dont give enough service to in terms of interventions. Im getting a sign that we are running close to the end of time. But that is really something that i think is a strength and something that we could focus more on, both in terms of adaptive sports, supported employment. Ill just briefly say this. The veteran actually gave me permission to talk about him. Hes someone whos on a longterm care spinal Cord Injury Center<\/a> and had a really tough time after injury. And here he is. Hes got a high tetraplegaia. Hes teaching japanese through skype and getting paid for it. It really changed his perspective. I think the last thing is really what could we do. We already talked about as professionals really doing both our jobs in our disciplines but also asking the question and conveying your concerns. As a system of care, i would say its obvious that we need more evidence and more research in veterans with spinal cord injuries related to Suicide Prevention<\/a>. So i would ask that all of us kind of consider how we can participate in that. The other thing that i would say is really augmenting our protective factors. There are things like supported employment. Other things, are we consistently making those available to veterans who could most benefit from them as early as feasible. I dont know if you recognize this, anyone recognize this . This is from sunday night. The mtv video music awards. I saw this on the plane flight on the news. This is a song. Do you wlaekz this numbe reco this number. Yes. Its the Suicide Prevention<\/a> number. Note it on your iphones. This is a song. Logic khalid and we leave this now, take you live to the base realignment and closure process, another way the government is trying to free up funds for military spending. The Defense Department<\/a> has asked for authorization for another round of base closures. Well be hearing from the chair of the last commission in 2005. Hell join a pentagon official this morning for this discussion. Thanks, everyone, for making the time to come over here in this first day of congress being back in town, which i assume is a busy time for everyone. First, im just going to introduce our guests and then explain to everybody a little bit. If youre here by accident and you dont know what brack is to my left is the assistant secretary of defense for energy and installations of environment at d. O. D. 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