Transcripts For CSPAN3 Veterans And Spinal Cord Inuries 20170920

America hosted the event late last month. Its just over twoandahalf hours. 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 clinicians . 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 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 ] 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 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. [ applause ] 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 . 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 other issues and you can see in this graph that the thub of appointments both inside and outside the v. A. Has been growing in recent years so not only are we trying to make changes to develop a high performing 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. 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 see a large proportion of the care is actually being delivered by partnerships and alaska happens to be great partnerships with our dod facility and Tribal Health partners in that state so more care is delivered outside of our walls then inside of our walls. Very different when you think about new york city where we have a lot of different clinics and Access Points and so more likely that veterans in that location will be treated by a v. A. Provider than a Community Provider. Its important to think about that as we think about moving towards this high performing 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 as it varies by specialty. Theres certain things we have been partnering for, freestanding dialysis clinic, we we buy a lot of dental care. Most or all Maternity Care is done outside the v. A. s walls, Community Nursing homes and home health. Theres certain things that are predominantly provided within a v. A. Facility such as Mental Health care service, jerry at tricks, spinal cord injuries and prosthetics. We need to think about the Different Services 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 v. A. 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 view them as two sides of the same coin. V. A. Care and Community Care are a link, and in fact, they have 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 v. A. 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 v. A. , 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 of care in v. A. , 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 v. A. , 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 v. A. 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 v. A. , 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 v. A. 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, i view them as concentric circles inside v. A. 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 v. A. , 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 v. A. , 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 v. A. 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 podiatry, 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 v. A. Appointment or cant be seen in the v. A. 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 and lakes or various other physical structures, or if you have a sort of medical condition that would prevent you from traveling to a v. A. 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 v. A. 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 abactively listened to our stakeholders, our veterans, our doctors, our vsos, our 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 v. A. 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 v. A. , but all these different programs have different rules. And in addition to our patients, because until recently, the Choice Program had v. A. 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 v. A. , 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. This is really what we have been striving towards 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. Theres six touch points that we identified along the veterans journey through commune care that we developed and we want to provide easy to understand eligibility information for all of 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 docs and the community, why would they work with us and why would they 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 come 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 to 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 half, just working on different projects that can move the needle and each one of those key areas that our veterans told us are important to 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, theres been a dramatic increase in choice authorizations over the last couple years. These are cumulative. 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. Which is why right now we have an open procurement down the street 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 embedded our contracting staff with our v. A. Employees in the office of Community Care 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 opportune time over the next couple months, the department in partnership with congress and our vso colleagues will really be discussing this question of how do we create this highperforming 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 administrative arbitrary criteria to clinically based criteria. When i talk about clinically based, 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 youre 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. I think we do a really good job, especially in this area and 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 as part of the network. And those are different skill set and will require different tools but i think its important for us to do that so we can really 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 those valuebased models, 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 dyad is really where the Knowledge Base resides of whats needed for that patient and how can we support that. Lastly, ill end on this is really how you veterans benefit. 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 veteran patients on the type of care that we do as well as the type of care thats in the community. And then new tools to help us navigate the system, whether its scheduling or coordinating care. So lastly, where do we go from here . I think 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 complementary, 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 better place than where we are today. Ill end and im happy to take any questions. Again, i want to thank you all for your service and for the work 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 what we would like for you to do, if you have a question, you have the mike stands. Just come straight forward and you can ask your question. Dr. Yehia has 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 therapist in the community, 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 hospitalbased 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. 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. The Home Care Services are not stopped. When we got the new Community Care dollars and the choice care 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 those. If youre having issues with that, lets talk and figure out how to help you because its not because of a 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 im 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 competency, like a quick exam, a colonoscopy, for example. Then how we do identify those highquality providers and make sure 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 competency, 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 consultative 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 i think 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 working with us in a collaborative manner. And ill take it a step further. 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 preferred 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. Followup 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 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 spokes 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 Knee Replacement or a hip replacement where you bundle the things that that patient needs, you know, they need to see they need some imaging studies, to see the orthopod, to have surgery, they need to do 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 over time. 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 varies 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 should be nothing that stops you from communicating with a Home Health Agency and 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. Im from the boston v. A. As we have heard this morning, the sci system of care and the v. A. Really 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 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 and you hut it on the 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. Patricia from spokane v. A. 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 and if i have an a. L. S. Patient and we dont do Clinical Care coordination, we do a business model, theyve communicated with the provider. Were lacking the clinical piece. The person that knows the provider that can help navigate my community. 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 paperwork, its more you received the records back from the doctor, is there who do you need to contact to let them know you came back. So were only in the early phases of changing that culture change. Because most of them have been Business Offices, 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. And im not going to mess up her schedule in the first hour of today. So what i would ask, if you have any additional questions for dr. Yehia, lana said you could forward any questions or concerns to her and we can make sure well 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 ] february 20th, a significant day for me for many reasons. You saw the picture of the car, the car i got pulled out of back on february 20th, 2002. 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 d. C. , i was the associate executive director and became the deputy executive director, and theres an old saying that success has many fathers but failure is 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 this 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 well and so effortlessly, and he groomed a lot of people, and ive got Lana Mckenzie standing behind me, and im waiting for carl blake, is carl 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 executive directors and homer was sort of 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 lorded over them with any power or authority, 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 whos an advocate but a champion, like homer was. Theres advocacy 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 whos there, whos accessible, whos consistent, whos trustworthy, and so this morning i want to recognize that individual. Im proud to give this award. Its called the lets see it called the homer s. Thompson jr. Excellence in clinical advocacy award. This year were going to recognize joe bethmurowski as the recipient. [ applause ] as joe comes up, joe is director of Field Services for the Veterans Benefits department of paralyzed veterans of america. If you know more about his life, and i wont get into his personal life, but he is deeply invested in. He was one of the people this isnt why he got the award, but he is one of the people that homer entrusted with his life. Homer went top boston, got a great team. We came back to d. C. And had the team at the department of Veterans Affairs Medical Center. When i heard his words when he landed, he was a happy man. The one thing we talked about is what joe did. He could run and specifically find a type of hamburger and chicken sandwich. While homer thats what champions do. They bring comfort. It was that homer trusted limit trusted him so much. Last year we had the award, and its a great pleasure for me to do it for homer. I thank you for all did and all the compassion and empathy. You really set a high bar. Im proud to give this award to you. [ applause ] [ applause ] thanks, carl. Im pretty overwhelmed, so im not sure what to say. 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. Thats probably one of the most powerful and memorable presentations that ive seen. And it takes me back to something i talk to our staff all the time about. People think i talk funny, and i dont mean my accent. I always use terms like were privileged to work in such a noble profession. I dont think thats true just for us in pva, but for everyone in this room. Theres times over the last couple of 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. After seeing him this morning, you probably know why were so proud to have him lead this organization. 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 tables for our next instructor, im excited to be here. My names jerry noose. Im a psychologist and its a privilege to be here and to get an opportunity to have this presenters actually talk about something thats very important to spinal cord injury, veterans and to all veterans which is to talk about Suicide Prevention. But before we get started with that i wanted to also thank sherman for his talk this morning that left me with a visceral 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 they all bring to the injury and what they all bring to the journey as well, so thank you again sherman. It was wonderful. This morning were going to have a presentation titled, addressing Suicide Prevention in spinal cord injury practice. Its every ones 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. Sunil sapperwald, chief of the spinal Cord Injury Program. Hes assistant professor of physical medicine and rehab at harvard medical school. We have dr. David carroll, whos the executive director of Mental Health operations in vha. Hes also a licensed psychologist, and dr. Caitlyn thompson, a National Director of the office for Suicide Prevention in vha. Welcome. [ applause ] thanks. And i wanted to really thank the Program Committee and pva for this opportunity. It really is a special privilege, and im 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. Id seen him at meetings, hello, hi, superficial basis. He wasnt in best of health when i did get to know him better. I can tell you every time i met him i came back feeling energy id and more passionate about what i was doing. A lot of that was the infection from his attitude. Even if his physical health was deteriorating, every time we got into 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 it was beneficial to both of us. It was a great pleasure to see joe honored because he embodies those traits. Having worked with joe in 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 injury and supporting the spinal cord injury team. The other people i want to thank is my copresenters here. David carroll and caitlyn thompson. Both of whom we just met, by the way. So weve talked on the phone, and really i think well, one of the things i would correct is that caitlyn, david, is the executive director for Mental Health services and Suicide Prevention in vha. Caitlyn was until very recently the National Director for Suicide Prevention in vha and has moved on to Risk Management Risk Management Program Evaluation in the private sector, but working really and i think part of the reason for doing this i have questions myself and still do, it was an opportunity to pick their brains and also for them to share their expertise with us. We have no disclosures that are relevant to this talk. One of the reasons for doing this was because earlier this year, for a few month, i was temporarily serving as the National Director of the spinal Cord Injury Program before dr. Singer could take her place as permanent director. There was one incident where there was a very unfortunate, tragic death of a person with spinal cord injury at a v. A. Facility. That triggered a lot of sort of thought process within our own selves about what went wrong, what could we have done as a system, could we have done something better, could we have done something different. As part of that, it brought the focus to issues that there is really there are limited Evidence Base for Suicide Prevention for people with spinal cord injury. Theres some literature, its largely limited to the model systems, and its largely related to epidemiological aspects that contribute to risk, but not much about Suicide Prevention at all. During that time i had the opportunity to have Conference Calls and emails with caitlyn and david and realized that the v. A. s made strides in Suicide Prevention, but 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 jerry mentioned. It often falls to the Mental Health provider. In truth, each of us has a very Important Role to play in Suicide Prevention. These really are the goals of the talk today based on that background. And then the other thing we realized, even though it would be good to apply the Evidence Base that exists in the general population to spinal cord injury, theres unique considerations that are relevant to spinal cord injury that i hope we have time to talk about. We have limited time, but well have Breakout Sessions where well try to make this part conversation and part presentation. David is going were going to go back and forth. David is going to talk a little bit about facts and figures related to spinal cord injury. Thanks. Good morning, everyone. It is a privilege to be here with all of you today and to speak to you about something that is most important to us. I first of all want to thank sunil and caitlyn for the opportunity to partner with them in this presentation today and to have the honor of being here for the townsend memorial lecture. Of course to give a shout out 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 Veterans Affairs and to all of us as a nation. What were going to do is to begin by talking about some data to set the context for this important work that we have to do, that were committed to do as a department and as a nation. 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. 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, our dod partners, with Community Partners, with all of the partners dr. Yohia was talking about in the first presentation this morning. This is something we need to do together. As the title of our talk says, this is everyones business. This isnt just the responsibility for the folks who work in the Mental Health clinic at the end of the hallway or for the Suicide Prevention coordinator staff. This is everyones responsibility. We can all do something about it. Thats the great news. Thats what i want to communicate with you this morning. Caitlyn is going to talk about 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, im i understand that. Lets see what we can do to figure out and get you help now, how we can get you into care. We can do something about this. Were not helpless, were trying to get that message out. So pardon my enthusiasm, but i just had to start there. Theres a very positive thing coming out of our work in v. A. And with our partners across the nation around preventing suicide and helping people reengage in their lives, in their health, in their wellness, whatever their situation may be. With that, let me talk about data. Ill stay on track here. Weve seen an increase in suicide. Other thing that i would note in v. A. On average, there are roughly six million, maybe seven million veterans enrolled in vha care, about five million of those veterans use v. A. Services every year. About 28 of those veterans who use v. A. Services every year are engaged in Mental Health care. Thats a great thing. 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. Thats why this is everybodys business because were committed to helping veterans and their families even if they arent typically engaged in v. A. Health Care Services. The rates in males went up. They went up at a higher rate in females. As we look at the next slide, data about veterans, between 2001 and 2014, the rate of suicide in u. S. Veterans increased by 31 . Slightly more than the overall population rate increase. 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 substantially. 62. 4 . When we look at the overall data and talk about the rate per day, this is something often portrayed in the media. For a long time, 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 there is a decrease in the number of veteran suicides as a percentage of overall suicide in the United States from 22 to 18 . This isnt necessarily good news. The number of veterans living in the United States also decreased between 2001 and 2014. In 2010 and 2014. And so the the daily number is 20. It is not a good news story. There is much more that we need to do. A couple of interesting and really important facts. You know, we are committed to prevent suicide at every age, among every group of veterans that there is. We know that roughly twothirds of veteran suicides are among those over the age of 50. 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. 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 received care from v. A. And veterans who do not receive care from v. A. As you can see on the slide, across the board for men, for women, the rate of increase in suicide for veterans who use v. A. Health Care Services went up, but it went up significantly less than it did for veterans who do not receive care from v. A. There is something about v. A. Care, theres something about what we do in v. A. , theres something about that connection between v. A. 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 v. A. Care or in whatever care that they want. We know that most veterans who die by suicide are not in v. A. Care. We want to get them connected to care if the community, as dr. Yahia was talking about, to v. A. Care, but we want to get them connected somewhere. Theyre not alone. There are Resources Available to them. Well talk about that as we go forward. Im going to talk a little bit about suicide risks, specifically after spinal cord injury. And so well talk about a patient, and i will say that the Case Scenario is fictional. Its just meant to illustrate situation thats might be encountered at spinal cord injury practice. A lot of what im saying did not truly happen to jason. But this is jason. Jason was a 27yearold veteran who left the army after returning from deployment in afghanistan about two years prior to his injury. He was working part time as a handyman and thinking about enrolling in college. Jason had a couple of drinks after an argument with his fiancee, and he was speeding on his way home. He was involved in a Motor Vehicle accident. That is the scene of the accident. On exam he was able too extend his arms, his triceps were still intact, but he had no finger movements and no movements below his neck. So or in the legs. He had this complete c7 spinal cord injury. And that is his mri that even in this, you can see he had a complete transsection of the dislocation at the c6 7 vertebral level. What is his risk of suicide, and what do we know about the literature that we could apply to jasons assessing suicide risk . We know that people with spinal cord injury are more likely to think about suicide, more likely to attempt suicide and die of suicide than the general population. The studies 1991, a little older study, but quite an extensive study based on model systems data from devivo and the more recent update of that data, 2014. And a lot of other studies generally 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. As we know, veterans and people with spinal cord injury are predominantly males. And males have a higher risk of suicide. This is really looking at standardized mortality rates, just for age, sex, and race. After adjuster for that, people with spinal cord injury are three to four more times likely to commit suicide. To die of suicide. Theyre 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 in 2015 where they looked at a large number of patients, and basically looked at, administered questions, the and one of them was the ninth question in which the ninth question talks about suicidal Suicidal Ideation in the past two weeks. This the Cross Sectional analysis. 7 reported a lifetime suicide attempt. Now this is one study. Its not been corroborated but it is 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 injuries. There isnt a lot of good data on suicide in veterans with spinal cord injury. And i think that is an opportunity to get more Evidence Base in that regard because we dont know as david mentioned, veterans in care of v. A. Might have a lesser suicide risk. We dont know if theres specific risks that apply to this population in addition to the usual risks that apply to individuals with spinal cord injury that may increase the risk. The v. A. Does have resources, and maybe protective factors that in some circumstances protect against suicide. The data that we have is limited. And there really 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 the slide. Its a table i copied from 2017 article from a couple of months ago. Basically it was 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 that the study, this last one, the Mccollum Smith study sorry, the study in 2014 actually looked at data, they also stratified it in the decade of injury. They found that there was actually a decrease in the it was still about between 3. 5 to 4 times of death. But there was a decrease over the decades. And in the 1990s, there seemed to have been a decrease in suicide, at least in that patient population. Part of the conjecture was perhaps there is a greater attention, you know, with the ada, 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 show like in the u. S. Population, suicide does seem to be more prevalent in nonhispanic, white in the white race. Some studies have indicated for in males. Some dont have a clearcut gender difference and its hard to tell because the numbers are so small especially for females with spinal cord injury. That gender and race data is specific. Its more prevalent in nonhispanic whites. This is surprising if you think about 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 paraplegia than tetraplegia. One of the things thats been suggested is that perhaps people with tetraplegia have more support and empathy that they get from the system, as well as more chances to interact with care providers, whereas people with paraplegia might have more isolation and a less attention to these resources and daily interactions, and that might be factoring in. There have been other things, but this seems to be something that is corroborated in several studies. In terms of duration injury again, i think this helps focus on where the prevention methods, 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 two to five was the highest risk for suicide with some increase also in year one in the more recent study, it was the first six years. And the suicide risk then decreased progressively and then significantly reduced about 60 for people who survived ten or more years after injury. The greatest suicide risk is in the first five to six years. Theres some suggestion, again, this is 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 weak data. There are psychosocial factors that have been associated with the studies with spinal cord injury, and not surprisingly depression, Substance Abuse including both drug and alcohol abuse, history of Mental Health disorders such as schizophrenia, bipolar disorders, and definitely a past history of suicide attempts. The mccollumsmith study in 2015 specifically looked at meaningful environmental rewards or, you know, pleasurable activities on a daily basis. There was an association with low environmental rewards and a sense of lower control on those activities with Suicidal Ideation. This particular association was with Suicidal Ideation. In terms of methods of suicide, this is from devivo study and also charlie few i think from san diego and Kevin Gearhardt had done a study that also pretty much followed the same pattern. 50 not unlike the u. S. Population in general of suicides after spinal cord injury are related to gunshot wounds. Some of this is older data. Thats the best we have. Followed by overdose, cutting, suffocation suffocation is sometimes by hanging in some studies the third most common. Drown, fall from heights, and then other methods. In europe by contrast it shows a danish study that showed overdose is the most common cause. Im next going to pass it on to caitlyn and then she and david will talk about specific issues related to myths and realities for suicide Risk Assessment. Hi, everyone. Again, just want to reiterate what my colleagues have said. Its such a delight to be here today. A real honor. So thank you for having me. I want to dispel some myths in terms of suicide Risk Assessment. Theres one myth that asking about suicide may lead to someone taking his or her life. Theres a lot of fear about asking about suicide. One of the big fears is if i ask somebody if theyre feeling suicidal and say do you feel like youre going 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. That is a very widespread myth that i want to make sure that youre all aware it 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. Weve heard this with so many so many survivors of suicide, that if somebody had just asked, you know, said, you know, im really concerned about are you feeling suicidal, that they would have opened up and talked about it. It shows 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, my fear is theyre going to say, yes, i am feeling suicidal and that is really scary because what then do you do . I first wanted to dispel some of the myths now. There are talkers, and there are doers. People say, well, you know, some people will talk about it, but then they wont really do it. In fact, people who talk about suicide must be taken seriously. Its not like everybodys going to come up and say, hey, buddy, guess what, im feeling suicidal, in those words. You have to think about the language that people use. It really is a wide spectrum. It might be somebody say, i feel so tired all the time, i dont know if i can go on. So as youre continuing to, you know, 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 how theyre doing. Be very, very aware of that. We know that about 80 of people who died by suicide gave some warning as to their intentions. We always 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 . They were so supported. They had young children, all these things. People look back and say, wait a minute, there were signs. Always trust yourself and make sure that you follow up if people are talking about feeling suicidal. Theres another myth that if somebody wants to die by suicide theres nothing you can do about it. That is not true at all. Most people who are feeling suicidal can get better. Theres treatment. Its either going to the v. A. , going to a clinic, its reaching out and talking with somebody. So knowing that that you can get better is especially important, particularly if youre talking with somebody who might be in crisis. When youre talking with somebody and theyre talking about, yes, i do want to take my life, or yes, i have thought 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. And that is just so powerful for that person who can feel so alone and so helpless. This myth of theyre not really going to kill themselves, you know, they just made plans for a vacation. They just got a new job. They just, you know, retired from, you know, from a horrible job and theyre going to move on to something they have all these plans theyve made, they have young children. The reality is that most people who feel suicidal and who take their own life, their perspective is not good. There is this overwhelming sense especially of hopelessness, of worthlessness. Theres a misperception that im a burden on so many people. Therefore, whats the point . And so that idea of oh, its nothing for me to worry about because of this, they know how much we love her they know how much we love them. Which is very, very it doesnt feel that way for most people who eventually do die by suicide or who attempts suicide. I want to run through and do a very abbreviated version of what we call our operation save or save training at v. A. This is a gatekeeper training. Gatekeeper training, there are a few kind of gatekeeper trainings. The army has their own gatekeeper training. Different organizations have their own. Im going to talk through v. A. s gatekeeper training. Really what it is, its for everybody. Its for nonclinicians, its for anybody who who comes in contact with a veteran or 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. S. A. V. E. Stands for what are the signs of suicidal thinking that we need to recognize. What is the most important question of all, and how do you ask it. Learning how to validate that veterans experience and verify their experience. And then the e is encouraging treatment and expediting getting them help. Again, very basic, easy to get through. I also wonder, how many people in the audience know who your local Suicide Prevention coordinator is at your local v. A. . Awesome. Fantastic. Thats wonderful to hear. If you dont know who your local Suicide Prevention coordinator at your v. A. Is, its very easy to find. We might have a slide on it. If you dont, its at veteranscrisisline. Net, or go to your v. A. And ask them for your Suicide Prevention coordinator. Its so important to collaborate with the spc as we tall them. They are your local experts in Suicide Prevention for veterans in your region. Any time youre concerned about a veteran, or if you want to get this training, please contact them. This is part of their job is to provide this training, to provide the support thats needed. Your Suicide Prevention coordinator. Im giving you the very brief abbreviated very abbreviated version of this. You can get the one to twohour, inperson training for your local Suicide Prevention coordinator at any really anywhere with your local chapters, pva, anything. What are some of the signs of suicidal thinking . So we need to learn to recognize these warning signs. As i said before, hopelessness, that is really known to be the paramount risk factor for those who 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 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, 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 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. Whether than 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 v. A. That the primary reason why people have been known to die by suicide is a relationship problem. And also pain. Physical pain. Those are especially important things to watch out for. Any sort of legal problems. Of course we know, just across the country, any time theres a recession or serious financial problems with somebody, the suicide rates go up. Thats known worldwide in various countries. Greece recently had a really high rate of suicides because of their financial problems within their country. Other things to make sure that youre recognizing. There are a few things that require, of course, immediate attention. 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. So these are things that require immediate attention. Ill talk about that. Asking the most question of all, 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 this is this is very, very normal, is that fear, again, of going straight to the question. Theres a lot of people who say, are you thinking about hurting yourself . Its 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, again, what is probably the most difficult thing that somebodys going through. There are ways to ask it. People are scared, too, what if i Say Something wrong . What if i do something wrong . The only thing you can do wrong is say, yeah, maybe you should go through with it. Which, of course, nobodys going to do, right . I mean, really. You just have to be that empathic human, caring person and continue the conversation. Another thing we do because its really it lessens our anxiety is asking the question. So, you arent thinking of killing yourself, are you . What is that saying to the person, right . Well, no, of course not. Theyre not going to answer well, yeah, i kind of am. You have to be very out there, up front, and ask the question, ask it when you have some time, dont wait until, oh, wait a second, you know i know, i just we just finished our session or whatever. By the way. This is incredibly important this conversation, as you all know. Really there isnt much that you can say thats wrong. Its just 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 whos saying that theyre suicidal. And that is just so scary. On the outside its being confident and talking with the person. 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 serious, you have young children, you just retired, you have so much to live for. The guilt is not going to work. 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 you know, if somebody is is at very high risk or at imminent danger, you need to get them to the hospital. You need to call 911. We also have the Veterans Crisis line, an extraordinary service. We have 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 at people. They will expedite getting the help 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 the veteran feels like you are with them, you are sending 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. And thats the end of my part. [ applause ] thank you. She will be back, because im going to ask her questions, too. Lets get back to jason. Jason seems withdrawn, hes not eating, sleeping, hes refusing to go to therapy. 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 a simple, no, youre not going to walk again. Hes getting over pneumonia. He has a suspected urinary tract infection. And he says Something Like what caitlyn mentioned i feel fatigued all the time, i just dont know if i can go on like this. That is something we often encounter in this patient population. The question then is how would you respond, and then the second question is what are some of the warning signs that would especially concern you about suicidal intent . We dont have a lot of time, but maybe take a minute and think about it and talk to the person next to you about what you would say, maybe practice saying say you are concerned. Practice saying what caitlyn mentioned, asking the question. It is difficult to dont ask it in a negative manner. Assume that its ask the question. I think because i know myself i feel very uncomfortable asking that question. Start by asking that question, and reflect on in for a minute. Everybody. I know you have a lot to say. Do you want another half minute or so . Maybe lets do that. I guess the issue is and well come back to some of this conversation at the end. But some of the questions that come up that i think ive encountered myself and seen people in my Team Encounter is how do you really distinguish between the timelimited sort of distrust that is natural and not for everybody everyone responds differently, people have different ways to respond to different events, including a spinal cord injury. But the time stress that we see in people with a spinal cord injury. Shermans portrayal at the time he heard at his spinal cord injury. As you can imagine, there are different thoughts going on so that is something that is often encountered and 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 . And so thats something that well talk about i think a little bit and katelyn already mentioned asking the question is important, if you feel that is an issue. Its also important to then bring up your concerns not just to keep it to yourself, because in some instances what happens is, you may notice something but, you know, youre a nursing assistant on a spinal cord injury unit. You think theres a whole team of people. Its really im not sure 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. And its the psychologists are always open to listen, 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 if needed, find the Suicide Prevention coordinator or at least contact someone who might be able to. Its really important to do that. I think the other tension that we run in to is, if we feel somebodys possibly at a risk, at what point and what is the extent of and this is truly is maximizing safety or cost as a priority . Or unnecessary interference. Thats always a concern. I think we have to default on the side of safety but at the same time, i think, we need to be cognizant of the fact people are there often for their initial rehabilitation when this scenario happened with jason. So he was going to rehab, yes he was refusing some therapy but then, if you truly think at what point would you then maybe have a one to one sitter, maybe restrict visitors and at one point you weigh the pros and cons of doing that and i think that goes to that second question we talked about and the signs that katelyn talked about. What are the red flags . If someone is communicating Suicidal Ideation if theyve shown some behaviors, those are the red flags that i think should alert you where you do need to err on the side of safety. As is attention. How are you going to force treatment on someone who refuses to get treatment and maintaining the therapeutic relationship . And then i think 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 strong Mental Health support as part of our spinal cord injury teams. We provide ongoing Mental Health evaluation, assessment and treatment. The issue really is, is there Something Else we should be doing more consistently in terms of suicide Risk Assessment and prevention . And that became apparent that partly because there is not good Evidence Based in the spinal cord injury population. Partly we dont know what is the standard, there are no well established standards of care for spinal cord injury providers, that what should be when should we be offering suicide Risk Assessment. At least the question if you are concerned, then its really important to ask the question. The other question that sometimes comes up, and this came up in that after we had discussions about the field. If someone if you truly think someone is at imminent risk. What is the best setting for treatment. Now we know people with spinal cord injury, that may not be the best setting in terms of taking care of those needs. That is truly attention and something that i think we still need to grapple with a little bit. And i dont have a good answer. Maybe we can talk a little bit about your thoughts. Im going to turn it over to summary. Im not going to spend a lot of time on this slide this is a slide that really summarizes keeping people safe. The upper left hand corner is the most Evidence Based things we can do. Were talking about gun safety, not gun control. Were talking about gun safety. Particularly when people are at risk, talking about opiod safety. Safety with medication, someone who is acutely suicidal. That is the number one most Evidence Based thing we can do as well as asking about things like depression and doing it in primary care settings. Were not talking about what is a Mental Health problem. The front line, in those kinds of settings, those are the important places. I want to make a comment there are eight slides coming up. 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. 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, they said, this doesnt look right, and they went up and 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 a random event they could have kept walking. Another case, just this past week a nurse noticed the nurse had a change in their routine. This just isnt right there was a problem, and the person opened up to that nurse and they got that patient into care. What you do on a daily basis. We know that va grounds keepers often come across people. The Canteen Service workers across va are taking save training. Its 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 16ss that they need. To support you in that work, here are the slides. Kaitlyn mentioned the great work that is done, 24 7 365 at the Veterans Crisis line. The answer, over 2000 calls on average every day. Dispatch emergency services, 75 to 80 times a day across the 24 hour period. 18002738255. And press one. Its also Veterans Crisis line. Net. All of our Suicide Prevention resources are on that website. It is wonderful, please look at that. Including the list of Suicide Prevention coordinators. We have over 400400 prevention facilitators, if you havent partnered with your Suicide Prevention coordinator, do that. Theyre not going to take care of every issue, theyre the quarterback and they can help you with that. Reach vet was a program we have launched in the fall of last year using all of the data 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 to the service 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. We have no idea who has gotten a gun lock from va, we have distributed over 3 million gun locks through va. They happen to have the veteran crisis line number on them. Just in that moment, interrupting someones moment of desperation if the gun is locked that saves lives. Going back to that research slide gun locks make a difference. Theyre available free at every Medical Center to everyone who wants them. Another website, make the connection. Hundreds of stories of veterans in their own word saying, i had a problem, i did something about it, and im glad i did, and my life is better. And we can connect with each other as veterans. And you can taylor that to your particular situation. There are websites again for va. There are mobil apps in support of Suicide Prevention. And finally, Consultation Services through the National Center for ptsd. Through the visn 19 myrec. We have Community Provider tool kits culture competency training we have across the organization. Please look at that, i am David Carroll va. Gov. I would be happy to follow up with you at any time. Just getting back to jason. So this is now weve talked about the acute suicide risk in the acute setting. Theres also its not just the severity of risk, its looking at risk temporally. We said it reduces after 10 years, there is still some risk. And in the first few years after initial rehab, theres so jason returned for routine followup. Hes medically stable, not overtly depressed. His pain has been increasing, and its been interferes with mobility. Hes expressing increasing feelings of being a burden to his family. The question really is, how do you assess and strategize chronic risk, what interventions are appropriate at this point we really dont have a lot of i would like you to reflect on this and talk about it during breaks and come up to kaitlyn and david after this to ask their Expert Opinion about how we could apply we do know that some of the suicide literature talks about this perceived burdensomeness we often hear from people that theyre perceiving, its a misperception about the burden they are on. And i think those are things that we need to both address and identify as well as looking at this issue of belongingness, where they feel they dont have a meaning or purpose, and i think the va thats the last part about talking about augments protective factors. We dont give enough service to in terms of interventions and im getting a sign that were running close to the end of time. That is something that i think is a strength and something we can focus more on. Both in terms of adaptive sports, supportive employment someone who is on long term care. Here he is he has c4 here he is from his hospital bed using technology to teach english to japanese students over skype, and getting paid for it, and really change his life it really changed his perspective. We already talked about individual professionals talking about doing jobs. Conveying your concerns as a system of care, what i would say is, its obvious we need more evidence and more research. I would ask that all of us 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. 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 . I dont know if you recognize this, anyone recognize this . This is from sunday night. The mtv video music awards. This is a song, do you recognize what this number is. Its the veterans Suicide Prevention hotline. Write this number down. You never know when you will know the number. I have never heard of these people sang this song. Saying they wanted to take their own life. I would look at that and i think that is the end. Do we have time for two minutes for questions . Id like to take two minutes if youre interested in staying. Understand the importance of a team member. If you want to go to the mike real quickly, well turn it over to our panel to answer your question. My name is valerie mcnairry, i work at the augusta va Medical Center, as a recreation therapist, i want to say, i have had enough incidents where i had to ask that question. And then pursue the assistance in help, getting that person help. Theres something i feel like i can apply immediately when i get back. When i do leisure assessments and im talking about interest. 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 making that question asked, and i did not know that we had free gun lots available. So thank you for that information. I would say that one of our Suicide Prevention coordinators, and maybe thats something we can do. Actually has a bowl of gun locks on our desk. When veterans come in, she automatically asks if they have a gun and hands it to them. Heidi maloney. Theres a cultural shift slightly and a slippery slope of physician assisted suicide. Many jurisdictions are passing laws for physician assisted suicide. Does the va have a statement about physician assisted suicide . I just saw a contemporary movie called you before me and it was all about physician assisted suicide . Do we have a statement about this and should we . We do not. We are focusing our resources. It is a Public Health. Thats part of the Public Health conversation. And when its appropriate, va will be happy to participate in it. Thank you. Thank you all, sorry we ran over a couple minutes. If people have questions, were going to be here for a little bit. Please feel free to come up and ask a question of our panel. Im sorry were out of time. Thank you for being here. Congress returns next week, facing a number of end of the month deads lines. 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