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Witness Testimony of The Honorable Dr. Robert A. Petzel, M.D., Under Secretary for Health Veterans, Health Administration, U.S. Department of Veterans Affairs

Good morning, Chairman Miller, Ranking Member Michaud and Members of the Committee.   Thank you for the opportunity to discuss VA’s delivery of comprehensive mental health care and services to the Nation’s Veterans and their families.  I am accompanied today by Dr. Mary Schohn, Director, Office of Mental Health Operations; Dr. Sonja Batten, Deputy Chief Consultant for Specialty Mental Health; and Dr. Janet Kemp, National Mental Health Program Director, Suicide Prevention and Community Engagement, all from the Veterans Health Administration (VHA)’s Office of Patient Care Services, Mental Health Services.

Since September 11, 2001, more than two million Servicemembers have deployed to Iraq or Afghanistan with unprecedented duration and frequency.  Long deployments and intense combat conditions require optimal support for the emotional and mental health needs of our Veterans and their families.  VA continues to develop and expand its mental health delivery system.  Since 2009, VA has learned a great deal about both the strengths of our mental health care system, as well as areas that need improvement.  VA constantly strives to enhance the services provided to our Veterans and will use any data and assessments to achieve that goal.

VA is working closely with our Federal partners to implement President Barack Obama’s Executive Order 13625, “Improve Access to Mental Health Services for Veterans, Service Members, and Military Families,” signed on August 31, 2012.  The executive order reaffirmed the President’s commitment to preventing suicide, increasing access to mental health services, and supporting innovative research on relevant mental health conditions.  The executive order strengthens suicide prevention efforts by increasing capacity at the Veterans/Military Crisis Line and through supporting the implementation of a national suicide prevention campaign.  The executive order supports recovery-oriented mental health services for Veterans by directing the hiring of 800 peer specialists, to bring this expertise to our mental health teams.  It also supports VA in using a variety of recruitment strategies to hire 1,600 new mental health clinicians and 300 administrative personnel in support of the mental health programs.  Furthermore, it strengthens building partnerships between VA and community providers by directing VA to work with the Department of Health and Human Services (HHS), to establish 15 pilot agreements with HHS-funded community clinics to improve access to mental health services in pilot communities, and to develop partnerships in hiring providers in rural areas.  Finally, it promotes mental health research and development of more effective treatment methodologies in collaboration between VA, Department of Defense (DOD), HHS, and Department of Education. 

VHA has begun work on implementation of Fiscal Year 2013 National Defense Authorization Act (P.L. 112-239) (NDAA), signed on January 2, 2013, including developing measures to assess mental health care timeliness, patient satisfaction, capacity and availability of evidence-based therapies, as well as developing staffing guidelines for specialty and general mental health.  In addition, VA is formulating a contract with the National Academy of Sciences to consult on the development and implementation of measures and guidelines, and to assess the quality of mental health care.  VA is also expanding efforts to recruit mental health providers without compensation to support delivery of mental health services.

My written statement will describe how VA delivers quality mental health care and engages in ongoing research in such specialty areas as post-traumatic stress disorder (PTSD), military sexual trauma, and suicide prevention.  It will then cover how we are refining mental health access, and finally examine VA’s recent enhancement of mental health staffing. 

I.        Mental Health Care

VA operates one of the highest-quality care systems.  VA is a pioneer in mental health research, discovering and utilizing effective, high-quality, evidence-based treatments.  It has made deployment of evidence-based therapies a critical element of its approach to mental health care.  State-of-the-art treatment, including both psychotherapies and biomedical treatments, are available for the full range of mental health problems, such as PTSD, consequences of military sexual trauma, substance use disorders, and suicidality.  While VA is primarily focused on evidence-based treatments, we are also monitoring and assessing those complementary and alternative treatment methodologies that need further research, such as meditation in the care of PTSD.  Our ultimate desired outcome is a healthy Veteran.

VHA provides a continuum of recovery-oriented, patient-centered services across outpatient, residential, and inpatient settings.  VA has trained over 4,700 VA mental health professionals to provide two of the most effective evidence-based psychotherapies for PTSD: Cognitive Processing Therapy and Prolonged Exposure Therapy.  The Institute of Medicine (IOM) report and the VA/DOD Clinical Practice Guideline have consistently affirmed the efficacy of these treatment approaches.  Furthermore, VA operates the National Center for PTSD, which guides a national PTSD Mentoring program, working with every specialty PTSD program across the country to improve care.  The Center has also begun to operate a PTSD Consultation Program open to any VA practitioner (including primary care practitioners and Homeless Program coordinators) who requests expert consultation regarding a Veteran in treatment with PTSD.  So far, 500 VA practitioners have utilized this service.  The Center further supports clinicians by sending subscribers updates on the latest clinically relevant trauma and PTSD research, including the Clinician’s Trauma Update Online, PTSD Research Quarterly, and the PTSD Monthly Update.  As IOM observed in its recent report, “Spurred by the return of large numbers of veterans from [Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND)], the VA has substantially increased the number of services for veterans who have PTSD and worked to improve the consistency of access to such services.  Every medical center and at least the largest community-based outpatient clinics are expected to have specialized PTSD services available onsite.  Mental health staff members devoted to the treatment of OIF and OEF veterans have also been deployed throughout the system.”[1]

Specialized care is available for Veterans who experienced military sexual trauma (MST) while serving on active duty or active duty for training.  All sexual trauma-related care and counseling is provided free of charge to all Veterans, even if they are not eligible for other VA care.  In FY 2012, every VHA facility provided MST related outpatient care to both women and men and over 725,000 outpatient MST-related mental health clinical visits were provided to 64,161 Veterans with a positive MST screen.  This is a 13.3 percent increase from the previous year (FY 2011).  Additionally, in FY 2012, of those who received care in a VA medical center or clinic, over 500,000 Veterans with a Substance Use Disorder (SUD) diagnosis received treatment for this problem.  VA developed and disseminated clinical guidance to newly hired SUD-PTSD specialists who are promoting integrated care for these co-occurring conditions, and provided direct services to over 18,000 of these Veterans in FY 2012.

Use of complementary and alternative medicine (CAM) for treating mental health problems is widespread in VA.  A 2011 survey of all VA facilities by VA’s Healthcare Information and Analysis Group found that 89 percent of VA facilities offered CAM.  VA’s Office of Research and Development (ORD) recently undertook a dedicated effort to evaluate CAM in the treatment of PTSD with the solicitation of research applications examining the efficacy of meditative approaches to PTSD treatment.  The result was three new clinical trials; all are currently underway, recruiting participants with PTSD.  VA has also begun pilot testing a mechanism for conducting multi-site clinical CAM demonstration projects within mental health that will provide a roadmap for identifying innovative treatment methods, measuring their efficacy and effectiveness, and generating recommendations for system-wide implementation as warranted by the data.  Nine medical facilities with meditation programs were selected for participation in the clinical demonstration projects.  A team of subject matter experts in mind-body medicine from the University of Rochester has been asked to provide an objective, external evaluation.  The majority of the clinical demonstration projects are expected to be completed by March 2013, and the aggregate final report by the outside evaluation team is due later in 2013. 

 

Veteran Suicide

Even one Veteran suicide is too many.  VA is absolutely committed to ensuring the safety of our Veterans, especially when they are in crisis.  Our suicide prevention program is based on the principle that in order to decrease rates of suicide, we must provide enhanced access to high quality mental health care and develop programs specifically designed to help prevent suicide.  In partnership with the Substance Abuse and Mental Health Services Administration's National Suicide Prevention Lifeline, the Veterans Crisis Line (VCL) connects Veterans in crisis and their families and friends with qualified, caring Department of Veterans Affairs responders through a confidential toll-free hotline that offers 24/7 emergency assistance.    VCL has recently expanded to include a chat option and texting option for contacting the Crisis Line.  Since its establishment five years ago, the VCL has made approximately 26,000 rescues of actively suicidal Veterans.  The program continues to save lives and link Veterans with effective ongoing mental health services on a daily basis.  In FY 2012, VCL received 193,507 calls, resulting in 6,462 rescues, any one of which may have been life-saving.  In accordance with the President’s August 31, 2012, Executive Order, VA has completed hiring and training of additional staff to increase the capacity of the Veterans Crisis Line by 50 percent.  However, VCL is only one component of the VA overarching suicide prevention program that is based on the premise that ready access to high quality care can prevent suicide.

VA has placed Suicide Prevention Teams at each facility.  The leaders of these teams, the Suicide Prevention Coordinators, are specifically devoted to preventing suicide among Veterans, and the implementation of the program at their facilities.  The coordinators play a key role in VA’s work to prevent suicide both in individual patients and in the entire Veteran population.  Among many other functions, coordinators ensure that referrals from all sources, including the Crisis Line, e-mail, and word of mouth referrals are appropriately responded to in a timely manner.  Coordinators educate their colleagues, Veterans and families about risks for suicide, coordinate staff education programs about suicide prevention, and verify that clinical providers are trained.  They provide enhanced treatment monitoring for veterans at risk.  They assure continued care and treatment by verifying that each “high risk” Veteran has a medical record notification entered; that they receive a suicide-specific enhanced care package, and any missed appointments are followed up on.  The coordinators track and monitor all suicide-related events in an internal data collection system.  This allows VA to determine trends and common risk factors, and provides information on where and how best to address concerns.

VA has developed two hubs of expertise, one at the Canandaigua Center of Excellence for Suicide Prevention (Canandaigua, NY), and another at the VISN 19 Mental Illness Research Education and Clinical Center (Denver, CO), to conduct research regarding intervention, treatments and messaging approaches and has developed a Suicide Consultation Program for practitioners that opened in 2013 and is already in use.

On February 1, 2013, VA released a report on Veteran suicides, a result of the most comprehensive review of Veteran suicide rates ever undertaken by the VA. The report shows current interventions and programs have been able to maintain relatively stable rates despite increasing rates of suicide in like populations in America.    With assistance from state partners providing real-time data, VA is now better able to assess the effectiveness of its suicide prevention programs and identify specific populations that need targeted interventions.  This new information will assist VA to identify where at risk Veterans may be located and improve the Department’s ability to target specific suicide interventions and outreach activities in order to reach Veterans early and proactively.  The data will also help VA continue to examine the effectiveness of suicide prevention programs being implemented in specific geographic locations (e.g., rural areas), as well as care settings, such as primary care in order to replicate effective programs in other areas. 

II.      Mental Health Care Access

At VA, we have the opportunity, and the responsibility, to anticipate the needs of returning Veterans.  Mental health care at VA is an unparalleled system of comprehensive treatments and services to meet the individual mental health needs of Veterans.  We have many entry points for VHA mental health care:  through our 152 medical centers, 821 community-based outpatient clinics, 300 Vet Centers that provide readjustment counseling, the Veterans Crisis Line, VA staff on college and university campuses and other outreach efforts. 

Since FY 2006, the number of Veterans receiving specialized mental health treatment has risen each year, from 927,052 to more than 1.3 million in FY 2012, partly due to proactive screening to identify Veterans who may have symptoms of depression, PTSD, problematic use of alcohol, or who have experienced MST.  Outpatient visits have increased from 14 million in FY 2009 to over 17 million in FY 2012.  Vet Centers are another avenue for access, providing services to 193,665 Veterans and their families in FY 2012.  The Vet Center Combat Call Center, an around-the-clock confidential call center where combat Veterans and their families can talk with staff, comprised of fellow combat Veterans from several eras, has handled over 37,300 calls in FY 2012.  The Vet Center Combat Call Center is a peer support line, providing a complementary resource to the Veterans Crisis Line, which provides 24/7 crisis intervention services.  This represents a nearly 470 percent increase from FY 2011. 

In response to increased demand over the last four years, VA has enhanced its capacity to deliver needed mental health services and to improve the system of care so that services can be more readily accessed by Veterans.  VA believes that mental health care must constantly evolve and improve as new research knowledge becomes available.  As more Veterans access our services, we recognize their unique needs and needs of their families—many of whom have been affected by multiple, lengthy deployments.  In addition, proactive screening and an enhanced sensitivity to issues being raised by Veterans have identified areas for improvement. 

For example, in August 2011, VA conducted an informal survey of line-level staff at several facilities, and learned of concerns that Veterans’ ability to schedule timely appointments may not match data gathered by VA’s performance management system.  These providers articulated constraints on their ability to best serve Veterans, including inadequate staffing, space shortages, limited hours of operation, and competing demands for other types of appointments, particularly for compensation and pension or disability evaluations.  In response to this finding, VA took three major actions.  First, VA developed a comprehensive action plan aimed at overcoming barriers to access, and addressing the concerns raised by its staff in the survey as well as concerns raised by Veterans and Veterans groups.  Second, VA conducted focus groups with Veterans and VA staff, conducted through a contract with Altarum, to better understand the issues raised by front-line providers.  Third, VA conducted a comprehensive first-hand assessment of the mental health program at every VA medical center and is working within its facilities and Veterans Integrated Service Networks (VISNs) to improve mental health programs and share best practices.

Ensuring access to appropriate care is essential to helping Veterans recover from the injuries or illnesses they incurred during their military service.  Access can be realized in many ways and through many modalities, including:

·        through face-to-face visits;

·        telehealth;

·        phone calls;

·        online systems;

·        mobile apps and technology;

·        readjustment counseling;

·        outreach;

·        community partnerships; and

·        academic affiliations.

            Face-to-Face Visits

In an effort to increase access to mental health care and reduce the stigma of seeking such care, VA has integrated mental health into primary care settings.  The ongoing transfer of VA primary care to Patient Aligned Care Teams will facilitate the delivery of an unprecedented level of mental health services.  As the recent IOM report on Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations noted, it is VA policy to screen every patient seen in primary care in VA medical settings for PTSD, MST, depression, and problem drinking.[2]  The screening takes place during a patient’s first appointment, and screenings for depression and problem drinking are repeated annually for as long as the Veteran uses VA services.  Furthermore, PTSD screening is repeated annually for the first 5 years after the most recent separation from service and every 5 years thereafter.  Systematic screening of Veterans for conditions such as depression, PTSD, problem drinking, and MST has helped VA identify more Veterans at risk for these conditions and provided opportunities to refer them to specially trained experts.  The PTSD screening tool used by VA has been shown to have high levels of sensitivity and specificity.  

Since the start of FY 2008, VA has provided more than 2.5 million Primary Care-Mental Health Integration (PC-MHI) clinical visits to more than 700,000 unique Veterans.  This improves both access by bringing care closer to where the Veteran can most easily receive these services, and quality of care by increasing the coordination of all aspects of care, both physical and mental.  Among primary care patients with positive screens for depression, those who receive same-day PC-MHI services are more than twice as likely to receive depression treatment than those who did not.  Treatment works and there is hope for recovery for Veterans who need mental health care.  These are important advances, particularly given the rising numbers of Veterans seeking mental health care.

 

Telehealth

VA offers expanded access to mental health services with longer clinic hours, telemental health capability to deliver services, and standards that mandate rapid access to mental health services.  Telemental health allows VA to leverage technology to provide Veterans quicker and more efficient access to mental health care by reducing the distance they have to travel, increasing the flexibility of the system they use, and improving their overall quality of life.  This technology improves access to general and specialty services in geographically remote areas where it can be difficult to recruit mental health professionals.  Currently, the clinic-based telehealth program involves the more than 580 VA community-based outpatient clinics (CBOCs) where many Veterans receive primary care.  In areas where  the CBOCs do not have a mental health care provider available, VA is implementing a new program to use secure video teleconferencing technology to connect the Veteran to a provider within VA’s nationwide system of care.  Further, the program is expanding directly into the home of the Veteran with VA’s goal to connect approximately 2,000 patients by the end of FY2013 using Internet Protocol (IP) video on Veterans’ personal computers. 

Mobile Apps and Technology

VA has made massive strides towards providing all of those in need with evidence-based treatments, and we are now working to optimize the delivery of these tools by using novel technologies.  From delivery of the treatments to rural Veterans in their homes, to supporting treatment protocols with mobile apps, VA’s objective is to consistently deliver the highest quality mental health care to Veterans wherever they are.  The multi-award winning PTSD Coach, co-developed with the DOD, has been downloaded nearly 100,000 times in 74 countries since mid-2011.  It is being adapted by government agencies and non-profit organizations in 7 other countries including Canada and Australia.  This app is notable as it aims to assist Veterans with recognizing and managing PTSD symptoms, whether or not they are comfortable engaging with VA mental health care.

For those who are kept from needed care because of logistics or fear of stigma, PTSD Coach provides an opportunity to better understand and manage the symptoms associated with PTSD as a first step toward recovery.  For those who are working with VA providers, whether in specialty clinics or primary care, this app provides evidence-informed tools for self-management and symptom tracking between sessions.  VA is planning to shortly roll out a version of this app that is connected to the electronic health record for active VA patients.

A wide array of mobile applications to support the evidence-based mental and behavioral health care of Veterans will be rolled out over the course of 2013.  These apps are intended to be used in the context of clinical care with trained professionals and are based on gold-standard protocols for addressing smoking cessation, PTSD and suicidality.

Apps for self-management of the consequences of traumatic brain injury and crisis management, some of the more challenging issues facing Veterans and our healthcare system, will follow later in the year.  Mobile apps can help Veterans build resilience and manage day-to-day challenges even in the absence of mental health disorders.  Working with DOD, VA will release mobile apps for problem-solving and parenting in 2013 to help Veterans navigate common post-deployment challenges.  Because we understand that healthy families are at the center of a healthy life, we are creating tools for families and caregivers of Veterans as well, including the PTSD Family Coach, a mobile app geared towards friends and families that is expected to be rolled out in mid-2013.

Technology allows us to extend our reach, not just beyond the clinic walls but to those who need help but have not yet sought our services, and to those who care for them and support their personal and professional missions.  In November 2012, VA and DoD launched www.startmovingforward.org, interactive Web-based educational life-coaching program based on the principles of Problem Solving Therapy.  It allows for anonymous, self-paced, 24-hour-a-day access that can be used independently or in conjunction with mental health treatment.

Readjustment Counseling – Vet Centers

In addition to integrating mental health care with primary care, VA provides a full range of face-to-face readjustment counseling services through the network of 300 community-based Vet Centers located in all 50 states, the District of Columbia, American Samoa, Guam, Puerto Rico, and the U.S. Virgin Islands.  In FY 2012, the Vet Centers experienced over 1.5 million visits from Veterans and their families, a 9 percent increase in visits from FY 2011.  The Vet Center program has cumulatively provided services to 458,795 OEF/OIF/OND Veterans and their families.  This represents over 30 percent of the OEF/OIF/OND Veterans that have left active duty.

The Vet Centers provide targeted outreach to returning combat Veterans through a fleet of 70 Mobile Vet Centers that can provide confidential counseling and outreach to Veterans who live geographically distant from VA facilities, ensuring availability of access to mental health care for Veterans, no matter where they may live.  In 2010, Public Law 111-163 expanded eligibility of Vet Center services to members of the Armed Forces (and their family members), including members of the National Guard or Reserve, who served on active duty in the Armed Forces in OEF/OIF/OND.  VA and DOD are working together to implement this expansion of services. 

The recently passed FY 2013 NDAA also includes provisions that expand the peer support counseling program to members of the Armed Forces and expand the Vet Center program to include counseling to certain members of the Armed Forces and their family members. One cornerstone of the Vet Center program’s success is the added level of confidentiality for Veterans and their families.  Vet Centers maintain a separate system of record which affords the confidentiality vital to serving a combat-exposed warrior population.  Without the Veteran’s voluntary signed authorization, the Vet Centers will not disclose Veteran client information unless required by law.  Early access to readjustment counseling in a safe and confidential setting goes a long way to reducing the risk of suicide and promotes the recovery of Servicemembers returning from combat.  Furthermore, more than 72 percent of all Vet Center staff are Veterans themselves.  This allows the Vet Center staff to make an early empathic connection with Veterans who might not otherwise seek services even if they are much needed. 

 

Outreach

In November 2011, VA launched an award-winning, national public awareness campaign, Make the Connection, aimed at reducing the stigma associated with seeking mental health care and informing Veterans, their families, friends, and members of their communities about VA resources (www.maketheconnection.net).  The candid Veteran videos on the Web site have been viewed over 4 million times, and over 1.5 million individuals have “liked” the Facebook page for the campaign (www.facebook.com/VeteransMTC).   AboutFace, launched in May 2012, is a complementary public awareness campaign created by the National Center for PTSD (www.ptsd.va.gov/public/about_face.html).  This initiative aims to help Veterans recognize whether the problems they are dealing with may be PTSD related and to make them aware that effective treatment can help them “turn their lives around.”  The National Center for PTSD has been using social media to reach out to Veterans utilizing both Facebook and Twitter.  In FY 2012, there were 18,000 Facebook “fans” (up from 1,800 in 2011), making 16 posts per month and almost 7,000 Twitter followers (up from 1,700 in 2011) with 20 “tweets” per month.  The PTSD Web site, www.ptsd.va.gov, received 2.3 million visits during FY2012.

VA, in collaboration with DOD, continues to focus on suicide prevention though its year-long public awareness campaign, “Stand By Them,” which encourages family members and friends of Veterans to know the signs of crisis and encourage Veterans to seek help, or to reach out themselves on behalf of the Veteran using online services on www.veteranscrisisline.net.  VA’s current suicide awareness and education Public Service Announcement titled “Common Journey” has been running in the top one percent of the PSA Nielsen ratings since before the holidays.  It is now being replaced with a PSA designed specifically to augment the Stand By Them Campaign titled “Side By Side,” which was launched nationally in January 2013.

In order to further serve family members who are concerned about a Veteran, VA has expanded the “Coaching Into Care” call line nationally after a successful pilot in two VISNs.  Since the inception of the service January 2010 through November 2012, “Coaching Into Care” has logged 5,154 total calls and contacts.  Seventy percent of the callers are female, and most callers are spouses or family members.  On 49 percent of the calls, the target is a Veteran of OEF/OIF/OND conflicts; Vietnam or immediately post-Vietnam era Veterans comprises the next highest portion (27 percent).

Community Partnerships

VA recently developed and released a “Community Provider Toolkit” which is an on-line resource for community mental health providers to learn more about mental health needs and treatments for Veterans.  The Veterans Crisis Line has approximately 50 Memoranda of Agreement with community and internal VA organizations to refer callers, accept calls, and provide and receive services for callers.  Furthermore, suicide Prevention Coordinators at each VA facility are required to provide a minimum of 5 outreach activities a month to their communities to increase awareness of suicide and promote community involvement in the area of Veteran suicide prevention. 

VA has been working closely with outside resources to address gaps and create a more patient-centric network of care focused on wellness-based outcomes.  In response to the Executive Order, VA is working closely with HHS to establish 15 pilot projects with community-based providers, such as community mental health clinics, community health centers, substance abuse treatment facilities, and rural health clinics, to test the effectiveness of community partnerships in helping to meet the mental health needs of Veterans in a timely way.  These are being established in areas where there are access issues or staffing concerns.

            VHA will continue to work closely with DOD to educate Servicemembers, VA staff, Veterans and their families, public officials, Veterans Service Organizations, and other stakeholders about all mental health resources that are available in VA and with other community partners.  VA has partnered with DOD to develop the VA/DOD Integrated Mental Health Strategy (IMHS) to advance a coordinated public health model to improve access, quality, effectiveness and efficiency of mental health services for Servicemembers, National Guard and Reserve, Veterans, and their families.

Academic Affiliations and Training

VA is strategically working with universities, colleges and health professional training institutions across the country to expand their curricula to address the new science related to meeting the mental and behavioral needs of our Nation’s Veterans, Servicemembers, Wounded Warriors, and their family members.  In addition to ongoing job placement and outreach efforts through VetSuccess, VA has implemented a new outreach program, “Veterans Integration to Academic Leadership,” that places VA mental health staff at 21 colleges and universities to work with Veterans attending school on the GI Bill.

VA’s Office of Academic Affiliations trains roughly 6,400 trainees in mental health occupations per year (including 3,400 in psychiatry, 1,900 in psychology, and 1,100 in social work, plus clinical pastoral education positions).  Currently, VA has one of only two accredited psychology internship programs in the entire state of Alaska.  VA is committed to expanding training opportunities in mental health professions in order to build a pipeline of future VA health care providers.  VA continues to expand mental health training opportunities in Nursing, Pharmacy, Psychiatry, Psychology, and Social Work.  For example, over 202 positions were approved to begin in academic year 2013-2014 at 43 VHA facilities focused on the expansion of existing accredited programs in integrated care settings such as General Outpatient Mental Health Clinics or Patient Aligned Care Teams (PACT).  These include over 86 training positions for Outpatient Mental Health Interprofessional Teams and 116 training positions for PACTs with Mental Health Integration, specifically 12 positions in Nursing, 43 in Pharmacy, over 34 in Psychiatry, 62 in Psychology, and 51 in Social Work.  The Office of Academic Affiliations is scheduled to release the Phase II Mental Health Training Expansion Request for Proposals in Spring 2013 which will further assist with VA future workforce needs. 

 

III.    Mental Health Care Staffing and Hiring

VA is committed to hiring and utilizing more mental health professionals to improve access to mental health care for Veterans.  To serve the growing number of Veterans seeking mental health care, VA has deployed significant resources and is increasing the number of staff in support of mental health services.  VA has taken aggressive action to recruit, hire, and retain mental health professionals to improve Veterans’ access to mental health care.  The department has also used many tools to hire the mental health workforce, including pay-setting authorities, loan repayment, scholarship programs and partnerships with health care workforce training programs to recruit and retain one of the largest mental health care workforces in the Nation.  As a result, VA is able to serve Veterans better by providing enhanced services, expanded access, longer clinic hours, and increased telemental health capability to deliver services.

Mental Health Staffing

VHA began collecting monthly vacancy data in January 2012 to assess the impact of vacancies on operations and to develop recommendations for further improvement.  In addition, VA is ensuring that accurate projections for future needs for mental health services are generated.  Finally, VA is planning proactively for the expected needs of Veterans who will soon separate from active duty status as they return from Afghanistan. 

Since there are no industry standards defining accurate mental health staffing ratios, VHA is setting the standard, as we have for other dimensions of mental health care.  VHA has developed a prototype staffing model for general mental health delivery and is expanding the model to include specialty mental health care.  VHA developed and implemented an aggressive recruitment and marketing effort to fill existing vacancies in mental health care occupations.  To support implementation of the guidance, VHA announced the hiring of 1,600 new mental health professionals and 300 support staff in April 2012.  Key initiatives include targeted advertising and outreach, aggressive recruitment from a pipeline of qualified trainees/residents to leverage against mission critical mental health vacancies, and providing consultative services to VISN and VA stakeholders.  Despite the national challenges with recruitment of mental health care professionals, VHA continues to make significant improvements in its recruitment and retention efforts.  Focused efforts are underway to expand the pool of applicants for those professions and sites where hiring is most difficult, such as creating expanded mental health training programs in rural areas and through recruitment and retention incentives. 

As part of our ongoing comprehensive review of mental health operations, VHA has considered a number of factors to determine additional staffing levels distributed across the system, including:

·        Veteran population in the service area;

·        The mental health needs of Veterans in that population; and

·        Range and complexity of mental health services provided in the service area. 

Specialty mental health care occupations, such as psychologists, psychiatrists, and others, are difficult to fill and will require a very aggressive recruitment and marketing effort.  VHA has developed a strategy for this effort focusing on the following key factors:

·        Implementing a highly visible, multi-faceted, and sustained marketing and outreach campaign targeted  to mental health care providers;

·        Engaging VHA’s National Health Care Recruiters for the most difficult to recruit positions;

·        Recruiting from an active pipeline of qualified candidates to leverage against vacancies; and

·        Ensuring complete involvement and support from VA leadership.

Mental Health Hiring

In April 2012, VA announced a goal to hire an additional 1,600 clinical providers and 300 administrative support staff.  As of January 29, 2013, VA has hired 1,058 clinical providers and 223 administrative staff in support of this specific goal.  President Obama’s August 31, 2012, executive order requires the positions to be filled by June 30, 2013.

In order to provide greater access to mental health services, VHA knew that it would have to set aggressive goals to fill these new positions as well as existing mental health staff vacancies.  Like any large health care system, VHA is constantly managing changes within its existing mental health workforce levels (e.g., retirements, transfers, promotions and resignations) to ensure providers are available to deliver care.  Therefore, VHA set a hiring target of 5,000 mental health providers and administrative support staff to:  1) hire for new positions; 2) fill existing vacancies; and 3) replenish naturally occurring turnover.  This ensures a robust flow into the workforce as we anticipate and respond to the needs of both workforce staffing and our Veterans.  VHA has made significant progress to this end, by hiring a total of 3,262 clinical and administrative support staff to directly serve Veterans since May 2012.  This progress has improved the Department’s ability to provide timely, quality mental health care for Veterans. 

In March 2012, VHA reported a core mental health workforce of 20,590.  This calculation was based upon data from VHA’s Allocation Resource Center (ARC), which reports monthly updates of Full Time Equivalent Employees (FTEE) based on departmental accounting of accumulated mental health clinical and administrative workload costs.  Using this methodology demonstrates a core mental health workforce of 21,502, an increase of 912, as of November 30, 2012. 

In our continued efforts to ensure we are providing effective direct care to our Veterans, VHA re-evaluated this methodology and concluded that the inpatient mental health care data in ARC was adequate – it measured what it was designed to measure. However, FTEE is not a head count of the workforce, and the data for outpatient mental health care included some non-clinical activities such as workload associated with mental health education, research, and administration.  Additionally, a small amount of mental health clinical workload which is provided outside of core mental health was not included in the original workforce calculation.  The ARC data also uses year-to-date methodology, which essentially prorates gains made over the year and does not adequately reflect hiring in real time.  For these reasons, VHA developed an improved methodology for capturing mental health on-board strength.  This methodology permits provider-level detail – including comparisons of staffing over time - to ensure accurate reporting of the direct care clinical workforce providing mental health services. 

This improved methodology required VA to develop a new system of accountability by combining information from three existing databases, which enhances our accuracy and allows VHA to:

1)     Ensure better visibility of  mental health clinical outpatient data to the provider-level;

2)     Ensure that non-clinical workload is properly accounted for and not included in direct care calculations; and     

3)     Obtain consistency in the application of the current comprehensive definition of mental health providers across VA.

Using this improved accounting methodology, VA determined the mental health workforce providing direct patient care to be 18,587 as of March 2012.  Applying this accounting methodology to the November 2012 data provides a more accurate picture of the on board strength, which has increased from 18,587 to 19,743 mental health FTEE, for a total, net increase of 1,156 providing direct care to our Veterans. Regardless of accounting methodology used, the data reflects a net increase in the number of mental health professionals providing clinical health services thus increasing the access to quality mental health care for our Nation’s Veterans.  We always strive to improve our data collection to better serve Veterans, and to ensure that our methods are transparent. 

 

Peer Support

There are many Veterans who are willing to seek treatment and to share their experiences with mental health issues when they share a common bond of duty, honor, and service with the provider.  While providing evidence-based psychotherapies is critical, VA understands Veterans benefit from supportive services other Veterans can provide.  To meet this need in accordance with the Executive Order and as part of VA’s efforts to implement section 304 of Public Law 111-163 (Caregivers and Veterans Omnibus Health Services Act of 2010), VA has hired over 100 Peer Specialists in recent months, and is hiring and training nearly 700 more.  Additionally, VA has awarded a contract to the Depression and Bipolar Support Alliance to provide certification training for Peer Specialists.  This peer staff is expected to be hired by December 31, 2013, and will work as members of mental health teams.  Simultaneously, VA is providing additional resources to expand peer support services across the Nation to support full-time, paid peer support technicians. 

Performance Measures

VA is reengineering its performance measurement methodologies to evaluate and revamp its programs.  Performance measurement and accountability will remain the cornerstones of our program to ensure that resources are being devoted where they need to go and are being used to the benefit of Veterans.  Our priority is leading the Nation in patient satisfaction regarding the quality, effectiveness of care and timeliness of their appointments. 

Recognizing the benefit that would come from improving Veteran access, VA is modifying the current appointment performance measurement system to include a combination of measures that better captures each Veteran’s needs.  VA will ensure this approach is structured around a thoughtful, individualized treatment plan developed for each Veteran to inform the timing of appointments. 

In April 2012, VA’s Office of Inspector General (OIG) report on VA’s mental health programs gave four recommendations:  1) a need for improvement in our wait time measurements, 2) improvement in patient experience metrics, 3) development of a staffing model, and 4) provision of data to improve clinic management.  Further, in January 2013, the U.S. Government Accountability Office reviewed VA’s healthcare outpatient medical appointment scheduling and appointment notification processes, specifically focusing on Veterans wait times, local VA Medical Center implementation of national scheduling policies and processes as well as VHA initiatives to improve Veterans’ access to medical appointments. 

In direct response, VA is using OIG and GAO results along with our internal reviews to implement important enhancements to VA mental health care.  Based on OIG and GAO findings, VA is updating scheduling practices, and strengthening performance measures to ensure accountability.  VA has examined how best to measure Veterans’ wait time experiences and how to improve scheduling processes to define how our facilities should respond to Veterans’ needs and commissioned a study to measure timely appointment access and resulting patient satisfaction.  Based on the results of this study, VA is changing its timeliness measures to best track different populations (new vs. established patients) using the approach which best predicts patient satisfaction and clinical care outcomes. In addition, VA is developing measures based on timeliness after referral to mental health services, patient perceptions of barriers to care, and measures of clinic capacity. By taking these steps, we are confident that we will be able to deliver accessible, high quality mental health care to Veterans. 

The development of improved performance metrics, more reliable reporting tools, and an initial mental health staffing model, will enable VHA to better track wait times, assess productivity, and determine capacity for mental health services.  All of these tools will continue to be evaluated and improved with experience in their use. 

 

Conclusion

Mr. Chairman, we know our work to improve the delivery of mental health care to Veterans will never be truly finished.  However, we are confident that we are building a more accessible system that will be responsive to the needs of our Veterans while being responsible with the resources appropriated by Congress.  We appreciate your support and encouragement in identifying and resolving challenges as we find new ways to care for Veterans.  VA is committed to providing the high quality of care that our Veterans have earned and deserve, and we continue to take every available action to improve access to mental health care services.  We appreciate the opportunity to appear before you today, and my colleagues and I are prepared to respond to any questions you may have.



[1]Institute of Medicine of the National Academies.  Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations Initial Assessment.  July 13, 2012.

[2]Institute of Medicine of the National Academies.  Treatment for Posttraumatic Stress Disorder in Military and Veteran Populations Initial Assessment.  July 13, 2012.