Transcripts For CSPAN3 Veterans Suicide Prevention Hearing 20171020

The committee for increased hiring authorities. This hearing is two hours and 20 minutes. Let me call this meeting of the Senate Veterans committee, this hearing to order. Thank all of you for coming today. Especially our witnesses. We have a number of members who are on the way, but were going to in the interest of time, were going to get started. Todays hearing is about the issue of suicide. As many people in the room know, this month in america is National Suicide Prevention Month across the country. Suicide is a terrible, terrible, terrible loss and wasteful loss of life, and preventable loss of life. I think john will remember when we first came in as a committee three years ago, our first bill that we passed was the clay hunt Suicide Prevention bill. Passed this committee 990, and well ask the secretary and the other members from the v. A. To give us any report they might have on the progress of the implementation in terms of the act, but its a very important act. In august of 2014, i held a hearing at Georgia State university as a member of this committee. It was a field hearing on the issue of suicide. The reason i did it was because in that year, in the months leading up to august of 2014, the georgia v. A. , principal v. A. Hospital on clairemont road and decatur had three suicides, two on campus. Mishandling of available tools for suicide Like Pharmaceuticals and things of that nature. Others for a lack of awareness. And many for a lack of capacity. And that was the real thing that concerned me, so we began working in the clairemont v. A. Hospital in atlanta to improve v. A. s response to suicide and to Mental Health issues. Suicide is a disease. And it is preventable. There are many things we can do, and to set our example, our staff director did a great job of seeing to it that every member of the staff, majority and minority has been through the safe training for Suicide Prevention. It stands for signs of suicide thinking should be recognized. Ask the most important question of all, are you thinking about committing suicide, which is a tough thing to dress, but a key question to ask. Validate the veterans experience, and encourage treatment and expedite getting help. And i can tell you from what we learned in atlanta and have learned in the v. A. , timing is everything, as it is in health care in most things. The golden hour, we know about in health care. When someone is contemplating suicide, its not something you put off to an appointment on wednesday or to another day. Its something you deal with immediately and you deal with quickly, and you expedite the response to it. I want to thank the staff for going through the training. And just like the heimlich maneuver has saved many a life in a restaurant, when somebody was choking and somebody else knew how to apply that maneuver and they freed their air passages. Just like cpr has helped people who had untimely heart attacks, just like cpr has helped people who might be drowning or might have drowned and brought back to life, but being aware of training necessary to save a life is critically important. Were going to see to it in our committee that we promote this training throughout the v. A. And throughout the government to see to it that we are saving lives and helping people to recover and restore their lives. I want to thank bob thinky for his commitment for doing it on the staff and thank all the Staff Members for doing it, and thank the members of the committee for their effort as well. We have two panels today on the issue of suicide. Our first panelist, mr. John day, assistant Inspector General for health inspections. The second is dr. Craig brian, executive director National Center for veteran studies, and dr. Matthew kuntz of montana. We appreciate all three of you being here today. Youll be allowed to give up to five minutes of testimony. We dont have a whistle that blows at the end of five minutes, but after ten, youll be in big trouble. And all your statements will be printed for the record and be memorialized in the record by unanimous consent. With that, well start with you, dr. Day, and go down the list from there. Welcome. Thank you, chairman isaacson and Ranking Member tester, members of the committee. Its an honor to testify before you today on the subject of Suicide Prevention. This topic is important to mr. Missile and all of the staff at the oig. We work to insure veterans receive the highest quality Mental Health care. We have reviewed in depth facts surrounding the death of many veterans who took their own lives. Often, we find these veterans suffered the effects of chronic Mental Illness and Substance Use disorder. In the aftermath of these deaths, we frequently hear from members of the veteran family, significant friends and v. A. Providers that they would have acted sooner or differently only if they had known. After the Virginia Tech incident shootings, a serious review of the privacy laws that impact the disclosure of medical information was undertaken. My staff met with and talked with a number of the individuals who were involved in this review to determine if there were Lessons Learned that could be applied to v. A. Changes to law seem too difficult to design, however changes in practice that utilize advanced directors or similar devices may often offer a way to improve communication at the critical point when a patient needs the help the most. I think there is a chance to improve communication by expanding the situations under which these and similar devices are used. V. A. Has thoughtfully derived a model to predict who may suicide. The question is when would an atrisk veteran take action to harm themselves or harm others . When would intervention be most effective . Research using social media and other more timely data has shown promise in understanding the human emotional state and therefore may assist in identifying when intervention for these atrisk individuals would be most successful. I think research and pilot studies in this has great potential. The testimony of others at this table point out that veterans, many veterans do not obtain their care primarily from the v. A. Hospital system. And so an effort to reach those veterans who are at risk is most appropriate and essential if we are to make a significant improvement in veteran suicide data. This concludes my oral testimony. And i would be pleased to answer your questions. Mr. Chairman, mr. Ranking member and members of the committee, i appreciate the opportunity to appear here today to discuss recent advances in veteran Suicide Prevention. I will not read my written testimony in full but will highlight a number of key points. The response to raising suicide rates the v. A. Has implemented numerous measures intended to prevent suicide among veterans. They have led to improved access to care as an example of how they can aggressively prevent the cause of Suicide Prevention. Suicide related outcomes among military veterans have been published in the last two years. Although most of these studies involved military personnel, theyre applied to the community as a whole. All of the interventions reduce suicidal ideation, but only two are related with reduction in suicidal behavior. Cognitive behavioral therapy reduced suicidal behavior by 60 to 76 . Theyre currently the only strategies shown to reduce suicidal behaviors among those who have served in the military. These treatments now serve as a foundation for studies in the v. A. As well as the dod. The latest findings not only confirm that suicidal behavior can be prevented among military personnel and veterans, they also show us how to do it. If these stud as tell us anything, its this. Some strategies work better than others, and simple things save lives. Tragically, few veterans are likely to receive these potentially life saving treatments for a number of reasons. Today ill focus on one particular barrier, inadequate training in medical health professionals. Two recent studies highlight this issue. In these studies, researchers found that a key Suicide Prevention strategy used by the v. A. Was not associated with subsequent reductions in suicidal behavior as what expected. The lack of effectiveness was attributed to poor quality implementation. V. A. Personnel often did not implement them. Researchers from both of the studies concluded the results were from insufficient training and additional training could change this course. The problem with insufficient training is not confined to the v. A. , though. Tragically, deficient training is endemic across the Mental Health Training System. A recent report highlights this issue. The Main Findings of that report are also sum husbanded in the attachment to my testimony. As you can see, a shockingly low number of Mental Health Training Programs provide any education or training about suicide to its students. Furthermore, state licensing boards, the very bodies charged with protecting the Publics Health and safety from unqualified professionals, typically do not require any exams or demonstration of competency in suicide Risk Assessment or intervention. The implications of this report are disturbing. The vast majority of our nations Mental Health professionals are unprepared to effectively intervene with suicidal veterans. This has critical implications for all veterans, both within and outside the v. A. We have long talked about the many barriers that stand in the way of a veteran receiving Mental Health treatment, and have invested heavily in removing those barriers. What unsettles me the most as a veteran is knowing that when a fellow veteran overcomes these barriers, he or she is unlikely to receive the treatments that are most likely to save their lives. The sobering and uncomfortable truth is that we have made it easier for veterans to obtain treatment that doesnt work, especially those veterans who receive services from nonv. A. Providers in their communities. If we want veterans to benefit from the most recent advances in Suicide Prevention research, we will need to insure implementation is accompanied by a comprehensive and robust training program. Luckily, the past few years have also led to considerable advances in our understanding of the most effective ways of teaching these methods to others. Much of this knowledge has actually been obtained by the v. A. And their researchers. In order to reverse the trend of veteran suicide, we must therefore think boldly and must be willing to disrupt the status quo. We need to adopt the newest strategies even though they may depart from existing procedures. We need to invest more heavily in Training Clinicians to use these procedures and create new initiatives to implement these in clinical trainings. These should not just target the v. A. And dod, but all clinicians in all settings as well as our universities and Training Programs that are possible to the readiness and preparedness of our Mental Health professionals. In conclusion, were at a critical turning point for veteran Suicide Prevention. Answers are now clear and effective strategies have been identified. We must now take the steps needed to insure these treatments and interventions are easily available to all veterans, both within the v. A. And in our communities. Thank you very much. We appreciate your testimony. Now from the great state of montana, the executive director of the National Alliance for Mental Illness in montana, mr. Kuntz. Yes, sir. Chairman isakson, Ranking Member tester and distinguished members of the committee, on behalf of montana, i would like to extend our gratitude for the opportunity to share with you our views and recommendations. We applaud the committees dedication in addressing the Critical Issues around veteran suicide. As someone who has personally lost a Family Member who was a veteran to ptsd, i want to appreciate my sincere thanks. Montana has the highest suicide rate in the country with 68. 6 per 100,000. This is significantly higher than both the National Veterans suicide rate and the Western Region veteran suicide rate. As an organization thats immersed in Suicide Prevention, we think its very important that you have a framework to understand suicide. The model that we use is a combination of biological susceptibility and environmental factors then lead to malfunctioning Neuron Communications which develop into suicidal ideation, behavior, and other symptoms. Examples of the factors of biological susceptibility are genetics and physical trauma, examples of factors on the environmental side are emotional trauma, but on the positive, therapy and supportive family. Youll note that i will not be covering lethal means restriction because i believe its incredibly hard to legislate that. But it is an important factor. Montana is a very rural state with an average of fewer than six persons per square mile. This creates unique challenges for our health care providers, and were deeply in need of more Mental Health providers. Ill move on to our recommendations. The first, to offer a Public Health intervention proven to reduce suicide during critical points in the military and veteran experience. Montana was influential in bringing the youth aware Mental Health program to the united states, and we would like to offer it as a template of something thats proven to work in another population and would be perfect to bring over to this one. Second recommendation, establish a clear policy goal to improve the diagnostic treatment system. The target that montana recommends to the committee is tasking v. A. To work with the department of defense, the National Institute of Mental Health and private partners to identify and prepare two additional brain diagnostic measurements for clinical work in the v. A. By the fall of 2020. Our next recommendation is to develop a plan for treatment resistant Mental Health conditions. Roughly a third of Mental Health conditions do not respond to traditional treatments. And this is a big issue, and its an issue thats not addressed in montana. The montana v. A. Has nothing in our state to address treatment resistant depression. This is very personal to me because i lost a dear friend who was a veteran in september 2015 to treatmentresistant depression, and to watch his options slowly slip away was one of the hardest things i have ever seen. Montana Blue Cross Blue Shield supports tms treatment for treatment resistant depression. I do not know why the montana v. A. Does not. Next recommendation, expand access to telepsychiatry, then make online Cognitive Behavioral Therapy available to all veterans. We also believe that the v. A. Should expand the availability of automated suicide Risk Assessment, develop a prize to create and validate a screening tool to determine which patients are at risk of developing side effects from closapine. Develop a public facing Online Research directory for nonv. A. Resources. Create a more synergistic relationship between the v. A. And community Mental Health centers. There are over 1,300 Community Health Centers Across the country, and we should be working with those to care for our veterans. Increase the v. A. s collaboration with outside researchers, and finally, establish a continuity of care pipeline for veterans directly from the department offense defense to v. A. Community providers. Thank you again for the opportunity to testify in front of this honorable committee. Your attention to this issue means a lot to me. Our entire organization, and their families. Thank you, mr. Kuntz. We appreciate your being here today. What im going to do is reserve my time since we have three members that are here and i know we have different meetings that are going to take place and go straight to our members for questions and ask my later when senator tester returns. Hes doing a presentation on another hearing. Hell be here in a little bit. Let me start off with john. Thank you very much, mr. Chairman. And thank you for holding such an important hearing, and again, also to senator tester, i cant think of anything thats more important to discuss, certainly, we all agree that this is a crisis. In arkansas, i think were number ten in suicide rate overall. Of that group, veterans represent about 8 of the population, but represent about 20 of the suicides. So were a state that is like so much of the rest of the country, in fact, the rest of the country, period, is experiencing significant problems. Dr. Bryan, you mention that recent reports have highlighted the inadequacies of our nations Mental Health professional training. In fact, i was looking at the chart. 15 of psychologists, 25 of social workers, 2 to 6 of marriage counselors, 28 of psychiatrists. You know, only those have really received what we would call even the Old Fashioned training, perhaps. Not to mention the work that you and others are doing in such a good way. Those are pretty staggering. How do we go about, unless we have a metric out there, how do we go about solving that problem . I will admit that this also, as youre thinking about that, and the rest of you all can jump in, too. Once we have the new research, once we perhaps get a metric, how do we get that, you know, not talked about but actually instituted in a timely manner . Correct. So both very good questions. The first one i think is a much bigger question. Ill admit it, this is a huge issue that were probably requiring a concerted effort in redesigning or reengineering our education and Training System and professional practice of Mental Health. We would need to find ways to incentivize graduate Training Programs and medical schools to insure that not only are they providing any amount of training but the training is scientifically supported. This can be accomplished in a number of ways, perhaps looking at grants and other federal incentives and initiatives to encourage certain types of curriculum as well as training opportunities. But also i think partnering with and working alongside various accreditation bodies to look at how do we determine whether or not an educational system is meeting minimum standards for the practice of Mental Health across these disciplines. If we can work with those organizations, i think we would be able to see some very dramatic shifts in curriculum. For your second question regarding dissemination and implementation, i think one of the challenges that many of us have as scientists, scientists tend not to be very good at communicating their ideas to nonscientists. So many of us in the dissemination field have really talked about how do we find opportunities to have researchers and scientists work with Communications Experts on how to convey this information, not only to the general public but also to other professionals, those who we want to target to be using these strategies. But we also need to target the consumer. So the consumer is educated and understands which treatments work best. So when they go to a health care provider, they can ask the right questions to determine if this is an individual who is likely to be able to help me. Yes, sir. Go ahead. Yes, sir, you know, one of the things we found to be very important is getting the research to the states. Creating a pipeline to have those conversations. We had to start up a Research Center in montana to make that happen. And because of the way that the v. A. Structures their centralized research, we probably will never have a v. A. Research doing much in montana. But if that pipeline is adjusted, that gets those conversations started, and it gets people trained. The other thing that i would recommend is for the v. A. To make its treatment algorithms for veterans more widely available. I think that the transition to the medical records is going to make that more, i guess more possible, but you know, get those treatment algorithms out to the field so people in nonv. A. Facilities can use them. Thank you. Is overmedication a problem . I would say my response is overmedication is broad. What we would see, for instance, a student of mine just finished their dissertation, about to publish the results finding there is about a larger than expected proportion of veterans who receive benzodiazepines. Despite being diagnosed with ptsd. Theyre not indicated for ptsd and can actually interfere with effective treatment for ptsd. Oftentimes, physicians and other prescribers rely on these because firstline treatments have not worked, so theyre hoping to provide some kind of symptom relief. The unfortunate aspect of this as my student found is that in those cases, those veterans with ptsd who received benzodiazepines are almost three times more likely to die by suicide. So theres another risk associated with contraindicated medications where i dont know if theyre overprescribed but im not necessarily certain that in all cases veterans and their prescribers are aware of all the risks and are able to weigh them with the benefits of those medications. Right. Thank you, mr. Chairman. Thank you, senator. Senator blumenthal, who i would point out is one of the real leaders in the clay hunt Suicide Prevention bill and did great work on that in the last congress. Thank you. Thanks, mr. Chairman. Thanks for your leadership on this important issue. I was indeed the lead democratic cosponsor on the clay hunt bill along with senator john mccain on the republican side. And believe that it was a start but only a first step in this effort. And much more needs to be done. Obviously, there are steps that have been taken by the v. A. In furthering this effort. And i know well hear from dr. Shulkin later, but the more i learn about this problem, the more complex and challenging i think it is. Dr. Bryan, one of the very important statistics in your testimony is that the suicide rate among veterans who do not use v. A. Services increased by 39 between 2001 and 2014. Whereas the suicide rate among v. A. Users increased by only 9 . Put aside the exact numbers, what i am hearing again and again and again is that the suicide rates are increasing among veterans who lack access, that because of geographic or other difficulties in reaching these services, or because they have received dis less than Honorable Discharges. And this has become a passion for me, because there is a whole group of veterans who suffered from pts, often undiagnosed, were separated less than honorably, and have been cast out. And barred from using those services, and often feel stigmatized and disengaged. Not only from the v. A. But from society in general. I have met with many of them, and i have worked with the department of defense on the review process, which has been changed as a result of leadership within the department of defense, commendably. But many of those veterans who were discharged less than honorably dont know about it. Dont know about the changes in policy. Dont know about the possibility of access to these services. So it is a vicious cycle. A lethal cycle, which can lead to suicide. So i guess my question to all of you, not only about the less than honorably discharged veterans but Women Veterans who also perhaps do not readily access these services, and their suicide rates are increasing. Those segments of the veteran community whose suicide rates are increasing need to be reached, and my question to each of you is, do you see that phenomenon as real . Do you recognize it . And can you elaborate on it, and what are your recommendations for addressing it . Sir, i agree with you. I think the adequate treatment of Substance Use disorder and access to therapy and the adequate treatment of depression, as mr. Kuntz indicated, to include pharmacologic treatment is critical. If you cant get people to a competent provider, its a very difficult problem. I agree with your statement. I have two thoughts in response. The first of which is i think what the statistics highlight is that the rates are going up, even among v. A. Users, but its a much lower rate. The v. A. Is doing something good that is not happening for those who do not receive the services. And so a common question is, how do we get more veterans into the v. A. . I think that is an important question. The other question, though, i think we need to ask is, why are there not other adequate Services Available to veterans in their communities . And i think this this really came to a head for me several years ago. I dont know if you read the New York Times article about the marine 27 who had a very high suicide rate and a lot of them did not have access to the v. A. , and theres a lot of discussion about that. I said, the implication of this is some veterans have access to really nothing or they have access to Community Providers who have little to no experience working with Service Members, veterans. They dont know how to treat ptsd. They have never seen traumatic brain injury before. As the statistics i showed you here, they have no experience with suicide risk. I think part of the solution will be how do we get more veterans into the v. A. , because as the rand report recently released highlighted, the quality of care in the v. A. For Mental Health exceeds that in the private sector. But for those who do not access v. A. Services whether because theyre not eligible or because they choose not to, we have to keep that in mind, some veterans choose not to, we need to make sure Quality Services are available to them. And what we have done in Salt Lake City, kind of as a model of this is, our center is on the university of utah campus right across the street from the salt lake v. A. , and what we say is were not a competitor to the v. A. Were the augment. And so the v. A. Sometimes sends their patients to us for treatment, and there are some veterans in the community who cannot go to the v. A. Or are unwilling and they come to us, and we can sometimes connect them with the v. A. For other services and benefits that maybe they didnt know. So i think we need to look at models like that on how Different Community agencies and the v. A. Can further strengthen working together to better meet the needs of all veterans. Thank you. Senator blumenthal, thank you for bringing up the less than honorable issue. That was something that came up in our family before my stepbrothers death. And its really big, as you all point out, that one of the ways it was solved in helena, montana, or improved, was by adding a vet center to our community. At the time, the v. A. Had fought it because they said that you already have a hospital. Everybody that will go there, you know, that would go to the vet center is already going to the hospital. That turned out not to be true. I think that part of it is when youre depressed or when you have ptsd, the first thing you cant stomach is bureaucracy. And you just quit. You face bureaucracy, you face this red tape, and you give up. And the vet centers have less bureaucracy. The fqhcs have less bureaucracy, in order to get in and start to play. I think thats part of whats not really shown in those statistics, is the folks that give up because they look at the bureaucratic red tape and say i cant mentally take it. I just want to thank all of you for your testimony today. Obviously, we just scratched the surface of this topic. I hope that we can get the latest numbers on vet suicide rates, on the differences between v. A. Users and nonusers. I sponsored legislation with my colleague senator blunt to its called the veteran peer act, legislation that would establish peer specialists in patientaligned care teams within v. A. Medical centers to do this kind of outreach. The peertopeer relationship among vets, i think, is an effective way to enable more access. But the v. A. Has been doing better, and i commend dr. Shulkin and his team. And will, as i mentioned, well be hearing from him, but on all counts, the nation needs to do better. Thank you. Thank you, senator blumenthal. For the benefit of the members here, were going to take questions by order of appearance altering by party. The next three questioners will be senator heller, senator manchin, and senator sullivan in that order. Mr. Chairman thank you. Thank you for this hearing. I want to thank those that are witnesses for being with us today. And i want to especially thank senator tester because i know this is an issue thats important to him. An issue thats important to montana. And it is unfortunate that montana leads us in the statistic, but the issue is that nevada is right behind them. The question that i continue asking myself is what makes montana and Nevada Unique . And mr. Kuntz, ill start with you as to why we see the stress in the areas of montana and nevada, maybe a little more unique than the rest of the country. Senator heller, its a great question. And ill tell you if i had the perfect answer for that, i would probably be making a lot more money. But i would tell you that just to see what is there is we do have higher access to lethal means in our state for the most part, when youre suicidal, the closer you are to committing suicide, i mean, is very real. We also have a lot of veterans per capita in our communities. And i think that thats important. One of the things thats a little bit different about our suicide trends, and i know if its the same in nevada, but we have more older veterans that are killing themselves. And i think that National Trend saying that its younger. But if you look at montana, that age 30 to 65, white males, is when we are losing them. And maybe its just that we have a lot of people in that population group. But i think its its also an issue of lack of care. We have no Psychiatric Residency Program in our state, and i know that a lot of nevada Rural Communities struggle too. So i think its a number of different factors, and weve got to tackle them one at a time. I really do appreciate your comments. We had secretary shulkin in the state just a month or so ago, and he expressed and his efforts to tackle this particular problem. We have hospitals both north end and south end of the state. We have a number of clinics that have been opened recently because of the efforts and the work of the secretary and the v. A. And its appreciated. Let me ask you, mr. Bryan, they have a Resiliency Program in israel that maybe weve already discussed this where they try to get this on the front end instead of the back end, where they actually train their soldiers, both mail and females, of trying to avoid some of the stressful situations they may find themselves in and train them for them. Are we doing the same thing here in our country . I would say in general, yes, in the sense that if you look at military training in general a lot of it is designed to foster resiliency, how to endure difficult diverse situations, perform under pressure, manage stress, et cetera. Where we have not had much success over the past decade or so is when we try to develop new Resiliency Programs that take more of a classroom format where we bring in outside experts who then teach or train, sometimes trainers within the yients who are then supposed to go and teach these concepts and skills to others within the unit. There have been a number of barriers with that. But unfortunately some of the Research Done on the larger Resiliency Programs have yielded no benefit. We have seen some promise, however, in other resiliency methods. The one that has garnered the best, greatest promise so far is a program developed by the army called battle mind that was shown to prevent or reduce ptsd symptoms, a small it gree, it wasnt large, but a small and noticeable degree amongst those who had the greatest and most intense levels of combat exposure while deployed. Which makes sense. Where we found the effect were among the ones who probably needed it the most and ones who had the highest level of trauma exposure while deployed. We have a couple threads of evidence suggesting that certain approaches might help to reduce or prevent, at least reduce the severity of ptsd. However, we have not been able to large scale implement and further study those different strategies. Is there any family training, not just the veteran themselves, but actual family training so they can identify some of these issues prior and help that veteran . Right. There are a number of programs, there is none that sort of rises above the top. Where a lot of the family Training Programs, and this is very common, the peer issue you mentioned before, a lot of the programs tend to take more of a heres a bunch of signs and symptoms of this health condition. And now refer someone to a Mental Health prefer. But what we lack is what do the Family Members do . So if a veteran is struggling with ptsd and does not want to go to treatment or there is a twoweek wait what are you supposed to do in the meantime . We dont currently have any programs training that. Newer research, the Crisis Response point that i mentioned before, this is something we have been teaching to Family Members, we have been teaching to peer specialists, the nonhealth care providers in the community who are closest to the veteran in need to not only recognize when they might need help, but also what to do about it, and doing things that have been scientifically shown to prevent suicidal behavior and prevent ptsd. Mr. Bryan, thank you. I want to thank you all of our panelists and i want to thank the chairman for his commitment because it makes a difference. We need to figure this out and make that kind of difference. Mr. Chairman thank you very much for the time. Thank you senator heller. We appreciate it. Senator manchin. Thank you, chairman. Thank you, Ranking Member tester for having this hearing. Have to turn my mike on first. For all of you to be here. My first question will be to mr. Kuntz. As you mentioned in your testimony, Community Health centers are critical part of providing health care in rural areas. Your state and my state are pretty rural. And in West Virginia, for instance, Community Health centers treat almost 400,000 patients. Thats almost 25 of our population. Out of that, we have 166,000 veterans in our state. Im sure many of them got treatments there rather than traveling long distances to the v. A. S if they lived out in the rural areas of West Virginia. I would like to hear you speaking on the importance of the Community Healths centers as Mental Health providers in your research. Are they capable . Do they have the personnel . Do they have the expertise to do that . So we can get im trying to get the treatment as quickly as possible without trying to, you know, build a whole another infrastructure to do it, if this vehicle is available for us, Community Health centers. Senator manchin, thank you for your question. Its an amazing point. I tell you that we have our licensing board in the state of montana, and we have lcsws that work at the fqhcs, we have fcsws that work at the v. A. Psychologists here. I mean, this is the same level of staff. The training may be a little bit different, but the fqhcs and rural Health Centers are adding Mental Health professionals all the time. The quality of care for our veterans can be as adequate there as they will be at the v. A. Centers . Yes, sir, the only thing they are not that good at is long term care. So i think that that shortterm turnaround coverage, maybe six sessions of counseling until theyre transferred to the v. A. , but if youre in a time crunch, that is exactly a place where i send people. You know, if you are struggling to get into the v. A. , go to the fqhc. Okay, good. Mr. Bryan, in your testimony you highlight a lack of adequate training on Suicide Prevention methods among the meantling health professionals, not just among v. A. Providers but nationwide. Would he know other v. A. Patients are using nonv. A. Care centers. We just talked about it. If they Committee Moves forward on efforts to work with nonv. A. Care, how can we best incentivize health care training, how do we get more people the expertise, Suicide Prevention . I think it will require a multipronged approach. I think the easiest or sort of most straightforward approach is to invest in training workshops. However, i will say that will likely have limited impact. If theres one thing ive learned over the past decade training thousands of Mental Health professionals is going to two days of workshop, getting a continuing education and a deck of power point slides oftentimes is not enough for them to actually use the therapy in an effective way. One of the things we have learned from the v. A. s efforts in educating is you have to provide ongoing support. You train people, you supervise them, you meet with them on a regular basis. You help them, you teach them how to overcome common barriers. I think as we look at training i think we have to look at it in more of a long term support. I think the second aspect is we will have to look at our educational system. Another lesson i learned over the decade of doing this training professionals at all levels is that if you teach a student how to do good medicine, they spend the next 30 to 40 years of their life doing good medicine. If you teach a student to use unsupported nonscientifically based interventions they start doing that for 10 or 20 years, and it becomes very difficult to get them to change back. And so when i really think of this question its not only training the Current Labor Force but we are also going to have to look at how do we change how we train and teach the future labor force. One more question, mr. Chairman, if i may. Dr. Daigh, in your testimony, you brought up the concern about confidengsality requirements for sharing a veterans treatment information to coordinate Mental Health between the veterans provider and extended family. Im glad you pointed out that issue. As it stands, more than half of v. A. Patients are abusing opiates and overdose on prescription pain medication at more than double the national average. And thats a horrible problem in my state of West Virginia, as most states are dealing with this. While the v. A. Has made really significant improvements, i still believe the areas that these are critical areas we must work on. In march i used the vet connect act of 2017 which would streamline the Health Records sharing between v. A. And Community Health providers since we are basically giving more services outside the v. A. The bill requires the Veterans Health administration to comply with hipaa, but insures that Community Providers can make informed decisions based on the veterans holistic medical history. My question would be, can you please elaborate on your findings as to why its so important for the providers, health care providers, to have access to this Behavioral Health treatment information for their patients and how the current law is undermining the quality of coordinated care and hurting our veterans . What do we need to do to change . I dont know if i can answer all of that. I think that give it a shot. In the personal relationship in the team at the v. A. Who is providing care to a veteran, they often know who the significant individuals are in that providers life. Not necessarily related members. So i think that coming up with mechanisms and v. A. Does currently use advanced directives, but to use them more widely and more thoughtfully and consider how they could be used so that when people get in crisis, v. A. Providers can reach out and talk to significant individuals to try to bring that person back in. To the second point of sharing medical records across, i think that the data exchanges have to work in order for the v. A. Medical record to communicate with all those other medical record systems. So if there is among the vital points Going Forward, that is an extremely vital point ill not advocating a change to the privacy rules. Im advocating we be more creative in getting permission so at the time a person is ill, a Larger Community can be brought in to the discussion. We are going to need your help on that because we have had trouble getting past that. We have a bill called jesses law, a little girl, 30 years of age who was addicted. She overdosed a couple times and then she died in the hospital. She died because when she went into the hospital she explained she was a recovering addict and she had asked repeatedly, she said please notify my records, make sure my records are identified that they know i am a recovering addict. Well, there was no such the records were buried. It wasnt like if you have allergic to court aacortisone o any of the things that are stamped and marked, the dispensing doctor didnt see it and they gave her 30 oxy kauntden. She was dead by 1 00 in the morning. Were having a hard time getting through the hipaa because of the patient privacy. Common sense has to prevail. You might be the ones that will help us transition this thing and get this legislation that gives you the chance to share that patients within the professionalal ranks so you can better serve them. You need to speak out on that one. Thank you. Thank you senator manchin. Senator from montana is back. We are going to let you do our opening statement. And questions at the same time. Are you ready for your questions now . Go ahead, senator. Go ahead. Senator tillis. First, i want to thank senator tester, because we have worked together over the past year or two getting with the department. We had a good meeting with dr. Shulkin in our office. I appreciate your continued very valuable contribution to us, keeping track of the transformation efforts within the v. A. Im sorry that i was not here earlier to hear the testimony. But well start back on the medical record. Back in North Carolina, i sat on the Electronic Health record board when we were trying to integrate Health Records among medical providers within the state. And since im here and on the Senate Armed Services committee, we were successful with getting a provision in the nda that makes absolutely certain, and i believe that the department is glad that we did, the v. A. , makes absolutely certain that we dont miss a step as we integrate the two Electronic Medical record platforms that are going to be common platforms. Theres still a lot more work to do with over 100 or 120 different instances of medical records in the v. A. Weve got to first make sure theres a good flow from dod to the v. A. And then we have to make sure we get that right and then we go to the next step, which is all the other providers that can be involved in providing a veteran care. So senator manchin, im glad you brought that up. I think its critically important. There are ways to do it. We need to push the envelope. We can address the privacy rules but we want to make sure the comprehensive view of the veteran in terms of their Health History is known to anybody who may provide them care at any level. Im kind of curious about the work that we need ive got the state the heartbreaking statistics for the state of North Carolina. But frankly, they are in some cases better than the national average. And other cases. Which led me to wonder to what extent do we see a correlation between the incidences of suicides in other states and the lack of v. A. Resources available to them, or other resources. In other words in a state like North Carolina where we have such a large military footprint, you have a Natural Group of people that have a therapeutic value just by being around other veterans. Then we have brick and mortar facilities. Have we looked at that and see if there is any correlation between foot print and outcomes to your knowledge . No, sir. Im the gentleman who compiles the data may be able to answer that question but i dont have an answer for that. I think its important because it could be instructive as we go through and look at how were prioritizing the footprint. And every one of the states are different. Thats why some of the performance of the v. A. Differs. Its based on support networks, bsos, a variety of other factors. I think that should be instructive as we look at how we deploy resources to increasing our presence. I dont know, i saw senator blumenthal, i think he was probably heading out of the hearing as i was moving in. But i was curious if he brought up the issue he and i share a concern with, it had to do with possibly bad paper and not tracking. What more should we do to go back and take a look at discharges other than honorable that if we had had a better understanding of what may have occurred during their service that could put them at higher risk and actually could have resulted in paper that they shouldnt have been discharged with . Yes, he did raise that issue. And this is, i think an important issue not only for suicide but also for a host of other social issues that are i think of high relevance. Weve seen high rates of homelessness, higher rates of criminal activity in that subgroup as well, other social problems. So i think if we address it here with Suicide Prevention, we actually probably would have a much larger social impact in other areas as well. Are you all aware of anything that we should do as best practices while we deal with the policy issues of how do we go back there are two pieces of this prospectively Going Forward. How do we make sure that at the point in time when we are making a discharge decision that we are taking in factors, particularly the invisible wounds of war that could have affected that persons behavior and resulted in the other than honorable . And then how do you go back . The statistics here show that a lot of the suicides were seeing are not in the current wars were fighting but theyre vietnam war and prior to that. Has there been much work done or any bright spots that we are going back into the veterans population and trying to help them, trying to clear up their record or at least make sure they are getting the care they need to avoid the possible suicide . Senator, probably the best one that i have seen is the vet centers. Because if you have been in combat, they dont care what your paperwork looks like. So there is a place where people can go. And i think that the other policy statement is these Mental Health conditions lead to conduct that eventually can get you discharged. And if you have been to combat, why is there a less than honorable . I mean, i dont know if we can scientifically say this didnt cause your behavior or didnt have some kind of effect. So my perspective, the tie goes to the runner. Yeah, you know, i would ill take that at face value. It may be something that we should talk about. I chair the personnel subcommittee and Senate Armed Services. But look at it in a way that there can clearly be, even in the u. S. Military, there are people who do things that i think are appropriate for disHonorable Discharge. Its a matter of how you get that right and how you do, based on the circumstances that a soldier was exposed to, to where that may be the tiebreaker is the nature of the environment they were exposed to and what would you reasonably expect as a medical practitioner as someone who would look at that and say this is probably where the tie needs to go to the soldier. One other point ill add. When you look at some of these decisions there are two separate processes by which a Service Member is separated from military service. The medical process and administrative process. They do not parallel each other. They dont necessarily interface with each other. And i can speak for myself as a former military psychologist, sometimes there was confusion about who has precedent because both issues are going on. Which one goes first . Which one goes second . So it can create a lot of confusion and a lot of frustration for everyone involved, the commanders, the health care providers, and the Service Member and the veteran. And so perhaps something looking Going Forward is how do we create a process wherein these two separate parallel tracks maybe you know, Work Together more explicitly, there is new policies in place wherein this is cross talk amongst these two stove pipes that now isnt happening. So its easier to make these types of decisions which i think would help to reduce a lot of these conflicts and questions. Thank you all. Thank you chair, and senator tester. Senator tester . Thank you mr. Chairman. I wasnt going to talk about this but since senator tillis brought it up, the easiest thing for the military to do is pitch somebody out for behavioral problems. The more difficult thing to do is talk to people, make an analysis whether combat changed them. I really thing thats incumbent upon the military to do that. This isnt the d. O. D. Committee, but its v. A. And its important. Okay, sxis the is for either dr. Bryan or dr. Daigh. You dont have to both answer, one or the other. Could you give me an idea on what percentage of veterans who attempted suicide were previously diagnosed with Mental Health issues . When you say attempted suicide, they died by suicide or they made nonfatal attempt at suicide . Attempt. I do know the statistics are available. I want to say the v. A. Report. Please take this with a grain of salt, around 70 give or take. 70 have already been diagnosed with a Mental Illness . Right, yes. Okay. Have we seen a correlation between combat exposure and suicides . We published a paper on this a couple years ago. And the answer is a little more complex to answer. So is there a relationship between deployment and general and suicide. Yes, thats fine. No. Is there a correlation between exposure to certain times of cambat related trauma . Yes. Killing and exposure to death, there was a small correlation. There is research that living in higher altitudes could impact suicide depression. Are you familiar with those studies and are they real . Yes, a colleague of mine at the university of utah is the leading scientist in that area. And they are real . Absolutely. What seems to happen is at higher altitude we have different oxygenation of metabolites in the bloodstream. So it affects how our brain processes neurotransmitters and how our brain in essence works. Interesting. Yes. This is, i think, more for you, matt. Veterans have been concerned about you seek Mental Health care, there is a stigma attached, it could have effects on their career, perception by family, friends, right down the line. Do you think we are making the appropriate steps to take care of the stigma thats associated with Mental Health issues . Have we done or made any progress in the area of destigmatizing Mental Illness . Senator tester, i think we have made some progress as a society. The one thing i guess i just dont understand why we dont do enough of is really brag about how some of our best americans had Mental Health conditions, had posttraumatic stress disorder. Why dont i mean, when you are talking about abraham lincoln, why arent we saying, bless us, that that guy had bipolar disorder or depression . I mean i think that some of our greatest leaders, like we are bringing a Sergeant Major from delta force to congress in november. And i mean, people like that need to stand up and say, in some ways my condition helped me. But on those days where i struggle, you better be there to help me, too. Right on. So you talked about older veteran suicide. Can you give me this kind of goes back to the question that i just asked mr. Kuntz. Can you give me an idea whether the newer generation of veterans are seeking Mental Health care more readily than the older generation . Or is there no difference . I dont have the data on that. Do you know . My sense i dont know the data offhand. My sense is that there is a decreased likelihood of younger generations of veterans that Access Services at the v. A. . Oh, really . So its actually gotten worse . Thats what i understand. I could be wrong but that was my understanding from some of my v. A. Colleagues. Maybe someone else has better data or understanding of the data than me. All right. One of the things that i think is interesting, we were contacted by a veteran from sydney, montana, thats in the far eastern part of montana very rural, who noted that the v. A. Is unable or unwilling to include Family Members in the intervention process if a veteran is in crisis. I dont know if this is true or not, but if it is true, i think we are making a big mistake. I would love to hear all of your opinions very briefly because you only got about a minute left, 30 seconds, on what the v. A. Can do better to engage families. Start with you, dr. Daigh. I think that use of advanced directives or some other mechanism that allows providers to talk about otherwise prohibited information to families widely when there is a crisis would help that intervention process. Okay, dr. Bryan. I think there are two key strategies that we can work with Family Members about. The first is basic crisis management, how to talk to someone in crisis and how to help them when they are struggling to identify solutions to their current problem. So actually working with the families to train them so they recognize and rectify. Correct. This is something we have been doing in Salt Lake City training Family Members on what to do. The second related piece of that, teaching Family Members and bringing them involved in the Firearm Safety aspect. Yes. How do we work with families to increase safety within the household even maybe during times of not crisis. Because if we have a safer household to begin with during a time of crisis, everyone in the house will be safer overall. Hold on just for a second, matt. Do you have statistics of how many suicides by veterans are committed by guns versus otherwise . Vast majority, close to 70 to 75 are through firearms. Okay. Yeah. Matt . Senator tester, i think telling the families how to communicate with the v. A. Because you can get around hipaa. I mean, you need to send us a letter. You need to send it to this portal. You can call us. We may not be able to tell you about the veteran, but if you are if your veteran is in trouble, this is how you communicate to us, and this is the way that you do it and the way that well respond. We tell our families, you do written letters to professionals. They start thinking about malpractice, and pretty quick they will get moving. But you have to train those families. And the same thing we have a familytofamily course which helps train them in how to interact with the treatment system. Well, thank you all for your testimony. I got i mean, we could spend all day long on this issue, truthfully, and we can spend all week and maybe the next month but i want to thank you for what you guys are doing. Each one of you in your own right are doing some really good work. And i think that you are the key to be able to partner with folks like you to really move this issue in a way where we have better outreach. We have better education. And we have better results. Thank you. Thank you, senator tester. I have a couple of quick questions and then well go to senator cassidy if he has a question and then well go to the second panel. Real quickly to this panel, mr. Kuntz you made reference to biological susceptibility. Is that a test . Is there a biological susceptibility test you can give someone, a blood test or something, markers or indicators there may be suicide sir, i absolutely wish there were. There is not a test now. Biological susceptibility is its something thats also dependent on other it can factor into every other health care condition. There is not necessarily a biological susceptibility test for skin cancer either, but some people are more prone. Thats one of the things we have asked the committee is to ask the v. A. For more biological indicators by the fall of 2020. I think that even if its not a specific this test for that, there are things like computerized executive functioning where we know if that executive functioning is getting worse, theres something going on in that brain. Its not necessarily ptsd or depression, but there are tests that need to be brought forward. And im hoping that they can be rolled in by the fall of 2020. The reason i asked the question is, when you listen to the testimony of all of you, there are two things that pop out. One is we havent had enough good training in the v. A. For dealing with suicide and we need to work on that. Dr. Shulkin is going to do that prioritizing Suicide Prevention is the main focus of his leadership. The other thing is that people dont ask the right questions, dont report the right and our timing is never very good, response timing on Suicide Prevention ought to be immediate, and not two weeks down the road. Thats why im proud of all our staff on the majority and Minority Side have taken the safe tech course. To look for the signs of suicide, to ask the question, are you considering suicide, not beat around the bush about it. To validate the veterans experience and to encourage treatment and expedite getting help. If we embrace the save program in the v. A. And work to do it we will save a lot of lives by simply having the awareness and the direction of knowing what to do. Knowing what to do is 90 of solving the problem, and 100 of solving the problem is identifying it. If we are better aware we wont need a biological test. Everybody wishes there were a biological test. But you are right, there is not persay a biological test, but there are indicators, whether its skin cancer or whatever it might be. Senator, did you have question. Yes. I apologize if these questions have already been asked. I apologize in advance. Dr. Daigh, you mentioned that in your studies that its unclear how you establish intent. So let me ask, if somebody dies from a Drug Overdose, say john belushi, is that considered a suicide or is that considered a Drug Overdose . So, in the in the course of our work, sir, we would rely on what the medical examiner said in their determination of all the relevant facts at the time the death occurred to state whether they thought it was an accidental death or an intentional death. So accidental in the sense that they are addicted to drugs, they took too much, they stopped breathing. That would not necessarily be a suicide. That indeed might be considered accidental overdose . We would record it that way, and we would yes, sir, we would have that interpretation and we would always wonder if we were right. Got that. And mr. Bryan, you mentioned this, but any of you all can answer these questions. Again im just trying to understand. Clearly, you cite the statistic i believe that 30 increased rate of suicide among veterans. Im not sure, i think thats compared to the general population, not to an age, gender based cohort. And going beyond that, im not sure it is related to socioeconomic class and or Disease Burden, intuitively people with greater Disease Burden are more likely to commit suicide. As we understand these statistics epidemiologically had are they matched against a matched cohort or is it against the general population . If they are not matched against a matched cohort, what are the excess rates relative to one which is matched . Correct. So the statistics that i cited was from the v. A. s report from last year. Those are age and gender adjusted for the reasons that you note, age, and gender what about s. E. C. . I was not involved in the analysis. I dont know what other variables they may have adjusted for. But age and gender age and gender are the most common adjustments we make when looking at military statistics and comparing to the general population. From my general knowledge, i dont know. Is suicide more common among certain, clearly, suicide would be more common among people who have addictions. Thats intuitive, right intheyre addicted for a reason. But are there other kind of breakups, if you were going to match them in the general population, in the general population as a whole, are there certain things in this social strata, its more common or in this Disease Burden is more common . Im asking this for my knowledge. Right. Yes. So if we look, for instance, like in the v. A. Report, they broke things down into different age groups. They looked at different diagnostic characteristics, what type of Mental Illness does a person have, diagnosis where they looked at opioid abuse as well. And what were men versus women. And what we tend to see is on a whole, veterans have a higher rate of suicide regardless of the categories. Im asking in the general populati population. Mr. Kuntz, are you senator cassidy, i can really speak well to montana, but i think since were the highest suicide rate in the country, there may be something to learn there. We created a Montana Suicide Review Team that went through all the death certificates in the state for exactly the reasons that youre talking about. We cant solve it unless we know it. And interestingly enough, the one demographic that really jumped out was white males between 30 and 60. That was, you know let me stop you, mr. Kuntz, because theres research out of princeton which says that in the general population, white males to a lesser extent, white females in that demographic are dying. But it does relate to lower socioeconomic class. Now, your state, i think, has a higher rate of poverty than new jersey. Yes, sir. Have you corrected that for kind of economic status or not . Sir, from looking at the economic status, it will also say that most of our suicides are from people that are economically struggling, in particular, people who have not a lot of education. The higher you go up the education totem pole, the less likely you are to commit suicide in our state. Although i will say there are some other factors that weave into this because if you have depression, anxiety totally get it. You know, popping people off popping people off of the education. Rich people shoot themselves, too, i hate to say. Yes, sir. But i dot sound and im sure dr. Shulkin will testify whether or not these v. A. Statistics, are these veterans typically a lower socioeconomic class, et cetera, how closely do they match the princeton data . If you all know that, i have ten more seconds. If not ill wait for dr. Shulkin. Thank you all. I yield back. Thank you very much. Senator tester. Yeah. I think that, mr. Chairman, im done with this panel. While theyre setting up for the next panel, i would just like to make a quick statement, if i could. Well do that. I want to thank the panelists for being here today. Your testimony has been eye opening and helpful, and well continue to focus on this. Dr. Shulkin needs focus on it in the v. A. We thank you for your attendance today. Well now switch the table around for our panel. If i might, mr. Chairman, while theyre doing that, i would like to give a quick statement. The Ranking Member is recognized. Thank you mr. Chairman. I would say look this discussion is very, very important today. It continues to be unacceptable. We have the number of suicides in the veteran population that we have. Make no mistake about it its also a national epidemic. Not specific to veterans, but we are here to talk about veterans. In fact, it is the tenth leading cause of death in the united states. Since the chairman dropped the gavel at the beginning this hearing six people have committed suicide in this country. Look, v. A. Data suggests that approximately 20 veterans commit suicide every day. On average and this is important statistic for us to know, only six were enrolled in v. A. Health care. What does that mean . We have got to do a better job of outreach. Once we do that job of outreach we have got to make sure those folks have the Health Care Professionals on the ground within the v. A. To get the help that they need. Why is that important for this committee . If we are going to get Health Care Professionals on the ground in urban and rural areas, and i think theyre needed in both, its going to cost some money. We have got to have more residency slots we have got to be more aggressive. I think its really an important issue moving forward. I think this last panel has showed it. We need to fill those vacancies within the v. A. We need to make sure we fully leverage the assets like our v. A. Centers. We can talk about this. And i think its important to talk about it and get the but as matt kuntz knows, i dont know if matt left or not. He was on the first panel. But i will tell you this guy not only talks the talk. He walks the walks. We need to follow his lead and make sure that we follow up this Committee Hearing with action that actually does right by our veterans in this country. And, by the way, if we do that, i think it helps the civilian population, too. So thank you very much, mr. Chairman. Thank you senator tester. It was an excellent panel i appreciate your leadership on this issue of suicide. We know its number one in our state both with the general populous and as well as veterans. We want to do everything we can to make sure were addressing it within the Veterans Administration. And we know that dr. Shulkin is focused on Suicide Prevention. We worked very hard in the first nine months of this year the Ranking Member and i and the entire committee to bring legislation to the floor that was sought by many of us and in some cases sought by the secretary to improve the v. A. We changed the paradigm at the v. A. , changed the headlines at the v. A. We are very proud of that. One of the reasons we have done it, the committee has been united, republican and democrat alike, to getting the job done. We have done that. Also because the v. A. Under dr. Shulkins leadership is seizes the advantage we have been giving. Last week was the first use of the accountability legislation in the termination of a Senior Member of the staff at the Veterans Administration far lack of performance, incompetentsy, et cetera, et cetera, that wouldnt have been possible had that legislation not be passed. Nor would it have been possible unless we had a secretary willing to take that initiative. I want to on behalf of the Ranking Member and myself and everybody on the committee thank you for taking advantage of the tools you have asked for and we have given you in the Veterans Administration. There are a lot more tools in the bag youre going to need to use, and were going to be there to support you and were going to help. And i wanted to thank you personally for using the accountability legislation last week. The cabinet member from the Veterans Administration to assist if necessary. I think thats the way its supposed to be. Great. Great. If you could recognize joe okay. No problem. Thank you mr. Chairman. And good morning senator cassidy, senator murray. Nice to see you. Senator manchin, the best attendance award. Thank you for staying for the whole thing. And i want to thank you, mr. Chairman, for several things. First of all, i think i couldnt agree more with your comments. Im very proud of this committee. I think its the best committee in the senate. It works together in the a bipartisan way, and working to really get things down. And im proud to be working with you on that. And also thank you for having the first panel first because they got all the hard questions and got to hear all the answers. And that was terrific. But as you know, we are here today, and this is an important hearing because our goal is to eliminate suicide. We want to do that through Risk Identification. We want to do it through effective treatments, education outreach, research, and strategic partnerships. Senator tester mentioned right before he left that our Research Shows that 20 veterans a day are dying through suicide, and he did something by saying that there were six americans who died during the course of our hearing. I think about that every day, how many veterans are dying for us not being more effective at the way that we are addressing this problem. We know veterans are at greater risk for suicide than americans. This is an american Public Health crisis. But for the veteran population, even more so. And we do know, as has been said several times already this morning, that 14 of those 20 arent receiving care within the v. A. System. We know from research that v. A. Care saves lives. And we know that treatment works. So this is a matter of trying to get more people treated. What were trying to do is more aggressively than ever before to outreach to veterans that arent getting access to care. But we cant help those that we dont see. So this is where we are extending our help into the community to work with community partners. We are doing more to reach veterans than ever before. As secretary i have authorized we do start providing emergency Mental Health services to those that were other than honorably discharged. And thats important. But we can do more in that extent with your help. We have asked every Medical Center this month to sign a suicide declaration pledge. Im pleased that you signed it this morning, mr. Chairman, along with the Ranking Member. When i was out in nevada, senator heller also signed it with his community members. So we are doing that across the country. And thats a pledge of specific action steps that we want leadership to take to be able to help reduce suicide. We have developed the largest integrated Suicide Prevention network in the country. Over 1,100 professionals who are dedicated to Suicide Prevention, including Suicide Prevention coordinators and other Mental Health professionals. Our goal that i have announced is to hire 1,000 additional Mental Health professionals to we can do even more and grow that network. Our Veterans Crisis line which we established in 2007 has now answered more than 3 million calls and dispatched 84,000 emergency ambulances to help people who were in urgent need of help. Thats incredible. Weve had 504,000 refers to Suicide Prevention coordinators. So we are helping a lot of people through that. The Veterans Crisis line number, and i encourage everybody to keep this in their phone because you never know when you are going to get that 2 00 a. M. Call and you dont want to be looking for this is 18002738255. 8002738255. We have recently appointed, seven weeks ago, dr. Matt miller to head up your Veterans Crisis line. This is the first time weve had a clinical psychologist in charge of the Veterans Crisis line. Because this is clinical work and this is not just a call center. We have expanded teleMental Health. We have 11 teleMental Health regional hubs throughout the country. And in 2006 alone we had 427,000 teleMental Health encounters. Thats more than ever before. We have taken from our Research Enterprises a Big Data Analytics program that we call reach vet that now predicts who may be at the greatest risk for suicide, up to 80 times the risk of suicide of a regular person over the next year. Now we call them. This is being done around the country to outreach and see what we can do to proactively help, so not waiting until there is a suicide attempt. On september 15th of this month we released state suicide data. Many of you have been referencing that data. But we think thats going to help people design more effective interventions. We have continued to develop Public Private partnerships because v. A. Cant do it alone. This morning i was talking to the Cohen Veterans Network as one of those partnerships. But many of our vsos and other groups who are here in the room today are those partners that we are working with. We continue to invest in two v. A. Center of Excellence Research initiatives to help us understand how to do interventions better and to take a Population Health approach towards reducing suicide. This month, as you have said, is Suicide Prevention month. Thats our be there campaign, where we are reaching out to make people aware and try to decrease the stigma of Mental Illness. With that today i have brought with us our new psa announcement. I just want you to listen to it for a second. Hopefully you will recognize who is helping us with this. In the fabric of america, they are the toughest threads, our bravest, and most selfless. They raise their hands, stepped forward, and served for each other, for you, and me. One of the first things they learned was the code that every Service Member lives by, leave no one behind. Now all of us need to live by it, too. Because some veterans are being left behind. 20 of them take their own lives every day. Why . Its not simple. It never is. What matters is that were there for them, just like they were there for us. A handshake, a phone call, a simple gesture make a big difference to a veteran in crisis. Learn how to be there for a veteran. At be there for veterans. Com. Honor the code. Be there. Leave no one behind. In the fabric of america were grateful to tom hanks for lending his credibility to help us get this message out. And you will begin to see this national psa with a video starting in about 30 days. So despite all this progress that we are making, we still have so much more work to do. Thats why, as you said mr. Chairman this is my number one priority. This is what were focusing on to make a difference. But we need your help. It wouldnt be a hearing if we didnt ask for your help. Those are three things that we could ask for your help on. We have to find a way to recruit more Mental Health professionals and frankly, not just for the v. A. , but for the country at large. To be able to train more. I have identified we need 1,000 more. We are not making the progress i want to be able to recruit them. Secondly, we want you to be part of helping us spread the word in the be there campaign. Thank you for signing the declaration. You are as well respected members in the senate helpful in spreading that word with us. Third we need more research. I think many of you have identified, there are no blood tests. The bio markers, we need to do this better. We need Better Research in genomics to make a difference. The v. A. Has that capability with your additional support. Thank you for holding this today. I would be glad to take any questions, along with dr. Carroll. Senator manchin be recognized first. Mr. Chairman, i cant thank you enough. Im so sorry, i have a hard 11 30, and children here. I wanted to ask a couple questions shulkin. I know that youre aware, and there are more and more stories in the news about veteran suicides. The most alarming one is theyre doing it at parking lots or doing it coming to the v. A. Facilities. We just had one in clarksburg. Yeah. I dont know what you can do to train your security in this and that. I dont know how to do it. But i know there is some timing involved here, and everything goes in lockdown if its on the property but its becoming more of an occurrence than we ever thought it could be. I dont know if you all have taken steps, if its been at a high enough level to where you know it is a problem around the country. Oh, believe me, we are extremely aware of this. It is so painful to hear each of these stories. You are right that what were seeing is that people are coming onto v. A. Property. And we are doing a number of things. Part of these declarations that every one of our filth are signing are ten action steps. One of them is to train just like this committee every one of our Staff Members in Suicide Prevention and Risk Identification and what to do. And we are establishing much off of what we learned in our homeless program, that you do this through a no wrong door approach. A veteran who is at risk and recognizes that should know where and when and have the responsibility to follow through. Can i ask this question real quick. Yes. What im concerned about, and it is alarming its not well publicized as you know. Its becoming more and more. When it happens in small rural states such is as West Virginia in a parking lot at the v. A. , we have an awful lot of veterans in our state. Im concerned about maybe this being taken inside the hospital, to where its more than just that person doing harm to themselves. Because they need help. I dont know how you secure that. Are we securing the hospitals . Can we secure because we all have to come through to come on v. A. Property. We have to have a stop. Theres a checkpoint. Right. Right. I dont know i would hope you would consider that. But i want to go to another question very quick im saying please, at the highest element you can, im concerned. You talked about 1,000 additional Mental Health. Im talking about rural montana, rural West Virginia. We had one vacancy for a psychiatrist in clarksburg that was posted in january 2017. Another vacancy for a psychiatrist in the Addiction Program in martinsburg. Thats been posted since october 2016. And another vacancy for a psychiatrist in martinsburg just posted within the last five or six months. This is vacancies at beckly and princeton. Are you having a harder time can you tell me of the 690 649 people that have been hired what is the ratio between rural and urban . Its probably easier to get somebody in an urban area than a rural. So we are going to have to put more effort in that. Yeah. Well, i think you have it right. Martinsburg is actually believe it or not, a success story. About a year and a half ago i was really concerned about their staffing levels. They have done a great job of bringing people on. In general, it is harder to recruit in rural areas. There is no doubt. Our urban areas that where there are more trainees and younger people are staying thats where we are establishing our 11 teleMental Health hubs to be able to help support the rural areas. But, you know, this is where we want to see expanded graduate medical Education Programs in those rural areas. Do you have a Loan Forgiveness Program . We do. Its part of the clay hunt act. We use up all of the dollars you allow us to do. We would like to use more. It is an Effective Police man. In the clay hunt program you have asked us to do that more but didnt appropriate money for us. We are trying to find the additional dollars that will be in july of 18. I have more questions i will give them later. I want to thank you all for the job you are doing. Thank you. Yes. I think i got this right. We are going to go to senator moran, then to senator murray, then to senator rounds. Then to senator tester. And ill finish up. Senator moran . Mr. Chairman thank you very much. Secretary thank you for joining us this morning on a huge significant and unfortunately so timely topic. First of all, i want to highlight the hearing that our appropriations subcommittee had in april on this topic. But i want to remind you, mr. Secretary, and i understand that senator murray has a question for you about v. A. Follow through on a commitment that was made at that hearing. It was committed by the v. A. That we would get monthly reports in regard to your efforts, the departments efforts to comply with the Inspector Generals recommendations and failures at the v. A. In regard to suicide and we have not received those reports on a monthly basis. Ill defer to senator murray, but i would join her in her request that what was promised would actually be followed through on. Let me then talk about another topic that senator tester and i have worked on. We have been trying for a long time, in fact, in 2010, now seven years ago, gave the v. A. The authority to hire marriage and family therapists and licensed professional Mental Health counsellors. The results of that authority have not resulted in any significant hiring of either one of those professionals. I would guess that senator tester and i are interested in this reason for the scarcity of professionals generally. But especially as you were indicating in Rural Communities. And so we have sought and have provided Congressional Authority for the v. A. To hire. You indicate you are in the process of hiring 1,000 additional professionals, but i would tell you that after seven years, those two categories only account for 2 of the Mental Health work force at the department of veterans affairs. Will you senator tester and i and others have a letter to you in this regard that was sent to you just a few days ago. But in this hiring, would you again commit to filling these positions with those professionals, something that has not happened . And if so, how many of those are going to be what would your prediction would be who fit an mft or lpmft, and would you provide me with those numbers as you fill those positions . And i assume that there will be a priority given in regard to places that are hard to recruit professionals. I also know that you have hiring authorities that are difficult. I dont know what your expediting hiring authorities are. What are they . Do you currently what do you have at your disposal . And do they apply to Mental Health professionals . What needs to happen to fix this problem . Weve noticed so many times that the things that are having to be posted dont result in any kinds of Quick Response for hiring at the v. A. We discussed this topic with dr. Stephanie davis who testified. Shes at the eastern part of our kansas vsn. She testified before our Senate Appropriations subcommittee in april. Jobs were posted on usajobs. Com, where applications can linger for four or five months. People find other jobs in the meantime. And it becomes even more impossible to recruit and retain. We know that positions sit vacant for months or even years while providers go through the process of the federal hiring mechanism. What can you do to get that process expedited . And then finally, mr. Secretary, i wanted to tell you that i was just earlier this month at the phoenix v. A. Where i saw one of the pilot programs under clay hunt act. Its their call, be connected. I was impressed. What this is about is having those who have similar circumstances who have served our countries who are veterans themselves who had ptsd and other problems as the counselors for those who are calling the number. I would be interested in knowing what the v. A. Is doing to support be connected and are there plans to expand that program elsewhere . A lot of questions. Im going to go really quickly. And anything that i dont do an adequate job, i will follow up. First of all, on the issue that you talked about us not providing timely followup. And that senator murray is going to comment on that, too. Look thats unacceptable. If we say we are going to commit to something, my expectation is is that we commit to it. I appreciate you letting me know about it. I can assure you my staff will be knowing about that. But we will do better. And thats just not the way i want the department run. So we will make sure that you get that. On the marriage and Mental Health counselors, ill look forward to the letter. I am aware that we continually hear about vas strictness on our accreditation issue. This is particularly a training issue since there are two accreditation programs. We are committed to bringing on marriage and family therapists. If dr. Carroll has any specific information on numbers, i would defer to him in a second. On the issue of hiring, its the single most challenging thing that i know of in va. It shouldnt be that hard to get people on board. In the accountability act that the chairman referred to that we passed together not too long ago, you gave direct hiring authority to Medical Center directors. That is really helpful to us. It allows us to skip over a lot of the red tape. I want that authority for all of our Critical Health professionals. I would urge us to Work Together on that. Its just too hard to get people hired into the va. Do you have the authority to do what you need to do . Only under Medical Center directors. So if we could work on expanding that, id love to target it for Mental Health, but we have other health needs as well. So id love to work with you on that. And on the be connected program, peer support is something we are really committed to. We think this works. Particularly for veterans who understand what theyve gone through. Thank you for your visit. Thank you for mentioning that. Thats something were going full force on. Do you have other plans for that program elsewhere . Yes. We already have about 1100 peer support counselors. Much of our vet center model is based on that model. We know it works. And vet Center Growth has been continuing to go up each year. Thank you. I know dr. Shulkin wants to point out that the third Mental Health Hotline Center is being set up in topeka, kansas, if im not mistaken. Youre correct. Were delighted to have you. Senator murray. Mr. Chairman, thank you so much for having this hearing. It really is such an important topic and able to listen to much of the first panel from my office in between meetings and it really was good. I appreciate it. Secretary shulkin, thank you for being here. Thank you for your testimony and thank you for saying in your testimony this is a number one priority. Because it is. But i do remain deeply troubled by the igs findings from may 2017 that v. A. Is not complying with a number of policies including 18 of facilities not meeting their requirement for five outreach activities each month, 11 of high risk patients medical records did not have a Suicide Prevention safety plan. And for 20 of inpatients and 10 of outpatients no documentation the patient was provided a copy of the safety plan. There were several short coming attention in the use of patient record flags, coordination of care, and critical improvements to follow up for highrisk patients after discharge. 16 of nonclinical employees did not receive Suicide Prevention training. And more than 45 of clinicians did not complete suicide Risk Management training in their first 90 days. Anything less than 100 isnt acceptable. When will all the igs recommendations be fully implements . First of all, this is exactly why the ig is valuable, pointing this out. I have no other mechanism to get data that comprehensive. We have committed to addressing the ig concerns. The reason we have made Suicide Prevention our number one priority and made all of our leadership this month sign off on the declaration is to fix those issues. We have committed to training. So over this year look, 100 is the right goal, but i cant tell you exactly what date were going to reach that, but were going to be working really hard to get as close to that as possible as quickly as possible. As senator more ran alluded to at the veteran suicide meeting back in april, i asked for monthly updates. Until all of the problems at the crisis line are resolved. V. A. Has not done that, and that is really unacceptable. I want a commitment to you today that we will get those updates starting right now. I think you have that commitment, yes. Okay. We will intend to see that happen. Let me ask you about Women Veterans. This is something ive asked about many times. I am really disturbed in the increase in suicide rate among our Women Veterans. Between 2001 and 2014 the rate of suicide for Women Veterans who do not use v. A. Care increased by 98 . Ive heard from Women Veterans many times that they dont think of themselves as veterans and i hear far too often from women who dont feel welcome at our v. A. Facilities. Just dont feel like thats their place. It is a significant problem that the Rand Corporation testified in april, as well. But this increase in suicide is the most important reason yet that i believe v. A. Has to redouble its efforts to reach out to women and get them into care. I wanted to ask you what are we doing to address that. Well, you gave a really important statistic, which is that those that over the last 15 years, between 2001 and 2014, those women that did not receive care in the v. A. , that the rate of suicide went up by an extraordinary number. You said 98 . Those that did use the v. A. , we actually saw a decrease, a decrease in suicide rates over that 15 year period of 2. 6 . So we know that particularly in population, but for all veterans, getting care and access to care makes a difference and saves lives. The issue about making the va more welcoming to women is a critical issue. Its a cultural issue. And we have worked hard to create Womens Centers and to change the culture and environment. I speak about this. So does our center for womens veterans all of the time. But, of course, we are absolutely, as this is our number one priority, committed to doing much more and to be more aggressive and to put more resources into this. This is something we have to keep working on, because if a woman doesnt consider herself as a veteran, she doesnt think about going to the v. A. If she is not welcome at the v. A. Or doesnt feel that the veteran facility is welcoming to her, she wont go. If she has other issues, child care, work, its doubly hard. This is not an easy problem to solve but we really have to put hearts, minds, resources and as a country recognize Women Veterans. I agree. So i feel very strongly about that. I just have a couple seconds left. I wanted if i can to ask about the v. A. s reach initiative. Models to identify veterans who may be at risk of suicide. Before it happens. I want you to tell us how that model works. Also 14 of the 20 veterans to die each day by suicide do not come to the v. A. For care. So again, i want to ask how does that work for folks who are not coming to the v. A. . That is a Big Data Analytic Research project. That when i was under secretary, i said its time to stop researching it and start putting it into practice. Senator testers point about every day we delay, theres going to be more deaths. So we have moved it into the clinical setting. Our Suicide Prevention coordinators get list of veterans names that are in the highest 0. 1 risk of suicide. 80 times higher risk than a person who is not on the list. And they proactively are calling out every day, saying, how are you doing, how can we potentially help you . In anything that you need help with and connecting with them. And i meet with those people. Dr. Carroll has more contact, of course. Its making a difference. I dont have statistics. Are you working with local groups and providers and nonva agencies . No. To use the program . We do not have that data. Reach vet data, because of its limitation, uses v. A. User data off of our Electronic Medical records. We have no way of identifying the 14 in the community. Thats a big issue for us. Yeah. I think expanding v. A. Access in Mental Health will save lives. Thats what i made the decision on other than Honorable Discharges to do that. We have a big hole here. One of the big holes is with the department of defense. What were working now with them and theyre being very cooperative is essentially an auto enrollment program, so nobody leaves active Service Without knowing where they can get their Mental Health care. I think thats going to be a big deal in eliminating the gap that we have. Thank you very much. Appreciate it. Senator cassidy. Dr. Shulkin, again, let me just echo others praises for the changes you have made in your reign so far. And so anyway, thank you for that. I mentioned earlier with the earlier panel theres a professor of economics out of princeton, ann case, and ill quote the article, rising morbidity and mortality among white, nonhispanic americans in the 21st century. Im trying to figure out is it a specific veterans phenomena or just reflective of the cohort in the va . And also throughout. Are you with me . Yes. I am. They find out that the increase for whites was largely accounted for by increasing death rates from drug and alcohol poisoning, suicide, be chronic Liver Disease and cirrhosis. Although all education groups saw increases in mortality from suicide and poisoning. I could go on. So i guess what im trying to figure out is how much of this is unique for the v. A. Relative to this study as opposed to its just kind of what were seeing in society . Well, first of all, your questions before were excellent. We do not adjust by socioeconomic status. Because the way we collect the data off the National Data death index and from the cdc data and v. A. Data doesnt have a socioeconomic status. As a physician when i used to practice, id find that usually folks who were a little bit more well to do didnt go to the va for health care. Yeah. Well, our eligibility doesnt allow it, unless theyre serviceconnected. Even though theyre serviceconnected, and actually had more money, he preferred a different facility. For whatever reason. Yes. Do you know the status . We are definitely more a safety net organization. By proxy, we assume that if we have a higher death rate among those being seen, that would probably affect your overall population . Yeah, yeah. So, you know, my background is not hepatology, but its Health Services research. Im going to give you my best educated guess. There is a socioeconomic status component that i think youre identifying, but the veteran population is more than that. You wouldnt see as large a difference. I think its both in here. Can we tease that out . Again, if its merely reflective of the larger population, that is tragic, but the v. A. Represents the hope. Right. If it is an additional risk factor, that is something to be identified and corrected. Well give that to our Health Services Research Team to see if we can do that. We published 75 articles on suicide and Suicide Prevention last year and we have a good team on this that i think could make tease some of that out. Now, let me ask. My staff has just given me, but i have not yet comprehended it, a spreadsheet thats been distributed, the Mental Health domain composite summary, fiscal year, 17, quarter three. I have stats for louisiana. I cant say i comprehend them yet, but i know you have done that analysis. Is there a difference in suicide rates associated with different facilities . Again, hopefully correcting for that each population is the same. Assuming its roughly a homogeneous population. I see analysis by state, not facility. Dr. Carroll, have you seen that . There is state differences in the population, both at large and for veterans. I accept that. But probably broadly louisiana is a higher africanamerican population and some states have a higher hispanic. And so there is going to be that broad demographic. But, dr. Casey pointed out its among nonhispanic whites. That have really seen a bump in the general population. Have you done any kind of very rough as i was told previously yes, we have it race and gender. I can see throwing race in there, because thats usually pretty apparent. Do we have a rough estimate on that . Those analysis are ongoing. Were looking at ethnicity and race as part of the ongoing evaluation of the data. Now, let me ask, as well, because youre sending out this data, thank you very much, looking at specific facilities. Im presuming that most vets, not all, but most vets, have a facility of choice. Yes. Does your analysis is your analysis going to include the rate of correcting for all of these other factors how each specific facility is doing . Senator murray pointed out were not getting 100 of these being passed out. I suspect that would vary from facility to facility as well . Yeah. I think the compliance with screening absolutely is done not only at the facility level but by the specific provider. Yes. The broader statistics which include the National Death index and other things may be harder to do by facility. But you could at least go by state. We need to know is this a va issue or does it reflect broader society. If its a v. A. Issue, we need to give you tools. As a broader society, we need to do something more broadly. Does that make sense . Right. You do know the difference between veterans that are getting care and those who are not. I saw that. And clearly, you would want to correct for that. Yeah. You mentioned the safety net, my suspicion is in some places youre serving as a safety net and in some places theres inadequacy. Yeah. In which case, we have to identify that and address it. Right. And if you need tools, we have to give them to you. Thank you very much. I yield back. Thank you. And thanks, Ranking Member, for yielding. I want to follow up on senator murray and senator cassidy talked about the suicide report. I first thank you for being here and thanks to dr. Carroll, too. I dont really understand my state, 244 veterans took their lives and took their own lives in 2014. I want to talk about them and the thousands around the country. Im not really clear on why you would release that statebystate report on a friday afternoon at 5 00. Thats not really my question. I dont understand why you would do that. Talk to me about how you share this data statebystate, how you share it with veterans, with Medical Centers, with Community Providers, with academia who address what you call the national Public Health issue. Yeah. Weve this analysis, which was released on september 15th, friday, at 5 00, is really the first time that weve released that type of specific data. So were actively trying to get that out and to share it with the groups that you mentioned. There was no attempt to downplay this issue. If there was, it was a bad strategy because what were seeing is all around the country, that data getting out there and being picked up by the press, being discussed in forums. This is exactly what we want to have happen, and were actively disseminating it. If you dont know your data, i want every Medical Center director knowing what their number is, how many veterans they lost. Last year, last month, last day. You cant design as effective an intervention. That means not just a patient from that Medical Center. It means population. Never got into the v. A. System in franklin county. Thats the populations. Talk, new psa employees no vet behind. 14 of 20 vets who take their lives each day dont use v. A. Care. Talk to us about the reach vet initiative. What metrics you have in place to see how its working, what your what the process to get those 14 who then wont take their lives if they get v. A. Care, talk that through. Yeah. So the reach vet program is not for is not for those that arent using v. A. Its for those who are using v. A. That we know are at high risk. The 14 that arent using v. A. , thats where were beginning to start tackling it through other strategies. Letting other than honorable have emergency Mental Health is a strategy that will bring some of those 14 into the v. A. For others that arent eligible or choose not to go to the v. A. , were working with community partners, and were working with Veterans Service organizations. Were working with the churches and the synagogues to make sure that they understand that they have a responsibility in this. The psa message essentially is Suicide Prevention is everybodys business. And we need Family Members, friends, coworkers, to be able to identify people at risk to get them help, whether its at the v. A. Or outside the v. A. Thank you. Thank you, mr. Chairman. Thank you for your work on this issue. You heard a number of my questions earlier today. I did. About that difference between the veterans who have used the v. A. And the veterans who have not done so. I know you have been asked a number of questions about that issue so far. I want to focus on the less than Honorable Discharge group. Do you have any thoughts about how that cohort can be better accessed and how they can be encouraged to come forward, because i think that the knowledge about them is also lacking . Yeah. Well, quite frankly, i did what i could. It was one of the first things i did as secretary, just to use the authorities i had to offer emergency Mental Health services. I thought it was wrong that we were not providing access and were letting them out there, and they are at higher risk for suicide as Homeless Veterans are at higher risk. But i did as much as i can. Now, i actually need your help. This, were going to need legislative changes to allow us to offer other than honorable other than Honorable Discharge people to be able to access our full array of Mental Health and physical services. All that i was able to do is offer 90 days of emergency treatment. And then im trying to find them other places to get care, working in the community. Were going to do everything we can, but it is not the ideal approach. We could use your help in this, senator. Well, i would like to work with you. I have other questions. Sure. I would hope we can pursue this. As to all of the veterans who right now are, through no fault of their own, perhaps, not part of the v. A. Yeah. I know youve been asked about the Suicide Prevention act. I would also like to follow up on that, particularly as to the funding that is necessary. The president has signed a number of measures dealing with veterans issues. Those pieces of legislation have been long in the works. And we have devoted a lot of time and attention to them. I hope that his apparent commitment to those issues will translate into funding, which is really the test. Its fine to wield a pen on measures that were started well before his presidency. Now its a test of his commitment. And i think that applies to issues like the Veterans Crisis line, the Suicide Prevention measure, and i would like to, again, ask you about Women Veterans. And what expanded or enhanced efforts you contemplate involving Women Veterans. Well, first of all, thank you for highlighting, i think, all of these issues that are important. The president s budget, the requested budget actually has increased funding for both Mental Health care and Womens Health care issues. Both critically important. So i think that he does share that commitment that you have to seeing us do better in these areas. Is that amount of money, in your view, sufficient . I was very pleased with the president s budget. I think that many of the issues that were dealing with werent Financial Issues solely, but in areas that we have to do better in, im not only seeking additional funds, as we saw in the president s budget, but im actually moving current budget funds into higher priority areas. And so i do think that we have sufficient resources this next year, should the president s budget get approved. I would be remiss if i didnt ask you about the west haven veterans facility. You and i have talked about it. It was built in the 1950s. Its out of date structurally. It needs more than just rehabilitation. It really needs rebuilding. And i wonder where it stands on the list of priorities and whether the president s budget is sufficient to cover the Capital Improvements there and elsewhere. As you know, you and i stood outside that building, and i think your assessment is generous. I trained at the west haven v. A. , and i dont think its changed too much since i was there. We are still undercapitalized in the v. A. We have a very old infrastructure. I think realistically, we can expect to take decades of essentially underfunding and fix it all at once. So we are putting more funds. We have requested more funds into the modernization of v. A. , i have announced i want to dispose of 1,100 facilities that arent being utilized well by veterans to put back into facilities that are busy like the west haven v. A. I dont have a specific number of where the projects are, but certainly, i am going to support fixing the west haven v. A. And other facilities that arent modernized, and part of that is were going to have to redo our matrix on how we make capital decisions because right now, i will tell you, the number one weighted factor and where the money goes is the seismic improvements. While thats really important, im not going to say that thats not critical, youre not on a fault line. And it puts facilities like west haven at a disadvantage. Were going to be looking at that. I hope i can be generous in pushing west haven to a higher level on the list, as you noted. I was being generous. It has really changed little, if at all. There are some cosmetic improvements, but you well know the level of dissatisfaction that exists about it. And i would add that it is dissatisfaction with the structure and the capital facility not with the staff. I agree. I want to just give a shoutout to the very dedicated men and women who work for the v. A. In connecticut. And i have no authority to speak on behalf of veterans in connecticut, but generally, i have gone to high level of approval in satisfaction. So they deserve our thanks, and they work under conditions that should be better for them and for our veterans. Im sure they will appreciate both of those sentiments. And i would like to invite you to come visit, again, and be at that facility with me again. And i want to thank you for that. I do have a visit scheduled. Ill let you know. Okay. When that is so we can get there together. Wonderful, and i thank you, by the way, in the meantime for the work being done on the wifi internet connections, which is very important there and at v. A. Facilities around the country. Exactly. Thank you. I want to add to your answer a second ago. If im wrong, i want you to tell me. As you go through your 1,100 location evaluation of underutilized facilities to rearrange your capital to invest in places that need more help, youre going to consider rural locations, rural states, population density and things of that matter so that north dakota and montana and states of a like population dont lose out on a statistic in terms of availability of cbox and Clinic Association . What i announced is that, first of all, i share the sentiment that we dont want policy that discriminates against locations because the rural or because theyre not on seismic fault lines. But what i announced previously was that in the state home money distribution, that the rural areas were never getting from the bottom of the list, so i committed to relooking at those criteria because the state home grant moneys really were going only to very small numbers of states, essentially. But i do want to make sure that we are modernizing the facilities in an equal way across the country. I want the Ranking Member to make sure we knew were looking after our interests as well. Senator tillis. Thank you. Senator tillis . Why youre such a good chair, mr. Chair. I was going to end with a capital project, but let me go to that because i think this is critically important. I believe the president has a real commitment to veterans and accelerating some things and frankly didnt move as quickly as i would have liked for them to have in the past couple of years. But i have the same view in my role in Senate Armed Services. Were always going to have fewer resources than you want. Right. And shame on any member of congress who advocates for moving something up ahead of line where the data doesnt say its the best way to provide care to the communities that need it. Im in North Carolina. Im in a 50 urban, 50 rural state with over 1 million veterans. 10 of my population. If you told me montana is where the resources need to go to serve that population, thats where i want it to go. Along with that, when youre taking a look at optimizing capital projects, shame on any member who tries to come up with a statutory protection for something that you dont think is in the interest of supporting the veterans. I every once in a while call up a v. A. Facility the night before i happen to be in town. Want to stop by and see them. I said this is not a surprise visit. I just want to talk to you all. I stopped in one a year or so ago who said they made a proposal to consolidate two operations that were only about 40 minutes apart. Made total sense. They thought they could provide better care to the veterans by consolidating the resources and getting more leverage, but we had a member of Congress Stop that because it happened to affect 75 jobs in their district. Thats not the way we should think if were going to get out of the way and let you support veterans in a more appropriate manner. So we need to make sure i need to make sure i have your commitment and any time you see us doing something thats at odds what is your best professional judgment is getting the resources to the communities who need it most and making optimal the resources that were given you, i want to know who that is because i think they should be held accountable. Now on to the Electronic Medical record. I want to go back to the questions i asked the first panel. Actually, i want to thank you for being here because i was rushing in and i mistakenly thought you were in the first panel, but it doesnt surprise me that you and your team were here to hear that testimony. I thank you for that commitment. I like the decision that you made for the baseline system, because i think its an accelerator between dod and v. A. , but similar to the question i asked when you were here last, we know we got over 120 instances that have to be consolidated within v. A. , but even more importantly, we have nonv. A. Care providers out there, choice providers out there. I believe that as you get further into the Implementation Plan that we discussed in my office, that youre going to identify that you need other layers in the Technology Stack to make sure that we know how prescriptions are being dispensed, whether theres any dangerous interactions, other indicators you can use to make that a more productive experience for the provider and for the patient. And so have you gotten to a point now where youre thinking through how as youre looking at your implementation priorities and your broader transformation plan, the remainder of the stack, or we used to call it gluewear, or buying and configuring tools youre going to need to flesh out that Technology Stack . Weve gotten to essentially the principles that you have talked about, saying a system thats going to work into the future is going to have to have the components that frankly you have done a good job of outlining. We havent gotten to defining which specific tools they are yet and how were going to meet those needs, as we talked about the days of v. A. Being a Software Developer are over, and were going to be looking at off the shelf current technologies. But theres going to be a lot more definition on that. I think yesterday we released to congress, to you, the 30day notice of an award of a contract. So we are keeping on the timeline that we talked about. Were marching forward. We have the principles. I have some updates to share with you on the strategic i. T. Plan, because i think we are making a lot of progress with that. We are going to announce that we will in this i. T. Conversion with obviously your support, we will be sunsetting 80 of the projects that were currently under development, so this will be i think not only the right thing for clinical care, but also the right thing for taxpayers. Thats great to hear. Im going to hold my time because i guess im the last member to speak. But we do have a number of questions for the record on Suicide Prevention issue. We are, i took note in the first panel, and i have asked my staff to get with the Senate Armed Services staff because i would like to have a Committee Hearing at the subcommittee level to talk about traumatic brain injury, ptsd, and things that were doing to do a better job of detecting and treating it, but i would like to add a second panel that then talks about the veterans who may actually first off, how do we track those who get an Honorable Discharge and make sure that were trying to anticipate or provide interventions for ones who may be at risk of suicide, and then for the ones who have other than Honorable Discharge, what are we doing to make their experience when they were in the military instructive to any decision about what category of discharge they get, and then finally, we have to come back to the v. A. And get your advice on how we do that for those who have already received that paper and they need care. And thank you for pushing the envelope. And i heard you loud and clear, its time for congress to give you more tools so you can provide more veterans with care. Thank you. Thank you, mr. Chair. Senator tillis, are you on the way out the door . You have five minutes. I want to ask you a favor, i have to leave, and senator tester has questions he wants to ask and i dont want to cut him off. Yes, sir. Ive got one i want to be sure is for the record. Youre a great you adopt the same software being used by dod. Thats a huge step forward. And you have been commended for that. Does that merger also allow you access to the same information dod has regarding the wounded the warrior transition units . Yes. Our warriors when they leave the battlefield or leave deployment in battlefield areas, theyre asked questions on the computer, answer by computer. It doesnt have a statement. Theyre answering a computer question. There are questions that give indicators of where there may be somebody at risk for suicide. So you have Interoperable Software one day soon. Well also have interoperability access to that information. Is that correct . There is certainly some exceptions with dod. One of the things i just learned recently, i dont know if you know this, the coast guard doesnt have wasnt in their contract, so were going to have to figure out a way to be interoperable with them or get them into this. So theres some small exceptions and were working through those. Our relationship with dod is extremely cooperative on this project. I think were helping them in their implementation. Theyre certainly helping us. But those types of data sources are extremely valuable to us. Youre to be commended for that move. Were very proud of it. Im going to turn it over to the Ranking Member and ask senator tillis to adjourn the meeting. I appreciate your patience. Thank you, mr. Chairman. Thank you, mr. Chairman. I want to thank you fellows for being here as well as the first panel. I just want to touch on brak really quick because i think theres some opportunities to get rid of some facilities that arent being used. You would agree manpower and recruitment of manpower is a continuing challenge, wouldnt you . Absolutely. So i would just say, as we look for ways to save money and common sense ways, what im really concerned of, and i know youre not a part of this. If you are, let me know. That they will come in and potentially, if we do it in congress or if you do it administratively, do a brak, and say, you know, what i just picked a town. Glasgow, montana. They have a sea dock, havent had a dock for years. We say the vets arent using this and close it down. Same thing could be said for senator rounds of south dakota. If Something Like that were to happen, i guarantee there would be a bipartisan explosion on this committee, which wouldnt be a good thing. I just bring that to your attention. Im all for making sure that youre getting rid of properties you dont use anymore, and have outlived their usefulness and utilizing the dollars. Thats a Good Government thing and i applaud those efforts. When we get into the because im going to tell you, i know there are some people who want to do a fullblown brack, and im going to tell you some of the metrics arent going to speak well. Because nay havent been staffed. In your testimony you said Suicide Prevention was a top priority. Uhhuh. You also mentioned vas meldinize to the primary care. Tell me what that means in montana. Well, what it means is va, by far, is leading the strategy across the country. Where if your in your primary care office you dont have to say i am ive been given a number to go and call for a Mental Health appointment. You get that Behavioral Health care as part of your primary care aucoffice experience. I agree this is i know. But how are you going to do it when you got to have somebody there that knows the issue, right . You have have the Mental Health professionals with your primary care people. Co located. Were about 20 short right now. So the best laid plans without the infrastructure blow it it goes back to what youre saying. We have a man power issue and its geographically distinct, particularly in areas that dont have a lot of medical schools and other places that train professionals. And senator muran talked about other opportunities out there that could get us, behind psychiatrists and psychologists, some other folks that can help. Is that proceeding . And is it proceeding well and are we making some inroads . Im going it tell you weve talked a lot about what altitude and all this stuff. We got to get arms around the whole baby before we can even get to a point where no other Health System has Suicide Prevention coordinators. Thats a va strategy i think is super effective. Were using peer support specialists in a way no other service is doing. Licensed psychologists and psychiatrists. Do you have any comment on the family and marriage therapists . We are encouraging as strongly as we can, facilities to hire them that as part of their within they are purview. The it other thing in your question to primary care Mental Health integration is our teleMental Health. And can you tell me and c box overall, do they all have telehealth capabilities . Not all of them. We list on our websites which ones do. But certainly the rural ones will be more likely than in new york city. One of the cool things that amazes me is you go into a primary care office and right there is a digital display that if the primary care doctor wants to dial in a psychologist or psychiatrist, they can do it right from their office and the pa patients there. I dont see that in many places in the private sector. Thats good. I want to go back to man power for a second. Earlier in the year you testified you were going to try to get a thousand additional Mental Health providers today. Youve hierd over 600 Mental Health providers. Im not going to ask what the difference is between additional and new but well, you just asked it and the answer is no. The 623 is keeping us even. Were not succeeding at that thousand net new profession ls. I need help in doing that. Doctor . Yes. What do we need to do . What we need to do is a, give us more direct hiring authority, just like you did in the acco t accountability act. Make it easier for me to hire. And we talked the fact that our recruitment and retention dollars were cut in half. That was shortsighted, quite frankly. We need the tools to bow able to recruit the very best Health Care Professionals. If were serious about tackling this, dont tie one of my hands behind my back. Did we cut your Recruitment Retention dollars . To pay for the kara legislation, yes, sir. We ought to be taken out and beaten. Keep going. Recruitment dollars and the flexibility to be able to had help expand training. Those are the three areas that would really make difference. Look, theres a National Shortage here. So, you know i think we all worry about not just whats happening in va but everywhere. These are all important strategies, particularly the training one. I yill make one side comment. Youre right it is a national problem. But the veterans, we made a promise to them. So we cant have a bunch of excuses. We got to have more solutions than appreciate you guys being here. Thank you. Im not going to ask other questions although i have them for the record. But i remember this discussion with then secretary mcdonald. It was a series of news stories some of our members got tempted into amplifying that had had to do with training and retention programs you thought were critically important. I think what we need to do is understand if your going to make this an attractive place for Health Care Professionals to come to, help the you betver a professional development and retention close to the prievate sector. Im sure i could find something that was not good idea. But i saw the number the va was spending on a per individual basis and it was pennies on the dollar and were go tag get to that ratio. But we need make sure were not saying we need to give you recruiting and retention resources and then we want to micromanage how you go about spending it. Yrv never been the head of a major Health System before. You have. And now youre the head of one of the biggest in the world. Id trust your decision about how you have technicians and therapists and other people you want to attract so youre getting your fair share of your best resources in the private sector. Thats another thing where you hear us say one thing and do another thing here, please give us your commitment that youll say thats not a good idea. Were going to leave the record open for one week for additional questions for the record. Thanks the first panel for being here. Its always a pleasure seeing the leadership from the va. This hearing is adjourned