Hearing Transcript on Charting the U.S. Department of Veterans Affairs' Progress on Meeting the Mental Health Needs of Our Veterans: Discussion of Funding, Mental Health Strategic Plan, and the Uniform Mental Health Services Handbook
CHARTING THE U.S. DEPARTMENT OF VETERANS AFFAIRS' PROGRESS ON MEETING THE MENTAL HEALTH NEEDS OF OUR VETERANS: DISCUSSION OF FUNDING, MENTAL HEALTH STRATEGIC PLAN, AND THE UNIFORM MENTAL HEALTH SERVICES HANDBOOK
SUBCOMMITTEE ON HEALTH
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED ELEVENTH CONGRESS
APRIL 30, 2009
SERIAL No. 111-17
Printed for the use of the Committee on Veterans' Affairs
U.S. GOVERNMENT PRINTING OFFICE
For sale by the Superintendent of Documents, U.S. Government Printing Office
COMMITTEE ON VETERANS' AFFAIRS
CORRINE BROWN, Florida
STEVE BUYER, Indiana, Ranking
Malcom A. Shorter, Staff Director
SUBCOMMITTEE ON HEALTH
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public hearing records of the Committee on Veterans' Affairs are also published in electronic form. The printed hearing record remains the official version. Because electronic submissions are used to prepare both printed and electronic versions of the hearing record, the process of converting between various electronic formats may introduce unintentional errors or omissions. Such occurrences are inherent in the current publication process and should diminish as the process is further refined.
C O N T E N T S
April 30, 2009
Charting the U.S. Department of Veterans Affairs' Progress on Meeting the Mental Health Needs of Our Veterans: Discussion of Funding, Mental Health Strategic Plan, and the Uniform Mental Health Services Handbook
Chairman Michael Michaud
Prepared statement of Chairman Michaud
Hon. Henry E. Brown, Jr., Ranking Republican Member
Prepared statement of Congressman Brown
Hon. Ciro D. Rodriguez
Prepared statement of Congressman Rodriguez
U.S. Department of Veterans Affairs:
Michael L. Shepherd, M.D., Senior Physician, Office of Healthcare Inspections, Office of Inspector General
Prepared statement of Dr. Shepherd
Ira Katz, M.D., Ph.D., Deputy Chief Patient Care Services Officer for Mental Health, Veterans Health Administration
Prepared statement of Dr. Katz
Disabled American Veterans, Adrian Atizado, Assistant National Legislative Director
Prepared statement of Mr. Atizado
Wounded Warrior Project, Ralph Ibson, Senior Fellow for Health Policy
Prepared statement of Mr. Ibson
SUBMISSIONS FOR THE RECORD
American Veterans (AMVETS), Christina M. Roof, National Deputy Legislative Director
Kaptur, Hon. Marcy, a Representative in Congress from the State of Ohio
Woods, Christine, Hampton, VA, Former Program Specialist and National Consultant, Office of Mental Health, Veterans Affairs Central Office, U.S. Department of Veterans Affairs
MATERIAL SUBMITTED FOR THE RECORD
Hon. Michael H. Michaud, Chairman, and Hon. Henry E. Brown, Ranking Republican Member, Subcommittee on Health, Committee on Veterans' Affairs, to Hon. Eric K. Shinseki, Secretary, U.S. Department of Veterans Affairs, letter dated May 5, 2009, and VA Responses
CHARTING THE U.S. DEPARTMENT OF VETERANS AFFAIRS' PROGRESS ON MEETING THE MENTAL HEALTH NEEDS OF OUR VETERANS: DISCUSSION OF FUNDING, MENTAL HEALTH STRATEGIC PLAN, AND THE UNIFORM MENTAL HEALTH SERVICES HANDBOOK
Thursday, April 30, 2009
U. S. House of Representatives,
Subcommittee on Health,
Committee on Veterans' Affairs,
The Subcommittee met, pursuant to notice, at 10:03 a.m., in Room 334, Cannon House Office Building, Hon. Michael Michaud [Chairman of the Subcommittee] presiding.
Present: Representatives Michaud, Brown of Florida, Snyder, Rodriguez, McNerney, Perriello, Brown of South Carolina, and Moran.
Mr. MICHAUD. I would like to call the Subcommittee on Health to order. I would like to thank everyone for coming today. We are here today to talk about the U.S. Department of Veterans Affairs (VA’s) progress on meeting the mental health needs of our veterans. Specifically, we will be discussing issues of funding and implementation of the Mental Health Strategic Plan and the Uniform Mental Health Service Handbook.
Many in this room are familiar with the daunting statistics on mental health from the April 2008 RAND Corporation Report on "Invisible Wounds of War." The RAND Report estimated that of the 1.64 million Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) servicemembers deployed to date, about 18 percent suffer from port-traumatic stress disorder (PTSD) or major depression, and about 20 percent likely experienced a traumatic brain injury (TBI) during deployment. In addition, the report showed that despite our current efforts about half of our servicemembers are not seeking and receiving the mental health treatment that they need. This raises serious concerns about the long term negative consequences of untreated mental health problems, not only for the affected individuals but also for their families, their communities, and our Nation as a whole.
To address this problem the VA has focused their efforts on improving mental health care for our veterans. For example, the VA has set aside substantial funding for mental health care, which amounts to $3.8 billion in fiscal year 2009. The VA also approved a Mental Health Strategic Plan in November of 2004, which is a 5-year action plan with distinct mental health enhancement initiatives. Additionally, I am aware of the 2008 Uniform Mental Health Service Handbook, which defines standards and minimum clinical requirements for mental health services that the VA will implement nationally.
I applaud the VA on these efforts, and it is important for the Committee to ensure proper oversight. Today’s hearing will explore the concern raised in the 2006 U.S. Government Accountability Office (GAO) Report which found that the VA spent less on mental health initiatives than planned and lacks the appropriate mechanism for tracking the allocated mental health funding. We will also seek a better understanding of the successes and the challenges faced by the VA in implementing the Mental Health Strategic Plan and the Uniform Mental Health Service Handbook. Today we will hear from various experts in the field, including the Disabled American Veterans (DAV), the Wounded Warrior Project (WWP), the Office of Inspector General (OIG), and the VA, and I look forward to the different panels today and their testimony.
I now would recognize a distinguished member of this Committee, Ranking Member Brown, for any opening statement that he may have.
[The prepared statement of Chairman Michaud appears in the Appendix.]
Mr. BROWN OF SOUTH CAROLINA. Thank you, Mr. Chairman. I appreciate you holding this hearing today. Mental health is a critical component of a person’s well being and essential to the mission of the Department of Veterans Affairs, "To care for those who have borne the battle is to effectively intervene and to care for the invisible wounds of war." The psychological toll of war is not always apparent and sadly has not always received the attention it should. However, I think we can all agree that the VA has come a long way, especially in the past few years, to improve mental health services and encourage veterans in need of care to get help.
Even though significant progress has been made, there is no doubt that we must still do more, as we continue to hear about veterans facing barriers and gaps in service. We must ensure that when a veteran needs and seeks help, that veteran gets the right care at the right time. In the past decade, we have made a substantial investment in VA mental health, increasing funding by 81 percent from $2.1 billion in fiscal year 2001 to no less than $3.8 billion in fiscal year 2009. That is why it was very disturbing when the Government Accountability Office, in November of 2006, reported that VA had not allocated all available funding to implement the Mental Health Strategic Plan.
It is our responsibility to see that the funding we provide is spent as intended to support a complete array of mental health prevention, early intervention, and rehabilitation programs for our Nation’s veterans. I look forward to hearing from our witnesses and having the opportunity to take a look at where we stand in taking care of the mental health needs of our veterans. With that, Mr. Chairman, I yield back.
[The prepared statement of Congressman Brown appears in the Appendix.]
Mr. MICHAUD. Thank you very much, Mr. Brown. We will start off with panel two. Congresswoman Kaptur is going to be delayed so we will move directly to panel two, Adrian Atizado from the Disabled American Veterans and Ralph Ibson from the Wounded Warrior Project, I would like to thank both of you for coming here this morning to talk about this very important issue that our veterans are facing. And we will start off this morning with Mr. Atizado.
STATEMENTS OF ADRIAN ATIZADO, ASSISTANT NATIONAL LEGISLATIVE DIRECTOR, DISABLED AMERICAN VETERANS; AND RALPH IBSON, SENIOR FELLOW FOR HEALTH POLICY, WOUNDED WARRIOR PROJECT
Mr. ATIZADO. Thank you, Mr. Chairman, Members of the Subcommittee. I would like to thank you for inviting the DAV to testify today. We appreciate this opportunity to discuss our views on meeting the mental health needs of our veterans.
We, as an organization, strongly believe that all enrolled veterans, and particularly every servicemember returning from war, should have maximum opportunity to recover and successfully readjust to life. We recognize the unprecedented effort made by VA, as you had mentioned in your opening statement, Mr. Chairman, over the past several years to improve the consistency, timeliness, and effectiveness of mental health services in VA. We also appreciate Congress’ continued support to help VA achieve this momentous goal. Nevertheless, we believe much still needs to be accomplished to fulfill our obligations to those who have serious mental illness and post-deployment mental health challenges.
The development of the Mental Health Strategic Plan by VA, as well as the Uniform Mental Health Services Handbook, provide an impressive and ambitious roadmap for the Veterans Health Administration's (VHA’s) mental health transformation. However, we have expressed, and continue to express, our concerns about the oversight of the implementation phase. VA specifically developed its new policy so that veterans nationwide can be assured of having not only accessible but timely access to the full range of high quality mental health and substance use disorder services at all VA facilities.
On April 6, 2009 the OIG issued two reports focused on VA mental health services. We had expected that these reports' would provide an in-depth nationwide assessment. Unfortunately, they fell far short of this expectation. We note that the report on the VA Handbook predominantly relies on self-reports from leadership at various VA facilities as to whether they have a particular program, and generally without any clear criteria on services offered, their intensity or capacity to provide such services.
The report does note that evidence-based services for PTSD are labor intensive, but that VA has no current means of tracking the true accessibility of such services. Moreover, the recent OIG report makes no attempt to calculate the intensity of PTSD services although OIG quoted VA research reports that raised concerns that intensity levels have been falling despite the fact that effective services for PTSD require very intensive services.
We are pleased that VA plans better tracking of true access to evidence-based PTSD therapies in its response to the report, and believe that this is an achievable goal and should be accomplished as soon as possible. We are pleased the OIG reported that Central Office, the Department of Veterans Affairs Central Office, had adequately tracked funds allocated for the mental health initiative in fiscal year 2008, and that the funds allocated were used as intended. While it is encouraging that the funds allocated are being predominantly utilized for the purposes intended, the report does not address two of the most pressing issues regarding true augmentation of VA mental health services. First, it does not calculate the actual increase in the number of providers. It merely audits the hiring of new staff. Second, their funds have been allocated as time limited or special purpose, although the need for additional services will clearly extend into the foreseeable future. We are concerned that if all mental health funds move into Veterans Equitable Resource Allocation (VERA) and are mixed with other funds allocated to medical centers, mental health and substance use disorder programs will, again, erode over time.
Based on the two recent OIG reports it is unclear if sufficient resources have been authorized given the comprehensive requirements outlined in VA’s Handbook. While we agree with OIG that implementation of the Handbook is ambitious, it must be approached with clear recognition that delays in immediate implementation inflict heavy costs on veterans.
The oversight process we envision, and which we recommend in mental health, is one that is data driven, transparent, and includes local evaluations and site visits to factor in local circumstances and needs. And empowered VA organization structure is needed to carry out this task. Such a structure would require VHA to collect and report data at national, network, and medical center levels.
We believe the recommendations further outlined in our written testimony, Mr. Chairman, could provide the architecture for effective oversight and improvement in VA programs. In summary, comprehensive, independent oversight is necessary to assure the current policy and new funding result in immediate access for all veterans who need such services.
Mr. Chairman, this concludes my testimony. I would be happy to answer questions that you or other Members may have.
[The prepared statement of Mr. Atizado appears in the Appendix.]
Mr. MICHAUD. Thank you very much. Mr. Ibson?
Mr. IBSON. Chairman Michaud, Ranking Member Brown, Members of the Subcommittee, thank you for inviting Wounded Warrior Project to offer our views on VA’s progress in meeting the mental health needs of our veterans. Wounded Warrior Project brings an important perspective to this issue given our founding principle of “Warriors Helping Warriors” and the organization’s goal of ensuring that this is the most successful, well-adjusted generation of veterans in our history.
This Committee has recognized that mental health care is a key VA mission and has provided critical leadership over the years. Your oversight efforts have been invaluable.
VA has taken important steps toward improving mental health care, beginning particularly in 2004 with its development of a strategic mental health plan and last year in establishing minimum clinical requirements for mental health services with its Uniform Mental Health Services Handbook. This hearing asks timely questions as we approach the 5-year mark since adoption of the strategic plan, and as VA is apparently moving toward ending a special funding initiative that had supported the plan and Handbook’s implementation.
VA has clearly made strides toward realizing its strategic mental health goals but in our view large gaps and wide variability in programs remain. Let me illustrate. While the strategic plan acknowledges the importance of specialized PTSD services for returning veterans, our warriors are experiencing both long waits for inpatient care and a dearth of OIF/OEF-specific programs. For the first time, VA policy calls for ensuring the availability of meeting mental health services, to include providing services through contracts and similar arrangements, but VA facilities have made only limited use of that contracting authority. Mental health care is increasingly being integrated into primary care clinics, but at any given VA Medical Center or large clinic, mental health may be integrated into only a single primary care team. Further, VA facilities have yet to fully incorporate a recovery orientation into their care delivery programs. And VA, while it has trained clinicians in two evidence-based therapies for PTSD, has no comparable initiative to ensure integrated or coordinated care of co-occurring PTSD and substance use disorders. Integrated treatment of these often co-occurring health problems appears to be the exception rather than the rule.
In our view, a strategic plan by its very nature should be revisited periodically, and while the current plan provides a credible foundation, we encourage the Committee to press the Department to reexamine that blueprint and take account of what has changed in the 5 years since the plan’s adoption. For example, it is not clear that the plan anticipated the increased prevalence of PTSD and other behavioral health conditions affecting this and other generations of veterans. The plan also emphasizes screening as a tool to foster early intervention, but fails to address the problem of veterans who are identified in screening as needing follow up but who elect not to pursue further evaluation or treatment. The plan also includes initiatives to foster peer-to-peer services, but only in the context of veterans with severe mental illnesses such as schizophrenia. In our experience, peer support can be powerful in helping OIF/OEF veterans with PTSD as well.
Whether we gauge VA’s progress through the lens of its 2004 strategic plan, or as we recommend in the context of an updated plan, we share DAV’s view that the transformation of VA’s mental health delivery system remains a work in progress. Accordingly, we believe it is critical to sustain robust funding for VA mental health programs. Without question, VA’s special mental health funding has supported a very substantial increase in staffing and expanded services at many facilities. But we understand that special funding will be phased out next year, with 90 percent of those special funds reverting to VA’s general health care funds to be allocated through the VERA system. The implications of that shift could be very detrimental, given that funding for veterans mental health care during a still evolving major transition would be allocated primarily based on the numbers of veterans under treatment rather than on improving the intensity of care provided current patients. Absent a special funding mechanism, there is real risk that critical mental health policy goals will not be realized, and that prior gains may be eroded.
Given that concern, we urge continued strong oversight to ensure that the Department does have a sound funding plan to support and sustain its still evolving transformation of mental health care. Let me emphasize, funding alone will not achieve strategic goals. Leadership is equally important. Finally there is a keen need for close monitoring and evaluation. We must bring each of those elements to bear to ensure that VA programs are meeting veterans’ mental health needs.
Mr. Chairman, that completes my statement. I will be happy to answer any questions.
[The prepared statement of Mr. Ibson appears in the Appendix.]
Mr. MICHAUD. Thank you very much. I have one question. Mr. Atizado, in your testimony you recommended that the VA develop an accurate demand model for mental health and substance use disorder services. Can you explain this point a little further, as far as what factor the VA should look at when developing a demand model?
Mr. ATIZADO. Well, much like VA’s overall health care demand model I believe it has to reflect that. It has to be very comprehensive. It has to take into account this new paradigm of care that VA has embraced and wants to provide. The amount and the intensity of service that is required under this transformation is much different from their previous way of caring for serious mental illness and post-traumatic stress disorder, as well as substance abuse disorder. And I think the current model does not accurately capture that, and doing so does not necessarily provide the bottom line that would allow VA in the field to implement these initiatives.
Mr. MICHAUD. Mr. Ibson, the Wounded Warriors Project is a great organization, and we appreciate all the work that you do. My question is, when you look at PTSD or TBI, how much concern do you hear from family members as far as the lack of service? Are the family members out there really more prevalently than the soldiers in looking at services, particularly relating to TBI or PTSD?
Mr. IBSON. Mr. Chairman, I think you hit on an important point. That these are not issues of the veteran alone. They are very much family issues. We do have very active engagement with our families. And they do bring those concerns to us. Concerns regarding the variability in service, concerns regarding the lack of inpatient programs, particularly for PTSD, and the dearth of programs that are specific to OIF/OEF veterans. Concerns around the challenges facing a young veteran who, in seeking treatment, may find himself or herself in a program with older veterans who have continued to suffer with these problems and have not made the progress that a young veteran might hope to make. That can be a real disincentive to, or impede the kind of progress that the veteran and family would hope to expect from a program. And it underscores the need for age appropriate services.
Mr. MICHAUD. The next question is actually for both of your organizations. In 2004, VA came forward with their Capital Asset Realignment for Enhanced Services (CARES) process, which looked at where there is a need for access points, particularly in the rural areas throughout the country. Have either of you heard concerns about lack of services in areas where there is supposed to be an access point, but currently is not an access point because the VA and Congress has not appropriated the funding needed for those access points? Is there more of a concern in those areas where you not even kept track of the areas that you are hearing concerns in both the Wounded Warrior Project as well as the DAV?
Mr. ATIZADO. Well Mr. Chairman, we do not know specific instances. We do have written, in fact, in our testimony that the VA’s Office of Inspector General did a combined assessment report on Montana. And in there, and that is obviously a highly rural area. And in there it does talk about the inability for that facility to attract and retain mental health provides. Not only that, that also impinges on the availability of services as well as the quality of services that can be provided. If a facility does not have enough direct mental health providers the intensity may not be provided, or not enough veterans can be served. So at least in that one report we know that there is a direct impact.
Mr. IBSON. I am not sure that I can speak to the implications of the issue as it relates to the CARES process, sir. But I think the Montana report is interesting as it goes to concerns you have spoken to, with regard to rural veterans and the success in Montana of working with the private sector to make access points for mental health care available. So I think in some marked contrast to the experience in other parts of the country, the underlying theme of equity of access I think continues to be a challenge for the Department.
Mr. MICHAUD. Thank you. Mr. Brown?
Mr. BROWN OF SOUTH CAROLINA. Yes, thank you, Mr. Chairman. In fact, I am going to just kind of throw this question out and either one can respond or both. Given the scope of the Mental Health Handbook that was last updated in September of 2008, do you think it is realistic for VA to implement all of the initiatives by the end of the fiscal year?
Mr. ATIZADO. Well Mr. Chairman, as I have stated, it is a very ambitious goal. I think that if things go the way they are now, how it is currently being implemented, I think VA will be seriously challenged to meet that deadline. Which is why we are very hopeful that something will come of this hearing. That better metrics will be provided to the field so that they have better guidance to meet the over 400 services that the Handbook is supposed to require.
Mr. IBSON. I think that is an excellent question, sir. And it is important to appreciate, I think, that underlying that Handbook is a vision of a real transformation in the way care is delivered, and the philosophy underlying that care. And emphasis on a recovery orientation is intended to supplant a focus on simply managing symptoms. And that is not simply a matter of funding. It is not simply a matter of programs. It is a real culture change that mirrors a change going on in the health care system generally, but one that has not preceded with great speed. And it is difficult to imagine that transformation reaching a culmination by the end of this year.
Mr. BROWN OF SOUTH CAROLINA. Okay, thank you both. Let me throw out another question and I would ask for a similar response. For a person to seek mental health services they must recognize that they need help. To what extent do you think the stigma associated with mental health care is affecting veterans’ willingness to seek help?
Mr. IBSON. I think there is no question but that, notwithstanding public education efforts to diminish stigma, it continues to play a role, and that it does play a role among returning servicemembers and to some extent among veterans as well. At the same time, I think we do see larger numbers of veterans turning to VA for mental health care. And this Committee, I think, certainly can take pride in the work that it has done to underscore the importance of mental health and to diminish somewhat the still lingering stigma.
Mr. ATIZADO. That is an excellent question, sir. I would like to first make a comment about what is being done upstream to sensitize servicemembers to the fact that mental health is just as important as physical health, that the U.S. Department of Defense (DOD) is doing. And I think it is providing some impact. I think VA’s outreach, while excellent and they have done quite a bit, requires a little bit great customer service. We are aware of a program that was instituted in Veterans Integrated Service Network (VISN) 12 called the Vet Advisor Program. And what that does, sir, is it actually contacts veterans who have self-identified, or who have been screened positive, such that they have the intention of seeking mental health services and they, for whatever reason, did not come back to VA to do so. And what this program does is it, VA trains these individuals specifically on the screening tools and verbiage, the culture. And they seek out these veterans. They call them. They make person contact. And they are very clear. The idea is to make sure that veterans are provided the greatest amount of an offer. Because if it is a very good offer, one tends not to ignore it. Not only that, they also walk them through what they can expect once they contact their VA Medical Center, what should happen next. And it really empowers them and educates them on a very personal level. And it has turned out to be a very successful program.
Mr. BROWN OF SOUTH CAROLINA. I know that if we let them fall through the process then they will end up homeless someplace, and that is a major concern of mine. Thank you both.
Mr. PERRIELLO. [Presiding] Thank you. We will turn now to Mr. McNerney.
Mr. MCNERNEY. Thank you, Mr. Chairman. Mr. Atizado?
Mr. ATIZADO. Adrian.
Mr. MCNERNEY. Adrian? Adrian, thank you. You know, I am going to sort of follow up a little bit on some of the prior questions. Many veterans service organizations (VSOs) have noted a slow start in implementing new mental health services and substance abuse programs. What do you think would be beneficial in terms of speeding up the VA’s response to these needs?
Mr. ATIZADO. Sir, that is a good question. I think one of the things that really hampered the speed of the implementation that we were hoping was that the Mental Health Handbook did not have objective metrics that the field would have to comply with. In other words, the perfect example is this OIG report. It did a survey based on self-reports and it did not dig any deeper than that. So when I am a mental health chief, or medical center director, and OIG calls me up and says, “Do you have this program?” I will say, “Oh, yes.” But they never really quite asked what services do you have available in that specific program? How many people do you expect to need to meet the demand in your facility? And that never really was provided to the field at the outset. And I think the strict monitoring and oversight really needs to get ramped up in order for these challenges to be met.
Mr. MCNERNEY. So, I mean, when you use the word “metric” in my mind that means results, or outcomes, rather than facilities or services?
Mr. ATIZADO. Yes, sir. For example, when the Handbook was issued publicly, and the field was asked, service chiefs in local facilities were asked, “What do you need to make this happen?” That was the only question, really, that was asked. There was not clear guidance on these new initiatives, these new intensive programs. Some places did not even have a program that is included in the Handbook and they had to start from scratch. With very little guidance it is extremely hard for the field to be responsive and provide the data needed at the highest levels in the VA for them to provide the resources and the support.
Mr. MCNERNEY. Thank you. Mr. Ibson, I am going to sort of paraphrase something you said. I did not have time to write it down word for word. Funding alone is necessary but not sufficient. You also need strong leadership and good oversight. Are we having, are we seeing the strong leadership that you refer to? And is the oversight that this Committee is supplying sufficient? Or do you have recommendations on how to improve on those two issues?
Mr. IBSON. Well I think your earlier question is an illustration of the point, sir. We saw leadership exercised at the VA in terms of adoption and issuance of a very forward looking and aggressive policy, a policy that could well be applauded. But what was missing, I think, as your question suggested and as Adrian’s response indicated, was a sufficient architecture or mechanisms to ensure that the broad policy directive could and would be implemented in an appropriate and timely way. I do think there has been a real focus on establishing broad policy and to get funding out to the field, and the challenge of how and when to get the policy fully implemented has been something of a catch up. And I think this hearing is certainly an important step to continue to underscore the importance of moving beyond policy and to realization of those goals and very specific measures.
Mr. MCNERNEY. So one of the things I am hearing is that the element of leadership that is missing as a clear, concise metrics, or both in terms of what facilities should provide in detail and also metrics in terms of what the outcomes are. If you are having good outcomes then you are going to get a good mark. If you are not having good outcomes you are not going to get a good mark.
Mr. IBSON. I think that is right, sir.
Mr. MCNERNEY. Thank you, Mr. Chairman.
Mr. PERRIELLO. Thank you. Mr. Moran, do you have questions?
Mr. MORAN. Mr. Chairman, thank you very much. I apologize for not hearing your testimony. If this is not a question for you, I would be happy to have you tell me that. One of the concerns I always have about the provision of health care services for our veterans is the geographic disparity, and from my perspective a rural disparity. I wondered if you have thoughts about the services different between urban, suburban areas of the country and the ability to access mental health services in rural America?
Mr. IBSON. I think there is no question but that that is the case, sir. And as we have discussed a little bit earlier there is still significant disparity across the country. I think there are important efforts in the VA’s Strategic Plan and the Uniform Services Handbook that we have been discussing to try and narrow that gap. One of the elements in the recently issued Handbook is an effort to ensure that there is service availability without regard to where the veterans may be living. And indeed, a directive for the first time for facilities if they cannot provide services in-house to provide them through contract or similar mechanisms.
Two problems with that: one is that there is no real requirement to assure that that private sector provider has the capability, the expertise, to provide, for example, care for individuals with post-traumatic stress disorder or a combat-related condition. And secondly, the facilities have not taken particularly aggressive steps to use that mechanism, even where capable providers might exist in the community. So I think it is yet another illustration of a transformation or a work in progress.
Mr. MORAN. In Kansas we have a reasonably comprehensive mental health delivery system with a series of mental health area agencies covering a very rural State. On numerous occasions those mental health centers have indicated a strong willingness to figure out how to connect with the VA system to provide services. I guess part of what you may be telling me is that they may not be totally trained in some of the needed aspects of mental health care that are required for our veterans, for our servicemen and women. I am looking for the ability to put those to use. We do not, I do not think we need to reinvent the system. Maybe we need to augment it. I think there is a delivery system that exists, at least in our State, that perhaps is underutilized.
I also know that we have been successful in Kansas of having a second Vet Center. We have had one in Wichita for a long time, and one now in Manhattan. Their plan is to place mobile vans in which they provide family counseling mental health services out to rural areas of Kansas. I am interested in your thoughts of whether those kind of services can be provided in that kind of setting. Is that something that is going to be effective?
Mr. IBSON. I think from my perspective, the jury is still out as to whether that is an optimal means of providing care. But certainly, given the needs across the system and given the needs of rural America, it is important that one explore all alternatives.
Mr. MORAN. This Congress has seen in the past significant improvements on our funding for health services. One of the common themes when I talk to those who provide services at home is, despite the additional money, we still cannot attract and retain the necessary professionals to provide the services. So, it is nice of you to give us the additional resources, important, but there is a general shortage of health care professionals, particularly in the mental health area, that the private sector is not meeting. They cannot come up with the necessary folks as well. So, it is a very broad issue that needs broad attention about attracting, retaining, and educating a necessary workforce. The demands are great; the numbers of people in the profession are too shy.
Mr. IBSON. Yeah. It is not a complete answer to your point, sir. But I think one of the themes reflected in VA’s planning, and a theme that I think can be continued, is greater reliance on peer-provided services. Not as a substitution for clinician services but as a complement to them, and as an important element of a system that, in philosophy, is moving toward recovery, toward enabling individuals to lead productive, fulfilling lives. And peer mentoring, which is a program Wounded Warrior Project fosters and runs, is an illustration of that kind of program. You know, veterans helping veterans—
Mr. MORAN. Thank you for that reminder. One of the ironies of the expansion of mental health services at one of our military installations in Kansas is that the neighboring hospital, the public hospital, closed its mental health facilities. Again, the inability to compete with the number of professionals. It sort of works both ways in the private sector. I do appreciate the idea that there are other possibilities. This mentoring program may be an opportunity, at least, to provide a level of services that would not otherwise be there. I am sorry, I have allergies. I can hardly talk. Thank you for your response. Thank you, Mr. Chairman.
Mr. PERRIELLO. Yes, Mr. Rodriguez?
Mr. RODRIGUEZ. Thank you, Mr. Chairman. I would like to ask permission to be able to submit some comments for the record, if possible. Thank you.
Let me first of all also take this opportunity to thank you for your testimony, and thank you for the written comments that you made. I am extremely pleased with the things that you stressed in terms of the importance of peer-to-peer. And if you have an opportunity after I stop talking, maybe you might suggest as to how we might go about making that happen.
Secondly, the other issue that was brought up regarding staffing. There is no doubt that looking at the vacancies, it is something that is essential and important, and how to best do that. I know we have a lot of great staff working for the VA. But I also know that we have a lot of staff that maybe should not be there now. And some that have been burned out because of the workload, and especially mental health services. They tell me that in England in mental health they work for a certain period of time then they are off for a good chunk of time because of the burn out factor. And I do not know if you want to make comments on that.
The third area that, and I am going to give a case on this one at the end, is the issue of working with the families, and how critical it is to reach out to those families of those soldiers and those veterans. And how important that is, especially when we deal with post-traumatic stress disorders. And there is one over with Congressman Brown, who talked about when they suffer from mental health problems the soldier is not going to say, you know, when they come out, they are going to say, “Hey, I am okay. I do not have a problem.” And part of the fact is that they have not acknowledged that and that is a serious situation. But the ones who catch onto this is the family. The family knows sometimes, “Hey, my son has a problem.” You know? “He is not the same young man that was here and has come back.” And so that somehow making some kind of outreach also to those soldiers that are out there is really important.
I wanted to also just kind of stress, I think it was mentioned, preventative maintenance and checking services that is also so, I think it is important in the process. I had gotten testimony in San Antonio from a psychiatrist. And there was some basic questions that were asked then about post-traumatic stress disorder. And he gave us a beautiful presentation about the fact that we have always had it. We have just called it Gulf War Syndrome. We have called it adjustment reaction. We have called it other things. And he said all you have to go back in history and read the Iliad. And I said I had not seen that since high school, but that you can, you know, that we have always had some of those difficulties. So I know that we are going to have to kind of push forward and see what we can make happen.
Congressman Moran also mentioned the importance of community health centers that we have back home. We have some great ones in San Antonio, where they are ready to provide access to services. And they have some great community mental health people out there that could be utilized, and that is not happening. And so I wanted to, you know, see if you might be able to make some comments on that. But before I do I want to, if Mr. Chairman, I want to be able to read this comment that I have. Because it is an incident that just occurred right outside that district. But the family lives in my district and, anyway, please allow me, you know, for a minute.
I wanted to bring up a situation that occurred Friday at Fort Bliss, Texas. And this is a DoD, not VA, but DoD. A soldier who returned fifteen months ago from deployment then immediately relocated to new assignment, had Post Traumatic Stress Disorder. And I do not know exactly, you know, how much services he was provided with. What I do know is that the family, his mother lives in my district, cried out for help, you know, for a long time, for assistance. They had repeatedly raised concerns that the soldier had Post Traumatic Stress Disorder and needed some immediate attention. And again, I am not sure how much attention he received. But the family indicates that it was insufficient. The last call for help was last Wednesday and Thursday to the unit there in El Paso. And Friday morning the soldier turned himself into the military police after allegedly having shot and killed an eighteen-year-old on his way to school and having also shot and wounded another soldier. And I just wanted to make it, you know, clear that the ultimate victims on this, of course, the young people that were killed and the soldier. But that soldier, a lot of times, it was the result of the Post Traumatic Stress Disorder, is also a victim in a lot of ways.
But I do not, you know, I wanted to kind of mention that particular case because it just happened. And we are kind of helpless. You know, these families are calling us for help and assistance, and we try to call, and I know it is, you know, that it is difficult. But yet, you know, they are becoming too numerous. And that is just one incident. We have soldiers right now committing suicide while in service. If they do that we know that they do not get any compensation whatsoever. In fact, I had a soldier commit suicide and was almost treated very poorly, you know, when the body came into the community. And so somehow we have got to do more. And so I wanted to get some feedback from you in terms of how do we make this happen?
[The prepared statement of Congressman Rodriguez appears in the Appendix.]
Mr. IBSON. Congressman, thank you for raising those issues. Wounded Warrior Project certainly works closely through our service teams, with military personnel. And if your caseworkers come across problems that we can help with, our doors are certainly open. We are certainly happy to engage.
You posed a question earlier about the peer-to-peer services and I want to acknowledge the work of this Committee and the Congress in passing legislation last year that authorizes VA to employ peer specialists. I believe they have begun to do so, though primarily to work with individuals with the most severe mental illnesses. And our testimony is to the effect that there are opportunities to expand those programs, in our view, to work effectively with younger veterans with other diagnoses, particularly PTSD. And we would see that as an area that VA could pursue, the Committee as well.
I want to cite your important remarks on the role of the families and I would very much like to underscore on behalf of Wounded Warrior Project the importance of family caregiver legislation, which we have discussed informally with the Committee staff, and to mention S. 801, a bipartisan bill introduced by Senator Akaka and Senator Burr, which would establish a foundation for supporting family caregivers of severely wounded servicemen and veterans as a very important step towards sustaining the caregiving that is enabling severely wounded warriors to remain at home rather than becoming institutionalized.
Mr. RODRIGUEZ. Mr. Chairman, I apologize for taking more than my time. Thank you.
Mr. PERRIELLO. Next we will go to Ms. Brown.
Ms. BROWN OF FLORIDA. Thank you, Mr. Chairman. Thank you for your testimony. And I have to tell you, I am very concerned about the mental health situation with VA. When you gave your testimony you indicated that some of the agencies, or some of the hospitals, you did not know whether or not they were qualified to work with the veterans’ situation. Well, that is what I am finding, that VA do not want to contract out mental health services. But we are not serving the population. All we have to do is look at the homeless. I mean, one-third of them are veterans. They either have drug problems, or they have alcohol problems, and we are not addressing them. Yes, it is a role for peer counseling. But these people need professionals. And we do not have enough professionals in VA. And they resist, they resist farming out, partnering with agencies that do mental health services. And I do not know why. The situation can only get worse. And if you have certain standards, certain guidelines, that is where you could bring in these agencies and work with them, and partner. But there is no role for peer counseling for severe problems. I am, that is my training. I am a counselor, at least back in my real life. So, I mean, what are we going to do?
Mr. IBSON. I certainly share your view that there is an important role for partnerships. And I would not want to represent that VA fails to partner. Certainly, there are some core VA homeless programs that had their genesis in this very hearing room which represent very fine partnerships. I think there is an opportunity for VA to employ its contracting authority. At the same time, it is important to recognize, I think, that when we are dealing with the very specialized condition like post-traumatic stress disorder it is important for VA to be assured that community providers have the capacity and training and expertise to do that. But—
Mr. IBSON. —there is an opportunity for VA to do that kind of training, I think.
Ms. BROWN OF FLORIDA. Right. But the problem is, VA has resisted contracting out, working with agencies. If the VA, puts out a contract and say, “We want this, this, and this, and you want this training,” I do not see why we cannot work more with community agencies and community groups that provide these mental, they are doing it anyway, they are just not getting paid for it.
Mr. IBSON. I share your view. There certainly is an opportunity for greater partnership here. And particularly in areas of the country, as Mr. Brown was indicating, where there is a dearth—
Ms. BROWN OF FLORIDA. Well, he is a rural area, I am in the inner city. But the question is, the problem exists in both places. What can we do to encourage VA to expand their mental health services working with other agencies? Because it is not happening, and the veterans are not getting served.
Mr. IBSON. Well certainly a hearing like this one today will be a very rich opportunity and a first step toward that. There is a certainly an opportunity to do more.
Ms. BROWN OF FLORIDA. Well, I believe that you are correct. Because failure is not an option. We are going to have more suicides, more problems in our community, if we do not address the problem with this new group that is coming back. And VA is just not geared up to handle it. We just need to, and I am not, it is not negative. VA has good services. But we need to expand what we are doing. We need the partnership.
Mr. IBSON. I would agree.
Ms. BROWN OF FLORIDA. Does VA have the authority to do it?
Mr. IBSON. Yes. I believe VA has very expansive contracting authority. And particularly, most particularly in areas where they either lack the capacity in-house to provide needed services or where geographic distance is a barrier. But I think this Committee has given VA very broad authority and there is certainly opportunity to use it.
Ms. BROWN OF FLORIDA. Thank you, Mr. Chairman.
Mr. PERRIELLO. Thank you very much, Mr. Atizado and Mr. Ibson for your testimony and for your service. And with that, let us call up panel three. Panel three will be Dr. Michael Shepherd, Senior Physician from the Office of Healthcare Inspections, Office of the Inspector General, U.S. Department of Veterans Affairs. He is accompanied by Larry Reinkemeyer, Division Director, Kansas City Office of Audit, Office of the Inspector General, U.S. Department of Veterans Affairs. Thank you, gentlemen, for being here today and sharing your comments with us. Dr. Shepherd?
STATEMENT OF MICHAEL L. SHEPHERD, M.D., SENIOR PHYSICIAN, OFFICE OF HEALTHCARE INSPECTIONS, OFFICE OF INSPECTOR GENERAL, U.S. DEPARTMENT OF VETERANS AFFAIRS, ACCOMPANIED BY LARRY REINKEMEYER, DIVISION DIRECTOR, KANSAS CITY OFFICE OF AUDIT, OFFICE OF INSPECTOR GENERAL, U.S. DEPARTMENT OF VETERANS AFFAIRS
Dr. SHEPHERD. Mr. Chairman and Members of the Subcommittee, thank you for the opportunity to testify today regarding VA’s progress toward meeting the mental health needs of our veterans. I will focus on our report, Implementation of VHA’s Uniform Health Services Handbook, and my colleague, Larry Reinkemeyer, will be able to answer questions related to another OIG report, "Audit of VHA Mental Health Initiative Funding."
In 2004, VHA developed its 5-year mental health strategic plan which included more than 200 initiatives. Because the plan is organized by the broader goals and recommendations of the 2003 "President’s New Freedom Commission Report," rather than specific mental health programs, some initiatives do not delineate specific actions—
Mr. PERRIELLO. Excuse me, doctor, could you move the microphone closer?
Dr. SHEPHERD. Sure. Is this better?
Mr. PERRIELLO. Yes.
Dr. SHEPHERD. [continuing] —that should be carried out to achieve these goals and are not readily measurable. The Handbook notes that when fully implemented these requirements will complete the patient care recommendations of the mental health strategic plan. Overall, medical facilities are expected to implement the Handbook requirements by the end of fiscal year 2009.
Because there are over 400 items in the Handbook we limited the scope of our review to the Medical Center level, where full implementation is more likely to occur prior to community-based outpatient clinic (CBOC) level implementation. Based on clinical judgment we chose 41 items from throughout the Handbook to evaluate. OIG inspectors agreed on what criteria constituted a positive response and affirmative responses were queried for demonstration of their validity.
We believe the items chosen reasonably estimate the present extent of implementation at the Medical Center level. Although it is an ongoing process, the data presented do not credit partial implementation. We found that 31 of 41 items reviewed were implemented at more than 75 percent of Medical Centers. For example, a mental health intensive case management program is in place at all facilities with more than 1,500 seriously mentally ill veterans.
We identified items indicative of areas in which VHA is at risk for not meeting the implementation goal, including timely outpatient follow up after mental health hospitalization; provision of intensive outpatient treatment for substance use disorders; provision of psychosocial rehabilitation and recovery programs at centers with more than 1,500 seriously mentally ill patients; and the provision of sufficient clinical psychologist staffing for VA community living centers.
Additionally, we are concerned that while a section of the Handbook addresses access to specific evidence-based psychotherapies for PTSD, it appears that VA does not have in place a national system to reliably track provision and utilization of these therapies. A national system would allow for a population-based assessment of treatment outcomes with implications for treatment of other veterans presenting for PTSD-related care. While VA has relevant process measures in place to monitor program implementation, we believe that VA should develop more outcome measures where feasible to allow for dynamic refinement of program requirements in order to meet changes in mental health needs and to optimize treatment efficacy.
Although this inspection contains some items related to suicide prevention, as a component of OIG’s CAP review process, in January 2009 we began a separate medical record-based review of suicide prevention items. We will conclude our inspection in June 2009 and then issue a roll up report on our findings.
In conclusion, the Handbook is an ambitious effort to enhance the availability and provision of mental health services to veterans. VHA has made progress in implementation at the medical center level. Because our review was limited to medical centers, we plan to conduct an inspection in fiscal year 2010 on implementation at the CBOC level where factors such a geographic distance and the ability to recruit mental health providers may pose greater obstacles to implementation.
In regard to mental health initiative funding, we found that VHA adequately tracks and uses mental health initiative funding as intended. Mr. Chairman, thank you again for this opportunity to appear before the Subcommittee. We would be pleased to answer any questions that you or members of the Subcommittee may have.
[The prepared statement of Dr. Shepherd appears in the Appendix.]
Mr. PERRIELLO. Thank you very much for being with us today, and thank you for your thoughts. What would you say at this point are the main limiting factors for you to be able to produce the kind of metrics that you have in mind?
Dr. SHEPHERD. For this report—limiting factors for us to produce the metrics, or for VA to produce, for VA? Well, one of the issues, again, which we cited and the previous panelists cited is, for example, in terms of provision of evidence-based treatments for PTSD. In the absence of knowing who you have provided these treatments to, whether they have done part of these treatments, completed these treatments, whether they have opted not to pursue thes