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Witness Testimony of Lt. Gen. Martin R. Steele (USMC, Ret.), Associate Vice President for Veterans Research, Executive Director of Military Partnerships, Co-Chair of the Veterans Reintegration Steering Committee, University of South Florida

University of South Florida

Chairman Miller, Ranking Member Michaud, on behalf of the University of South Florida, thank you for holding today’s oversight hearing on the provision of mental health care to veteran patients – particularly those who are at-risk of suicide – through the Department of Veterans Affairs (VA) health care system. By way of background, the University of South Florida (USF) is a high-impact, global research university dedicated to student success. Over 2,200 veterans and their families are enrolled as students at USF.  Military Times Edge Magazine recently ranked USF the 5th best college for being Veteran Friendly in the U.S. out of 4,000 colleges and universities. USF is the 8th largest university in the U.S., serves over 47,000 students and employs over 1,645 full-time instructional faculty and 6,840 full-time staff across three branches. USF is home to medical clinics and hospitals, a major mental health research institute, and two public broadcasting stations.  The USF System has an annual budget of $1.5 billion and an annual economic impact of $4.4 billion. Under the leadership of our President, Dr. Judy Genshaft, and our Senior Vice President for Research & Innovation and the Executive Director, Center of Excellence for Aging & Brain Repair, Dr. Paul Sanberg, numerous USF researchers are currently involved in funded studies related to such topics as suicide prevention, traumatic brain injury, post-traumatic stress disorder (PTSD), robotics and prosthetics, speech and audiology, gait and balance, and aging-related disorders.

Relationships

In addition to USF’s designation as one of the nation's top public research universities, it is one of only 40 public research universities nationwide with very high research activity that is designated as community engaged by the Carnegie Foundation for the Advancement of Teaching. USF has numerous research and health-care partnerships through affiliation agreements with hospitals and not-for-profit organizations in the metropolitan Tampa Bay area. The James A. Haley Veterans Hospital, located within walking distance of USF Health’s Morsani College of Medicine, provides research and training experiences for faculty, staff, and students. USF Health is also closely affiliated with Tampa General Hospital and the Lakeland Regional Medical Center, which provides training for residents and medical students. The USF Health Byrd Alzheimer’s Institute, Shriner's Children's Hospital (on the Tampa Campus), and Florida Hospital (also within walking distance), as well as All Children's Hospital, Bayfront Medical Center, and the C.W. Bill Young VA Medical Center (all located in St. Petersburg), provide additional research and training grounds for USF faculty and students.

These affiliation agreements with organizations provide for collaboration through shared facilities, faculty and equipment, as well as support for graduate students and internship programs. These types of agreements enable the institutions to pool such resources as laboratory space and enable compliance committees to stimulate an exchange of ideas.  USF has standing Memorandums of Understanding with US Central Command (CENTCOM), US Special Operations Command (SOCOM), and works closely with MacDill Air Force Base in Tampa, Florida.  Our Veterans Reintegration Steering Committee consists of research scientists from throughout USF faculty, staff, and students who work with veterans, representatives from the VA, the Care Coalition of SOCOM, and Draper Laboratories.

USF Tampa brings a multidisciplinary understanding of the enabling–disabling process and with the University’s newly authorized PhD degree in rehabilitation science will integrate the work currently conducted within a variety of health professional, basic and social science, and engineering disciplines across campus and the Tampa Bay region. Our holistic approach to caring for veterans and their families is reflected in the diagram below:

In order to address the mental health needs of our veterans and diverse population of at risk students, the University of South Florida has embarked on a Collaborative Suicide Prevention Project.  This is a three year initiative funded by a $306,000 grant from the Substance Abuse and Mental Health Services Administration (SAMHSA). (See Appendix A).  We intend to build upon university and state level resources and programs to enhance the existing university infrastructure and capacity, through improved collaborative partnerships across departments, student-led organizations, and community agencies, to develop a comprehensive suicide prevention approach to identify at-risk students through gatekeeper trainings, refer and link students to services through the Students of Concern Assistance Team, and train mental health professionals who, as a result of a professional training program, are able to assess and manage suicidal risk in students.

The goals/measurable objectives of this campus project are to (a) increase the number of persons involved in suicide prevention efforts; (b) increase the number of memorandums of understanding across departments and offices and with the community; (c) enhance the existing campus suicide prevention crisis plan and resource directory; (d) reduce barriers and improve attitudes toward suicide prevention amongst campus leaders across departments, administrative offices, and student-led organizations/groups; (e) develop a campus-wide suicide prevention marketing plan; (f) increase the quantity/quality of culturally competent prevention trainers; (g) increase distribution of suicide prevention materials; (h) increase family involvement in suicide prevention; (i) increase the number of students identified by prevention activities; (j) improve the quantity/quality of professional assessments of students; and, (k) increase the number of referrals and successful, sustainable treatment linkages.

To achieve these goals, this project is strategically engaging and working with various departments and centers such as Psychology, Social Work, Health, Wellness Centers, and the Joint Military Leadership Center as well as with non-profit community mental health agencies in Year 1. In Year 2, efforts will focus on preparing the campus for the identification of at-risk students by putting protocols and systems in place to effectively respond to at-risk students. The campus crisis response plan will be disseminated, professionals (24) on campus who receive referrals of at-risk students will be trained using the online QPR-T program and a supplemental role play training developed by the Florida GLS grantees, campus and family outreach efforts to increase awareness of the suicide prevention program, NSPL, and existing crisis support services will be started (6000 incoming students and families), and 6 trainers will be trained to deliver the Year 3 gatekeeper training program and mental health and substance abuse seminars. In Year 3, gatekeeper training will be deployed to identify at-risk students (24 trainings, 575 people trained) and an appropriate resource network will have been established to respond to referrals.

Ultimately such infrastructure enhances awareness among students and staff of risk factors and warning signs, reduces stigma, increases help-seeking behavior, and facilitates referrals and access to services.  USF is committed to allocating the majority of grant funds for the development of infrastructure and mental health promotion and training activities.

Complex systems comprised of many stakeholders who share goals but work under different systems with limited resources (e.g., community agencies, different departments and student service organizations) can present a major barrier due to lack of coordination (lack of adequate infrastructure, training, technical support, buy-in, and leadership).  Additional barriers concern the integrity of implementation of proposed programs across organizations.  The present project acknowledges and will address these potential barriers by doing a comprehensive needs analysis among key stakeholders, students and staff facilitated through the active building of partnerships within the university and the surrounding community.  Identified stakeholders will be linked together to establish points of contact for training and ultimately, referral within the community.  Training to increase awareness and knowledge of risk indicators and referral sources among staff and students will address associated barriers to utilization.  Needs analysis with students will serve to establish targets for outreach and potential social marketing messages to address stigma and facilitate help-seeking.

Blue Ribbon Panel of VA-Medical School Affiliations

A Blue Ribbon Panel of VA-Medical School Affiliations (Panel) was established in 2006 to advise the Secretary of Department of Veterans Affairs (VA) on a “comprehensive philosophical framework to enhance VA’s partnerships with medical schools and affiliated institutions”.

The Panel believed that the crisis in the U.S. healthcare system offered a unique opportunity to explore fundamentally new and better models of patient care, education and research.  Given its enduring partnership with the academic community, its past and present investments in academic infrastructure and its particular expertise in clinical system redesign, the Panel believed VA was uniquely well-positioned to take a leadership role in educating the future healthcare workforce, advancing medical science and helping to transform the healthcare system for the 21st century.

The panel reaffirmed the vital importance of academic affiliations and recommended that VA’s partnership with the academic community be strengthened in order to further enhance health care for Veterans and lead the transformation of the U.S. healthcare system.  Capitalizing on synergies between VA and its academic partners will assure the continued development and maintenance of an effective and diverse healthcare workforce, both for VA and the Nation.  To do so, however, will require significant changes in the organization and governance of the partnership.

As the Panel revealed, currently available mechanisms for meaningful dialogue between VA and the academic community were inadequate.  Relationships could be greatly improved by having more effective forums for discussion, strategic planning and decision making.  To realize the full potential of the partnership, the Panel recommended that VA and its academic affiliates establish more effective national, regional and local management structures.

Barriers

There are a number of issues about which the House Committee on Veterans’ Affairs should be aware and consider for further action.  Discussions with fellow academic researchers and clinicians have revealed several common experiences in attempts to conduct applied, translational research with Veterans Affairs systems that could benefit veterans with mental health problems including PTSD, suicide risk, substance use disorders, military sexual trauma, and other issues that seem to affect the OEF/OIF veterans who are experiencing these problems at a higher rate than previous cohorts.

Academic researchers interested in conducting studies involving the VA system must anticipate long periods of time and considerable effort in order to become eligible to collaborate with the VA.  As a result academic researchers avoid working directly with the VA healthcare system for funding or research opportunities that require a rapid response, and instead, seek other, less efficient ways to recruit veterans outside of the VA system, such as newspaper ads or contacting private organizations that work with veterans and their families.

Using the example of a university professor who wants to collaborate with the VA on mental health research, here are major challenges reported by a number of researchers across the U.S.:

  1. Credentialing Requires Considerable Time:  The professor must go through a lengthy approval process and training leading to “Without Compensation Status” (or WOC) to be included on any study involving VA patients.  Even so, the professor cannot be considered as the lead investigator by the VA (see next item).
  1. Lead Investigator Confusion:  VA regulations require that for any research study involving VA patients, the principal investigator of the study (or P.I.) must be at least a 5/8ths VA employee.  For example, the university professor submitting a research grant as P.I. to the National Institute of Mental Health (NIMH) to improve treatment of PTSD must find an employee of the VA to be P.I. for the VA system’s records even if that VA employee does not really implement the study.
  1. Research Approval Process:  Both the VA and the university require researchers to be trained and certified in protection of human research subjects.  The process may differ somewhat at each VA facility, but often the professor would not only be required to undergo training on the university’s Institutional Review Board (or “IRB”) processes and protection of human subjects, but also undergo the VA’s similar training requirements.
  1. Lack of Coordination of VA and University IRB processes:  Assuming the professor is credentialed by the VA as WOC, the professor’s study first must be reviewed and approved by the local VA facility’s Research and Development (R&D) committee. This committee may meet only once a month. If modifications are requested by that committee, it has to wait until the next month before next review. Once approved by the VA R&D, the proposal then goes to the University’s IRB for review.  If a full IRB committee review is required, that could take at least another month.  Often, changes requested by the university IRB lead to starting the process all over again. In some cases studies have been delayed by a year due to this back and forth process.
  1. Approvals are Local to Each VA.  A study that requires multiple VA sites often requires each VA facility’s R&D committee to approve the study.  Research would be more efficient if a “central” or national VA committee would credential university researchers for such studies.
  1. Sharing Data – VA healthcare data are valuable for examining the nature and extent of mental disorders, costs, and treatment effectiveness. To protect veterans privacy and the confidentiality of their healthcare data, a professor would use de-identified data, referring to records that are stripped of all names, ID numbers, any other personal information by the VA system before any researcher would be able to use the information.  However, data sharing agreements are treated much the same as other research studies and require the same lengthy process.  We would recommend that the VA find a way to create a data repository that academics could access and analyze for research purposes.  There are many successful models for this such as data systems provided by the CDC, SAMHSA (Substance Abuse & Mental Health Services Administration) where researchers access data from Medicare, Medicaid, hospital admissions and procedures, mental health and substance abuse treatment admissions, etc.
  1. Barriers to Innovation – A professor who has an innovative approach to treatment of PTSD is highly unlikely to receive approval by a VA healthcare facility.  The VA promotes two evidence-based practices:  (4 to 5 sessions) of cognitive-based therapy (CBT) or prolonged exposure therapy (typically even longer in duration). One of their measures of quality of care is to ensure that a minimum number of sessions have been provided.  Shorter-duration (1 or 2) sessions of innovative Accelerated Resolution Therapy for PTSD has been shown to be effective in published research from the  University of South Florida, yet the VA has not accepted invitations to collaborate on a pilot study of patients diagnosed with PTSD.
  1. Veterans Are a Challenging Research Population – Outside of research conducted within VA hospitals, nursing home units, outpatient centers, and other VA health facilities, recruiting veterans from the community can be a difficult task.  Professors who wish to implement evidence-based, mental health treatment must go to great lengths and cost to recruit veterans from the community.  As a result, treatment studies suffer from small numbers of participants, or long recruitment times, despite the fact that the VA system indicates there are waiting lists for veterans needing mental health care.

General Recommendations

  • Consider methods for academic researchers to be approved to serve as lead investigators of studies on VA patients provided that they meet both VA and university ethical standards for credentialing as principal investigators and are limited to access to patients according to their profession and/or licensure.  This may encourage or facilitate multi-site, VA/Academic partnerships.
  • Develop or encourage the VA to create “fast-track” approvals of collaborative, pilot studies between VA and university research studies that involve minimal risk to patients, but could provide significant benefit to treatment of mental disorders.  Such studies would be required to have scientific evidence that shows (1) the treatment is based on effectiveness studies conducted using rigorous scientific methods, and (2) minimal or no risks to the veterans’ wellbeing.
  • Develop agreements between the VA system at the national level and academic communities such that de-identified healthcare data would be made available to researchers outside of the VA system for research studies examining VA treatment effectiveness, cost, and long term benefits.
  • Without having to go through VA credentialing and research committee approval, permit university researchers to distribute flyers or other general information in waiting rooms. The information would be limited to studies that: (1) are approved by the university IRB; (2) are only being conducted on the university’s property; and (3) do not involve any data or personal information collected by the VA facility.
  • Currently, such efforts are not permitted without having an internal (5/8ths) VA employee as a P.I. and the lengthy VA and university committee approval processes mentioned earlier.

Our assessment of the Blue Ribbon report mandates reconsideration of their recommendations and their applicability to today’s environment.  The very definition of academic affiliates needs to be reexamined to move beyond a limited focus on healthcare to a much more encompassing venue which would include employment, business development, enhanced use lease relationships, and increased research funding.

In 2012, a VA Research Scientist from USF, along with a Research Scientist from the Medical Research Service at James A. Haley VA Medical center, conducted pre-clinical animal research linking PTSD, MTBI and potential suicides in the military.  A summary of their report is found at Appendix B.  We believe their research needs to be extended to learn more about how the brain is affected by physical and emotional trauma.  More importantly, we believe this type of animal research will lead to more effective treatments for PTSD and TBI which will potentially reduce the risk of suicide in our military and veteran population.

Unfortunately, the available funding budget for this research has not changed in 20 years and currently 80% of the VA research applicants are being turned down primarily for a lack of funding.  The 2012 study was funded by the Roskamp Institute in Sarasota, Florida.

In 2012, the VA Inspector General’s report on the review of Veterans’ Access to Mental Health Care, indicated that during the informal survey of frontline mental health professionals, 71 percent reported that, in their opinion, their facilities did not have adequate mental health staff to meet current demand for care.

Furthermore, the 2006 Blue Ribbon Panel noted with concern the aging of VA’s research infrastructure, which significantly limits its ability to conduct an efficient and effective biomedical research program.  The Panel recommended that VA enhance its research facilities through new construction and renovation of existing research space and by fully exploiting opportunities to share core resources with its academic affiliates.

To that end, the University of South Florida recommends strong consideration of the development of a singularly unique, one of a kind, research and outpatient treatment facility, as outlined in Appendix C. This initiative is intended to be a collaborative venture between DOD, VA, and USF in order to meet the health and welfare needs of our veterans and their families.

The USF initiative project is committed to providing the nexus to foster research collaborations in pursuit of excellence in the rehabilitation adjustment, resilience, and reintegration of wounded warriors and their families into civilian life.  Our nation’s dedicated heroes from all wars deserve to have the benefit of the best research and services available in order to return to their lives with jobs and homes for the sacrifices they and their families have made for our country.

Thank you for holding this hearing and for the opportunity to submit testimony.

Contact:  Lieutenant General Martin R. Steele, U.S. Marine Corps (Retired), Associate Vice President for Veterans Research, Executive Director, Military Partnerships, USF Research & Innovation, University of South Florida, 3702 Spectrum Blvd., Suite 165, Tampa, Florida  33612-9445.  Office: 813-974-2343, Mobile: 347-672-8609, Email: martinsteele@usf.edu, www.research.usf.edu   (See Appendix D).