Mr. Chairman, Ranking Member Brown, and distinguished Members of the Subcommittee, on behalf of AMVETS, I would like to extend our gratitude for being given the opportunity to discuss and share with you our views and recommendations on “Charting the VA’s Progress on Meeting the Mental Health Needs of Our Veterans: Discussion of Funding, Mental Health Strategic Plan, and the Uniform Mental Health Services Handbook.”

AMVETS is privileged in having been a leader, since 1944, in helping to preserve the freedoms secured by the United States Armed Forces.  Today our organization prides itself on the continuation of this tradition, as well as our undaunted dedication to ensuring that every past and present member of the armed forces receives all of their due entitlements.  These individuals, who have devoted their entire lives to upholding our values and freedoms, deserve nothing less, if not more.

Given the extent of the matters at hand, AMVETS has chosen to focus primarily on the “Uniform Mental Health Services in VA Medical Centers and Clinics” (Veterans Health Administration (VHA) Handbook 1160.01, September 2008) and its implementation.  VHA Handbook 1160.01 was designed to incorporate the new minimum clinical standards and requirements for all VHA mental health services.  It delineates the essential components of the mental health program that are to be implemented nationally by every Department of Veterans Affairs (VA) Medical Center and each Community-Based Outpatient Clinic (CBOC). These requirements are to be in place by fiscal year ending September 30, 2009.  May it also be noted that any modifications or exceptions for meeting the requirements must be reported to, and approved by, the Deputy Under Secretary for Health. All facilities are expected to be in full compliance by the date set forth, however AMVETS was unable to acquire any data on what the consequences of non-compliance will be. 

Although there is overlap between the “Mental Health Strategic Plan” (MHSP), developed in 2004 as a five year plan of action of over 200 initiatives, and “VHA Handbook 1160.1” VA has used the handbook as a more operational approach to organizing all aspects of veterans’ lives affected by mental health issues, including, but not limited to, homelessness, substance abuse, and Post Traumatic Stress Disorder therapies.  VA has stated that when the handbook is fully implemented and all patient care recommendations are in place, that every veteran will have ready access to comprehensive, evidence-based care.  Mr. Chairman, AMVETS believes that VA should be held accountable for fulfilling that statement.  Never has there been a time when such care has been needed.  VA/VHA set forth and agreed to that promise of care and system improvement and AMVETS strongly believes that this committee should do everything in their oversight to ensure all requirements are met by VA/VHA no later than the deadline VA set for themselves, year ending FY09’.

AMVETS is fully aware that the handbook is an ambitious undertaking; however VA/VHA has had five years to implement these changes.  It is in the opinion of AMVETS that the standards of care set forth by the handbook guidelines will dramatically increase the quality of mental health care and enhance VA’s overall availability, provision, and coordination of mental health programs.  But only if the handbook is implemented correctly, uniformly, and in a timely manner, can the result benefit the mental health well being of our veteran community. 

AMVETS would also like to notify Mr. Chairman and the Subcommittee on Health of several inadequacies within the system we have unearthed while researching the future of VA health care.  These concerns range from minor errors to critical errors that we feel could be resulting in unnecessary deaths of veterans.  Today I will impart to you an overview of our findings and recommendations to address each concern.

As the end of FY09’ rapidly approaches, AMVETS fervently believes that VA must immediately augment the evaluations of current facilities, development and training of staff, and overall outreach efforts to all medical facilities and personnel to ensure the timely implementation of the handbook’s requirements.  These basic, yet fundamentally critical guidelines will provide the foundation for the stability and reliability of the entire VHA mental health care system.  Moreover, while AMVETS believes that the measures laid out by the handbook should have already been uniformly implemented, AMVETS is still very hopeful on the success of the handbook and all the agencies involved in this undertaking.  AMVETS does acknowledge the significant challenges that are inevitably faced when transforming a mental health care system. However this is not a time for hindrance or hesitations that will impede the implementation of a stable and successful uniform standard of mental health care.

On April 6, 2009 the Department of Veterans Affairs Office of the Inspector General (OIG) issued Report No. 08-02917-105 entitled, “Healthcare Inspection: Implementation of VHA’s Uniform Mental Health Services Handbook.”  As required by the Military Construction, Veterans Affairs, and Related Agencies Appropriation Bill, fiscal year 2009, the OIG conducted a review on the progress of the implementation of VHA’s Mental Health Strategic Plan.  Additionally, the Committee was also concerned that the VHA policy on the diagnosis and treatment of Post Traumatic Stress Disorder (PTSD) had not been uniformly applied as directed. These concerns are what prompted this review, thus leading to Report No. 08-02917-105. 

OIG affirmed that due to the given dimension of the handbook, a comprehensive review of the implementation would be challenging, and thus decided to limit their scope of the review to the medical center level.  In addition, they chose selected items from the handbook to evaluate for implementation, which did not include the review of suicide prevention-related items.  AMVETS also noted that Community Based Outpatient Clinics (CBOCs) were not included at all in this review.  OIG has stated that a separate review of CBOCs is occurring and the results of the review will be released in June 2009.  AMVETS believes that these factors are very important to keep in mind when using the data of this review as an overview of the entire plan, and will address this later in our testimony.

The OIG report was compiled of data gathered from 149 of the 171 VA medical center sites.  In addition, OIG administered web-based surveys, comprised of 39 index questions, to be completed by the individual medical directors of each of the 171 sites.  Of the surveys mete out by OIG, they received 138 responses either from the directors themselves or a designee.  OIG then performed telephone interviews to obtain further feedback on the potential barriers to the implementation of the UMHS handbook.  AMVETS has thoroughly reviewed the OIG’s final report and is very distressed by many of their findings. 

According to the handbook, regarding community mental health care, Veterans Integrated Service Networks (VISNs) and facilities must collaborate with Vet Centers in outreach to returning veterans and their families.  OIG found that 87 percent of the facilities they spoke with (138 of 171 or only 81 percent of total VA medical sites) had affiliated themselves with at least one Vet Center as laid out by the handbook.  Unfortunately, OIG also found that five percent of facilities they interacted with had no affiliations what so ever to a Vet Center.  AMVETS is very concerned that if OIG found non-compliance in their review (composed of only 81 percent of total VA medical facilities’ and excluding CBOCs) of one of the most basic requirements set forth by the handbook, what is occurring at the facilities not included in the review?  AMVETS finds it absolutely unacceptable that 100 percent of the facilities contacted by VA’s OIG did not respond to the request for review, and respectfully asks the committee why this was permitted to occur, and if it was not permitted what actions have been taken in regards to said facilities? 

The handbook also requires that all VHA emergency departments have mental health coverage by an independent, licensed mental health provider either onsite or on-call, on a seven day a week, 24 hours basis.  Additionally, for level 1A medical centers: mental health coverage must, at minimum, be onsite from 7 am to 11 pm and VA facilities with urgent care centers must have onsite or on-call coverage during their times of operation.  Of the facilities interviewed by OIG, only 79 percent had emergency departments. OIG reported that they had initially attempted to ascertain the extent of 1A facilities with onsite emergency department coverage from 7am to 11pm, but it became clear that that many (no specific number given) do not even have the required 1A emergency departments.  Even more disturbing is that many of the mental health facilities’ directors were not aware that there facility level had been changed to 1A.  One director suggested to OIG that it would be helpful for central office to send all facility Mental Health Directors a list of up to date facility level designations so they could meet the handbook requirements. If VA/VHA is having difficulties in communicating the most basic, yet most critical, information to their own facilities as of March 2009, AMVETS respectfully inquires as to how VA/VHA plans on implementing an entire mental health care handbook?  AMVETS also respectfully asks the committee what steps it is taking to ensure the FY09’ deadline is met and that veterans will have access to the mental health services they need?

One of the most glaring deficiencies AMVETS observed in OIG’s report is in regards to “Issue G: Specialized PTSD Services.”  The handbook requires that all VA medical centers have specialized outpatient PTSD programs, either a PTSD Clinical Team (PCT) or PTSD specialists based on locally determined patient populations needs.  It is also a requirement of the handbook that every facility have staff with training and expertise to serve the Operation Iraqi Freedom (OIF)/ Operation Enduring Freedom (OEF) team or PTSD program staff.   OIG reported that of the VA medical centers surveyed 80 percent reported having a PCT and of those 65 percent reported having an OIF/OEF PTSD Specialty Clinic.  However, AMVETS was made aware of the fact that in the smaller facilities a single PTSD specialist that is available in that facility was often classified as a “clinic or program.”  It should be noted that these are self reported numbers and AMVETS was unable to locate any documentation showing that the reported numbers were valid and accurate.

The handbook also requires that all VISNs must have specialized residential or inpatient care programs to address the needs of veterans with severe systems and impairments related to PTSD and that each VISN must provide timely access to residential care to address the needs of those veterans with severe conditions.  According to OIG: specialized inpatient PTSD programs are unusual, as most PTSD care was moved to residential and outpatient basis.  The Mental Health Directors surveyed reported having a residential PTSD program or inpatient PTSD program at only 33 percent of all facilities.  Several directors, not included in the 33 percent, pointed out that their facilities had reliable access to the VISN program, but did not mention the fact that the average waiting period before entry into a VISN program was 4-8 weeks, often longer.  AMVETS finds this completely unacceptable and almost negligent due to VA’s own evidence that untreated veterans suffering from PTSD are more likely to become suicidal or violent.  AMVETS measured the success and suicide rates among veterans who have had extended waiting periods before admittance into a PTSD program versus those who had timely access to care and was astounded at the higher rates of suicide, substance abuse, and domestic violence among those who were put on VISN PTSD waiting lists.  Upon further review AMVETS observed that OIG presented similar concerns in their May 10, 2007 “Review of the Care and Death of a Veteran Patient- VA Medical Centers St. Cloud and Minneapolis, Minnesota.”  AMVETS finds it unfortunate that these trends are continuing to be over looked or hindered by either lack of public knowledge or funds.  What ever the hesitation reasoning is on behalf of VA AMVETS respectfully asks the committee to again use all oversight and guidance to prevent any more losses of life, due to non-uniformed access to care and the non-compliancy of many VA medical facilities.  AMVETS recommends the immediate formation of a task force on oversight and compliancy to help ensure the integrity and implementation of the handbook. Furthermore AMVETS believes that if VA/VHA desires to enact the handbook by their self set deadline they will fully support the formation of such actions.  These are only a few of the observations and reports that AMVETS found unacceptable and no where near meeting the requirements set by the handbook. 

It has always been the belief of AMVETS that to successfully implement change, we must understand the current policy and procedure to which change is needed. For without full knowledge and understanding all of our efforts are in vein.  Our veterans deserve immediate action by all parties involved in the implementation of the handbook.  We must all work together to ensure our veterans mental health care needs are fully met.

Mr. Chairman, this concludes my testimony.  I thank you again for the privilege to present our views, and I would be pleased to answer any questions you might have.