[House Hearing, 113 Congress]
[From the U.S. Government Publishing Office]
MAKING A DIFFERENCE: SHATTERING BARRIERS TO EFFECTIVE MENTAL HEALTH
CARE FOR VETERANS
=======================================================================
FIELD HEARING
before the
SUBCOMMITTEE ON HEALTH
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED THIRTEENTH CONGRESS
FIRST SESSION
__________
TUESDAY, SEPTEMBER 17, 2013
FIELD HEARING HELD IN ANDERSON TOWNSHIP, OHIO
__________
Serial No. 113-36
__________
Printed for the use of the Committee on Veterans' Affairs
______
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COMMITTEE ON VETERANS' AFFAIRS
JEFF MILLER, Florida, Chairman
DOUG LAMBORN, Colorado MICHAEL H. MICHAUD, Maine, Ranking
GUS M. BILIRAKIS, Florida Minority Member
DAVID P. ROE, Tennessee CORRINE BROWN, Florida
BILL FLORES, Texas MARK TAKANO, California
JEFF DENHAM, California JULIA BROWNLEY, California
JON RUNYAN, New Jersey DINA TITUS, Nevada
DAN BENISHEK, Michigan ANN KIRKPATRICK, Arizona
TIM HUELSKAMP, Kansas RAUL RUIZ, California
MARK E. AMODEI, Nevada GLORIA NEGRETE MCLEOD, California
MIKE COFFMAN, Colorado ANN M. KUSTER, New Hampshire
BRAD R. WENSTRUP, Ohio BETO O'ROURKE, Texas
PAUL COOK, California TIMOTHY J. WALZ, Minnesota
JACKIE WALORSKI, Indiana
Helen W. Tolar, Staff Director and Chief Counsel
______
SUBCOMMITTEE ON HEALTH
DAN BENISHEK, Michigan, Chairman
DAVE P. ROE, Tennessee JULIA BROWNLEY, California,
JEFF DENHAM, California Ranking Minority Member
TIM HUELSKAMP, Kansas CORRINE BROWN, Florida
JACKIE WALORSKI, Indiana RAUL RUIZ, California
BRAD R. WENSTRUP, Ohio GLORIA NEGRETE MCLEOD, California
VACANCY ANN M. KUSTER, New Hampshire
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
official version. Because electronic submissions are used to prepare
both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
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September 17, 2013
Page
Making A Difference: Shattering Barriers To Effective Mental
Health Care For Veterans....................................... 1
OPENING STATEMENTS
Hon. Dan Benishek, Chairman, Subcommittee on Health.............. 1
Prepared Statement of Hon. Benishek.......................... 33
Hon. Brad R. Wenstrup, Subcommittee on Health.................... 3
Prepared Statement of Hon. Wenstrup.......................... 34
WITNESSES
Howard Berry, Father, Joshua Berry (deceased).................... 5
Prepared Statement of Mr. Berry.............................. 35
Nate Pelletier, Executive Director, Joseph House, Inc............ 6
Prepared Statement of Mr. Pelletier.......................... 38
Rodger Young, Clermont County Veteran Service Commission......... 10
Prepared Statement of Mr. Young.............................. 40
Paul Worley, Adams County Veterans Service Commission............ 12
Prepared Statement of Mr. Worley............................. 42
Kristi D. Powell, Scioto County Veterans Service Commission...... 14
Prepared Statement of Ms. Powell............................. 42
Linda D. Smith, FACHE, Medical Center Director, Cincinnati VA
Medical Center, Veterans Health Administration, U.S. Department
of Veterans Affairs............................................ 22
Prepared Statement of Ms. Smith.................................. 46
Accompanied by:
Kathleen M. Chard, Ph.D., Director, Cognitive Processing
Therapy Implementation, Director, Trauma Recovery
Center, Cincinnati VA Medical Center, Veterans Health
Administration, U.S. Department of Veterans Affairs
Emma Bunag-Boehm, MSN, APRN, BC, Primary Care Provider,
OEF/OIF/OND Clinic, Clinician, Persian Gulf Registry,
Cincinnati VA Medical Center, Veterans Health
Administration, U.S. Department of Veterans Affairs
Chadwick Watiker, MSW, LISW-S, BCD, Cincinnati Vet Center
Team Lead, Readjustment Counseling Service, U.S.
Department of Veterans Affairs
MAKING A DIFFERENCE: SHATTERING BARRIERS TO EFFECTIVE MENTAL HEALTH
CARE FOR VETERANS
Tuesday, September 17, 2013
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Health,
Washington, D.C.
The Subcommittee met, pursuant to notice, at 10:00 a.m., at
7850 Five Mile Road, Anderson Township, Ohio, Hon. Dan Benishek
[Chairman of the Subcommittee] presiding.
Present: Representatives Benishek and Wenstrup.
Also Present: Representative Massie.
OPENING STATEMENT OF CHAIRMAN DAN BENISHEK
Mr. Benishek. Please remain standing for the Pledge of
Allegiance, led by Commander Rick Simpson.
[Pledge of Allegiance.]
Mr. Benishek. Good morning. Thank you all for joining us
this morning. It is a pleasure for us to be here in beautiful
Cincinnati with all of you.
To start, I would like to ask unanimous consent for our
friend and colleague from Kentucky, Congressman Thomas Massie,
to sit at the dais and participate in today's proceedings.
Without objection, so ordered.
I am honored to serve as the Chairman of the House
Veterans' Affairs Committee, Subcommittee on Health, and to be
joined on the Subcommittee by your Congressman and my friend,
Dr. Brad Wenstrup. As -
[Audio Disturbance.]
Mr. Benishek.--lieutenant colonel. In the spring of 2005,
he was deployed to Iraq for a year, and while there he served
his fellow soldiers, sailors, airmen and Marines, as well as
prisoners and civilians, in the Abu Ghraib prison as Chief of
Surgery and Deputy Commander of Clinical Services. For his
brave and loyal service there, he earned numerous awards and
accolades, including the Bronze Star. Brad is a doctor of
podiatric medicine and former small-town business owner.
Needless to say, the immense wealth of knowledge,
experience and insight that Brad brings to the Subcommittee is
very invaluable. I am extremely grateful to work side by side
with him and with his leadership on behalf of our Nation's
veterans and their families.
So when Brad asked me to come to Cincinnati, his hometown,
to address an issue of such importance to us all, the provision
for high-quality and effective mental health care to veterans
in need, I was happy to take the opportunity.
Yesterday, Brad and I paid a visit to the Cincinnati
Department of Veteran Affairs Medical Center. While there, we
had an in-depth discussion with medical center leaders and
toured the facility. Having worked myself as a surgeon in the
Iron Mountain VA Medical Center, I most enjoyed the meeting
with some of our hard-working Ohioans who strive day in and day
out to provide the best possible care and services to the
veterans in this community.
I would like to take a moment to thank each of those health
care providers, administrative personnel and support staff for
their dedication to our servicemembers, veterans and their
families. It is clear that there are some very special things
going on here in Cincinnati for our heroes, and you have much
to be proud of here in Ohio.
However, where the health care and services provided for
our veterans is concerned, exercising our responsibility for
oversight and policy in Congress is paramount. This past
February, the VA issued a sobering report which showed that for
the last 12 years there have been 18 to 22 suicide deaths among
our veterans every single day.
Ladies and gentlemen, we have lost far too many of our
veterans on the battlefield of mental illness. We have to do
better, and we have to do it now. Key to that effort is
breaking down barriers to care that veterans in the midst of
struggle often face when attempting to access the care they
need to successfully transition home and maintain happy,
healthy and productive lives. No veteran should be reluctant to
ask for help because they are ashamed or embarrassed; and no
veteran who takes the brave step of seeking care should be told
they have to wait for an appointment that is weeks or months
away, or travel long distances from their home and family to
receive the services that they need.
Today, we will discuss the actions we must take to reduce
the stigma and improve the accessibility and availability of
mental health care for veterans here in Ohio and across the VA
health care system. We will also discuss the increasingly vital
role that faith-based and community groups play in helping our
veterans and what we need to do to increase and improve
meaningful partnerships between the VA and these community
resources, who are often the first and most trusted point of
contact for veterans and families in need.
Finally, we will also discuss the critical part that family
members and other loved ones play in the healing of our heroes
and the need to increase family awareness, involvement, and the
integration of mental health services, particularly for those
veterans most in need of support.
I look forward to hearing from the local Ohioans, many of
them veterans, who will testify today. I thank you for being
here and for your devotion to improving the lives of Ohio's
veterans. With the help of communities like Cincinnati and
discussions like the one we were having here this morning, I am
hopeful that we will shatter the mistaken perceptions that
mental health care is not available, not appropriate, or not
effective, and there will come a day when no veteran is
discouraged from reaching out and seeking care, and no family
suffers alone.
With that, I now recognize your Congressman and my
colleague and friend, Dr. Brad Wenstrup, for his opening
statement.
[The prepared statement of Hon. Benishek appears in the
Appendix]
OPENING STATEMENT OF HON. BRAD R. WENSTRUP
Mr. Wenstrup. Thank you, Mr. Chairman.
If you would, everyone, I would like for us to bow our
heads and let us take a moment to remember those who lost their
lives in yesterday's tragic Washington Navy Yard attack. Their
service and sacrifice will forever be remembered by their
families and loved ones.
[Moment of silence.]
Mr. Wenstrup. Good morning, everyone, and welcome to the
House Committee on Veterans' Affairs, Health Subcommittee field
hearing entitled, ``Making a Difference: Shattering Barriers to
Effective Mental Health Care for Veterans.'' I want to formally
and officially welcome you to Cincinnati.
As you have seen in the past few days, this district is a
district that I am privileged and proud to represent. I want to
thank you for the leadership you have shown on the issue of
veterans' mental health care and for hosting this field hearing
today. I am also grateful that Representative Thomas Massie, a
strong supporter of our military and our Nation's veterans, has
taken time out of his busy schedule to be here with us as well.
Congressman Massie, thank you.
To the witnesses on our panels, to each person in the
audience, and especially to every veteran present today, thank
you for joining us. It is important for us all to be engaged in
this issue if we are going to truly improve the care that our
veterans receive.
A field hearing is an opportunity to bring Congress to
Cincinnati, and I am pleased that the Subcommittee on Health
will hear directly from the veterans, the family members of
veterans, the service officers, and the community providers of
this region, who will provide a valuable perspective on the
common barriers to mental health care that our veterans face.
Veterans of Southern and Southwest Ohio are a diverse
group. They were raised on farms, urban high-rises, and in
suburban neighborhoods. But they share a common bond. They made
the voluntary commitment to serve our Nation. Only 1 percent of
Americans have served in uniform. Their accomplishments have
been amazing and truly unmatched by the rest of the world.
As a veteran of the war in Iraq and a member of the Army
Reserve, I have witnessed the heroism of my fellow veterans and
have deep respect for them. We can never repay them for their
sacrifice, but we can honor it by ensuring that they and their
families receive the care that they deserve.
In Ohio, we have a robust system of veteran service
commissions that serve our veterans with zeal and dedication. I
am grateful to have representatives from commissions in three
different counties present to testify here today.
There is a growing recognition that we must develop better
treatment for the invisible wounds that veterans bring home,
including depression, post-traumatic stress disorder, substance
abuse, and traumatic brain injury. These wounds effect veterans
of all our past wars, but the veterans of Operations Enduring
Freedom and Iraqi Freedom face unique mental health challenges.
Because of technology and advances in that, more soldiers are
surviving physical combat injuries, but they present
disproportionate neurological and psychological wounds.
Studies suggest that 1-in-5 veterans of the wars of Iraq
and Afghanistan have PTSD. A decade of war with frequent and
extended deployments have made it more critical than ever
before to create a quality mental health care system for our
veterans.
There are many challenges in our current system that do not
allow veterans to get the care they need. Sometimes veterans
are simply unable to access care. They have difficulties in
scheduling timely appointments, or the office is simply too far
away. Other times, veterans are unwilling to ask for or accept
help. They feel ashamed of their mental injuries. Each veteran
has unique struggles and needs, and we need a mental health
care system that is able to provide effective individualized
care.
But today, we will discuss how the Department of Veterans
Affairs can better improve its approach to and delivery of
mental health care. Truly effective care, however, will extend
beyond the VA. It will require the involvement of veterans'
families and their communities, including veteran service
organizations, community health care providers, and faith
organizations. Each of us has a role to play in improving
veterans' access to mental health care.
Again, I want to thank each and every one of you for being
here today for this important discussion.
Mr. Chairman?
[The prepared statement of Hon. Brad R. Wenstrup appears in
the Appendix]
Mr. Benishek. Thank you, sir.
We will start with our first panel who are already seated
today at the tables.
Doctor, would you please introduce the panelists?
Mr. Wenstrup. Yes. On our first panel joining us today is
Mr. Howard Berry, the father of Army Staff Sergeant Joshua
Berry. Josh served in Afghanistan and was stationed at Fort
Hood during the shooting on November 5, 2009. Josh suffered
from PTSD and ultimately took his own life on February 13,
2013. Howard is here to tell his son's story, as well as his
own.
Barriers to effective mental health care exist not only for
our servicemembers, but for their loved ones as well. I
sincerely appreciate Mr. Berry's willingness to share his
experiences as a way to improve outcomes for veterans and their
families.
Also with us today is Mr. Nate Pelletier, Executive
Director of the Joseph House here in Cincinnati. Mr. Pelletier
is an Army veteran of Operation Iraqi Freedom.
Mr. Rodger Young, veteran service officer at Claremont
County Veterans Service Commission. He is an Air Force Master
Sergeant with 20 years of service.
Paul Worley, Army veteran who has agreed to represent the
Adams County Veterans Service Commission here today. He has
served three tours in the global war on terror.
Ms. Kristi Powell, veteran service officer at the Scioto
County Veterans Service Commission, Air Force veteran.
Thanks to each of you for your service to our Nation and
for the work you do every day to help your fellow veterans. I
look forward to your input on this important issue.
On the second panel, I will be pleased to welcome Ms. Linda
Smith, the Director of Cincinnati VA Medical Center, here to
testify on behalf of the VA. She is accompanied by Dr. Kathleen
Chard, Director of Trauma Recovery Center at the Cincinnati VA
Medical Center, Professor of Clinical Psychiatry at the
University of Cincinnati; and also accompanied by Ms. Emma
Bunag-Boehm, primary care provider for the OIF/OEF/OND Clinic
and the Persian Gulf Registry clinician at the Cincinnati VA
Medical Center; and also by Mr. Chadwick Watiker, an Air Force
veteran, Cincinnati Vet Center Team Leader. I want to thank you
all for being here today.
Mr. Benishek. Thank you, Doctor.
Once again, thank you all for being here.
Mr. Berry, I think we will begin with you. Please proceed
with your testimony.
We are trying to keep it around 5 minutes each, so I
appreciate your consideration there.
Please begin.
STATEMENT OF HOWARD BERRY, FATHER OF JOSHUA BERRY (DECEASED);
NATE PELLETIER, EXECUTIVE DIRECTOR, JOSEPH HOUSE, INC.; RODGER
YOUNG, CLERMONT COUNTY VETERANS SERVICE COMMISSION; PAUL
WORLEY, ADAMS COUNTY VETERANS SERVICE COMMISSION; KRISTI D.
POWELL, SCIOTO COUNTY VETERANS SERVICE COMMISSION
STATEMENT OF HOWARD BERRY
Mr. Berry. Good morning. My name is Howard Berry. I am the
father of the late Staff Sergeant Joshua Berry. My son was
injured both physically and mentally during the shooting at
Fort Hood in 2009. I am not an expert on the diagnosis and
treatment of PTSD, but I am an expert on the pain and suffering
of the surviving family members of soldiers who turn to suicide
as a final solution to their problems.
Please read what I submitted for the record. Some of the
observations and possible solutions to consider are not just my
thoughts. I solicited input from family, friends, soldiers who
served with my son, veterans and caregivers. All have
contributed to what I hope you will read.
The reason I am humbly asking you to read what I wrote is
simple. I am skeptical due to the fact that I have already
written the President twice, all 100 senators, and all Members
of the House of Representatives. To date, I have received eight
responses. That is less than 2 percent.
I had the opportunity to attend some of the trial at Fort
Hood several weeks ago. I was fortunate to stay with my son's
former commanding officer and his family. I learned that Josh's
captain sustained a traumatic brain injury during a subsequent
deployment to Afghanistan. He also suffers from PTSD. He
described what it is like to live with PTSD to members of
Senator Cornyn's staff during a meeting I scheduled while in
Texas.
He said, ``I have a wonderful wife and three children. I
retired from the Army after 21 years of service. I have a good
job and a house and two cars. I am living the American Dream. I
have PTSD. I don't know where, when, or how long an episode
will last when it starts. When it does, I cannot see the wife,
kids, career, job, home. All I feel is pain, guilt, and shame.
I should have died in Afghanistan. I have no worth. I should
take my life. The PTSD I have is mild compared to what Staff
Sergeant Berry had. His was severe.''
Stigmas encountered by soldiers with PTSD start in the
military, continue through treatment at the WTUs, the VA, and
into society. Current perceptions are that PTSD-affected
soldiers are different or messed up. We need to keep them at
arm's length. We need to watch them.
I recently spoke with a director from a local company. I
asked him if he had one job to fill and two equally qualified
applicants, one a veteran with a Purple Heart, which one would
he hire? He replied, ``The veteran.'' I then asked him to
consider the same scenario, only the veteran has PTSD. He did
not respond.
I understand that he has a responsibility to look out for
the company's interest, that he must look out for the welfare
and the safety of all the people employed there. That is his
job. The society we live in has to change. PTSD-affected
soldiers deserve better treatment, like all of us.
The suicide rate is still rising among our veterans. I hope
my coming here today to speak to you is not a waste of our
time. I hope this is the beginning of better days for veterans
with PTSD. After all, we are all responsible.
Please read what I submitted.
Thank you; God bless.
[The prepared statement of Howard Berry appears in the
Appendix]
Mr. Benishek. Thank you very much, Mr. Berry. I truly
appreciate your testimony. I am so sorry for the loss of your
son. Thank you for telling some of us his story.
Mr. Pelletier, please go ahead.
STATEMENT OF NATE PELLETIER
Mr. Pelletier. Thank you, Mr. Chairman, and thank you, Mr.
Berry, for being here. I would first like to say that on behalf
of all veterans, this is why we continue to serve our
population, so that your son is remembered and so others do not
follow in his footsteps.
I would first like to say that in my testimony, I am very,
very proud of our VA Medical Center that we have here in
Cincinnati and the work that has been done. I personally
received best-in-class care here as a disabled veteran. As a
veteran leader here in the community, I have a vested interest
in ensuring that our Federal and community resources enable our
warriors that are in transition to soon be veterans and that
our current veterans successfully reintegrate into our
communities.
I have recently conducted research that studied the impact
of transitioning veterans and drafted a proposal to assist not
only the VHA, which is the main effort post-transition, but the
Departments of Defense, Labor, HUD, Human Resources, and all
supporting agencies within our community to make sure that we
improve and implement a sustainable transition system for our
veterans or before they become veterans.
As the executive director of a local agency supporting
veterans' needs, I am in the fight every day. I have witnessed
what can happen if those who have served our country fall into
what I call the ``distrust gaps'' of an inefficient transition
and support network within the veteran community. I lived that
on the very first day of the Joseph House on April 1st. One of
my War on Terror clients overdosed on heroin and nearly died in
his room. Thankfully, his roommate, who was also there for
addiction reasons, was EMT-certified and saved his life that
day. That day, I knew it was real.
Over the next three years, roughly 300,000 new veterans are
going to return to our communities, and we want to make sure
that we utilize their talents in every way that we can. To this
end, I want to show the interconnected ways that draw attention
to this Committee on the VHA side. We need to address the scope
of expansion of our local VHAs, and also address the
administrative leadership's ability to support community
partnerships.
During the transition of new veterans into the community,
the VHA currently feels the burden to fill gaps in the process
due to the absence of a seamless transitioning system. I define
this as ``scope creep.'' The DoD, VA, all parts of the VA,
including benefits and health, the Department of Labor, as well
as other agencies and community organizations have acknowledged
that the transition process is inefficient and that the
responsibilities of each organization are unclear.
With this in mind, some examples of VHA scope creep
include, but are not limited to employment assistance, which
can be handled in our community, as well as education
assistance, benefits assessment, family supportive services,
and some maybe unrelated medical tasks that can be handled
through the partnerships in our communities.
As we attempt to define these responsibilities, I feel it
is necessary to look at the process in the three different
categories: the processes that the VHA can fund and own
responsibility to execute; processes that the VHA funds and
outsources to the community partners to execute; and finally,
processes that the VHA outsources to the community partners who
are either VA or privately funded and can own the
responsibility to execute on their own.
In addition to addressing the systems and process
responsibility to reduce scope creep, I think it is important
for the VA administrative leadership to empower and leverage
VHA and community partnerships.
In an attempt to fully assess the effectiveness of the VHA
in our community and scope creep, we really need to say what
are the primary responsibilities of our local VAMCs. In my
mind, the purpose of the VHA is very focused and clear: support
the medical needs of veterans who qualify for medical services
post military service. Any services in addition to these
primary responsibilities should be assessed according to those
three categories that I previously mentioned.
The first step to effectively optimize the veteran support
administration is to take an active role in partnering and
oftentimes leading the convening of mobilized community efforts
in our community. We are doing this right now in Cincinnati. We
need more involvement from the VHA.
We can assess two areas of concern nationally and locally,
particularly locally here as it concerns us, one being
employment and chemical dependency, that we are seeing real
difficulty among our returning veterans. In my mind, employment
is a critical node in the process. If you look at all the
different nodes to ensure the ecosystem is best for our
veterans, sustaining income and having a job that not only
provides that income but a sense of purpose is vital to their
successful reintegration.
Often, what I have talked from the sources at the Joint
Chiefs of Staff Office for Warrior and Family Support, that it
is not just PTSD. Not having that stability to be able to
provide for yourself and your family can also trigger symptoms
of depression, self-esteem, a sense of purpose, other things
that may not be directly related to combat-related issues.
Too frequently, these breakdowns lead to the use of
unhealthy coping mechanisms, which then leads to things such as
substance abuse. This is what I call the downward spiral of the
veteran's reintegration or lack of reintegration back into our
communities.
To really access the importance of employment again, the
Joint Chiefs of Staff Office for Warrior and Family Support
said they are accountable for $960 million in unemployment
compensation to veterans without the ability to fix the problem
because in the transition to the community, those veterans are
no longer a part of the Department of Defense.
I feel that we see that the first access the VHA has, that
veterans have, is to our local VHA, and they feel the burden to
meet some of these gaps. I think this is an example of scope
creep within the VHA due to the inefficiencies related to who
owns what in the transitional process.
Besides veteran employment efforts, I think the VA
administration can optimize the partnerships with the community
agencies to provide clinical treatment for our veterans. This
is a very specific topic here. As the director here of the
Joseph House, my clients are prime examples of the system
breakdown within the ecosystem of support. I have currently
identified that 12 out of 27 of my clients are not only
suffering from chemical addiction, but also from a co-occurring
disorder related to mental health, most of them from PTSD.
Recently, we just reassessed those numbers, and it is 78
percent of my current clients from yesterday suffering from co-
occurring disorders related to chemical addiction and mental
health. Subsequently, those are broken down to family support,
employment, and all those other things that they need to be
able to successfully reintegrate.
I would also like to mention that although the VA
administration has provided exceptional support through their
VHA Community Outreach Division to fund and evaluate current
programs like the Joseph House, VA has been reluctant to
partner in the community-based veteran mobilization efforts or
the community action team effort here in Cincinnati. We can
really do better by having participation in there, not just to
figure out what they can do to support us, but what we can do
to relieve the burden of their scope creep.
Local agencies such as the Joseph House, Talbert House,
Volunteers of America in the region provide services and
treatment for veterans that are suffering from chemical
dependency. The majority of these programs are actually funded
by VA Grant Per Diem programs. Although the VA provides a
series of measures to validate funding each year, they also
operate their own internal substance clinic within the
hospital. Again, a very action item where we can look at what
can the VA do internally, and what can we do externally to
serve our veterans. We are already funded to do it in our
communities.
Also we have seen, although it is not true everywhere, but
that the private agencies or funded agencies in the VA and the
community require certifications of their clinical counselors.
We are not often seeing the same at the VA hospital, where it
is not part of the hierarchy to actually have an LICDC or a
CDCA certification to be a clinical counselor. Just a couple of
examples of things we can look at.
And then also related back to chemical dependency locally
here, we are seeing an increasing rise in the use of opiates in
our community versus alcohol. This is an alarming effect, and
we have power within our community agencies to really partner
to do that very well, to relieve the burden on our local VAs.
Just in summary, I would like to reiterate the
opportunities to optimize VHA scope creep and the VA
administrative leadership for the community are not a
reflection of the dedicated staff and those that are leading
them, but an opportunity to optimize our processes.
If I could, in closing, just give you an example of how I
experienced the stress of a veteran who recently was discharged
from our local VA. In 2011, I received a call from a soldier on
a Wednesday, a weekday night. I believe it was a Wednesday at
10:30 p.m. Actually, the call came from the local VA hospital,
to see if I could house a War on Terror veteran for the night.
He was no longer able to stay in the hospital because his time
was up.
At around 11:30 he arrived at the house, at my house, and
for the next two hours he tearfully told me his story. Like
many soldiers, he signed up to serve his country and suffered
severe trauma related to combat that came home with him post
deployment. If I recall correctly, his father had also recently
passed away, and his mother was suffering from chemical
dependency as well.
Despite the breakdown of his support, he soldiered on and
secured a meaningful job, but was later laid off like so many
other Americans. Without stable housing or employment, he found
solace on the streets and had built a relationship with local
law enforcement to allow him to just spend a few nights on the
street while he reached out for help during the day. And
unfortunately, like many homeless citizens in distress, he
turned to alcohol and other drugs as his coping mechanism.
While he fortunately found his way to the VA where he
completed their chemical dependency program, he did not have
the support network to sustain his sobriety post treatment, and
my home became his last resort that night.
This story, like so many others, is simply unacceptable. We
must think strategically, we must act operationally, and
continue to identify opportunities to improve the system while
always keeping the end-state in mind, ensuring our veterans
thrive and are productive members of our society. One veteran
left behind is one too many.
[The prepared statement of Nate Pelletier appears in the
Appendix]
Mr. Benishek. Thank you, Mr. Pelletier.
Mr. Young, you are up.
STATEMENT OF RODGER YOUNG
Mr. Young. Good morning. My name is Rodger Young. I am a
Veteran Service Officer for the Clermont County Veterans
Service Commission. Veteran Service Officers assist veterans in
obtaining their VA benefits. This can include enrolling into
health care, applying for compensation or pension, education
benefits, burial benefits--can you hear me now?
Mr. Benishek. Pull the microphone closer.
Mr. Young. Can you hear me now? How is that?
Good morning. My name is Rodger Young. I am a Veteran
Service Officer for the Clermont County Veterans Service
Commission. Veteran Service Officers assist veterans in
obtaining their VA benefits. This can include enrolling into
health care, applying for compensation or pension, education
benefits, burial benefits, VA home loans, and financial
assistance programs. We are also charged with aiding veterans
with their appeals and dealing with the overpayments and
billing issues at the VA. We are pretty much the proverbial
one-stop-shopping for VA benefits.
Our office was invited here today for this Committee to
provide feedback on the services the Veterans Healthcare
Administration provides and also comment on the programs and
stigmata associated with the PTSD programs.
To start off, I would like to give some positive feedback
first. I have noticed--I have been with the Veterans Service
Commission for five years, and within the last couple of years,
the VA has transitioned into nursing teams. The nursing teams
have been very well organized, and it opened up the
communications between the veterans and their doctors.
Along with that, they also opened up the MyHealthyVet Web
site, which is a great way again to open up communication
channels between the veterans and their doctors, and also for
them to download some of their medical information.
Coupled with that, VBA, the Veteran Benefit Administration,
also has their own Web site, and the E-Benefits Web site also
is a major hub for VA benefits and downloading of VA
correspondence.
I want to personally commend the staff, especially at the
CBOC Clermont County. They always have great service, great
nursing teams, very cooperative and friendly with the VSOs, and
they treat every veteran with the utmost care and respect.
The quick reference flipbooks are also a great way of
passing on information concerning health care, and I have seen
the Ohio Department of Veterans Services is also tagged on to
that.
The areas I feel that we need to improve on over at the VA
as far as health care goes, non-VA health care--fee basis is
what it used to be called--it is not as easy as it sounds. Many
veterans are confused about the program and when VA will
actually pay for the emergency or care and transportation. VHA
needs to be clear on what VA will pay and the requirements
before the health care is covered. Again, the handout makes it
sound easy. There should also be a claim form to send in to VHA
along with the hospital bills.
The processing time is another big concern. It takes so
long for the veteran to even receive an answer if the VA is
going to cover their bills or not. And by this time, the bills
are handed over to collections, and the veteran, of course,
their credit is going to go bad and everything else.
VHA also needs, I feel, a call center for billing specific
non-VA care alone. Normally, you are going to get an answering
machine when you call, and very rarely will we get a call back
on that.
Another problem that they are having down there, especially
at the medical center, is average wait time for surgeries,
anywhere from six months to a year. I feel personally if the VA
does not have the facilities available for surgeries, they
should fee base it out somewhere, to one of the local
hospitals.
Still getting complaints about the professionalism down
there at the VA Medical Center. I know there are a lot of great
folks down there, but there are a lot of angry folks down there
also, which concerns me. A lot of the angry folks we have
identified. As one veteran put it to me, some of those folks
down there at the medical center need to go to Happy College.
[Laughter.]
Mr. Young. I get little to no complaints over at the
Georgetown facilities or the Clermont CBOC.
Another problem that we have, disability questionnaires. I
know we are looking for a way to expedite some of these claims.
That is the key. That is probably the best idea I have heard
since I have been a service officer, is to bring in these DBQs,
which the doctors can fill out there at the CBOCs and at the VA
medical centers. Matter of fact, the central office there in
Washington, Tom Moe--I'm sorry, Tom Murphy; I misspoke there.
Tom Murphy actually told us that they are supposed to be doing
that. The CBOCs, we have no problem with this, with the medical
centers.
We are having an issue with filling out the DBQs, and these
disability questionnaires, once filled out--take a diabetes
claim, for instance. You have a Vietnam vet in-country. These
disability questionnaires will clearly identify that he has a
diagnosis of diabetes, what he is doing for the diabetes,
medication. That is a 20 percent rating. That is easy. Versus a
claim that is going to take eight months to a year-and-a-half
just to identify the same things.
Also, another thing that we run into, if doctors refer
veterans to file a claim, especially to our office, please
ensure the diagnosis and notes are annotated in CAPRI or in
their systems. It makes everybody's life much easier. I get a
lot of veterans coming into the office, and I will file a claim
for PTSD, no problem there, especially if a psychiatrist sends
a veteran over there. But please, if you send a veteran over
there under the impression he has PTSD, please annotate that he
has PTSD. There are times when we get claims back. The claim
was denied because there was no diagnosis.
Veterans endure many adjustments when returning home from
deployment to include indoctrination back into family life,
adjusting back into their home station and their rules, and
trying to process what has happened while deployed. In general,
many veterans are reluctant to seek help for mental issues due
to the stigmata associated with PTSD. Employment is a big issue
to include separation from the military if they self-identify.
Also, they may run into problems with their family, and also
with current gun laws. Many veterans will not self-identify as
having PTSD or won't seek help because of these things.
Feedback from the CBOC staff indicate cognitive therapy is
working on many veterans, and I will vouch for that. It does
work. Success stories, to be honest, though, I don't have any.
PTSD, folks, you can get treated for that, but it does not go
away.
Many veterans who seek help for PTSD receive some relief
through medications to tone down the symptoms, but I have never
seen a veteran completely cured of it. Realize in past wars,
veterans would endure one to two deployments in the warzone.
Contemporaneously, it is not uncommon to see five to eight
deployments nowadays.
PTSD programs have prevented many suicides, but I think we
still have a long road ahead of us in treating PTSD. In my
opinion, we need to fix the stigmatas associated with PTSD so
more veterans will seek help, and then we need to rehabilitate
them to function in today's society outside the military.
Veterans, they feel disconnected when they come home. They
are totally disconnected from the civilian society. They are
programmed for military.
Our office appreciates the invitation today to outline some
of the hurdles VA faces and the vast improvements it has made
to ensure the veterans are taken care of. Partnerships within
VHA, VBA, and the VSO offices will solidify a smooth transition
for the returning veterans and their families. Standardization,
consistency and communication within these agencies is the key
element to minimize the confusion within the veteran
communities.
[The prepared statement of Rodger Young appears in the
Appendix]
Mr. Benishek. Thank you very much, Mr. Young.
Mr. Worley, could you begin, please?
STATEMENT OF PAUL WORLEY
Mr. Worley. Good morning, Mr. Chairman, Members of the
Committee. It is an honor to testify before you today. Thank
you for allowing me the opportunity to speak this morning about
mental health care for veterans.
My name is Paul Worley, and I am an Army veteran. I served
as an infantry rifle platoon leader and scout platoon leader in
the 2nd Battalion, 502nd Infantry Regiment, 101st Airborne
Division in Iraq in 2005 to 2006. In 2008, I went to
Afghanistan and served as an operations officer for Regional
Command South in Kandahar. In 2010, I went back to Iraq as a
company commander and saw the drawdown and was there for
Operation New Dawn.
At times and places few will ever know, we fought for each
other against an unseen enemy. I was honored to serve my
country and privileged to lead the best soldiers in the world.
Today, I am equally proud to represent my fellow veterans and
to talk about the issues we face in regards to mental health.
When it comes to mental health care for veterans, the major
issues are access and availability. The VA is the largest
integrated health care system in the country. There are going
to be issues, as there are in every health care system, but
that does not mean that the system is broken.
In Adams County, Ohio, our veterans are faced with the
issue of getting reliable transportation to their mental health
appointments. The nearest clinics are located in Portsmouth and
Chillicothe, which are at least a 45-minute drive for the
majority of our veterans. For those who receive services in
Cincinnati and Columbus, the task of getting to their
appointments is even more daunting.
Our local veteran service commission and our local veteran
service organizations, including our VFW Post 8327 and our
Disabled Veteran Chapter 71, currently provide transportation,
but it is not enough to meet the demands of our veterans and
their families. I believe it is essential that we provide more
mobile veteran centers to provide access to our rural
residents.
Another access issue we face in southern Ohio is Internet
availability. Our Internet infrastructure in Adams County is
extremely limited due to the terrain and the financial
challenges of our local population. Many veterans do not have
ready access to fill out forms online or to obtain the
information they need about mental health services. As more and
more information is shared online, it is critical that we
provide our veteran population with this essential basic modern
need.
I believe that the military as a whole has made positive
progress to reduce the stigma of post-traumatic stress disorder
within its ranks over the past 10 years. However, I believe
that there is still a great amount of work to do to reduce the
stigma of PTSD among the American people. Young veterans
seeking civilian jobs are extremely reluctant to seek help
because of the risk of an employer not hiring them. All
veterans deal with the stigma that seeking help for mental
health is a sign of weakness. More education is needed to make
sure that the American public comprehends the issues associated
with PTSD.
It is very encouraging that the VA has recently hired an
additional 1,300 mental health care workers that will
potentially alleviate some of the availability issues. I
believe that the VA employees and leadership want nothing but
the very best care and benefits for our veterans. However, we
need to continue to improve the mental health care system. We
need to be prepared to pay for veteran health care services as
readily as we were to fund the wars that caused these issues.
The price tag may be great, but that truth does not take away
the Nation's duty to care for its veterans.
The country sent us to war. Now is the time to make sure
that this country is delivering on the solemn promise made to
our veterans for their voluntary service. No one gets left
behind. Thank you.
[Applause.]
[The prepared statement of Paul Worley appears in the
Appendix]
Mr. Benishek. Thank you, Mr. Worley.
Ms. Powell, please begin.
STATEMENT OF KRISTI D. POWELL
Ms. Powell. Good morning. Thank you for this opportunity.
My name is Kristi Powell. I work with Scioto County
Veterans Service Office. It is through my job there that I get
the opportunity to work with my fellow veterans, and it is
through this job that I will be their voice today for victim
survivors of military sexual trauma, as I will refer to as MST
throughout.
The Department of Veterans Affairs Web site states that
about 1-in-5 women and 1-in-100 men seen in VHA respond ``yes''
when they are screened for MST. This is a very high rate, and
it is very alarming and concerning.
The veterans in my county are struggling with the services
that the VA can provide. Although a disabled vet myself, I do
go to the VA, and I strongly advocate for veterans to utilize
the VA, but we need to recognize that we are struggling with
programs for specialized things like PTSD, TBI, and MST.
The veterans in my community, when they do raise their hand
and address themselves as being a survivor of MST, they are not
getting the care that they received in the cases that I
provided in my testimony. What I would like to see is that we
recognize this as an ongoing problem, a current problem, and
one that is not going away. It would be great if we could see
every VA develop a plan to help these veterans.
Currently, veterans have to travel very far distances.
There is not a lot of facilities to treat women survivors of
MST. Currently, one of my veterans had to go all the way to New
York State just for the care that she deserves. So there is not
care locally being provided.
In the cases that I did give you, the women were subjected
to being in all-men counseling groups and around individuals
that they should not have been around when trying to struggle
with a rape and the scars that it has left on them.
A survivor and a victim of MST should be able to go to
their local VA with confidence that they are going to receive
the care that they deserve, and that care should be available,
like I said, at every VA that is around. For my veterans, a
drive one way to get care is over an hour.
The VA is responsible for serving the needs of veterans by
providing health care, rehabilitation, and this just is not
being done. I would like to just raise awareness on this
subject today, and I won't go into detail. I hope that
everybody received a copy and can read the cases that I
provided on the veterans in my community. Thank you.
[The prepared statement of Kristi D. Powell appears in the
Appendix]
Mr. Benishek. Thank you very much for your testimony, Ms.
Powell.
I really appreciate you all being here today.
I think I am going to start by yielding myself 5 minutes
for questions. I think I want to start with a question for Mr.
Berry.
I think you have some very compelling testimony there
concerning the loss of your son, of course. Were you able to
talk to a veteran service coordinator at the VA? Were you
involved at all with your son getting care from the VA? Were
you a part of it?
Mr. Berry. PTSD?
Mr. Benishek. Yes.
Mr. Berry. For his care?
Mr. Benishek. Well, apparently they have a family services
coordinator that helps families of veterans with veterans that
have to deal with the VA. So were you involved with a family
service coordinator?
Mr. Berry. No, I wasn't. None of my family members nor I
were ever approached in any way to learn about PTSD or
participate in what needed to be done as far as the care for my
son, what we could do, what to look out for, anything. And when
I did try to ask questions, they always kept tossing the HIPAA
laws up, ``We can't communicate with you because of the HIPAA
laws.''
These soldiers are brittle. We need to surround them with a
circle of care, and the door was closed. Even after his death,
I found out that a lot of the things that--the HIPAA law
doesn't go away. I am, like, well, I don't understand. But,
see, I don't understand a lot of things that took place
regarding my son's care, and all I have had have been questions
since the day he died. I still haven't had any answers.
Mr. Benishek. Well, I hope today that the second panel will
review your testimony and maybe come up with some answers for
us regarding that question. I brought up the veterans service
coordinator and making sure we try to have the family and
friends of the veterans more involved with the care. So, I
appreciate that.
Mr. Pelletier, I have a question for you, too. You told me
about a veteran that showed up at your house at 11 o'clock at
night after being discharged from the VA hospital. Is that
correct?
Mr. Pelletier. That is correct.
Mr. Benishek. Didn't they have a discharge plan for the
patient? I mean, how is it that the guy ended up on your
doorstep?
Mr. Pelletier. What I know, Mr. Chairman, is only what he
told me, that he had finished the program and was not allowed
to be there for another night based on, I guess, the
regulations of the program. Now, he was able to go back the
next day, so it was more or less a one-night event where he
needed a place to sleep.
Mr. Benishek. All right. It just seems to me that, as a
physician, I know when the patient has a discharge plan to be
going the same day. We know where the patient is going that
day, and it seems odd that there would be no plan for his
discharge or a place for him to be, and then he would call you.
So I was just wondering if there was a plan, it wasn't carried
out or the patient wasn't satisfied with that plan, or he just
didn't have anything else to do and he finally showed up at
your door.
And how often has that occurred? Where do you get your
people from? Are they from discharges, or are they just from
people finding homeless people on the street?
Mr. Pelletier. That relates to Joseph House, your first
question. I was contacted by a staff member at the VA hospital
in reference to him and his need, and I talked to him on the
phone. So it was from VA. Now, I don't know--and I won't speak
on what I don't know. So if he had a program aligned for him,
he may have. I was not aware of it. All I know is that I felt
the need for it to happen.
Mr. Benishek. Right. Does it turn out that many of your
patients come from discharges from the hospital?
Mr. Pelletier. Are you referring to the Joseph House?
Mr. Benishek. Yes.
Mr. Pelletier. That house was actually my personal house
where he came to stay with me, not at the Joseph House.
Mr. Benishek. Right.
Mr. Pelletier. He stayed in my own home. It was not until
about a year-and-a-half I took over the Joseph House.
So at the Joseph House, we do receive clients from the VA.
We receive clients from multiple sources. Given our location,
we are right in the middle of the area, we have a lot of walk-
ins because they are literally sleeping a block away from where
we exist.
But we do have a lot of referrals from the VA to the
program, and keep in mind that a lot of clients that I serve
have chemical dependency. It requires them to go through
multiple programs. That doesn't mean that one is better than
the other, but it will take maybe a few different attempts to
find the right fit, which also establishes, I think, why we
need to have a great partnership, to understand the needs of
each client to make sure we try to get them in the right place
the first time.
Mr. Benishek. All right. Thank you.
Ms. Powell, let me just take another moment here and ask
you a question. This military sexual trauma issue, I am very
interested in this issue. It is my understanding that many
people don't report the fact that they have been a victim of
military sexual trauma because of the fact that they are just
afraid as to what is going to happen to them or if they are
going to be discharged, are they going to be segregated. I am
working on legislation to take the reporting and the
prosecution of offenders out of the military chain of command.
Do you feel that that would be helpful, removing the
prosecution from the military chain of command? Are you
familiar with that?
Ms. Powell. Yes, sir, I am. In the cases with the female
veterans I am currently dealing with, that is an issue. None
have reported. They did not report while they were active duty
due to being afraid of reprimand, and also being afraid to
testify against their perpetrator.
Mr. Benishek. You mentioned a circumstance where a victim,
a female victim of military sexual trauma was in a treatment
program that was all men involved. Is that a frequent
circumstance?
Ms. Powell. When it happened the second time with the
second case, a female, then I realized that it was a problem,
and it is due to there not being separate wings or
individualized treatment plans available for care. If there
were separate female units, then they definitely would not have
been put in the group counseling with the men.
But, yes, this is occurring frequently, and that was the
issue that I addressed. As soon as they identify themselves as
MST, the red flag should go up and they should not be subjected
to that type of group counseling.
Mr. Benishek. Well, yes. All right. Well, I am hoping that
the next panel will address some of these questions that you
all have brought up here this afternoon.
I will now yield the floor to my colleague, Mr. Wenstrup,
for his questions.
Mr. Wenstrup. Thank you, Mr. Chairman.
Mr. Berry, I want to again thank you for being here today.
I think that your testimony clearly depicts the challenges that
so many face when they return from war, and I think that it
clearly depicts our need for a greater transition for our
soldiers as they exit the military and go to the VA side. There
seems to be a wall there and a disconnect, and I think that
attention will be focused more on transitioning as we move
forward, and I think it is very important, and your story
clearly depicts that, and I thank you for bringing that out for
us today.
On that front with transition and support, I have a
question for you, Mr. Pelletier. You identified the need for a
stronger referral system between the VA and the community
providers. Would you clarify some of the weaknesses in the
current referral system and ways that maybe we can make it
better?
Mr. Pelletier. Right. I think to sum up, if you have seen
one VA, then you have only seen one VA. Speaking locally here,
given that we have a very robust community effort to mobilize
our sources externally from the VA, what we found in these
convening sessions that we have is that there are vital people
in the VA who could be part of those groups, whether it is
around--particularly around health, but housing and chemical
dependency are very interconnected when it comes to health
issues, that they are not allowed to participate, period, due
to restrictions on the administrative side, to participate in
those convening sessions.
We have five active teams right now in our community. They
are focusing on the--well, every community is different, but
five major efforts to support our veterans who don't have that
support. We are here to help because, like I said, the VHA has
taken on so much responsibility that it is hard to do the
primary tasks. But it is hard to help if we can't interact in
an effective way, and they have the most access to our clients.
I am a big fan of the OIF/OAF clinic and Operation New Dawn
and Karen Cartwright's leadership there. She says that she has
access to the majority of the new veterans coming in. We need
to be able to understand the landscape and for them to be
involved.
Mr. Wenstrup. Thank you.
Mr. Young, I believe you mentioned about the disability
questionnaire. Were you speaking to that? And are those claims
done electronically or hand-written?
Mr. Young. Hand-written.
Mr. Wenstrup. They are hand-written, the questionnaires?
Mr. Young. Right.
Mr. Wenstrup. Just one thought that I had on that.
Sometimes with an electronic type of form, if they are
obligated to fill it out, it won't let them complete it if
there are missing portions of it, and I think that that might
be a solution for us. Does that sound like it may work? Because
you commented on parts not being there, like the diagnosis,
which is key. So if you can't complete the form without having
all the boxes checked, might that be of help?
Mr. Young. That could be one solution. Actually, the
diagnosis would show up in CAPRI, which they could see up there
at the VA regional office. The disability questionnaires we
will actually expedite, and those are normally hand-written. I
am not sure how we would get that integrated to their system so
they could do that.
Mr. Wenstrup. Thank you.
Ms. Powell, this has been a very major issue for us. I am
on the Armed Services Committee as well as Veterans' Affairs
Committee, and the sexual trauma, military sexual trauma has
been highlighted.
One question I have is when you are seeing some of these
victims, are they mostly clearly recent incidents, or are some
people from 20 years ago that are now coming forward? What are
you seeing?
Ms. Powell. Okay, sir. Yes. When I had the roundtable
discussion in case number 3, I was really taken aback that the
different eras of women that served were all survivors of MST.
There is a woman who served in the `80s, one from the `90s, and
then others from currently today. So it has been going on for
some time now.
The women from the past are misled and don't have current
information as well because they think that to receive care,
that they have to provide information about their specific
incident, so they stay silent.
And I would like somehow to make that--they have to become
aware of the services that can be provided and they don't have
to stay silent anymore, because that is a long time that she
has been the way she is, where she cannot even leave the house,
she cannot work, she self-medicates, just to deal.
Mr. Wenstrup. For those in uniform today that are victims,
I just returned from Madigan Army Medical Center in Washington,
and they started a new program that I hope is successful and
that can carry on throughout the military, and it is a sexual
assault response team where people can come in anonymously and
start to engage, usually with a legal team and social workers,
on what their options are. So when they take this step, they
don't have to be afraid because it is not anything that goes on
their record, and they get better guidance through that.
Through the National Defense Authorization Act, this year,
we put in many whistle-blower protections and things like that.
So it is being addressed very seriously, and hopefully that
will have long-term benefits.
It doesn't change your challenge for today on the VA side,
but hopefully it will, and maybe some of the models of what we
are seeing with that program can reap some benefits. I
appreciate you taking that on.
Ms. Powell. Thank you.
Mr. Wenstrup. Thank you.
Mr. Chairman, I yield back.
Mr. Benishek. Now I will yield to Mr. Massie for questions.
Thank you.
Mr. Massie. Thank you, Chairman Benishek. I want to thank
you for your work on the recent bill, the first appropriations
bill that we passed, reallocating priorities so that we can try
and get rid of the backlog in the VA filings, and that did pass
the House of Representatives. Hopefully, we can get that
through as part of the latest budget and continuing resolution.
Also, I want to thank you for traveling such a long
distance to come and help us in our region on this issue.
Mr. Wenstrup, I appreciate you organizing this hearing. I
think among all the congressmen, you are probably the most
qualified to cover this issue given your service in the
military, and also in the health care profession.
What strikes me today is that we are trying to ameliorate
or work on an issue for people that starts in the military. It
starts sooner than when they are discharged. So the question
that I have for really anybody on the panel here is, what
policies could our military adopt during active service to
reduce the onset of mental illnesses or to mitigate the effects
of mental illness after military discharge? For instance, you
mentioned one of the nodes was employment. Are we doing enough
in the military to prepare people for employment, or are there
ways that we can prevent MST by preventing the acts? Would
anybody like to speak to that?
Mr. Pelletier. Congressman, I would be happy to. There are
several ways to address it. The way I have been addressing it
is looking at the holistic picture of someone who is about to
get out of the service, who is about to sign that paperwork,
and the next step will be to reintegrate into society.
So if you look at kind of a TedX model, there are all kinds
of things that could break down within transitioning warriors,
as we like to call them, and it relates to employment, it
relates to mental health. I just want to bring attention to
that PTSD is certainly a diagnosis. It can go beyond what
happens in combat. It can happen within the community.
Something can trigger it after you get out that may not have
been picked up. Or it could just be mental health issues
related to combat stress, which is not always PTSD,
transitional stress that can relate to mental health.
So, yes, I do think it needs to be addressed before they
get out and that we figure the accountability for it. I think
what we need to do is when those soldiers or warriors have
decided to make the next step and sign the paperwork, they
don't get out the next day. There is a period of time. We need
to figure out how long that period of time we can invest in
their transition.
My proposal is an actual recommendation of a process we
could look at. It is not an answer, but it is a process where
we address all those things that we need to look at with our
veterans or soon-to-be veterans. We do a very good job right
now, at least where I came from at Fort Stewart, in addressing
the mental health. PTSD, I had gotten out in '08. Employment is
not addressed, but it is also not the responsibility.
So what we need to look at is where do the responsibilities
lie in the system and that overlap of where, even before the
DoD hands over, when can we bring in community or national
partnerships to begin that work. The Joint Chiefs of Staff
Family and Warrior Support Command is absolutely where I think
the discussion can happen, because they overlap from DoD and
community partnerships, but they are only facilitators. They
are not the leaders.
Mr. Massie. Thank you very much.
Mr. Berry, along the lines of that question, do you think
that multiple deployments or extended deployments contributed
to your son's condition?
Mr. Berry. My son served in Afghanistan, was only deployed
one time. Ultimately, the incident that led to his taking his
life, making that choice, was what took place at Fort Hood, and
then the subsequent--I call it pussyfooting around for the next
three-and-a-half years, or whatever.
There were so many things that I couldn't understand, and
his skill sets were compromised. So how could I expect him to
understand what decisions were being made regarding the trial
and how it was being handled? I couldn't wrap my brain around
them. How could I expect him to?
And I even actually have letters that were written on
numerous occasions by doctors that were involved in his care,
and I asked permission to use them, and I was told that if I
did, that his physicians would terminate from their positions.
I just thought that that was--I wasn't doing anything to
disparage anyone. It was just a statement that was made that
just said that the decision that my son made to end his life
was based on what happened at Fort Hood, and I am not allowed
to share that.
Mr. Massie. I also share your concern over how that
incident was characterized in the official story, and I
appreciate you coming today to testify.
Mr. Young, you mentioned something that I don't want to let
it be swept under the rug. You said you are still getting
complaints about the VA in Cincinnati. What are veterans
telling you about the professionalism there, and are you
concerned that they don't seek treatment because of the stigma
or something associated with that particular center? Can you
elaborate on your comment?
Mr. Young. I will address the OEF/OIF clinic, very
professional. I have heard nothing but good things come out of
the OEF/OIF clinic. But there are other physicians down there
that I hear they either tell them or kind of disregard of,
``No, you don't have that.'' They kind of give them the brush-
off, is what I normally hear, or ``I don't believe in that.'' I
have heard that one more than once. ``I don't believe in
PTSD.'' Coming from a VA, that is ridiculous.
Mr. Massie. Is there a system or a method to report those
incidents?
Mr. Young. Yes, there is. There is patient advocacy, and
that is usually who we refer them to first. If we hear many
incidents coming out of there, typically we will address the
director on what is going on.
Mr. Massie. Thank you.
I yield back.
Mr. Benishek. Thank you.
Brad, do you have any other questions?
Mr. Wenstrup. I just have one question.
We talked a lot today about transitions, deployment
actions, things like that, and I do hear the DoD side trying to
take part in that. I hope that that comes to fruition.
My question to each of you is, for those that you serve,
when they come to you, especially veterans that are new
veterans, just leaving the military, do you feel that they come
to you with any guidance before they get to you on how to
navigate the VA system?
We can go down the line.
Ms. Powell. My answer is no. The new veterans that are
getting out today are not receiving any kind of beneficial
information on what to do next. So they are getting out, and
they experience a lot of separation anxiety. They don't know
what to do next. They weren't told to copy their medical
records, and now we are having problems locating those for when
they got hurt in service. They know nothing about the VA at all
until someone, an older person they see on the street tells
them to come into our office, basically.
Mr. Worley. And I just recently got out two years ago, and
I left from Fort Stewart, Georgia. I saw a big transition when
I first came in the Army from 2004 to where we were in 2011. I
think these soldiers are armed with--everyone is armed with the
right information, but a lot of times they are out processing
when they get back from a deployment, and all that is on their
mind is, I'm getting out, I have to show up to these mandatory
classes, but they are not paying attention until when they get
out and it has been a year and their unemployment has ran out,
and then all of a sudden, well, I probably should have paid
attention, but then they don't have leadership in place. They
can't go to their team leader or squad leader and say,
``Sergeant, can you tell me what I need to do?''
So it is tricky, but at least in Adams County, we have made
strides to make our veterans service office more available to
our veterans. It is just hard with younger veterans because
they are starting their lives when they get back. They are
concentrating on their family, and it may be, like you said
earlier, they may not get those issues until something triggers
it later on.
But I do believe that they are armed with the information.
They just don't pay attention. They are focused on other things
when they leave.
Mr. Young. I concur with Mr. Worley there. I think the TAPS
briefs are very good, and they have a lot of information, but I
think the veterans with the--I think mine was a week-and-a-half
long, and I think they are just inundated with so much
information, and they are more concentrating on family and
employment upon discharge.
The VA, I know back when I had a TAPS brief, they lightly
touched on VA and moved on. The first thing that went through
my mind is VA health care, I am thinking a guy is missing
limbs. I am not thinking that is a health care for me.
But I think they need to touch more on the VA and the VA
benefits available to them. I think the employment information
was good that they gave us, but they need to hit on a little
more about the VSO offices so we can kind of guide them on
where to go when they get out. I think that would definitely
help.
Mr. Wenstrup. Thank you.
I yield back.
Mr. Benishek. I want to thank you all so much for appearing
here this morning. It is very, very helpful for this Committee
to hear this input.
You all are now excused, and I will ask the second panel to
come forward.
Dr. Wenstrup introduced the second panel a bit earlier, and
we were fortunate enough to meet with most of the panel
yesterday in our visit to the medical center. I want to thank
you all for being here today. I know that, Ms. Smith, you are
going to be the one testifying, but I would hope that maybe you
would address some of the issues that the first panel brought
up in your testimony. We have your written testimony already,
what you are prepared to say, but I think that some of the
testimony that we heard in the previous panel is pretty
compelling, and I know that we will later on, if you don't
address those or if I can't think of all the things, we are
going to submit questions to you later to try to address the
issues that that panel brought up so that I don't forget any of
those details later, so we would appreciate that.
But in saying that, please proceed with your testimony.
STATEMENT OF LINDA D. SMITH, FACHE, MEDICAL CENTER DIRECTOR,
CINCINNATI VA MEDICAL CENTER, VETERANS HEALTH ADMINISTRATION,
U.S. DEPARTMENT OF VETERANS AFFAIRS, ACCOMPANIED BY KATHLEEN M.
CHARD, PH.D. DIRECTOR, COGNITIVE PROCESSING THERAPY
IMPLEMENTATION; DIRECTOR, TRAUMA RECOVERY CENTER, CINCINNATI VA
MEDICAL CENTER, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT
OF VETERANS AFFAIRS; AND EMMA BUNAG-BOEHM, PRIMARY CARE
PROVIDER, OEF/OIF/OND CLINIC; CLINICIAN, PERSIAN GULF REGISTRY,
CINCINNATI VA MEDICAL CENTER, VETERANS HEALTH ADMINISTRATION,
U.S. DEPARTMENT OF VETERANS AFFAIRS; AND CHADWICK WATIKER,
CINCINNATI VET CENTER TEAM LEAD, READJUSTMENT COUNSELING
SERVICE, U.S. DEPARTMENT OF VETERANS AFFAIRS
STATEMENT OF LINDA D. SMITH
Ms. Smith. Thank you for the privilege of being here, for
all those in the audience who are attending, and in particular
for the previous panel. We definitely will follow up on every
issue that was raised earlier this morning.
Good morning, Chairman Benishek, Dr. Wenstrup, and
Representative Massie. Thank you for the opportunity to discuss
the Cincinnati VA Medical Center's efforts to provide high-
quality care, specifically mental health care, to veterans in
our catchment area, and our pilot Veterans Transportation
Service.
I am accompanied today by Dr. Kathleen Chard, Director of
the Trauma Recovery Division of our Mental Health Care Line,
and Professor of Psychiatry and Behavioral Science at the
University of Cincinnati's College of Medicine; Emma Bunag-
Boehm, a primary care provider for the Post-Deployment Clinic,
Cincinnati VAMC; and Mr. Chad Watiker, Cincinnati Vet Center
Team Leader.
The Cincinnati VAMC is a two-division campus located in
Cincinnati, Ohio, and Fort Thomas, Kentucky. The medical center
serves 17 counties in Ohio, Kentucky and Indiana, with six
community-based outpatient clinics. We are a highly affiliated
teaching hospital, providing a full range of patient care
services, with state-of-the-art technology, medical education
and research capabilities. The Medical Center provides primary
care, the full range of mental health services, and tertiary
and medical surgical care.
Over 42,000 veterans are enrolled in VA health care through
our facility. This number includes about 3,600 female veterans
and 3,500 OIF/OEF veterans. The medical center has 15 full-time
staff in our OEF/OIF/OND clinic providing primary care, mental
health care, social work services, pain management care, and
other services for military personnel returning from all recent
combat theaters.
The Cincinnati VAMC's Trauma Recovery Center consists of an
outpatient PTSD clinical team and a residential PTSD program
which offers eligible individuals family education, medication
management, and evidence-based PTSD treatments in a variety of
formats. These unique programs have been featured in national
media for their patient-centered, evidence-based treatment
programs for PTSD. The VAMC also provides care and services to
veterans who have experienced military sexual trauma.
Mental health services at the Cincinnati VAMC are unified
under a multidisciplinary Mental Health Care Line. A
comprehensive variety of mental health services is offered by
the seven divisions of the Mental Health Care Line through 303
staff members. To date, the Mental Health Care Line provides
care to an additional 1,482 unique veterans that were seen over
the same period in Fiscal Year 2012.
VHA has developed many metrics to monitor performance in
the delivery of our health care services. Cincinnati VAMC
consistently scores above targets set by VHA regarding key
areas of mental health treatment, including follow-up rate for
veterans discharged from acute inpatient mental health
treatment and percentage of qualifying veterans receiving
evidence-based psychotherapy sessions.
The Cincinnati VAMC has also seen tremendous success in
improving patients' access to care, receiving an outstanding 5-
star quality rating under the category ``Mental Health Wait
Time.''
Recognizing that increasing access to care improves health
care outcomes, the Cincinnati VAMC began operation of the
Veterans Transportation Service in May of 2012, offering
mobility management and transportation services. Mobility
management guides veterans to the most medically appropriate
and cost-effective means available through a private, veteran-
focused agency or public transportation services. VTS fills in
the remaining gaps, providing door-to-door, wheelchair-
accessible transportation for those veterans living in the
medical center's catchment area who have no other viable
transportation options.
In August 2013, the Cincinnati VAMC hosted its first
Community Mental Health Summit, where facility leadership and
staff met with 66 individuals from 36 community agencies. At
the summit there was an open exchange of detailed information
about mental health programs and services available through VA
and the community.
In conclusion, VHA and the Cincinnati VAMC are committed to
providing the high-quality care that our veterans have earned
and deserve, and we continue to improve access and services to
meet the mental health care needs of veterans residing in
Cincinnati and the local surrounding area. We appreciate the
opportunity to appear before you, and we appreciate the
resources Congress provides VA to care for veterans. We are
happy to respond to any questions you have.
[The prepared statement of Linda D. Smith appears in the
Appendix]
Mr. Benishek. Thank you very much for your testimony.
Mr. Berry's testimony is pretty compelling. He lost his son
while the son was being treated for PTSD as an out-patient. How
many patients in the last two years under your care have
committed suicide?
Ms. Smith. In the last year, a total of three veterans in
Fiscal Year 2013 actually committed suicide that were receiving
our health care services. In Fiscal Year 2012 it was five, and
in Fiscal Year 2011 it was nine. So we are seeing, I believe,
improvements in our outreach for veterans at risk for suicide.
We have a full-time suicide prevention coordinator. The month
of September is designated as a special month to recognize the
suicide risk, and we will be outreaching in the community and
to all veterans who come to our medical center with a
comprehensive package of information about suicide and ways to
avoid it.
Mr. Benishek. Mr. Watiker, you are with the veterans
center, so it is somewhat different than the VA hospital. Tell
me about your program and are you seeing an increasing number
of patients, and is your staffing adequate to get people in on
a regular basis, what is your wait time. Give me a little bit
of an example of the challenges that you have and what could be
better about your system.
Mr. Watiker. Yes, sir. Thank you for that question, Dr.
Benishek. The vet center program is geared toward readjustment
counseling services for war-zone veterans and their families to
help them with the transition from military life to civilian
life. There is no time-limit restriction, and the cost is free
because they have paid for the service already with the time
that they served, being in a deployment status.
We have well-trained clinicians that provide individual
counseling, group intervention, couples, marital counseling,
military sexual trauma, and bereavement counseling for those
who have had loved ones die while in active duty service.
Mr. Benishek. How long does it take to get in to see you?
Mr. Watiker. Our access to our services, if a veteran comes
into our office today, they are going to be seen by a
clinician, assessed, develop a plan, and coordinate a follow-up
that meets the best to their schedule.
Mr. Benishek. Is there like a suicide notation made on the
initial visit?
Mr. Watiker. We definitely do it as part of our ----
Mr. Benishek. Your evaluation?
Mr. Watiker. Yes, sir. As part of our initial assessment we
do a comprehensive assessment, a bio-psychosocial assessment
with the individual. But with everyone we screen, we screen any
type of suicidal ideation or homicidal ideation.
Mr. Benishek. Dr. Chard, we were talking earlier, but I
don't quite remember your answer to how long does it take for
someone to call and get into an outpatient evaluation in your
setting.
Ms. Chard. Thank you, sir. If someone called today for an
outpatient appointment in the PTSD division, we can get them in
within the week. So if you called me today, we can get them in
within this week to see both an individual therapist and a
psychiatrist or a nurse-practitioner for a medication consult.
Mr. Benishek. And is there any sort of a suicide evaluation
done on the phone when somebody calls in? Because to me, even a
week seems like a long time if somebody is calling in desperate
for help.
Ms. Chard. Exactly. When we do our initial phone screen, we
do a suicide assessment, and we actually complete a suicide
assessment on every visit that the patient has within the PTSD
and the Mental Health Care Line.
Mr. Benishek. All right.
Mr. Wenstrup?
Mr. Wenstrup. Thank you, Mr. Chairman.
A couple of questions. We saw a lot of things yesterday
when we visited, and that is the Cincinnati VA. Can you share
with us some of the differences from state to state? Do you
feel that every VA is the same? Obviously, there are some
differences. And how do you think we are dealing with that on a
national level compared to what we have here in Ohio?
Ms. Smith. I really can't comment nationally. I can comment
on what we do, and I know that we get a lot of direction from
VA central office through our network about changes and
improvements in the ways that we provide care. It seems that
the changes are evolving even more and more quickly. I have
been with VA almost 33 years now, and the pace of change and
the pace of improvement in services is really remarkable, just
from Dr. Chard's program as an example, and the ongoing
improvements that have been made in the treatment provided for
PTSD, including now the three separate programs, Emma Bunag-
Boehm's program where we have gone from two staff and in our
OIF/OEF clinic to now 15. So I would say the pace of change is
just incredible and driven by, in large part, the interest that
Congress has had in continuing to improve VA health care
services, and I thank you for that.
Mr. Wenstrup. Thank you. You know, I know when I returned
from the war, I got notices from the VA saying you need to get
in and get enrolled. The outreach was there, and I think it
continues, and I do give the VA tremendous credit for that.
On the lines of suicide prevention, in the Army there is a
lot being done proactively in what to look for, how to watch
out for your buddy, don't be afraid to say, hey, I'm taking you
in, you need help. That is great. We know that most of the
suicides are occurring after they are out of uniform. How do we
build that type of system once they are out, as opposed to when
they are in?
Ms. Smith. And this is part of what I see as a really
increased sophistication and improvement in the mental health
care at Cincinnati, and I am sure at other facilities. I will
let Dr. Chard provide details.
Ms. Chard. So with a team of three people in the suicide
prevention office, we are able to do a lot more outreach than I
think ever before. We do attend a lot of civic activities
locally. We make sure that we attend all of the NAMI meetings
that we are invited to. We always have our staff at the PDHRAs,
and they are there to do the vesting visits because sometimes
they don't want to come to the VAs, as you spoke about. We do
need to vest them early and let them see a face that they can
see when they come to the VA. So we do a lot of outreach there.
One of the things that I love that VA has created is a peer
support technician program where we actually hire veterans as
peer supporters so that you can attend a group that is not run
by clinicians, but is run by a trained peer support person so
they can have that private environment to share their
experiences, talk about their needs with someone who has
already been through the program and can speak about what it
was like to go through it, what obstacles they encountered,
what they found to be helpful, and I think that has been a
really strong success throughout the VA and the Nation.
Mr. Wenstrup. That is something that comes with the length
of time that this has been going on. You have alumnus, if you
will, who can participate and help.
I know it is sometimes difficult, too. I will ask you,
Emma. You see patients for the first time, often. And as we
talked about before, there are people who don't want to come
forward to mention what they are struggling with, and sometimes
they refuse to go there.
I can remember in Iraq, we had to do a physical on Saddam
Hussein, who was on a hunger strike, and he wouldn't let us
evaluate his mental status. He refused psychiatry or
psychology. So we had to use a little psychology and work
within his physical exam to ask questions to really assess
where he was mentally.
So have you found that over the time of doing this, that
you are able to sort of break through that, when you sense
somebody doesn't want to tell you something, that you can break
that down a little bit? And how do you do that? And if you do
feel like you have gotten through and detect something, where
do you go from there?
Ms. Bunag-Boehm. Thank you, Representative or Dr. Wenstrup,
for this opportunity to come and speak with you. I thank you
for your service to our Nation.
To answer your question, we, in our clinic, we have a team
of nurses who does the initial intake, and we have those
clinical reminders that we need to complete. Now, a lot of
times, the servicemembers or veterans will not answer those
questions. So when they come to my office and I develop this
rapport with them, then along the way I go back in and ask them
the same questions, and a lot of times they will be honest with
me and start opening up more.
In our clinic, after they see me as the primary care
provider, we have a psychologist and social workers who are
trained mental health providers as well. So if I identify that
something is going on with this veteran, I also want to say
that our clinic is like a medical home and it is a one-stop
visit store or something. So they are aware that they might be
there for a while because we want to make sure that everything
that they need we give to them on that same day.
Now, if they cannot do it because they are busy, then they
have the option of coming back. But we try to do everything at
that one visit, and a lot of times they will agree to that. So
then it is handed off to the psychologist, and then we go from
there.
As you are aware, our clinic is--I mean, it has been very,
very effective, and our clinic has really gone far. And thank
you again to Congress for giving us those resources. Thank you.
Mr. Wenstrup. I think you have made a lot of strides. I
know servicemembers that have been treated by you that have
been very grateful for the care that they have received, and I
know it is a difficult challenge. And this somewhat addresses
Mr. Berry's concerns today on how we get the families engaged,
because I think that is important, and I hope that we can
continue to do that.
I just have one last question. So, we have been at war for
12 years, and we have a lot of returning veterans, especially
to this area of the country. What would you say are some of the
major things that you have changed since, say, 2001, 2002,
2003, 2004, compared to today?
I will ask both of you, all three of you actually.
Ms. Chard. Certainly. I think some of the most significant
changes have actually been in the increase in mental health
staff. So we have had an exponentially larger number of staff
hired. Thank you, obviously, to your efforts.
Speaking more specifically to the PTSD program, we have
grown by three-fold. We have opened a women's program, which we
did not have until 2007, and now we have the Traumatic Brain
Injury PTSD Residential Program, and we are currently the only
one in the Nation. So we are able to serve veterans in our area
with both male issues, female issues, or TBI/PTSD issues in
that program, both residential and outpatient.
Mr. Benishek. I would just ask that the speakers use the
microphone because we have had some comments that it has been
difficult to hear your testimony.
Ms. Smith. There are so many changes, it is hard to think
through what has just happened in the last few years.
Certainly, construction funding has allowed us, and also money
for additional lease space has allowed us to really expand. We
moved our eye program off campus, which opened up additional
space for clinical care. We have, I think, four concurrent
construction projects going on at every corner of the hospital
to not only increase our capacity to provide care, but also to
make that care more convenient and easier to get to.
Probably the biggest improvement in terms of ease of access
is the parking garage that is just now in the process of
opening that should make it very easy for veterans to get into
our health care services.
We are building a brand-new community living center, what
used to be called our nursing home care unit, and this is in
recognition of the fact that moving veterans back and forth
from Fort Thomas, Kentucky across the river to Cincinnati
creates a lot of unnecessary trips for many of those nursing
home residents, and now we will be able to have them located
closer to clinical care and at the same time give them private
rooms and immediate access to all health care services.
We have done a lot to renovate our domiciliary and PTSD
programs in recognition of the large number of veterans
returning needing mental health care, and also those veterans
who either have substance abuse or homeless issues and need
some residential treatment. I see us significantly expanding
those services at Fort Thomas and really make that a real
state-of-the-art and evidence-based program that I believe will
rival any in the VA Nation in terms of the types and quality of
services provided there.
And again, this has all been done with funding that
Congress has given us, and we are very appreciative that we
have been able to add all those services.
Ms. Bunag-Boehm. And with the increase of our staff in our
OIF/OEF/OND clinic, we are able to do more outreaching. We have
partnered up with units in and around the greater Cincinnati
area, Reserve and Guardsmen units. So we are often invited into
their 30-day, 60-day and 90-day family gatherings.
So on the 30th day, or actually whenever they come home,
our program manager, Karen Cartwright, or our outreach
coordinator, Mary Plummer, who is herself a veteran, they go
into the units to give briefings. So with those briefings, they
talk about the VA and what the VA offers them, from medical
health care to benefits to everything else that they need to
do.
We have a mobile van which you saw yesterday, and we go
outreaching to places where we are invited. So we take the
opportunity to enroll veterans and at the same time get them
vested into the VA health care, and then get them started. So
if they need to be referred to a specialty clinic, then we get
them referred, and these are from counties, and a lot of our
community-based outpatient clinics offer those specialty
clinics.
Another thing that we would like to highlight is that we
have the VITALS program wherein our psychologist is the liaison
between our local universities in and around greater Cincinnati
again, and a lot of times my veterans go back to school, and
Dr. Jessica Theed is my liaison. So if they cannot come to me
right away, they will seek her out, and then Dr. Theed will
notify me if we need to see the patient, if I need to do more
for the patient.
And again, we would like to thank you for giving us the
resources to do what we are doing now. Thank you.
Mr. Watiker. First of all, I would like to thank you on
behalf of the Readjustment Counseling Service for the resources
that you provided for us, because one of the biggest changes
for RCS is that you have allowed us, with the resources you
have provided, to purchase 70 mobile outreach vet centers
across the Nation. We have two here in Ohio. This allows us to
do, not only mobile outreach to the local community, but
outreach to the whole community to provide clinical and veteran
services if we don't have a community access point. It also
allows us to work with our VA counterparts for emergency
response teams to national crises, as needed, to support the
veterans and families outside of the State of Ohio, or within
the state as well.
When I talk about the community access points, it is one of
the things that, with our outreach efforts, we were able to
provide face-to-face connections with our veterans and families
to easily engage them into vet center and VA resources. For
example, we have outreached now to Highland County where it is
a rural community. I heard earlier about the difficulty in
accessing mental health care. One of my clinicians goes up
there to a community access point through the veterans service
office and provides mental health care to those veterans and
families and helps them get linked up to VA resources.
I thank you for the question.
Mr. Benishek. Thanks.
Mr. Massie?
Mr. Massie. Thank you, Mr. Chairman.
Dr. Chard, we heard from Mr. Berry that no one from the VA
reached out to him to help the family understand the effects of
PTSD or to participate in care. And then he later also stated
that the HIPAA laws were an impediment to learning about his
son's condition.
Can you respond to Mr. Berry's testimony and also share
with us how you have to work within the HIPAA laws, and if
there is anything that Congress can do to change those laws, or
do they strike the right balance of privacy for the patient, or
do they restrict you too much from involving the family?
Ms. Chard. Thank you. And, of course, any loss of any
individual is one loss too many. It was very tough for me to
hear that story because of my desire to always want to help
every veteran that comes in our door.
And the sad truth is exactly what you said. HIPAA laws
prevent us. If an individual veteran does not want us to talk
to their family members, they can invoke that right, and we are
therefore not allowed to provide education, answers, support,
any information at all to that person's family.
Now, you asked about the balance, and I think the hard part
is the situations where the veteran wants to be protected. I
can't tell you the number of situations where I have had
veterans going through custody hearings, going through
difficult divorces, having difficult bosses who have asked for
information from us and we have been able to protect them as
they are going through those custody hearings where someone is
trying to take away their child, saying they have PTSD and they
cannot be trusted.
So it is a very difficult situation that we are in, in that
we do have to have a balance where we both protect the rights
or personal care of an individual, but also try to get as much
information out to family members as we can.
Mr. Massie. Is that a right they have to assert? Do they
invoke it, or is it an opt-in?
Ms. Chard. HIPAA is a standard thing that all of us are
given when we go to the doctor's office. There is HIPAA
information that we are given, and we sign a statement saying
we understand the HIPAA law. It is a standard for every one of
us every time we go to a doctor's office.
Mr. Massie. So it is basically an opt-in.
Ms. Chard. You can opt out of HIPAA and give someone
rights. You actually have to sign that you agree to let me talk
to someone.
Mr. Massie. So it is opt-out.
Ms. Chard. Yes.
Mr. Massie. By default, you can't share that. They would
have to voluntarily ask you to do that.
Ms. Chard. Correct. But I do encourage everyone here to
talk about the National Center for PTSD Web site. We have one
of the best Web sites, funded by Congress, for information for
family members and veterans and civilians about PTSD, and it is
the National Center for PTSD Web site at VA.gov, and there is
great information for family members there.
Mr. Massie. Can you encourage the veterans to engage their
families? I mean, do you do that?
Ms. Chard. We certainly do.
Mr. Massie. And let them know about their HIPAA rights,
that they can be waived, that they can share that information?
Ms. Chard. We actually try in all the cases that I can ever
remember to engage the family literally from step 1, because we
do, at our orientation group, ask that the veteran bring a
family member to our orientation group. We then, in addition to
our psychosocial history, we ask if they have any family
members that they are willing to have involved in their care.
And then finally, we offer couples and family-based treatments
that are evidence-based where we actually encourage the veteran
to not just have them informed about their care but be a part
of their weekly care, if they are willing.
Mr. Massie. Thank you.
Ms. Smith, Mr. Berry testified that his son was upset about
the hassles involving going to the Cincinnati VA Medical
Center, up to and including having to answer the same questions
over and over. He felt that that caused him to relive his
experience at Fort Hood. And then also, I think perhaps in his
written testimony he stated that having doctors in residency
treating vets kind of breaks this tendency that the patient
would like to have the same doctor every time they go so they
don't have to answer the same questions, because you want to
build a connection with the doctor and trust.
Do you agree with Mr. Berry why or why not should folks who
are undergoing treatment for mental illness see doctors in
residency, or should there be some continuity?
Ms. Smith. Let me try to answer that question as broadly as
I can. Every one of our mental health veterans will eventually
have a mental health treatment coordinator, and I believe we
are close to achieving that, somebody that can kind of navigate
their care through the various areas where they get care or
treatment.
Our veterans, when they come to clinic, whether it is to
one of Dr. Chard's PTSD clinics or with Emma, do have an
attending physician or an attending provider responsible for
their care. We are a site for training, and we have a large
number of training programs which we are very proud of. But it
is not the responsibility of a medical student or a psychiatric
resident or a clinical social work trainee to provide care for
our veterans. That responsibility resides with the individual
provider, as in the case with Emma in our clinic, or the
physician that also covers the OIF/OEF clinic, and also for Dr.
Chard's clinic. Those are permanent providers.
Now, it may be true if a veteran is seen at a specialty
clinic, especially med surge specialty clinics, where their
first contact may be with a medical resident or surgical
resident. But there is always an attending physician at those
clinics.
I will let Dr. Chard just briefly talk about how we assign
mental health providers.
Ms. Chard. Certainly. So when someone comes into the VA,
they are immediately attached to a provider, whether it is a
psychiatrist, a psychologist, or a social worker, and whoever
they first meet is attached as their mental health treatment
coordinator. That person's name is on the front page of their
chart. So if that individual calls in the middle of the night,
if that person comes into our psychiatric emergency room saying
``I don't remember who that person is, I have walked away from
the VA for six months, but I need somebody,'' we have a name on
the very front cover page that everyone can see, including the
vet center, and call that individual and say Mr. Jones, Mr.
Smith is back and he needs care, where did he leave off, what
can we do for him, and that individual will reinitiate care
with him and get him to the best environment, or her to the
best environment.
Mr. Massie. Thank you. I yield back.
Mr. Benishek. Mr. Watiker, I just have one more question. I
understand that you have authority for bereavement counseling
for families. Were you made aware of Mr. Berry's son's suicide,
and do you reach out to families that have suicide that you are
aware of?
Mr. Watiker. As far as in the specific case of Mr. Berry,
we get referrals from a variety of different organizations.
Mr. Benishek. I'm sorry, I can't understand what you are
saying.
Mr. Watiker. I'm sorry, sir. As far as speaking to Mr.
Berry's case, we get referrals from a variety of different
organizations, whether that is through family members or
through veteran service officers, or even from our national
organization or our national bereavement headquarters out of
Colorado. And from there, once we get a referral, for whatever
family member is requesting services, we make contact with that
family member and engage them for services.
Mr. Benishek. So you have to be notified by the family,
then.
Mr. Watiker. The family member or another representative,
an organization who is acting on behalf of the family members.
And once we get that referral, then we will make contact with
that specific family member to offer bereavement services.
Mr. Benishek. All right. Thank you.
Mr. Watiker. Thank you.
Mr. Benishek. Well, I appreciate you all being here this
morning. I know you are very proud of the service that you
provide there. As you said, Dr. Chard, even one suicide is one
too many. You all know that there is definitely room for
improvement despite the statistics that you have shown us that
you are doing well.
It is our job really to be sure that the system works as
efficiently as possible. With 18 to 22 suicides a day among our
veteran population, you can understand our concern as to what
the VA is really doing to make it better. Despite your
statistics that look good, it is very distressing to me and,
I'm sure, my fellow Members here on the panel, that our
veterans deserve the absolute best, and we want to make sure
that your agency is doing the best they can.
So I really want to thank all of our witnesses and members
of the audience for joining us today. It has been a pleasure
for me to spend time in southern Ohio and see the medical
center and some of the other great medical facilities here in
town.
Before we conclude, are there any veterans in the audience?
Could any veterans in the audience please stand up or raise
their hands so we can recognize them?
[Applause.]
Mr. Benishek. Thank you. Thank you. I want to thank you
very much for your service. We owe you a great debt that we
still remain a free country. It has been an honor for us to be
here with you this morning.
And with that, I ask unanimous consent that all Members
have 5 legislative days to revise and extend their remarks and
include extraneous material, and we may submit further
questions for the panel, which we will expect answers to. So,
without objection, I will order that.
The hearing is now adjourned.
[Whereupon, at 11:53 a.m., the Subcommittee was adjourned.]
A P P E N D I X
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Prepared Statement of Hon. Dan Benishek M.D.
Good morning and thank you all for joining us this morning. It is a
pleasure for us to be here in beautiful Cincinnati, Ohio, with all of
you.
I am honored to serve as the Chairman of the House Veterans'
Affairs Committee Subcommittee on Health and to be joined on the
Subcommittee by your Congressman and my friend, Dr. Brad Wenstrup.
As I am sure you know, Brad has served for the last fifteen years
as a member of the U.S. Army Reserves, where he has achieved the rank
of Lieutenant Colonel.
In the spring of 2005, he deployed to Iraq for a year. While there,
he served his fellow soldiers, sailors, airmen, and marines - as well
as prisoners and civilians - in Abu Ghraib as the Chief of Surgery and
the Deputy Commander for Clinical Services.
For his brave and loyal service there, he earned numerous awards
and accolades, including the Bronze Star.
Brad is also Doctor of Podiatric Medicine and a former small
business owner.
Needless to say, the immense wealth of knowledge, experience, and
insight that Brad brings to the Subcommittee is invaluable. I am
extremely grateful to work side by side with him and for his leadership
on behalf of our Nation's veterans and their families.
So, when Brad asked me to come to Cincinnati - his hometown - to
address an issue of such importance to us all - the provision of high
quality and effective mental health care to veterans in need - I seized
the opportunity.
Yesterday, Brad and I paid a visit to the Cincinnati Department of
Veterans Affairs (VA) medical center. While there, we had an in-depth
discussion with medical center leaders and toured the facility.
Having worked myself as a surgeon at the Iron Mountain VA Medical
Center, I most enjoyed meeting with some of the hard working Ohioans
who strive day-in and day-out to provide the best possible care and
services to the veterans in this community.
I would like to take a moment to personally thank each of those
health care providers, administrative personnel, and support staff for
their dedication to our servicemembers, veterans, and their families.
It is clear that there are some very special things going on in
Cincinnati for our heroes and you have much to be proud of here in
Ohio.
However, where the health care and services provided to our
veterans is concerned, exercising our responsibility for oversight of
policy and practice is paramount.
This past February, VA issued a sobering report which shows that -
for the last 12 years - there have been 18 to 22 suicide deaths among
our veterans every single day.
Ladies and gentleman, we have lost far too many of our veterans on
the battlefield of mental illness. We have to do better. And we have to
do it now.
Key to that effort is breaking down barriers to care that veterans
in the midst of struggle often face when attempting to access the care
they need to successfully transition home and maintain happy, healthy,
and productive lives.
No veteran should be reluctant to ask for help because they are
ashamed or embarrassed. And, no veteran who does take the brave step of
seeking care should be told they have to wait for an appointment that
is weeks or months away and/or travel long distances away from their
homes and families to receive the services they need.
Today, we will discuss the actions we must take to reduce stigma
and increase the accessibility and availability of mental health care
for veterans here in Ohio and across the VA health care system.
We will also discuss the increasingly vital role that faith-based
and community groups are playing in helping our veterans and what we
need to do to increase and improve meaningful partnerships between VA
and these community resources, who are often the first and most trusted
point of contact for veterans and families in need.
Finally, we will also discuss the critical part that family members
and other loved ones play in the healing of our heroes and the need to
increase family awareness, involvement, and integration in mental
health care services, particularly for those veterans most in need of
support.
I look forward to hearing from the local Ohioans - many of them
veterans - who will testify today. I thank you for being here and for
your devotion to improving the lives of Ohio's veterans.
With the help of communities like Cincinnati and discussions like
the one we are having this morning, I am hopeful that we will shatter
mistaken perceptions that mental health care is not available, not
appropriate, or not effective and there will come a day when no veteran
is discouraged from reaching out and seeking care and no family suffers
alone.
Prepared Statement of Hon. Brad Wenstrup
Good morning, and welcome to the House Committee on Veterans'
Affairs Health Subcommittee field hearing, ``Making a Difference:
Shattering Barriers to Effective Mental Health Care for Veterans.''
Mr. Chairman, I want to formally and officially welcome you to
Cincinnati! As you have seen these past two days, this district - a
district I am so privileged to represent - has an incredibly rich
tradition of military service. I want to thank you for the leadership
you have shown on the issue of veterans' mental health care and for
hosting this field hearing here today. I am also grateful that
Representative Massie, a strong supporter of our military and our
Nation's veterans, has taken time out of his schedule to be here.
Congressman Massie, thank you.
To the witnesses on our panels, to each person in the audience,
and, especially, to every veteran present today: thank you for joining
us. It is important for us all to be engaged in this issue if we are
going to truly improve the care our veterans receive.
This field hearing is an opportunity to bring Congress to
Cincinnati. I'm pleased that the Subcommittee on Health will hear
directly from the veterans, the family members of veterans, the service
officers, and the community providers of this region. They will provide
a valuable perspective on the common barriers to mental health care
that our veterans face.
The veterans of Southern and Southwest Ohio are a diverse group.
They were raised on farms, in urban high-rises, and in suburban
neighborhoods. But they share a common bond: they made the voluntary
commitment to serve our Nation. Only one percent of Americans have
served in uniform. Their accomplishments have been amazing and truly
unmatched by the rest of the world. As a veteran of the war in Iraq and
a member of the Army Reserve, I have witnessed the heroism of my fellow
veterans and have deep respect for them.
We can never repay them for their sacrifice, but we can honor it by
ensuring that they and their families receive the care that they
deserve. In Ohio, we have a robust system of Veterans Service
Commissions that serve our veterans with zeal and dedication. I am
grateful to have the representatives from commissions in three
different counties present to testify today.
There is growing recognition that we must develop better treatment
for the ``invisible wounds'' that veterans bring home, including
depression, posttraumatic stress disorder, substance abuse, and
traumatic brain injury. These wounds affect veterans of all our past
wars, but the veterans of Operations Enduring Freedom and Iraqi Freedom
face unique mental health challenges. Because of technological
advances, more soldiers are surviving physical combat injuries, but
they present disproportionate neurological and psychological wounds.
Studies suggest that one in five veterans of the wars in Iraq and
Afghanistan has PTSD. A decade of war with frequent and extended
deployments has made it more critical than ever before to create a
quality mental health care system for our veterans.
There are many challenges in our current system that do not allow
veterans to get the care they need. Sometimes, veterans are simply
unable to access care: they have difficulties in scheduling timely
appointments or the office is simply too far away. Other times,
veterans are unwilling to ask for or accept help. Each veteran has
unique struggles and needs, and we need a mental health care system
that is able to provide effective, individualized care.
Today, we will discuss how the Department of Veterans Affairs can
better improve its approach to and delivery of mental health care.
Truly effective care, however, will extend beyond the VA: it will
require the involvement of veterans' families and their communities,
including veterans service organizations, community health care
providers, and faith organizations.
Each of us has a role to play in improving veterans' access to
mental health care.
Again, thanks to each of you for being here for this important
discussion.
Prepared Statement of Howard Berry
My name is Howard Berry. I am the father of the late SSG Joshua
Berry. He was wounded both physically and mentally as a result of the
shooting at Fort Hood on 5 Nov 2009. My son suffered terribly from
PTSD. He chose to end his life on 13 February 2013. I am not an expert
on PTSD. I am however an expert on the pain that this disorder places
on the surviving family members of soldiers who do not respond to
treatment, soldiers who look to suicide as the solution to end their
suffering.
I am left with a lot of questions, many that will only be answered
by the passage of time. Please bear with me as I attempt to share with
you some of the experiences my son had while being treated for PTSD. I
will also share some of the changes I believe will give other soldiers
a better chance to find success in their recovery.
Soldiers suffering from PTSD have skill sets that have been
compromised. The simple things that we encounter in our day to day
lives were extremely difficult, if not impossible, for my son. He had
tremendous difficulty adjusting to civilian life. We do a marvelous job
taking a civilian and turning him into a soldier. We do a lousy job
helping that soldier make the transition back to civilian life. My son
was one of those who could not successfully return to civilian life, as
he was given limited training to transition, which was combined with
the damage done to his skill sets.
The invitation to this symposium listed four topics for discussion,
and I will attempt to share my thoughts on each.
(1) The impact of patient waiting and travel times on veterans'
ability to receive mental health care and actions needed to increase
the accessibility and availability of mental health care services for
veterans.
Josh travelled by car to get to his appointments. During his
treatment, he had valid concerns about travel time and fuel cost. He
had to consider how long it would take to find a parking space at the
Cincinnati VA, and if he would have enough gas left to go home after
his appointment. Josh was upset about the hassles involved in going to
the Cincinnati VA, up to and including having to answer the same
questions again and again, resulting in reliving the horror he
experienced at Fort Hood. He saw no benefit in answering the same
questions repeatedly.
Josh was even involved in an accident one afternoon when leaving
the VA to go home. This was another excuse that he would give to not go
to the VA. It was just one more bad experience, added to a list of bad
experiences, to, in his mind, deter him from seeking treatment. His
skillsets were so broken that he also failed to maintain auto insurance
coverage, which created yet another financial obstacle. When I asked
him why he had not paid his bills, I discovered that he was not opening
mail, period. He said he only got bad news whenever he did, so he
didn't see the point.
I am sure Josh's story of broken skillsets is similar to the
stories of other soldiers. It must be difficult to admit the need for
help. Our goal is to find a way to improve their skillsets, and their
ability to seek treatment for their injuries.
One way to improve the accessibility of treatment is to consider
the needs of the soldiers themselves. A lot of folks are parents. How
many appointments are missed, or aren't even scheduled, because vets
cannot find someone to watch their children? Is there childcare
available on site for veterans' children while they are receiving
healthcare?
Many of these soldiers are busy people. Transitioning into life as
a civilian includes taking on financial and family responsibilities.
Are appointments currently consolidated, so the veteran makes one trip
instead of several to get treatment? For instance, can a vet schedule
appointments back to back to see a physical therapist and a
psychiatrist?
Many soldiers who suffer from PTSD also miss appointments. If they
stop calling and stop coming in, does anyone take notice? Do they fall
through the cracks?
I believe taking a battle buddy approach to making sure their
fellow soldiers are OK will greatly improve the care they ultimately
receive. This will also work well in rural areas where vets have
limited access to care. Just talking with another person makes a world
of difference. When my son enlisted, he told me that if something bad
happened to him, someone had his back. After returning from deployment
and trying to transition to civilian life, I asked him the same
question. For him the answer was no. I could see and hear the pain he
felt before he died. He felt that his country had wiped its feet on
him. He felt that he had gone from a hero to a zero. I'm sure a battle
buddy/mentor would have given him a better chance at recovering. I bet
lot of soldiers returning home would jump at the chance to continue to
be of service to their brothers and sisters in arms.
Essentially, there needs to be a mentoring program, a pairing of a
vet with a similarly ranked veteran. Consider the Alcoholics Anonymous
concept of a sponsor/sponsee relationship. They meet as equals, the
sponsor listening to the sponsee and sharing their experience, strength
and hope with him, simply showing what he did to recover. I know this
works. I cannot explain why. I do know we are only as sick as our
secrets. I wish Josh had someone to share his secrets with; knowing
that he wouldn't be judged or looked down upon would have helped him.
In addition to a sponsor, there needs to be support groups where
veterans can freely speak to one another anonymously, removing the
fears and stigma that a person with PTSD suffers from.
Furthermore, there needs to be a review of practices in all VA
locations. Are the standards of care used to treat PTSD affected
soldiers the same in all 50 states? If not, why? Are successful
programs copied and less effective ones phased out? Do VA facilities
across our country freely communicate with one another in a timely and
consistent manner? What programs will result in a reduction of the
suicide rate? We must determine what works and what doesn't work. After
all, the goal is to reduce the number of service men and women who take
their own lives when they feel they have no other option.
Another area in need of improvement is the early identification of
warning signs in soldiers who are likely to take their lives due to the
severity of their PTSD. We need to identify these brittle soldiers as
soon as possible. This group of combat soldiers has a disproportionate
suicide rate when compared to other groups of servicemen and women.
Those who need additional attention, due to the severity of their PTSD,
should subsequently receive a higher level of care. Can resources be
allocated to provide for their needs?
Although accessibility, timeliness, and availability are important,
continuity is just as crucial. Having doctors in residency treating
vets with PTSD inhibits the development of strong doctor/patient
relationships. A vet may begin to build a connection with a doctor,
someone he is starting to trust, only to have that person replaced on
the next visit. Having to start over from square one only forces our
vets to relive painful experiences. How many times would you be willing
to tell your story before it felt futile? I have been telling my son's
story for over six months now. I know how it feels.
(2) The effect of stigma on veterans' willingness to seek mental
health care and actions needed to eliminate it in the veteran
community.
The stigma placed on our veterans starts in the military. My son
was trained to suck it up and roll on, as I'm sure countless others
have and are currently taught to do. If there is not bone or blood
showing, you don't speak up, as it is looked on as a sign of weakness.
Josh was told on one particular occasion by a superior that he was
nothing but an old, broken down NCO, who needed to get out of this
man's army. This was after he had experienced the horror at Fort Hood
and was getting treatment for his PTSD. I know he felt that he was
betrayed by some of the people put in place to help him.
Why don't we begin by calling PTSD what it is? It is a wound. We
need to give veterans a reason to hold their heads high and not be
ashamed by the perceived weakness associated with PTSD.
My son felt that he was as expendable as a broken rifle or a worn
out pair of boots. I'm sure there are other veterans who are silently
suffering and feel the same way. I believe that one way to help
soldiers suffering from PTSD sustained in combat is to award them with
a Purple Heart. They should be given the same considerations as
servicemen and women who have shed blood for our country. This would
help to even out the playing field in civilian life. Giving them the
same benefits, including points towards employment, education and
healthcare would be proof that their country acknowledges the
sacrifices they have made to protect others' freedom. Their injuries
merit equal treatment.
I know there is a lot of resistance to this. I have been
disappointed to hear from older veterans who are reluctant to support
this change. They feel their sacrifice will be diluted by the inclusion
of those with PTSD. I thought soldiers were trained to look out for one
another. Why aren't they included in this Band of Brothers?
If Purple Hearts are not awarded, then Congress needs to step up
and create a separate award, one with equal benefits, one that will
give these vets the recognition they deserve, one that honors the
sacrifice they have made. Give these veterans a reason to hold their
heads up high. It is the right thing to do.
I recently had a discussion with a director where I work. I gave
him a scenario: ``you have one position to fill with two equally
qualified candidates. One of them is a veteran with a Purple Heart. Who
would you hire?'' He responded with, ``The veteran.'' I then asked him
to consider the same scenario, only this time, the veteran has PTSD. He
did not immediately respond. I apologized for putting him on the spot.
After all, he has an obligation to protect the company's interests,
including the other employees' wellbeing and safety. If society puts
these veterans at a disadvantage, it is no wonder that many don't seek
treatment for PTSD. I'll bet many do not take their medication as
directed or at all, fearing this may have an impact on their
employability if their medication is discovered on a drug screen.
(3) The role of faith-based and community providers in assisting
veterans in need and actions needed to increase and improve meaningful,
collaborative partnerships between VA and these critical community
resources.
One way we can support these veterans is through media coverage.
Our society is driven by what we hear and see. Positive media coverage,
starting from within the military, will help to remove the stigma
associated with PTSD. Sharing the successes of programs that have
proven to be effective as well as success stories of soldiers who have
transitioned to civilian life will show the nation that vets with PTSD
deserve a fair shake.
We must strive to create connections, emotional bonds, with the
rest of Americans, showing them that the veterans in their community
are just like them. The difference is that they stand up in the face of
danger and fight for our freedom. PTSD should not be a reason for fear
in our society. Soldiers being treated for PTSD should be looked up to,
not down on. We need to show our nation that they are not broken by the
violence they have seen. We need to show them that they have worth and
are included in the pursuit of happiness, something that is currently
out of reach for many of them. The media can help create a bridge to
bring churches and non-profit organizations together to support our
vets. By including stories of success in our media outlets, we can
change how society looks at PTSD affected veterans.
I know I could not continue to speak for my son and others like him
without a deep sense of faith. If a guy like me can learn how to do
this, I believe anyone can.
(4) The role of family in mental health care treatment and actions
needed to increase family awareness, involvement, and integration in
mental health care services.
Families are directly and indirectly affected by soldiers returning
home with PTSD. The anger, resentments and hopelessness carried by
these returning vets are often carried over to civilian life. If
nothing changes, the family suffers their own version of PTSD. We love
them, but we don't understand what to do. We don't want to make things
worse, yet we have no solution to work towards. We learn to suffer as
silently as the veteran.
Neither I nor any of my family members were ever asked if we wanted
to learn how to help someone with PTSD. I could not communicate freely
with anyone regarding my son's care due the HIPAA laws. These laws were
enacted to protect the individual. However, I see compliance to this
law as a major contributing factor in the death of my son.
I also feel the law is currently used to protect the agency, not
the individual. Letters that were written on my son's behalf could not
be used by me without putting those who authored them at risk. The
bottom line is this: if I choose to use them, the people responsible
for authoring them would be dismissed. I don't understand the reasoning
behind this. It must be fear. If more administrators spend less time
covering their backsides and use a common sense approach instead, more
would be accomplished.
My son felt that the PTSD he suffered from was acquired through
such a unique experience, the shooting at Fort Hood, that no one could
ever understand. He could not focus on any of the similarities between
his experiences and those of other soldiers--all he could see were the
differences. In his eyes, he could have managed the PTSD from his tour
in Afghanistan, but that going eye to eye with a superior officer who
was shooting to kill amplified his trauma to another level, a terminal
uniqueness that grew from the fact that his injuries were sustained in
the center of a military installation, and not in a war zone.
I am sure that there are other soldiers who feel just like Josh
did, that their unique set of circumstances can't be understood, that
their experiences are too traumatic for others to comprehend. And to a
degree, we don't understand because we have not really tried to. But we
have to find a way to break down these walls. We have to convince them
that we want to understand, that they are not alone as we support them
in their recovery. We need to make these soldiers feel like they're a
part of the solution, and not a part of the problem. Their ability to
succeed begins with creating a circle of care that includes the
military, the VA, the family, and our society as a whole.
Families need the opportunity to work with the medical
professionals, social organizations, both religious and non-profit.
PTSD affected soldiers need to see support in every direction they
look. If we work together to make their burdens lighter, we have a
chance to have the kind of country my son fought for.
The suicide rate is still rising among our veterans. I hope my
speaking to you today was not a waste of our time. I hope it is the
beginning of positive changes. After all, we are all responsible.
Prepared Statement of Nate Pelletier
The Cincinnati VAMC is a best in class medical center; and, as a
disabled Veteran, I've personally received outstanding care. As a
Veteran leader, I have a vested interest in ensuring our federal and
community resources enable all Warriors in transition and Veterans to
successfully reintegrate. I've conducted research that studied the
impact of transitioning Veterans and drafted a proposal \1\ to assist
not only the VHA, but the Departments of Defense, Labor, HUD and HHS
\2\, as well as supporting agencies and community partners on how to
improve and implement a sustainable transition system. As an Executive
Director of a local agency supporting Veterans in need, I've witnessed
what can happen if those who have served our country fall into the
``gaps'' of an inefficient transition and support network. On my very
first day of work at the Joseph House, Inc., one of our War on Terror
clients overdosed on heroin and nearly died in his room. Thankfully,
his roommate was EMT certified and saved his life that day.
---------------------------------------------------------------------------
\1\ Clifford, P., Fischer, R. & Pelletier, N. (2013). Exploring
Veteran disconnection: Using culturally responsive methods in the
evaluation of Veterans Treatment Court services. Unpublished
manuscript.
\2\ Pelletier, N. (2012). Successful Warrior to Successful Veteran.
Cincinnati, OH: Author.
---------------------------------------------------------------------------
Over the next 3 years, more than 300,000 new Veterans will return
to civilian society. Our communities need to be ready to serve them and
utilize their talents in the community and in the workforce. To this
end, there are two topics that are interconnected and deserving of this
Committee's attention- VHA's scope expansion and VA administrative
leadership's support for community partnerships.
During the transition of new Veterans into the community, the VHA
currently feels the burden to fill ``gaps'' in the process due to the
absence of a seamless transitioning system. I define this as ``scope
creep''. The DOD, VA (VBA/VHA), DOL, as well as other agencies and
community organizations have acknowledged that the transition process
is very inefficient and that the responsibilities of each organization
are unclear. With this in mind, some examples of VHA scope creep
include but are not limited to: employment assistance, education
assistance, benefits assessment and family supportive services
unrelated to medical services. As we attempt to define the
responsibilities of the VHA during this process, we can categorize the
decision making process into three groups - 1) processes that VHA funds
and owns responsibility to execute, 2) processes that VHA funds and
outsources to community partners to execute, 3) processes that VHA
outsources to community partners who are VA or privately funded and can
own the responsibility to execute. In addition to addressing the
systems and process responsibility to reduce scope creep, it is
important for the VA administrative leadership to empower and leverage
VHA and community partnerships.
In an attempt to fully assess the effectiveness of our VHA and
recommend areas to partner with the community to reduce scope creep, we
must define ``what are the primary responsibilities of the VHA?'' The
purpose of the VHA is very focused and clear- support the medical needs
of Veterans who qualify for medical services post military service. Any
services in addition to their primary responsibilities should be
assessed according to the three process categories mentioned
previously.
The first step to effectively optimize the system of Veteran
support is for the VA administration to take an active role in
partnering and often time leading the convening of mobilized community
action teams to collectively meet the needs of our Veterans. To
quantify and provide some examples of how the VA administration could
partner more effectively in Cincinnati in order to reduce scope creep,
we can assess two areas of concern nationally and locally- employment
and chemical dependency, as well as their potential relation to co-
occurring mental health disorders.
Employment is a critical ``node'' that a Veteran must attain and
sustain to successfully reintegrate (with the exception of those who
are 100% disabled and unable to work). If this node collapses, it is
most often the catalyst that dissolves secondary nodes within the
ecosystem of support for a Veteran such as mental health stability
(i.e. triggers PTSD symptoms- depression, self-esteem, sense of
purpose, etc.) and can cause a Veteran to retract from social
reintegration as well as lead to even further breakdowns in the
ecosystem of support such as family relations, and sustainable housing.
Too frequently, these breakdowns lead to the use of unhealthy coping
mechanisms such as a reliance on drugs and alcohol. This is often the
beginning of the ``downward spiral'' and collapse of a Veteran's
sustainable reintegration. So where does the responsibility lie for
disconnection in Veteran employment during the transition from Warrior
to Veteran?
According to sources at the Joint Chief of Staff's Office for
Warrior and Family Support, the DOD is accountable for more $960
million dollars in unemployment compensation to Veterans (unfortunately
without the ability to fully evaluate their progress due to the fact
Veteran's are no longer tracked in the DOD system post out-process).
However, more often than not, the VHA receives the primary burden of
responsibility to assist unemployed Veterans given that they usually
have the most access to the Veteran population in the region. This is
an example of scope creep within our local VHA due to the
inefficiencies related to ``who owns what'' in the transitional process
from Warrior to Veteran. Therefore, the VA administration should
emphasize the importance of engaging with the private sector and
community partners who focus entirely on job placement. More often than
not, this will be supported under category 3 mentioned above and
secondarily, could reduce both the DOD and VHA scope creep.
Besides Veteran employment efforts, the VA administration can also
optimize their VHA partnerships with the community agencies providing
clinical treatment for Veterans with addictions. As the Executive
Director of the Joseph House, Inc. for homeless Veterans with
addictions, my clients are prime examples of the systematic breakdown
of a Veteran's ecosystem of support. My clinical team has
conservatively identified that 12 out of our 27 clients in our
treatment program as of September 2013 have also been prescribed
psychotropic medication for a co-occurring mental health disorder. It
is important to note, that up to 78% or more of my senior clients
(post-Vietnam) are suffering from co-occurring mental health and
addiction disorders that are either unrelated to military service,
possibly caused by socio-economic struggles, childhood adversity or
other past experiences. However, a majority of our younger clients (War
on Terror) are suffering from disorders related to PTSD, combat stress,
and/or transitional anxiety in addition to these past experiences that
have either led to chemical dependency or enhanced a pre-service
addictive behavior. As it relates to our clients, mental health and
chemical dependency are the primary nodes that have broken down within
their ecosystem of support that likely caused their current state of
homelessness.
Although the local VA administration has provided exceptional
support through their VHA Community Outreach Division to fund and
evaluate current programs like the Joseph House, Inc., it has been
reluctant to support VHA participation in community-based Veteran
mobilization efforts or ``community action teams.'' The VHA could
optimize the impact of Veterans recovering from chemical addiction with
effective engagement in both the housing and health sub-committees of
the local Veteran community action team. VHA participation at an
operational level will allow them to better assess funding support for
community agencies according to the three process categories mentioned
above. Furthermore, a more interactive relationship with community
agencies will enable them to share and assess best practices so that
they can not only help improve the local agencies they currently fund,
but their internal treatment program as well.
Local agencies such as the Joseph House, Inc., Talbert House
Parkway Center, Volunteers of America to name a few in our region,
provide services and treatment for Veterans suffering from homelessness
and chemical dependency. The majority of our funding is provided
through the VA Grant Per Diem program. Although the VA provides a
series of measures to validate our funding each year, they also operate
their own internal substance use program within the VAMC hospital.
After reviewing their internal hospital program compared to local
agencies, it is evident that they fund a higher percentage of staff
treating a smaller percentage of Veterans compared to our external
agencies. It is important to note that the qualifications and
certifications per ODMHAS (Ohio Dept. of Mental Health and Addiction
Services) for our cliental programs and staff are parity to the VAMC's
program. Also, many of our clients have been referred to us from the
VAMC hospital program due to negative discharges or time limitations of
the program. Thus, a more collaborative partnership could potentially
enable a more effective program match as soon as a Veteran is
identified for treatment. Moreover, it is important to acknowledge the
changing landscape in chemical addictions.
More Veterans, particularly the War on Terror Veterans are choosing
opiates such as heroin vs. alcohol. It is important that we address the
treatment options for opiate addiction vs. alcoholism and which
programs are more qualified to provide treatment services - VHA or
community agencies, or at minimum, create a stronger referral system
between the two to ensure that the Veteran receives the proper care in
a timely manner as soon as they are diagnosed. Recent studies have
pointed out that, while substance use remains a key issue for Veterans,
there has been a decline in specialized programs. Clients often respond
better and stay engaged longer with specialized drug treatment
programs. Therefore it is beneficial for the VHA and local agencies to
partner to meet the treatment needs of new Veterans. \3\ This is why it
is essential that the VA administration encourage their VHA teams to
partner with the community in order to channel resources into one of
the three process categories mentioned above, optimize internal and
external treatment programs, and ensure that a Veteran is referred to
the most relevant program to meet their treatment needs.
---------------------------------------------------------------------------
\3\ Eggleston, M., Straits-Troster, K. & Kudler, H. (2009).
Substance use treatment needs among recent Veterans. North Carolina
Medical Journal, 70(1), 54-58.
---------------------------------------------------------------------------
In summary, it is important to reiterate that the opportunities to
optimize VHA scope creep and VA administrative leadership's support for
community engagement are not a reflection of the dedicated VA/VHA/VAMC
leadership and staff, but the opportunity to optimize internal
processes in order to sustain their primary responsibility of providing
medical care for Veterans who qualify for benefits and treatment. To
this end, it is the responsibility of all us who have ``skin in the
game'' to operate more collaboratively to improve the transitional
system and process of new Veteran reintegration and community efforts
to sustain the well being of all our Veterans and their families.
In 2011, I received a call from the local VAMC at 10:30pm on a
weekday to see if I could house a War on Terror Veteran for the night
that had. Although he had just completed the chemical dependency
program at the VAMC, he now had nowhere to go, no friends to call, no
family to help and his time was up per the VA program guidelines. At
around 11:30pm he arrived at my home, and for the next 2 hours he
tearfully told me his story. Like many Soldiers, he signed up to serve
his country, and suffered severe trauma related to combat that came
home with him post deployment. If I recall correctly, his father had
also recently passed away, and his mother was suffering from her own
chemical dependency. Despite the breakdown of his support system, he
``Soldiered on'' and secured a meaningful job, but was later laid off
like so many other Americans. Without stable housing or employment, he
found solace on the streets and had built a relationship with local law
enforcement to allow him to just spend a few nights on the street while
he reached out for help during the day. And unfortunately like many
homeless citizens in distress, he turned to alcohol as his coping
mechanism. While he fortunately found his way to the VA where he
completed their chemical dependency program, he did not have the
support network to sustain his sobriety post treatment, and my home
became his last resort that night. This story like so many others is
simply unacceptable. We must think strategically, act operationally and
continue to identify opportunities to improve the sytem while always
keeping the end-state in mind- ensuring our Veterans thrive in our as
productive members of our society. One Veteran left behind is one too
many.
Prepared Statement of Rodger Young
My name is Rodger Young, I'm a Veteran's Service Officer for the
Clermont County Veteran Service Commission. Veteran Service Officers
assist veterans in obtaining their VA benefits. This can include
enrolling into healthcare, applying for compensation/pension, education
benefits, burial benefits, VA Home Loans, and financial assistance. We
are also charged with aiding veterans with their appeals and dealing
with overpayments and billing issues. We are the preverbal ``one-stop-
shopping'' for VA benefits.
Our office was invited to attend this Committee to provide feedback
on the services Veteran Healthcare Administration (VHA) provides and
also comment on the programs/stigmata associated with Post Traumatic
Stress (PTSD).
1) Positive Feedback:
a) The nursing teams are working well; open communications is the
key to successful healthcare.
b) MyHealtheVet is a great way to open the communication channels
from veteran to doctor.
c) Love the Ebenefits website which is the main hub for VA
benefits/downloading VA correspondence ect . . .
d) I commend the staff at CBOC Clermont County Ohio . . . great
service, great teams, very cooperative/friendly with VSOs and they
treat every veteran with the utmost respect.
e) The quick reference flipbooks are great for passing on
information concerning healthcare
2) Areas to improve upon (our feedback from the veterans):
a) Non-VA care (FEE Basis) - I attached the handout VHA mailed
concerning paying for outside medical care due to a medical emergency.
Many veterans are confused about the program and when VA will pay for
emergency care/transportation. VHA needs to be clear on what VA will
pay and the requirements before the care is covered; the handout makes
it sound easy. There should also be a claim form to send to VHA along
with the hospital bills. The processing time is another concern. It
takes so long to obtain an answer many veterans are turned over to
collections/credit ruined while waiting for an answer; appeal take even
longer. VHA needs a call center for billing/non VA care alone; normally
will get an answering machine and no return call.
b) Average wait time for surgeries
c) Still getting complaints about the professionalism at VAMC
Cincinnati (friendliness), little to no complaints on Georgetown/
Clermont CBOCs
d) DBQs
e) If doctors refer veterans to file a claim, please ensure
diagnosis/notes are annotated in CAPRI. Makes everyone's life much
easier when filing a claim.
Veterans endure many adjustments when returning from deployment to
include indoctrination back into family life, adjusting back into their
home station and their rules, and trying to process what had happened
while deployed. In general, many veterans are reluctant to seek help
for mental issues due to the stigmata associated with PTSD (employment
to include separation from the military, family and current gun laws).
Feedback from the CBOC staff indicate cognitive therapy is working on
many veterans. Success stories to be honest I don't have any.
Many who seek help for PTSD receive some relief through medications
(to tone down the symptoms) but I've never seen a veteran completely
cured. Realize in past wars veterans would endure 1-2 deployments into
the
warzone; contemporaneously, it's not uncommon to see 5-8
deployments. PTSD programs have prevented many suicides but I think we
still have a long road ahead in treating PTSD. In my opinion, we need
to fix the stigmatas associated with PTSD so more veterans will seek
help and then we need to rehabilitate them to function in today's
society outside the military.
Our office appreciates the invitation today to outline some of the
hurdles VA faces and the vast improvements it has made to ensure the
veterans are taken care of. Partnerships within VHA/VBA/VSO will
solidify a smooth transition for the returning veterans and their
families. Standardization, consistency and communication within these
three agencies are essential to minimizing the confusion within the
veteran communities.
Rodger Young, MSgt, USAF(Ret)
Veterans' Service Officer
Clermont County Veterans Service Commission
76 South Riverside Drive, 3rd Floor
Batavia, OH 45103
(513)-732-7363
Prepared Statement of Paul D. Worley
Mr. Chairman and Members of the Subcommittee, it is an honor to
testify before you today. Thank you, for allowing me the opportunity to
speak this morning about mental health care for veterans. My name is
Paul Worley and I am an Army veteran. I served as an infantry rifle
platoon leader and scout platoon leader in 2nd Battalion, 502nd
Infantry Regiment, 101st Airborne Division (AASLT) in Iraq in 2005-
2006. In 2008, I served as an operations officer at Regional Command
South, NATO Headquarters in Kandahar, Afghanistan. My last tour of duty
in Iraq was from 2009-2010, where I served as a mechanized infantry
company commander for 3rd Battalion, 69th Armor Regiment, 1st Brigade
Combat Team, 3rd Infantry Division. At times and places few will ever
know we fought for each other against an unseen enemy. I was honored to
serve my country and privileged to lead the best soldiers in the world.
Today, I am equally proud to represent my fellow veterans and to talk
about the issues we face in regards to mental health.
When it comes to mental health care for veterans the major issues
are access and availability. The VA is the largest integrated health
care system in the country. There are going to be issues, as there are
in every health care system, but that does not mean that the system is
broken.
In Adams County, Ohio, our veterans are faced with the issue of
getting reliable transportation to their medical and mental health
appointments. The nearest clinics are located in Portsmouth and
Chillicothe, which are at least a forty five minute drive for most
veterans. For those who receive services in Cincinnati and Columbus the
task of getting to appointments is even more daunting. Our local
veterans' service commission and veteran service organizations,
including VFW Post 8327 and DAV Chapter 71, currently provide
transportation, but it is not enough to meet the demands of our
veterans and their families. I believe it is essential that we provide
more mobile veteran centers to provide access to our rural residents.
Another access issue we face in southern Ohio is internet
availability. Our internet infrastructure is extremely limited due to
the terrain and the financial challenges of our local population. Many
veterans do not have ready access to fill out forms online or to obtain
the information they need about mental health services. As more
information is shared online it is critical that we provide our veteran
population with access to this basic modern need.
I believe that the military as a whole has made positive progress
to reduce the stigma of post-traumatic stress disorder within its ranks
over the past ten years. However, I believe there is still a great
amount of work to do reduce the stigma of PTSD among the American
people. Young veterans seeking civilian jobs are reluctant to seek help
because of the risk of employers not hiring them. All veterans deal
with the stigma that seeking help for mental health is a sign of
weakness. More education is needed to make sure the American public
comprehends the issues associated with PTSD.
It is very encouraging that the VA has recently hired an additional
1300 mental health care workers that will potentially alleviate some of
the availability issues. I believe that the VA employees and leadership
want nothing but the very best care and benefits for our veterans.
However, we need to continue to improve the mental health care system.
We need to be prepared to pay for veteran health care services as
readily as we were to fund the wars that caused these issues. The price
tag may be great, but that truth does not take away the nation's duty
to care for our veterans. The country sent us to war.
Now is the time to make sure that this country is delivering on the
solemn promise made to our veterans for their voluntary service.
Prepared Statement of Kristi D. Powell - USAF Veteran
I would like to thank the panel for this opportunity to discuss the
issues that veterans face when seeking mental health care services
through the VA, especially for MST (Military Sexual Trauma). I will
touch on the four particular topics of discussion that cause barriers
for the veteran when trying to receive mental health and other care and
also of specific cases/examples of these barriers that we have in my
county and with the VA's in our area. I would like to begin by
introducing myself and giving you the specific examples of problems
that veterans are currently facing when trying to receive treatment for
MST.
My name is Kristi Powell, I am a United States Air Force Veteran. I
hold a Bachelor's Degree in Substance Abuse Counseling and a Masters
Degree in Criminal Justice. I am currently employed at a job which
allows me to assist in the needs of veterans. It is through my job and
outside involvement with veterans' activities that I am able to hear
veterans' stories, hold roundtable discussion groups, and help aid in
their healthcare. I have also been blessed to have the opportunity to
be their voice today. These examples are of different veterans of
different ages, different eras served in the military and all separate
times frames of when they experienced their problems within the VA as
far as their health care.
Case/Example 1: A female veteran in her late 40's came into the
office very distraught. She showed signs of anxiety; she was crying and
it was very apparent that something was wrong. After talking for
awhile, she confided in me what had happened that was making her so
distraught. She began to tell me how she was raped in the military by
an officer and that it has impacted her life so severely that she can
hardly function. She cannot work, she doesn't leave her apartment very
often and she is on numerous medications just so she can get through
the day and also to be able to sleep at night. Through the VA she
learned of a program referred to as PRRTP (Psychosocial Residential
Rehabilitation Treatment Program) that could possibly help her with her
MST. She also felt that if she went to this program that it would help
her in getting her service-connected claim for MST/PTSD so atleast the
VA would know that she has severe problems with the MST that she was
trying to address. She entered the PRRTP program at the VA hoping to
receive the care that the VA claimed that they could give her and that
they advertise. (Note: when referring to the care that the VA
advertises I am specifically referring to the Department of Veterans
Affairs website on MST in which it gives the following information that
I copied and pasted):
Outpatient
Every VA health care facility has providers knowledgeable
about treatment for problems related to MST. Because MST is associated
with a range of mental health problems, VA's general services for
posttraumatic stress disorder (PTSD),depression, anxiety, substance
abuse, and others are important resources for MST survivors.
Many VA facilities have specialized outpatient mental
health services focusing specifically on sexual trauma.
Many Vet Centers also have specially trained sexual
trauma counselors.
Residential/Inpatient Care
VA has programs that offer specialized MST treatment in a
residential or inpatient setting. These programs are for Veterans who
need more intense treatment and support.
Because some Veterans do not feel comfortable in mixed-
gender treatment settings, some facilities have separate programs for
men and women. All residential and inpatient MST programs have separate
sleeping areas for men and women.
How can I get more information about services?
Knowing that MST survivors may have special needs and
concerns, every VA health care facility has an MST Coordinator who
serves as a contact person for MST-related issues. He or she can help
Veterans find and access VA services and programs.
So the veteran enters the VA PRRTP program as inpatient treatment
for MST/PTSD. The veteran's anxiety began immediately upon arriving.
After being admitted to the program the VA told her she was done for
the day and that she go get chow. Upon entering the chow hall, she
noticed that she was the only female veteran in the dining facility
with all males. The veteran returned to her floor where she immediately
found a VA nurse. She told the VA nurse she was having extreme anxiety
and that she was told that the VA could help her with her MST/PTSD. The
veteran felt betrayed that the VA would enter her in a program and then
put her around all males throughout the day. On her first day of the
program, she reported to where they told her to go, again she walked in
the room to discover that she was the only female. Although confused
and very uneasy about the situation she told herself that she had to
stay because the VA briefed her that if she left the program early then
she would not be allowed to be readmitted later and she still believed
at the time she had to do it for her pending claim. In these group
sessions she was told to participate, participation including stating
the reason that you are there. She stated, when it was her turn, that
she was there for MST. The males in the group automatically started in
on insults and taunting her with comments about MST. A male in the
group even stated to her ``why would you put yourself in that position
by joining the military knowing that would happen.'' The same male then
started bashing homosexuals by calling them derogatory names. This
veteran responded by saying that it offended her and he responded back
by saying ``you don't get excited by men?'' The facilitator of that
group allowed this to go on and did nothing to stop or correct the
conversation. After the group session was over, the female veteran went
over to the facilitator and asked if there was a female psychologist
that she could speak to. The facilitator gave her a name and so the
female veteran immediately went and told the psychologist what
transpired in group. The psychologist said that she would refer the
veteran to the PCT program ( PCT programs I was told specialize in the
treatment of combat-related PTSD). Even after this horrific event, the
veteran still continued on with group. She completely isolated herself
and refused to participate anymore while suffering severe anxiety
attacks from being surrounded by all men. The same male from the group
started following her around and making comments to her. He triggered
her anxiety associated with her rape so much that the psychologist and
the social worker stated that maybe this was not the program for her.
The next morning the social worker came and talked to the veteran about
what had transpired and what some options were. The comments continued
by the male in the group in front of everyone, these comments were
usually sexual in nature and as before, the facilitator did nothing to
object to it. Finally the veteran had enough, she checked herself out
of the VA and came back home. While at home, the veteran could not get
the male or his comments to leave her mind. Something told her to
Google his name, when she did numerous things came up. She noticed one
was a mug shot so she clicked on it and it was that same male that
taunted her in her group. He was listed as a convicted sex offender. He
had raped a woman in Mansfield, Ohio and had his address listed on the
website as the VA's. This VA allowed an MST survivor who suffers from
severe mental health conditions associated with her rape to be in a
group counseling session and freely around a convicted rapist. This
veteran is now so traumatized that she refuses to go back to the VA for
any type of healthcare. This event has completely set her back in any
progress that the veteran had made prior to entering the VA for help.
Case Example 2: A female veteran in her 20's came into the office.
After talking to her, she disclosed that she was living in the homeless
shelter and that she had a substance abuse problem. She was crying and
stating that she did not know what she was going to do. I told her
about the programs that are being offered at the VA and asked her if
she would like me to help her see if one of the programs was open for
her to enter treatment. She told me that she was already in a program
up there and left and that she was not allowed back into any of them
because of leaving. I asked her which one and what happened. She told
me that she was raped while deployed to Afghanistan by her Lt. After
being raped and her being harassed continually by him she started self
medicating when she returned to the states. Her performance declined at
work and she was eventually discharged from the military. When she came
home, her substance abuse continued as she tried to mask her pain. She
started using harder drugs such as heroin just to deal with life. Her
parents did not know how to handle her so they kicked her out which
forced her into the homeless shelter. She entered the VA in hopes of
getting help with her MST and substance abuse problem. While at the VA,
she also was put into an all male group session in which the taunting
began immediately with name calling. They would call her ``princess''
and tell her to sit down when she told the group that she was there for
MST. The taunting from the males became so bad that she left treatment
and immediately got high to deal with pain that resurfaced from being
raped. It was with this second veteran that I realized that this is not
a coincidence; this is an on-going and unchanging issue at the VA.
Since this vet was going through withdraws I took her back to the VA.
While waiting for her to be admitted through Urgent Care, I took her
with me to talk to the patient advocate. My first stop was the OEF/OIF
patient advocate since she was from that era. I told the patient
advocate that this was the second case that I knew of and that it was a
severe problem. I asked him because I wanted to know what I personally
had to do or who I had to talk to for this issue to be addressed and so
it would not happen to another veteran trying to receive care. The
patient advocate looked at me and asked ``at what point do you feel
that these MST veterans would be able to attend group sessions?'' I
honestly looked at him in disbelief, I could not believe that this was
his first question and only concern. My reply was ``probably never. It
would only be when the veteran states for themselves that they are
ready.'' I then got up, left his office and went to the next person in
line which was the Women's Health Social Worker. The social worker
listened to my concerns and complaints about how MST veterans are being
treated and the lack of care that they are receiving; she could not
however give me any explanation to why this was happening but more or
less said that the VA does not have the space or resources to have an
all-female area. I stated to her although I completely understood
budget restraints, as soon as a veteran discloses that they are a MST
victim/survivor that should be the red flag for the VA to do an ITP
(Individualized Treatment Plan). Under no circumstances should the
veteran be subjected to the same sex and/or race of the person that
sexually harassed and/or assaulted them. The social worker agreed and
said she would definitely let the director of the VA know. The social
worker gave me her word that she would find the appropriate care for my
fellow young veteran that was suffering from so many mental health and
substance abuse issues. The catch to waiting for new treatment would be
that it might take some time to find something so she would be stuck at
the VA in the same scenario with all men until then. I talked to my
veteran and I asked her what she wanted to do, she agreed stating it's
either this, the homeless shelter or die. Since I admitted her through
the urgent care, the standard rule from what I understand is that the
veteran goes to the psych ward for 3 days. I escorted this vet up to
the psych ward and it was filled again with all male vets that were in
their for numerous different types and levels of mental illness with no
separate section for female and/ or male vets that were survivors of
MST. I informed the staff on the ward that she was suffering from MST.
The one guy that was working that floor did not even know what MST was.
I told the vet to call me at anytime if she felt she could not handle
it and it was triggering her anxiety or want to use drugs or anything
else. She did call me but she also made it through her three days. The
social worker did keep her promise to me and this vet by later
transferring her to New York State where she has been referred to an
all-female treatment facility with other female vets where she gets to
stay for a year. In her correspondence she tells me that I saved her
life by being active in her health care and being her voice when no one
cared. She loves the facility where she is at and she celebrates every
day that she is alive and sober and getting help for all the pain that
she has hide within herself. This worked out for this particular
veteran but not all veterans are given this opportunity for treatment.
Case/Example 3: Due to the problems that I have seen within the VA
when it comes to women's healthcare, I had participated in a Roundtable
discussion with an Ohio Senator. Again I voiced my concerns about what
was taking place and what I was witnessing at the VA when it came to
treatment for MST. Months later, a representative from his office
called and asked if I would be interested in hosting another roundtable
in which she could come down and sit with me and about 10 other women
veterans to discuss problems they are having in receiving care. I
started calling women veterans from the area. I picked one (the veteran
from case #1) to join me to discuss MST. The other four female veterans
were random and I had never met them nor knew anything about their time
in service or if they even utilized the VA. I called random women
veterans in hopes of creating a roundtable full of different women to
voice their concerns about VA healthcare. After meeting and talking for
awhile, I brought up MST to the representative and started voicing my
concerns. As soon as I opened this discussion up and the other women
veterans knew that this was my passion and my new fight, they began to
open up and all five women veterans were MST victims/survivors. As I
listened to what they were willing to share, it occurred to me that
this problem has been present for quit sometime and although progress
is occurring, the VA is still not where it should be with the number of
MST statistics that they are reporting on their website. According to
the Department of Veterans Affairs website, ``About 1 in 5 women and 1
in 100 men seen in VHA respond ``yes'' when screened for MST. Though
rates of MST are higher among women, there are almost as many men seen
in VA that have experienced MST as there are women. This is because
there are many more men in the military than there are women.''
With the statistics that the VA has provided and from what I have
witnessed in my county alone, I am in hopes that positive changes
occur. Men and women who served their country and are victims/survivors
of MST/PTSD should not be left to fight this battle alone. The VA
should do the necessary steps to develop Individualized Treatment Plans
and separate wings/facilities that are specially staffed to meet the
needs of MST victims/survivors. Women veterans should not have to worry
about encountering all men when they go to the VA for treatment; with
separate wings/facilities a female could feel more confident in
choosing to get care through the VA without fear. The services provided
for MST/PTSD should be available at every VAMC. At the present time,
only certain locations throughout the United States have all-female
treatment areas and the wait time for a veteran to get into the program
is very lengthy (6 months or more). The veteran also has to apply and
be accepted into the program and they are then placed on a waiting
list. Even in the cases I mentioned above, the drive one way to this
particular VA is one hour. In some areas of Ohio, a female veteran is
expected to drive 3 plus hours one way for a gynecology exam.
The VA is the federal agency responsible for serving the needs of
veterans by providing health care, disability compensation and
rehabilitation, education assistance, home loans, burial in a national
cemetery, and other benefits and services. The VA bears the words, ``To
care for him who shall have borne the battle and for his widow, and his
orphan.'' Not only are these words a reminder to the VA of the
commitment they made to care for those injured in our great nation's
defense but I am here as well to remind them and let them know that
more needs to be done to fulfill their commitment to the veterans of
this country.
I thank you again for allowing me this opportunity to speak before
you.
Sincerely,
///SIGNED///
Kristi D. Powell
Prepared Statement of Linda D. Smith, FACHE
Good morning, Chairman Benishek, Ranking Member Brownley, and
Members of the Committee. Thank you for the opportunity to discuss the
Cincinnati VA Medical Center's (VAMC) efforts to provide high quality
care, specifically mental health care, to Veterans in our catchment
area and our pilot Veterans Transportation Service. I am accompanied
today by Dr. Kathleen Chard, Director of the Trauma Recovery Division
of our Mental Health Care Service Line, and Professor of Psychology and
Behavioral Neuroscience at the University of Cincinnati, College of
Medicine; Emma Bunag-Boehm, Primary Care Provider for the Post-
Deployment Clinic, Cincinnati VAMC, and Mr. Chad Watiker, Cincinnati
Vet Center Team Leader.
I will begin my testimony with an overview of the Cincinnati VAMC.
I will then focus on our comprehensive mental health programs and end
with a brief overview of the Veterans Transportation Service, which has
improved access to care for many of our Veterans.
Cincinnati VAMC Overview
The Cincinnati VAMC is a two-division campus located in Cincinnati,
Ohio and Fort Thomas, Kentucky. The Medical Center serves 17 counties
in Ohio, Kentucky, and Indiana with six Community-Based Outpatient
Clinics, located in Bellevue, Kentucky; Florence, Kentucky;
Lawrenceburg, Indiana; Hamilton, Ohio; Clermont County, Ohio; and
Georgetown, Ohio. The Cincinnati VAMC is a tertiary referral facility.
We are a highly-affiliated teaching hospital, providing a full range of
patient care services, with state-of-the-art technology, medical
education and research capabilities. The Medical Center provides
comprehensive health care through primary care, dentistry, specialty
outpatient services, and tertiary care in areas of medicine, surgery,
mental health, physical medicine and rehabilitation, and neurology.
Our facility is the Veterans Integrated Service Network (VISN) 10
referral site for a number of surgical and medical programs and a
regional referral center for posttraumatic stress disorder (PTSD). The
PTSD program at the Fort Thomas division of the Cincinnati VAMC in
northern Kentucky also provides training to practitioners from various
active duty military branches and other VAMCs. Our Inpatient Mental
Health Unit is frequently visited by other VA facility staff to learn
about our Recovery Model of Care.
The Cincinnati VAMC has an active affiliation with the University
of Cincinnati College of Medicine and is connected both physically and
functionally to the University. Over 500 fellows, residents, and
medical students are trained at the Cincinnati VAMC each year. In
addition, there are also over 85 other academic affiliations involving
dentistry, pharmacy, nursing, social work, physical therapy and
psychology.
The Cincinnati VAMC is fully accredited by The Joint Commission,
the College of American Pathologists, the Commission on Cancer of the
American College of Surgeons, the Commission on Accreditation of
Rehabilitation Facilities, the Accreditation Council on Education, the
Accreditation Council for Graduate Medical Education, the American
Association of Cardiovascular and Pulmonary Rehabilitation and
accrediting bodies for residencies in Optometry, Pharmacy and
Radiology. Our research programs are also fully accredited.
Over 42,000 Veterans are enrolled in VA health care through our
facility. This number includes over 3,600 female Veterans and 3,500
Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF)
Veterans. Growth in terms of enrolled Veterans has increased by over 4
percent this fiscal year (FY) and approximately 25 percent over the
past 5 years. We also have seen a 13percent increase (322 cases) in
surgeries performed and a 15 percent increase in referrals from other
VAMCs this fiscal year compared to FY 2012.
The Cincinnati VAMC recently volunteered for the first VA survey of
our Patient Aligned Care Team (PACT)/Medical Home Program by The Joint
Commission and was commended for the quality of care and services we
provide. Seventeen out of 43 four-person teams (physician, nurse,
licensed practical nurse, and clerk) received national PACT recognition
from the Veterans Health Administration. We also recently implemented a
Hospital in Home Program that has enrolled over 100 Veterans since
February 2013. This program has allowed us to avoid admission of
Veterans to an inpatient unit by providing daily services in the home,
thus avoiding some health care expenses. Since the program began in
February 2013, we estimate a cost savings of over $700,000 and a 245-
day reduction in Bed Days of Care.
Our facility continues to grow in order to meet increased demand
for services. Construction projects include a recently-completed
parking garage, a new imaging center, patient-centered renovations to
our first floor, a new research building which will break ground in
September 2013, an off-campus, state-of-the-art Eye Center, an
ambulatory surgery center, and an expansion of our operating rooms. We
also have a number of construction projects of interest to include: a
Sleep Study Center, a new Traumatic Brain Injury (TBI) Clinic and new
Community-Based Outpatient Clinics in Florence, Kentucky and
Georgetown, Ohio.
The Cincinnati VAMC has 15 full-time staff in the OEF/OIF/Operation
New Dawn (OND) clinic providing primary care, mental health care,
social work services, and pain management care for military personnel
returning from Iraq, Afghanistan, and all recent combat theatres.
Efforts to reach returning military personnel involve redeployment
briefings, post-deployment briefings, family readiness meetings, local
Veterans Service Organizations meetings/functions, community events and
letters, and personal phone calls to recently-discharged
Servicemembers. Our pilot Veterans Integration to Academic Leadership
Program (VITAL) places a psychologist on local college and university
campuses with the sole task of connecting with student Veterans and
providing services on-site. The Post Deployment Integrated Clinic model
of care and outreach efforts by the Cincinnati VAMC staff for the OEF/
OIF/OND population are considered best practices within VA. As a
result, we have been able to enroll approximately 65 percent of
eligible OEF/OIF/OND Veterans in our catchment area.
One of the most exciting new initiatives at the Medical Center is
our Tele-Intensive Care Unit (ICU), which allows the delivery of
critical care services across a geographic distance through the use of
electronic devices and connections. Critical care nurses and physicians
perform sophisticated 24/7 remote monitoring of Veterans in VA critical
care units throughout the State of Ohio and soon will be monitoring
critically-ill Veterans in the VA Southeast Network (VISN 7).
Trauma Recovery Center
The Cincinnati VAMC's Trauma Recovery Center consists of an
outpatient PTSD clinical team (PCT) and a Residential PTSD Program. The
PCT offers eligible individuals individual family education, medication
management, and evidence-based PTSD treatments in individual, group,
and couples formats including Prolonged Exposure and Cognitive
Processing therapy (CPT), Couples-Based PTSD treatment, Virtual Reality
Therapy and Dialectical Behavior Therapy.
The Residential PTSD Program, described in Veterans Health
Administration (VHA) Handbook 1162.02, Mental Health Residential
Rehabilitation Treatment Program, is a 7-week, cohort-based program for
men and women and an 8-week program for Veterans with PTSD and a
history of TBI. The Residential programs are unique and highly-
successful programs that have been featured in national media for their
patient-centered, evidence-based treatment programs for PTSD. In
addition to utilizing CPT, the residential groups focus on anger,
communication, distress tolerance, life skills, interpersonal
effectiveness, nutrition, communication, and sleep. The women's
residential program was identified as a best practice, and the TBI/PTSD
residential program is the only one of its kind in the Nation.
The Cincinnati VAMC also provides care and services, including
counseling, to Veterans who have experienced military sexual trauma
(MST) and come to VA for care. Under Title 38 United States Code,
Section 1720D, VA is authorized to provide counseling and appropriate
care and services, as required, to Veterans to overcome ``psychological
trauma, which in the judgment of a mental health professional employed
by the Department, resulted from a physical assault of a sexual nature,
battery of a sexual nature, or sexual harassment which occurred while
the veteran was serving on active duty or active duty for training.''
Section 1720D defines sexual harassment as ``repeated, unsolicited
verbal or physical contact of a sexual nature which is threatening in
character.''
Mental Health Care
Mental health services at the Cincinnati VAMC are unified under a
multidisciplinary Mental Health Care Line (MHCL). A comprehensive
variety of mental health services is offered by the seven divisions of
the MHCL. The divisions are Outpatient Mental Health, Substance
Dependence, Assessment and Intensive Treatment, Trauma Recovery Center,
Domiciliary Care for Homeless Veterans, Community Outreach, and Special
Services. Presently, the MHCL employs 30 psychiatrists, 53
psychologists, 72 social workers, and 83 nursing personnel. The total
number of staff working for the MHCL is 303. From FY 2007 to FY 2012,
our MHCL staffing grew approximately 74 percent, and the number of
Veterans treated grew 55 percent. In the first 10 months of FY 2013,
the MHCL provided care to approximately 15.5 percent more Veterans than
were seen over the similar period in FY 2012. That amounts to an
additional 1,482 unique Veterans. During this period of growth, the
Cincinnati VAMC has been successful in recruiting highly-qualified,
mental health staff in all professions.
VHA has developed many metrics to monitor performance in the
delivery of mental health services. These monitors include the
following:
1) Patients who are discharged from acute inpatient mental health
treatment have follow up within 7 days. VHA's goal is that 75 percent
of Veterans in this category should have contact. This year, the
Cincinnati MHCL has successfully contacted approximately 85 percent of
Veterans discharged from acute inpatient mental health treatment for
follow up.
2) Qualifying Veterans should have a Mental Health Treatment
Coordinator (MHTC) assigned to them. VHA's goal is that 75 percent of
qualified Veterans should be assigned an MHTC. The Cincinnati MHCL
currently has approximately 85 percent of qualifying Veterans assigned
to an MHTC. As new Veterans access Mental Health services, assignment
of an MHTC is part of the treatment planning process.
3) In the OEF/OIF/OND clinic, Veterans diagnosed with PTSD who
agree to treatment are expected to have 8 evidence-based psychotherapy
sessions over a 14-week period. VHA's target is that 67 percent of
Veterans who agree to treatment receive 8 sessions in a 14-week period.
The Cincinnati MHCL is currently at approximately 72 percent.
4) In FY 2013, VHA began using two measures to evaluate Veteran
access to mental health care. For Veterans who have established mental
health treatment, the Medical Center tracks the percentage of Veterans
who are able to schedule an appointment within 14 days of their desired
date, which is VHA's goal. The Cincinnati MHCL has achieved that goal
approximately 99 percent of the time. For Veterans who are new to
seeking mental health care, the Medical Center tracks VHA's goal of
having Veterans complete an initial appointment in 14 days or less of
when the appointment was made. For FY 2013, the Cincinnati MHCL has
provided this level of access approximately 83 percent of the time. In
July 2013, the average wait time for a new mental health care patient's
first appointment was 8 days, and approximately 85 percent of Veterans
had their first appointment within VA's goal of 14 days. In the most
recent VA Strategic Analytics for Improvement and Learning report, the
Cincinnati VAMC received an outstanding 5-star quality rating which
included the category ``Mental Health Wait Time.''
While these metrics are important, we realize they tell only part
of the story of Cincinnati VAMC's mental health accomplishments. In
addition to the aforementioned Trauma Recovery Center, Cincinnati has
an array of strong mental health services. For example, the acute
inpatient mental health ward has 20 beds and has received multiple
national recognitions for its patient-centered, recovery-oriented
program. The Substance Dependence Division is also strong as a leader
in tobacco cessation treatment and ambulatory detoxification. Our
opiate substitution program is an important resource for local
Veterans. Our Primary Care Mental Health Integration Program has one of
the highest rates of utilization in the Nation. For 2013 to date, the
VAMC had 1,717 tele-mental health encounters, an 89 percent increase
over FY 2012, and as a result, increased access to care for Veterans
and reduced requirements for travel.
The Cincinnati MHCL has had a Family Services Coordinator for many
years, supporting the families of Veterans with severe mental illness.
We are responding to the new generation of OEF/OIF/OND Veterans with
programs such as brief family consultation, Support and Family
Education, Behavioral Family Therapy, and couples counseling. A VHA-
funded research project, Couple-Based Treatment for Alcohol Use
Disorders and PTSD, is investigating the effects of couple-based
counseling for alcohol dependency, PTSD, and partner relationships. The
Cincinnati VAMC has also been chosen as a site for the Practical
Application of Intimate Relationship Skills (PAIRS) program. This is a
9-hour, intensive weekend training program to improve a Veteran's
relationship with their partner.
Homeless Programs/Initiatives
The Cincinnati VAMC is also working actively with many other
Federal, state, and local entities to meet Secretary Shinseki's goal of
ending homelessness among Veterans in 2015. The homeless programs at
the Cincinnati VAMC are robust, consisting of strong outreach/community
partnerships, Grant and Per Diem (GPD), Housing and Urban Development/
Veterans Affairs Supportive Housing (HUD/VASH), Health Care for
Homeless Veterans (HCHV) contract beds, and Veterans Justice Outreach
(VJO) programs. We have developed a Homeless/Low Income Resource Guide
and the HUD/VASH Quarterly Newsletter that VA Central Office recognized
as best practices. Our VJO program was featured in a recent
rehabilitation accreditation newsletter, CARF International's
``Promising Practices Innovation in Human Services,'' April 2013.
On May 3, 2013, the Cincinnati VAMC held its 4th Annual Homeless
Summit, which was attended by a broad base of community partners,
including Joseph House, Greater Cincinnati Behavioral Health, Talbert
House, Drop Inn Center, and Strategies to End Homelessness.
Additionally, the Cincinnati VAMC works closely with numerous faith-
based organizations, such as City Gospel Mission, Interfaith
Hospitality Network, St. Francis/St. Joseph Catholic Worker House,
Mercy Franciscan at St. John's, and the Mary Magdalen House.
The Community Outreach Division of the MHCL, under which the
homeless programs fall, will be moving to Downtown Cincinnati this
month to a strategic location allowing increased access and walk-in
service. A portion of the division will remain in Fort Thomas, Kentucky
to allow access for homeless Veterans in Northern Kentucky. Listed
below are the homeless programs and initiatives available through the
Cincinnati VAMC:
GPD - We have 173 beds, including seven beds for female Veterans.
Our programs run at capacity and have a high success rate, short length
of stay, and low cost per episode.
HUD/VASH - We have 275 vouchers in Hamilton and Clermont counties
in Ohio and Northern Kentucky and were awarded an additional 40
vouchers for FY 2014. The Cincinnati VAMC was among the first medical
centers in the Nation to incorporate Housing First principles within
HUD/VASH by piloting a 25-voucher program in October 2010 and retooling
the entire program to incorporate Housing First principles in March
2011. According to the Homeless Operations Management Evaluation
Systems (HOMES) Database, our chronically homeless housed rate is
approximately 89.26 percent, among the highest in the Nation. We
finished FY 2012 with a 94.84 percent housed rate and the Medical
Center is on target to exceed that rate in FY 2013.
HCHV Contract Beds - We have 12 beds (six, two-bedroom apartments)
under this program. Each bedroom is private and locked, ensuring
safety, security, and privacy.
Veterans Justice Outreach - We actively collaborate with four
operational Veterans Treatment/Diversion Courts and look forward to
collaborating with a fifth court in the planning stages moving towards
implementation. The addition of this fifth court will give us
partnerships with Veterans Treatment Courts in all three states within
our catchment area, providing Veterans with help in meeting treatment
goals instead of incarceration.
Veterans Transportation Service (VTS)
Recognizing that increasing access to care improves health care
outcomes, the Cincinnati VAMC began operation of the VTS in May 2012,
offering both mobility management and transportation services. Mobility
management guides Veterans to the most medically-appropriate and cost-
effective means available through a private, Veteran-focused agency or
public transportation resources. VTS fills the remaining gaps,
providing door-to-door, wheelchair-accessible transportation for those
Veterans living in the Medical Center's catchment area who have no
other viable transportation options. VTS has served 750 unique
Veterans, approximately 40 percent of whom are wheelchair-bound,
providing nearly 10,000 rides, since its inception.
Community Partnerships
The Cincinnati VA has been building community mental health
partnerships by holding annual homelessness prevention summit meetings
for the past 4 years. Those summit meetings inspired our development of
the Cincinnati Homeless/Low Income Resource Guide. In addition to
having been cited by VHA as a best practice, the guide has become a
highly valued document for community agencies. Based on events like the
homelessness summits, VHA has been holding Community Mental Health
Summits during the Summer of 2013.
In August 2013, the Cincinnati VAMC hosted its first Community
Mental Health Summit. At the Summit, facility leadership and staff met
with 66 individuals from 36 community agencies. The facility was joined
by staff from the local delegation of Members of Congress, one state
agency, one county agency, and six universities.
Presentations were made on the following topics:
University Liaison. The Cincinnati VAMC has a well-established
outreach program which partners with local colleges and universities to
ease the transition of Veterans seeking higher education.
PTSD Treatment. Cincinnati MHCL discussed its programs with Dr.
Chard speaking on this topic.
Suicide Prevention. Each VAMC has been allocated at least one full
time suicide prevention coordinator. The MHCL has 3 full time social
workers devoted to this task. VHA works steadily to reduce stigma
associated with receiving mental health care. VHA has declared that
September 2013 is Suicide Prevention Month, and VHA is sponsoring the
public service announcement ``Talking About It Matters''. During
September 2013, the Cincinnati MHCL Suicide Prevention team will give
11 presentations in the community focusing on eliminating the stigma
that complicates preventing suicides.
At the Mental Health summit, there was considerable open exchange
of detailed information about mental health programs and services
available through VA and in the community. This was an opportunity to
share ideas and promote further collaborations. Particular suggestions
that emerged included annual follow-on summit meetings and for MHCL to
develop a simple telephone access to respond to Community Agency
queries about MHCL services.
Conclusion
VHA and the Cincinnati VAMC are committed to providing the high-
quality care that our Veterans have earned and deserve, and we have
continued to improve access and services to meet the mental health
needs of Veterans residing in Cincinnati and the local surrounding
area. We appreciate the opportunity to appear before you today, and we
appreciate the resources Congress provides VA to care for Veterans. Dr.
Chard, Ms. Bunag-Boehm, Mr. Watiker, and I are happy to respond to any
questions you may have.