STATEMENT OF
MICHAEL J. KUSSMAN, MD
UNDER SECRETARY FOR HEALTH
DEPARTMENT OF VETERANS AFFAIRS
SENATE COMMITTEE ON VETERANS' AFFAIRS
JUNE 4, 2008
Mr. Chairman and members of the Committee, good morning.
Thank you for the opportunity to discuss VHA's mental health services with you today. I am aware that today's hearing had its origins in the situation that recently arose in our Temple, Texas facility. On March 20, 2008 a VA psychologist and program coordinator for the Post Traumatic Disorder (PTSD) sent an internal email to the PTSD Clinical Treatment Team. The email, as characterized by others, does not reflect the policies or conduct of our health care system. The email has been taken out of context, though we certainly agree that it could have been more artfully drafted. This is an unfortunate situation, which has also unfairly damaged the reputations of VA's dedicated and committed health care employees. The erroneous characterization may also hurt veterans and their families, as some of them may call into question the quality of VA's health care. As a result, those individuals may not seek needed medical care from the Department, leaving their health care needs unaddressed.
At the witness table with me is Dr. Norma Perez, who wrote the email in question. As I have stated, Dr. Perez' motives and actions have been unfairly characterized by others. I am grateful to the Committee for giving her the opportunity to speak for herself, and I will therefore not say anything further about her email or about the specific situation at Temple.
VA has been, and remains, absolutely committed to delivering world-class mental health care to enrolled veterans. We are very proud of our accomplishments in this area. VA will spend more than $3.5 billion for mental health services in Fiscal Year 2008, and we are very proud of our accomplishments in this area. Indeed, many mental health professionals and organizations outside the Department have recognized VA's
 
leadership in this area, and I firmly believe that no one receives better mental health care in this Nation than veterans enrolled in VA's health care system. This is particularly true for veterans with post-traumatic stress disorder (PTSD). VA is nationally recognized for its outstanding PTSD treatment and research programs. Although the quality of VA health care has been found equal to, and often superior to, that furnished elsewhere, the popular perception of the quality of VA care is sometimes less favorable. This is unfortunate and undeserved. Some continue to believe that health care services furnished by a government system can never be as good as those delivered by the private sector. In many cases, we have not done enough to educate the public about VA's many achievements and outstanding programs. And we could do more to ensure our own health care employees are informed about the Department's recognized awards and achievements outside their own areas of expertise. VA and this country have much to be proud of in terms of the health care provided to veterans by the very skilled and talented cadre of VA clinicians, not to mention our researchers who continue to improve the clinical care veterans receive.
Improving VA's mental health services has been an active pursuit of the Department for many years. In 2004, we developed a Mental Health Strategic Plan that was both unprecedented and widely acclaimed within the Mental Health Community. Through that effort, we began to address gaps in the mental health services provided at the local level, and to initiate programs at the national level. This plan was intended to serve as a guide for four to five years. During that time, we have continually reassessed our progress and amended the strategic plan based on new information, particularly concerning new evidence-based standards of care and improvements in the delivery of mental health services. We continue to periodically re-assess the plan, as appropriate.
As alluded to earlier, the strategic plan was designed to incorporate evidence-based treatments wherever possible; encourage system redesign activities; and move our system to a recovery-based model as required by the President's New Freedom Commission for Mental Health. For these significant changes to be successful, they must be accompanied by a major educational effort appropriately targeted at our staff
 
and clinicians. I now believe, in retrospect, that we have not done as good a job as we should have to educate veterans and our staff.
As we have initiated new programs that emphasize recovery models for our newest veterans, we have, in some places, not adequately responded to the needs of those who use, and have benefited from, our existing programs, such as group therapy sessions for combat-theater Vietnam era veterans. In addition, some of our own providers have not fully understood our new approach, unfortunately compounding the confusion experienced by veterans at those sites. In response, we have developed an aggressive communication and education plan for both clinicians and veterans, which will be launched in the coming weeks.
Be assured that despite these inadvertent, but significant, educational and communication lapses on our part, our commitment to our veterans and to improving their health status is unwavering. Their well-being and their continued improvement to full functional status has always been the objective of the strategic plan. We will work even harder to ensure we are fully sensitive to veterans' needs from this point forward and will keep them apprised of further changes based on newer evidence.
As we have always sought to do, we will do the right thing for every veteran who has entrusted us with his or her care - one veteran at a time. We will do more to make sure our decision making process for these clinical policy determinations is open and transparent to veterans. Moreover, we will work with members of this Committee, with other mental health professionals, and with veterans themselves to ensure veterans continue to receive the highest quality care available.
At this time, Mr. Chairman, let me talk more generally about the status of mental health care in our Department. VA strongly believes that fully addressing the physical and mental health needs of veterans is essential to their successful re-integration into civilian life. As evidence of that commitment, we plan to spend more than $3.5 billion in
 
Fiscal Year (FY) 2008 for mental health services and the President's Budget has allocated $3.9 billion for that purpose in FY 2009.
Mental health care is being integrated into primary care clinics, Community Based Outpatient Clinics, VA nursing homes, and residential care facilities. Placing mental health providers in the context of primary care for the veteran is essential; it recognizes the interrelationships of mental and physical health, and also provides mental health care at the most convenient and desirable location for the veteran.
In contrast to the private sector, whenever a veteran is seen by a VA provider, he or she is screened for PTSD, military sexual trauma, depression, and problem drinking. Screening gives us an early opportunity to assess and treat the veteran for any identified problem. Our clinicians act on positive screens, and we will continue to monitor their compliance with our national screening directives.
VA employs full and part time psychiatrists and psychologists who work in collaboration with social workers, mental health nurses, counselors, rehabilitation specialists, and other clinicians to provide a full continuum of mental health services for veterans. We have steadily increased the number of these mental health professionals over the last three years. We have hired more than 3,800 new mental health staff in that time period, for a total mental health staff of over 16,500. VA will continue expanding our mental health staff and also will continue to expand hours of operation for mental health clinics beyond normal business hours.
We have reduced wait times throughout our system. At Temple, for example, 99.58 percent of all mental health appointments are within 30 days of the desired appointment date. Nationwide, the percentage is 99.34 percent - and for veterans with PTSD, the percentage rises to 99.66 percent. We've also set standards for timeliness in our Compensation and Pension Examinations. Nationally, our average in March is 28 days to process these exams; Network 17, in which Temple is located, processed exams in 22 days.
 
Our Department will continue to aggressively follow up on patients in mental health and substance abuse programs who miss appointments to ensure they do not miss needed, additional care. VA will also continue to monitor the standards the Veterans Health Administration has set for itself: to provide initial evaluations of all patients with mental health issues within 24 hours, to provide urgent care immediately when that evaluation indicates it is needed, and to complete a full evaluation and initiate a treatment plan within 14 days for those not needing immediate crisis care. At present, 93.4 percent of all veterans seeking mental health care receive full evaluations within 14 days. VISN 17 has a percentage exactly equal to the national average.
On May 1, VA began contacting nearly 570,000 combat veterans of the Global War on Terror to ensure they know about VA medical services and other benefits. The Department will reach out to every veteran of the war to let them know we are here for them. Last month, we completed calls to more than 15,000 veterans who were sick or injured while serving in Iraq or Afghanistan. If any of these 15,000 veterans do not now have a care manager to work with them to ensure they receive appropriate health care, VA offered to appoint one for them.
While the numbers of veterans seeking VA care for PTSD is increasing, VA is monitoring parameters (such as time to first appointment for new and established veterans of all service eras) to ensure they receive prompt and efficient services for PTSD and other mental disorders. In FY 2009, funding enhancements will close gaps in services and allow us to implement a more comprehensive and uniform package of clinical services for PTSD and other disorders.
The Mental Health Initiative provides for the implementation of the Veterans Health Administration's Comprehensive Mental Health Strategic Plan (MHSP). Funding has been allocated for the Comprehensive MHSP each year since FY 2005 and has been committed through FY 2008.
 
Funds were specifically allocated last year to promote dissemination and delivery of exposure-based psychotherapies for PTSD. In addition, we are providing training and dissemination of evidence-based psychotherapies for other mental disorders. VA has allocated additional funds to implement evidence-based programs integrating mental health with primary care, with particular emphasis on depression. That program will be further expanded in FY 2008 and FY 2009.
Since the implementation of the Mental Health Strategic Plan, VHA has dedicated more than $458 million to improve access and quality of care for veterans who present with substance use disorder treatment needs. We have authorized the establishment of 510 new substance use counselor positions and plan to continue expanding our services throughout FY 2008 and FY 2009. In FY 2008, for example, our mental health enhancement budget includes over $37.5 million for expanded services.
VA is developing plans to allocate medical care funds from the FY 2008 funding to hire even more new mental health professionals, develop new programs, expand existing services, and create an appropriate physical environment for care by upgrading the safety and physical structure of inpatient psychiatry wards, as well as domiciliary and residential rehabilitation programs.
Further, VA is taking significant steps to prevent suicide among veterans. We have provided training to all VA employees to underscore that even strong and normally resilient people can develop mental health conditions making them susceptible to suicide; care for those conditions is readily available and should be immediately provided; and treatment typically works.
VA's suicide prevention program includes two centers that conduct research and provide technical assistance in this area to all locations of care. One is the Mental Health Center of Excellence in Canandaigua, New York, which focuses on developing and testing clinical and public health intervention related to suicide risk and prevention. The other is the VISN 19 Mental Illness Research Education and Clinical Center in
 
Denver, which focuses on research in the clinical and neurobiological sciences with special emphasis on issues related to suicide risk.
VA has opened a unique suicide prevention call center in Canandaigua focused entirely on veterans. Suicide prevention coordinators are located at each of VA's 153 hospitals. Altogether, VA has more than 200 mental health providers whose jobs are specifically devoted to preventing suicide among veterans.
In developing the suicide prevention call center, the Department has partnered with the Lifeline Program of the Substance Abuse and Mental Health Services Administration. Those who call 1-800-273-TALK are asked to press "1" if they are a veteran, or are calling about a veteran.
From its beginnings in July, 2007 through the end of April, 16,414 calls have come to the hotline from veterans and 2,125 family members or friends have called on behalf of a loved one. These calls have led to 3,464 referrals to suicide prevention coordinators and 885 rescues involving emergency services. Of note, 493 active duty service members have also called our suicide hotline.
Unlike other such hotlines, VA's hotline is staffed solely by mental health professionals - 24 hours a day, seven days a week. Our hotline staff is trained in both crisis intervention strategies, and in issues relating specifically to veterans, such as traumatic brain injury and post traumatic stress disorder. In emergencies, the hotline staff contacts local emergency resources, such as police or ambulance services, to ensure an immediate response.
If the veteran is a VA patient and willing to identify him or herself, the hotline staff is able to access the veteran's electronic medical record during the call. These records provide information that is invaluable during a crisis, including information on medications; the patient's treatment plan; and names and numbers of persons to contact during this emergency. VA hotline staff can also talk directly to the facility that is treating the
 
veteran. They can place consults in the patient's medical record. For veterans not under VA care, staff can refer them to an individual VA Medical Center or Community Based Outpatient Clinic as appropriate, and see to all of the necessary administrative requirements.
And our hotline staff follows up on these referrals. They also check patients' records to see if consultations were completed and to ensure follow-up actions were taken or are ongoing. If the record does not show this information, the suicide prevention coordinator at the VA facility is called and tasked with following up on the case to ensure that no referral is lost in the process.
In addition to the care offered in Medical Centers and Community Based Outpatient Clinics, VA's Vet Centers provide outreach and readjustment counseling services to returning combat-theater veterans of all eras. It is well-established that rehabilitation for war-related PTSD, substance use disorder, and other military-related readjustment problems, along with the treatment of the physical wounds of war, is central to VA's continuum of health care programs specific to the needs of combat-theater veterans.
The Vet Centers' mission is to provide readjustment and related mental health services, through a holistic mix of services designed to treat the veteran as a whole person in his/her community setting. Vet Centers provide an alternative to traditional mental health care that helps many combat-theater veterans overcome the stigma and fear related to accessing professional assistance for military-related problems. Vet Centers are staffed by interdisciplinary teams that include psychologists, nurses and social workers, many of whom are veteran peers.
Vet Centers provide professional readjustment counseling for war-related psychological readjustment problems, including PTSD. Other readjustment problems may include family relationship problems, lack of adequate employment, lack of educational achievement, social alienation and lack of career goals, homelessness and lack of adequate resources, and other psychological problems such as depression and/or
 
substance use disorder. Vet Centers also provide military-related sexual trauma counseling, bereavement counseling, employment counseling and job referrals, preventive health care information, and referrals to other VA and non-VA medical and benefits facilities.
VA is currently expanding the number of its Vet Centers. In February 2007, VA announced plans to establish 23 new Vet Centers increasing the number nationally from 209 to 232. This expansion began in 2007 and is planned for completion in 2008. Eighteen of the new Vet Centers have hired staff and are fully open. Five other Vet Centers have hired staff and are providing client services, but are operating out of temporary space while they finalize their lease contracts. They will all be open by the end of the Fiscal Year.
To enhance access to care for veterans in underserved areas, some Vet Centers have established telehealth linkages with VA medical centers that extend VA mental health service delivery to remote areas to underserved veteran populations, including Native Americans on reservations at some sites. Vet Centers also offer telehealth services to expand the reach to an even broader audience. Vet Centers address veterans' psychological and social readjustment problems in convenient, easy-to-access community-based locations and generally support ongoing enhancements under the VA Mental Health Strategic Plan.
In summary, Mr. Chairman, I am very proud of what VHA does in the area of mental health care. More than 200,000 people are fully committed to helping veterans receive the health care benefits they have earned through their service and sacrifices. I hope we can continue to move forward from this episode, and help veterans and their families; Congress; the news media and others to better understand what VA has done, and is doing, to fulfill our Nation's commitment to those who have worn the uniform of our Armed Services.