STATEMENT OF
MARY SCHOHN, PH. D.
DIRECTOR OF MENTAL HEALTH OPERATIONS
VETERANS HEALTH ADMINISTRATION
DEPARTMENT OF VETERANS AFFAIRS
BEFORE THE
SENATE COMMITTEE ON VETERANS’ AFFAIRS
NOVEMBER 30, 2011

Chairman Murray, Ranking Member Burr, and Members of the Committee:  Thank you for the opportunity to appear before you to discuss the Department of Veterans Affairs’ (VA) commitment to providing responsive and effective mental health services that meet the needs of our Nation’s Veterans.  In particular, I will address wait times for mental health appointments and implementation of our mental health policies.  I am accompanied today by my colleagues, Antonette Zeiss, Ph.D., Chief Consultant for Mental Health; and Jan E. Kemp, Ph.D., National Mental Health Director for Suicide Prevention.

Let me state clearly at the outset that we take very seriously this Committee’s concerns regarding needed improvements to VA’s mental health care services.  We are diligently and quickly working to make changes identified by this Committee and through our own review.  We look forward to continued dialogue and partnership with this Committee and Congress on our shared mission.

 The Veterans Health Administration (VHA) places a high priority on providing timely, quality care to our Nation’s Veterans living with mental health issues.  While we have made marked improvements in the mental health services available to Veterans, we continue to experience rapid increases in demand.  We have seen a 34 percent increase in the number of Veterans using VHA mental health services, from 897,129 Veterans in FY 2006 to 1,203,530 Veterans in FY 2010.  During the same period, mental health staff levels increased by 47.8 percent, from 14,207 to more than 21,000. 

 In addition, VHA has been implementing major improvements for Veterans since 2006, including expanding the availability of telemental health services;  establishing VA’s National Center for PTSD Consultation Program available by toll free number (866-948-7880) or online to assist VA clinicians with questions about PTSD, its symptoms and treatment; developing, in collaboration with the Department of Defense (DoD), a mobile smartphone app for tracking and self-management of PTSD symptoms, the PTSD Coach, which has been downloaded over 30,000 times in over 50 countries worldwide and has been awarded the 2011 Federal Communication Commission’s Chairman Award for Advancements in Accessibility; and launching a national messaging campaign, “Make the Connection,” designed to connect Veterans and their family members to the experiences of other Veterans, and connect them with information and resources to facilitate the transition from service to civilian life.  VA appreciates Congress’ support, which enabled enhancement of these important mental health services.

In October 2011, the Government Accountability Office (GAO) issued a report on “VA Mental Health:  Number of Veterans Receiving Care, Barriers Faced, and Efforts to Increase Access.”  GAO made no recommendations to VA in the report, and recognized the extensive efforts VA is making to increase access. The report stated:

VA has implemented several efforts to increase Veterans’ access to mental health care, including integrating mental health care into primary care.  VA also has implemented efforts to educate Veterans, their families, health care providers, and other community stakeholders about mental health conditions and VA’s mental health care.

Moreover, VA recently received the results of a report for which VA had contracted with the RAND Corporation and the Altarum Institute to complete a “Program Evaluation of Veterans Health Administration (VHA) Mental Health Services.”  These results indicate that across the country, as of FY 2009 (the last date of data collection) VHA facilities reported substantial capacity for treating Veterans with mental illness, with reported substantial increases between original measurement and 2007.  Capacity has continued to increase since the RAND/Altarum data collection as VHA transitions toward full implementation of the Uniform Mental Health Services Handbook.  For example, they reported after-hours availability of mental health care at VA medical facilities at 81 percent, and our internal data monitoring show 100 percent of facilities having this availability in 2011.

In October 2011, the journal Health Affairs published an article referencing the RAND/Altarum study.  The study authors claim that this is the largest and most comprehensive assessment of a mental health system ever conducted.  The report, which was based on a review of administrative data from 2007, concludes that most quality indicators showed good care compared to privately insured mental health patients not seen in VA.  While there are numerous differences demographically between the private plan patients and VA patients, this is the most comparable data source available.  The demographic differences would tend to work against VA, which has a generally older, sicker, poorer population.  However, on nine administrative measures used to evaluate important processes in mental health care, VHA performance on seven of these performance indicators is higher than that reported in the literature for non-VA providers. VA is not as good as non-VA care on the other two, but these are measures of care for Substance Use Disorder care patients.  The RAND/Altarum researchers point out ways in which the population differences could bias results against VA, for example, saying, “Performance on the SUD indicators within VHA may lag private plan performance due to the significantly higher prevalence of SUD in our cohort (57 percent) than in the privately insured population (19.1 percent).  The study’s authors also noted that a major issue to further improve VA mental health services is to reduce variation across Veterans Integrated Service Networks (VISN) and facilities.  VA agrees with this analysis and has made reducing such variation a major focus of our efforts.  Despite the strengths and improvements noted in the GAO and RAND/Altarum study, we recognize we have much more to do.  Put simply, our work to care for America’s Veterans’ mental and overall health can never stop and we must continually improve.

I want to provide you with a brief summary of the results of the query of VA mental health staff requested by Chairman Murray at the July 14, 2011, hearing titled, “VA Mental Health Care: Closing the Gaps.”  Then, I will discuss a set of actions VA is implementing to further determine what gaps still exist, and finally, the actions VA is taking to deliver measurable improvements in our mental health care for Veterans.

After the request from Chairman Murray at the July hearing, VHA queried selected VA front-line mental health professionals for their perceptions on the adequacy of staffing and resources to serve Veterans with mental health needs.  To meet the Committee’s deadline, VHA developed a Web-based query that was administered from August 10, 2011, to August 17, 2011.  VHA queried 319 general outpatient mental health providers from each facility within five VISNs selected by Senate Veterans’ Affairs Committee staff.  A total of 272 professionals responded (a response rate of 85 percent).  Approximately one-third (31 percent) of the respondents were social workers, about one quarter (25 percent) were psychologists, and a similar percentage were psychiatrists and nurses (22 percent each).

The Mental Health Query was not a formal survey, but rather an informal tool designed to provide a quick assessment of a small sample of provider perceptions.  VHA views it as one step in its ongoing commitment to assessing and addressing providers’ perceptions and needs.  The survey recorded providers’ perceptions relating to performance measurement, mental health staffing, space availability in medical and mental health facilities, off-hours mental health clinics, and balancing demand for Compensation & Pension/Integrated Disability Evaluation System (C&P/IDES) examinations.  Specifically, many front-line providers believe that Veterans’ ability to schedule timely appointments as measured by the VA performance system does not match providers’ experience and that mental health staffing at their facility is inadequate.  They also believe that space shortages, inadequate off-hour clinic availability, and competing demands for C&P/IDES examinations are barriers to providing access.

Based on these perceptions, VHA leadership has already taken a number of actions.  Since the query was completed, VHA has:

• Disbursed $13 million in funding to hire new mental health staff, which will provide telemental health psychotherapy services to areas where there is lower staffing, such as small community-based outpatient clinics. 

• Hired additional staff for our Veterans Crisis Line and the Homeless Call Center, given that needs continue to expand for these services.  In addition, VHA is aggressively filling existing vacancies for mental health staff. 

• Implemented a Spouse Telephone Support Intervention as part of our Caregiver Support Program after Veterans participating in pilot programs reported decreased symptoms of depression and anxiety. The spouse support program builds spouses’ ability to cope with the challenges that reintegration to civilian society can bring, helps them serve as a pillar of support for returning Veterans, and eases the transition for families post-deployment. 

In addition, to supplement the preliminary survey findings, VHA will continue to reach out to providers for their perceptions on mental health care.  By the end of January 2012, we will have completed 10 focus groups of providers to better understand their concerns.  Based on the findings of the focus groups, VISN leadership will conduct a formal staff survey at every facility, and a sampling of their associated community-based outpatient clinics, to generate facility-based plans.  Surveying will begin in the second quarter of FY 2012, and we expect we will complete the survey by the end of the third quarter of FY 2012.

As always, VHA’s goal and focus is to have mental health services closely aligned with Veterans’ needs and tightly integrated with VA health care facility operations.  To this end, VHA leadership has developed and is implementing an action plan with aggressive timelines for completion.  Some of the actions outlined above are part of this action plan.  The results-oriented action plan pursues five key objectives:  1) improve the accuracy of the mental health scheduling process to improve our performance measurement system; 2) measure the adequacy of mental health staffing through development of a consistent national staffing model; 3) systematically identify and address space shortages in mental health areas; 4) increase off-hours access; and 5) balance the demand for C&P/IDES examinations.  These actions have already been initiated, with deliverables scheduled throughout FY 2012. 

To address mental health access, VHA has put in place a new four-part mental health measure that will be included in the FY 2012 performance contract for VHA leadership.  This performance contract forms the basis for evaluation of VHA leadership, including VISN Directors.  Thus, the measures in the performance contract define what leadership is accountable to accomplish, and the evaluation based on their performance defines various outcomes for them, including bonuses. 

The new performance contract measure holds leadership accountable for meeting the following objectives:

1) The percentage of new patients to mental health who have had a full assessment and started in treatment within 14 days of seeking an appointment. 
2) Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) patients newly diagnosed with post-traumatic stress disorder (PTSD) receive at least eight sessions of psychotherapy within a single 14 week period;
3) Follow-up by a mental health professional within seven days after discharge to the community; and
4) Four visits within 30 days for any patient flagged as a high suicide risk. 

We are combining these actions with the overarching mandate articulated in the VA strategic effort known as “Improving Veterans Mental Health (IVMH) Major Initiative” and VHA Handbook 1160.01, “Uniform Mental Health Services in VA Medical Centers and Clinics.”  VHA’s actions prescribe mental health teams; staffing plans based on approved patient panel sizes; and measureable improvement of patient-centered outcomes for depression, PTSD, suicide, substance use, and mental health recovery.  In addition, VHA recognizes that accountability for delivering improved performance rests squarely with VA facility and VISN leadership.  VHA is using its management and oversight processes to ensure that all facilities and VISNs have appropriately prioritized the improvement of mental health care and are making measureable progress.  A critical function of VHA Central Office and VISN oversight includes identification of facilities with high performance on mental health access and dissemination of high performing practices to other facilities and VISNs. 

VA greatly appreciates Congress’ continued support of VA’s mission.  VA has worked hard to increase Veterans’ access to mental health services through non-traditional settings such as primary care and community living centers, community outreach programs, and telemental health services.  We have made significant improvements in the range and quality of services offered by providing state-of-the-art psychotherapy and biomedical treatments to cover the full range of mental health needs.  We are pleased that these efforts have been recognized in recent external reviews by GAO and separately by RAND/Altarum study.  As I said earlier, our work is and will never be complete.  We must be focused on constant improvement and excellence.  VA continues to implement Veteran and family education and is training other community stakeholders about mental health conditions experienced by Veterans.  We remain committed and will continue to provide all services to meet the needs of our Veterans and to provide them the quality care they so richly deserve.

I appreciate the opportunity to discuss VA’s ongoing efforts in delivering quality mental health care.  My colleagues and I are prepared to answer any questions you may have.