VA Mental Health: Ensuring Access to Care

Chairman Isakson, Ranking Member Blumenthal and distinguished members of the committee, on behalf of National Commander Dale Barnett and The American Legion; the country’s largest patriotic wartime service organization for veterans, comprising of over 2 million members and serving every man and woman who has worn the uniform for this country; we thank you for the opportunity to testify and for taking on one of the most serious challenges facing America’s veterans, that is “VA Mental Health: Ensuring Access to Care”.  

The mental health of our nation’s veterans is something that The American Legion takes very seriously. One of The American Legion’s legislative priorities for the 114^th Congress is to ensure Congress and the Department of Veterans Affairs (VA) provide help for veterans struggling with mental health issues and brain injuries and that they dedicate extensive resources to study the devastating effects of post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI).  The American Legion believes that additional resources and alternative treatments must be provided as options for veterans and servicemembers in need of treatment for brain injuries and mental stress.   

The American Legion has helped drive the focus on unprecedented numbers of veterans returning home from Operation Iraqi Freedom (OIF), Operation Enduring Freedom (OEF), and Operation New Dawn (OND) with PTSD and TBI which have been known as the signature wounds of these conflicts. To address this problem, The American Legion convened a TBI and PTSD committee in 2010, to investigate Department of Defense (DOD) and VA existing medical science and procedures, as well as alternative methods for treating servicemembers and veterans suffering with PTSD and TBI as a result of their combat service.[1]   In addition to the TBI and PTSD Committee, The American Legion’s System Worth Saving Task Force, established in 2003, assesses the quality and timeliness of veterans health care within the VA healthcare system, of which mental health care is a critical component to the overall evaluation. 

On August 31, 2012, President Obama signed Executive Order (EO) Number 13625: Improving Access to Mental Health Services for Veterans, Service Members, and Military Families directing the Departments of Defense (DOD), Veterans Affairs (VA), and Health and Human Services (HHS), in coordination with other federal agencies, to take the necessary steps to ensure that veterans, servicemembers and their families receive the mental health and substance use services and support they need.

These steps include strengthening suicide prevention efforts across the military services and in the veteran community; enhancing access to mental health care by building partnerships between VA and community providers; increasing the number of VA mental health providers serving our veterans; and promoting mental health research and development of more effective treatment methodologies. [2]

The American Legion applauds VA for the work the department has been engaged in to meet the objectives of the President’s Executive order, but much work still needs to be accomplished. The American Legion urges Congress to ensure VA has the funding needed to deliver comprehensive mental health services and to continue to provide the necessary oversight to ensure our Nation veterans receive timely and appropriate mental health services.[3]

VA Mental Health Hiring Initiative

Staffing shortages within VA leadership, physicians, and medical specialists within the Veterans Health Administration (VHA) remain a top concern of The American Legion.  Since 2003, The American Legion’s primary healthcare evaluation tool “System Worth Saving” (SWS) Program has tracked and reported staffing shortages at every VA medical facility visited across the country. The 2014 SWS report found that several VA medical centers continue to struggle with filling critical positions within the VA healthcare system.[4]

In the Spring of 2013, VA attempted to address  the increasing numbers of veterans seeking mental health care by announcing the hiring of an additional 1,600 mental health clinical providers and over 800 peer support specialists.  VA reported they have exceeded the President’s 2012 Executive Order requirements and believe they are on the way to improving veterans access to mental health services. Yet problems with mental health scheduling clearly still exist, as VA’s Office of the Inspector General (OIG) found in a June 2015 study of mental health care in Augusta, Maine.[5]  VA’s continued struggles are indicative of how the lack of available mental health providers can contribute to long wait times for patients. Despite VA efforts in 2014 to hire an additional 1,600 mental health-care providers, time has shown that VA’s effort to address the lack of mental health providers still remains a serious problem. 

On January 30, 2015, the OIG released a report entitled “Veterans Health Administration’s Occupational Staffing Shortages” as required by Section 301 of the Veterans Choice and Accountability Act (VACAA) of 2014. The OIG report determined one of the occupations of critical need within VHA for Fiscal Years 2011 through 2015 for staffing shortages were psychologists.[6] 

When The American Legion’s System Worth Saving team travelled across the country, medical center staff continues to inform our team that they continue to struggle with recruiting mental health professionals. For example, during a September 1, 2015, SWS site visit one medical center[7] identified the following mental health vacancies:

·         14 mental health psychiatrists,

·         7 mental health psychologists,

·         15 mental health social workers,

·         1.5 mental health peer support specialists,

·         and 1 neuro-psychologist totaling 38.5 mental health vacancies in a single medical center.

On average, a position may be vacant anywhere from 90 days to six months before the position is filled resulting in a significant delay in veterans receiving treatment for their mental health conditions.

The VA has a systematic problem with recruiting talented people to either run their medical centers or to provide front line health care to veterans. The Blue Ribbon Panel, created by VACAA to examine reform of the VA healthcare system, provided a presentation to the VA Commission on Care noting:

·         39 percent of senior leadership teams at VA medical centers had at least one vacancy;

·         43 percent of network directors are in a “acting” status resulting in a severe leadership problem with VHA. 

·         More than two-thirds of network directors, nurse executives are eligible for retirement, as are 47 percent of medical center directors. 

Leaders within the VA healthcare system have to be empowered and more needs to be done in order to grow new leadership. 

The American Legion calls on VA to establish a short and long range strategic plan to address their recruiting and retention problems.  Whether the problem is pay disparity with the private sector or other disincentives to employment at VA, this needs to be examined and corrected. VHA needs to continue developing and implementing staffing models for critical need occupations, and work more comprehensively with community partners when struggling to fill critical shortages within VA’s ranks.[8]

VHA must find a way to fill these vacancies if they are serious about addressing the mental health needs of this nations veterans’.  If VHA cannot fill the vacancies, then VHA must determine how they can better allocate the staff and resources they have to maximum effect.  Solving the staffing problem requires both short term and long term solutions.  In the short term, how can you treat the veterans who need care with the providers you have?  In the long term, how can you recruit more providers, and if there are shortages of providers, how can VA help create more mental health professionals?

Community Mental Health Provider Pilot Program

On August 31, 2012, President Obama signed Executive Order (EO) 13625:  Improving Access to Mental Health Services for Veterans, Servicemembers, and Military Families. The goal of the Executive Order was to create a vast network of support that had the capabilities of providing quality and timely mental health care services for veterans, servicemembers, and their families. Section 3(a) of the EO directed VA to create partnerships with community providers to decrease veterans wait times and increase the geographical range for veterans accessing mental care treatments and services. Through this action, VA implemented 24 VA/Community Mental Health Clinics (CMHCs) pilot programs with community-based mental health and substance abuse providers across nine states and seven Veterans Integrated Service Networks (VISNs) to enhance veteran access to mental health care programs and services between VA and community mental health care providers.

In June 2013, President Obama directed all 152 VA medical centers across the country to hold Community Mental Health Summits with community-based programs and organizations to support veterans and their families. These summits were established to promote awareness of mental health services, assist veterans to gain access to mental health community programs and services, and to build health communities for veterans and their families to participate in.  Annual mental health summits are held at every VA medical center (VAMC) across the country. The VA’s goal is to reach all veterans regardless of whether they are enrolled and receiving their health care through the VA.  

Communication within the veterans’ community is essential.  As The American Legion learned from over a dozen community town halls we facilitated under our Veterans Crisis Center program last year, getting veterans in touch with VA to talk about their challenges is a critical tool to solving some of VA healthcare challenges.  Recognizing the importance of this initiative, The American Legion has been worked to track the experiences of our members with VA’s Mental Health Summits.

One veteran told us:

 “A Mental Health Summit was held on September 10^th at the Jesse Brown VA Hospital in Chicago. It was moderated by a staff psychologist from the hospital and was attended by many people from various agencies and organizations. We heard from several veterans about their experiences in the VA mental health system and they were all positive. We also had a networking session which was, in my opinion, very positive. I made several good, new contacts that I will utilize in the future. Unfortunately, I understand that not all experiences veterans have with the VA mental health system are positive. But it was good to hear some success stories and speak to the veterans about what they went through.”

Another veteran described their experience:

“I was asked to participate in a mental health focus group at the Seattle VA. The purpose of the group was to provide feedback to VA about promoting awareness, helping veterans gain access etc. I missed the first meeting, attended the 2^nd and the 3^rd and decided to not participate in the group. Our first task was to adopt bylaws for our group, select a president and a secretary. As I missed the first meeting the group had already selected a leader for the meeting. Staff offered a bylaws template at the previous meeting. The second meeting consisted of taking turns reading the bylaws out loud. Third meeting was even less constructive. Having served on the King County board to end veteran homelessness, served on several other boards in different capacities including President, and being well connected to service organizations such as the Legion, I felt that I had a lot to offer this group. However, most of the group assembled did not have experience in running organizations, access to technology to read documents between meetings. I decided that spending 2 ½- 3 hours driving round trip to attend a one hour lunch meeting progressing at a pace I deemed a snail would find slow a waste of my time. I was Unimpressed in Seattle”.

The disparity between these two experiences is representative of perhaps the biggest challenge VA faces in delivering healthcare – inconsistency between locations.  Where one veteran in the Midwest can have such a positive experience and another in the Pacific Northwest can have such a negative experience, it’s indicative of a system that still has a ways to go to deliver consistent care and results.  VA must work harder to achieve that consistency if mental health efforts are going to be effective.

The American Legion is not alone in finding these inconsistencies.  The recently completed  Independent Assessment of VA healthcare, mandated by VACAA, has similarly illustrated the vast range of inconsistency across VA facilities in the implementation of programs.  It is not necessarily that VA is not attempting to implement good policy, it is often that it is executed with disparate results depending on location.  That is not a recipe for success.

Conclusion:

Much of the problems VA faces in delivering effective mental health care revolve around two primary considerations – lack of staff and lack of consistency.  The former is something VA and Congress have attempted to address with additional hiring, with mixed results.  The latter is something that is completely within VA’s realm of control.  If they are to change their culture to be better focused on serving veterans, ensuring consistency needs to be at the top of the list of priorities for achieving that goal.

The country’s obligation to its Armed Forces and its veterans includes a responsibility for their care and treatment from wounds inflicted upon them while serving their country. The challenge raised by traumatic brain injury and post-traumatic stress disorder demands a dedicated, well coordinated, and flexible response that adapts care and treatment to an individual’s needs, not the other way around.

The American Legion thanks this committee for their diligence and commitment to examining this critical issue facing our servicemembers and veterans as they struggle to access mental health care across the country. Questions concerning this testimony can be directed to Warren J. Goldstein, Assistant Director in The American Legion Legislative Division (202) 861-2700.