[Senate Hearing 112-508]
[From the U.S. Government Printing Office]






                                                        S. Hrg. 112-508

      VA MENTAL HEALTH CARE: EVALUATING ACCESS AND ASSESSING CARE

=======================================================================

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                      ONE HUNDRED TWELFTH CONGRESS

                             SECOND SESSION

                               __________

                             APRIL 25, 2012

                               __________

       Printed for the use of the Committee on Veterans' Affairs









         Available via the World Wide Web: http://www.fdsys.gov


                                _____

                  U.S. GOVERNMENT PRINTING OFFICE

74-334 PDF                WASHINGTON : 2012
-----------------------------------------------------------------------
For sale by the Superintendent of Documents, U.S. Government Printing 
Office Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800; DC 
area (202) 512-1800 Fax: (202) 512-2104  Mail: Stop IDCC, Washington, DC 
20402-0001









                     COMMITTEE ON VETERANS' AFFAIRS

                   Patty Murray, Washington, Chairman
John D. Rockefeller IV, West         Richard Burr, North Carolina, 
    Virginia                             Ranking Member
Daniel K. Akaka, Hawaii              Johnny Isakson, Georgia
Bernard Sanders, (I) Vermont         Roger F. Wicker, Mississippi
Sherrod Brown, Ohio                  Mike Johanns, Nebraska
Jim Webb, Virginia                   Scott P. Brown, Massachusetts
Jon Tester, Montana                  Jerry Moran, Kansas
Mark Begich, Alaska                  John Boozman, Arkansas
                       Kim Lipsky, Staff Director
                 Lupe Wissel, Republican Staff Director









                            C O N T E N T S

                              ----------                              

                             April 25, 2012
                                SENATORS

                                                                   Page
Murray, Hon. Patty, Chairman, U.S. Senator from Washington.......     1
Brown, Hon. Scott P., U.S. Senator from Massachusetts............     3
Tester, Hon. Jon, U.S. Senator from Montana......................    57
Moran, Hon. Jerry, U.S. Senator from Kansas......................    59

                               WITNESSES

Schoenhard, William, FACHE, Deputy Under Secretary, Health, 
  Operations and Management, U.S. Department of Veterans Affairs; 
  accompanied by Antonette Zeiss, Ph.D., Chief Consultant, Office 
  of Mental Health Services; and Mary Schohn, Ph.D., Director, 
  Office of Mental Health Operations.............................     5
    Prepared statement...........................................     7
    Response to posthearing questions submitted by:
      Hon. Patty Murray..........................................    11
      Hon. Bernard Sanders.......................................    16
      Hon. Johnny Isakson........................................    18
      Hon. Roger F. Wicker.......................................    20
Halliday, Linda, Assistant Inspector General for Audits and 
  Evaluations, Office of Inspector General, U.S. Department of 
  Veterans Affairs; accompanied by Larry Reinkemeyer, Director, 
  Kansas City Office of Audits and Evaluations...................    27
    Joint prepared statement.....................................    28
    Response to posthearing questions submitted by:
      Hon. Bernard Sanders.......................................    32
      Hon. Johnny Isakson........................................    32
Daigh, John, M.D., Assistant Inspector General for Healthcare 
  Inspections, Office of Inspector General, U.S. Department of 
  Veterans Affairs; accompanied by Michael Shepherd, M.D., Senior 
  Physician, Office of Healthcare Inspections....................    33
Tolentino, Nicholas, OIF Veteran and Former VA Mental Health 
  Officer........................................................    34
    Prepared statement...........................................    36
Jones, MajGen Thomas S., USMC (Ret.), Founder and Executive 
  Director, Outdoor Odyssey Youth Development and Leadership 
  Academy........................................................    43
    Prepared statement...........................................    44

                                APPENDIX

Altman, Claire Haaga, Executive Vice President/Chief Operating 
  Officer, HealthCare Chaplaincy; prepared statement.............    69
American Society for the Advancement of Pharmacotherapy; prepared 
  statement......................................................    70

 
      VA MENTAL HEALTH CARE: EVALUATING ACCESS AND ASSESSING CARE

                              ----------                              


                       WEDNESDAY, APRIL 25, 2012

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 9:35 a.m., in 
room SD-138, Dirksen Senate Office Building, Hon. Patty Murray, 
Chairman of the Committee, presiding.
    Present: Senators Murray, Tester, Brown, and Moran.

           STATEMENT OF HON. PATTY MURRAY, CHAIRMAN, 
                  U.S. SENATOR FROM WASHINGTON

    Chairman Murray. Good morning. This hearing will come to 
order. I would like to welcome all of you to today's hearing to 
evaluate VA access to mental health care services.
    Today's hearing builds upon two hearings held last year. At 
each of the previous hearings, the Committee heard from the VA 
how accessible mental health care services were. This was 
inconsistent with what we heard from veterans and the VA mental 
health care providers. So last year, following the July 
hearing, I asked the Department to survey its own mental health 
care providers to get a better assessment of the situation.
    The results, as we all now know, were less than 
satisfactory. Among the findings, we learned that nearly 40 
percent of providers surveyed could not schedule an appointment 
in their own clinic for a new patient within the VA-mandated 
14-day window; and 70 percent reported inadequate staffing or 
space to meet mental health care needs.
    The second hearing, held in November, looked at the 
discrepancy between what the VA was telling us and what the 
providers were saying. We heard from a VA provider and other 
experts about the critical importance of access to the right 
type of care, delivered timely by qualified mental health 
professionals.
    At last November's hearing, I announced that I would be 
asking VA's Office of Inspector General to investigate the true 
availability of mental health care services at VA facilities. I 
want to thank the IG for their tremendous effort in addressing 
such an enormous request. The findings of this first phase of 
the investigation are substantial and troubling. We have heard 
frequently about how long it takes for veterans to get into 
treatment, and I am glad the IG has brought those concerns to 
light.
    The IG will also discuss an entirely different and more 
useful way of understanding access to care. This model would 
give more reliable data and reduce the rampant gaming of the 
system that we have seen thus far. The IG has also found the 
existing scheduling system is hopelessly insufficient and needs 
to be replaced.
    VA has struggled with developing a new scheduling system. I 
understand VA is working to get a replacement system in place. 
I would like the Department's commitment that they will work to 
get this done right and get it done soon.
    The IG findings also show some serious discrepancies in 
what VA has been telling this Committee and veterans. VA stated 
that 95 percent of veterans received mental health evaluation 
within 14 days. In reality, it was only about 50 percent. VHA 
data reported that after the evaluation was completed, 95 
percent of veterans received a treatment appointment within 14 
days. In reality, it was only 64 percent. For those in 
treatment, 12 percent were scheduled beyond the 14-day follow 
up appointment window, with providers telling the IG that they 
were delaying follow up for months, not because of the 
veterans' needs, but because their schedules were too full.
    VA is failing to meet its own mandates for timeliness and 
instead is finding ways to make the data look like they are 
complying. VA can and must do much better. Important steps have 
been taken in the right direction by the Department. Last week, 
VA announced the addition of 1,600 mental health providers. And 
late last year, VA announced an increase in staffing levels at 
the Veterans Crisis Line.
    As we will see today, the hard work remains in front of us 
at a time when veterans are dying by suicide at an alarming 
rate. We know that the sooner a veteran can get a mental health 
care appointment after they request it, the more likely they 
are to follow through with care.
    We cannot afford to leave them discouraged when trying to 
access care, and when in care, we must be getting veterans 
their next appointment in a clinically appropriate time. We 
need to be sure there are enough resources so providers do not 
have to delay treatment because their schedules are too full.
    While I commend VA for the decision to hire another 1,600 
mental health providers, there is still no reliable staffing 
model to determine where these individuals are needed. Without 
that model, VA needs to explain how they will know where to 
place these additional providers.
    There are other challenges with getting the best providers 
into the system. I understand that nationally there are 
shortages of mental health providers, and it is even harder for 
VA because they cannot always pay the highest salaries in the 
community. There are still a large number of vacancies in VA's 
mental health ranks.
    I want to hear from the Department how they will fill the 
existing gaps and ensure the new positions they have announced 
do not become 1,600 empty offices. Ultimately, what really 
matters is how long it takes for a veteran to start that first 
treatment session. What really matters is not abandoning that 
veteran.
    I recently saw Andrea Sawyer whose husband Lloyd suffers 
from PTSD and depression. Andrea bravely testified before this 
Committee last July about the tremendous difficulties she and 
her husband faced in getting him into care. Lloyd still faces 
challenges, but he is now getting the care he needs. That is 
what matters. We cannot let our veterans down, especially when 
they have shown the courage to stand up and ask for help.
    I look forward to hearing from VA how they intend to 
address the issues the IG has found. Now more than ever is the 
time for action and for VA to show effective leadership. Let 
the hearing today serve as an unequivocal call to action. The 
Department must get this right.
    In closing, I do want to be clear that while we have 
discussed a number of problems with the system at large, none 
of this reflects poorly on VA's providers. I believe I can 
speak for all of us in thanking VA's many mental health 
providers for the incredible job that they do. Let there be no 
mistake, these individuals are incredibly dedicated to their 
mission. They choose to work harder than most of their peers, 
often for less lucrative benefits, all because they believe in 
what they do and because they have a deep and unshaking 
commitment to our veterans.
    To all of VA's psychiatrists, psychologists, social 
workers, and other providers, and to all the administrative 
staff who support them, thank you so much for the good job, and 
keep up the good work.
    With that, I want to turn it over to Senator Brown who is 
standing in for Senator Burr today.

               STATEMENT OF HON. SCOTT P. BROWN, 
                U.S. SENATOR FROM MASSACHUSETTS

    Senator Brown. Thank you, Madam Chair. It is good to be 
here as the Ranking Member in place of Senator Burr. It is good 
to be back on the Committee serving with you. I want to thank 
you for holding this very important hearing.
    Some of these I am still serving, I see and hear of these 
types of situations regularly. $5.9 billion, that is the 
increase that VA got. And out of that, do you think we could 
hire some more people to address these very real concerns? $5.9 
billion.
    To read some of the things that we have been reading about 
the suicidal veteran calling for help, gone unanswered, one 
more person killing themselves, and the veteran's mental health 
care is delayed--put out by the Washington Post, actually 
yesterday, talking about how the system is being gamed by the 
VA, and not actually scheduling and following through with 
scheduling and providing a good opportunity for these soldiers 
to get the care and coverage that they need--it is mind 
boggling.
    I mean, I understand the delay. I understand that there are 
problems. I understand that claims go over a year. But for 
somebody who calls and says, ``Hi, I'm thinking of killing 
myself.''
    ``Well, do you feel that way right now?''
    ``Well, not right in this moment. But I tried to hang 
myself yesterday. Does that count?'' And then to be blown off; 
it just makes absolutely no sense to me at all.
    So I am glad you are holding this hearing. I want to 
continue to look into mental health services. Your insights in 
this Committee help perform the oversight to ensure that 
veterans get the services they need, and that is a good thing.
    As you know, one of the several hearings regarding mental 
health services--this is another one--last year, I remember we 
did learn about the various serious mental health services that 
were needed and, quite frankly, lacking. I want to just say 
that today's hearing will focus on evaluating the availability 
of these services and accessing the care that is delivered.
    The testimony we hear today will be from VA's Inspector 
General, as well as Iraq veteran and former VA mental health 
officer, Nick Tolentino, who feels there is an ongoing cultural 
problem at the VA.
    Nick, I want to thank you for your testimony and pointing 
out where the loopholes are sought and openly shared to hide 
the fact that the facilities are not meeting their performance 
metrics. And I have got to tell you, it is unacceptable, as I 
said, for some of you who still serve and see and speak 
regularly with people that are affected by these various 
serious ailments.
    The gaming of the system has to stop. The IG found in their 
audit, and Nick confirmed in his testimony, that our veterans 
are not given the opportunity to actually offer a desired date 
for their next appointment. They were simply told when and 
where to show up and no consideration or compassion to address 
the very real concerns that they have.
    The scheduling system is not the only problem with 
delivering mental health care. Even though the VA has increased 
the staffing by 48 percent between 2006 and 2010, both the IG 
and Nick point out that it is understaffed and lacks a 
methodology to assess their staffing needs. And it is no 
surprise that just 1 week after this hearing, VA announced they 
are hiring 1,900 additional mental health staffers.
    Well, that is great. It is a good start. But, man, what 
have we been doing up to this point? We need to do it better. 
We have people's lives depending on these decisions that we are 
making. And it is a good step, as I said, but how long will it 
take to actually fill these positions? And what happens to that 
soldier who calls, as been happening with Jacob Manning and 
others.
    We will hear today from community groups that are helping, 
General Tom Jones, founder of Semper Fi Odyssey, to help 
veterans from the current conflicts manage their mental health. 
And I want to thank you, sir, for that effort, going above and 
beyond. It will help veterans volunteer their time to help 
fellow soldiers cope with those invisible wounds of war, which 
we all know about. It is a great example of the community 
coming forward and addressing needs not currently being met. So 
thank you for that.
    In the end, simply hiring more staff and fixing VA's broken 
scheduling system will not cure all the issues, but it will 
certainly take a combination of changes at the facility level 
and the VA office level. And the VA will use all available 
resources, including fee bases, care, staffing increases, and 
developing better performance metrics to fix a severely broken 
system.
    I concur with you that the individual people that are 
there, they are doing yeoman's work, but it is still not 
enough. Is it you need more people? You need more computers? 
What is it? $5.9 billion should go a long way to addressing 
those issues.
    Madam Chair, as I reference, I am heading upstairs just to 
give HSGAC a quorum, then I will be right back down. So I look 
forward to everybody's testimony. Thank you.
    Chairman Murray. At this time, I would like to introduce 
the first panel. Representing the VA is Mr. Bill Schoenhard, 
VA's Deputy Under Secretary for Health, Operations and 
Management. He is accompanied today by Dr. Antonette Zeiss, 
Chief Consultant for the Office of Mental Health Services, and 
Dr. Mary Schohn, Director of Mental Health Operations with the 
Veterans Health Administration at the Department of Veterans 
Affairs.
    From the Office of Inspector General, we have Dr. David 
Daigh, Assistant Inspector General for Healthcare Inspections, 
accompanied by Dr. Michael Shepherd, senior physician in the 
IG's Office of Healthcare Inspections. Also from the Office of 
Inspector General, we have Ms. Linda Halliday, Assistant 
Inspector General for Audits and Evaluations, accompanied by 
Mr. Larry Reinkemeyer.
    Next, we will hear from Nick Tolentino. He is a Navy 
veteran of the Iraq War and a former mental health 
administrative officer in the VA.
    Finally, we will hear from the founder and executive 
director of Outdoor Odyssey, retired U.S. Marine Corps, Major 
General Thomas Jones.
    So, Mr. Schoenhard, we will begin with your testimony. We 
have a lot of answers we need from you, so please begin.

STATEMENT OF WILLIAM SCHOENHARD, FACHE, DEPUTY UNDER SECRETARY, 
HEALTH, OPERATIONS AND MANAGEMENT, U.S. DEPARTMENT OF VETERANS 
     AFFAIRS; ACCOMPANIED BY ANTONETTE ZEISS, PH.D., CHIEF 
CONSULTANT, OFFICE OF MENTAL HEALTH SERVICES; AND MARY SCHOHN, 
      PH.D., DIRECTOR, OFFICE OF MENTAL HEALTH OPERATIONS

    Mr. Schoenhard. Thank you.
    Chairman Murray, we appreciate the opportunity today to 
address the access to and the quality of mental health care 
services to our Nation's veterans. And we appreciate so much 
discussion of a topic that is integral to the well being and 
full living out of a fulfilled life of our Nation's veterans.
    Mental health is integral to the overall well being and 
physical health of a veteran. It is important, if there is 
underlying depression, problem drinking, or substance abuse, or 
other medical mental ailment, that this be diagnosed in order 
to ensure that those who have served our country have the full 
treatment of something that is so core to their overall well 
being and to their ability to also implement the physical 
health aspects of medication management, staying employed and 
the rest, which is so important to the quality-of-life of a 
veteran who has served this country.
    It is the sacred mission of VA to ensure that this very 
integral part of our care is well delivered.
    I appreciate so much your comments regarding the 20,500 
providers who on the ground work so hard every day to serve our 
Nation's veterans in this important mission.
    In the written statement, I have outlined three areas of 
improvement and concern, but I would like to first mention that 
we appreciate so much your leadership, the Committee's review, 
and the Inspector General's review. This is an important aspect 
of care, and we appreciate all of the assistance.
    We will be working very closely with the Inspector General 
as we go forward with their report as it relates to the first 
recommendation that I would like to address. And that is that 
we agree with the Inspector General that our appointment 
measurement system should be revised to include a combination 
of measures that better capture the overall efforts throughout 
a course of treatment for a veteran, while maintaining 
flexibility to accommodate a veteran's unique condition and 
phase of treatment.
    We must also continue our efforts to strengthen mental 
health integration into our primary care in order to ensure in 
the primary care settings that we are assessing mental health 
needs of our Nation's veterans and also be able to address the 
stigma that is often associated with this, that can be 
discussed in a primary-care setting.
    The second point I would like to make, as announced by 
Secretary Shinseki last week, we are increasing staff to 
enhance both the access to and the quality of mental health 
care by hiring 1,900 additional staff, more than 1,600 of those 
who are mental health clinicians. As I mentioned, this will 
augment the current complement of 20,500 mental health 
employees in our system and is designed to provide additional 
staff in our facilities.
    It is also designed to increase our staffing of our crisis 
line, which is so integral to the identification and treatment 
of people who are in crisis, as Senator Brown spoke of so 
eloquently. And it is also an important aspect of increase in 
that we will be adding additional examiners for compensation 
and pension examinations.
    It is an important transition from active duty to veteran 
status for those who are currently on active duty and for those 
who present with new conditions. We have a solemn 
responsibility to ensure that we increase our staff to ensure 
that we can handle this volume in a timely fashion, and that we 
can do this in a way that does not erode our capacity to serve 
our existing patients.
    I want to emphasize that this additional staffing will 
continue to be evaluating and assess data and refine the 
staffing model. We are currently piloting this in three VISNs, 
and this is a work in progress that will be continually 
improved as part of our comprehensive approach to ensuring that 
our facilities have the resources to ensure that we accomplish 
this mission.
    The third point I would like to make is that deploying 
evidence-based therapies to ensure veterans have access to the 
most effective methods for PTSD and other mental health 
ailments, we are making more widespread and improving our 
training for those who are receiving care and delivering care 
of evidence based treatments. We are shifting from a more 
traditional approach to one with newer treatments.
    We would acknowledge that we have not always communicated 
these changes as clearly as we might to our Nation's veterans, 
so we are redoubling our efforts to improve communication not 
only to our providers but to our veterans to ensure that these 
evidence based therapies are implemented in a way that can be 
supported by the veteran, and fully educated and trained 
personnel assuring that that is delivered.
    In summary, we just thank you again for your encouragement, 
for your support. This is an important part of care that is 
fundamental to the well being of our Nation's veterans. We look 
forward to answering your questions and those of the Committee.
    [The prepared statement of Mr. Schoenhard follows:]
Prepared Statement of William Schoenhard, FACHE, Deputy Under Secretary 
       for Health for Operations and Management, Veterans Health 
       Administration (VHA), Department of Veterans Affairs (VA)
    Chairman Murray, Ranking Member Burr, and Members of the Committee, 
I appreciate the opportunity to address access to, and quality of, VA's 
mental health care. I am accompanied today by Mary Schohn, Ph.D., 
Director, Office of Mental Health Operations and Antonette Zeiss, 
Ph.D., Chief Consultant, Office of Mental Health Services.
    VA has testified twice within the past 12 months on its mental 
health programs, and values the feedback received from those hearings. 
From these hearings and subsequent field visits, VA has learned a great 
deal about the strengths of our mental health care system, as well as 
areas that need improvement. VA's Office of Inspector General (OIG) 
also recently completed a review of VA's mental health programs and 
offered four recommendations. The OIG cited a need for improvement in 
our wait time measurements, improvement in patient experience metrics, 
development of a staffing model, and provision of data to improve 
clinic management. VA is using the OIG results in concert with our 
internal reviews to plan important enhancements to VA mental health 
care. VA constantly strives to improve, and we will use any data and 
assessments--positive or negative--to help us enhance the services 
provided to our Veterans.
    Reviews have confirmed that Veterans seeking an initial appointment 
for a mental health evaluation generally receive the required rapid 
triage evaluation in a timely manner; this was confirmed by the OIG 
report on mental health access. While a mental health evaluation within 
14 days of the triage referral generally occurs, we were concerned to 
learn from the OIG report that those evaluations do not always result 
in the full diagnostic and treatment evaluation required by VA 
policies. Further, Veterans seeking follow up appointments may 
experience waits of longer than 14 days, especially for some intensive 
services such as beginning a course of evidence-based psychotherapy. 
While the explanations for these findings are varied, none are 
satisfactory--we must do more to deliver the mental health services 
that Veterans need. My written statement will describe how we have 
traditionally evaluated access to mental health care and how we propose 
to evaluate access in the future. It will then explain how we assess 
the quality of care delivered and potential new considerations on this 
topic. Both sections will address the need for increased staffing and 
better data collection.
                             access to care
    Ensuring access to appropriate care is essential to helping 
Veterans recover from the injuries or illnesses they incurred during 
their military service. Over the last several years, VA has enhanced 
its capacity to deliver needed mental health services and to improve 
the system of care so that services can be more readily accessed by 
Veterans. Mental health care must constantly evolve and improve as new 
research knowledge becomes available, as more Veterans access our 
services, and as we recognize the unique needs of Veterans--and their 
families--many who have served multiple, lengthy deployments. In 
addition, enhanced screening and sensitivity to issues raised by 
Veterans are also identified as areas for improvement.
    In an effort to increase access to mental health care and reduce 
the stigma of seeking such care, VA has integrated mental health into 
primary care settings. The ongoing transfer of VA primary care to 
Patient Aligned Care Teams will facilitate the delivery of an 
unprecedented level of mental health services. Systematic screening of 
Veterans for conditions such as depression, Post Traumatic Stress 
Disorder (PTSD), problem drinking, and military sexual trauma has 
helped us identify more Veterans at risk for these conditions and 
provided opportunities to refer them to specially trained experts. 
Research on this integration shows that VA is seeing many Veterans for 
mental health care who would not otherwise be likely to accept 
referrals to separate specialty mental health care. These are important 
advances, particularly given the rising numbers of Veterans seeking 
mental health care. In an informal Mental Health Query administered by 
VA in August 2011, VA learned that many of its providers in the sites 
queried believe that Veterans' ability to schedule timely appointments 
may not match data gathered by VA's performance management system. 
These providers also identified other constraints on their ability to 
best serve Veterans, including inadequate staffing, space shortages, 
limited hours of operation, and competing demands for other types of 
appointments, particularly for compensation and pension or disability 
evaluations. In response to this query, VA took two major actions. 
First, VA developed a comprehensive action plan aimed at enhancing 
mental health care and addressing the concerns raised by its staff. 
Second, VA conducted external focus groups to better understand the 
issues raised by front-line providers. As part of this action, VA is 
visiting every VA facility this year to conduct a first-hand review of 
its mental health program. As of April 25, 2012, 63 of 140 (45 percent) 
site visits have been completed, one to each VA health care system, 
with the remainder scheduled to be completed by the end of the fiscal 
year.
    As part of this ongoing review of mental health operations, 
Secretary Shinseki recently announced that VA will be adding 
approximately 1,600 mental health clinicians--including nurses, 
psychiatrists, psychologists, social workers, marriage and family 
therapists and licensed mental health professional counselors--as well 
as 300 support staff to its existing workforce of 20,590 mental health 
staff. This addition was based on VA's model for team delivery of 
outpatient mental health services, and as these increases are 
implemented, VA will continue to assess staffing levels. Further, as 
part of VA's efforts to implement section 304 of Public Law 111-163 
(Caregivers and Veterans Omnibus Health Services Act of 2010), VA is 
increasing the number of peer specialists working in our medical 
centers to support Veterans seeking mental health care. These 
additional staff will increase access by allowing more providers to 
schedule more appointments with Veterans. VA began collecting monthly 
vacancy data in January 2012 to assess the impact of vacancies on 
operations and to develop recommendations for further improvement. In 
addition, VA is ensuring that accurate projections for future needs for 
mental health services are generated. Finally, VA is planning 
proactively for the expected needs of Veterans who will separate soon 
from the Department of Defense (DOD) as they return from Afghanistan. 
We track this population to estimate the number of such Veterans, how 
many are anticipated to seek VA care, and how many who seek care are 
anticipated to need mental health evaluation and treatment services. 
These processes will continue, with special attention to whether 
patterns established up to this point may change with the expected 
increase in separations from active duty military.
    Historically, VA has measured access to mental health services 
through several data streams. First, VA defined what services should be 
available in VA facilities in the 2008 Uniform Mental Health Services 
in VA medical centers and Clinics Handbook and tracks the availability 
of these services throughout the system. Moreover, VA has added a five-
part mental health measure in the performance contracts for VHA 
leadership, effective starting in fiscal year (FY) 2012. The new 
performance contract measure holds leadership accountable for:

     The percentage of new patients who have had a full assessment and 
begun treatment within 14 days of the first mental health appointment;
     The proportion of Operation Enduring Freedom/Operation Iraqi 
Freedom/Operation New Dawn (OEF/OIF/OND) Veterans with newly diagnosed 
PTSD who receive at least eight sessions of psychotherapy within 14 
weeks;
     Proactive follow-up within 7 days by a mental health professional 
for any patient who is discharged from an inpatient mental health unit 
at a VA facility;
     Proactive delivery of at least four mental health follow-up visits 
within 30 days for any patient flagged as a high suicide risk; and
     The percentage of current mental health patients who receive a new 
diagnosis of PTSD and are able to access care specifically for PTSD 
within 14 days of referral for PTSD services.

    VA policies require that for established patients, subsequent 
mental health appointments be scheduled within 14 days of the date 
desired by the Veteran. This has been a complicated indicator, as the 
desired date can be influenced by several factors, including:

     The Veteran's desire to delay or expedite treatment for personal 
reasons;
     The recommendation of the provider; and
     Variance in how schedulers process requests for appointments from 
Veterans.

    VA understands virtually every health care system in the country 
faces similar challenges in scheduling appointments, but as a leader in 
the industry, and as the only health care system with the obligation 
and honor of treating America's Veterans, we are committed to 
delivering the very best service possible. As a result, VA has decided 
to modify the current appointment performance measurement system to 
include a combination of measures that better captures overall efforts 
throughout all phases of treatment. VA will ensure this system is 
sufficiently flexible to accommodate a Veteran's unique condition and 
the phase of treatment. Some Veterans may need to be seen more 
frequently than within 14 days (for example, if they need weekly 
sessions as part of a course of evidence-based psychotherapy), while 
others may not (for example, if they are doing well after intensive 
treatment and will benefit most from a well-designed maintenance plan 
with far less frequent meetings). A thoughtful, individualized 
treatment plan will be developed for each Veteran to inform the timing 
of appointments.
    VA has formed a work group to examine how best to measure Veterans' 
wait time experiences and how to improve scheduling processes to define 
how our facilities should respond to Veterans' needs. In the interim, 
the work group has recommended a return to the use of the ``create 
date'' metric, which will minimize the complexity of the current 
scheduling process. The ``create date'' refers to the date on which a 
Veteran requested an appointment, and the wait time will be measured as 
the numbers of days between the create date and the visit with a mental 
health professional. The work group is currently developing an action 
plan to be reviewed by the Under Secretary for Health by June 1, 2012. 
Performance measurement and accountability will remain the cornerstones 
of our program to ensure that resources are being devoted where they 
need to go and being used to the benefit of Veterans. Our priority is 
leading the Nation in patient satisfaction with the quality and 
timeliness of their appointments.
    Decisions concerning staffing and programs were determined 
historically at the facility level to allow flexibility based on local 
resources and needs. However, as evidence accumulates, it is clear that 
sites can benefit from more central guidance on best practices in 
determining needed mental health staff. Therefore, we recently 
developed a prototype staffing model for general mental health 
outpatient care using a methodology that considered findings in the 
academic literature, consultation with other health care systems, and 
productivity data. We are using these results to pilot this staffing 
model in Veterans Integrated Service Networks (VISN) 1, 4, and 22, and 
we anticipate national implementation of this new model by the end of 
the fiscal year. While the model may be refined as a result of the 
pilot testing, it provides a clear basis for assessing staffing for 
mental health services, and shows that currently there are shortfalls 
at some sites nationally.
    By adding staff, offering better guidance on appointment scheduling 
processes, and enhancing our emphasis on patient and provider 
experiences, we are confident we are building a more accessible system 
that will be responsive to the needs of our Veterans while being 
responsible with the resources appropriated by Congress.
                            quality of care
    VA has made deployment of evidence-based therapies a critical 
element of its approach to mental health care. Mental health 
professionals across the system must provide the most effective 
treatments for PTSD and other mental health conditions. We have 
instituted national training programs to educate therapists in two 
particularly effective exposure-based psycho-therapies for PTSD: 
cognitive processing therapy and prolonged exposure therapy. The 
Institute of Medicine and the Clinical Practice Guidelines developed 
jointly by VA and the DOD have consistently concluded the efficacy of 
these treatment approaches.
    Not everyone with PTSD who receives evidence-based treatment may 
have a favorable response. Although VA uses the most effective 
treatments available, some Veterans will need lifetime care for their 
mental health problems and may see slow initial improvement. Almost 
everyone can improve, but some wounds are deep and require a close, 
consistent relationship between VA and the Veteran to find the most 
effective individualized approaches over time. Veterans and their 
families should not expect ``quick fixes,'' but they should expect an 
ongoing commitment to intensive efforts at care for any problems.
    A recent analysis of data from VA's large Cooperative Study (CSP# 
494), a study on prolonged exposure to the stress factors associated 
with and contributing to PTSD symptoms among female Veterans and active 
duty Servicewomen, identified those factors that predict poor treatment 
outcome. This is the largest randomized clinical trial of prolonged 
exposure treatment ever conducted (284 participants), and the first one 
focusing solely on Veterans and military personnel. VA staff would be 
pleased to brief you in greater detail on the methodology and results 
of this study. Our analysis shows that Veterans with the most severe 
PTSD are least likely to benefit from a standard course of treatment 
and to achieve remission. Other factors that predicted poor response 
were unemployment, co-morbid mood disorder, and lower education. In 
other words, those with the worst PTSD are least likely to achieve 
remission, as is true with any other medical problem.
    Even when Veterans are able to begin and sustain participation in 
treatment, timing, parenting, social, and community factors all matter 
a great deal. Treatment, especially treatment of severe PTSD, may take 
a long time. During this period, Veterans with PTSD are at risk for 
many severe problems including family and parenting issues, inability 
to hold a job or stay in school, and social and community function. 
Further, evidence also shows that whereas a positive response to 
treatment may reduce symptom severity and increase functional status 
among severely affected Veterans, the magnitude of improvement may not 
always be enough to achieve full clinical remission. This is no 
different than what is found with other severe and chronic medical 
disorders (such as diabetes or heart disease) where effective treatment 
may make a substantial and very important difference in quality of life 
without eradicating the disease itself. Thus, providing the best 
treatments with the strongest evidence base is crucial to care, but 
that must be placed within an ongoing commitment to recognize that 
initial care may need to be followed by ongoing rehabilitative care, 
for the major diagnostic problem, for other co-occurring mental health 
problems, and for the host of psychosocial problems that may accompany 
the diagnosis (or diagnoses).
    Outcome evidence generated from cases involving Veterans who are 
receiving these therapies in VA substantiate that they are effective 
for Veterans participating in ongoing clinical care not associated with 
research projects. Based on ongoing surveys, we know that all VA 
facilities have staff trained at least in either prolonged exposure or 
cognitive processing therapy, and usually both. In addition, one of the 
preliminary results of our site visits found that many facilities have 
a strong practice of training more staff in these and other evidence-
based therapies for a wide array of mental health problems.
    As more providers are trained in these approaches to care, 
facilities are shifting from their more traditional counseling approach 
to these newer treatments. We have not always communicated well enough 
to Veterans the nature or reason behind these changes. These new 
programs emphasize a recovery model, which is strengths-based, 
individualized, and Veteran-centered. A recovery-oriented model does 
not focus exclusively on symptom reduction, but has as its goal helping 
Veterans achieve personal life goals that will improve functioning 
while managing symptoms. These efforts have been recognized as 
successful in the academic literature and through a Government 
Performance and Results Act review conducted by RAND/Altarum, which 
concluded that VA mental health care was superior to other mental 
health care offered in the United States in almost every dimension 
evaluated.
    Before the development of these evidence-based approaches, VA made 
every effort to offer clinical services for PTSD based on clinical 
experience and innovation. Some of these approaches have developed into 
the evidence-based approaches we have now, while others have not been 
shown to offer the help that was expected. Even those therapies that 
did not help in truly alleviating PTSD could come to feel like 
``lifelines'' to those receiving them. For example, some sites hold 
group educational sessions to help Veterans understand PTSD symptoms 
and causes, and these sometimes developed into ongoing groups. While 
group therapy for PTSD can be effective and is cited in the VA/DOD 
Clinical Practice guidelines, group therapy is understood (and 
validated) as possible only in fairly small groups--usually fewer than 
10 participants. Educational groups often have far more members, 
sometimes up to 50 or more; while this can be an effective way to 
conduct psycho-education, it cannot be considered ``group therapy.''
    Veterans who have used some of the PTSD services previously adopted 
by VA may not be familiar or comfortable with newer approaches, and we 
must continuously educate Veterans and others about what treatments are 
most likely to be effective and how Veterans can access them. Some of 
our own providers have not understood these changes. The National 
Center for PTSD has been providing guidance through the PTSD mentoring 
program to help facilities collaborate with providers and Veterans in 
the transition. We have developed educational processes to help clarify 
the need for and rationale behind efforts to change clinical practice 
patterns to ensure best possible care for VA.
    The Under Secretary for Health's realignment of the Veterans Health 
Administration last year created an Office of Mental Health Operations 
with oversight of mental health programs across the country. This has 
aligned data collection efforts with operational needs and connected 
resources across the agency to bring the full picture of VA's mental 
health system into focus. In fiscal year 2011, VA developed a 
comprehensive mental health information system that is available to all 
staff to support management decisions and quality improvement efforts. 
This year, a collaborative effort between VA Central Office and field 
staff is underway to review mental health operations throughout the 
system and to develop quality improvement plans to address 
opportunities for improvement through dissemination of strong practices 
across the country.
                               conclusion
    VA remains fully committed to delivering high quality, timely 
mental health care. VA defined this commitment in 2004 with the 
Comprehensive Mental Health Strategic Plan, which was fully implemented 
and evolved into the Uniform Mental Health Services Handbook in 2008. 
Efforts to implement the Handbook have been largely successful, but 
more effort is needed to ensure full implementation at every 
appropriate VA facility. In addition, new challenges and opportunities 
continuously require response. For example, OEF/OIF/OND Veterans have 
faced more and longer deployments than previous generations of 
Servicemembers, and their families have shared these challenges. Many 
of these Veterans also have survived battlefield injuries that 
previously would have been fatal. Other challenges are presented by 
Vietnam era Veterans who seek mental health care at far higher levels 
than prior generations of older adults. In part, that is because we did 
not have the effective treatments for them when they returned from 
service more than 40 years ago. We know that the therapies discussed 
previously are effective for this population, and we welcome their 
search for mental health care. As VA reaches out to serve all 
generations, and as our intensive, effective outreach programs bring in 
greater numbers of Veterans to VA's health care system, we must 
constantly find ways to keep pace with the need for expanded capacity 
for mental health services and for those services to be based on the 
best possible known treatments. Secretary Shinseki's recent 
announcement that VA will add approximately 1,600 mental health 
clinicians and 300 support staff reflects VA's continuing commitment to 
meet the needs of Veterans. As these increases are implemented, VA will 
continue to assess staffing levels.
    New technologies, staff, training, approaches to care, and data 
measurement will provide VA the mechanisms it needs to deliver the 
necessary quality and timely mental health care. VA is developing 
solutions in each of these areas or is currently implementing new 
efforts to offer better access to and quality of mental health care.
    Madam Chairman, we know our work to improve the delivery of mental 
health care to Veterans will never be done. We appreciate your support 
and encouragement in identifying and resolving challenges as we find 
new ways to care for Veterans. This concludes my prepared statement. My 
colleagues and I are prepared to respond to any questions you may have.
                                 ______
                                 
  Response to Posthearing Questions Submitted by Hon. Patty Murray to 
 William Schoenhard, Deputy Under Secretary for Health for Operations 
  and Management, Veterans Health Administration, U.S. Department of 
                            Veterans Affairs
                              health care
    Question 1. The Department has conducted several site visits to 
medical facilities across the country to get a better sense of what is 
happening at various points of access to mental health care. Please 
provide the Department's assessment of the findings from these site 
evaluations.
    Response. Site visit teams review the implementation of the Uniform 
Mental Health Services Handbook (UMHSH) across 18 domains; these 
domains capture all components of the mental health program that are to 
be implemented nationally. The team identifies strengths and 
opportunities for growth in each of these domains based on facility 
data submitted as pre-work, data from the Mental Health Information 
System, information gathered at the site through interviews with 
facility and mental health leadership; information gathered during 
interviews with front-line staff; and finally information gathered from 
Veterans, Veterans' family and friends and community stakeholders. 
Prior to the facility debrief at the end of the visit, the site visit 
team determines the top five strengths and opportunities for growth at 
the facility. Strengths are determined by the team as practices which 
exceed the UMHSH guidance in any of the 18 areas, while opportunities 
for growth are areas in which the facility would benefit from targeted 
approaches for improvement.
    An analysis of the initial 55 site visits completed through 
March 31, 2012, has been completed based on the summaries of the top 
five strengths and top five growth areas aggregated across facilities.
Common Strengths:
     Identification of the mental health staff as hard working, 
mission-oriented individuals focused on the care of Veterans.
     Numbers of staff trained in Evidence-Based Psychotherapy and 
supported by mental health leadership to complete all necessary 
training requirements.
     Suicide prevention services, including providing education to 
staff on suicide prevention while simultaneously providing continuity 
of care services for Veterans at high risk for suicide.
     Substance Use Disorder treatment.
     Provision of services to Veterans who are homeless.
     Development of excellent community partnerships to assist in 
providing the best care for Veterans.
Common Opportunities for Growth:
    Identification of opportunities for growth does not mean it is not 
present at a facility, but rather that this area is in need of further 
development. The most common opportunities for growth identified were:

     Expansion of recovery-oriented programming, especially in 
inpatient settings, and further developing Psychosocial Rehabilitation 
and Recovery Centers (PRRCs) while increasing the presence and role of 
Local Recovery Coordinators.
     Expansion of peer support services.
     Need to fill vacancies and/or address concerns related to staff 
members covering multiple roles related to covering for staff 
vacancies.
     Need to expand the Primary Care-Mental Health Integration program 
to include both co-located collaborative care providers and care 
management services within primary care.
     Need to continue to improve transitioning of Veterans between 
different levels of care, including tracking and follow-up of Veterans 
as care is transferred from various settings such as inpatient to 
residential, residential to outpatient, and outpatient to inpatient.
     Need to improve wait times, access, and scheduling of appointments 
for Veterans.

    Question 2. OIG found VA's performance measures do not accurately 
convey whether patients are being provided timely access to mental 
health care. How will VA ensure medical centers are reliably and 
accurately reporting whether they are providing patients timely access 
to mental health care service, as well as verify those reports?
    Response. The Department of Veterans Affairs (VA) has formed a 
workgroup, including leadership from VHA clinical operations, mental 
health operations, systems redesign, and field representation, to make 
recommendations on methods to measure Veterans' wait time experiences 
and to improve scheduling processes based on Veterans' needs. The 
Veterans Health Administration (VHA) has piloted the use of metrics 
that will simplify the interactions required between a scheduler and a 
Veteran as well as increase the number of measurement points to include 
the full continuum of care. In the interim, the workgroup has 
recommended using the ``create date'' metric for new patients, which 
minimizes the complexity of the current scheduling process. The 
``create date'' is captured ``automatically'' by the computer when an 
appointment is made. VHA has also developed and successfully piloted a 
proposed standard process to more reliably capture ``desired date'' for 
established patients. The work group recommendations were accepted by 
the Under Secretary for Health (USH) on July 1, 2012. To support 
implementation of the new metrics, VHA has established a workgroup to 
develop training materials and processes to educate clinicians and 
schedulers about the new requirements. As part of implementation, an 
auditing process will be developed to assess reliability and accuracy 
with the new reporting requirements. In addition, VHA will continue to 
use the site visit methodology to verify the process. Full 
implementation of the new metrics is anticipated by the start of fiscal 
year (FY) 2014.

    Question 3. OIG indicated VA's mental health care measures for 
evidence based therapies are not valid. How will VA hold medical 
centers accountable to ensure evidence based therapies are being 
provided as treatment guidelines state?
    Response. The measure evaluated by the VA Office of Inspector 
General (OIG) as the evidence-based psychotherapy measure was still in 
draft form at the time of the audit. This measure is not directly a 
measure of evidence-based practice, but is a proxy measure to assess 
the percent of patients receiving an intensity of treatment (eight 
sessions in fourteen weeks) deemed as adequate for effective provision 
of psychotherapy. A software development project is underway to develop 
templated progress notes that will more directly measure implementation 
of evidenced-based therapies. These templates provide a mechanism of 
tracking utilization of evidence-based psychotherapies (EBP), currently 
not available in our system, and will be required for use whenever EBPs 
are employed. Once these become available, Veterans Integrated Service 
Network (VISN), facility and VA Central Office Leadership will be able 
to review the data to follow-up on practices that do not meet the 
treatment guidelines.

    Question 4. How will OMHS ensure a non-clinical encounter with 
veterans related to the mental health care services is not recorded as 
a session of treatment for performance measure purposes?
    Response. Encounters which are entered in the Electronic Health 
Record (EHR), include information about the clinic where a visit 
occurred (documented with a stop code), the provider who met with the 
Veteran, and a Current Procedural Terminology (CPT) code. CPT codes 
describe what medical and diagnostic services occurred during a 
particular visit. Certain CPT codes are used to reflect the delivery of 
mental health treatment. If an encounter is non-clinical in nature, it 
would be reflected in the CPT code utilized, and it would not include a 
CPT code that is reflective of treatment. Based on the logic of the 
mental health metrics, non-clinical encounters would not be recorded 
with treatment CPT codes, and thus would not be recorded as a session 
of treatment for performance measure purposes.

    Question 5. Psychotherapy session note templates were proposed by 
VA's Office of Patient Care Services, Mental Health Services to help 
clinicians consistently document use of evidence-based psychotherapies 
and accurately track use of these treatments, as well as allow program 
evaluators to monitor treatment outcomes. Please provide the Committee 
with the status of the implementation of these session note templates.
    Response. Mental Health Services has developed session-by-session 
documentation templates for evidence-based psychotherapies being 
nationally implemented in VHA. The first set of evidence-based 
psychotherapy documentation templates is on the current Work Plan of 
the Office of Information and Technology for planned distribution to 
the field by the end of fiscal year (FY) 2013.

    Question 6. Please describe the methodology used to allocate 
special funding for mental health initiatives. What steps is VA taking 
to hold recipients of such funding accountable for its targeted use and 
to prevent recipients from reallocating the funds to be used for other 
priorities set forth by VISN or medical center leadership?
    Response. VHA, through the offices of Workforce Management and 
Consulting (WMC) and the Office of Mental Health Operations (OMHO) is 
closely tracking the hiring of the additional staff recently funded as 
well as the filling of existing vacancies to ensure the monies are 
being spent for mental health staff. WMC and OMHO are providing 
biweekly reports and as needed to VHA senior leadership on the hiring 
status.

    Question 7. After the Department concludes its site visit reviews 
of mental health care services, how will VA ensure systematic 
surveillance efforts are carried out to better understand care trends, 
links between care processes and treatment outcomes, and facility-by-
facility differences in performance?
    Response. OMHO is currently completing site visits at all 140 VHA 
facilities this fiscal year. Upon receipt of the site visit report, the 
facility schedules a meeting with Director of OMHO, the OMHO technical 
assistance specialist, facility leadership, facility mental health 
leadership, and VISN mental health leadership. On this call, the 
findings are reviewed and the facility is asked to submit an action 
plan to address the recommendations. OMHO provides ongoing 
consultation, at a minimum on a quarterly basis, with the facility to 
ensure implementation of the action plan. VHA is aggregating the data 
across facilities to look for systemic areas that require improvement 
across the system.

    Question 8. In 2005, and again in 2007, OIG released reports 
highlighting problems with VA's patient scheduling system, including 
the calculation of wait times and inconsistent practices used by 
schedulers to capture appointment information. Despite the 
identification of these issues nearly seven years ago, the most recent 
IG report again identified these same issues as significant challenges. 
Please explain how recommendations issued by OIG and concurred with by 
the Under Secretary for Health remain unresolved for so long, and 
discuss the lessons learned.
    Response. In response to problems identified by OIG in 2005 and 
again in 2007, VHA stepped up its efforts to systematically train 
schedulers on correct scheduling practices and to audit their 
performance. These requirements were outlined in VHA policies published 
in 2008 and 2009. Internal VHA surveys show that compliance with VHA 
policy, especially in the area of entering desired date correctly has 
improved from the 60 percent range when OIG first studied the problem 
to the current 90 percent range in Mental Health. Because of the large 
number of employees scheduling appointments (50,000+) and the large 
number of appointments made each year (over 80 million), even a small 
rate of error will result in a large absolute number of desired date 
inaccuracies. While the problem is not completely solved, performance 
has improved. VHA has learned that training alone will not solve the 
problem, and is working to improve the reliability of Desired Date 
entry again by piloting efforts to standardize communication processes 
and electronically audit desired date accuracy.
Additional Information:
    VHA has, over the years, attempted to improve and strengthen the 
policy direction, measure, display, and report waiting times, and 
respond to all known issues. Appendix 1 and 2 provide detailed 
timelines of significant activities. The following table is a brief 
summary of major events:
----------------------------------------------------------------------------------------------------------------
                                                     Events                     VHA Responses
------------------------------------------------------------------------------------------------------------------------------------------------------------- GAO/IG Report Findings ----------------------------    Directives
    Timeline                                                       VHA Waiting Time Metric
--------------------------------------------------------------------------------------------------------------------------1999---  ------------------------------------------Third Next Available-------------------------------
----------------------------------------------------------------------------------------------------------------
     2000-2004                                               Next Available                            2002-028
----------------------------------------------------------------------------------------------------------------
        Jan-03    Audit of Veterans Health Administration's   Electronic Waiting List
                  Reported Medical Care Waiting Lists
----------------------------------------------------------------------------------------------------------------
        Jan-04                                               Beginning of Time Stamp Measures
----------------------------------------------------------------------------------------------------------------
                                                             Create Date for New Patients
----------------------------------------------------------------------------------------------------------------
                                                             Desired Date for Established
                                                              Patients
----------------------------------------------------------------------------------------------------------------
          2005   Audit of Outpatient Scheduling Procedures
----------------------------------------------------------------------------------------------------------------
          2007   Audit of the Veterans Health                Access List
                  Administration's Outpatient Waiting Times
----------------------------------------------------------------------------------------------------------------
          2008   Audit of Efforts to Reduce Unused           Consult Wait Time Measures Started        2008-056
                  Appointments
----------------------------------------------------------------------------------------------------------------
                 Audit of Alleged Manipulation of Waiting
                  Times in Veterans Integrated Service
                  Network3
----------------------------------------------------------------------------------------------------------------
                 Review of Alleged Manipulation of Waiting                                             2009-070
                  Times, North Florida/South Georgia
                  Veterans Health System
----------------------------------------------------------------------------------------------------------------
          2009                                               Recall Scheduling System
----------------------------------------------------------------------------------------------------------------
    Oct 1 2009   Veterans Health Administration Review of    Desired Date for New and                  2010-027
       (FY2010)   Alleged Use of Unauthorized Wait Lists at   Established Patients
                  the Portland VA Medical Center
----------------------------------------------------------------------------------------------------------------
                 Audit of VA's Efforts To Provide Timely
                  Compensation and Pension Medical
                  Examinations
----------------------------------------------------------------------------------------------------------------
          2012   Review of Veterans' Access to Mental
                  Health Care
----------------------------------------------------------------------------------------------------------------

Specific Explanation of Issues:
     Appointment waiting times are a negotiation between patients, 
providers, and the schedule capacity considering a number of factors. 
Experience has taught that there is no one perfect way or ``solution'' 
to the measurement of waiting times.
     Private sector waiting time methods focus on capacity measures 
such as time to the third next available open appointment slot. VHA 
possesses and uses third next (and first next available) capacity 
measures and has since 1999.
     Because of the weaknesses in capacity measures to show the 
individual patient experience, beginning in 2004, VHA went well beyond 
other healthcare systems to measure 4 time stamps for every one of the 
approximately 80 million appointments per year.
     Each one of the time stamp points (Desired Date, Create Date, 
Scheduled (future) Appointment and Completed Appointment) has its 
strengths and weaknesses. Appendix 4 provides a comprehensive 
explanation of these strengths and weaknesses. The challenges in 
measuring waiting times exist for every healthcare system, not just 
VHA.
     Based on VA commissioned research studies that have just recently 
become available, VHA has new information on which measures are best 
associated with patient satisfaction and patient outcomes. VHA has 
learned:

         - Create Date has the strongest association with New Patient 
        Satisfaction and outcomes
         - Desired Date (prospective) has the strongest association 
        with Established Patient Satisfaction and outcomes

     Limitations of the Desired Date (DD) measure include reliance on 
schedulers to accurately determine Desired Dates. Multiple OIG reports 
since 2005 found the DD was not entered correctly in some cases. 
Internal audits of VA's scheduler performance in 2005 found DD 
correctly entered about 60 percent of the time. VHA agreed with the OIG 
finding and undertook mandatory scheduler training, yearly scheduler 
audits and feedback, facility certification of scheduling directive 
compliance, nationally hosted educational sessions, etc. The most 
recent audit of 43,643 appointments, done about 54 months ago, 
indicated that Mental Health Schedulers correctly entered the DD 91.61 
percent of the time.
     It should be pointed out that there is yet another approach to 
measure wait times and that is from one completed appointment to 
another completed appointment. This is the method used in the widely 
debated Mental Health access performance measure looked at by the OIG 
recently where the time from completion of initial evaluation to 
completion of final evaluation was used. This method attempted to 
``zero in'' on the experience of these specific mental health patients, 
required complex programming of the system, and does not measure the 
entire waiting time experience of the patient. The OIG attempted to 
combine the wait time methods of measuring one completed appointment to 
another completed appointment combined with DD wait times. The system 
was not designed to make this connection limiting the ability of the 
system to see the patient experience accurately.
     As stated earlier, wait time measurements are only one piece of 
information that a clinic needs in order to manage their clinic 
operations. In addition to wait time, the clinic needs to know at a 
minimum, the panel size (or case load), the appointment demand, supply 
and activity, the no-shows, the cancel and reschedule rate, and the 
appointment continuity. This information is used to manage day-to-day 
clinic flow to optimize access.
Lessons Learned:
    (1) There is no perfect measure of waiting times in the VA, or 
probably in private sector for that matter.
    (2) With more than 50,000 people making appointments in VHA, many 
of whom are entry level employees and with the high turnover in that 
job, it is probably unrealistic to expect DD will be entered correctly 
in every case.
    (3) VHA should use different methods for measuring wait times in 
different sub- populations of patients (see appendix 4 and above). This 
is the best information on the ``correct'' methods to measure wait 
times that is known to exist at this point.
    (4) It is important to clearly understand the method used to 
measure wait times when interpreting actual patient experience. For 
example, Mental Health measure reflects only a portion of the entire 
patients wait time, but was reported as reflecting the entire patient 
wait time.
    (5) Management of wait times would be enhanced by a better 
scheduling system.

    Question 9. Following the November 30, 2011, hearing on mental 
health care, VA indicated in questions for the record that off-hours 
care for mental health is available widely available. Based on 
completed site visits, has VA found discrepancies with what facilities 
have reported and what the site visits discovered regarding off-hours 
availability? Are facilities meeting the Extended Hours Access for 
Patients policy requirements?
    Response. The Mental Health After Hours Report was reviewed through 
the second quarter of FY 2012. All medical centers visited through 
April 2012 have confirmed mental health clinic activity in off-hours as 
confirmed by medical record encounters. However, the site visits have 
identified three large CBOCs that had no confirmed off-hours services 
in the first two quarters of FY 2012. These CBOCs are associated with 
two medical centers visited by OMHO through April 2012. Final site 
visits reports for these facilities have not yet been generated. 
However, overall, there does not appear to be a discrepancy between the 
Mental Health After Hours Report and what has been found on the site 
visits to date. As part of the site visit feedback, some facilities 
have been encouraged to expand the utilization of extended hours to 
assist with increasing access and reaching out to meet particular needs 
of Veterans.

    Question 10. An OIG report identified that VA does not have a 
scheduling system that works. VA is replacing the medical scheduling 
software but will not be available for full implementation until 2014 
at the earliest. Given VA has a scheduling system that is simply 
insufficient, what steps is the Department taking to expedite the 
replacement of this system so that veterans who need access to mental 
health care services can be scheduled for appointments in a timely and 
reliable way?
    a. What steps is the Department taking to expedite the replacement 
of this system?
    Response. In February 2009, the previous effort to replace VHA's 
25-year-old scheduling system was ended without success. Work to 
examine the reasons for failure, including a comprehensive risk 
assessment concluded in 2010. At that point, VA reactivated the project 
with a decision to pursue a Commercial Off-The-Shelf software package 
to replace VistA Scheduling and be compatible with the current open 
source version of VistA.
    In December 2011, VA published a Request for Information about 
scheduling software and received 35 responses from a broad range of 
industry sources. These responses validated the assumption that 
commercial products can meet most of our needs.
    VA is in the process of designing a contest under the America 
Competes Act to address the most difficult component of the scheduling 
module: the ability to schedule across all facilities in the system.
    In April 2012, Information Technology leadership led a joint VHA/
OIT/CTO workgroup which defined the projected outcomes from conducting 
a contest under the America Competes Act. A draft integrated project 
team (IPT) charter was completed and an OIT project manager was 
assigned full-time to the project in May 2012.

    b. What is VA doing now to make immediate access improvements for 
Veterans?
    Response. In the interim, VA is contracting to develop two near 
term improvements to the current scheduling system. The first is a 
Veteran-facing application intended to reside on handheld devices that 
would allow a Veteran to request an appointment within a Veteran-
specified date range. The second is a scheduler-facing application 
which would change the scheduler's view from the current blue-screen 
roll-and-scroll to a more user friendly calendar view of the schedule. 
Both of these short term improvements would provide significant 
improvements as the Veteran would be able to express their desired 
appointment date (improving the reliability of wait time measurement) 
and the scheduler would be able to much more efficiently find an 
available clinic slot. These improvements are being pursued along with 
the ultimate solution of replacing the scheduling system.
    In addition to software efforts, VA continues to train key staff in 
``Advanced Clinic Access'' principles through multiple internal venues. 
An initiative focused on improvements in Specialty Care, including 
access improvements was piloted in every network in 2012. This 
initiative will expand in 2013. VA is also working to decrease the rate 
of no-shows through system-wide initiatives including network and 
facility collaborations, virtual phone educational sessions, change 
strategies customized to individual facility problems. These 
initiatives are working to enhance the information available to local 
managers to pinpoint problematic clinics.
                                 ______
                                 
Response to Posthearing Questions Submitted by Hon. Bernard Sanders to 
 William Schoenhard, Deputy Under Secretary for Health for Operations 
  and Management, Veterans Health Administration, U.S. Department of 
                            Veterans Affairs

    Question 1. As of today, how confident are you that schedulers are 
fully complying with the 2008 Uniform Mental Health Services in VA 
medical centers and Clinics Handbook with regard to performance 
compliance standards?
    Response. We are confident that schedulers correctly establish 
Desired Date more than 90 percent of the time. In the first quarter of 
FY 2012, VA conducted an internal audit of a sample of mental health 
schedulers at each VA facility and the results demonstrated that 
schedulers were accurately capturing the Veteran's Desired Date 91.61 
percent of the time.

    Question 2. Can you explain why the performance compliance 
standards could be so universally ``misunderstood'' or 
``misinterpreted'' throughout the VA health care system?
    Response. We believe the question refers to the performance 
standard regarding scheduler entry of Desired Date. Desired Date is a 
time-stamp used to measure waiting times. VA has the experience of many 
approaches to the measurement of wait times. The table below shows the 
high level timeline of these events and measures for the past 11 years. 
In response to congressional and oversight bodies, VHA has gone well 
beyond other healthcare systems (that measure access at the ``clinic'' 
level) in implementing a measurement of ``Desired Date'' in order to 
understand access at the individual patient level. ``Desired Date'' 
means the date which the patient or provider wants the patient to be 
seen. The definition is necessarily broad in order to accommodate all 
scheduling situations. For example an established patient scheduling an 
agreed-upon future appointment with their provider is very different 
than a new or established patient requesting an out-of-cycle 
appointment for a new problem. Training 50,000 people who schedule 
appointments to enter Desired Date correctly for each situation for 
over 84 million appointments per year is a daunting task. The turnover 
of schedulers alone requires constant vigilance and training. However, 
internal VHA reviews show the performance has improved from correct 
entry about 60 percent of the time (in 2005) to more than 90 percent 
currently. VHA is currently taking steps to improve the reliability of 
Desired Date entry by piloting standard communication and electronic 
audit processes. The aim of these efforts is to improve the reliability 
of Desired Date information even more.

    Question 3. Were any schedulers reprimanded or fired because they 
were accurately reporting lower percentages in performance compliance 
standards than their counterparts who deviated from the VA Directives?
    Response. Although VHA's Office of Workforce Services maintains 
data regarding adverse employee actions for senior staff, they do not 
have data regarding whether schedulers were reprimanded or fired due to 
inaccurate reporting of lower percentages in performance compliance 
standards.

    Question 4. Do you have any idea how many veterans decided not to 
participate in VA Mental Health Care programs because they didn't want 
to wait beyond 14 days to be evaluated or have an appointment? Would 
the veteran's decision be documented as ``resistant to treatment'' or 
``denied treatment'' or ``no show'' in his or her medical record?
    Response. VHA does not currently collect data on Veterans who have 
decided that they did not wish to be evaluated due to having to wait 
beyond 14 days for a full evaluation appointment. If a Veteran decided 
that they did not wish to engage in VA mental health programs, the 
clinician who met with the Veteran should document an accurate 
reflection of the interaction with the Veteran. In the situation 
described in your question, such a statement might be ``Veteran did not 
wish to engage in mental health care programs due to an extensive wait 
for an appointment.'' Such electronic health record entries cannot be 
readily pulled at a national level.
    If a Veteran had an appointment scheduled and did not attend, they 
would be identified as a ``no show'' and attempts would be made to 
reschedule the appointment. The requirement is to attempt at least 
three times to reach the patient to reschedule or determine that they 
no longer are requesting services. There would never be a presumption 
of ``resistance to treatment.''

    Question 5. Who is responsible for quality control assurance of the 
Performance and Accountability Report (PAR)? Knowing that clinical 
scheduling has been identified as a problem by VA's Office of Inspector 
General since 2005, how did the flawed data get past quality control 
reviews?
    Response. There is no recognized ``gold standard'' in the health 
care industry for calculating appointment timeliness, and no best way 
to capture the needs of patients and clinicians in a single access 
number. The metrics used in the Performance Accountability Report were 
developed with the input of subject matter experts and approved by 
senior agency leadership. VA made the decision to calculate waiting 
times using the ``Desired Date'' methodology after several options were 
assessed by an internal working group. At the time, we believed this 
approach, while imperfect, would provide the most patient-centered 
perspective possible within our decades-old scheduling system, and that 
the improvement trends in the metrics, rather than their absolute 
values, would help gauge VA efforts at improving access.
    Although the metrics themselves were calculated electronically from 
automated data systems, we were aware that over 50,000 staff across VA 
had the capability of scheduling appointments and that their individual 
actions would impact the validity of the data. Taking that into 
account, we thoughtfully designed staff education and a process of 
periodic auditing to assure our numbers were as accurate as humanly 
possible. Seven years ago, compliance with policy was assessed at 
approximately 60 percent; a level of performance that we recognized was 
insufficient. As a result of continued education and feedback, the most 
recent audits of mental health scheduling have indicated over 90 
percent compliance with the capture of ``Desired Date'' as dictated by 
VA policy.
    In order to eliminate any ambiguity about our intent or our 
performance, we will report to Congress from this point forward 
appointment times calculated using the ``create date'' entered into our 
scheduling package, while continuing to internally track waiting times 
based on Desired Date of appointment as well. We now have evidence from 
internal research that, for Veterans seeing us for the first time, 
waiting times calculated using ``create date'' may be overall more 
predictive of patient satisfaction. The same research also suggests 
that for established patients, waiting times calculated using ``Desired 
Date'' is the better predictor of satisfaction.
    It is important to point out, however, that we capture only an 
incomplete picture of access with such measured waiting times. Holistic 
mental health care requires the engagement of a team of professionals, 
including psychiatrists, psychologists, social workers, advanced 
practice nurses, and primary care providers to assure access to 
appropriate evaluation and treatment. VA has done considerable work 
over the past decade to integrate mental health evaluation and 
treatment into team-driven primary care settings, including 
collaborative care models and the extensive use of telemedicine. These 
modalities assure that Veterans experiencing emotional distress can be 
seen immediately, without the additional step of scheduling a separate 
consultation or appointment and waiting for a response. While such 
approaches are truly Veteran-centered and appreciated by patients and 
clinicians, ironically, they are not captured in our scheduling system, 
which was designed decades before such approaches were made part of our 
clinical routine.

    Question 6. If an active-duty servicemember is diagnosed with PTSD 
by a military behavioral health care professional and is subsequently 
medically discharged from the Armed Forces, is there a formal process 
between the Military Health Care System and VA to make sure the 
veteran's treatment plan is successfully transferred between the two 
Federal agencies?
    Response. VA has a formal process in place to transition ill and/or 
injured Servicemembers from DOD to VA. VA has 33 VA Liaisons for 
Healthcare, registered nurses or licensed social workers, stationed at 
18 Military Treatment Facilities (MTFs) with concentrations of 
recovering Servicemembers returning from Iraq and Afghanistan. These 
staff transition ill and/or injured Servicemembers from DOD to the VA 
system of care. VA Liaisons are co-located with the DOD case managers 
at the MTFs and provide onsite consultation and collaboration regarding 
VA resources and treatment options. Each referral from the DOD 
treatment team, including referrals for Servicemembers being medically 
discharged with PTSD, utilizes a standardized referral form completed 
by the DOD Nurse Case Manager identifying the ongoing treatment needs. 
In addition, each referral to a VA medical center (VAMC) includes 
supporting medical documentation such as progress notes and narrative 
summaries. At MTFs without an onsite VA Liaison, DOD Case Managers can 
refer Servicemembers directly to the Operation Enduring Freedom/
Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) Program 
Manager at the Servicemember's home VAMC. These referrals also utilize 
the standardized referral form identifying the ongoing treatment needs 
as well as the supporting medical documentation. As part of this 
process, a Servicemember's treatment plan is transferred from DOD to 
VA, though the Servicemember/Veteran has a choice whether or not to 
enroll and participate in the VA health care system.

    Question 7. Did the VA pay any bonuses to employees based on the 95 
percent compliance rate for new patients receiving an evaluation within 
14 days or appointments within 14 days of their desired date?
    Response. This information is local information that is not 
available centrally.
                                 ______
                                 
 Response to Posthearing Questions Submitted by Hon. Johnny Isakson to 
 William Schoenhard, Deputy Under Secretary for Health for Operations 
  and Management, Veterans Health Administration, U.S. Department of 
                            Veterans Affairs
    Question 1. The OIG has reported several times on inappropriate and 
inconsistent scheduling practices in 2005, 2007, and now again in 2012. 
VHA has taken steps to address these issues, however, the problem 
persists.
    (a) Why does this continue to be an issue and what is contributing 
to the inappropriate practices?
    Response. Establishment of Desired Date (DD) requires knowledge of 
the patient and provider negotiation (for return appointments) and an 
understanding of what the patient wants under IDEAL circumstances (for 
new appointments, or for established patients who request a new 
appointment). Schedulers must enter the correct date in a roll-and-
scroll line in the middle of a complex computer appointing process. If 
they are pressed with other duties (checking in, checking out, 
answering phones and questions from staff and patients), it is easy for 
the scheduler to be expedient and accept the default on the DD 
question.
    (b) Is it simply a lack of training for schedulers?
    Response. Not entirely. The process of establishing DD can be 
difficult. VHA is pushing to simplify and standardize the parts of the 
communication between the provider and patient so the establishment of 
DD in that situation (which is the majority of the cases) should be 
simpler and more reliable.
    (c) Are the schedulers receiving the required annual trainings and 
taking the annual tests to ensure they are properly carrying out VHA 
directives?
    Response. The schedulers are required to successfully complete the 
scheduler modules and Soft Skills training at the time they are hired. 
The scheduler supervisors are responsible for conducting a yearly audit 
on their performance, and addressing performance gaps. Additional 
training is available and should be undertaken by those schedulers who 
are uncomfortable with the scheduling protocols.

    Question 2. According to the OIG, this is leading to skewed data 
that is not helpful to key decisionmakers from the managerial level to 
the administrative level to Congress.
    (a) Do these inconsistencies occur in all the VISNs, or some 
performing better than others?
    Response. The inconsistencies in question are the correct entry of 
the Desired Date (DD) into the VistA scheduling system. The latest VHA 
self-study on entry of DD, completed December 23, 2011, looked at 
43,643 mental health records from the five busiest Mental Health 
Clinics in all VISN's. Overall, VHA found DD was entered accurately 
91.67 percent of the time. Since most appointments made are for 
established patients rather than new patients, this study is thought to 
include predominately established patients; therefore, VHA is less 
certain about the accuracy of DD for new patients.
    No VISN enters DD correctly all of the time. This is because of 
several factors, including: the difficulty associated with determining 
the DD (as noted in the examples below); reliance on humans who may 
make mistakes to enter the DD; variation in systems and processes 
within and between clinics; and high turnover rates of scheduling 
clerks, resulting in less experienced staff performing the task at 
times.
    Some examples of different approaches to determining the Desired 
Date follow:

     If the patient has an established relationship with the provider 
and agrees to return for a future appointment, the date the patient and 
provider agree upon as the desired return date is the DD. This 
situation is often called ``internal demand'' in the Advanced Access 
literature and comprises the majority of appointments in VHA. For 
example, a patient with diabetes may be due for a return visit in 6 
months, in which case the Desired Date for the follow-up appointment 
would be the date 6 months from the present appointment, regardless of 
when the follow- up appointment is ultimately scheduled.
     Alternatively, if an established patient requests a previously 
unanticipated appointment, or a new patient requests their first 
appointment, the scheduling clerk is instructed to ask the patient when 
they would like to be seen (regardless of when they are able to be seen 
in an open slot). The answer to this question establishes the DD for 
this ``external demand'' situation. For example, if a Veteran calls on 
a Monday requesting an appointment right away and says Thursdays are 
good, the following Thursday (e.g., 3 days from the appointment 
request) is entered as the Desired Date. The appointment is then 
negotiated and created without changing the Desired Date, even if there 
is no appointment availability on the date the patient initially 
requested.

    (b) What is VHA doing to correct this problem?
    Response. VHA chartered a workgroup to make recommendations to the 
USH on developing new metrics to better measure the Veteran waiting 
experience. The workgroup made a number of recommendations that were 
accepted by the USH on July 1, 2012. These recommendations are in the 
process of being implemented.

    Question 3. In the discussion on metrics, VHA mentioned that the 
work group recommended they return to using the ``create date'' metric 
to help give a better picture of veterans' waiting times.
    (a) When the use of this was metric abandoned?
    Response. VHA still collects the data on Create Date (CD), but 
stopped using it as a performance measure in 2010.
    (b) Why did VHA stop using it?
    Response. VHA stopped using it because field facilities indicated 
there were multiple case of patients who wanted to make appointments 
earlier than 14 or 30 days from the time they wanted the appointment to 
occur. It was an attempt to make the waiting time measure more patient-
centric.

    Question 4. In light of Sec. Shinseki's announcement of the 
addition of 1600 mental health clinicians and 300 support positions, 
how will these positions be distributed amongst the VISNs?
    (a) How did VHA determine the numbers of needed clinicians and 
support staff?
    Response. VHA is piloting a staffing model to ensure consistent 
staffing patterns for outpatient mental health services based on 
numbers of patients served, the range of services available at a 
facility, characteristics of the facility, and complexity of services. 
A projection for national implementation of the model showed that many 
sites would need additional staff. This need was also suggested by data 
from site visits, providers and Veterans. The initial projection was 
then modified in conjunction with VISNs/facilities to correct for local 
practices such as the use of tele-mental health or contracting.
    (b) Is this number an appropriate reflection of the need for mental 
health providers throughout the VA system?
    Response. VHA is piloting the staffing model, which is based on 
Veteran population in the service area, mental health needs of Veterans 
in that population, and range and complexity of mental health services 
provided in the service area. VHA will be assessing the adequacy of the 
model based on access, Veteran and provider satisfaction, use of 
evidence-based psychotherapy among other therapies, and will continue 
to adjust staffing as needed to meet the mental health needs of 
Veterans.
    (c) What will VHA do in the interim to help veterans receive timely 
mental health services?
    Response. As part of the site visit process, VHA is working with 
facilities to reduce barriers to access as they are identified. In FY 
2012, VHA provided $12 million in funding to expand the use of tele-
mental health for PTSD and is continuing to work with sites to identify 
opportunities to use this technology to provide expanded services. VHA 
is also expanding the implementation of mental health in primary care 
which allows Veterans to have access to mental health services within 
the primary care setting. Sites are also able to use fee and/or 
contract services to provide timely services.

    Question 5. The VHA Action Plan states that the work group will 
provide the Under Secretary for Health with an action plan to create 
new metrics no later than July 1, 2012.
    (a) How long will the review process take?
    Response. The review process began with the July action plan 
deadline and will continue, with expected refinements, and initial 
piloting of the new metrics by the first quarter of FY 2013.
    (b) What is the timeframe for implementation of the work group's 
action plan?
    Response. It is anticipated that the action plan will be 
implemented by December 31, 2012.
                                 ______
                                 
Response to Posthearing Questions Submitted by Hon. Roger F. Wicker to 
 William Schoenhard, Deputy Under Secretary for Health for Operations 
  and Management, Veterans Health Administration, U.S. Department of 
                            Veterans Affairs
                     post-traumatic stress disorder
    Over the years, the public has seen an increase in Veterans who 
suffer from PTSD. With the recent withdrawal of U.S. combat forces from 
Iraq and the administrations announcement to end combat operations in 
2014 in Afghanistan, I expect that there will be an increasing number 
of veterans that will be diagnosed with PTSD. I am concerned about the 
process to determine how benefits are given to those who suffer from 
PTSD amid this backlog.

    Question 1. My office has received complaints about doctors at VA 
hospitals in Mississippi who are skeptical of accepted science 
regarding PTSD. What actions will be taken to ensure that certain 
doctors, who receive a large number of complaints, over an extended 
period of time, will be properly vetted by the VA and that appropriate 
action will be taken?
    Response. VHA is invested in ensuring that Veterans receive 
evidence-based care for PTSD and appreciates being informed when 
concerns are identified about PTSD treatment. Complaints about any 
provider that are reported to the patient advocates locally are 
recorded in a complaint tracking file. Supervisors are notified when a 
complaint is made and the supervisor follows up with the concern at 
that time. Additionally, all VA credentialed and privileged providers 
are required to be reviewed on a variety of performance standards twice 
a year through the Ongoing Professional Practice Evaluation (OPPE). 
Quality monitors are reviewed with providers by their supervisor. If 
there is a continued pattern of complaints regarding a provider, this 
would be reviewed at that time as well as with the mid-year performance 
and end-of-year performance evaluations. If improvements are not made, 
the supervisor may pursue disciplinary actions and/or dismissal if no 
progress is made on written goals.

    Question 2. What is the number of denials for PTSD claims at the 
Jackson Regional Office based on the doctor's recommendations? 
Additionally, what is the number of claims which were initially denied, 
but later reversed on appeal?
    Response. VBA does not track claims by physician. In FY 2011, 
service-connection for PTSD was granted on approximately 11,500 appeals 
nationally. Of these, 1,573 were granted by the Board of Veterans' 
Appeals.

    Question 3. Can you please provide the statistical data on the 
denial rate at the Jackson VA Regional Office in comparison to other VA 
Regional Offices?
    Response. In FY 2011, the average percentage of claims denied 
nationwide was 23.2 percent for claims for PTSD, to include original 
claims, claims for increase, and claims that were previously denied. 
The Jackson Regional Office's (RO) denial rate was 33.4 percent.
    In 2006 and 2009, the Institute for Defense Analyses (IDA) 
conducted studies to determine factors that contribute to differences 
in disability compensation awards. One factor they found was that 
claims approval rates vary significantly based on the population 
served. For example, ROs processing high volumes of pre-discharge 
claims and claims from recently separated Servicemembers have higher 
grant rates. Pre-discharge claims and claims from recently separated 
Servicemembers usually have service treatment records readily available 
and up-to-date medical information and have a higher number of issues 
claimed. IDA also found that other factors that contribute to the 
differences include median family income, percentage of the general 
population with a mental disability, length of service, and population 
density (urban, rural, and highly rural). In areas experiencing 
difficult economic conditions, Veterans are more likely to submit 
first-time claims, claims for an increase in benefits, and to resubmit 
claims that were previously denied, also impacting grant and denial 
percentages.

    Question 4. Why is the VA Form 9 processed at Regional Offices 
before they reach the Board of Veteran Appeals?
    Response. VA Form 9s are processed at ROs prior to going to the BVA 
because it provides additional opportunities to resolve the appeal at 
the lowest possible level. ROs must ensure the following actions take 
place after a VA Form 9 is filed:

     Determine if the VA Form 9 was timely filed
     Obtain clarification of appealed issues if VA Form 9 is incomplete
     Consider additional evidence submitted by the appellant
     Accommodate appellant requests for a local hearing at the RO
     Consider any new issues raised by the appellant

    These prerequisite steps to certifying an appeal are in place to 
ensure ROs have done everything possible to resolve the appeal prior to 
sending the claim to the Board of Veterans' Appeals.

    Question 5. Describe how the VA conducts quality control of PTSD, 
C&P Exam Results, and C&P Examiner Performances?
    Response. The Systematic Technical Accuracy Review (STAR) program 
assesses the accuracy of disability benefit determinations and is 
administered by VBA's Compensation Service. It utilizes employees well-
versed in the claims adjudication process to review and analyze claims 
data nationwide. Although there is no special review for PTSD claims, a 
percentage of them are reviewed along with other categories of claims. 
The STAR reviews focus on nationwide rating consistency by reviewing RO 
rating decision variance across frequently rated medical diagnostic 
codes, including those for PTSD and other mental disorders. In 
addition, earlier this year VBA implemented the Quality Review Team's 
transformation initiative that will result in improvements in the 
service VBA provides. Dedicated teams of quality review specialists at 
each RO evaluate decision accuracy at both the RO and individual 
employee level, and perform in-process review to eliminate errors at 
the earliest possible stage in the claims process. The teams are 
comprised of personnel trained by our national quality assurance review 
staff to assure local reviews are consistently conducted according to 
national standards.
    VHA's Office of Disability and Medical Assessment (DMA) conducts 
quality reviews of VA Compensation and Pension (C&P) examination 
requests made by VBA and examinations completed by VHA clinicians. The 
Quality Management section, an integral component of DMA's quality and 
timeliness mission, is responsible for the collection and evaluation of 
VA disability examination data to support recommendations for 
improvement throughout the VHA and VBA examination process. The quality 
review program incorporates a three-dimensional approach consisting of 
an audit review process to assess medical-legal completeness, 
performance measures, and a review process to assess clinical 
examination reporting competence.
    A mix of staff knowledgeable in both the clinical protocol/
practices of the C&P examination process and staff with VBA rating 
experience perform the reviews. This monthly random sample can include 
all potential exam types. This quality review process started in 
October 2011, replacing the former C&P Examination Program that was 
discontinued in October 2010. Ongoing enhancements to data collection 
will provide VBA and VHA with detail data to support process 
improvement.
    DMA is charged with improving the disability examination process by 
monitoring the quality of examinations conducted. Quality is monitored 
monthly using an audit review tool and the results are reported on a 
quarterly basis. This intense audit is conducted on all types of 
disability examinations, assessing consistency between the medical 
evidence and the examination report.
    DMA monitors disability examiner registration and certification and 
designs and conducts continuous education and training. DMA, in 
conjunction with the Employee Education System, oversees the program 
for mandatory registration and certification as outlined by VHA 
Directive 2008-05, ``Certification of Clinicians Performing 
Compensation and Pension Examinations,'' (below). This program provides 
all compensation and pension (C&P) clinicians with a common resource of 
essential knowledge about the C&P process and ensures that all 
Veterans' disability examinations are performed by clinicians who are 
specially trained to conduct C&P examinations.




    Chairman Murray. Thank you very much.
    Ms. Halliday?

 STATEMENT OF LINDA HALLIDAY, ASSISTANT INSPECTOR GENERAL FOR 
   AUDITS AND EVALUATIONS, OFFICE OF INSPECTOR GENERAL, U.S. 
     DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY LARRY 
    REINKEMEYER, DIRECTOR, KANSAS CITY OFFICE OF AUDITS AND 
                          EVALUATIONS

    Ms. Halliday. Madam Chairman, Members of the Committee, 
thank you for the opportunity to discuss the results of our 
recent report on veterans access to mental health care services 
in VA facilities. We conducted the review at the request of the 
Committee, the VA Secretary, and the House of Veterans' Affairs 
Committee.
    Today I will discuss our efforts to determine how 
accurately the VHA reports wait times in mental health services 
to both new and established patient appointments. Dr. Daigh, 
the assistant Inspector General for the Office of Healthcare 
Inspections, will address whether the wait times data VHA 
collects is an accurate depiction of the veterans' ability to 
access those services.
    We are accompanied today by Dr. Michael Shepherd, a senior 
physician in the Office of Healthcare Inspections, and Mr. 
Larry Reinkemeyer, the Director of the Kansas City Office of 
Audits.
    Our review found that inaccuracies in data and inconsistent 
scheduling practices diminished the usability of information 
needed to fully assess current capacity, resource distribution, 
and productivity across the VA system. In VA's Fiscal Year 
2011, in the performance accountability report, VHA reported 95 
percent of first time patients received a full mental health 
evaluation within 14 days. However, we concluded that that 14-
day reported measure has no real value as an access to care 
measure because VHA measured how long it took to conduct the 
mental health evaluation, not how long the patient waited to 
receive that evaluation.
    We calculated the number of days between the first time 
patient's initial contact with mental health and the completion 
of their evaluation. We projected that VHA provided only 49 
percent or approximately 184,000 of these evaluations, within 
14 days of either the veterans' request or referral for mental 
health care. On average, it took VHA about 50 days to provide 
the remaining patients their full evaluation.
    Once VHA provides the patient with their evaluation, VHA 
schedules the patient for an appointment to begin treatment. In 
Fiscal Year 2011, we determined that VHA completed 
approximately 168,000 or 64 percent new patient appointments 
for treatment within 14 days of their desired date. Thus, 
approximately 94,000 or 36 percent of the appointments 
nationwide exceeded 14 days.
    In comparison, VHA data showed that 95 percent received 
timely care. We also projected that VHA completed approximately 
8.8 million or 88 percent of the follow up appointments for 
treatment in 14 days. Thus, approximately 1.2 million or 12 
percent of the appointments nationwide exceeded 14 days. In 
contrast, VHA reported 98 percent received timely care for 
treatment.
    We based our analysis on the dates documented in VHA's 
medical records. However, we have concerns regarding the 
integrity of the date information because providers told us 
they used the desired date of care based on their schedule 
availability.
    I want to point out that we reported concerns with VHA's 
calculated wait time data in our audits of outpatient 
scheduling procedures in 2005 and outpatient wait times in 
2007. During both audits, we found schedulers were entering an 
incorrect desired date, and our current review show these 
practices continue. For new patient appointments, the 
schedulers frequently stated they used the next available 
appointment slot as the desired date of appointment for new 
patients. This practice greatly distorts the actual waiting 
time for appointments.
    To illustrate, VHA showed 81 percent or approximately 
211,000 new patients received their appointments on their 
desired appointment date. We found the veteran could still have 
waited two to 3 months for an appointment, and VHA's data would 
show a zero day wait time.
    Based on discussions with medical center staff and our 
review of the data, we contend it is not plausible to have that 
many appointments scheduled on the exact day the patients' 
desired.
    I offer the rest of my time to Dr. Daigh, who will provide 
the overall OIG conclusion.
    [The prepared joint statement of Ms. Halliday and Dr. Daigh 
follows:]
        Prepared Statement of the Office of Inspector General, 
                  U.S. Department of Veterans Affairs
                              introduction
    Madam Chairman and Members of the Committee, thank you for the 
opportunity to discuss the results of a recent Office of Inspector 
General (OIG) report, Veterans Health Administration--Review of 
Veterans' Access to Mental Health Care, on veteran access to mental 
health care services at VA facilities. We conducted the review at the 
request of the Committee, the VA Secretary, and the House Veterans' 
Affairs Committee. The OIG is represented by Ms. Linda A. Halliday, 
Assistant Inspector General for Audits and Evaluations; Dr. John D. 
Daigh, Jr., Assistant Inspector General for Healthcare Inspections; Dr. 
Michael Shepherd, Senior Physician in the OIG's Office of Healthcare 
Inspections; and Mr. Larry Reinkemeyer, Director of the OIG's Kansas 
City Office of Audits and Evaluations.
                               background
    Based on concerns that veterans may not be able to access the 
mental health care they need in a timely manner, the OIG was asked to 
determine how accurately the Veterans Health Administration (VHA) 
records wait times for mental health services for both initial (new 
patients) and follow-up (established patients) visits and if the wait 
time data VA collects is an accurate depiction of veterans' ability to 
access those services.
    VHA policy requires all first-time patients referred to or 
requesting mental health services receive an initial evaluation within 
24 hours and a more comprehensive mental health diagnostic and 
treatment planning evaluation within 14 days. The primary goal of the 
initial 24-hour evaluation is to identify patients with urgent care 
needs and to trigger hospitalization or the immediate initiation of 
outpatient care when needed. Primary care providers, mental health 
providers, other referring licensed independent providers, or licensed 
independent mental health providers can conduct the initial 24-hour 
evaluation.
    VHA uses two principal measures to monitor access to mental health 
care. One measure looks at the percentage of comprehensive patient 
evaluations completed within 14 days of an initial encounter for 
patients new to mental health services. Another method VHA uses is to 
calculate patient waiting times by measuring the elapsed days from the 
desired dates\1\ of care to the dates of the treatment appointments. 
Medical facility schedulers must enter the correct desired dates of 
care in the system to ensure the accuracy of this measurement. VHA's 
goal is to see patients within 14 days of the desired dates of care.
---------------------------------------------------------------------------
    \1\ The desired date of care is defined as the earliest date that 
the patient or clinician specifies the patient needs to be seen.
---------------------------------------------------------------------------
                             review results
    Our review focused on how accurately VHA records wait times for 
mental health services for initial and follow-up visits and if the wait 
time data VA collects is an accurate depiction of the veterans' ability 
to access those services. We found:

     VHA's mental health performance data is not accurate or reliable.
     VHA's measures do not adequately reflect critical dimensions of 
mental health care access.

    Although VHA collects and reports mental health staffing and 
productivity data, the inaccuracies in some of the data sources 
presently hinder the usability of information by VHA decisionmakers to 
fully assess current capacity, determine optimal resource distribution, 
evaluate productivity across the system, and establish mental health 
staffing and productivity standards.
VHA's Performance Data Is Not Accurate or Reliable
    In VA's fiscal year (FY) 2011 Performance and Accountability Report 
(PAR), VHA reported 95 percent of first-time patients received a full 
mental health evaluation within 14 days. However, the 14-day measure 
has no real value as VHA measured how long it took VHA to conduct the 
evaluation, not how long the patient waited to receive an evaluation. 
VHA's measurement differed from the measure's objective that veterans 
should have further evaluation and initiation of mental health care in 
14 days of a trigger encounter. VHA defined the trigger encounter as 
the veteran's contact with the mental health clinic or the veteran's 
referral to the mental health service from another provider.
    Using the same data VHA used to calculate the 95 percent success 
rate shown in the FY 2011 PAR, we conducted an independent assessment 
to identify the exact date of the trigger encounter (the date the 
patient initially contacted mental health seeking services, or when 
another provider referred the patient to mental health). We then 
determined when the full evaluation containing a patient history, 
diagnosis, and treatment plan was completed. Based on our analysis of 
that information, we calculated the number of days between a first-time 
patient's initial contact in mental health and their full mental health 
evaluation. Our analysis projected that VHA provided only 49 percent 
(approximately 184,000) of first-time patients their evaluation within 
14 days.
    VHA does not consider the full mental health evaluation as an 
appointment for treatment, but rather the evaluation is the 
prerequisite for VHA to develop a patient-appropriate treatment plan. 
Once VHA provides the patient with a full mental health evaluation, VHA 
schedules the patient for an appointment to begin treatment. We found 
that VHA did not always provide both new and established patients their 
treatment appointments within 14 days of the patients' desired date. We 
reviewed patient records to identify the desired date (generally 
located in the physician's note as the date the patient needed to 
return to the clinic or shown as a referral from another provider) and 
calculated the elapsed days to the date of the patient's completed 
treatment appointment date.
We projected nationwide that in FY 2011, VHA:
     Completed approximately 168,000 (64 percent) new patient 
appointments for treatment within 14 days of their desired date; thus, 
approximately 94,000 (36 percent) appointments nationwide exceeded 14 
days. VHA data reported in the PAR showed that 95 percent received 
timely care.
     Completed approximately 8.8 million (88 percent) follow-up 
appointments for treatment within 14 days of the desired date; thus, 
approximately 1.2 million (12 percent) appointments nationwide exceeded 
14 days. VHA data reported in the PAR showed that 98 percent received 
timely care for treatment. Although we based our analysis on dates 
documented in VHA's medical records, we have less confidence in the 
integrity of this date information because providers at three of the 
four medical centers we visited told us they requested a desired date 
of care based on their schedule availability.
            Scheduling Process
    Generally, VHA schedulers were not following procedures outlined in 
VHA directives and, as a result, data was not accurate or reliable. For 
new patients, the scheduling clerks frequently stated they used the 
next available appointment slot as the desired appointment date for new 
patients. Even though a consult referral, or contact from the veteran 
requesting care, may have been submitted weeks or months earlier than 
the patient's appointment date, the desired appointment date was 
determined by and recorded as the next available appointment date. For 
established patients, medical providers told us they frequently 
scheduled the return to clinic date based on their known availability 
rather than the patient's clinical need. Providers may not have 
availability for 2-3 months, so they specify their availability as the 
return to clinic timeframe.
    OIG first reported concerns with VHA's calculated wait time data in 
our Audit of VHA's Outpatient Scheduling Procedures (July 8, 2005) and 
Audit of VHA's Outpatient Wait Times (September 10, 2007). During both 
audits, OIG found that schedulers were entering an incorrect desired 
date. Nearly 7 years later, we still find that the patient scheduling 
system is broken, the appointment data is inaccurate, and schedulers 
implement inconsistent practices capturing appointment information.
            Workload and Staffing
    According to VHA, from 2005 to 2010, mental health services 
increased their staff by 46 percent and treated 39 percent more 
patients. Despite the increase in mental health care providers, VHA's 
mental health care service staff still do not believe they have enough 
staff to handle the increased workload and to consistently see patients 
within 14 days of the desired dates. In July 2011, the Senate Committee 
on Veterans' Affairs requested VA to conduct a survey that among other 
questions asked mental health professionals whether their medical 
center had adequate mental health staff to meet current veteran demands 
for care; 71 percent responded their medical center did not have 
adequate numbers of mental health staff.
    Based on our interviews at four VA medical centers (Denver, 
Colorado; Spokane, Washington; Milwaukee, Wisconsin; and Salisbury, 
North Carolina), staff in charge of mental health services reported 
VHA's greatest challenge has been to hire and retain psychiatrists. We 
analyzed access to psychiatrists at the four visited medical centers by 
determining how long a patient would have to wait for the physician's 
third next available appointment. Calculating the wait time to the 
third next available appointment is a common practice for assessing a 
provider's ability to see patients in a timely manner. On average at 
the four VA medical centers we visited, a patient had to wait 41 days.
VHA's Measures Do Not Adequately Reflect Critical Dimensions of Mental 
        Health Care Access
    The data and measures needed by decisionmakers for effective 
planning and service provision may differ at the national, Veterans 
Integrated Service Network, and facility level. No measure of access is 
perfect or provides a complete picture. Meaningful analysis and 
decisionmaking requires reliable data, on not only the timeliness of 
access but also on trends in demand for mental health services, 
treatments, and providers; the availability and mix of mental health 
staffing; provider productivity; and treatment capacity. These demand 
and supply variables in turn feed back upon a system's ability to 
provide treatment that is patient centered and timely.
    Decision makers need measures that:

     Are derived from data that is reliable and has been consistently 
determined system-wide.
     Are based on reasonable assumptions and anchored by a reasonable 
and consistent set of business rules.
     Are measurable in practice given existing infrastructure.
     Are clinically or administratively relevant.
     Provide complementary or competing information to other measures 
used by decisionmakers.
     Measure what they intend to measure.
            Measuring Access to VHA Mental Health Care
    Included in the FY 2012 Network Director Performance Plan are the 
following measures: the percentage of eligible patient evaluations 
documented within 14 days of a new mental health patient initial 
encounter; a metric requiring a follow-up encounter within 7 days of 
discharge from inpatient hospitalization; a measure requiring four 
follow-up encounters within 4 weeks of discharge from inpatient 
treatment for high risk patients; and a measure of the percentage of 
new Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) 
veterans receiving eight psychotherapy sessions within a 14-week period 
during one year period.
    VHA's 14-day measure calculates the percentage of comprehensive 
patient evaluations documented within 14 days of an initial encounter 
for patients new to mental health services. In practice, the 14-day 
measure is usually not triggered until the veteran is actually seen in 
a mental health clinic and a comprehensive mental health evaluation is 
initiated. For example, a new-to-VHA veteran presents to a primary care 
clinic, screens positive for depression, and the primary care provider 
refers the veteran for further evaluation by a mental health provider. 
The ``clock'' for the 14-day follow-up measure will start when the 
veteran is actually seen in a mental health clinic and a comprehensive 
mental health evaluation is initiated, not at the time of the primary 
care appointment. Consequently, the data underlying this measure only 
provides information about the timeliness within which comprehensive 
new patient evaluations are completed but not necessarily the 
timeliness between referral or consult to evaluation.
    Veterans access VHA care through various routes, such as VA medical 
center emergency departments, primary and specialty care clinics, 
women's clinics, or mental health walk-in clinics. Alternatively, they 
may seek services at community based outpatient clinics or Vet Centers 
in their communities. They may also initiate mental health services 
with private providers and later come to VA seeking more comprehensive 
services. The 14-day measure does not apply to veterans who access 
services through Vet Centers or non-VA-based fee basis providers.
    A series of complementary and competing timeliness and treatment 
engagement measures that better reflect the various dimensions of 
access would provide decisionmakers with a more comprehensive view of 
the ability with which new patients can access mental health treatment.
    The timeframe immediately following inpatient discharge is a period 
of high risk. The 7-day post-hospitalization and the four follow-up 
appointments in 4 weeks for high-risk patient measures are clinically 
relevant. The eight psychotherapy session in 14 weeks measure attempts 
to be a proxy for whether OEF/OIF patients are receiving evidence-based 
psychotherapy. The measure is clinically relevant but the utility is 
presently marred by inaccurate data or unreliable methodology.
    Beyond measures of timeliness (or delay) to mental health care, 
user friendly measures that incorporate aspects of patient demand, 
availability and mix of mental health clinical staffing, provider 
productivity, and treatment capacity, anchored by a consistent set of 
business rules, might provide VHA decisionmakers with more information 
from which to assess and timely respond to changes in access 
parameters.
Recommendations
    Our report contained four recommendations for the Under Secretary 
for Health:

     Revise the current full mental health evaluation measurement to 
ensure the measurement is calculated from the veterans contact with the 
mental health clinic or the veteran's referral to the mental health 
service from another provider to the completion of the evaluation.
     Reevaluate alternative measures or combinations of measure that 
could effectively and accurately reflect the patient experience of 
access to mental health appointments.
     Conduct a staffing analysis to determine if mental health staff 
vacancies represent a systemic issue impeding the Veterans Health 
Administration's ability to meet mental health timeliness goals, and if 
so, develop an action plan to correct the impediments.
     Ensure that data collection efforts related to mental health 
access are aligned with the operational needs of relevant 
decisionmakers throughout the organization.

    The Under Secretary for Health concurred with our recommendations 
and presented an action plan. We will follow-up as appropriate.
                               conclusion
    VHA does not have a reliable and accurate method of determining 
whether they are providing patients timely access to mental health care 
services. VHA did not provide first-time patients with timely mental 
health evaluations and existing patients often waited more than 14 days 
past their desired date of care for their treatment appointment. As a 
result, performance measures used to report patient's access to mental 
health care do not depict the true picture of a patient's waiting time 
to see a mental health provider.
    While no measure will be complete, meaningful analysis and 
decisionmaking requires reliable data. A series of paired timeliness 
and treatment engagement measures might provide decisionmakers with a 
more comprehensive view of the ability with which new patients can 
access mental health treatment.

    Madam Chairman, thank you for the opportunity to discuss our work. 
We would be pleased to answer any questions that you or other Members 
of the Committee may have.
                                 ______
                                 
Response to Posthearing Questions Submitted by Hon. Bernard Sanders to 
  the Office of Inspector General, U.S. Department of Veterans Affairs
Ms. Linda Halliday
    Question 1. During your investigation, did you observe any obvious 
trends, such as an influx of National Guard servicemembers recently 
discharged from active-duty that helps explain why some veterans are 
scheduled appointments within the performance standards while others 
are not?
    Response. We did not identify any trends specific to particular 
groups of veterans. As part of our review, we interviewed key personnel 
involved in the scheduling process at four VA medical centers located 
in Spokane, Washington; Milwaukee, Wisconsin; Salisbury, North 
Carolina; and Denver, Colorado. None of the personnel interviewed 
stated that a recent influx of National Guard servicemembers recently 
discharged from active-duty caused any of their access issues.

    Question 2. Did any scheduler or scheduler's supervisor explain why 
there was such a deviation from VA Directives with regards to mental 
health appointments?
    Response. The schedulers that we interviewed received the required 
annual training that clearly shows how the appointments should be 
scheduled. However, at two of the locations (Salisbury and Denver), 
schedulers indicated that supervisors told them not to follow the 
Directive. Instead, schedulers access the software to see when the next 
appointment is available. The scheduler then backs out of the 
scheduling package and goes back in to enter the date of the available 
appointment as the desired date. An audit trail is not created in 
Veterans Health Administration's (VHA) records that documents and 
captures these actions.
Dr. John Daigh
    Question 1. Would you consider group therapy for ``high risk'' 
mental health patients as ``clinically inappropriate'' if it is not, at 
minimum, done in concert with individual therapy?
    Response. ``High risk'' is a term that can have a variety of 
meanings. Patients may over a short period of time transition from 
``high risk'' to ``low risk'' and back to ``high risk.'' Mental health 
providers need to consider all forms and combinations of therapy when 
constructing a treatment plan. A more specific answer requires the 
facts and circumstances of a specific patient.

    Question 2. During your investigation, did you discover any group 
therapy for ``high risk'' mental health patients who were not at the 
same time receiving individual therapy? If so, how frequently was this 
group therapy done in lieu of a more individuated or comprehensive plan 
of therapy?
    Response. The scope of our review did not include this issue.
                                 ______
                                 
 Response to Posthearing Questions Submitted by Hon. Johnny Isakson to 
    Office of Inspector General, U.S. Department of Veterans Affairs
    Question 1. The OIG has reported several times on inappropriate and 
inconsistent scheduling practices in 2005, 2007, and now again in 2012. 
VHA has taken steps to address these issues, however, the problem 
persists.
    A. Why does this continue to be an issue and what is contributing 
to the inappropriate practices?
    Response. The required management oversight is not effective. 
Schedulers told us that supervisors focused their attention on the 
appointments where schedulers were not able to schedule the patient 
within 14 days of the desired date of care rather than the integrity/
accuracy of the appointments they were able to schedule within 14 days.
    B. Is it simply a lack of training for schedulers? Are the 
schedulers receiving the required annual trainings and taking the 
annual tests to ensure they are properly carrying out VHA directives?
    Response. We do not think it is lack of training, but more that the 
oversight is not effective and the lack of focus on ensuring the data 
integrity of the scheduling information. At the sites we visited, the 
training and competency records were up to date and schedulers stated 
they were receiving training on proper scheduling procedures. 
Scheduling supervisors also stated they evaluated schedulers' 
competency annually, as required. The training provided to schedulers 
aligns with VA's Directives.

    Question 2. According to the OIG, this is leading to skewed data 
that is not helpful to key decisionmakers from the managerial level to 
the administrative level to Congress.
    A. Do these inconsistencies occur in all the Veterans Integrated 
Service Networks (VISNs), or are some performing better than others?
    Response. For our review, we visited four VA medical centers 
located in four different VISNS, and confirmed inappropriate scheduling 
practices occurred at three of the four centers. Our analysis did not 
attempt to draw a conclusion between VISN performance so we cannot 
offer an opinion in this area.
    B. What is VHA doing to correct this problem?
    Response. VHA has indicated they are changing the way new patient 
appointment timeliness will be evaluated by using the ``appointment 
create date'' instead of the ``desired date'' to evaluate appointment 
timeliness. VHA agreed with our concerns that the ``desired date'' is 
ambiguous and that a simpler methodology will improve the reliability 
of scheduling data.

    Chairman Murray. Dr. Daigh.

STATEMENT OF JOHN DAIGH, M.D., ASSISTANT INSPECTOR GENERAL FOR 
   HEALTHCARE INSPECTIONS, OFFICE OF INSPECTOR GENERAL, U.S. 
    DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY MICHAEL 
    SHEPHERD, M.D., SENIOR PHYSICIAN, OFFICE OF HEALTHCARE 
                          INSPECTIONS

    Dr. Daigh. Madam Chairman, Ranking Member, and Members of 
the Committee, it is an honor to testify before you today. I 
and my staff from the Office of Health Care Inspections on a 
daily basis deal with clinical care issues in VA, and we know 
that both the employees and leadership within VA strive to 
provide the highest quality care. And despite the subject of 
this meeting, I do believe VA provides very high quality health 
care to its veterans. In fact, with respect to quality metrics, 
I believe VA leads the Nation with respect to both the use of 
data and the publication of that data on the Web site.
    With respect to access to care metrics, I believe it is 
quite a different story. I believe those metrics are flawed. I 
believe, as our report indicates, Dr. Petzel has indicated that 
he will put together a group to try to resolve the issue and 
get the access to care metrics in line so that they do 
accurately reflect the business processes that are ongoing at 
VA.
    I plan to talk about some of the access to care metrics in 
the private sector, but I think what I would like to make are 
two different statements after hearing your opening statement, 
ma'am.
    The first would be I think VA has a number of missions. 
They have a mission to provide health care. They have a mission 
to do research. They have a mission to train individuals who 
will work in the United States and elsewhere in the health care 
industry. They have a mission to be available in times of 
national disaster. And I think as individuals out there in 
hospitals they decide how they are going to spend their time, 
those missions are generally accepted as being equal--there is 
not a directive that says the primary mission is the delivery 
of health care, and we will address those requirements first as 
professionals schedule their time or allocate their time.
    So, I think when we have a crisis like we have, that a 
prioritization of mission, again, stated clearly from top to 
bottom, would allow individuals across the system to rethink 
how they are spending their time.
    The second issue I think is important is to set a standard 
of productivity. I realize that health care cannot be numbers 
driven. I realize it is a personal interaction between a 
patient and a provider. But at the same time, there has to be 
some method to determine that you are getting enough work or 
productivity from the people that are working for you.
    So, I think although VA has worked on these issues for a 
while, that there just has to be a clear, measurable, and in my 
view, productivity standard that is easily relatable to the 
work done in the private sector by a similar provider, so that 
one can decide whether the money spent is actually being 
effectively used. The other issues that are brought forward in 
terms of the kind of access to care standards we could use, I 
think that Mr. Schoenhard and others well understand those, and 
I think we can work with them in order to improve the standards 
that they currently have in place.
    With that, I will end my comments and be happy to answer 
any questions.
    Chairman Murray. Thank you very much.
    Mr. Tolentino.

  STATEMENT OF NICHOLAS TOLENTINO, OIF VETERAN AND FORMER VA 
                     MENTAL HEALTH OFFICER

    Mr. Tolentino. Madam Chairman, Senator Brown, Members of 
the Committee, as and OEF/OIF combat veteran, I am honored to 
appear here today to share deep concerns about the 
administration of VA's mental health care system.
    My testimony is based on my experience as a VA mental 
health administrative officer, as well as service on a VA 
network executive committee, membership on several VA national 
work groups, and a background in quality management that led to 
an MBA degree. Deep concerns about the Manchester, NH, VA 
medical center's failure to provide needed care ultimately led 
to my resignation last December.
    I want to commend this Committee for your vigilant 
oversight of VA mental health care. Let me also acknowledge the 
VA's recent announcement and plans to add positions to its 
mental health workforce and address problems you have helped to 
uncover. But I want to emphasize that additional staffing alone 
will not remedy the systemic problems in the VA management of 
mental health care.
    Let me be clear. I do not wish to discredit the VA or its 
mental health staff who work diligently to help veterans. But 
for all it strives to do, the VA's mental health system is 
deeply flawed. The system is too open to putting numerical 
performance goals ahead of veterans' mental health care needs. 
It is too susceptible to gaming practices and making the 
facilities look good and too little focus on overseeing the 
effectiveness of care it promises to provide. These systemic 
problems compromise the work of a dedicated mental health staff 
and fail our veterans.
    Like many VA medical centers, the overriding objective at 
our facility, from top management on down, was to meet our 
numbers, meaning to meet our performance measures. The goal was 
to see as many veterans as possible, but not necessarily to 
provide them the treatment they needed. Performance measures 
are well intended, but they are linked to executive pay and 
bonuses, and as a result, create incentive to find loopholes 
that allow the facility to meet its numbers without actually 
providing the services. Far too often, the priority is to meet 
a measure rather than meet the needs of the veteran.
    Many factors, including understaffing, make it very 
difficult to meet performance requirements. But administrators 
do not feel that they can acknowledge that. Instead, as soon as 
new performance management program manuals were published each 
year, network and facility leadership began planning how to 
meet those measures. That led to brainstorming, even with 
colleagues of mine across the country, to find loopholes to 
game requirements that could not be met.
    While I have detailed multiple examples in my full 
statement, I would like to share two of them now.
    Several performance measures mandate that veterans in 
mental health treatment be seen within certain timeframes. At 
Manchester, where demand for mental health was great and 
staffing very limited, the facility director demanded a plan to 
get better and seen at any cost. We got the order: focus only 
on the veteran's immediate problem. Treat it quickly in that 
appointment, usually with medication, and do not ask further 
questions about needs because, ``We don't want to know, or 
we'll have to treat it.''
    Another directive requires that a patient who is actively 
suicidal or high risk for suicide should be seen at least once 
per week for 4 weeks after an inpatient discharge. This is to 
ensure the veteran's receiving the intensity of care needed to 
reduce the risk of readmission and to increase the success of 
treatment.
    Instead of providing these high-risk patients individual 
therapy, Manchester instead created a group for them, a step 
that was both clinically inappropriate and contrary to the 
directive's intent. Veterans who refuse to join the group were 
often labeled resistant to treatment.
    The idea that group therapy could be substituted for 
individual psychotherapy spread throughout the network. In 
fact, the network mental health executive committee actually 
promoted this idea as a so called best practice. Even though it 
was not at all good clinical practice, it was seen as a good 
way to meet performance measures.
    I believe that most VA facilities have an understaffed 
mental health service because the VA lacks a methodology to 
determine what mental health staffing is needed at an 
individual facility. In a misguided attempt to justify more 
mental health staff at Manchester, the head of our mental 
health service stated that the priority needed to be quantity 
rather than quality. She said, and I quote, ``Have contact with 
as many veterans as we can, even if we aren't able to help 
them.''
    The outcome was that the facility continued to enroll a 
growing number of veterans, far more than our mental health 
clinicians could handle. And as a result, veterans fell through 
the cracks. Tragically, there was no effective oversight, even 
to detect those deep systemic problems we faced.
    For example, every year, the medical center would complete 
a mandatory central office survey to assess facility compliance 
with the VA's mandate to provide uniform mental health 
services, but each year our network told us we were never to 
answer that services were not provided. Many of our answers 
were actually changed to say that required services were being 
provided when they in fact were not.
    During my years at Manchester, other members of the mental 
health staff and I repeatedly raised concerns with both 
facility and network leadership regarding practices we believed 
were unethical or violated VA policy. Those concerns largely 
fell on deaf ears. Our staff also repeatedly brought the 
concerns to our facility's ethics committee. And to our great 
frustration, however, the ethics committee consistently 
declined to take up these issues because they felt they were 
clinical matters.
    For me, the final straw was the medical center's failure to 
take meaningful action upon discovery that a mental health 
clinician was visibly intoxicated while providing care to our 
veterans. Ultimately, I could not continue to work at a 
facility where veterans' well being seemed secondary to making 
the numbers look good.
    I very much hope the VA will make real changes to address 
the systemic problems I have described. I believe that there 
are steps the VA can take beyond adding staff. I humbly offer 
these suggestions.
    First, the VA should stop monetarily rewarding leadership 
for meeting numerical and process requirements that are not 
real measures of effective mental health care.
    Second, the VA should institute a much more extensive 
oversight into how care is actually being provided and how 
program funding is deployed to ensure the funds actually go to 
the programs they are intended to supplement.
    Finally, I would urge this Committee to press the VA to 
develop and implement a very long overdue empirically supported 
mental health methodology so that it is no longer necessary to 
guess whether 1,900 more mental health staff will be enough.
    In closing, I am honored to have had the opportunity to 
share both my experience and assessment of problems that I hope 
you can help to resolve. I would be very pleased to answer any 
questions you may have. Thank you.
    [The prepared statement of Mr. Tolentino follows:]
  Prepared Statement of Nicholas Tolentino, OIF Veteran and Former VA 
                  Mental Health Administrative Officer
    Chairman Murray, Ranking Member Burr and Members of the Committee: 
I am honored to appear before you today to share my experience, 
perspective and resultant concerns about the delivery of timely, 
effective mental health care in the VA system. I want to begin by 
sharing with you that I am myself an OIF/OEF combat veteran, medically 
retired after nearly 14 years of service in the United States Navy.
    In April 2009 I took a position as the Mental Health Administrative 
Officer of the Mental Health Service Line at the Manchester VA Medical 
Center (VAMC) in Manchester, NH. While working in the Navy as an 
Independent Duty Hospital Corpsman, I earned my MBA and developed a 
deep interest in the quality-management of medical facilities. An 
opportunity to support VA efforts to aid my brothers and sisters, was 
for me, an ideal transition into civilian work and service. As the 
Mental Health Administrative Officer I was responsible for a vast 
number of the administrative functions of the Mental Health Service 
Line. In addition to those duties and responsibilities, I served as a 
member of the VISN 1 Mental Health Executive Committee which worked to 
address network-wide mental health service issues, and also as chairman 
of the Manchester VAMC Mental Health Systems Redesign Team, which 
worked to address local issues specific to the function and design of 
our mental health services. Deep concerns about needed care we were NOT 
providing at Manchester ultimately led me to resign last December.
         additional mental health staffing alone is no panacea
    As a combat veteran, I want to commend this Committee for your 
vigilant oversight into VA mental health care. Let me also acknowledge 
Secretary Shinseki's announcement of plans for additional staff to 
supplement VA's over-stretched mental-health work force and address the 
problems your oversight helped uncover. But additional staffing alone 
will not remedy fundamental national problems in VA's administration 
and management of mental health care. The problems I will highlight in 
this testimony--problems I have seen at the medical center, VISN level, 
and on multiple national work groups--are significant enough to derail 
and undermine the Secretary's well-intentioned effort.
   how vaco mental-health performance measures distort care delivery
    It is important for me to make clear that in sharing these 
concerns, I do not intend to discredit the VA, an organization with a 
critical role. I know from experience that many VA mental health 
staff--clinical and administrative--work tirelessly to help the 
veterans they serve. But I also know from experience that that system 
is deeply flawed. The system is too open to putting numerical 
performance goals ahead of veterans' mental health care needs--too 
susceptible to ``gaming'' practices to make facilities ``look good''--
and too little focused on overseeing the effectiveness of the mental 
health care it promises to provide. I have seen just how easily these 
systemic problems can compromise the important work of dedicated VA 
mental health staff, and fail our veterans.
    By way of context, the Manchester VAMC serves some 12,000 veterans 
in the state of New Hampshire. We are the only VA in New Hampshire and 
we are a small facility with no inpatient services. The mental health 
service line staffing has itself grown exponentially over the past five 
years with increased national attention and funding for mental health, 
and is now comparable in size to many of the other services provided on 
site; however demand for mental health care has grown faster.
    Historically, but even more so during the almost four years that I 
worked at Manchester, the overriding medical center objective--from top 
management on down was to ``meet our numbers,'' that is, to meet 
performance measures and to see as many veterans as possible. 
Performance measures play a significant but troubling role in VA mental 
health care. While it is not unreasonable to expect a facility to want 
to meet numerical performance objectives and provide needed care to as 
many veterans as possible, VA Central Office's well-intentioned 
performance requirements often prove antithetical to providing 
appropriate care.
    First and foremost, the achievement of performance measures is 
linked to pay and bonuses for Executive Career Field (ECF) employees, 
most commonly, upper management (myself included). The financial 
incentive to meet these measures too easily creates a perverse 
administrative incentive to find and exploit loopholes in the measures 
that will allow the facility to meet its numbers without actually 
providing the services or meeting the expectation the measure dictates. 
The upshot of these all too widespread practices is that meeting a 
performance target, rather than meeting the needs of the veteran, 
becomes the overriding priority in providing care.
    You might ask: Why not provide the services the way the measure 
dictates and simply ``make the numbers'' in that way, why employ 
loopholes? While most performance measures are intended to ensure that 
care is provided in ways that are effective (based on empirical 
research), timely, and relevant to the needs of the population, they do 
not necessarily take the following operational realities into account:

    1. Staffing: Most facilities' mental health services are 
understaffed, and mine was no exception. Without solid means to measure 
the relative needs of each facility, given its size, population served, 
etc., staffing levels are haphazard. (For example, White River Junction 
VAMC in Vermont, our neighboring facility, serves half the number of 
veterans in their mental health service, but has double the staff). 
Performance measures, rightfully, are not flexible as they relate to VA 
facility capabilities, as a veteran does not deserve lesser treatment 
because his local facility is small. However, the expectations 
reflected in VA's performance measures often far exceed the 
capabilities of the staff that must meet them. In my experience, it was 
a routine matter for facility and VISN administrators to find and use 
loopholes to ``meet their numbers'' whenever they were confronted with 
a gap between a performance requirement and a facility's limited 
capabilities that had adverse implications for their paychecks. 
Tragically, though, this kind of ``gaming'' of the system meant that 
veterans too often weren't getting needed mental health services.
    2. Mandated services are not always relevant to a facility: By way 
of example, in a well-intentioned effort to improve rural veterans' 
access to mental health care, VA Central Office set mandates, and 
accompanying performance requirements, that called for providing 
certain percentages of veterans with telehealth services. However, not 
all facilities have this need. While our facility in particular, did 
not have much demand for this service, the requirement led us to place 
many veterans in telehealth treatment whether they wanted it or not, 
and in circumstances where it was not clinically relevant or of any use 
to the veteran. Additionally, group therapy and other services not 
otherwise needed or indicated for such technology were forced to adapt 
their treatments to fit this new initiative. The upshot was that 
precious staff time was devoted to a mode of treatment that veterans 
neither needed nor wanted.

    One might think that administrators whose facilities are truly 
incapable of meeting a performance requirement would simply acknowledge 
that they cannot meet a target and request additional staff or other 
needed support. Unfortunately the system does not encourage that 
behavior, and facility administrators generally don't wish to ``look 
bad.'' Moreover ``failing to meet'' a performance measure has adverse 
implications:

    1. The first and most obvious is that failing to meet a performance 
measure has a direct impact on administrators' personal paychecks.
    2. When a facility fails a measure, it must take on a significant 
amount of administrative work. Action reports must be generated and 
submitted to the VISN, data must be tracked and analyzed and a 
tremendous amount of attention is brought onto the administration. No 
one likes that. (The irony is that there are loopholes around even this 
administrative requirement.)
    3. And finally, unlike the VA Primary Care Service Lines, for 
example, that have a well-defined staffing methodology, VA lacks a good 
method for establishing individual facility mental health staffing 
needs. While on paper a facility can appear ``fully staffed'' based on 
VACO's determination for that region, in reality the veteran workload 
and needs far exceed the man hours available to serve them. In my 
experience, when a service line manager does submit a request for 
additional staff, often the request doesn't make it past the facility 
director because he or she will want data to support the need before 
taking it higher up the chain. Gathering data takes a great deal of 
work, and the data gathered rarely depicts the demand in a way that 
translates into man hours needed. This takes us back to why even VACO 
has difficulty establishing a good method for establishing staffing 
needs for individual facilities.

    Manchester offers a troubling case in point. Failure to meet a 
performance measure has not historically resulted in staffing needs 
being addressed. Instead, failure has resulted in more work for an 
already stretched staff, and a leadership response that has insisted 
that ``we are already fully staffed,'' and therefore any failure to 
meet measures must be an indication of inefficient use of resources, 
not a lack of resources. The mental health service line manager 
translated the call for ``improved efficiency'' to mean ``find more 
loopholes.''
                           gaming the system
    I know from my experience on the VISN 1 Executive Committee and on 
various national VA workgroups that these problems are not unique to 
Manchester VAMC. Unfortunately, most VA facilities struggle to fit into 
the highly uniform expectations of VA performance measures. While the 
goal of expecting all facilities to provide uniform quality care is 
laudatory, the rigid one-size-fits-all approach contributes to systemic 
problems.
    As soon as the new ECF Performance Management Program manual and 
performance measure technical manuals are published each year, even in 
draft form, planning among VISN leaders, facility leaders, Quality 
Management staff, and Service Line staff begins regarding how to meet 
the measures for that year. Staff analyze those measures that are 
determined not likely to be met by a facility due to either low demand, 
lack of resources, etc., and the group brainstorms to find loopholes 
that can be exploited to game the requirement. The group will also ask 
other facilities in the region and nationally for their ``solutions'' 
to similar problems. Let me offer some examples:

          Desired Date of Appointment: VACO's performance measures 
        include a requirement that a veteran treated by the mental 
        health service is to be scheduled for a mental health 
        appointment within 14 days of his or her ``desired date'' for 
        service.
          At Manchester, despite the fact that effective treatment 
        requires a level of intensity and frequency determined by the 
        veteran's symptoms, limited staffing (and other problems) made 
        it impossible to offer veterans the frequency of psychotherapy 
        appointments to meet their clinical needs. While a veteran and 
        his or her clinician might agree that the veteran should return 
        next week to continue his progress, the appointment 
        availability was simply not there. Nevertheless our service 
        ``met'' this measure by simply eliminating the opportunity for 
        the veteran to give us a desired appointment date. Instead, the 
        veteran was told when the next appointment with his provider 
        was available and that appointment (often weeks, even months 
        away) was entered as his ``desired'' date, thus ``meeting'' the 
        measure.
          (Veterans who are unable to be scheduled for their actual 
        desired date should be placed on an Electronic Wait List (EWL) 
        developed for this purpose and meant to track the demand versus 
        the availability of services. (But facility leadership 
        ``unofficially ordered'' that the EWL was NOT to be used under 
        any circumstances.)
          Meeting frequency measures for clinical contact: Several 
        different performance measures mandate that veterans in mental 
        health treatment be seen within certain timeframes and 
        frequencies based on such classifications as whether the 
        veteran was new to treatment, a high risk for suicide, etc. At 
        Manchester, where demand for mental health care was great and 
        the resources were very limited, the facility director pressed 
        the mental health service line manager to develop a plan to 
        ``get the veterans seen'' at any cost. The plan that was 
        ultimately developed ``gamed'' the system so that the facility 
        ``met'' performance requirements but utterly failed our 
        veterans. Specifically, instead of conducting an assessment of 
        veterans' mental health needs and scheduling and providing the 
        appropriate intensity and frequency of services, the plan 
        called for providing only the most limited mental health 
        services (such as medication management or a mental health 
        check-in from time to time) through the facility's primary 
        mental health clinic. The service line manager's order was to 
        focus only on the immediate problem with which the veteran 
        presented in that moment, treat that quickly in that 
        appointment (this meant only medication) and not to ask further 
        questions about needs because, ``we don't want to know or we'll 
        have to treat it.''
          This perverse approach reduced the need to schedule 
        appointments in an already backlogged scheduling system. (When 
        appointments aren't scheduled there is no evidence that the 
        facility is NOT getting the veterans in for appointments in a 
        timely way that meets the measures. Thus, the facility succeeds 
        in appearing to meet the measure.) Veterans were encouraged and 
        often required to make use of the walk-in service, despite 
        clinical contraindications. This fundamentally unethical 
        approach meant that veterans who needed much more intense care 
        made no progress toward symptom remission and achieving 
        treatment goals.
          High Risk Patients: By VHA directive, a patient who is 
        actively suicidal or identified to be at high risk for 
        completing suicide should be seen, at minimum, on a once-weekly 
        basis for four weeks after being discharged from an inpatient 
        unit. This is to ensure the veteran is receiving the intensity 
        of care necessary to reduce the likelihood of readmission to 
        the inpatient ward and to increase the success of the treatment 
        provided. Manchester's response to this requirement was to 
        create a group for these high-risk veterans to attend, instead 
        of providing individual therapy. Not only was this clinically 
        inappropriate and in direct conflict with the intent of the 
        directive, but if a veteran refused to be in a group, that 
        veteran was often labeled ``resistant to treatment.''
          Group therapy to meet intense-therapy requirement: Another 
        performance requirement mandates that a certain percentage of 
        OEF/OIF veterans who have a primary diagnosis of PTSD are to 
        receive a minimum of 8 psychotherapy sessions within a 14-week 
        period. While the clear intent of that measure is based on 
        research that emphasized immediate, intense individual 
        psychotherapy as the best clinical approach to combating PTSD, 
        the technical wording of the measure did not effectively 
        restrict the nature of appointments to the clinically indicated 
        individual psychotherapy. Manchester took advantage of that 
        lack of ``guidance'' in the technical wording and once again 
        used group therapy sessions as a means to meet the measure. And 
        once again, veterans who refused to attend group therapy were 
        labeled as non-compliant with treatment. So while the facility 
        looked ``on paper'' as though it had met this VA performance 
        measure, the vast majority of the patients in fact were not 
        getting the intensity of care that the measure intended.
          Group therapy as ``best practice:'' Despite clinical 
        contraindications, the idea that group therapy could be 
        substituted for individual psychotherapy spread throughout the 
        VISN. Manchester was certainly not the first facility to use 
        this strategy. In fact, the VISN Mental Health Executive 
        Committee, which met annually to discuss how individual 
        facilities were meeting performance measures, actually fostered 
        this idea as a so-called ``best practice.'' While the idea of 
        substituting group therapy for individual therapy for any and 
        all patients is not at all good clinical practice, it was 
        looked on as a good way to meet requirements. The VISN actually 
        brought that so-called ``best practice'' to a national level, 
        promoting this practice at a national VA mental health 
        conference.
          (While I am not a clinician, I am aware of the various 
        methodologies for treating many mental health disorders and 
        symptoms relevant to the veteran population. Group therapy is a 
        very effective and important aspect of mental health service. 
        The problem with its use in these instances is the lack of 
        choice and intensity in the treatment. Group therapy is by its 
        nature a less intense form of psychotherapy, generally 
        speaking. In addition, the veterans were given no choice over 
        whether they would receive individual therapy or group therapy. 
        Instead, at many facilities they are directed into a mode of 
        care many do not want, need, or with which they are 
        uncomfortable, because the facilities' need to meet the 
        associated performance measure is the overriding priority.)
          Targeted populations: Some performance measures identify 
        target populations, and result in assigning certain classes of 
        patients' priority and access to preferred treatment 
        modalities. The obvious result is that veterans of other eras 
        or demographics may receive less than desirable or not-so-
        clinically indicated treatments to create space for the 
        preferred population. Under these circumstances the 
        individual's clinical needs are not considered. A Vietnam 
        veteran in crisis with significant symptoms would be passed 
        over for that all-too-rare appointment spot with a 
        psychotherapist, if an OIF veteran also seeks that appointment. 
        The fact that the OIF veteran may not be in urgent need for 
        services is not considered. He would get the appointment 
        because a performance measure dictates that he get a more 
        timely appointment than all others. While the intent of 
        fostering early intervention is a good one, the drive to meet 
        the measure impedes exercise of good clinical judgment.
      budget gaming confounds provision of good mental health care
    I'm well aware that this Committee has been instrumental in 
increasing VA mental health care funding over the years. But 
``disconnects'' between VA Central Office and VA medical facilities 
have in some instances stood in the way of special funding (to enhance 
mental health services) actually reaching the veterans. (Such ``special 
funding'' was intended to support the implementation of the Uniform 
Mental Health Services policy in VA medical centers and Clinics (VHA 
Handbook 116.01), which aims to ensure that a uniform set of mental 
health services would be accessible to veterans across the country.) 
Despite a clear directive, Manchester did not actually use special 
funding as intended or fully implement the Uniform Services Package 
(the ``USP'').
    On numerous occasions, VA Central Office would establish a new 
initiative related to the USP, and provide special funding for a 
particular mental health staff position to carry out that initiative. 
Most times a VHA or VACO Memorandum would be sent out to the facilities 
stating that the posting and hiring of the position was mandated and to 
be done ``ASAP.'' However, Manchester's leadership would mandate that 
the position go through various administrative approval boards (despite 
the Memorandum having specifically stated that the position is not to 
be subjected to such processes). This process would greatly increase 
the amount of time taken to post and hire for the position. During this 
time--often 3-6 months in duration--the position would be caught up in 
meetings awaiting ``approval'' and the salary dollars received by the 
facility would go unspent, creating a substantial excess (often 
referred to as lag funds). At the end of the fiscal year, these lag 
funds would be converted to cover salary expenses of regular staff or 
converted into facility General Purpose (GP) funds to reduce overall 
facility debt accrued over the course of the year. I can recall many 
instances, across several fiscal years, where Manchester acquired 
hundreds of thousands of dollars of special mental health funding 
without fulfilling the actual intent of the funding.
    In FY 2011, for example, approximately $500 thousand in mental 
health funds were converted to general operating funds. As a result, we 
were not able to hire the specialty mental health staff we needed or 
provide the initiative-programs with the tools required to perform 
effectively. But because VA Central Office directed all medical centers 
to carry out a number of new initiatives, including expansion of 
Geriatric Psychiatry services, substance abuse services and expansion 
of homeless programs, for example, clinicians at the facility were 
forced to take those titles on as a collateral duty, or the services 
were simply not offered. While concerns over the situation were raised 
at both the facility and VISN level, they received only minimal 
attention for a short time, without resultant change.
    (By assigning collateral duties to clinicians who already held 
important titles and functions, Manchester was able to appear fully 
staffed without having to hire additional clinicians. On paper we were 
able to say that we had an ``Military Sexual Trauma (MST) 
Coordinator,'' for example, despite the fact that that clinician was 
also carrying other mandated titles and responsibilities. This 
gamesmanship impacted appointment availability and further stretched 
limited resources. Moreover, most titled positions come with many 
administrative duties (weekly or monthly conference calls, data 
tracking, etc.). So when a clinician carries several titles, much of 
his or her time is consumed by those administrative tasks, resulting in 
less appointment availability for veterans).
    Good mental health care, of course, requires that we provide 
veterans privacy, and the necessary office space to make that possible. 
We had a need for additional mental-health-service space at Manchester, 
and a project was submitted to VACO to remodel a storage area so that 
we could co-locate multiple mental health offices with primary care. 
VACO provided us mental health special funds to perform the work. But 
after the work was completed, the facility leadership decided that the 
space would not in fact be used for mental health offices, but would 
instead be used to expand Primary Care. Mental health received no 
additional space and was informed that the facility priority was now 
Primary Care, given the identification of the upcoming Primary Care 
expansion. This scenario was repeated with the submission of a project 
to add an additional wing to the medical center specifically for the 
expansion of mental health. After the project received initial VACO 
approval, the facility leadership once again chose to use it for 
Primary Care, though not altering the project-intent statements to 
reflect this fact.
          mental health budget: distortions in providing care
    Manchester's Mental Health Service Line Manager's response to our 
staffing dilemma was made clear to us in a meeting in which she 
emphasized that the service line priority needed to be ``quantity'' 
rather than ``quality.'' By that she meant to ``have contact with as 
many veterans as we can, even if we aren't able to help them.'' The 
strategy was an attempt to show workload numbers as a way to justify 
requests for adequate resources. The upshot, though, was that the 
facility was enrolling growing numbers of veterans with very real 
mental health needs, but the mental health clinicians were reporting 
``we already have more patients than we can handle.'' As a result, 
veterans began to fall through the cracks.
    Under such circumstances where demand for needed treatment far 
exceeds the services available, VHA's Uniform Mental Health Services 
Handbook dictates that mental health services ``must be made accessible 
when clinically needed'' either in-house or under contract 
arrangements. But despite that mandatory language, the VISN's Mental 
Health Service Line Manager took the position that ``these are more 
guidelines than rules.'' There was, in theory, a process through which 
to get fee-basis care authorized--that required going through the 
service-line manager to get approval from the chief of staff--but I was 
told requests for approving fee-basis mental health care were very 
rarely approved. And even if they were approved, the facility lacked 
any effective means to case-manage these patients, as required under 
the directives regarding fee-services. Similarly, it was often a battle 
to even send a patient to another facility for needed care.
    Let me share just one horrific example to illustrate how the 
mindset at Manchester turned good patient care on its head. A 
psychiatrist assigned to the Substance Abuse Treatment Team, on more 
than one occasion was faced with a veteran seeking treatment to end his 
opioid addiction. Because the psychiatrist believed that he didn't have 
time to assist the patient, he prescribed the very opioids to which the 
veteran was addicted. He tried to justify this by stating that he 
needed to ``hold the patient over,'' and went on to schedule him an 
appointment to return sometime in the future. The psychiatrist said 
``they are going to get the drugs from somewhere so we might as well 
just go ahead and give them to them.''
                      lack of effective oversight
    It is heartbreaking to reflect on the many, many barriers staff 
encountered to getting patients the mental health care they needed and 
deserved. While patients truly fell through the cracks, there was no 
effective oversight to detect that and to address the deep systemic 
problems we faced. Every year our medical center took part in a Central 
Office survey to assess medical facilities' compliance with the Uniform 
Mental Health Services Handbook; as part of that surveying we were 
asked to delineate the services we provided. Each year, however, the 
VISN Mental Health Office gave the facilities the guidance that we were 
never to answer that services were not provided. Many of the answers 
were changed to say that specific (required) services WERE being 
provided when they weren't. Specifically, we were instructed that the 
``fallback'' answer was that the services were provided by fee-service, 
although this was never actually the case.
    During my years at Manchester, other members of the mental health 
staff and I repeatedly raised concerns with facility leadership as well 
as at the VISN level regarding practices and decisions which were 
either frankly unethical or violated VA policy. Those concerns largely 
fell on deaf ears.
    Internally, our medical center has an ethics committee, and staff 
often brought concerns regarding the compromises to mental health care 
to that committee. To our great frustration, however, the ethics 
committee consistently declined to take up these issues on the basis 
that they were ``clinical matters'' beyond its purview.
    Manchester is located in relatively close proximity to the National 
Center for PTSD headquartered at the VA Medical Center in White River 
Junction, Vermont. The National Center is not an oversight body, but 
its director, Dr. Matt Friedman, did visit Manchester on one occasion 
during my tenure and advised on various requirements the facility 
needed to meet. He was simply told, ``we don't have the staff'' to meet 
those requirements, and was not invited back.
                  unethical practices: the last straw
    I could detail other instances of unethical practice at the 
Manchester VAMC that contributed to my decision to resign, but the 
final straw occurred when the medical center failed to take meaningful 
action in response to the discovery that a VA clinical 
psychopharmacologist was intoxicated while providing patient care. On 
October 31st, 2011 the Mental Health Service Line Manager discovered 
that a psychopharmacologist at our facility was noticeably intoxicated 
and slurring his speech. The Service Line Manager became aware of this 
situation when a veteran reported that the clinician had failed to 
appear for an appointment. Looking into the matter, I discovered that 
he had written numerous prescriptions during that day, presumably 
during the period of his intoxication. The very next day, while the 
clinician was again treating patients, a water bottle was found hidden 
in that clinician's personal office refrigerator that was filled with a 
brown fluid clearly smelling of alcohol. An internal panel was 
convened, but the panel seemed to be more of a formality than an actual 
investigatory board. I was disturbed to learn that the incident did not 
lead to the clinician's removal, and instead he was simply transferred 
to work in the pharmacy. To make matters worse, the service line 
manager's response to my protest regarding the lack of action was to 
imply that, as a combat veteran, I was likely also vulnerable to 
substance-abuse. That implication, notwithstanding my impeccable 
employment history, was not only personally insulting, but unfathomable 
coming from a psychiatrist responsible for the facility's mental health 
service. A similar attempt to imply that my combat veteran status is a 
personal liability was made after my resignation, when I provided 
voluntary testimony to an internal investigative board. The board 
attempted to discredit my testimony by stating that my responses to 
incidents I'd reported were simply magnified by my combat experiences 
and resulting emotional instability.
                            recommendations
    Ultimately, I could not continue to work at a facility where the 
well-being of our patients seemed secondary to making the numbers look 
good. I do care deeply that the VA health care system not only makes 
our veterans' mental health a real priority, but that it institutes the 
kinds of changes needed to make VA mental health care timely and 
effective. I believe there are steps that can be taken--beyond adding 
additional staff--to make this happen. Let me offer three 
recommendations:

    1. VA must stop measuring and monetarily rewarding administrators 
for meeting numerical and process requirements that are simply not 
sound proxies for effective mental health care.
    2. VA must institute much more extensive oversight into how care is 
actually provided and how program funding is deployed to ensure the 
funds actually go to the programs that they are intended to supplement.
    3. Finally, I would urge that this Committee press the VA to 
develop and implement a very long overdue mental health staffing 
methodology, so that it is no longer necessary to guess whether, for 
example, 1900 more mental health staff will be enough.

    In closing, I'm honored to have had the opportunity to share with 
you my ``on the ground'' experience and assessment of problems that I 
hope you can help resolve. I'd be pleased to answer any questions you 
may have.

    Chairman Murray. Thank you very much.
    Major General Jones.

   STATEMENT OF T.S. JONES, MAJGEN, USMC (RET.), FOUNDER AND 
   EXECUTIVE DIRECTOR, OUTDOOR ODYSSEY YOUTH DEVELOPMENT AND 
                       LEADERSHIP ACADEMY

    General Jones. I am Tom Jones, retired Marine, founder and 
director of Outdoor Odyssey, which is a camp for at-risk youth. 
I do not have any expertise in mental health. I have a lot of 
experience dealing with those who have mental health issues.
    I have been visiting Walter Reed in Bethesda every week 
since the start of the war in Afghanistan in 2001. I have met 
thousands of folks. I have been privileged to be on the board 
of the Semper Fi Fund, started by wives, run by wives, that 
deals with families of the wounded.
    I also started Semper Fi Odyssey as an outgrowth of Outdoor 
Odyssey. While it started as a normal transition course, I met 
a Marine Corps captain in Bethesda who was grievously wounded, 
visited him many times over the next year. And while he is in 
therapy, he asked me to help him to start a 501(c)(3), since I 
had already done so, a nonprofit.
    We originally started as a normal transition course, 
however, it was patently obvious after a while that the mental 
health issues were such that we really got into the whole issue 
of dealing with mental health. Because of my medical 
background, I was able to bring a lot of folks in from the 
outside. I noted Navy psychiatrist, Dr. Bill Nash. And he was 
so moved by the experience that he had me be involved in a 
number of gatherings of mental health professionals. From that, 
I was able to--because I am an adjunct at the Institute for 
Defense Analysis here in D.C., I was able to start a project 
looking at best practices on mental health.
    What we have done, we have run 30 sessions now, week long 
sessions, of Outdoor Odyssey. I chiefly used Outdoor Odyssey 
because I had the facilities. What we have done is build on a 
volunteer strategy with team leaders. And almost all the people 
involved are in voluntary category.
    What has transpired is this whole issue of trust, cohesion 
and bonding, which works in the military when you are dealing 
with veterans. Of our cohort, 30 sessions, 35 or so, we attend 
each time. Just had one last week. So we have dealt with over a 
thousand not only veterans but those soon to be discharged from 
the military.
    We work in conjunction with the Wounded Warrior Regiment, 
so it gives us a pretty good index not only of the problems we 
are having in the military, but also, most strikingly, the 
problems we are having in the veteran community. And what we 
have found is that many, if not most, of the people who are 
undergoing clinician's care have not divulged even the source 
of the main stressor that has created the problem.
    I agree with several of the panelists here. I do not think 
the numbers of additional mental health coordinators is solely 
going to solve the problem. I think the mental health 
coordinator has to have a better understanding of what the 
demands are of the individual warrior. I think the one thing 
that we have learned through our experience with bringing 
mental health professionals to these experiences is that many 
of them can get a better perspective of what these individuals 
are facing through interaction with them.
    So I would encourage other folks here, even my panel 
members, if we are so inclined to be involved, I think the 
insights and the site picture provided to you is absolutely 
illuminating. What we have learned--I call them salient 
outcomes. We can see the same things you get in a normal 
transition course, and we are getting breakthroughs where 
people are actually coming forward and talking about demons 
that they heretofore have never talked about before. We build a 
network of trust that is lasting, not just a network in the 
sense of a transition course, but a network that will follow 
them after they leave the experience.
    Most importantly what we have learned is the fact that a 
large percentage and a growing percentage of folks are having 
mental health issues. And I would say--it is an opinion, but I 
think it is a pretty well-founded opinion--that the numbers are 
going to be growing in the future. I would think that we need 
experiences where folks that do deal in the setting of a 
clinician have a better understanding of what the issues are 
that they are dealing with.
    I am very honored to be here. I thank you very much. I will 
answer any questions, and I will certainly encourage any 
members of your staff to visit. We have got plenty of chow and 
a place to put you down. Thank you very much.
    [The prepared statement of General Jones follows:]
    Prepared Statement of T.S. Jones, MajGen, USMC (Ret.), Founder/
 Executive Director, Outdoor Odyssey Youth Development and Leadership 
                                Academy
    Dear Chairman Murray and Members of the Senate Committee on 
Veterans' Affairs: Good morning. My name is Tom Jones, and I serve as 
the Executive Director of Outdoor Odyssey as well as an Adjunct Staff 
Member of the Institute for Defense Analyses (IDA). In 1998, I founded 
Outdoor Odyssey and have served as its Executive Director in a 
voluntary capacity since that time. I am very pleased to have the 
opportunity to appear before the Committee this morning on this very 
critical subject. Although, unlike other speakers this morning, I have 
no certified expertise in mental health, I have been privileged to gain 
a great deal of experience in dealing with servicemembers who continue 
to struggle with mental health issues and have witnessed countless 
examples of success, attributed in no small measure to the power of the 
team, cohesion and one-on-one genuine concern. My experiences are the 
by-product of my involvement with wounded warriors as an active-duty 
officer, reinforced after my retirement through my role as a Board 
Member of the Semper Fi Fund and the fact that I founded and oversee 
the activities of Outdoor Odyssey. I will briefly outline my 
perspectives on the issue at hand in the following sections: 
Background; Semper Fi Odyssey; Cadre of Support; Salient Outcome, 
Lessons Learned and Opinions.
                               background
    Although I have visited wounded Marines and Sailors weekly since 
the initiation of combat action soon after 9/11, and have certainly 
gained key perspectives from those same visits, my insights have been 
honed in large measure by the approximately thirty (30) weeklong 
sessions I have hosted at Outdoor Odyssey designed to assist wounded 
warriors make the transition from the military to the civilian sector. 
These sessions, now known as Semper Fi Odyssey, represent the 
collaborative efforts of two nonprofits, working with the Wounded 
Warrior Regiment of the United States Marine Corps.
    As mentioned above, I founded Outdoor Odyssey in 1998, geared to 
identify and impact at-risk youth; at-risk in this context are those 
elementary-age youth identified by educators as those who face 
significant challenges to successful achievement in school. The focus 
of Outdoor Odyssey identifies strong, potential leaders among high 
school juniors and seniors and prepares these youth through a 
Leadership Academy to engage, bond with and then provide follow-on care 
to at-risk youth from their own community through an aggressive 
mentoring program. These high school mentors are themselves mentored by 
community leaders, serving as Umbrella Mentors. Leveraging the success 
of this program with 38 school districts in western Pennsylvania, 
programs have been created over the past 14 years to engage countless 
other educational institutions to provide leadership development and 
team building opportunities. At the risk of appearing arrogant, I have 
been blessed at Outdoor Odyssey, as the success of these programs has 
allowed Outdoor Odyssey to expand both facilities and programs to 
become a high adventure leadership academy rivaled by few and surpassed 
by no other similar organization that I have had the opportunity to 
visit. I offer this information, as programs incorporated at Outdoor 
Odyssey associated with mentoring, bonding, goal setting, etc., 
represent the by-products of my lengthy Marine Corps experience and set 
the stage for development of the Semper Fi Odyssey experience.
    Due to my involvement with Outdoor Odyssey, I was able to assist a 
wounded Marine Corps' Captain pursue his dream of building a transition 
program for wounded warriors who could not remain in the military. I 
met this young man during my visits to what was then known as Bethesda 
Naval Hospital and discussed his dream with him on numerous follow-on 
visits. Due to my experience with starting a 501(c)3 nonprofit, I 
helped him create a nonprofit and agreed to host the first session at 
Outdoor Odyssey and later assisted him by traveling to other sites in 
the United States to hold follow-on sessions. The original concept was 
to have quarterly sessions in different regions of the country; follow-
on sessions were held in Vail, Colorado; Tampa, Florida and New York 
City. While the plan was conceptually sound, it precluded development 
of continuity of effort and the creation of a cadre of volunteer 
support; moreover, it soon became apparent that the costs associated 
with such a concept were staggering and, therefore, prohibitive to 
success. Due to the potential that I saw in the program and the obvious 
and compelling need of the wounded warriors, I went to my fellow board 
members of the Semper Fi Fund to assist with certain of the financial 
requirements. In an effort to significantly reduce financial demands, I 
offered to host the next four sessions at Outdoor Odyssey. The initial 
weeklong program, then known as COMPASS, gained immediate traction with 
those who oversaw the Wounded Warrior Regiment and visiting mental 
health professionals. I was able to recruit significant help from 
associates within the Washington, DC, and Pittsburgh regions, and the 
weeklong programs evolved from one solely oriented on transition from 
the military into one providing the participant bona fide skill sets in 
all aspects of his/her life. Most important, the sessions became a 
vehicle to identify and deal with a growing number who were struggling 
with mental health issues. A noted Psychiatrist, Dr. William Nash, 
along other mental health professionals, visited the sessions regularly 
and requested my support in sharing the power of these sessions with 
others at major mental health gatherings; the aforesaid led to my 
involvement in a major project sponsored by OSD (P&R) and connected to 
the Institute for Defense Analyses (IDA).
    Unfortunately, the nonprofit inspired by the young Marine Corps 
Captain did not survive for a variety of his (Captain) professional and 
personal reasons. Key lessons acquired during the weeklong sessions, 
however, provided ample evidence of significant success, and the Semper 
Fi Fund and Outdoor Odyssey collaborated to form Semper Fi Odyssey, 
with approximately thirty (30) sessions now having been held. To remove 
even a hint of any conflict of interest, I stepped down from the Board 
of Directors of the Semper Fi Fund and am now on the Board of Advisors 
of the Fund and maintain an Emeritus Status on the Board of Directors.
                           semper fi odyssey
    As mentioned above, Outdoor Odyssey and the Semper Fi Fund, have 
collaborated to develop Semper Fi Odyssey, working in conjunction with 
the Wounded Warrior Regiment for the identification of the majority of 
the participants. The vast majority of the participants are combat 
wounded, with a few struggling with illnesses such as cancer or 
undergoing recovery from injuries sustained in activities other than 
combat. With the exception of staff members of the Wounded Warrior 
Regiment who routinely participate, all of the participants will soon 
be medically discharged from the Marine Corps. Additionally, a growing 
number of veterans have been identified for involvement by case workers 
of the Semper Fi Fund; this cohort is exclusively comprised of those 
struggling to overcome mental health issues. Most of this later group 
have been clinically diagnosed with PTSD and/or TBI, and almost ALL 
diagnosed with PTSD are currently under a clinician's care. Moreover, 
and of significance, many of the participants who have been diagnosed 
with PTSD have not shared with the clinician the source of the stressor 
that ultimately led to the PTSD. For a variety of reasons, many 
struggling with PTSD have a very difficult time of developing a 
covenant of trust with the mental health provider.
    Albeit it's virtually impossible to briefly describe Semper Fi 
Odyssey, suffice it to say that the weeklong session is a holistic 
approach to engage the Marine and through a covenant of trust help him/
her build a realistic plan for the future. Rest assured, my use of 
holistic approach does NOT connote esoteric pabulum laced with lofty 
phrases but one-on-one, eye-ball level leadership, inspiring the 
participant to come to grips with the mental, emotional, physical and 
spiritual aspects of his/her life. Participants form teams and are led 
by very successful, volunteer veterans who are assisted by active-duty 
officers and senior noncommissioned officers who themselves have fought 
alongside the participants in Iraq and/or Afghanistan. The imperative 
to include the active-duty component became patently obvious as the 
evidence of operational stress grew in significance. All of the 
veterans who serve as Team Leaders have made a successful transition 
into the civilian sector, with the majority of this cohort having 
entered the business world; moreover, a sizable percentage of these 
veterans have experienced combat.
    While the syllabus of Semper Fi Odyssey ranks as taxing and quite 
challenging, the underlying objective is the development of both 
professional and personal goals, supported by definitive, 
understandable and usable tools to reach these goals. Participants are 
LED to examine themselves VERY closely and are invariably inspired to 
share innermost thoughts and ``demons.'' In general, participants 
arrive skeptical and somewhat tentative; however, the genuine concern 
of the Team Leader invariably ``breaks the ice,'' leading to team 
cohesion and trust among team members.
    While the course includes the obvious pieces of any typical 
transition course, the focus of effort is to provide the participant 
the ability to know and talk about himself/herself, without falling 
victim to the commonly-known habit of building a resume that doesn't 
reflect in ANY manner the individual described. Without question, by 
the final day of the Semper Fi Odyssey session, the participant has 
grown immeasurably in his/her ability to understand and share insights 
about his/her strengths, while being armed with the ability and 
assistance to tackle weaknesses and challenges. More important, the 
participant leaves the experience with the skills to build and follow a 
plan to succeed, reinforced by the knowledge that he/she now has a 
cadre of supporters (read network) for the future.
    I simply couldn't adequately outline all of the elements of the 
week's experience but will now offer but one vignette from our most 
recent weeklong event which concluded this past Saturday, the 21st of 
April 2012. We reinforce the classroom work and Team Leader time with 
physical activities to the degree possible, based on the physical 
challenges of the participants. As noted above, Outdoor Odyssey offers 
a wide variety of high adventure activities and facilities that enable 
sessions in activities such as yoga and physical fitness, using 
equipment usable to those with physical challenges. The participants 
thrive on events such as the zip line, high ropes course and climbing, 
obviously tempered by physical limitations. This past week, two 
Marines, having but one leg between them, executed the long staircase 
of our indoor facility, with the Marine with an artificial leg carrying 
the Marine with NO legs up to the high ropes course on his back. These 
two Marines then negotiated a VERY tough and rigorous ropes course in 
tandem; there was not ONE dry eye in the building. A Senior Staff Non-
commissioned Officer, deathly afraid of heights and heretofore 
declining to undertake the high ropes course, was SO inspired by the 
experience that he scaled the stairs and negotiated the course. Without 
exaggeration or any sort of hyperbole, the Marine without legs felt 
ten-feet tall and bullet proof upon completion of the experience. 
Everyone (and I mean everyone) saw a stark example of the power of the 
mind--regardless of the body. This particular event will impact not 
only those involved last week but many others as well in the days 
ahead, as it was chronicled by camera in the form of pictures and film.
    The final, collective event of the week is the visit to the crash 
site of Flight 93 that came down in a western Pennsylvania farm field, 
roughly a 20-minute drive from Outdoor Odyssey. Without question, the 
emotional release ranks as palpable; Marines, most for the first time, 
are able to come face-to-face with the reality of 9/11. As the VAST 
majority of these young folks joined the military in large part due to 
the events of that fateful day, the experience reinforces key messages 
shared relative to survivor's guilt and other stressors associated with 
the trauma of combat.
                          cadre of supporters
    It would be virtually impossible to accurately chronicle all of the 
volunteer support that goes into the weeklong Semper Fi Odyssey 
session. However, it is critical to note that the word volunteer ranks 
as KEY to any and all success of the sessions held thus far at Outdoor 
Odyssey. Folks routinely arrive skeptical of the worth of the 
experience, as many, if not MOST, have listened to many folks offer 
assistance that has eventually fallen short of advertised pedigree. 
Without question, though, the power of the week rests on the two most 
important words in leadership: genuine concern. The one-on-one sessions 
and interpersonal dynamics with those who freely give of themselves and 
their time set the experience aside from all others the participant has 
encountered. Moreover, and critical from my perspective, the nature of 
the volunteer, able to convey genuine concern, truly sets the stage for 
the covenant of trust that is developed; this can NOT be 
overemphasized!! To provide an illustration of the utility of the 
volunteer, I will use the most recent Semper Fi Odyssey as an example; 
this event was conducted last week, concluding this past Saturday, the 
21st of April. While not all-inclusive, I'll show certain positions 
that played integral roles in the weeklong session, coupled with 
examples of the various backgrounds of those filling the respective 
roles:

     Team Leader: clearly the key to the success of Semper Fi Odyssey; 
most Team Leaders (TLs) volunteer for the entire week, with a small 
percentage sharing the responsibility, changing at midweek; eleven 
teams were used during the recent session, with TLs coming from such 
locations as Oregon, Wyoming, New York, Virginia and, of course, 
Pennsylvania. The TLs from Oregon, Wyoming and New York were all 
Vietnam veterans; the gent from Oregon was an infantry officer in the 
USMC, followed by a stint as a F-4 pilot in the Corps; he is now CEO of 
his own company; he has traveled to Outdoor Odyssey six times to serve 
as a Team Leader; his brother was a company commander killed in Viet 
Nam in an epic battle experienced by one of our local Team Leaders from 
Pittsburgh who has now served in that capacity for 20 weeklong 
sessions. The gent from Wyoming is an Orthopedic Surgeon, who served in 
Vietnam as a Battalion Surgeon of the same battalion as the brother of 
the gent from Oregon and the aforementioned TL from Pittsburgh. Several 
of the Team Leaders hail from Pennsylvania--all former Marine Officers 
and/or Senior Non-commissioned Officers and serving in leadership 
positions in various businesses. Additionally, two retired Colonels 
from the DC area served as TLs during this recent session: both retired 
Colonels and CEOs of their own companies (one from the Air Force and 
one female retired from the Army--both having served multiple times as 
TLs). During this recent session, we were blessed with the support of 
several active-duty Marines to serve as TL or Assistant TL: two Majors, 
two Captains and two Gunnery Sergeants--all with multiple combat 
deployments to Iraq and Afghanistan. Previous sessions have seen TLs 
from Texas (Professor at Texas A&M and former Marine), Alabama (former 
enlisted squad leader in Viet Nam and successful businessman) and 
Florida (former Navy SEAL and financial advisor). Team Leaders coming 
from the Washington D.C. area are simply too numerous to list, with the 
vast majority being retired Colonels, LtCols and Senior Non-
commissioned Officers--most with combat experience.
     Mental Health Professional: During this session, we were supported 
by a psychiatrist (retired Navy Captain) who had served as the 1st 
Marine Division Psychiatrist in Iraq and, upon his retirement, played a 
key role in the development of the Marine Corps' program of record for 
dealing with mental health injuries known as OSCAR (Operational Stress 
Control and Readiness). We vigorously follow the tenets of OSCAR, 
working hard to identify those struggling to overcome stress injuries, 
while working to support the mental health professional for those 
clinically diagnosed to be struggling with illnesses. This particular 
psychiatrist has been with us many times and strongly endorses our 
work, while providing significant reinforcement to the Team Leader. 
During this recent session, we were also supported by a psychologist 
from a prominent university, located in Pittsburgh; this gent had 
learned of Semper Fi Odyssey from a fellow mental health professional 
and actively sought the opportunity to partake and assist. I am 
confident that we will benefit from his services for many sessions in 
the days ahead.
     Representatives from the University of Pittsburgh and Penn State: 
One of the most popular, and I would state most successful, 
presentations of the week has routinely been one oriented on dealing 
with stress management. Clearly, the sessions at Semper Fi Odyssey have 
identified that day-to-day stressors significantly exacerbate the 
incidence of operational stress or post-traumatic stress that many, if 
not most, servicemembers face after a combat deployment. We have been 
blessed for approximately twenty (20) sessions with a representative 
from the University of Pittsburgh who provides a striking and most 
stimulating presentation that includes tools that can be immediately 
implemented to address stress levels and improve sleep habits. Many 
participants have offered compelling testimony relative to the power of 
this two-hour block of instruction. Additionally, during this most 
recent weeklong session, we had seven representatives from Penn State 
and the University of Pittsburgh form a panel to address any and all 
questions posed by the participants, focusing on post-secondary 
education, veteran benefits, Vocational Rehab and any area related to 
education and training sought and/or required following departure from 
the military. This group consisted of college professors, specialists 
in veterans programs and benefits, department heads and overseers of 
various programs associated with the matriculation to higher learning. 
As many of the participants face some level of physical challenge upon 
departure from the military, this session has proved to be MOST 
beneficial, providing insights into learning aids available to the 
veteran. The session takes approximately two hours, with panel members 
but rarely unable to answer the specific questions proffered by the 
participants; however, for those queries that stymy the group, an 
answer is invariably provided by one of the representatives later in 
the week.
     Yoga Instruction: Semper Fi Odyssey has been supported by the 
nonprofit Exalted Warrior for approximately the last twenty (20) 
sessions. The key instructor hails from Tampa, Florida, and routinely 
spends the entire week at Outdoor Odyssey. Sessions are incorporated 
into the daily routine during at least four days of the weeklong 
schedule, with voluntary sessions held each evening after completion of 
scheduled events. This recent session was supported by two instructors, 
one of whom a Navy Admiral (retired career SEAL) who was instrumental 
in the founding of the Exalted Warrior nonprofit organization. 
Instruction is modulated according to the physical capabilities of the 
participants, and MANY extol the virtues of these sessions to assist in 
relaxation and meditation, while helping to address problems with 
sleep.
     Fitness Instruction: For the last three plus years, we have been 
supported by the Fitness Anywhere Corporation via the involvement of a 
former Navy SEAL who is an exercise physiologist, chiropractor and bona 
fide fitness expert of the first order. Instruction orients on the use 
of a device known as the TRX, and, simply put, it can be used by 
virtually anyone regardless of physical challenge. The addition of 
several periods of this instruction into the weeklong syllabus has been 
HUGELY popular, with every session having one or more participant 
opining that use of the TRX was the first time the participant felt 
like a warrior since being wounded. The Fitness Anywhere Corporation, 
founded by a retired Navy SEAL, offers a TRX free to every participant, 
based on the recommendation of those overseeing the Semper Fi Odyssey.
     Professional Assessment: A company owned by the father of a 
wounded Marine Captain offers his company's service during each session 
of Semper Fi Odyssey to conduct a computerized assessment of each 
participant in the manner of the Meyers Briggs personality assessment. 
The evaluation provides the participant insight into his/her personal 
makeup, principally focused on elements of the individual's 
personality, strengths and orientation relative to occupational fields. 
Fortunately, during this recent session, the Marine Corps' Captain, an 
above-the-knee amputee from combat in Iraq and a recent returnee from 
Afghanistan where he served as a company commander, represented his 
father for the presentation of the assessment results.
     Numerous Instructors: Quite a variety of other professionals, too 
numerous to list, visit Semper Fi Odyssey during the weeklong session 
to provide various periods of instruction. Many of these individuals 
are former military; however, we work hard to recruit, train and 
incorporate talent without military experience, as it serves to better 
educate the populace of the staggering sacrifices borne by today's 
servicemember. Moreover, involvement by those without military 
experience provides the participant the opportunity to learn more from 
those he/she will likely encounter after departure from the military. 
Many of the instructors utilized for the weeklong sessions, be they 
former military or not, have been responsible for the creation of 
actual job opportunities for a number of the participants. An example 
of the periods of instruction provided by these instructors are as 
follows: goal setting; operational planning skills; resume building; 
interview skills and techniques; opportunities in the Federal 
Government; business 101 perspectives; STAR techniques for articulating 
accomplishments, etc. Of additional note, EVERY weeklong session has 
included presentations oriented on bona fide job opportunities; several 
sessions have had participants linked to his/her future employer.
     Interviewers: Our most seasoned Team Leader, a former Marine Corps 
Infantry Officer with considerable combat experience, hails from 
Pittsburgh. This gent trains the new Team Leaders and plays an integral 
role in virtually anything and everything that goes on at Semper Fi 
Odyssey. He owned his own computer company for over three decades in 
Pittsburgh and knows virtually everyone in the city. He has built an 
inventory of over seventy potential interviewers, and personally 
coordinates the involvement for approximately 15-20 interviewers for 
the final day of instruction for each session of Semper Fi Odyssey. 
Each interviewer ranks as a leader in his/her field, and the variety of 
fields represented covers virtually any occupation one could pursue. 
The interview session provides each participant the opportunity to 
undergo at least three or more mock interviewers by folks they have 
never met, instilling a level of stress and offering an opportunity to 
evaluate the participant's ability to talk about his/her skills, 
experiences and passion to serve. A number of the interviewers are 
military veterans; many, if not most, routinely hold interviews for 
actual positions within their respective organizations. Without 
question, those interviewers recruited for this experience are 
passionate about the unique opportunity that they themselves have in 
helping the participant transition into the civilian sector. It is NOT 
uncommon for an interviewer to become a mentor for one of the 
participants he/she has had the privilege of interviewing. This 
particular session ranks as one of the most, if not the most, popular 
of the week, greatly instilling confidence in virtually every 
participant. The following is a snapshot of the interviewers from the 
most recent session: former Vietnam Army Officer and former CEO of 
largest Electrical Construction Company in US; President of 
manufacturing firm; Human Resource Manager of major bank; Senior 
Franklin Covey Facilitator; West Point Grad and Vietnam Infantry 
Officer and President and CEO of major construction company; President 
of Performance Consulting; President of company that provides host of 
services to small businesses; Director of Systems Engineering of KEYW 
Corporation; lawyer and owner of Law Office; former Marine Sergeant in 
Vietnam and owner of nine restaurants in Pittsburgh; President and CEO 
of prominent technology company in Pittsburgh; Superintendent of one of 
Pittsburgh's School Districts; former Marine enlisted infantryman in 
Vietnam and high level labor negotiator; Director of three assisted 
living homes; former infantry Sergeant with experience in Iraq who owns 
a major construction company; former Army Engineer with service in 
Vietnam who is now a TV and radio talk show host in Pittsburgh; 
Orthopedic Surgeon in Pittsburgh who served as a battalion surgeon 
supporting Marines in Vietnam; Assistant VP of Federal Reserve Bank in 
Cleveland; Manager of Recruitment at the University of Pittsburgh 
Medical Center.
    Salient Outcomes, Lessons Learned, and Opinions: As I pen this 
written testimony, we have now been privileged to engage approximately 
30-35 participants for 30 weeklong sessions. Without any exaggeration, 
trust, cohesion and team building represent the major by-products of 
the Semper Fi Odyssey experience, helping the participant share, learn 
and grow during the week while setting the stage for future success. 
Participants build relationships that are lasting and depart with the 
assurance that they are armed with connecting files to people who will 
indeed follow up with them in the days ahead. Obviously, those who 
choose to break contact can; however, those who elect to remain 
connected and gain follow-on support have a vehicle to do so. 
FORTUNATELY, the vast majority of past participants remain connected. I 
offer the following insights from the Semper Fi Odyssey experiences:
Salient Outcomes:
     Conduct self assessment and built definitive plan for improvement
     Gain bona fide skills in application of life-planning tools
     Identify and connect to people in their lives that they can count 
on and trust
     Build a honest network of support among fellow participants and 
volunteer support
     Make commitments that lead to accountability and likelihood of 
noble pursuits
     Experience trust and cohesion, inspiring participants to share 
``demons''
     Made significant breakthroughs relative to mental health issues 
that pave the way to improve follow-on care
     Develop SMART (specific; measurable; attainable; realistic; time 
bound) Goals
     Hone interview skills and STAR techniques that reinforce a TRUE 
resume
     Build a tentative network of support in the eventual geographical 
location of residence
     Enjoy being treated as a warrior and inspired by useful, workable 
skills
     Learn that others with similar experiences have grown and 
prospered greatly
Lessons Learned:
     Vast majority of wounded warriors require some level of assistance 
in preparation for transition
     A growing % of wounded warriors struggle with operational stress 
issues, and a growing number are being diagnosed with PTSD and/or TBI
     Trust, team building and cohesion pay REMARKABLE dividends in 
preparing Marines for eventual departure
     Many, many programs, based on sound concepts and procedures, 
simply DO NOT connect to the individual warrior, lacking one-on-one, 
eye-ball level leadership and understanding
     Many diagnosed and under a clinician's care do NOT disclose 
stressor at root of the problem
     Team building and cohesion led to significant number of 
breakthroughs among those diagnosed with PTSD but heretofore unable to 
disclose nature of stressor
     Experiences at Semper Fi Odyssey paid huge dividends in project 
sponsored by OSD designed to identify best practices; OSCAR is truly a 
winner if presented correctly
     Individuals who care and possess genuine concern for the wounded 
warrior are essential
     Key personnel within OSD are working to provide a grant that would 
enable support to be provided to members of any branch of the service
Opinions:
     Any cohort of combat veterans who have served in Iraq and/or 
Afghanistan would provide indications of stress levels roughly 
equivalent to those observed in wounded Marines
     A very large percentage of mental health professionals DO NOT 
remotely connect to combat vets and are presently unable to establish 
the necessary covenant of trust
     Semper Fi Odyssey could easily serve as a prototype for programs 
within the active-duty services
     Many, many veterans will be identified to be struggling with 
combat stress issues in the near future--and for many, many months to 
follow
     There exist too many disparate programs that DO NOT connect to the 
individual servicemember
     The Semper Fi Odyssey model stands to greatly assist mental health 
professionals engage veterans with mental health issues
     We need to build a mechanism of support that would permit the 
inclusion of members from any branch of the service

    Very Warm Regards and Semper Fi.

    Chairman Murray. Thank you very much.
    Mr. Schoenhard, first let me say that I am very happy to 
hear that the VA is finally acknowledging there is a problem. 
When the Department is saying there is near perfect compliance, 
but every other indication is that there are major problems, I 
think it is an incredible failure of leadership that no one was 
looking into this. In fact, when you sit at that table before 
this Committee, we expect you to take seriously the issues that 
are raised here. It should not take multiple hearings, and 
surveys, and letters, and ultimately an IG investigation to get 
you to act.
    I also would like to suggest that if the reality on the 
ground could be so far off from what Central Office thought was 
happening as it relates to mental health, then you better take 
a very hard look at some of the other areas of care for similar 
disconnects.
    Now, what we have heard from the IG is very, very 
troubling. For months now, we have been questioning whether 
Central Office had a full understanding of the situation out in 
the field, and I believe the IG report has very clearly shown 
you do not. So I want to start by asking you today, after 
hearing from this Committee, from veterans, from providers, and 
from outside experts, why you were not proactive about this 
problem months ago?
    Mr. Schoenhard. Chairman Murray, we have been looking at 
mental health for many years. As you know, with the support of 
the Congress, we increased our capacity and hired about 8,000 
new providers between 2007 and 2011. We relied primarily on a 
uniform mental health handbook that would be the source of the 
way in which we would deliver care to our Nation's veterans. 
That has been the focus of the Department, to ensure that we 
are getting evidence based therapies and a staffing model that 
was largely based on the handbook put out in 2009.
    I think what we have learned in this journey, and we have 
been wanting to work very closely with our providers, is a 
number of things. As I mentioned in my opening statement, the 
way in which we measure these performance measures is not a 
good measure of wait time. We want to work very closely with 
the IG and with any other resources that are available to 
assist us in ensuring that we provide Vet Centered performance 
measures going forward.
    Chairman Murray. Mr. Schoenhard, with all due respect, I 
think back in 2005, the IG said this information was there. So 
that is a long time with a lot of veterans in between. So my 
question is, how are you going to address that growing gap that 
we have seen, what Central Office believes, and what is 
actually happening in the field?
    Mr. Schoenhard. As Dr. Daigh described in our response to 
the IG report, we have a number of things going on. One is 
first we have a working group that will report this summer on a 
new set of performance measures that includes providers on the 
ground assisting us with ensuring that we have developed 
measures in conjunction with support from the IG that are 
really Vet Centered, that are centered on the veterans' 
individual condition, and one in which we can revamp and go 
forward.
    We fully embrace that our performance measurement system 
needs to be revised, and we will be doing that with the work of 
people on the front lines to assist us. We have the benefit of 
these mental health site visits that are assisting us. We are 
learning as we go on other issues having to do with scheduling. 
And all of this effort is assisting us in not just having 
people at Central Office develop proposed solutions, but to 
engage the field in a way that we need to in order to ensure we 
are Vet Centered and we are able to support our providers in 
delivering this care.
    Chairman Murray. I appreciate that, but it is very 
troubling to me that this did not happen five, 10 years ago; 
that we are just now--after months of this, years of this, that 
that disconnect is there. But we will go back to that, because 
I want to ask Mr. Tolentino--and I really appreciate your 
willingness to come forward today. And I believe your testimony 
is going to be very helpful to addressing many of the changes 
that are needed in a timely fashion.
    In your testimony, you suggested that VA institute more 
extensive oversight into how mental health care is actually 
delivered and funds are spent. Given how adept many of the 
facility administrators are getting around the current system 
without being caught, how do you think the VA can most 
effectively perform that oversight?
    Mr. Tolentino. Madam Chairman, to be perfectly honest, I do 
not have a very good answer for you because of the fact that 
the gaming is so prevalent. As soon as something in put out, it 
is torn apart to look to see what the work around is.
    I feel that the reporting that is done is--it is very 
redundant reporting that feels like it goes nowhere. There is 
no feedback loop. One way we are telling you exactly what you 
in most times want to hear that we did at the facilities and 
even at the network, but there is no coming back and 
rechecking, or coming back and feedback to say, well, you said 
you spent this money on these services, but there is no 
workload to verify it. There is nothing concrete to be able to 
speak to what you say you have done.
    In the short time that I worked there, many times we got 
vast amounts of financial monies for different programs, but 
very, very seldom did we ever get requests to verify what we 
have done with workload, with any kind of feedback reports, or 
anything like that. So I think opening the lines of 
communication and a very transparent feedback loop at that.
    Chairman Murray. Mr. Schoenhard, my time is out. I want to 
turn it over to Senator Brown, but I do want to address a very 
important issue here.
    The Department has announced 1,600 new mental health care 
providers, and I appreciate that step. I think it is really 
needed. But I am concerned that VA hospitals all across the 
country are going to run into the same hurdles that Spokane VA 
has been in not being able to hire health staff. And I hope 
that medical centers are doing everything, including using all 
available hiring incentives to fill those vacancies. By the 
way, I assure you that is the next question this Committee is 
going to look at.
    But I want to ask you specifically how are you going to 
make sure that 1,600 new mental health care providers that you 
announced do not remain 1,600 new vacancies?
    Mr. Schoenhard. Chairman Murray, that is a very important 
question. And we have stood up in our human resources group in 
VHA workforce two task forces to assist us with this. One is 
the recruitment and retention of mental health providers with a 
particular focus on psychiatry. That is where our greatest need 
and problem is in retaining and recruiting mental health 
providers.
    The second task force is a hiring task force; that is, what 
can we be doing to expedite and make sure that we are having 
the process of recruitment as speedy as possible. The group has 
put together a number of good recommendations that we will be 
implementing.
    Part of what Dr. Daigh spoke of earlier in terms of our 
four part mission, one of the great assets, having been in the 
private sector for many years before coming to VA, is that many 
mental health providers, including hundreds of trainees, 
currently today get part of their training in VA and have the 
opportunity to experience this going forward. We need to better 
link with these trainees and ensure that we have a warm hand 
off for employment when they finish this.
    Chairman Murray. OK. That is one issue. But then how you 
arrived at your staffing plan is really unclear to me.
    Mr. Schoenhard. Oh, I am sorry.
    Chairman Murray. The new 1,600 mental health providers that 
you allocated and the information that we got from the 
Department yesterday on where that was going to go is not 
supported by any concrete facts or evidence. In fact, yesterday 
the VISN 20 director told Senator Begich and me that she 
learned about the new positions only a couple days ago, did not 
know if it was sufficient, and did not know how the Department 
even reached those numbers.
    So I want to ask you, how did you arrive at that number of 
1,600, and what makes you confident that it is going to be 
effectively placed across the country? What is the plan, 
staffing plan you used to do that?
    Mr. Schoenhard. Thank you. I am sorry. I misunderstood the 
question. I am going to ask Dr. Schohn if she may want to speak 
on this. But we used a model that looks at the volume of 
services. We are piloting this in three VISNs, and I would be 
happy to answer further.
    Ms. Schohn. Thank you. Yes. As part of our response to the 
Committee in November, we plan to develop a staffing model. The 
staffing model----
    Chairman Murray. I am sorry. You plan to develop a staffing 
plan that is not yet in place?
    Ms. Schohn. No, no. We did develop a staffing model, but we 
submitted to you that that was part of our action plan in 
November. We developed a staffing model, and we are in the 
process of implementing it in VISNs 1, 4 and 22, to understand 
how to implement it. So we do not want to just simply say here 
is the number of staff without actually a plan for how this 
rolls out, issues the right number of staff, to really evaluate 
how well and how effective this methodology is.
    Our plan, however, also is not to wait until we get a full 
evaluation of this plan, but basically to staff up so that we 
will be fully ready to implement this plan throughout the 
country by the end of the fiscal year. So we will have--we are 
planning--the plan itself is based on identification of 
existing staff at facilities, the veteran population, the range 
of services offered, and the demand for services. And our plan 
is to be able to use this to project the need so that we will 
have a standard model in the future that is empirically 
validated, that we all know how many staff we need.
    Chairman Murray. My time is up. I do want to come back to 
this because it is critically important. But I will let Senator 
Brown and Senator Tester first speak.
    Senator Brown. Thank you.
    So, Mr. Secretary, you announced last week that the VA will 
hire 1,900 additional mental health staff, 1,600 mental health 
providers and then 300 support staff. Yet in response to a 
question for the record submitted by Senator Burr, a poll of 
your facilities in December 2011 revealed that there were 1,500 
open mental health positions.
    So I guess my question is, are these 1,900 positions 
announced last week by the VA in addition to those already 
identified to Senator Burr as open?
    Mr. Schoenhard. Senator, the 1,900 additional positions are 
based on what we believe are the needed complement----
    Senator Brown. I know. But is it in addition to the 1,500?
    Mr. Schoenhard. It is in addition--these are additional 
positions, in addition to those that we are searching to 
recruit for, that are currently open.
    Senator Brown. So is it 3,400 positions you are going to be 
filling?
    Mr. Schoenhard. No, sir. These are additional positions on 
top of what we are currently recruiting in terms----
    Senator Brown. You said in 2011, there are 1,500 open 
positions. And now you are saying you have 1,900----
    Mr. Schoenhard. Fifteen hundred vacancies. And Dr. Schohn, 
you may want to comment to this. But I think it is important 
for this----
    Senator Brown. Who is in charge? Is it you or her, or what?
    Mr. Schoenhard. Well, for the Committee, let me just 
clarify. These are not related to the number of vacancies. 
These are related to the number of positions that are needed in 
our facilities. And so we will be adding 1,900 positions, 1,600 
in clerical and provider support, in addition to those that we 
are currently recruiting for.
    Senator Brown. All right. So how long do you think it will 
take to fill these positions?
    Mr. Schoenhard. Well, it depends on the level of provider 
that we are searching for. But----
    Senator Brown. Give me an idea. Is it a week? Is it a 
month, a year?
    Mr. Schoenhard. It can take four or 5 months, sir.
    Senator Brown. Four or 5 months. OK. And how do you 
determine the number of additional staff and which type of 
clinicians are actually needed? How do you make that 
determination?
    Mr. Schoenhard. We are allocating the FTEE to the VISN for 
its distribution to the facilities. We will be working with the 
facilities in the VISNs. Part of what we have not described 
here that is in place now is a robust system by which Dr. 
Schohn is working with the mental health leads in the VISNs. 
And with a new management information system that we have in 
place, we have greater visibility to VISN management of this 
open and going forward.
    Senator Brown. So this is four to 5 months, then, still, 
that we are talking about?
    Mr. Schoenhard. Sir, we are planning by mid May to have 
identified where the specific positions go.
    Senator Brown. But in the interim----
    Mr. Schoenhard. But we want to do that in conjunction with 
the VISN leadership.
    Senator Brown. Thank you. But in the interim, you have 
soldiers that are killing themselves and people who are hurting 
and need services. I know that the Uniform Mental Health 
Services Handbook also says that you can actually--on a fee 
basis, you can actually refer out people who need help.
    Mr. Schoenhard. Yes.
    Senator Brown. So I am curious as to--you read about these 
things. And if there is such an overload and there is such a 
breakdown, why is only 2 percent per year of the total unique 
patient population in mental health sent out for non-VA care. 
Why is it only 2 percent, yet the handbook says that you should 
and could do it?
    Mr. Schoenhard. Yes. We do that where we can. Often where 
we have shortages, the community has shortages.
    Senator Brown. Well, it seems like there are--I mean, based 
on what we have heard and the testimony we have been receiving, 
there is clearly a shortage. So in the interim, before you work 
and upload these 1,900 people, why don't you get these people 
out the door and get them care and coverage right away?
    Mr. Schoenhard. Sir, first let me clarify, for those who 
need urgent care, we are emphatic that we ensure that those who 
are at risk are well treated. And it is referred to as suicide 
prevention coordinator for immediate treatment.
    Senator Brown. Well, Jack Manning needed care and coverage, 
and he did not get it. And he killed himself. I mean, there are 
others like that. So what is the definition of critical care 
and immediate care? I mean, to me it means immediate, like the 
guy calls; he gets help right then and there.
    Mr. Schoenhard. Absolutely. Anyone who presents with any at 
risk factors should be seen and treated right away----
    Senator Brown. But they are not.
    Mr. Schoenhard [continuing]. Within the 24-hour triage.
    Senator Brown. But they are not.
    Mr. Schoenhard. They should be.
    Senator Brown. But they are not.
    Mr. Schoenhard. Well----
    Senator Brown. Is that right? They are not.
    Mr. Schoenhard [continuing]. We have an obligation to 
ensure that they are.
    Senator Brown. But they are not. Correct? So if they are 
not--I mean, I know the answer. So you can certainly just say 
that, yes, they are not. We have had some people slip through 
the cracks. If that is the case, then, we need to actually 
outsource and use these resources that we have, these other 
folks that are out there, who want to try to help.
    We should be doing that. Do you agree or disagree?
    Mr. Schoenhard. Sir----
    Senator Brown. Sir, do you agree or disagree?
    Mr. Schoenhard. I think we should take them on in our 
system because we can best serve their urgent needs by----
    Senator Brown. Sir, with all due respect, that is not 
happening. OK? That is why we are here. That is why the IG 
report said that there is a breakdown with you meeting 
performance standards and actually not handling the individual 
needs of the individual soldiers who are killing themselves. So 
it is clearly not working.
    So my question is, do you think we should be sending out 
more people or not--yes or no--to the fee based--outside the VA 
system?
    Mr. Schoenhard. We should sent out where we do not have the 
capacity, but we should--for those who are most at risk that 
need urgent care, we should ensure that they receive treatment 
within the VA.
    Senator Brown. But you are not. Correct?
    Mr. Schoenhard. Well----
    Senator Brown. I am not saying every time, but there are 
instances where there has been a problem.
    Is that a fair statement?
    Mr. Schoenhard. And where we do that, we need to ensure 
that we have----
    Senator Brown. Sir, listen. It is pretty simple. Are there 
instances in which we, the VA, collectively, everybody here, we 
have let somebody fall through the cracks.
    Yes or no?
    Mr. Schoenhard. There are instances where veterans----
    Senator Brown. OK. All right. We are not perfect. So in 
those instances, though, should we then be making sure that we 
do not do that again. And if there is a problem, that we refer 
them to the appropriate open agencies that can help right away.
    Is that a fair statement?
    Mr. Schoenhard. Yes, but----
    Senator Brown. We are only doing 2 percent. Only 2 percent 
of those folks actually are referred out. And it is clear that 
there may be some sectors, some VA sectors, where there is a 
problem. Not everybody. And these are not for the people who 
are out there working their tails off each and every day. I get 
it. They are overloaded. They are overworked. If that is the 
case, let us refer them out and get them care and coverage.
    Mr. Schoenhard. Dr. Schohn or Dr. Zeiss may want to 
comment.
    Senator Brown. I will. I will get to them.
    I just want to say, Nick, if you could just comment on the 
testimony you have heard, and comment on the fact that, based 
on your experiences in Manchester, do you see--or what do you 
think of the testimony from the Secretary, first of all? Number 
1.
    Number 2, am I missing something? Is there an appropriate 
way to refer people out like that? And is it being done? And if 
it is not, why not, and should it be done?
    Mr. Tolentino. Senator, listening to the testimony so far, 
there are a couple of things I would like to comment on. One is 
the hiring practices, saying it is hard to recruit and fill 
these positions.
    There are barriers that are on the front lines that are not 
being heard at this level up here, such as when these special 
purpose funds come in, they are for X number of years--1 or 2 
years, whatever it may be. And a lot of facilities, many 
facilities--not just Manchester--those positions were then 
being listed as not to exceed 2 years, or not to exceed 1 year, 
to be able to go along with the special funding, so that they 
did not have to worry about their budget in the future, and 
instead gave them the option to opt out.
    So if I am a psychiatrist or a mental health clinician, 
why, especially in this economy, am I going to leave a full 
time position to go to work for the VA if it is not even 
guaranteed that I am going to be there in 2 years, or that 
position is going to be there in 2 years? That is the reality. 
That is just one of many examples that the front lines are 
encountering in trying to get people in there.
    Second, when you are talking about the fee service, it 
felt, where I was at--let me qualify that. It felt where I was 
at that the fee service was saying that our system was not 
adequate. So we are not going to send people out if we cannot 
deliver this care that we are so very proud of, that we offer. 
And when they were fee'd out, the problem that--in the Uniform 
Mental Health Handbook, it says that the VA is then responsible 
for ensuring the care management of those people out in the 
community. And that was not even evident either, because we did 
not have even the personnel to do that.
    Senator Brown. Thanks for your answer.
    I also want to----
    [Pause.]
    Senator Brown. I will stay all day, Madam Chair. I mean, 
this is an important issue.
    I want to talk about the bonus program, to the fact that 
you have people who are getting salary, and then they are 
getting bonuses on performance. I would like to talk about that 
in the next round of questioning because I think it is 
important to note that if somebody is getting a salary to do 
their job, and they are just hitting numbers to get a bonus, I 
find that a little bit surprising. So I would like to talk 
about that, and I will refer to the next round.
    Chairman Murray. OK. Absolutely. And we will have as many 
rounds as we need, I assure you.
    Senator Tester.

                 STATEMENT OF HON. JON TESTER, 
                   U.S. SENATOR FROM MONTANA

    Senator Tester. Thank you, Madam Chair, and thank you for 
holding this hearing. I want to thank everybody who has 
testified today.
    Just from a rural perspective, I will tell you that one of 
the reasons the VA cannot contract out in a rural State like 
Montana is because the private sector does not have any more 
mental health professionals than the VA has. And I just want to 
point that out because mental health professionals, whether it 
is in the private sector or in the VA, getting this to these 
folks is a big problem.
    I very much appreciate Mr. Tolentino's--about nobody is 
going to go to work for a year or 2 years in the VA when in 
fact in the private sector, they have much more predictability 
in their jobs. And we need to take that into consideration when 
we start allocating dollars for the VA, to make sure that they 
have the advantage to be able to compete. I very much 
appreciate that perspective.
    Along those same lines, I just want to ask--Senator Brown 
was right in the area of 1,500 positions opened and an 
additional 1,900. So there are about 3,400 positions. They may 
not all be psychiatrists, and they may not all be clinicians. 
But how you are going to fill those in an area where the 
private sector is sucking folks up? Because it is a big issue 
there, too. And the VA--it is interesting to me.
    Do you have an allocation by a VISN of these 1,600 folks? 
Do you?
    Mr. Schoenhard. Yes, sir.
    Senator Tester. Could we get a list of those? How they are 
they going to be allocated?
    Mr. Schoenhard. Yes, sir.
    Senator Tester. I know you talked about metrics, number of 
veterans and that kind of stuff. Could you give me a list of 
metrics on why the numbers are there, how many are going to be 
psychiatrists, how many are going to be nurses, clinicians?
    Are any of them going to be psychologists?
    Mr. Schoenhard. Sir, we are leading to the VISN and in 
discussion with the facilities, it could be psychologists. It 
could be family--it could be a variety of different mental 
health providers.
    Senator Tester. Thank you. And when it comes to contracting 
out, do you guys typically only use psychiatrists, or can you 
use psychologists, too?
    Mr. Schoenhard. No. We can contract with others.
    Senator Tester. Oh, super. That is good, because there are 
some accessibility of those folks in a place like Montana.
    I want to put two things that Mr. Tolentino said along with 
Major General Jones. And, Major General Jones, I want to thank 
you for what you are doing. I very much appreciate it.
    Mr. Tolentino said when he was there, it was clearly common 
if somebody came in with a problem, do not ask if there is 
another issue. There are all sorts of correlations here that 
are wrong. But I just want to tell you that--OK. So if that is 
done--and I believe he is probably right because that then 
became a problem. But if you combine that with what Major Jones 
said, that the folks that he is working with, the major 
stressor is unknown, we have a problem in our system here. 
Because the only way you are going to find out how to get to 
the real root of the problem when it comes to mental health--
and I am not a mental health professional--is you have got to 
find out what that stressor is. You have got to find out what 
created that problem.
    Does that kind of--well, let me just ask you. If you had a 
VA professional in one of the CBOCs or at one of the hospitals 
tell their people do not ask any questions because we do not 
want to know, I am hoping the hell that does not come from your 
end. And why would do they do that?
    Mr. Schoenhard. Sir, if that is being done, that is totally 
unacceptable. And we will review the situation we had to review 
going on in Manchester. And we will continue to follow up any 
time that that occurs because----
    Senator Tester. I am going to tell you, I think you ought 
to do it in every VISN you have. That is just my opinion 
because that is totally unacceptable. We are not going to get 
our arms around this. You guys have been dealt this hand with 
multiple deployments. So the mental health issue is a big 
issue. And it is an issue that, quite honestly, if we do not 
get our arms around it, there are going to be more and more 
people who slip through the cracks, whether we want them to or 
not. That is the way it is.
    Our use in the private sector is important. Our 
partnerships we develop are important. Nobody wants to 
dismantle the VA, but when it comes to mental health issues, I 
think it is all hands on deck. I just think it is all hands on 
deck.
    Last, I just--and I have a bunch of questions here. They 
were written out. The metrics that are used--and I know the 
access to care metrics were the ones that one of you said--and 
it might have been you, Dr. Daigh, about those being flawed.
    I do not know if this is the same thing or not, but the 
report I read means that they were kind of jimmying the numbers 
to look like people were getting treatment in a timely manner 
when they were not.
    Dr. Daigh. I think that the problem is that the schedulers 
were not consistently operating by a business rule that said 
you should schedule the appointment according to the date that 
was desired. And the desired date, what is the desired date? 
The desired date the patient wants, the doctor wants?
    So in the to and fro of scheduling, I think VA created 
metrics which are not supportable in a systematic way. Then you 
look at the dataset. It is not usable from my point of view. So 
I think that is, in large measure, part of the problem with the 
access measures across the system.
    We also hear reports of gaming and people trying to game 
the system. But I do not have evidence that I can give to you 
of gaming, but I certainly can say that from the dataset, we do 
not think it accurately reflects access as it is in the VA.
    Senator Tester. OK. Well, one last thing, and this will be 
the last one. There is a stigma in this country, and probably 
in the world, but definitely in America, the United States, 
attached to mental health issues, injuries. I have multiple 
stories about folks who will not go get treatment because they 
are afraid it will be on their record, afraid they will not be 
able to get a job, afraid it might impact the job they do have, 
perception by family, friends, colleagues.
    Does the VA have an active education program to try to 
reach out to those folks to let them know that this is part 
of--as Major General Jones says, it is increasing, it is 
present, and it is growing. And it is not uncommon, and it is 
OK.
    Is there some kind of educational outreach going on?
    Mr. Schoenhard. Yes, Senator. There is Make the Connection 
initiative that has just been undertaken. I think it gets back 
to the primary care integration of mental health, where we are 
able to screen for PTSD.
    The other aspect of care that we have not mentioned today 
is the Vet Centers, which are also ways in which veterans can 
approach for help, for whatever reasons they would be reluctant 
to access a traditional system.
    Senator Tester. I agree. And before I go--and I want to 
thank the Chairman for the length--I just want to say thank you 
for all you do. Look, I put myself on the line for the VA every 
day because you guys have got a big job to do. But you have got 
to make sure that what is going on up here, things that the 
chairman says and other people on this Committee, that it 
actually gets to the ground, because we are hearing that things 
are not going so well in some areas. We are hearing things are 
going fine in others. And mental health is a huge challenge, 
and it is not easy. And please do make sure that it gets to the 
ground.
    If there is stuff like Mr. Tolentino said about temporary 
dollars, temporary money, hell, I would not take a job like 
that if I was in demand. So let's figure out how to fix that, 
figure out how to make it work. And let's figure out also--by 
the way, because we have Healing Waters in my State that does a 
great job, and there are some others. Let's figure out how we 
can dovetail onto things like what Major Jones is doing because 
that can be an incredible paradox--I mean, you know, whether 
you are fishing or riding a horse, or whatever, I do not care. 
Those can be incredible programs to get people back on their 
feet.
    Thank you very much, Madam Chair.
    Chairman Murray. Thank you.
    Senator Moran?

                STATEMENT OF HON. JERRY MORAN, 
                    U.S. SENATOR FROM KANSAS

    Senator Moran. Thank you, Chairman, Chairwoman.
    Secretary Schoenhard, I was pleased to hear the VA announce 
its plan to hire 1,900 mental health workers. And then I was 
additionally pleased with the announcement yesterday about the 
family therapist and the licensed professional mental health 
counselors. My discouragement is how long it took for the VA to 
implement.
    I have a history with particularly those two professions, 
that in 2006, Congress passed the Veterans Benefits Health Care 
and Information Technology Act. And part of that act was a 
piece of legislation that I introduced to encourage, authorize, 
and insist that you hire those two professionals within the VA. 
And now five and a half years later, it is occurring.
    So while I think I will stay on the positive note, I am 
discouraged by how long it took, but I am very pleased at this 
point in time to see that you moved in that direction. I 
encourage you to hire those people and put them to work as 
rapidly as possible.
    Part of my interest in this topic is coming from a State as 
rural as Kansas, in which our access to mental health 
professionals is perhaps even more limited than more urban and 
suburban States. And we need to take advantage of the wide 
array of professional services that are available at every 
opportunity. And so I am here to encourage you, now that you 
have made this announcement, let's bring it to fruition. And 
thank you for reaching the conclusion and getting us to this 
point.
    I want to direct my question to General Jones. I thank you 
very much for your Semper Fi Odyssey efforts. I had a Kansan 
visit with me within the last month who has organized a 
program--I do not know that it is modeled after what you are 
doing, but the same kind of focus and effort. And it is 
somewhat related to the conversation or the questions of 
Senator Tester about kind of the stigma or lack of willingness 
to admit that one needs help; lack of perhaps knowledge about 
what programs are available; how to connect the veteran with 
what is there.
    I wanted to give you the opportunity to educate me and 
perhaps others on what it is that you have been able to do to 
bring that veteran, who is not likely to know the existence of 
your program or programs like yours. And second, what can be 
done to overcome the reluctance of military men and women and 
veterans to access what is available, such as your program.
    General Jones. Thank you, sir. Well, first off, I think 
that the Semper Fi Fund that I have been a board member of 
provides the ability for these veterans to come. Admittedly, 
most of the veterans that come back to their case workers of 
the Semper Fi Fund have some problems, or they would not be 
there, and they have had a difficult time making a transition.
    So when they arrive in Western Pennsylvania for one of the 
week long sessions, they arrive with a major degree of 
skepticism and very tentative. And we try to restore them to 
the strength of their experience in the Marine Corps, the team, 
the cohesion, team building, and basically restoring their 
trust. I would say trust in the system and trust in others.
    I think that my work through the Semper Fi Odyssey, because 
of the mental health professionals that have come in and really 
bought in to the program, and have really advertised the 
program and allowed me to speak to other groups, led to a 
project I am doing with the Institute of Defense Analysis, 
sponsored by OSD, that looks at best practices.
    So for a long time, we never talked much about mental 
health issues until recently. As a Vietnam platoon commander, 
we never talked about it. But now there are programs in the 
Marine Corps, and I would say the Army, too, Comprehensive 
Soldiers Fitness, in the Army. The Marine Corps' program is 
Operational Stress Control and Readiness.
    It is a great program, but it is not easy to overcome the 
stigma. And the program really rests on the strength of the 
NCO. No major general is going to ride into a link, or squad, 
or platoon, or company, and build immediate trust. It is going 
to come from the NCO.
    So overcoming that skepticism, overcoming that chasm of 
trust is difficult, but it is happening, especially those units 
that have deployed four and five times; young NCOs, young 
officers, who are seeing the power of what a squad leader or 
platoon commander can do to identify problems when they are 
still in the category of combat stress injuries and have not 
migrated to combat stress illnesses.
    I think that is the strength of the Marine Corps' program. 
I think the problem with--mind you, this is only my opinion 
now--the Army program is that it is very well built. The 
application is not focused on the young NCO as is the Marine 
Corps' program. I am not saying this because I am a Marine, but 
I just sense the NCO identifying in Iraq or Afghanistan if 
there is a problem.
    You can start the dialog right there. You can start the 
reconciliation process right there. You do not have to wait 6 
months after he returns and he has got this problem in his 
metal wall locker he pulls out then, when he is by himself.
    So we try to restore, and very successfully restore, 
because all these veterans come in and actually volunteer their 
services. This past week, we did 35 Marines. We had an 
individual travel all the way from Oregon six times. His 
brother was killed in Vietnam as a company commander. He 
himself was a Marine Corps officer. He is a CEO of a very 
successful business, but he is giving up a week of his time.
    We had an orthopedic surgeon come in as a team leader from 
Wyoming. Well, it does not take a Phi Beta Kappa very long to 
tell that, hey, these people are giving themselves for me, so 
that chasm of trust is taken care of pretty quickly. I would 
say by Wednesday of a 7-day program, these people start 
realizing these people care about me. Then you are on the road 
to identification. That is when the demons start coming out. 
That is when you find out that a guy, when the company 
commander was killed, feels guilty--irrationally but true--and 
he has never shared that with a clinician. That is when you 
find out a guy has been behind curtains of his own apartment in 
Racine, Wisconsin, for 2\1/2\ years, and the only person he has 
talked to is his clinician. He has never divulged to his 
clinician that he killed a Marine accidentally because their 
sectors aligned with each other.
    So I think we have no full-proof system, but I think the 
power of the Corps and the power of the Army clearly has team, 
clearly has cohesion, clearly has trust. And if you can restore 
that to what degree you can restore that, then you are on the 
road to a good program.
    There is no shortage of people that come and chronicle 
their experience with a clinician. And they are not damning the 
clinician at all, but the clinician simply does not understand 
the individual adequately enough to build that bond of trust.
    Senator Moran. General, thank you, for your service to our 
country and to the veterans. And thank you all for your 
interest and well being of our Nation's service men and women.
    Thank you, Chairman.
    Chairman Murray. Thank you very much.
    Dr. Daigh, let me turn to you. As you well know, it is hard 
enough to get veterans into the VA system to receive mental 
health care. Once a veteran does take a step to reach out for 
help, we need to knock down every potential barrier to care. 
Clearly, the report your team produced shows a huge gap between 
the time that the VA says it takes to get veterans' mental 
health care and the reality of how long it actually takes them 
to get seen at facilities across our country.
    Now, VA has concurred with all of your recommendations, but 
I think it is clear we all have some real concerns because some 
of these issues have been problems for years. So can you 
address a question of what you think it would take to get the 
VA to get this right this time?
    Dr. Daigh. I think, to begin with, the veteran population 
is dispersed across the country, and the VA is not evenly 
dispersed across the country. So those veterans that go to 
fixed facilities to receive their care, the VA, I am guessing, 
probably is trying to address in this current plan for 1,600 
people. I have not seen the details of the plan, so I do not 
know.
    So I think the first issue is to realize that you have a 
problem where you have facilities and where you do not have 
facilities. And I think the second problem is that, as has been 
stated here, there simply are not enough mental health 
providers to hire off the street in a timely fashion, I 
believe.
    I mean, we looked at the other day--I think there is 
something like 1,200 psychiatry graduates a year in this 
country, from our medical schools. So there is a limited pool, 
and there is a great deal of demand for mental health 
providers. In our discussions with private sector, they said 
that because of the downturn in the economy and other facts, 
that the non VA, non military demand had also gone up, in their 
experience, 10, 20 percent the last couple of years.
    We were asked several years ago to look at access to mental 
health care in Montana. And it was a very interesting review 
for me, in that Montana VA had linked up with the community 
mental health centers in Montana.
    I believe that--I may be out of date by a couple years 
since we did it a couple of years ago--but there was an 
organization of community mental health centers. And by 
allowing veterans to go to those mental health centers, which 
are usually staffed by psychologists and social workers and 
usually not by physicians, they were able to dramatically 
improve the access time to get folks to talk to competent 
people in their neighborhood, in their city, to get some care.
    I think in order to make that care cohesive, as Mr. 
Tolentino said, you have got to be able to get medical records 
back and forth so that there is a coordination of care.
    So I think the all hands on deck idea is one that I wholly 
endorse and one where, if I look at some of the cases--tragic 
cases we have looked at in the past--it was not infrequent for 
veterans to show up at a community mental health center in 
their town. And because they were veterans, they were then sent 
to the VA, and there was not a link. They were not accepted, or 
there was no payment mechanism, or there was no authority. So I 
think that would be a useful step.
    Second, I think you really do have to sit down--and as bad 
as metrics are, I think you just do have to sit down and model 
what you are going to do, and figure out what demand is, and 
try to lay out a business case for what you are doing.
    Chairman Murray. Is that in place at the VA today?
    Dr. Daigh. I do not believe that they have for mental 
health the level of business plan that I think they should 
have, nor do I think they have it for most medical specialties.
    Chairman Murray. Ms. Halliday, do you want to comment on 
that?
    Ms. Halliday. No. However, I would like to say, though, to 
your original question, where you said what is needed to fix 
this, I really believe VA needs to focus on the data integrity 
of the information they are collecting, along with the new set 
of metrics. And I think they need to hold the medical facility 
directors accountable to ensure that data integrity.
    We have seen scheduling practices that resulted in gaming 
the system to make performance metrics look better at the end 
of the day, over the past 7 years, they need a culture change. 
To get that culture change, I think they really need to hold 
the facility directors accountable for how well the data is 
actually being captured.
    The auditors that actually did the work in the field at the 
sites for this review had general observations, that the focus 
was always on the outliers, who was not getting care outside 
of, say, the 14-day window, but there really was very limited 
focus on how well the schedulers were capturing that 
information.
    That is the information that starts to identify demand. It 
starts to tell you what type of services you are going to need 
and whether you need to address emergent care; or to 
strategically address care over the long term, you have to have 
reliable information. So coupled with I think a positive step 
to increase the staffing, that is clearly very important.
    Chairman Murray. OK. Thank you very much.
    Senator Brown?
    Senator Brown. Thank you very much.
    So, Mr. Secretary, I want to get back to, obviously, the 
bonus issue. This year's budget for 2012 is $5.9 billion; next 
year, 2013, $6.2 billion, an obvious increase. And the VA gave 
out in 2011 $194 million to senior executive service employees.
    Do you think that is appropriate?
    Mr. Schoenhard. Well, sir, we have--at VA, under Secretary 
Shinseki's leadership--run an extensive review of performance 
bonuses and have reduced those in both the number of 
outstanding ratings and the dollar amount that has actually 
been implemented.
    Senator Brown. So the number was actually higher at one 
point than----
    Mr. Schoenhard. It was, sir.
    Senator Brown [continuing]. $100 million?
    Mr. Schoenhard. Yes. We have taken this very much to heart. 
So let me just offer that the integrity of our performance 
measures, and the integrity of our scheduling system, and the 
fidelity with which we implement these and adhere to them that 
are veteran centric is extremely important to the Department. 
So we take very seriously the comments that have been made by 
the IG, and we will be rigorously following up.
    We have been emphasizing the integrity of the system. And 
it is obvious that some of what we have put in, in my opinion, 
in performance measures, particularly as it relates to desired 
date, may get us into a discussion where it leads to this kind 
of confusion. Because what sometimes happens is that a 
scheduler will say I want to schedule you for when you want to 
next come in. And the veteran might say, ``When are you next 
available? I will be happy to take whatever is there.'' And 
that is a trick bag we need to get out of, by going back, in 
our view----
    Senator Brown. Sir, listen. I understand that. But my 
question is really focusing on bonuses now. I understand that 
there are holes and we need to fix them. The Chairwoman brought 
up that this has been an issue since the mid 2000s, 2005, 2008, 
whatever, and it is something you are going to continue to 
obviously work on. And I get that. It is not perfect. I 
understand that as well.
    But I am a little curious. What is the average salary for 
these people that are actually getting these bonuses?
    Mr. Schoenhard. Sir, can we take that for the record?
    Senator Brown. Yes. I would like to--I am going to get you 
some--what is the salary? What are the bonuses based on? How do 
you justify $194 million of the tax dollars to go to pay for 
bonuses? This should be part of their job. I just want to make 
sure I understand it. And maybe if not, then I will stand 
corrected.
    Nick, what do you think about the opinion of tying these 
bonuses to quality rather than quantity? What do you think 
about that possibility?
    Mr. Tolentino. Senator, my opinion with the bonuses is that 
I think he already mentioned it. It is bonuses for doing your 
job. So if you are doing your job up to par, you are rewarded 
for that. And what I was always taught from my 14 years in the 
military is your bonus is your reward for going above and 
beyond. And clearly, I am not seeing that, in the treatment of 
veterans and the care that they need.
    So my opinion is, I truly do not agree.
    Senator Brown. Do you think that money could be used 
somewhere better?
    Mr. Tolentino. Beg your pardon?
    Senator Brown. Do you think that $194 million could be used 
somewhere better?
    Mr. Tolentino. I do.
    Senator Brown. Thank you.
    Mr. Tolentino. I do, Senator.
    Senator Brown. First of all, thank you once again. I 
enjoyed the testimony from Senator Moran.
    Why do you think the veterans are reluctant to share their 
experiences with a clinician and that you are finding that 
during your situation in Semper Fi Odyssey and during that 
week, you have found that so many folks have actually opened 
up? Why do you think that--is it a trust issue? Is it just 
being in the military? Or what is it?
    General Jones. Yes, sir. It is clearly a trust issue. The 
issue--the combat--obviously, there is operational stress. 
There is----
    Senator Brown. Can I just add one thing to that? And what 
do you think the VA could do to establish that bond that 
apparently you have?
    General Jones. I think that the issue is a lot of--it is a 
trust issue, the lack of trust. And it is a fact that, quite 
honestly, many clinicians do not understand the nuances of 
combat stress. In fact, some of the tools that are being built 
now are much like a wreck on 95 in a traumatic event.
    Combat stress is very different. It is very personal. And 
it is something that people have a fear and then trust with 
somebody else to share those experiences. And the longer the 
person waits for the reconciliation process, the more difficult 
the problem may be.
    The answer to that, what I think they could do, is I think 
that we need to provide more opportunities, like we are doing 
at Semper Fi Odyssey, for some of these people in the mental 
health community. As mentioned before, I do not think that 
1,900 more people, or 3,400 more people, are going to solve the 
problem unless you are hiring the person that really can, in 
fact, connect to the individual that will inspire him or her to 
share their perspective.
    Senator Brown. Great. Thank you. Thank you all very much.
    Chairman Murray. Dr. Schohn, at this Committee's November 
mental health hearing, you said you were not aware of any 
facilities that were gaming the system and not fully reporting 
waiting times. You heard Mr. Tolentino's testimony about the 
Manchester VA regularly using loopholes to artificially meet 
their mental health performance measures, often at the direct 
expense of veteran care.
    So now that you have read the IG report and performed your 
own audit of mental health practices at various VA facilities, 
and you have listened to his testimony, I want to ask you the 
same question today that I asked you in November.
    Do you believe that VA facilities are gaming the system and 
now fully reporting wait times?
    Mr. Schoenhard. Senator, I would say that we have zero 
tolerance for that. We are going to continue our audits and 
reviews to ensure, with additional training of scheduling 
practices, that this is not occurring. This is certainly not a 
practice that can be condoned.
    Chairman Murray. Well, you heard Mr. Tolentino. He talked 
about the Manchester VA increasing their mental health workload 
numbers in order to get additional resources, despite not 
having enough staff to support that growth; the quantity over 
quality, I believe that you stated. And the result is veterans 
not getting the care that they need. I am really shocked that 
the VA allowed providers to be put in that kind of dilemma, 
where they have to choose between following directions from the 
leadership and following the ethics of their profession.
    So let me ask you, what are you going to do to ensure that 
the quality of care is not being sacrificed as you continue to 
meet these timeliness standards?
    Mr. Schoenhard. I think it is a multifold approach going 
forward, that we are underway and have been implementing here. 
First, we need to ensure a staffing model that we will continue 
to perfect, that we have sufficient staffing on board to serve 
the veterans' needs. We also need to look, as Dr. Daigh said 
earlier, at the productivity of that. And there is a 
productivity directive that is being developed to ensure that 
care is being rendered in a productive way.
    Second, we need to make sure that we have the measures in 
place to ensure that the veterans are receiving timely care in 
accordance with their condition.
    If I might just go back to an earlier discussion with 
Senator Brown. As we were discussing those veterans who are 
most critically at need, who are urgently in need of crisis, I 
feel so strongly that we should be sure to respond to those. 
But certainly in the case where we would not have, say, an 
inpatient psychiatric bed available, we would fee that out to 
the private community. And that is something that should happen 
in order to ensure the veteran is cared for. But it is 
fundamentally important that we get visibility for this.
    In the conversation with Senator Brown, what I was trying 
to emphasize is that we must have visibility, and we must 
respond to those who are most in crisis. And if that requires 
that we fee out because we do not have a bed available or 
something, we would do that. We do do that. But we would only 
do that after making sure we do not have the capacity because, 
candidly, part of the risk is the handoff to the private 
sector. And it is important we get visibility, we bring those 
veterans in, and we take care of them.
    Chairman Murray. Let me go back to the scheduling issue 
because that is a critically important piece of all this. Back 
in 2005 and again in 2007, the IG released reports that 
highlighted problems with the patient scheduling, including the 
calculation of wait times, inconsistence practices by 
schedulers, all that. And despite having heard about this for 7 
years now, here we are today.
    So why is it so difficult to address these problems, and 
should we be more optimistic it is going to happen this time?
    Mr. Schoenhard. Well, VHA has established needs, Madam 
Chairman, for scheduling, including a vision of a modern 
scheduling package that would, among other things, provide 
patients the ability to make their own appointments.
    Chairman Murray. And the implementation date?
    Mr. Schoenhard. We published an RFI in December 2001. We 
would like to take, for the record, when we will be 
implementing because we are underway in this new initiative.
    Chairman Murray. Dr. Daigh, do you believe that is going to 
happen?
    Dr. Daigh. I do not have enough information to comment, 
ma'am. I would have to check and see where they are with this. 
I would just say this has been an issue for a number of years, 
and it has not been solved. So I am not aware of the specifics 
of what they are talking about.
    Chairman Murray. OK. I have several other questions I am 
going to submit for the record.
    But I do want to say, I want to thank all of you for being 
here today and sharing your views. Critically, access to VA 
health care in a timely fashion is absolutely essential, 
especially as we have a growing number of men and women who are 
returning from the war, where this is a signature wound that we 
are very cognizant of, and we need to be prepared. And this 
Committee is focused on this, wants answers and follow up, and 
not just this to be another hearing, but wants real action 
taken.
    So, Mr. Schoenhard, I appreciate the VA stepping up to this 
today. I appreciate them accepting the IG report. I really 
appreciate the IG for all the work you did in a short amount of 
time. A large number of your resources were focused on this.
    Of course, to our other witnesses, thank you very much for 
being here today.
    I want to make it very clear: this is not something we are 
going to have a hearing on, and leave, and go do something else 
tomorrow. This has to be taken care of. We owe it to these men 
and women. I do not want to continue to hear that anybody is 
gaming the system. I want to know that the action plan is being 
put in place to make sure that the hiring you have announced is 
actually taking place. If there are barriers to that, we want 
to know about it.
    And I want to know how you decided which VISNs are going to 
get the practitioners that you plan to recruit. I want VA to 
know that this is not just another hearing here in Washington, 
DC.
    So this is very critical. I think we have made some 
progress, but, boy, do we have a lot of work ahead of us. And I 
think the Nation expects that of us. I intend to stand up to 
it, and I expect all of you to stand up to it as well.
    I do want to just take a second and congratulate Ms. 
Halliday on her recent promotion to Assistant Inspector 
General. We do look forward to working with you.
    With that, this hearing is adjourned. Thank you.
    [Whereupon, at 11:12 a.m., the Committee was adjourned.]
                            A P P E N D I X

                              ----------                              


  Prepared Statement of Claire Haaga Altman, Executive Vice President/
             Chief Operating Officer, HealthCare Chaplaincy
    Madam Chairwoman and Committee Members: Thank you for this 
opportunity to present the testimony of HealthCare Chaplaincy, Inc. My 
name is Claire H. Altman and I represent HealthCare Chaplaincy, a New 
York City based nonprofit organization founded in 1961, whose mission 
is to improve the effectiveness and efficiency of health care through 
the innovative ways chaplains promote and advance palliative care 
research, education, and practice. Fully understanding that the 
distress in a health care setting involves the mind, the body and the 
spirit, board-certified multi-faith chaplains serve as the spiritual 
care expert on medical teams. Our chaplains, employed in clinical 
settings alongside doctors, nurses and other health care professionals, 
work closely with patients and families, religious or otherwise, to 
help find comfort in difficult times.
    With minor exceptions, every veteran who enters the VA has seen 
active duty in military, naval or air service. During their tours, they 
have worked side by side with chaplains. Chaplains in a military 
setting provide care to the spirit to servicemembers of any faith or no 
faith. Chaplaincy is a well-established and trusted institution in the 
Armed Forces. When a servicemember wants to have a confidential 
conversation about crisis of meaning and purpose, he or she is often 
more comfortable approaching the chaplain who has been in the trenches 
with them, as opposed to the social worker or psychologist. Off the 
battlefield, this attitude carries into civilian life. Chaplains are an 
understood and trusted presence.
    Many veterans suffer from serious spiritual and mental distress; 
22% of N.Y. Afghanistan and Iraq war veterans have probable diagnoses 
of Post Traumatic Stress Disorder (PTSD) and/or depression. It is 
difficult for them to discuss their issues with their families and 
friends, often exacerbating their distress and isolation. This distress 
can manifest itself in a number of ways--suicide, substance abuse, 
strained familial ties, difficulty finding or retaining a job, and the 
list goes on. As we are also seeing now, PTSD and/or depression are 
reemerging as older veterans confront age-related illness and loss.
    Unfortunately, many veterans fear utilizing the more standard 
support services due to a potential stigmatization and loss of 
confidentiality, as well as not wanting to be perceived as ``weak.'' 
However, veterans generally trust chaplains and speaking with them is 
not perceived as a sign of weakness. In addition, the confidential 
nature of the chaplain visit will not affect future deployment or 
career considerations.
    Another barrier to service delivery is that veterans and their 
families who are experiencing crises of meaning and purpose often go 
unrecognized in civilian hospitals where otherwise chaplains and other 
health care professionals would be available to help them. We know of 
no civilian hospitals that ask patients or their family about their 
affiliation with military service.
    HealthCare Chaplaincy recommends two actions: 1) include chaplaincy 
services in VA funded outposts/clinics to provide services that 
servicemembers know and trust; and 2) ensure that civilian hospital 
systems across the country include admissions questions asking if a 
patient is a veteran, has seen military combat or is a family member of 
a veteran.
    We applaud the work of this Committee and are encouraged that these 
hearings are taking place to shine a much needed light on the critical 
needs of our servicemembers.
                                 ______
                                 
     Prepared Statement of American Society for the Advancement of 
                            Pharmacotherapy