Transcripts For CSPAN3 Veterans And Spinal Cord Inuries 20170908

Now, federal and local Veterans Affairs officials and Health Care Providers visit the paralyzed veterans of america conference to talk about how to provide better access and specialized care for veterans with spinal cord injuries and diseases. All right, so, before we have dr. Baligh yehia come up and give what will be great keynote remarks, i want to start the morning off with having a conversation with you about something thats near and dear to me as one of those who represent a Success Story of a great specialized care system, spinal cord injury and disease system of care. Before i get into exactly what the topic is, though, i want to ask a couple questions. What are some of the reasons why one becomes a clinician . Why did you choose to become a healer . Money . Raise your hand if its money. Bunch of millionaires in here, right . Social status. Everybody respects a doctor. Job security. Youre always going to have people focused on getting better, so you need people in those industries. And if youre a healer, youve got some job security if you do it well enough, and its probably a combination of all of those. But again, from the perspective of the patient, im willing to bet that somewhere on that list of what brought you into your respective discipline was a sense of compassion. What is compassion . Its a feeling of deep sympathy and sorrow for another who is stricken by misfortune. Who are we talking about . People who have become disabled, been diagnosed with a disease, but its accompanied by a strong desire to alleviate the suffering, so that puts you in the position of the healer. And as clinicians, thats what you do. You literally alleviate suffering. So, by show of hands, how many of you are va collisi ana clini . Among you, who can undoubtedly say that you demonstrate compassion in your clinical work with each and every patient you touch . Each and every one of them. Its not a lot of hands. It should be more than that. You should all be raising your hands. Or you try. At least you aspire to show compassion. Show of hands if you aspire to show compassion with each and every patient. All right. So, tell me this, then why are we in this position where you enjoy the privilege of providing care for our nations bravest, our heroes . Is your system in a position now where it may go away . Why . Were not talking about the expansion of care. Dr. Yehia will talk about the excellent plan va has to make it successful. Im specifically talking about the spinal cord system and disease way of care thats enduring an earthquake and were testing its foundation. How did we get there . What happened . Now, given all thats happened, we can talk about phoenix, we can talk about toma, we can talk about all the other major things, but im talking about what i see when i go to your individual facilities and i talk to the nurses about morale, i talk to leadership about making Foundational Mission a priority, im talking about when access to care is denied. I know you all sincerely believe you show it, i believe that. And a question today, though, is it enough . I dont believe its enough, not with whats going on today. So lets take compassion a step further and separate the power to heal from another critical aspect of care that we consider important. Empathy. The psychological identification with or vicarious experiencing of the feelings, thoughts, or attitudes of another. And who are the another in this case . Veterans. Who suffered trauma, who suffered disease, combat trauma, sexual trauma, exposure. This is who were talking about. Now, how is empathy different from compassion . Unlike compassion, empathy is not about alleviating suffering, its about something rarely, if ever, found outside of the va, a military cultural competency that understands veterans. You wont see it outside the va in many cases. Its your Competitive Edge. When youre talking about competing with other systems, thats the edge you have, if you know what it really means. But the question is, do we know what it really means to be empathetic . And what role does it play in your role as healers . Thats the question were going to test this morning. So i want to do that by revisiting my journey, taking you on my journey. So i want you to bear with me. Close your eyes for a moment. And stretch. Close your eyes. I see you. Trust me, empathy. And i want you to stretch your imagination. [ explosion sound ] open your eyes. Thats how fast it happens. In a blink, no warning. That quickly. And at this point, stop moving. This side of the room, youre quadriplegics. Stop moving, please. On this side of the room, youre paraplegics. Youre lucky ones. Youre lucky. You get to move your arms and legs, but you cant move anything else, and you cant move. Bear with me. If your nose itches, you cant move. You cant. Youre paralyzed. You have to accept it. Over here, you can wave your arms, you can scratch, but dont stretch your legs, because you cant, and you just have to accept it. This is empathy. And i want you to take this journey with me for just a few minutes. While youre sitting there newly paralyzed, right now as you are, the next song you will hear after that accident you just suffered, its not a chainsaw or a lawnmower, its the jaws of life. [ drilling sound ] your car is cut open like a can. Things you remember are the smell of twisted, burnt metal, and its going to haunt you for the rest of your life every time you have that smell. Your body is extricated from the vehicle, and the last sound you will hear before going completely unconscious is this. [ sirens ] then it fades to black. And the first sound you will hear when you wake up is this. [ air and beeping sounds ] this is what it sounds like to be maintained by a machine, when you wake up to that sound. Thats what woke you up, in fact. And these are the next set of sounds that will haunt you for the next few nights as you try to figure out what the heck happened while staring in the dark. [ indiscernible voices ] hospital sounds, misery, cheerfulness, misery, a mix of everything. And youll be visited by a litany of people, people who are in your discipline, doctors, nurses, social workers, psychologists, nutritionists, as you face immobility, dependence, helplessness, sleeplessness, hunger, anxiety, depression, and nonstop pain. And meanwhile, your marriage, your kids, your bills, your classes, that thing you didnt get done, it all appears to freeze, but it doesnt. It simply moves on without you. And then all the preexisting conditions, all the choices you made that got you here, the diet, oral hygiene, the addictions, your education level, sexual trauma, exposure to combat, all that now unforeseeably matters and has an impact, but now it matters. And then your own mind begins to play tricks on you. You shake your head, even though youre paralyzed. Have you ever heard about the running dream that your patients have . This is the dream where typically at about 3 00 or 4 00 in the morning, just as the suns coming up, youre in the middle of a dream sequence where youre in a wheelchair. You now understand what happened to you, and your body starts to force you to think about what it was like before it happened to you. Youre in the chair, youre rolling along, and suddenly, you take the first step, you stand up, you take the first step, step, step, step, step, trot, trot, and youre running as fast as you can, and then you wake up. And no matter how hard you try, you cant go back to sleep to get back into that body that knew what it felt like to run. This is your mind doing this to you. Now i want to talk a little bit about my first family medical conference and the way it went. My uncle bill was a vietnam veteran, gunnery sergeant. When i became paralyzed, he was the one that came and sat in on the conference, and he had a lot of pride in his nephew, chief warrant officer, marine corps, drill instructor, and he didnt want to see me this way. And he said, doctor, is my nephew ever going to walk again . Doctor. No my thoughts are, what . Thats it . Its that simple . What about the 3 that walk again . Statistics. I might be one of that 3 . Youre a doctor. Youre not god. How do you know . How are you so certain that you can basically define my life in two letters, one word, no . And speaking of god, why me . Why . What did i do . Does anybody care . Now ive completed rehab, ive tried to move on with my life, my new life, and now im a veteran whos homeless. Now im an angry veteran. Now im noncompliant, im overweight, im making poor dietary choices, im a burden to you. Im a veteran being denied access. Im a veteran being denied the drug i need. Im a veteran who needs my wheelchair fixed right now. Im a veteran who fears retaliation if i complain. Im an undesirable. Im a human being and i need your help. Please dont make me wait. Please dont make me wait a second longer. Does anyone care . I wonder if thats the last question paul chism asked before he died, alone. Hes not an abstraction to me. This is a person that i talked to, touched, got to know. And i dont need to tell you what happened to him, because its right there. Heres the thing, though he became disillusioned with the relationship that he had with his providers and the va. Some of it was because he had a traumatic brain injury. He was an opioid abuser. There were reasons. An undesirable. And he said, you know what, im not doing this. Ill pay for my care in the private sector, ill cobble it together from different sources. Ill get an attendant here, have home care nursing here, ill have room care here. And over the course of his life that was cut all too short by his choices, he found out the hard way, the best care is in the va, is in the spinal cord injury of care, for him, and he wanted to come back. The problem is, he was now a victim of his choices, and he became a victim of his choices, and he died wondering whether anybody cared about him. Now, because i care about you, im going to give you a gift that you cant give to me or to any of the paralyzed veterans in this room or to the 60,000 men and women who served their country and now live with paralysis. Please, move your legs. Move them around. Move your arms, quadriplegics. Move them, come on. Youre doing it for me. Move your legs. Stretch. Feels good, doesnt it . Now tell me how anybody whos a heal healer would ever deny access to care, ever slow down an admission, ever put something aside and make someone wait, who would never had that gift ive just given you, or leave a veteran in isolation or put policy and process and rules before compassion. I know youre all people, you have to make a living, you have to follow rules to keep your job, and youre professionals. Guess what, were not professional patients. You dont give us our purpose. We give you your purpose. Were why you exist, and im thankful that you exist. And so, in closing, we talked about this yesterday, there are forces out there that want to eliminate this specialized system of care. Again, were not talking about expanding to the community and all the things that have to happen to give greater access. Were talking about this specific system of care. And theyll move a step closer to being successful with every Paul Chisholm that we end up finding out about, every one of those Paul Chisholms is going to be the reason. Your Competitive Edge in these times is your ability to provide care with compassion, but more importantly, your ability to empathize. I want to thank you this morning for empathizing with me. Thank you. [ applause ] you going to do that after his call . Good morning. My name is carl blake, associate director of Government Relations for paralyzed veterans of america here in washington, d. C. Before i introduce our keynote, i want to say to sherman, im one of those 3 . Im actually a pva member whos fortunate enough to be able to move my legs. But it rings very true listening to what sherman had to say, because what you do matters to me as an actual user of the Va Health Care system and the sci system of of care. So i thank you all for being here. You all make a huge difference for people like me, and i really dont know what we would do without folks like you. So, this morning, im stalling a little bit because were miking up our keynote speaker. Were fortunate to be joined this morning by our keynote, dr. Baligh yehia. He is currently the deputy undersecretary for health for Community Care. It probably goes without saying that he maybe has the toughest riddle to crack in washington, d. C. , right now, how to deliver on access that is continuing to gr grow. While in expanding that access into the community, which is a complicated proposition, all the while hes surrounded by a political minefield trying to solve this problem. I certainly dont envy what dr. Yehia has to deal with, even though we kind of cross paths because i deal with the political environment entirely. So, its certainly a complicated proposition. I asked him, i said, whats the one thing you want these folks and this audience to know most, and he said they need to know that im a practicing va physician. Youll note that when we were sitting up front, he raised his hand when sherman asked that question, so he has a vested interest in the system that were here talking about today. I think you probably have his bio. I couldnt do justice to the number of awards that hes received, his background. He received his md from the university of florida, did his residency at johns hopkins, and hes been at university of pennsylvania medical system for some time now. Hes also a professor there while also practicing in the va and while navigating the political minefield that is Community Care policy with va at the national level. So, please show a nice, warm welcome for our keynote speaker this morning, dr. Baligh yehia. Thank you. Thank you all. Can you hear me okay . All right. Well, thank you for having me today. And sherman and i have done a couple conversations together and sat on different panels, and im always inspired by what he has to say and i think its important for clinicians to be moved by talks like that, because i think it shows that youre not callused, youre open, and youre there to do the right thing for patients. So, thank you. What i wanted to talk about today is really how we move towards high [ inaudible ] i can use the podium mike. Can you guys hear me okay . [ yes from audience ] okay, lets start again. Today well talk about moving towards a High Performance network. Theyve already limited me because i like to use my hands and move around, so im going to do my best to stay in front of this microphone. I think we should start where Many Health Care organizations across the country are starting, which is how do you maximize value for our patients. And for us, its really our commitment to that. Many of you have seen a slide similar to this, which is really the triple aim of health care, which is how can we get better health, better care and experiences, and then better value for our patients. And this is really a little bit of what many Health Care Systems and plans and organizations across the country are striving to do in this environment, which is really maximizing the good experiences and care and positive outcomes that we want for our patients while at the same time being as efficient as possible in using our resources. When we think about how to maximize that Value Proposition for our veterans, i think we really need to start with them, and we need to think a little bit about where they are. We have veterans that live in every corner of the United States, literally in smallest of cities or smallest of towns to the largest of cities. And this is very unlike other Health Care Systems or health plans, where they actually get to choose which market they enter into, and then they compete for patients. Were very different. We need to provide health care to a population that can live anywhere. And so, that fundamentally makes what we do different than entering into a market organically and saying, hey, we think this is a good market to be in, were going to try to attract patients to us. We have to go where the patients are, not the other way around. And its important to note that we cant have a physical infrastructure in every single one of those locations, and so we really start to think about, well, how do you create a network of providers across the country to take care of our veterans that live everywhere. We also need to be thinking about this in the context of increasing demand for care. As many of you know, we have an aging population, and what age comes more comorobitic conditions and other issues. And you can see on this graph, the number of appointments both inside and outside the va has been growing in recent years. And so, not only are we trying to make changes to develop a highperforming network, were doing it in the context of more individuals coming to us to receive their health care. We also need to think about the location. And so, you know, im like many of you, every one of your patients is different and theres unique nuances about who they are as an individual and what their medical condition is. We have the same thing in different geographies, and i just put up three different locations for you as an example. When we think about alaska or maybe some more of the frontier states like montana, youll actually see a large proportion of the care is actually being delivered by partnerships, or in alaska, it happens to be great partnerships with our dod facility and our Tribal Health partners in that state. And so, actually, more care is delivered outside of our walls than inside of our walls. Very different when you think about new york city, where we have a lot of different clinics and different access points, and so more likely veterans in that location are going to be treated by a va provider versus a Community Provider. So, its important to think about that as we think about moving towards this highperforming network. It cannot be the same in every location. It has to vary by that geography and the population density of veterans. I think very important for this group here as well is it varies by speciality. You know, for decades now, there are certain things that we have been partnering for freestanding dallas colialysis. We buy a lot of dental care. Most or all Maternity Care is done outside va walls, Community Nursing homes and va health. Whereas there are some things predominantly within the facility, meant Capital Health care services, geriatrics, rehab medicine, spinal cord injury and prosthetics. So we also need to think about the different services, because not only do they vary by geography, they also vary by what type of care is purchased. So, thats important, because when we think about how do we design the right system, and its definitely the topic of discussion these days here in d. C. , is whats this right proportion of va and Community Care and how can they work together. You need to think about all those different nuances. And i really am a person that doesnt think of this as all or none. I really review them as two sides of the same coin, va care and Community Care are linked. And in fact, theyve been linked for decades, and well talk about that in a second. It just seems to happen right now that theres a lot of spotlight on Community Care, but weve been in the business of partnership at va for decades upon decades. What do i mean by a highperforming network . And i wanted to talk a little bit about the characteristics of that that we are striving towards and then talk a little bit more about how do we get there throughout the rest of our time together. First it means strengthening and growing our Foundational Services. You might have heard this term by the secretary or others. You know, every single Health Care System across the country does not excel in every single area, and i think its important for us to invest in those services that are most important to veterans, that are most unique to the va, and make sure that they are state of the art and world class, and thats what Foundational Services means is making sure that the care that cannot be provided outside of our walls is delivered with excellence to all the veterans that need it. And at the same time, it means identifying those services that are readily available in the community and deliver it in a high quality and partnering with the right people to help deliver that care to our veteran population. Again, its hard to be 100 perfect in every single field. Most Health Care Systems focus their efforts on developing certain excellence, and we want to make sure that we do that as well. We also want to move towards a process of monitoring quality utilization, satisfaction and value. And again, a lot of Health Care Systems across the u. S. For their own entity can do that. We are now moving into this world of partnership and networks, but we dont have the best clarity on what is the quality of our Community Partners, how are they using and ordering health care . What is the veteran satisfaction with those providers . And so, we are going to need to develop those competencies as a system so that we can make sure that we provide our patients with information on not only the quality care in va, which i think is well known, but also on our within our network of providers they might end up accessing or touching for one type of care or another. We also need to transition to seamless Electronic Exchange of Health Information. Again, this is not something thats unique to the department, but its really what all of medicine is trying to achieve. The more care that we have inside and outside the va, the more coordination that has to occur. And really, the currency of good coordination is information, making sure that our patients know who, when, where and why theyre going to a different provider, making sure that as a va clinician, i understand what tests were ordered and what the care plan was if i referred someone out, and vice versa for the Community Provider, making sure they have the records that they need and medications they need so we dont duplicate tests, we dont order things that dont need to be ordered. And so, this idea of Health Information exchange will become even more critical in the world of highperforming network. We also need to start to evolve again with the rest of the Health Care Field to not only just, i call it like paying for volume or widgets, but paying for value. How do we partner with those providers and really reward them for delivering the outcomes that we need . And thats going to be very important. A lot of the Health Care Field is moving to valuebased payments. At va, were only starting to explore what those are now, but i view this as part of our future of making sure that our partnerships are really centered around Value Propositions and not just the number of volume of visits thats being conducted. And then lastly, we need to think about new care models that support personalized and coordinated care. What i mean about care models here is really this concept that we have care thats received within our va facilities, theres care that we might purchase on behalf of our veterans in the community, and as many of you know, about 80 of our veterans have another form of independent Health Insurance that they can use at any time that they want. So when you think about these, this circles inside va care, purchased care, and then care thats accessed privately, how do you connect the dots there . And when i talk about care models, its about how do you connect the dots between these three different rings and making sure that a patient isnt being prescribed an opioid in one place and another place and that everyone understands that theyre working off the same care plan. Like i said, these are things that are challenges for the va but also are challenges for american medicine, and thats where i really see an opportunity for us to not only lead in areas like spinal cord injury and rehabilitation medicine and military and cultural competent care, but also in the area of coordination and how can we actually deliver care in a coordinated manner that is really that the rest of health care is looking towards cracking that nut. So now that i gave you a little bit of where we want to get to, we want to move towards highperforming network, i want to take us back and think about how has Community Care evolved and then how are we going to get to that end state . Again, when i came to the va, the office of Community Care was nonexistent. So in my three years there, this office was formed. However, when you look back, as i mentioned, weve been doing partnerships since the 1940s. Again, its the concept i talked about before. We have veterans that live in every corner of the United States. How do you service them . How do you make sure that they get the care that they need . And those partnerships really started to blossom with our academic teaching affiliates. And im a prime example of that. When i was in medical school at the university of florida, i trained at the gainesville north florida va. That was my first time on the medicine wards as a thirdyear medical student. And i remember being asked by my attending to place an iv in one of our veteran patients. And again, im a thirdyear medical student. Youre actually interacting with patients. Youre super excited. Youre also very nervous, because i dont i havent had that much practice there, and i was terrified. And i remember sitting at the bedside of one of our veteran patients, and he could tell that i was a little bit nervous, and he said, you know they call everyone doctor doctor, dont worry, ive been through a lot worse, you know, give it a try. And that really gave me a sense of calm, and i was able to successfully place the iv and put the fluids in that he needed. But i think like me and many other doctors in this room and across the country, you know, part of the reason why im here is to give back, because i would not be who i am today without the care that i received and the teaching that i received from our veteran patients in places like gainesville. So that academic teaching affiliation i think is critical, because we do train the workforce of america in, not only in medicine but in nursing and pe die entry, you name it. So, then it started to grow even more. We were working one on one with a dod. It then became more formalized. We then started a program called project arch, or project hero, followed by project arch. We formalized our relationships with the Indian Health service and Tribal Health partners. And not until the end of 2013 did a Large National contract called pc3 roll out. And shortly after that came the Choice Program. So, you can see that theres been kind of an increase in the last couple years really focusing on choice, but choice is one of multiple programs that we access the community. And this idea of partnership, of creating relationships, we take care of our veteran patients, is not new. And so, really what we need to figure out is how do we create that network, how do we make sure those partnerships work, and how do we make sure that were referring out the right type of care in the right locations. One other point ill mention here is, too much of a good thing sometimes creates problems, and thats a little bit of what happened here. Over time, rather than sunsetting many of these different programs, they just added on and added on and added on. And so, now in 2017, we have seven to eight ways of doing kind of the same thing, which is creating partnerships with outside entities, referring care and purchasing care. And all of them have different Eligibility Criteria, different rules surrounding them that actually creates some problems. So, well talk a little bit more about that. And so, how do we get to a state where we can consolidate and streamline all of these different programs and make them work for our veterans. Ill mention a little bit about the choice act. I think for many of you, you might be living and breathing this, but it was really born in august of 2014 to address the access issues in the department. And it provided various resources to Access Medical care for eligible veterans. Now, the Eligibility Criteria for this program are numerous, but the ones that we typically talk about are 30 days. If youre waiting for a va pointman, or cant be seen in the va and need to be seen and youre waiting more than 30 days, geographic distance, which is 40 miles from a primary care physician, unusual excessive burden, if you have to go over mountains or lakes or various other physical structures, or if you have a sort of medical condition that would prevent you from traveling to a va. The list goes on and on and on, but thats a little bit of, like, the overview of the program. There is a set of Eligibility Criteria for patients and then there is a set of Eligibility Criteria for the type of providers we work with, and there was a set amount of money to administer this program. That was recently a new infusion of dollars was placed in only a couple weeks ago. The challenges of this program. You know, i do a lot of town halls with veterans and Community Providers across the country, and for many of you here that are researchers, you might know of a concept called thenatic saturation, where after you have a number of different interviews, you start hearing the same thing. It didnt take long for me to start hearing the same thing. This program has a lot of issues with it, and well talk about those. Some of those issues stem from the fact that we were required by law to distribute 9 million cards, choice cards, but not every one of those patients is eligible for that program. As you can see, those Eligibility Criteria are very limited. And when you have a card that looks like an insurance card to a veteran or any patient, they think they can just go out there and get care, and that wasnt the case. And so, we had a lot of education to do to educate folks about how to use the program. And a lot of bumps along the way because people got care that wasnt authorized, and it created problems. Also, we had 90 days to administer, to stand up this program. I always like to compare it to tricare, which is really a program thats somewhat similar in dod. And so, we had 90 days or 3 months. They had three years to stand up this program. Standing up a very Large National program in this short amount of time creates problems. And so, that also put va really behind the eight ball from the beginning. To achieve this timeline, one of the things that they did was take this contract that i had talked about before, the pc3 contract, and modify it to do the Choice Program. Well, our contracting partners were not designed to run this race at that point. Thats not what the purpose thats not what they signed up for initially. And so, you can see the challenges here. We had a short limitation timeline, we had a law that was very confusing, we had our partners that really initially came to work with us on something different. Plus, since then, weve changed that law six times, which gives you another sense of how many different issues existed in that legislation that needed to be addressed. And so, while the program is definitely better than when it was at the beginning, its not what we need to do and my sense is you cant keep improving on something that fundamentally needs to be changed. And so, we are looking for a brandnew way to approach Community Care, a consolidation of all the different programs and a modernization, not just a continuation of the status quo of the current program. I think one of the things that i learned from many of my mentors getting trained as a clinician was really, was to listen, and thats one of the first things that our team did was we actively looked at our stakeholders, our veterans, our doctors, our vsos, Community Leaders and health care leaders, and heres what they told us. And again, this gets to the concept of thematic saturation. I hear this in almost every single setting that i sit around, whether its a roundtable or a town hall with our patients and our doctors and our Community Partners. We have way too many Eligibility Criteria. People are very confused. Can i actually access Community Care or not . How do i know . Where do i find out . And so, we hear that a lot. Theres just confusion around am i eligible or not, especially from the Community Providers and our va staff. Theres multiple referral and authorization requirements, and they vary by the program. You know, for this pathway, you need to fill out this form or fill out these boxes. For this pathway, you need to do something different. Lack of standard care coordination. I see this, again, time and time again, where every facilitys doing a little bit something different, and the care coordination process also varies by program. In terms of our Community Care network, we have different ways to partner with providers. Some are through large contracts, some are through things called provider agreements, others are through affiliation agreements. So, our Community Partners might be working with us under more than one way, and thats also hard for them, because to them, theyre seeing our veteran patient, and its just their veteran patient, and some of this behindthescenes stuff just complicates it. Theres variable payment rates and structures. Again, some are actually set in law of what the payment rates are for the purchase of health care. Others are more varied. And it creates confusion when to our partners, they see the va, but all these different programs have different rules. And in addition to our patients, because until recently, the Choice Program had va as a secondary payer for certain conditions, which means that veterans had to pay certain cost shares up front. That was very different than the other programs. So, again, it created that confusion. Then lastly, Customer Service. Who do you call . How do you make sure theyre picking up the phones and answering your questions . So, this is just really a highlevel summary of many of the things that i heard from our veterans and our partners and from you and others like you across the country. So then comes a question, well, then how do you even start to tackle this . How do you take a program that was really first at a crisis, and i think its im glad that we had the opportunity to provide access to Community Care, but how do you turn it into something that is a positive experience, something that complements the va and something that really helps us create that highperforming network . Again, it goes back to putting the patient at the center. So, the first thing that our team did was a concept or a process called journey mapping. Many of you may be familiar with that. We really tried to think of what is the veterans experience through this Community Care process . And with the help of different engineers and Design Thinkers we really mapped out the steps that a veteran takes as they go from the v. A. To the community and back and this is really our what weve been striving toward at the office of Community Care since the beginning. Our goal is to deliver one program that is easy to understand, thats simple to administer and that meets the needs of veterans and their families, Community Providers and v. A. Staff. So i start all of our meetings and our work with that in mind, that is our goal, all the different projects and things we do stem from that. Theres six touch points that we identified along the veterans journey through commune care that we developed and we want to provide eligibility information for awfully our stakeholders. The second is referrals. We want to provide veterans timely access to a Community Provider of their choice. When we think of care coordination, i really think this is the secret sauce for success here. If we can make care coordination work, then we can make our high performing network work and we can serve as a model for the rest of the industry which is coordinating care through Seamless Exchange of information. When we think about the Community Care network, we want to make sure we have a Robust Network that provides access high Quality Community providers both inside and outside the v. A. , provider payment. Its important for us to be good partners for providers and that means paying timely and accurately. If we cannot be good partners for our docks, why would they work with us and take care of our veterans . For me thats a very important piece to ensure that we provide those services that are needed to our patients. Lastly, Customer Service which is providing quick resolution of questions and inquiries to our various stakeholders. So thats where we started. We started with a veteran at the center and their journey and then the other component that i thought was very important is, how do you if you want to create any lasting changes, it really needs to om from the ground up. We set the direction here, we really needed the help of front line staff to do that and so we established what i call tiger teams or portfolio teams that really touched on each one of those different important parts of the veterans journey and people came out of the woodwork. All you had to do was ask. We put out a call and said who wants to help us solve this problem and work on making this program better. Nurses, doctors, administrators, schedulers, all kinds of folks. Not only did they raise their hand but they volunteered to go on detail for our team for three months at a time where theyre away from their job focusing specifically on creating solutions and weve been doing what i call sprints for the last year and a half just working on different projects that can move the needle at each one of their key areas that our veterans told us are important for them. So involving that front line staff is really important to creating that change and its funny, the big ideas and the big changes that we have been making, whether its from a contract mod perspective, rolling out new i. T. Projects or care models, theyre not from folks here, theyre really from folks on the front line saying i have a better way of doing this, let me share it with you, and if youre open to listening its amazing what you can do. So heres a little bit of whats happened, because of some of these different changes that weve been making, there is been a dramatic increase in choice authorizations over the last couple years. In the first year of the program, theres only about just less than 300,000 authorizations. Now we have more than 3. 8 million authorizations that have been sent since the start of the program with dramatic growth this year and last year. An authorization is really an episode of care. It could lead to multiple appointments. You might authorize someone for, you know, five or six pt appointments and they would count as one authorization. So behind that number are millions of appointments. Weve been working to increase our Provider Network and make sure that we have the top quality providers that can help service veterans, so when we first started in the first year, we had about 175,000 different entities across the country, these are hospitals, clinics and now we have almost half a million and really focusing not just on signing up anyone that needs that wants to sign up but really signing up the right folks in the right places and making sure theyre the ones that are delivering excellent quality care. Just to tell you about how weve been working with our contracting partners as i had described before, one of the ways we administered the Choice Program was through Large National contracts, so weve modified those contracts more than 80 times to make them work better for our patients and for you and for our Community Providers. It shows you the fact that we had to modify it so much that they werent designed originally to run this. We have an open procurement on the treat to really help us develop a new Network Moving forward and were excited about that. One of the things i also learned, again taking a play from the tricare playbook was collaboration and when you collaborate, the best way to do it is really to be in the same room with someone. We have right now at 74 different locations across the country where we actually have yes, ma embedded our contracting staff to help improve that process and thats been very successful and we hope to continue to do that. So and the last one is really, i had mentioned about care coordination and the exchange of information. Weve more than doubled the number of partners that we work with through the electronic Health Information exchanges. These exchanges are really set up on a community level. Theyre not set up by v. A. But v. A. Participates and now we are part of we can now Exchange Information for 1. 2 million veterans that we werent able to before which allows those Community Providers and the v. A. To tap into that Electronic Health exchange and make sure that we know whats been done or whats to be done. So thats a little bit of where we came from, where what weve been doing and i want to focus a little bit on tomorrow which is where we want to go. As you can see, we have multiple programs. All of them create a level of confusion, Administrative Burden and bureaucracy so what does the future look like . I think this is really the op pour tune time over the next couple months, our colleagues will really be discussing this question of how do we create this high performing network and consolidate and modernize our Community Care program while at the same time strengthening v. A. . I have a couple, just thoughts here. We want to move from administrative Eligibility Criteria like those 30 days and 40 miles which i always tell folks, there was nothing in medical school that taught me thats how you think about access to care, theres nothing about, you know, if youre less than 30 or more than 30 or if you live this far away or that far away. We need to move away from this criteria to clinically based criteria. It really means having a conversation between a patient and a doctor to understand where the right place to get care is, when is the best time to get that care and how should that care be delivered. We really want to move from excessive bureaucracy and confusion to making something thats simple, easy to use with more choices. As you can imagine, just by the fact of having all these different programs, by nature creating bureaucracy and administrative hurdles. We want to get to one program and the way you do that is by taking the best of each of those different programs and kind of combining them together and when i talk about making eligibility clear, making the referral process simple, that will create some efficiencies in the system and make it more user friendly for everyone. We need to go from minimal care coordination to robust care coordination. I cant harp on this enough. The more care that we purchase outside or that we partner with the better we have to get at care coordination. We do a really good job, especially in this area in spinal cord injury and cancer care, primary care and were coordinating very well within our system and our team and now we need to figure out how to take those concepts and figure out how to coordinate with part of a network and those are different skill sets and required different tools. Its important for us to do that so we can have the whole picture and provide the best care for our patients. Lastly, again, its very important, we need to move from lack of timely payments and an outdated process to something thats timely and contemporary. Pushing towards systems and partnerships that can help us process our bills more accurately and timely so we can build the network that we need to build for our v. A. Staff and for our veterans. Its all about the veteran provider relationship and thats i think whats very important to me is when i think about the Choice Program today, theres a lot that have got in the way of that veteran provider relationship, those criteria which are arbitrary, different handouts that we have today with the third party. Its really not allowed that relationship to thrive as it should be and so as we move into what this new program could look like, i think we have to keep that in mind, that provider relationship is going to be key, its not only healing and therapeutic in nature but its also provides the most that die aide is where that Knowledge Base resides and how can we support that. Lastly, ill end on this is really how do set transbenefit . What we hope to get to in the future is that improved care coordination with a consistent point of contact. We want to make sure that not only do our patients but our doctors have access to this seamless information. We actually hope to create something new which is really a Robust Network of convenient care clinics, so if someone really has the sniffles or a paper cut or needs to get something and cant get to us quickly they can access some of these walkin type care. We really want to be we want to have the best in class and our v. A. Foundational services and also partner with the high quality providers to create that network, i think its important to have the transparency for our veterans patient for the type of care we do. And new tools to help us navigate the system whether its scheduling or coordinating care. So lastly, where do we go from here . The time is now. This is literally the opportunity that we have to get this right. A couple months ago they gave us about 2. 1 billion to infuse into the Choice Program thats going to carry us a number of months into the future but definitely not for the rest of the year. I think that while we have that time period its really imperative on us to work with our partners and congress to help us consolidate and modernize all these different programs and get it right so that we dont keep kicking the can down the road and getting it right to me really means strengthening the v. A. , building a high performing network thats complimentary, cracking the nut on Seamless Exchange of information and care coordination and if we can get those three pieces right, i think we can we can end up in a pearl place than we are today. Ill end and im happy to take any questions. I want to thank you all for your service and for the work that you do every single day. Its its great to be here and i want to thank carl and sherman and lana and the rest of the team for having me. Theyve been excellent partners and this is not this is hard, so i just want to also mention the folks, the brain trust over here thats working on trying to get this right, if it was simple it would have been done already, so i look forward to learning from you more through your questions today and see how you can help us shape the future for v. A. Community care. Thank you. [ applause ] so if you have a question, you have the mike stands just come straightforward and you can ask your question. The doctor hes been generous with his time. He still has 20 minutes. Hes agreed to take any question. I laugh that he says its hard. He didnt even talk about politics. Its really hard. So if youd like just come to the mike stand. Thank you very much for your talk this morning. Im michael prevy im the chief of spinal cord injury at the augusta v. A. Since the consolidation of the Choice Program just weeks ago with the elimination of choice first and basically rolling everything in, we have had a terrible time, an absolutely unbelievable challenge because theres for this population, there is a distinct and very important differentiation between the Choice Program as you describe it here, seeing a provider, seeing a specialist, seeing a physical therapy, seeing a primary care doctor close to home, in this population, we are highly specialized area and the providers in the community dont know how to take care of our patients. So thats the first piece and so we are very dependent on the beneficiary travel program, which may not be part of choice but needs to be needs to be maintained at all cost for our population. The second piece is the care in the community to us means home care. The Home Care Services, have been eliminated in many situations in our center because it comes out of hospital based dollars. And so it takes not quite an act of congress but an act of the director to approve unskilled and skilled home care for people with disabilities who are dependent on that and as a result, they end up having to stay in the hospital. We cant even get them into a nursing home if theyre not eligible for a v. A. Contract. And so by lumping the Home Care Services in with the provider services, two different animals, weve been this whole problem has has has been created for us. Umhum. So is it mike . Yes. So, mike, at the end of this just come back and chat with me and kristen so we can help clarify some of that. When we got the new Community Care dollars and the Choice Program, many of the Home Care Services that were being provided were through things called provider agreements. So we pushed out a lot of resources to the field in the last couple weeks to do that, so you should be seeing you should be able to access those in the way you need to access them, if youre having issues with that, lets talk and we can figure out how to help you because its not from lack of resources. We have plenty of resources to be able to deliver those home care resources with that new infusion of dollars. Your other point was about really the Community Providers and the type of care that they deliver. So like many of you, maybe you might have practiced both inside the v. A. And outside the v. A. And i think iep im not one to to kind of paint everyone with a same picture. That happens to us a lot in the v. A. And i think theres a ton of Community Providers that are delivering excellent care. Our goal when we talk about building this high performing network is to do two things. Number one, is to strengthen those v. A. Services so hopefully they exist so you dont need to refer to a Community Provider because we can provide them inhouse, timely and stateoftheart. Thats the first point of what i mean by high performing network is for certain things like spinal cord injury. You shouldnt even need to be referring out. We need to make sure that that theyre there to support our patients. At the same time there are things that we think are provided at high quality in the community and maybe dont require that expertise as much in military and cultural then how do we identify those high quality providers and make sure that theyre in our network. The last thing that ill say is, i think its part of our job to educate and provide resources so one of the things that weve done is weve started pretty much like a Free Training Program for Community Providers where they can get free cme credits. We have a four course cme program on military cultural kpensy, free of charge. They can go to a website and get that certificate and they can get that. We also have a lot on opioids Mental Health care and others and even in some areas were providing consult takive services. If theres a Community Provider that has a question they can reach out to some folks in the v. A. To get that answer. Were not where we need to be there but as we start to really refine what that network looks like, i hope that we have more and more providers that have completed those sort of trainings slash working with us in a collaborative manner. We want to reward and incentivize those providers to do that and so when i talk about value based payments right now were paying for volume. When you think about a lot of the health plans, they might be incentivizing minimizing the use of some care and thats how they become a pefred status. We want the complete opposite. I want to make sure that our providers in the community that are delivering high quality care and are investing in taking care of veterans and learning about veterans, they might need to get a little bit of a plus up in how we work with them contractually. Thats where i want to get to. Were not there yet but i think i hope that over time youll start to see more of that. Ed radner from the minneapolis v. A. Spinal cord center. Follow question regarding the home care. In our facility we havent had a problem with authorization for home care. We dont have a problem with having agencies that have been contracted, our problem is workforce. So we can make referrals but the agencies dont have staff and we have excess hospitalizations, premature nursing home placements and, in fact, deaths because we cant organize adequate home care. What can they the v. A. Do to improve the workforce, not the contracting but the workforce for home care particularly for the highest need kind of patients who need daily or twice daily intensive home care like spinal cord injury. Thats a great question and i dont know if i have the whole answer there but you bring up this very important point which v. A. Is part of the fabric of the american Health Care System and so theres certain macro forces above us that we we also face. A lot of our stakeholders may not know that and i always try to make a distinction between whats a v. A. Issue and whats an american medicine issue. That workforce issue is an american medicine issue. We have we have such a dearth of mental Health Care Providers especially in certain areas, primary care provider, it sounds like in minneapolis, Home Health Agencies, it probably is not only just the minneapolis v. A. But maybe the university of minnesota and others that are experiencing that same issue and so i think we we are part of that, we train such a large group of clinicians, one of the things that we are trying to do in this new proposal is really focusing on graduate medical education and the original choice act there was some resources that were provided to help v. A. Train more residents. We hope to do something similar in the future or asking to do something similar in the future where we would be able to cover the cost of a residency for payback time in the v. A. When theyre completed very similar to what the public Health Service does or the dod does. So i hope we can start to contribute somewhat to that issue by Training Clinicians and then bringing them back to those shortage areas to practice and as you know many folks that actually complete their Residency Training tend to stay in that area and hopefully theyll stay and continue serving our veteran populations and others. Thats a tough one and i think we we need to be working with others in the american medicine spectrum to address that. So i would like to continue our home care discussion, here. Sure. Since thats a huge part of whats going on with choice. I am from the denver v. A. We are currently a spinal cord injury spoke site and by next year are supposed to be a hub site. And what our Home Care Department has now done is gone to medicare criteria to authorize all home care and i will tell you that the majority of my spinal cord injury patients are not homebound. They are young, active, healthy men, for the most part. They work full time in many cases. They require assistance in their home in order to be able to get up in the morning, get dressed, get out to work on time and that does not meet medicare criteria. So we have battled with our Home Care Department on making the exceptions for our spinal cord injury patients and that includes our ms patients as well, and we get pushback and theres like, no, v. A. Requires medicare criteria. All right. Well, this doesnt jive because if you go to medicaid criteria, which many of our veterans would qualify for, medicaid does not have that same homebound requirement. And so were trying to work with them in order to get some of those changes, but like our colleague has just said recently, home care should not be a part of this Provider Network, it should be funded in a very separate way, because its utilized very differently. In my facility, my department probably uses 90 of all health care authorized services because its longterm. And so its not the shortterm you just had your hip replaced, you need six to eight weeks of home care. And so i think this needs to be looked at from a very different criteria on that community side. Sure. In addition to that one of my frustrations with home care i never, ever see the home care notes and when i ask for the home care notes, my Home Care Department tells me they dont exist because the home care people are not required to send in their notes in between their 485s. I can get the 485 and see what theyre supposed to be doing but i have no i have no reasonable expectation to know that that 485 is being carried out from one 485 to the next. It would be really nice if there was an expectation that like the Community Providers, those home care agencies were required to submit those notes to us so that we knew things were being carried out correctly. Ive had a patient on Speech Therapy that the Home Care Company is billing us for for four years and thats not appropriate and until i started asking for those notes and asking by the way, he was being seen for swallowing issues which he did not have, but thats what the documentation indicated, so here we have four years of payments to a Home Care Agency for a high level therapist that the patient didnt need and should never have been authorized, but because we dont have that followup, you know its technically fraud because the patient didnt need that service, but i have no way of documenting that. So having some of those pieces in place. Sure. It sounds like we need a little work group on home health and i have a couple volunteers it sounds like. Two things that ill say [ applause ] nationally were not we havent set any sort of standards whether its medicaid or medicare so its more local. One of the things im realizing is helpful, though, is what i call standard episodes of care and we do this for many especially for facilities that dont have a lot of specialty services. We try to create a bundle, a package of Different Things that would be required for that. Perfect example is like for a fee replacement or hip replacement, where you bundle the things that that patient needs, they need to see they need imaging studies, they need to see the original owe pod, they need the pt after. I can definitely see a standard episode for spinal cord injuries specifically thats different for home care thats different than the home care for after you had a surgery. So i think theres a way to address that. Right now were rolling out a number of these standard episodes overtime. I think i would need you guys expertise here to help us determine what would be appropriate and you might have more than one depending on different conditions and then once weve put those into the system they could be used in a more standardized fashion across the different facilities. So i think thats solvable because it adversaryies from one place to another and some locations theyre authorizing a ton and others its a little bit so we can work on that. I think for the records piece, this is why i keep i was harping very strongly on exchange of information and that care coordination because it is so critical. We have a couple new tools that we are just deploying, one sounds simple but its been making a big change and maybe your team needs to access it is literally secure email. Before before a few months ago we couldnt really Exchange Information securely encrypted back and forth between Community Providers. Now we have a tool that does that. It could be part of your outlook and so were weve deployed that first initially to the Community Care team and now were going to more broadly across the v. A. And so there shouldnt be nothing that stops you from communicating with a Home Health Agencies in getting those records and i think now we can provide it in a way that isnt through a fax machine but through a secure electronic email. Again, maybe we can touch base after and i can share with you a little bit about that. Its deployed, denvers one of the sites that has some of those resources. We just need to connect the dots there. The as we heard this morning the sci system of care and the v. A. Is a very strong system that provides the full spectrum all the way from acute and initial care to longterm care but the one gap that is existing is assisted living and im hoping that there are opportunities to explore with the Community Partnership with the v. A. To provide assisted Living Options for veterans who are aging with spinal cord injury but dont have to choose between living at home and being institutionalized and have the full spectrum of assisted living. Yeah. We dont you hit tonight head. Its part of our when i think of the larger v. A. Package, assisted living is not on there. We have nursing home care and home health care, i think thats something that is up for discussion. Theres a lot of things that come with that, like pros and cons in terms of how you how you, to be frank, make sure we have resources to take care of that in this ever expanding area but we should definitely be thinking about that so i appreciate it. Id just like to speak a little bit about the care coordination, looks to me like a Business Model and when were talking about Specialty Care if i have an als patient and we dont do Clinical Care coordination, we do the Business Model, theyve communicated with the provider, were lacking the clinical piece, the person that knows the provider that can help navigate my kpunt, and so its clinical. If somebody feels theyre doing a great job because were beefing up this Clinical Care program its not meeting the needs of the veteran facetoface. Im so glad you brought that up, because so it is a Clinical Care coordination model not a business care coordination model. One of the things that was very important to me, when i first came into the v. A. To lead the office of Community Care, there was never a clinician that was leading this office. It was actually called the Business Office because there were transacting dollars back and forth to buy care. I think its a Clinical Program. Thats why im standing in front of you as a clinician thats leading this program. Its a Clinical Program and we need to think of it as such. Were talking about coordinating care, were talking about the local office of Community Care really serves as that department when those services arent available. If you dont have radiation oncology that is your radiation oncology program. What were trying like anything else, theres a marriage between the business and the clinical and some of the work were doing is even really working to align the local office of Community Care under more clinical type leadership and weve created what we call our operating model that has nurses in there working with primary care providers or the care team. I hope that it evolves, theres many good things about pack. I hope we take the very good things about pack and evolve the care coordination model like that. Im so glad you brought that up. Because it is not we dont want it to be transactional. Its not did you fill out the right paper work, its more you received the records back from the doctor, is there what needs to get done . So were only in the early phases of changing that culture change. So were working to try to change that. So wed welcome your ideas there but i think thats important. Im the unfortunate bearer of bad news. Lana runs a very tight ship. If you have any additional questions for the doctor, lana has said you can forward anything, any concerns, whatever you have to her and well make sure we get them to him and his staff. I can promise you theyre very responsive to whatever we direct towards them. I think we owe him a round of applause for his time here. [ applause ] really big reason, the picture of the car, that was the car i got pulled out back on february 20th, 2012. And its every year i celebrate the anniversary of that date because its sort of a birth date. Maybe a lot of your patients talk about survival day or survivor day or reborn day or whatever they call it but its a day of a new awakening beyond your initial birth because you become a different person while trying to hold on to that identity you were born with. 14 years on the anniversary of that date, another significant thing happened. It was the day that we lost a person who was very important to me homer s townsend jr. He was the executive director of paralyzed veterans of america while when i got to dc, i was the associate executive director and became the deputy executive director and its an old saying that success has made fathers but failures an orphan. A lot of people who take credit for my success maybe theyre right on some level, ive attribute everything ive become in paralyzed veterans of america to this one individual who long before i thought about coming to d. C. To become an advocate, long before i saw myself as a champion for veterans, he saw that potential. And it wasnt necessarily what he said to me, it was how he carried himself as an advocate and as an champion. Do we have that picture yet . Who here knew homer townsend . Hands up. If you didnt know him, you missed out on a true treasure. In terms of understanding advocacy specifically clinical advocacy because were talking about life and death literally in many cases and he became the person through his work and through his example that i wanted to most emulate in my next life, in my new life as a paralyzed veteran and so when we lost him on february 20th of last year, of 2016, it was a tough day for paralyzed veterans of america. Because i knew i will become executive director and the question became, how can i do this . How do i do this . He did it so will well and so effortlessly and he groomed a lot of people and ive got Lana Mckenzie standing behind me and im waiting for carl to get back in here. Come on up here carl. That picture was one of the last pictures that the three of us took. All three of us were associate directors and homer was the godfather to all of us. He was the guy that v. A. Secretaries and under secretaries and sci chiefs, they came to see him. Not because he but because they trusted his wisdom on things and his insight. So when we lost him, we, being the v. A. , we being pva society lost a true treasure in who he was but how we memorialize him became a question, how do we best recognize his contribution . One of the ways we do that is every year starting last year we have the homer townsend memorial lecture, which youll get after im done speaking and but that lecture is kicked off with a very important moment of recognition for not just somebody whose an advocate but a champion, like homer was. Theres vaigs but then when you champion something it becomes your life and theres a bit of a difference there. That distinction is what we recognize in somebody whose typically here at the summit and its characterized by tenacity, a consistency, uncompromising and most of all empathetic, empathy which is what we talked about this morning. So while i have lana, carl and myself here, theres a gap. Theres somebody missing and the only way we can best fill that void is by finding someone who best embodies homers characteristics and qualities as a champion and pull them into this picture that were going to take this morning. And so this years recipient is a person that ive known for quite a while and it was the consistency and the tenacity that distinguished this individual as a champion for veterans as a champion for the voiceless, for people who will never have an opportunity to fight for on their own behalf because they cant and so it requires somebody whose there, whose accessible, whose consistent, whose trust worthy and so this morning i want to recognize that individual. Im proud to give this award, its called the lets see it its called the homer s. Townsend jr. Excellence in clinical advocacy award were going to recognize joe bask more alski as the recipient. [ applause ] now as joe comes up here, joe is the director of Field Services for the Veterans Benefits department of paralyzed veterans of america. If you knew more about his life and i wont get into his personal life, but he is deeply invested. He was one of the people and this isnt why he got the award, but he was one of the people that homer entrusted with his life homer went to boston. He had a great team. He came back to d. C. And we had heidi maloni. They took his life in their hands and when i heard his last words it was a voice mail he left when he landed, he was a happy man and the one thing we talked about is what joe did. He can talk about things like having to run and find a specific type of hamburger or chicken sandwich while homer thats what champions do. They bring comfort and it wasnt just that, it was the fact that homer trusted him so much and so i think last year we had lana mckenzy receive the initial award and it brings me the pleasure to do the same thing for joe. I thank you for what you do for homer and every veteran you touch, all the compassion and empathy and you set a high bar so ill probably give this award to you. [ applause ] say a few words. [ applause ] thanks, carl. Im pretty overwhelmed so im not really sure what to say and its not just because of this award, i think a lot of us probably still have goosebumps from shermans presentation earlier. All i can keep seeing in my head is that running video and thinking about the things that we take for granted every day. Something as simple as the inability to scratch our nose. Ive been with pva for 20 years now and thats probably one of the most powerful and memorable presentations that ive seen. And it takes me back to something i talked to our staff all the time about, people think i talk funny and i dont mean my acce accent, but i always use terms like were privileged to work in such a noble profession and i dont think thats true just for us and pva but for every one in this room. Theres times over the last couple years, you know, sherman has asked me to do things and i know no matter what ive done or what i do throughout my career ill never be able to make the type of sacrifices that homer did or sherman for that matter. And after seeing him this morning, you probably know why were all so proud to have him lead this organization. So thank you all very much for this honor. I dont think ill ever measure up to the people that came before me but im truly honored. Thank you. [ applause ] good morning. While theyre busy setting up the table for our next presenters, i wanted to welcome you all to lecture and im excited to be here. My names jerry noose. Im a psychologyist. Its a privilege to be here and to get an opportunity to have us presenters talk about something thats very important to final cord veterans which is to talk about Suicide Prevention but before we get started with that, i wanted to also thank sherm hen for his talk this morning that me personally left me with a advice ral reaction to what its like to be a person who is spinal cord injured and to remember and to bring us all to the moment that people get injured and also to bring us back to the context in which they Carry Forward with them in their own lives, and so i hope we can all remember that as were working with patients as to what they all bring to the actual injury and what they all bring to the journey as well and so thank you again sherman it was wonderful. This morning were going to have a presentation titled addressing Suicide Prevention and spinal cord injury practice. Its everyones responsibility and as a psychologist im thrilled to see its everyones responsibility. We have three wonderful presenters im very excited to introduce you to. Dr. Sue nil sapper wall whose the chief at the v. A. Boston Health Care System. Hes also assistant professor of physical medicine at harvard medical school. We have dr. David carroll whose the executive director of Mental Health operations in vha. Hes also a licensed psychologist and dr. Katelyn thompson whose a National Director for the office of Suicide Prevention in vha. Welcome. [ applause ] thanks. I want to really thank the Program Committee and pva for this opportunity. It really is a special privilege and especially thankful that this is in memory of homer townsend. I really only got to know homer well in the last few months of his life, unfortunately. I seen him at meetings and just, hello, hi and relatively superficial basis and he wasnt in the best of health when i actually did get an opportunity to know him better, but i can tell you that every time i met him i came back feeling really energized and more passionate about what i was doing and a lot of that was the infection from his attitude. Even if his physical health was deteriorating, every time we got into this conversation and sometimes we would have totally different perspectives on the issue, you could tell how passionate and animated he became and how energized he became and that really i really looked forward to seeing him on a regular basis and realized that it was beneficial to both of us. This was also a great pleasure to see joe be honored because i think he does embody a lot of those traits having worked with joe at boston for several years before he moved up the ladder. I can tell you hes unique in terms of advocacy for veterans with spinal cord injuries and supporting the spinal cord injury team. The other people i want to thank is my copresent rds here, david cor ral and katelyn thompson. Both of whom we just met, by the way, so but weve talked on the phone and and really i think well, and one of the things i would create is that katelyn, david is the exclusive director for mental Health Services and suicide prechgs in vha, katelyn was until very recently the National Director for Suicide Prevention in vha and has now moved on to the risk management. I Risk Program Management in the private sector but working closely with veterans and i think part of the reason for doing this is because i had a lot of questions myself and i still do and it was an opportunity to really pick their brains and also for them to share their expertise with us. So we have no disclosures that are relevant to this talk. But one of the reasons for doing this was because earlier this year for a few months i was temporarily serving as the National Director in the spinal Cord Injury Program before dr. Vicker could take her place as the permanent director and during that time there was one incident where there was a very unfortunate tragic death of a person with spinal cord injury at a v. A. Facility. And that triggered a lot of sort of thought process within our own selves about how what went wrong, what could we have done as a system, could we have done something different, could we have done Something Better . And as part of that, it really brought the focus to issues there are a very limited Evidence Base for Suicide Prevention in people with spinal cord injury. Theres some literature about suicide in spinal cord injury. Its largely limit to the model systems and tez largely related to ep deem logical aspects that constitute a risk but not much about Suicide Prevention at all. During that time i had the opportunity to have a couple of Conference Calls and emails with katelyn and david and realized that what i already knew that the v. A. s made a lot of strides in Suicide Prevention but that we have a wealth of expertise within the v. A. And there are opportunities to really apply that into our spinal cord injury practice. Also i think at the same time realize that a lot of us dont quite know what our role is in Suicide Prevention as geri mentioned it often falls to the Mental Health provider but each of us has very Important Role to play in Suicide Prevention. And so i these really are the goals of the talked to based on that background and then the other thing that i think we realize that even though it would be good to apply the Evidence Based that exists in the general population to spinal cord injury, theres some unique considerations that are relevant to spinal cord injury practice that i hope we have a chance to talk about and i know we have limited time but well try to have at least a couple of Breakout Sessions where well try to make this part conversation and part presentation. So david is going to were going to go back and forth. David is going to talk about facts and figures related to spinal cord injury. Thanks. Good morning, everyone. It is a real privilege to be here with all of you today and to speak to you about something that is most important to us and first of all i want to thank katelyn and sunil for the opportunity to partner with them in this presentation today and to have the honor of being here for the townsend memorial lecture. And of course to give a shoutout to all of our veterans in the audience, all of the v. A. Employees and everyone else who is our partner in this important work. Suicide prevention, the health and wellbeing of veterans is the most important thing to all of us who work for the department of the Veterans Affairs and to all of us as a nation, and what were going to do this morning is to begin by talking about some data just to set the context for this really important work that we have to do that were committed to do as the department and as a nation. Ill use the mouse. There we go. So suicide is a Public Health issue. In fact, i would say its a Public Health crisis in the United States. Between 2001 and 2014 the rate of suicide in the u. S. Civilian population increased by almost 24 . Currently death by suicide is the 10th leading cause of death in the United States. This is not just an issue for one segment of the population and our focus today is on veterans but this is a Public Health issue. This is a Public Health crisis. V. A. Is working with partners across the nation, with the Substance Abuse and mental Health Services administration, the department of health and Human Services with our dod partners, with Community Partners with all of the partners that the doctor was talking about in the first presentation this morning. But this is something we need to do together and as the title of our talks is, this is everyones business. This isnt just the responsibility for, you know, the folks who work in the Mental Health clinic at the end of the hallway or for the Suicide Prevention coordinator staff, but this is everyones responsibility and we can all do something about it. Thats really the great news and thats thats when i want to communicate with you this morning and katelyn is going to talk about some training that weve developed in v. A. That can make people at ease in having the conversation with somebody to say, you know, you seem to be in a crisis, have you been thinking about taking your own life and to have the confidence to say that and then to have the ability to say, well, lets i understand that. Lets see what we can do to figure out and get you help now. How we can get you into care. So we can do something about this. Were not helpless and were really trying to get that message out. So pardon my enthusiasm but i just had to start there because this is theres a very positive thing that is coming out of our work in v. A. And with our partners across the nation around preventing suicide and helping people reingauge in their lives and in their health and wellness whatever their situation may be. So with that, let me come back and talk about data. Ill stay on track here. So weve seen an increase in suicide and the other thing that i would note in v. A. , on average there are roughly 6 maybe 7 million veterans enrolled in care, 5 million of those veterans use v. A. Services everywhere. About 28 of those veterans who use v. A. Services every year are engaged in Mental Health care and thats a great thing but there are roughly 22 million veterans living in the United States. Our commitment in v. A. To prevent suicide is to all 22 million veterans, and so thats why this is everybodys business, because were also committed to helping veterans and their families even if they arent typically engaged in v. A. Health care services. So the rates in males went up, they went up at a higher rate than females and as we look at the next slide which is the data about veterans, between 2001 and 2014, the rate of suicide in u. S. Veterans increased by 31 . So slightly more than the overall population rate increased. Actually probably significantly more, but more than the u. S. Population. And whats particularly noteworthy on this slide is the rate of suicide among female veterans increased very substantially, 62. 4 . When we look at the overall data and talk about the rate per day, this is something that is often portrayed in the media, for a long time it was the rate that was in the media was 22 veterans on average die each day from suicide. Based upon the 2014 data, that rate is 20 veterans a day on average die from suicide. You can see that there is a decrease in the number of veteran suicides as a percentage from 22 to 18 . This isnt really necessarily good news, however, because the number of veterans living in the United States also decreased between 2001 and 2014 and 2010 and 2014 and so so the the the daily number is 20, but it is it is not a good news story. There is much more that we need to do. A couple of interesting and really important facts. We are committed to prevent suicide at every age among every group of veterans that there is, but we know that roughly twothirds of veteran suicides are among those who are over the age of 50. So it is a particular issue for veterans later in life and we also know that twothirds of veteran suicides are the result of a firearm injury. So were going to be talking some more about safety and gun safety in our presentation this morning. And the last data slide is something about vha care. So what we did is to look at the rate of increase in suicide among those veterans who receive care from va and veterans who do not receive care from va. As you can see on the slide for across the board for men, for women, the rate of increase in suicide for veterans who use Va Health Care services went up but it went up significantly less than for veterans who do not receive care from va. So there is something about va care, theres something about what we do in va, theres something about that connection between va and veterans that is helpful. And so part of our mission, as we go forward is to really reach out and to engage veterans in va care, or in whatever care that they want. We know that most veterans who die by suicide are not in va care. We want to get them connected to care in the community, as dr. Yahia was talking about, to va care but we want to get them connected somewhere. Theyre not alone there are Resources Available to them and well talk more about that as we go forward. Im going to talk a little bit about suicide risk after spinal cord injury. Well talk about a patient and i would say that the Case Scenario is fictional. Its just meant to illustrate situations that might be encountered at spinal cord injury practice. Its not a lot of what im saying did not truly happen to jason. But this is jason and jason was a 27yearold veteran who left the army after returning from deployment in afghanistan about two years prior to his injury. Is he was working part time as a handyman and thinking about enrolling in college. So jason had a couple of drinks after an argument with his fiancee and he was speeding on his way home and he was involved in a Motor Vehicle accident. And that is his scene of the accident. So an exam he was able to extend his arms, so history crepes was still intact. But he had no finger movements and no movements below his neck. Or in the legs. So he had a complete c7 spinal cord injury and that is his mri that even in this he had a complete transsection of the dislocation of the c67 at the vertebral level. We know that people with spinal cord injury are more likely to think about suicide. More likely to attempt suicide and more likely to die from suicide than the general public. The studies, theres a 1991, a little older study, but quite an extensive study based on model systems data and a more recent update of that data by calvin 2014. And a lot of other studies indicate that people with spinal cord injury are three to five times more likely to die of suicide than the general population. This is not looking at true data. Because as we know, veterans with spinal cord injury and people with spinal cord injury are predominantly male and males have a higher risk of suicide. This is looking at standardized mortality rates, which adjust for age, sex and race. After adjusting for that, people with spinal cord injury are three to four times more likely to die of suicide. They are also more likely to think about suicide and attempt suicide this was a larger number than i had thought, at least. This is one study. But in 2015, where they looked at a large number of patients in basically looked at the administered several questions and one of them was the Patient Health questionnaire 9, phq 9 talks about Suicidal Ideation in the past two weeks. And 30 of their patients, across the spe spectrum of time since injury reported Suicidal Ideation in the past two weeks in the crosssectional analysis. 7 reported a lifetime suicide attempt. This is one study. Its not been corroborated. But its very high. There are gaps in knowledge, studies in the u. S. Are largely conducted based on model systems data, which applies to about 13 of People Living with spinal cord injury. We dont know if the same thing translates to veterans with spinal cord injury there isnt a lot of good data on suicide of veterans with spinal cord injury. And thats arbitrary to get more Evidence Base in that regard. As david mentioned, veterans who are in care of va might have a lesser suicide risk. We dont know if there are specific risks that apply to this population. In addition to the usual risks that apply to individuals with spinal cord injury. That might increase the risk. The va does have resources and maybe there are protective factors that in some circumstances protect against suicide. But the data that we have right now is limited. And there is no data on specific Evidence Base of Suicide Prevention methods that have been tried and tested in spinal cord injury. I dont expect you to read this table i copied from 2017 articles that just came out a couple of months ago. But basically its looking at, a systemic review of seven or eight studies that have been published about epidemiological risk of suicide. And the bottom line is that suicide accounts for 4 to 10 of deaths after spinal cord injury, based on the data. The one thing i would say, is this study, the last one, the Mccullum Smith study, the study in 2014 looked at data, they stratified it in the decade of injury so and they found that there was actually a decrease in the, it wasnt, it was still about between 3. 5 to 4 , times of death. But there was a decrease over the decades. And in the 190s, there seem to have been a decrease in suicide in that population. And part of their conjecture was perhaps theres a greater attention with the a. D. A. And greater resources, greater attention to community integration, that perhaps that has some bearing on the decrease in suicide risk in that decade. I think that then goes directly to some preventive factors that well talk about. So what do we know about what are the factors associated with suicide risk post sci . A lot of studies have corroborated just like in the general u. S. Population, suicide does seem to be more prevalent in nonhispanic white, in the white race. Many, some studies have indicated more in males, some more in, some dont really have a clearcut gender difference. And its hard to tell because the numbers are so small, especially for females with spinal cord injury. So that gender and age data is also inconclusive. But it does seem to be more prevalent in nonhispanic whites. In terms of level of injury. This is somewhat surprising, if you think of it intuitively. It does not relate to what you might think is the most impaired individuals. In fact, several studies have corroborated that suicide successful suicide is more common in people with paraplegic than it is in tetraplegic. There are various things that people have conjectured. One thing that people have suggested is that people with tetraplegia have more available support and empathy they get from the system as well as more chances to interact with care providers. Whereas people with pairplegia might have more isolation pa parapleg paraplegia, have less availability to these resources. And that might be factoring in. This seems to be something corroborated in several studies. In terms of duration of injury. This focuses on prevention efforts should be especially targeted. The first five to six years after injury seems to be the highest risk. In the devivo study years 25 was the highest risk for suicide, with some increase also if year one in the more recent cow study. It was the first six years. And the suicide risk decreased progressively and then significantly it reduced about 60 for people who had survived ten or more years after injury. So the greatest suicide risk is in the first five to six years. Theres some suggestion again, this is very weak evidence in terms of the mode of injury, that people who get hit by an object for example, just passively are less likely to commit suicide than those who have an active involvement in whatever caused their injury. But that again is really brief data. So there are various psychosocial factors that have been associated in these studies with spinal cord injury. And not surprisingly, depression, Substance Abuse, drug and alcohol abuse. History of Mental Health disorders, schizophrenia and bipolar disorders and history of past suicide attempts. And the mccullumsmith study had an instrument looking at meaningful environmental rewards or you know, pleasurable activities on a daily basis and there was an association with low environmental reward and a sense of lower control about on those activities. With Suicidal Ideation. This particular association was with Suicidal Ideation. Methods of suicide. From the devivo study and charlie foou from san diego and Kevin Gerhart had done a study that followed the same pattern. But 50 , not unlike the u. S. Population in general of suicides after spinal cord injury are related to gunshot wound. Some of this is all the data but thats the best data we have, followed by overdose, cutting, suffocation, by hanging in some studies the third most common. Drowning, fall from heights and other methods. In europe by contrast, this is a danish study, that showed that overdose is the most common cause. And perhaps that has something to do with gun availability in the United States. Next going to pass it on to kaitlyn and she and david will talk about specific issues related to myths and realities. Hi, everyone, again just want to reiterate with my colleagues have said, such a delight to be here today and a real honor. I want to dispel some myths in terms of our suicide Risk Assessment. Theres one myth about asking about suicide may lead to someone taking his or her life. Theres a lot of fear about asking about suicide. And so one of the big fears is if i ask somebody if theyre feeling suicidal and if i say do you feel like you want to kill yourself . Im going to put it into their head as an idea for them to then kill themselves. Theyre going to then kill themselves and its going to be my fault. And that is a very widespread myth that i want to make sure that youre all aware, it is not, is not a reality. The reality is, is that if you ask somebody if theyre feeling suicidal, or if theyre feeling like taking their own life, it in fact opens up this huge conversation for them. And weve heard this with so many, so many survivors of suicide that if somebody had just asked them, said you know what . Im really concerned about you. Are you feeling suicidal . That they would have opened up in and talked about it. And it shows that youre not scared. That youre not scared to talk about what are probably the most difficult feelings in somebodys life. Another fear that people have is, if i ask somebody about suicide, if theyre feeling suicidal, my fear is that theyre going to say yes, i am feeling suicidal. And that is really scary. Because then what do you do . So im going to talk through some strategies that we can go through. But i first want to dispel some of these myths right now. There are talkers and there are doers. So people say well, you know, some people will talk about it and you know, but they wont really do it. In fact, people who talk about suicide must be taken very seriously. So if you hear somebody and its, you know, its not like everybody going to come up to you and say hey, you know, hey, buddy, guess what, im feeling suicidal. In those words. But you have to think about the language that people use and its really a wide spectrum. It might be somebody saying i just feel so tired all the time. I just dont know if i can go on. And so as youre continuing to talk with people and talk with each other, really recognize the fact that everybody has their own language and their own way of talking about whether or not, how theyre doing. So you know, be very, very aware of that. Because we know that about 80 of people who died by suicide gave some warning as to their intentions. And we hauls hear those stories. And we know those people perhaps who have died by suicide. And you say they had everything going for them. What happened . Or you know, they were so supported. They had young children. All of these things. And in fact people who then look back and say wait a second, there was you know there were some signs. So always, always trust yourself, and make sure thaw follow up if people are talking about feeling suicidal. Theres another myth, if somebody wants to die by suicide, theres nothing you can do about it. And that is not true at all. Most people who are feeling suicidal can get better. Theres treatment. Its either going to the va, its going to a clinic, its reaching out and talking with somebody. And so knowing that, that you can get better, especially important. Particularly if youre talking with somebody who might be in crisis. When youre talking with somebody and saying, and theyre suddenly talking with you about yes, i do want to take my life, or yes, i have thought of, about taking my life. Its then saying to that person listen, i am here with you. Were, im going to hold your hand through this and were going to get through this together. That is just so, that can be so powerful. For the that person who can feel so alone and so helpless. Again, you know, this myth of theyre not really going to kill themself, you know, they just made plans for a vacation. They just got a new job, they just you know, retired from a horrible job and theyre going to move on to something you know, they have all of these plans that theyve made. They have young children. The reality is is that most people who feel suicidal and who eventually take their own life, their perspective is not good. There is this overwhelming sense, especially of hopelessness. Of worthlessness. There is a, a this misperception that im a burden on so many people. And so therefore, whats the point . So that, that idea of oh, its you know, nothing for me to worry about, because of this, they know how much we love them. They know how much we love them. Which is, which is very, very it doesnt feel that way for most people who eventually do die by suicide or who attempt suicide. So i want to run through, im going to do a very abbreviated version of what we call operation save, or our save training at va. This is a gatekeeper training. And there are a few different gatekeeper trainings. The army has their own gatekeeper training. Im going to talk through vas gatekeeper training. Its for everybody. Its for nonclinicians, its for anybody who, if, who comes in contact with a veteran, really anybody else. And it talks about the very specific and very easy ways that you can intervene with somebody who might be feeling suicidal. So save is an acronym. It stands for what are the signs of suicidal thinking we need to recognize . What is the most important question of all and how do you ask it . Learning how to validate the veterans experience and verify their experience. And then the e is encouraging treatment and expediting getting them help. Very basic, easy to get through. I wonder how many people in the audience know who your local Suicide Prevention coordinator is at your va . Awesome. Fantastic. Thats wonderful to hear. If you dont know who your local Suicide Prevention coordinator at your va is, its very easy to find. I think we might have a slide on it. If you dont, its at veteranscrisisline. Net or go to your va and ask them for your Suicide Prevention coordinator. Its so important to collaborate with that spc. They are your local experts in Suicide Prevention for veterans in your region. And any time youre concerned about a veteran or if you want to get this training, please, please contact them this is part of their job is to provide this training, provide the support thats needed. So your Suicide Prevention coordinator. Im giving you the brief, abbreviated version of this. But you can get the one to twohour inperson training for your local Suicide Prevention coordinator really anywhere with your local chapters. What are some of the signs of suicidal thinking . As i said before, hopelessness is that really known to be the like the paramount risk factor for those people who are feeling suicidal. Most people, a huge percentage of people who have survived suicide attempts, have said that hopelessness was one of their biggest factors. Feeling that like theres no way out. Other things to watch out for. Any change in behavior. Any change in terms of anxiety or sleeping. Feeling of course feeling like theres no reason to live. Any change in anger, engaging in risky activities without thinking. Increasing alcohol or drug use or withdrawing from family and friends. Another thing thats really important to recognize is that suicide for anybody happens when people are tends to happen when people are going through major transitions in their lives. So whether thats separating from the military. Whether thats retiring. Especially also when people are going through difficult relationship problems. We know from a lot of the studies that have been done at va, that the primary reason why people have been known to die by suicide, is a relationship problem. And also, pain. Physical pain. So those are especially important things with a watch out for, any sort of legal problems. Across the country, any time theres a recession or theres serious financial problems with somebody, the suicide rates go up. Thats known worldwide. In various countries, greece recently had a real, a real high rate of suicides because of their financial problems within their country. So other things to make sure that youre recognizing. There ra few things that require immediate attention. And thats when somebody is saying i really do want to kill myself. I am looking for ways to die. Im purchasing a weapon. Im stockpiling my medication. And so these are things that require immediate attention. And ill talk about what to do with that immediate attention. Asking the most important question of all its what i said before, are you feeling suicidal . Are you thinking about killing yourself . Are you thinking about taking your life . Lots of people also you know, they and this is, this is very, very normal. Is that fear again of going straight to the question. That fear and so theres a lot of people who say, are you thinking about hurting yourself . Which is okay. But still, youre eventually going to have to get to that question, anyway. And most people that we have talked with again, its are you thinking about killing yourself. Get right to the crux of it. It again shows youre not scared to talk about what is probably the most difficult thing that somebody is going through. So, theres some ways to ask it. I mean its really a lot of people are very scared, too. What if i then Say Something wrong . What if i do something wrong . The worst thing, the only thing that you could do wrong is say well yeah, maybe you should go through with it. Which of course nobody is going to do, right . I mean really, you just have to be that empathic, human caring person and just continue the conversation. Another thing that people, that we do, because its really, it, it lessens our anxiety is asking the question, so you werent thinking of killing yourself, are you . Well what is that saying to the person, right . Well, no, of course not. Theyre not going to answer well, yeah, i kind of am. So you have to be very again, very out there, very up front and just ask the question, ask it when you have some time. Dont wait until oh, wait a second, we just finished our session or whatever by the way. This is incredibly important this conversation as you all know. So there isnt much that you can say thats wrong. Its just what then continuing and validating that persons experience. Which is where we go to the v. Its talking openly about it. Even though inside you might be freaking out, because you are right now with somebody who is saying that theyre suicidal. And that is just so scary. But on the outside, its being confident and its talking with the person. And as i said before, its just saying were going to get through this together. Youre going to be okay. Were going to get you some help and i am here with you. Not passing judgment. Are you kidding . Are you serious . You have young children. You just retired. You have so much to live for. The guilt is not going to work. It is going, it is being with that person, in their experience, and its walking through whatever theyre feeling at that time. And then what do you do . You encourage treatment and you expedite getting help. So if somebody is, is at very high risk or is in imminent danger. You need to get them to the hospital. You need to call 911. We also of course have the Veterans Crisis line, which is an Extraordinary Service and i know lots and lots of veterans are using it. And lots of people use it, too. We even have psychiatrists who call to say, i have a patient here, and theyre feeling suicidal. And im not sure what to do. Its 18002738255. You press 1, its 24 7. Extraordinary people. And they will expedite getting the help that you need. You dont want to leave the veteran alone. You want to make sure theres a warm handoff to wherever youre going. You want to make sure that the veteran feels that you are with them. Youre taking them to the emergency room, youre calling somebody and handing the phone directly to them. That way its, you know that the veteran is going to be safe. Thats the end of my part. [ cheers and applause ]. She will be back because im going to ask her questions, too. So lets get back to jason. So jason seems withdrawn, hes quiet, hes not eating, hes not sleeping well. Hes refusing to go to therapy. Just in the past couple of days he was told by his physician that he would never walk again. In the kind of family meeting that sherman talked about. Where the question was asked, and there was just a simple no, you are not going to walk again. Hes getting over pneumonia, he has a suspected urinary tract infection. The question is and he says something like, what kaitlyn just mentioned. I feel fatigued all the time. I just dont know if i can go on like this. Now that is something that we often encounter in this patient population. So the question then is how would you respond, and then the second question, what are some of the warning signs that would especially concern you about suicidal intent. We dont have a lot of time. Maybe take a minute or two and think about it and talk to the person sitting next to you. About what you would say, maybe practice saying, say you are concerned. Asking the question. Dont ask it in a negative manner. But ask the question. I think, i know that i myself feel very uncomfortable asking that question. So maybe start by asking that question and reflect on this for a minute. Everybody. I know you have a lot to say. Do you want another halfminute or so . Lets do that. 25ing. The timelimited distress we encounter in people who have spinal cord injuries. The presentation by sherman this morning was such a powerful portrayal of what he felt, what he heard at the time of his spinal cord injury. As you can imagine, there are different thoughts going on. So that is something that is often encountered. So the question is, we get so used to that, are we then able to see when someone is truly needs to go one step further, to ask that question about suicide risk. Should we be asking that for everybody in that situation . So thats somebody sg that well talk about. We mentioned i think asking the question is important. If you feel that is an issue. Its important to bring up your concerns, not just to keep it to yourself. Because in some instances, what happens is you may notice something, but youre nursing assistant on a spinal cord injury unit. Think theres a whole team of people. Its really, im not sure if im, i should even bring this up. I know at least in boston. Our nurses feel free to go to our psychologist and say, hey, im concerned about this patient. And im hoping thats true in all your teams. The psychologists are always open, but its up to us to make sure that if were not quite sure what to do next, that we go to a Mental Health provider on our team, we if needed find the Suicide Prevention coordinator or at least contact someone who might be able to. Its really important to do that. The other intention we run into is if we feel someones at, possibly at a risk, at what point in what is the extent of, and this is truly a tension that does occur, is maximizing safety of cost a priority . Versus excessive or unnecessary interference with autonomy. Thats always a concern. I think we have to default on the side of safety. At the same time i think we need to be cog stant of the fact, people are there often for their initial rehabilitation, when this, this scenario happened with jason. Yes he was refusing therapies. If you truly think at what point would you then maybe have a onetoone sitin, restrict visitors, at what point would you weigh the pros and cons of doing that it goes to that second question we talked about. The signs that caitlyn talked about, what are the red flags . If someone is really communicating Suicidal Ideation, either by words or in writing, if theyve shown son prop torrey behaviors, those are the kind of red flags that should alert you, where you do need to err on the side of safety. But that truly is a tension, as to how youre going to force treatment on someone who refuses to get treatment and maintaining that therapy relationship. One of the other things we ran into when the va responded to that particular incident i talked about. Was a lot of folks, myself included felt, that we do provide, we have really strong Mental Health support, as part of our spinal cord injury teams, we do provide ongoing regular Mental Health evaluation assessment and treatment. But the issue really is, is there Something Else we should be doing more consistently, in terms of suicide Risk Assessment and prevention, and that i think became apparent, that partly because there was not good evidencebased in the spinal cord injury population. Partly we dont know what is the standard. There are no really wellestablished standards of care for spinal cord injury providers, that what should be, when should we be offering suicide Risk Assessment. If youre concerned, its really important to ask the question. After we had discussions with the field about how to respond to that unfortunate incident happened, was if you truly think someone is at imminent risk for taking their own life, what is the best setting for their treatment . Mostly the recommendation is an inpatient psychiatry unit. We know with people with spinal cord injury in that acute setting, bowel, bladder, skin care needs that may not be the best setting in terms of taking care of those needs. The sci units are not restricted or locked units. So that is truly a tension, and something i think we still need to grapple with a little bit. I really dont have a good answer. But its a true tension in terms of the experience and maybe we can talk about your thoughts or experiences regarding that. In the q a session. Im going to turn it on to david to talk about what is the summary of research. And what the sources are within the va. This is a slide that smaurizes the the body of research around Suicide Prevention and whats important. I want to point to the fact that keeping people safe in the upper lefthand corner is one of the most evidencebased things that we can do. Whether were talking about gun safety, not talking about gun control. Were talking about gun safety. Particularly when people are at risk. Talking about opioid safety, safety with medications, safety in the environment for someone who is acutely suicidal. That is, the number one most evidencebased thing that we can do. As well as asking about things like depression, and doing it in primary care settings. So this is again, this is not, were not talking about what is traditionally considered a Mental Health problem. But in the, the front line, whether its in primary care, if its an sci clinic. In those kinds of settings. You know those are the important places. And i want to make a comment, that we have, theres our eight slides coming up. And we dont have time, we want to make sure we have time for questions here. And have some conversation with you. Im going to go through them, very quickly to give you a heads up. Before i do that, i want to go back to the save training that kaitlyn was talking about. It is so important. Weve had at least two wonderful stories in the last few months from va Medical Centers. In one case a staff member was walking across the campus, its on a lake. They saw somebody sitting on a park bench on the edge of the lake and they said this doesnt look right. Went up and they asked the question. Are you thinking about suicide . Are you thinking about taking your life today . And the person said yes. And they got that person into care. It was, it was a random event. Could have just kept on walking. In another case this past week, a nurse on an inpatient unit noticed the patient had a change in their routine and the nurse said this isnt right and again had the conversation. And there was a problem. And the person opened up to that nurse. And they got that, that patient into care. So what you do on a daily basis. We know that va groundskeepers in the National Cemeteries often come across people, the can teen Service Workers across va are taking save training. It is now required for every va employee. Every year. And it is really our commitment to be there for veterans. And be there is our campaign that were rolling out in the month of september for Suicide Prevention month. That is our commitment to be there for veterans. To ask the question, to help them connect with the services that they need. To support you in that work, here are the slides. Kaitlyn already mentioned the great work that is done 24 7, 365 at the Veterans Crisis line. They answer over 2,000 calls on average every day. Dispatched emergency services. 75 to 80 times a day across the 24hour period. 18002738255. Press 1. Its also Veterans Crisis line. Net. There are all of our Suicide Prevention resources for va, are on that website. It is wonderful, please look at that. And including the list of Suicide Prevention coordinators. We have over 400 Suicide Prevention coordinators at every facility if youre at a facility if you havent partnered with your Suicide Prevention coordinator, do that. Theyre the quarterback, theyre not going to take care of every issue regarding Suicide Prevention. We all need to do that. But theyre the quarterback and they can help you with that. Reach vet is a program weve launched in the fall of last year. Using all of the data that we have in va to identify veterans who may be at risk for suicide based on all of that data, that may not have bubbled up to the surface clinically yet. And thats being pushed out to providers, so providers can ask patients and review their care plan with them. Va has had a very Robust Program on gun safety. Its not about gun control. We have no idea who has gotten a a gun lock from va. But we have distributed over three million gun locks through va. And they happen to have the Veterans Crisis line number on them. We know just in that moment, interrupting someones moment of desperation if the gun is locked, that saves lives. And going back to that research slide that is one of the prominent findings in terms of the Suicide Prevention research. Gun locks make a difference and were continuing, theyre available free at every Medical Center to anyone who wants them. Again check with your Suicide Prevention coordinator. Another website, make the connection, hundreds of stories of veterans in their own word, saying yeah, you know, i had a problem and i did something about it. And im glad i did. And my life is better and and you know, we can connect with each other as veterans. And you can tailor that to your particular situation. There are websites again for va. There are mobile apps in support of Suicide Prevention. And finally, consultation services. Through the National Center for ptsd. Through the vision 19 myrec. And dr. Yahia talked about the veteran and military culture competency training that we have across the organization. So please look at that, im david carroll, to rs, to ls in my last name. I would be happy to follow up with you at any time. So getting back to jason. This is now weve talked about the acute suicide risk in the acute setting. Theres also, its not just the severity of risk, its also looking at risk s temporally. In the first few years, after initial rehab, so jason returned for routine followup. Medically stable. His pain has been increasing and its been interfering with mobility. The ability to take care of self and to participate in the community. Hes expressing increasing feelings of being a burden to his family. The question is how do you assess and strats fi chronic risks, who do we screen and what interventions are appropriate at this point . I think i would like you to reflect on this and maybe talk about it during breaks and come up to kaitlyn and david after this. To ask their Expert Opinion about how we could apply what theyve said to this particular scenario. So now this is something that we often encounter. We do know, that some of the suicide literature talks about the issue of perceived burdensomeness. Which we often hear from people, with spinal cord injury that theyre perceiving, often a misperception about the burden they are on their caregivers and loved ones. Think those are things that we need to both address and identify. As well as looking at this issue, issue of really belongingness, where they feel that they dont have a meaning or purpose. And i think the va, thats where the last part about augmenting protective factors, thats one part that i think we dont give enough service to, in terms of interventions and im getting a sign that were running close to the end of time. But that is really something that i think is a strength, and something that we could focus more on. Both in terms of adaptive sports, supportive employment. Ill briefly say this veteran gave me the permission to talk about him. Someone who is on longterm care, spinal cord injury center. And had a tough time after injury. Here he is using hes got a high at the titetraplegia, thin are these kind of protective things supportive employment. It changed his perspective. I think the last thing is really what could we do, weve already talked about as individual professionals really doing both our jobs, as in our disciplines, but also asking the question. And conveying your concerns as a system of care. What i would say is i think its obvious that we need more evidence and more research in veterans with spinal cord injury related to Suicide Prevention. So i would ask that all of us kind of consider how we can participate in that. The other thing that i would say is really augmenting our protective factors. And saying what is it that we already do a great job. But there are things like supported employment. Other things, are we consistently making those available to veterans who could most benefit from them, as early as feasible. Anyone recognize this . From sunday night, the mtv video music awards. I saw this on a plane flight in the news. This is a song, do you recognize what this number is . Yes, its the veterans Suicide Prevention line. I would say you should write this number down. Note it on your iphones. This is a song i dont, i havent heard of these people, but logic khalid and alicia, kyra. Sang this song, its about someone calling the Suicide Prevention line. Saying they wanted to take their own life and getting out of it. I would look at that and i think that is the end. Do we have time for two minutes for questions . [ applause ] were a little after 10 15. I would like to take two minutes if youre interested in staying. A lot of questions about Suicide Prevention and particularly as a psychologist on an sci unit, understanding the importance of being a team member being involved in Suicide Prevention is very important. If anyone has a question, well turn it over to our panel to answer the question. Hi my name is valerie mcnary, i work at the augusta va Medical Center. As a recreational therapist, i have had enough incidents where i had to ask that question. And then pursue the assistants in getting that person help. But theres something i feel like i can apply immediately when i get back. When i do leisure assessments and im talking about interests, guns, shooting sports. Hobbies, that surround guns come up frequently. I have had inklings where ive asked the question about gun safety. But now i see that maybe thats going to be part of the assessment process and actually making that question asked and i did not know that we had free gun locks available. So thank you for that information. I would say one of our Suicide Prevention coordinators, maybe thats something we could do if our sci panel, is actually has a bowl of gun locks on our desk. So when veterans come in, she automatically asks if they have a gun and hands it to them. Heidi maloney, the va in d. C. , im a nurse practitioner. Theres a cultural shift slightly, and a slippery slope of physician assisted suicide. Many jurisdictions are passing laws for physicianassisted suicide. Does the va have a statement about physicianassisted suicide . I just saw a contemporary movie, called you before me, all about physicianassisted suicide. Do we have a statement about this and should we . We do not at this time to my knowledge. My belief is that suicide is preventible at the va and thats where were focusing our resources. Thats part of the Public Health conversation and when its appropriate, va im sure will be happy to participate in it. Thank you, im sorry we ran over a couple of minutes. If people have questions, david and kaitlyn are going to be here for a little bit. Please feel free to come up if you have a question to ask our panel. Im sorry were out of time. Thank you for being here. Secretary david shelken, you oversee the second largest Government Agency and department with over 350,000 employees. What is your management style . Whats your approach to this job . Well, my approach is that we have mandate from the president and the country i have an urgency and impatience in my management style. But it is to make sure that this Organization Successful in fulfilling its mission to take care of the countrys veterans. How did it get offtrack and when . When i look back through the history, this is decades and decades of problems that havent been dealt with for a long time that essentially the solutions were difficult, so they got pushed off from administration to administration. So theres a natural progression of these problems continuing to essentially develop until we see them now so clearly. Clearly, you cant go back and change things, if you could, what would you have changed, going back in years . I think its a matter of not putting off the hard decisions. And when there are problems that are developing and when organizations outside of government are taking solutions and modernizing, government can afford to fall behind and keep its head in the sand so these are really management issues, that i think have been important to address. And now were going to tackle those headon. More of secretary shulkin on the va, reflections on his childhood and what it was like growing up in an army family. Tonight at 8 00 p. M. Eastern on cspan. Next the u. S. Chamber of commerces briefing on issues impacting business and the labor force. Two Chamber Vice President s highlight tax reform, immigration, Employee Benefits and federal regulations. My make is megan van eten and im the director of media and communications at the chamber. Welcome to our annual labor day press briefing. First ive got up here randy johnson, our senior Vice President for labor immigration and Employee Benefits. And jd foster, our senior Vice President for Economic Policy and chief economist. They will each speak for about 15 minutes. Well open it up for q a and you can ask your questions then