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Witness Testimony of Janet E. Kemp, RN, Ph.D., Veterans Health Administration, National Suicide Prevention Coordinator, U.S. Department of Veterans Affairs

Mr. Chairman, Mr. Ranking Member, and Members of the Committee: 

Thank you for allowing me to testify on behalf of the Department of Veterans Affairs on the Department of Veterans Affairs’ (VA’s) Suicide Prevention Hotline and on VA’s overall program for suicide prevention.  I am pleased to report to you today on the programs and methods VA has developed that are saving lives and improving the quality of care our veterans receive.  My name is Jan Kemp and I am the VA National Suicide Prevention Coordinator.  I am accompanied today by Dr. Kerry L. Knox, Director, Canandaigua Center of Excellence for Suicide Prevention and Dr. Antonette Zeiss, Deputy Chief Consultant, Office of Mental Health Services.  Before beginning a description of the programs we have implemented, I want to acknowledge that every veteran suicide is a tragedy for the veteran’s family, friends, and our nation as a whole.

In his testimony before the House Committee on Veterans Affairs on May 6 of this year, Secretary Peake announced the formation of a Blue Ribbon Work Group of Federal Partners to review VA’s Suicide Prevention Program, and to make recommendations for enhancing it.  On September 9, that Group praised VA’s current program, noting that VHA has developed a comprehensive strategy to address suicides and suicidal behavior that includes a number of initiatives and innovations that hold great promise for preventing suicide attempts and completions.  Moreover, the Work Group also noted VHA is optimizing care through best clinical practices and is exploring additional system-wide policies to further reduce suicide risk.  The Work Group complimented VA’s efforts of incorporating new treatment modalities, such as cognitive behavioral therapy interventions, into clinical care based on emerging research  The Work Group made several recommendations addressing both the clinical and public health activities to further enhance VA’s suicide prevention programs.  VA is committed to following these recommendations and to ongoing review of its program for suicide prevention.

VHA’s program for suicide prevention is based on the general principle that prevention requires ready access to high quality mental health care, as well as programs that target suicide prevention more directly.  Regarding overall mental health care, VA has previously testified about increases in the budget for mental health services, from approximately $2 billion in Fiscal Year 2001 to over $3.5 billion this year and projected costs of over $3.8 billion for FY 2009; about VA’s hiring of almost 4,000 new mental health staff members since 2005; and for the successful implementation of a new standard of care last August requiring that new referrals or requests for mental health services be met with initial assessments within 24 hours and complete diagnostic and treatment planning evaluations within 14 days.  The VHA standard is that 90 percent of new mental health patients must be seen within 14 days of the initial contact; every VISN is meeting this standard, while nationally, performance is at the 95 percent level. 

I will focus now on our activities directly related to suicide prevention.

Suicide prevention requires both clinical and public health approaches.  My testimony will first cover information about the VA National Suicide Prevention Hotline (the Call Center) and will later discuss the Hotline as a component of a clinical prevention program and a public health strategy.

VA and the National Suicide Prevention Hotline:

In July, 2007, VA launched a Veteran’s Suicide Prevention Hotline as a collaboration with the United States Department of Health and Human Services Substance Abuse and Mental Health Services Administration and its Lifeline program.  Through this partnership, VA’s program benefits from several years of publicity for the Lifeline program. In turn, through the partnership, VA has been able to support awareness of the program for all Americans, as well as for veterans.

When someone calls the national Hotline number, 1-800-273-TALK, they receive a message saying that if they are a US military veteran, or if they are calling about a veteran, they should press “1.”  When they do so, they are connected quickly to the VA Hotline Call Center in Canandaigua, NY.

When VA established this Call Center, we carefully reviewed the existing and emerging literature and identified training standards that all responders should meet.  Consequently, the VA Call Center is staffed exclusively by mental health professionals, nurses, social workers, and psychologists with specific training as responders from one of the Lifeline Crisis Centers, in addition to their professional expertise.  Moreover, by using VA’s electronic medical record, responders are able to access the medical records of enrolled veteran callers willing to identify themselves.  Additionally, responders maintain contact with Suicide Prevention Coordinators at each VA medical center and are able to refer callers for follow-up care.  Finally, co-locating the Call Center with the Center for Excellence in Suicide Prevention ensures a critical mass of staff to direct VA’s current programs and to contribute to the research, education, and training that will guide us in the future.

The VA Call Center is staffed to respond to six call lines on a 24/7 basis.  We are receiving more than twice as many calls, have more than doubled our staff, and tripled the number of lines we have over the past year and are able to conclude that some specific increases in demand can be attributed to the efficacy of public health messages.  Occasionally, when the VA Call Center has reached capacity, veterans are transferred to one of several community-based “overflow” centers where the staff has received special training in veteran-specific issues; this tends to happen once or twice a day.  However, VA constantly monitors the number of calls we receive and is prepared to respond and adjust our resources as necessary.

From its inception through August 2008, the Call Center responded to more than 69,300 calls.  32,854 callers identified themselves as veterans or veterans’ family members or friends, while the rest of the calls were from others or from individuals who declined to disclose their veteran status.  Among veteran-callers who identified their era of service, 35.8 percent were from OEF or OIF.  Calls from veterans led to 5,980 referrals to Suicide Prevention Coordinators for follow-up for the problems that led to the call, and 1,628 rescues, calls to police or ambulances for immediate responses for those judged to be at imminent risk.  Calls from those who were not identified as veterans led to 3,266 direct transfers where VA staff contacted a community-based call center while the caller was still on the line to transfer care.  Calls from 789 active duty service men and women led to interventions to help them access Department of Defense (DoD) resources and to engage in care.

The Hotline has already demonstrated its success through the number of rescues made.  A sample of these is submitted as appendix material.  Another source of evidence comes from the follow-up on those referred to the Suicide Prevention Coordinators.  There have been two known suicides from among the 5,980 referrals.  From the start of Fiscal Year 2008 through the end of July 2008, the Coordinators engaged in care for 91.8 percent of those referred; the other callers gave incorrect information.  VA engages with every veteran we can reach.  Contact led to new enrollment in VA for 2.6 percent of referrals, immediate evaluations for 6.6 percent, and hospital admission for 18.5 percent, while the rest were referred to a coordinator who facilitated access to other program; 1.8 percent of service men or women were ineligible for VHA services as a result of the nature of their discharge and for them, the Coordinators identified appropriate services in the community and arranged a referral.  

The Hotline as a Component of a Clinical System

For a substantial number of veterans, the Hotline has directly facilitated mental health care; for others it has provided information and support that may facilitate care less directly; and for still others, it has provided problem-solving about perceived problems with ongoing care.  From a clinical perspective, the Hotline is a vehicle for engaging and retaining veterans in mental health services, especially those veterans at risk for suicide.  In general, the path by which this happens is through referral from the Hotline to the Suicide Prevention Coordinator at a VA Medical Center, who then provides referrals to specific providers or programs at the Medical Center or its Clinics.

VA’s Suicide Prevention Coordinators have related roles within each medical facility and within their communities.  By design, VA’s Suicide Prevention Coordinators manage efforts within the facility and the community, just as the National Hotline and the Center of Excellence coordinate activities across the nation and within VA.  The Coordinators receive mentorship and guidance from the National Suicide Prevention Coordinator who also directs the Hotline.  Specifically, Suicide Prevention Coordinators facilitate care for veterans at risk of suicide and serve as an advisor to facility staff on suicide prevention strategies.  By promoting awareness and implementing other specific suicide prevention activities, these Coordinators help advance VA’s goal of reducing veteran suicides and increasing access to mental health services.

Within each Medical Center, the Suicide Prevention Coordinators also help evaluate suicide risk among veterans and augment care for those found to be at high risk.  They are charged with developing relationships with community agencies and providers and facilitating referrals to a VA medical center for veterans found to be at risk in the community.

The Suicide Prevention Coordinators at each facility maintain listings of veterans receiving care within the facility who have attempted suicide and others at high risk.  They also maintain an internal chart “flagging” system to support enhanced care and report this information to the National Suicide Prevention Coordinator.  They are charged with ensuring veterans identified as high risk receive enhanced monitoring and care, regardless of whether the information about risk comes from the Hotline, from the community, or from providers within the facility.  These responsibilities include ensuring:

  • The veteran’s mental health diagnoses and care plan are reviewed in light of the evidence for suicide risk and that the care plan appropriately addresses the veteran’s condition and functional limitations;
  • Specific treatments for reducing suicide risk have been considered;
  • The care plans include ongoing monitoring for suicidality and plans for addressing periods of increased risk.  These plans must include specific processes for follow-up for missed appointments;
  • There is an individualized discussion about reducing the means for completing suicide that addresses issues such as medication storage, gun safety, and high risk behaviors;
  • A family member or friend has been identified, either for involvement in care or for contact as necessary;
  • There is a written safety plan, reviewed periodically, developed in collaboration with the veteran that is included in the veteran’s chart; and,
  • The veteran receives letters from the provider or the Coordinator on a regular basis to reinforce the message that compassionate care is available through VA.

The Hotline as a Component of a Public Health Program

The public health components of VA’s Suicide Prevention Program include training organized by each facility’s Suicide Prevention Coordinators about risk factors and warning signs for suicide for individuals and organizations with veteran contact within the community and VA staff. In both local and national presentations, VA focuses on increasing awareness of the Hotline to communicate that veteran suicide is a preventable public health problem and that effective care is available, without stigma, from VA.

By serving as a reminder that suicide is preventable and that care is available, the Hotline is valuable to all veterans and Americans, not just those who call.  This message is being delivered by VA senior leadership and staff from all facilities and has been targeted to the media, consumers, professional organizations, and members of the community.  It is essential that VA, other federal partners, and community organizations collaborate and coordinate their efforts so the general public and veterans alike have a single system which they can safely and reliably access in moments of crisis.  Our collective mission is to listen with a single pair of ears and speak with a single voice to deliver a shared message consistent with the best practices for suicide prevention. 

During this past summer, VA implemented a public service campaign promoting the Hotline and suicide prevention in Metro trains, stations, and buses in the Washington, D. C. area. Washington was chosen for this pilot project because it is a community with a large population of veterans and active duty service men and women and because VA leadership is embedded in this community in a way that allowed us to monitor its impact.

Based on the data, VA received more than twice as many calls (increase of 20 per week to 50 per week) from the Washington area after these advertisements appeared.  A comparable area (Baltimore) remained steady during this same period (20-25 calls per week).  This demonstrated increase leads us to support the extension of the campaign to other areas. However, these numbers reflect only part of the impact.  VA hopes other benefits of the campaign include enhanced knowledge of the availability of mental health services for veterans in need and increases in the probability that veterans in need in the future will seek care, either through the Hotline or other means.

VA has also established a National Suicide Prevention Awareness Week to ensure all staff are aware of available resources and now how to use them to help veterans.  Each medical center is required to recognize VA National Suicide Prevention Awareness Week. This year’s programs will focus on presentations from the facility’s local suicide prevention coordinator about the program’s activities and directions about how staff can interact with it.

Program Evaluation

VA is evaluating its Suicide Prevention Program on many levels.  The most important evaluation will be a test of whether there are decreases in the rates of suicide among veterans.  Given that the program is a component of a health care system, this effect would be greatest and most rapid among those who utilize VHA health care services.  However, even in VHA utilizers, it will be several years before we can evaluate the direct impact of the program.

VA’s Program maintains that prevention requires ready access to high quality mental health care and programs are needed to directly target suicide prevention.  Our evaluations, then, must include VA’s quality monitors for mental health services, as well as measures related to more direct activities, including:

  • The number of community informational and educational outreach programs conducted by each facility;
  • The number of calls to the Hotline, and reports developed from re-contacting callers;
  • Follow-up and treatment engagement for Hotline callers referred to each facility’s Suicide Prevention Coordinators;
  • Development, charting, and review of a safety plan for patients found to be at high risk; and,
  • The number of repeated attempts in patients who have survived a suicide attempt.

As VA’s Suicide Prevention Program continues to evolve, we will also continue to develop our evaluation measures.  One of the program’s future goals is to develop valid and reliable outcome measures based on real-time monitoring for veteran suicides in the community to support a rapid response to any identified trends.  However, further research is necessary before this can occur.

Moving Forward

VA’s Suicide Prevention Program has been enhanced substantially since May 2008.  We have added staff to develop Suicide Prevention Teams at each medical center, hired more responders and increased staffing for the Hotline, and implemented an electronic chart “flagging” system to facilitate increased monitoring and enhanced care for those at high risk.

VA’s Suicide Prevention Hotline is an important step forward and is a component of a comprehensive program for suicide prevention.  It reflects VA’s overall mission of providing high quality mental health services to America’s veterans.

Thank you for your time.  I will be pleased to answer any questions from the Committee.


 

VA National Suicide Prevention Hotline Call Report Totals YTD

  Total calls Identified as Veterans Identified as family/ friend of vet SPC referrals Rescues Warm transfers
Oct 7-27 2943 950 206 222 56 174
Oct 28- Dec1 4952 1773 242 354 122 224
Dec 2 - 31 4111 1703 237 283 70 161
Jan 1 - 31 4544 1800 262 385 97 217
Feb 1 - 29 5324 2094 340 436 115 259
March 1 - 31 5984 2508 381 500 127 332
April 1 -30 6057 2668 457 545 159 342
May 1 - 31 6250 2940 418 515 163 343
June 1 -30 5925 2690 423 615 173 366
July 1-31 6804 3332 435 624 193 355
August 1-31 7038 3551 526 762 214 308
FY 08 totals to date 59932 26009 3927 5241 1489 3081
             
FY 07 totals 9379 2918 not avail. 739 139 493
             
TOTAL to Date 69311 28927 3927 5980 1628 3574

 

  Center of Excellence Mental Health Crisis/Suicide Hotline YTD 08 Referral Breakdown
Month October 07 Totals November 07 Totals December 07 Totals January 08 Totals February 08 Totals March  08 Totals April 08 Totals May 08 Totals June 08 Totals July 08 Totals August 08 Totals FY08 YTD
Follow-up findings:                        
Immediate Evaluation at VA or CBOC provided 21 8 7 63 51 58 25 28 23 15 24 323
Admissions to inpatient hospitals 47 40 47 72 73 106 92 99 131 125 131 963
Care provided and treatment plan developed for on-going care 263 253 248 333 399 469 498 469 569 598 696 4795
Referral to other VA Services such as OIF/OEF program, substance abuse program or homeless program, etc 25 15 22 285 250 255 279 297 240 353 438 2459
Enrolled in VA Health Care System 3 7 16 25 7 11 17 11 12 8 4 121