[House Hearing, 118 Congress]
[From the U.S. Government Publishing Office]


                   SSG FOX SUICIDE PREVENTION GRANTS:
                         SAVING VETERANS' LIVES
                       THROUGH COMMUNITY CONNECTION

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

                                HEARING

                               before the

                         SUBCOMMITTEE ON HEALTH

                                 OF THE

                     COMMITTEE ON VETERANS' AFFAIRS

                     U.S. HOUSE OF REPRESENTATIVES

                    ONE HUNDRED EIGHTEENTH CONGRESS

                             FIRST SESSION

                               __________

                       TUESDAY, DECEMBER 12, 2023

                               __________

                           Serial No. 118-44

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]       


                    Available via http://govinfo.gov
                    
                               __________

                   U.S. GOVERNMENT PUBLISHING OFFICE                    
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-----------------------------------------------------------------------------------     
                  
                     COMMITTEE ON VETERANS' AFFAIRS

                     MIKE BOST, Illinois, Chairman

AUMUA AMATA COLEMAN RADEWAGEN,       MARK TAKANO, California, Ranking 
    American Samoa, Vice-Chairwoman      Member
JACK BERGMAN, Michigan               JULIA BROWNLEY, California
NANCY MACE, South Carolina           MIKE LEVIN, California
MATTHEW M. ROSENDALE, SR., Montana   CHRIS PAPPAS, New Hampshire
MARIANNETTE MILLER-MEEKS, Iowa       FRANK J. MRVAN, Indiana
GREGORY F. MURPHY, North Carolina    SHEILA CHERFILUS-MCCORMICK, 
C. SCOTT FRANKLIN, Florida               Florida
DERRICK VAN ORDEN, Wisconsin         CHRISTOPHER R. DELUZIO, 
MORGAN LUTTRELL, Texas                   Pennsylvania
JUAN CISCOMANI, Arizona              MORGAN MCGARVEY, Kentucky
ELIJAH CRANE, Arizona                DELIA C. RAMIREZ, Illinois
KEITH SELF, Texas                    GREG LANDSMAN, Ohio
JENNIFER A. KIGGANS, Virginia        NIKKI BUDZINSKI, Illinois

                       Jon Clark, Staff Director
                  Matt Reel, Democratic Staff Director

                         SUBCOMMITTEE ON HEALTH

               MARIANNETTE MILLER-MEEKS, Iowa, Chairwoman

AUMUA AMATA COLEMAN RADEWAGEN,       JULIA BROWNLEY, California, 
    American Samoa                       Ranking Member
JACK BERGMAN, Michigan               MIKE LEVIN, California
GREGORY F. MURPHY, North Carolina    CHRISTOPHER R. DELUZIO, 
DERRICK VAN ORDEN, Wisconsin             Pennsylvania
MORGAN LUTTRELL, Texas               GREG LANDSMAN, Ohio
JENNIFER A. KIGGANS, Virginia        NIKKI BUDZINSKI, Illinois

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

                              ----------                              

                       TUESDAY, DECEMBER 12, 2023

                                                                   Page

                           OPENING STATEMENTS

The Honorable Mariannette Miller-Meeks, Chairwoman...............     1
The Honorable Julia Brownley, Ranking Member.....................     2

                               WITNESSES

Dr. Erica Scavella, MD, Assistant Undersecretary for Health for 
  Clinical Services, Veterans Health Administration, U.S. 
  Department of Veterans Affairs.................................     4

        Accompanied by:

    Dr. Todd Burnett, Psy.D., Senior Consultant for Operations, 
        Suicide Prevention Program, Veterans Health 
        Administration, U.S. Department of Veterans Affairs

Ms. Missy Meyer, Director of Community Integration, America's 
  Warrior Partnership............................................     6

Mr. Ken Falke, Chairman/Founder, Boulder Crest Foundation........     7

Ms. Joyce King, Project Director, SSG Fox Veterans Suicide 
  Prevention Program, Sheppard Pratt.............................     9

                                APPENDIX
                    Prepared Statements Of Witnesses

Dr. Erica Scavella, MD, Prepared Statement.......................    31
Ms. Missy Meyer Prepared Statement...............................    35
Mr. Ken Falke Prepared Statement.................................    38
Ms. Joyce King Prepared Statement................................    45

                       Statements For The Record

Swords to Plowshares.............................................    49
Wounded Warrior Project..........................................    53
D'Aniello Institute for Veterans and Military Families (IVMF) at 
  Syracuse University............................................    54

 
       SSG FOX SUICIDE PREVENTION GRANTS: SAVING VETERANS' LIVES
                      THROUGH COMMUNITY CONNECTION

                              ----------                              


                       TUESDAY, DECEMBER 12, 2023

             U.S. House of Representatives,
                            Subcommittee on Health,
                            Committee on Veterans' Affairs,
                                                   Washington, D.C.
    The subcommittee met, pursuant to notice, at 10:31 a.m., in 
room 360, Cannon House Office Building, Hon. Mariannette 
Miller-Meeks [chairwoman of the subcommittee] presiding.
    Present: Representatives Miller-Meeks, Radewagen, Bergman, 
Murphy, Van Orden, Luttrell, Kiggans, Brownley, Deluzio, and 
Landsman.

   OPENING STATEMENT OF MARIANNETTE MILLER-MEEKS, CHAIRWOMAN

    Ms. Miller-Meeks. Good morning. The Subcommittee on Health 
will come to order. It is a sad reality that roughly 17 
veterans, on average, are losing their lives to suicide every 
single day. One death alone from suicide is one too many. It is 
a sobering reality, and the loss of just one veteran has a 
profound ripple effect on their fellow veterans, their 
families, and their communities. Like most of my colleagues 
across this dais, one of my top priorities on this committee is 
to decrease the number of veteran suicides. As we have examined 
this year through multiple hearings, there are many factors 
that come into play when a veteran loses hope. As we have also 
examined, there should be no limits on what we can examine as 
potential solutions.
    As a 24-year Army veteran, I have seen unique challenges 
that many of my fellow Service members and veterans face, both 
in service and as they adjust to living back in their 
communities. It is imperative that we continue to work on 
solutions, such as the Staff Sergeant Parker Gordon Fox Suicide 
Prevention Grant program to give veterans and their family 
members the support that they so desperately need and deserve, 
and that support is available wherever they live.
    Over 60 percent of veterans who died by suicide in 2021 
were not seen in Veterans Health Administration (VHA) in 2020 
or 2021, and over 50 percent had received neither VHA nor 
Veterans Benefits Administration (VBA) services. In order to 
reach all veterans, we must continue to expand our work in the 
community. Fox Grants assist veterans and their families by 
providing veteran based outreach, veteran suicide prevention 
services, connections to the VA, and additional community 
resources, with the focus on reducing the number of veteran 
suicides. Throughout this process, veterans and their families 
are provided assistance on how to connect with VA clinical or 
nonclinical help if eligible.
    According to the VA's just released Annual Suicide 
Prevention Report, through June 2023, grantee organizations 
reached more than 10,000 veterans and their families in need. 
Coordinated assessments by these organizations identified 
approximately 130 imminent risk veterans and resulted in 800 
nonemergency referrals and approximately 1,800 social service 
referrals to address drivers of risk such as homelessness, 
unemployment, income supports, and legal services. These are 
not just numbers; these are veterans' lives.
    The committee recently sent out a request for information 
to grantees of the program and received an overwhelming amount 
of positive feedback. As we look to the future of this grant 
program, I am eager to better understand what can be done to 
address any process challenges and expand on any potential 
opportunities. I would like to thank the VA for their 
commitment in providing aggressive technical assistance to 
grantees through various forums and working groups. The program 
office responsible for implementing this pilot embraced this 
mission, and we look forward to continued dialog with them as 
we move forward.
    Thank you all for being here, and I look forward to hearing 
the perspectives from our witnesses on this important program, 
especially now as we continue to struggle with the stubborn 
suicide rate among veterans. With that, I yield to Ranking 
Member Brownley for her opening statement.

      OPENING STATEMENT OF JULIA BROWNLEY, RANKING MEMBER

    Ms. Brownley. Thank you, Chairwoman Miller-Meeks. Today's 
hearing will focus on one of the most complex topics and 
biggest challenges our subcommittee faces, and that is suicide 
amongst our Nation's veterans. At the outset, if anyone 
listening today is struggling with thoughts of suicide, or if 
you know a veteran or service member who is in crisis, please 
reach out to the Veterans Crisis Line. Simply dial 988 and 
press 1. You can also send a text message to 838255 or go to 
veteranscrisisline.net for an online chat. You will reach 
trained responders who are ready to help.
    Last month, the Department of Veterans Affairs released its 
2023 National Veteran Suicide Prevention Annual Report, which 
provided data on suicide mortality among veterans and 
nonveteran U.S. adults over 2 decades from 2001 through 2021. 
Sadly, the overall number of suicides among veterans rose 
between 2020 and 2021. Women veterans were among the most 
heavily impacted subpopulations in 2021, as there was a 24.1 
percent increase in the age adjusted suicide rate for women 
veterans, compared to 6.3 percent among male veterans.
    Any life lost to suicide is a tragedy, and this committee 
continues to examine all possible suicide prevention strategies 
and ways to increase veterans' access to quality mental 
healthcare. Over the past several years, Congress has passed 
more than 40 veterans mental health bills through standalone 
and omnibus legislation. These include the Commander John Scott 
Hannon Veterans Mental Health Care Improvement Act, the 
Veterans Comprehensive Prevention, Access to Care and Treatment 
(COMPACT) Act, and the Support the Resiliency of our Nation's 
Great Veterans (STRONG) Act. These bills contained dozens of 
provisions that aim to increase veterans' access to mental 
health care, strengthen VA's suicide prevention programs, 
bolster VA's research and mental health workforce training, 
establish pilots to examine complementary and integrative 
approaches, and improve the transition from active duty to 
veteran status.
    One such pilot program was the Staff Sergeant Parker Gordon 
Fox Suicide Prevention Grant Program. It was created in 2020 
under the Hannon Act. It took some time for VA to stand up this 
program and publish the necessary regulations. In September 
2022, VA awarded the first round of grants to 80 organizations 
in 43 states, the District of Columbia, and American Samoa. The 
second round of grants was awarded about 3 months ago, with 77 
of the original grantees receiving grants again, along with 
three new grantees. These are now grantees in 43 states, 
Washington, DC, Guam, and American Samoa.
    The goal of the Fox Grant Program is not to expand access 
to direct clinical care, rather it is to partner with 
organizations that provide services to address some of the 
upstream factors that can contribute to veteran suicide risk. 
Such factors include housing instability, employment 
instability, legal trouble, lack of social support and 
engagement, and unstable interpersonal relationships. The 
primary population Congress aims to reach through the Fox Grant 
program is the approximately 60 percent of veterans dying by 
suicide each year who have had no recent engagement with VA 
healthcare.
    I hope to hear more today about how grantees are putting 
Fox Grant funds to use, and hopefully we will hear some success 
stories about veterans whose lives may have been saved by this 
program. I will acknowledge that it will be some time before 
the potential benefits of this program will show up in VA's 
annual suicide prevention report, as each report published 
reflects data from 2 years earlier. However, before we consider 
reauthorizing the Fox Grant Program, the subcommittee needs to 
know more about the impact that the funds have had and see some 
clear measures of success.
    In accordance with the Hannon Act, within 18 months of 
awarding the first Fox grants, that is, by March 19, 2024, VA 
is required to provide an interim report to the House and 
Senate Veterans Committees about the effectiveness of the Fox 
Grant Program. Perhaps today's hearing can provide a preview of 
VA's findings. I look forward to a robust discussion.
    Madam Chairwoman, before I yield back, I wanted to take a 
moment to recognize the service of the Republican Staff 
Director of the Health Subcommittee, Ms. Christine Hill, who I 
understand will be retiring soon. Back in early 2020, about 6 
weeks before the pandemic, Christine and I had an opportunity 
to travel with several other committee Staff to South Dakota 
and North Dakota, where we visited the Cheyenne River Sioux 
Indian Reservation and Standing Rock Sioux Indian Reservation. 
We had a lot of fun and learned a lot.
    We learned a lot on the trip about veterans' barriers to 
healthcare, housing, and transportation, and we also got to 
know each other a little better as we traversed several hundred 
miles through Indian country. Counting her 20 years in the Air 
Force after graduating from the academy, some time working in 
the Senate and at the VA, and most recently, her 10 years with 
the committee, Christine has spent over 36 of her career in 
Federal service. We are sorry to lose her wealth of experience 
and institutional knowledge, but Christine, your retirement is 
very well deserved, and I wish you all the very best in your 
third chapter. Thank you for your service to your fellow 
veterans and to our Nation. With that, Chairwoman Miller-Meeks, 
I yield back.
    Ms. Miller-Meeks. Thank you, Ranking Member Brownley. I am 
going to say ditto and save any comments for later. I would 
like to introduce our witnesses on our panel today. Joining us 
today Dr. Erica Scavella, Assistant Under Secretary for Health 
and Clinical Services, Department of Veterans Affairs, Todd 
Burnett, Senior Consultant for Operations, Suicide Prevention, 
Department of Veterans Affairs, Psy.D. in Psychology, Missy 
Meyer, Director of Community Integration, American Warriors 
Partnership, Ken Falke, Chairman/Founder, Boulder Crest 
Foundation, and Joyce King, Project Director, Staff Sergeant 
Fox Veteran Suicide Prevention Program, Sheppard Pratt. Dr. 
Scavella, you are now recognized for 5 minutes to deliver your 
opening statement on the VA.

                  STATEMENT OF ERICA SCAVELLA

    Dr. Scavella. Thank you. Good morning, Chairwoman Miller-
Meeks, Ranking Member Brownley, and distinguished members of 
the subcommittee. Thank you for the opportunity today to 
discuss the Staff Sergeant Parker Gordon Fox Suicide Prevention 
Grant Program. Accompanying me today is Dr. Todd Burnett, our 
senior consultant for operations within the Suicide Prevention 
Program.
    The grant program honors veteran SSG Parker Gordon Fox, who 
served in the Army and joined the Army in 2014. Unfortunately, 
he died by suicide in July 2021--2020, excuse me. The grant 
program, authorized by Section 201 of the Hannon Act, 
represents an important step in leveraging community networks 
and expertise in veteran suicide prevention efforts beyond what 
we can do within VA. The grant program complements VA's 10-year 
national strategy for preventing veteran suicide. It supports 
and aligns with the priority goals and the White House's 
strategy for reducing military and veteran suicide.
    Given the multiple factors that may lead to suicide death, 
preventing suicide requires a comprehensive public health 
approach. What this means in practical terms is that VA must 
harness the full breadth of the Federal Government in close 
partnership with States, Territories, Tribes, and local 
governments, as well as collaboration with industry, academia, 
communities, community-based organizations, families, and 
individuals to prevent veteran suicide.
    I am proud to report that the grant program is providing 
resources toward community-based prevention efforts to meet the 
needs of veterans, their families, and other eligible 
individuals through outreach, suicide prevention services, and 
connection to VA and community resources.
    The impact of this program has been meaningful. I would 
like to share two stories that illustrate just how this program 
has affected those who have sacrificed for our Nation. The 
first is a young woman who was pregnant, she was a veteran, and 
she fled from a domestic violence situation and engaged a 
grantee for services. She was enrolled in prenatal care and 
other healthcare supports at VA. She is quoted as saying, ``I 
could not have survived without your help.''
    Another example is a Marine Corps veteran who presented to 
a grantee with suicidal thoughts seeking help for combat 
related trauma. After getting linked to help, he confided that 
he had been engaged in steps toward ending his own life, and 
had he not contacted the grantee, that would have happened. He 
says that the services saved his life.
    VA has collected and received many more examples like 
these. These engagements within grantee communities are 
critical interventions needed across the Nation to prevent 
veteran suicide. As of October 31, 2023, grantees have 
completed approximately 20,000 outreach contacts and engaged 
over 3,500 participants. The grant program facilitates 
engagement within clinical mental health care, but it is unique 
in that most services that are provided are actually not 
clinical.
    As the Nation continues to recognize, as we as physicians 
recognize, as we as healthcare community recognize, research 
evidence confirms that the social determinants of health are 
drivers of suicide risk. The grant program takes a bold step to 
acknowledge and meet the need for suicide prevention 
interventions outside of clinical care. The grant program is 
proudly in its second year. Beyond the formal evaluation 
process, we are implementing solutions for lessons learned in 
real time to improve the grantee and participant experience.
    Just last week, VA convened its fourth two-day technical 
assistance meeting in Orlando, Florida, with over 150 grantee 
representatives present. Attendees received tailored technical 
assistance as well as the opportunities to connect with grantee 
peers.
    In conclusion, we are grateful for the enactment of the 
Hannon Act and other laws that have helped to fuel advancement 
in veteran suicide prevention. The grant program is one tool 
that VA has rolled out in its public health approach to veteran 
suicide prevention. We need everyone at the table. We need 
everyone working in the same direction. This requires both 
moving away from the belief that suicide prevention rests 
solely on the shoulders of our mental health providers and 
moves us further toward engaging within and outside of clinical 
healthcare organizations and delivery systems to decrease both 
the individual and societal risks of suicide.
    Suicide is preventable, and each of us has a role to play. 
This is our mission, and we are so thankful that you are with 
us along this journey. This concludes my testimony. My 
colleague and I are prepared to answer your questions.

    [The Prepared Statement Of Erica Scavella Appears In The 
Appendix]

    Ms. Miller-Meeks. Thank you, Dr. Scavella. Ms. Meyer, you 
are now recognized for 5 minutes to deliver your opening 
statement.

                    STATEMENT OF MISSY MEYER

    Ms. Meyer. Chairwoman Miller-Meeks, Ranking Member 
Brownley, members of the subcommittee, thank you so much for 
your invitation to testify today regarding the Staff Sergeant 
Parker Gordon Fox Suicide Prevention Grant. America's Warrior 
Partnership is a proud recipient of the Fox Grant, and we 
utilize a unique upstream community integration model to 
accomplish the goals set forth by this grant to work with 
communities to prevent suicide.
    I would like to share a story. On November 13, a post-9/11 
Army veteran called our national network with an active plan to 
end his own life. He had moved from Florida--from New York to 
Florida after a divorce, and he was facing bankruptcy. He was 
in crisis. He was not happy with his care he received from the 
VA in New York. He was tired of taking all the pills he said 
that were prescribed for both his Post-Traumatic Stress 
Disorder (PTSD) and bipolar disorders. He had an appointment 
the following morning for a medical evaluation with the Fort 
Myers, VA. This gentleman, we wanted to get a referral for 
mental health the next morning. He was in agreement with that. 
I reached out to the local suicide prevention coordinator there 
in Fort Myers and was unable to get a call back. I left a 
message that we had an actively suicidal veteran that needed 
care and that call has still not been returned. However, we 
were able to connect with the 988 crisis line and get that 
veteran the support that he needs. We are still working with 
him and walking with him for as long as he will let us.
    American Warriors Partnership (AWP) network staff worked 
hard to connect that veteran with the services that he needed 
and we are so thankful for the 988 crisis line being available 
to us. While he states he loved his girlfriend too much to take 
his own life, he certainly needed the support we were able to 
offer.
    Our goal is to improve the quality of life for veterans and 
to end veteran suicide by empowering local communities to serve 
them proactively and holistically before a crisis. In September 
2022, outreach began with the Fox Grant and by March 2023, AWP 
began enrolling Fox participants. Since that time, AWP has 
completed intakes and suicide risk assessments for 1,057 
warriors via the Columbia-Suicide Severity Rating Scale, as 
required by the VA. One hundred eighty-five of those men and 
women indicated some level of suicide risk. This means over 17 
percent of that 1,057 had some level of suicidal ideation.
    Once AWP knows a veteran or service member is experiencing 
some level of suicidality, we must find them local and national 
resources. In an acute suicidal crisis, as I said, that results 
in a call to the crisis line and a referral to other local 
counseling centers. However, there is no expedited care for Fox 
participants. There is no special number or special 
intervention to serve those people immediately. This is one of 
the major shortcomings of the Fox program. There is no program. 
It is a transaction. It needs to be relational, not a VA 
sponsored phone call for assessments with no plan or 
infrastructure on the backend connecting to services. The Fox 
Grant Program needs to have follow up available for veterans in 
need and making sure that that infrastructure is in place and 
not having veterans disclosing these thoughts with no services 
available to them.
    Following the intake and suicide risk assessment, we create 
a holistic service plan. If the veteran is willing, we conduct 
additional assessments for the participant. There are nine 
different assessments and questionnaires required for the 
participant to be enrolled. Several assessments have ended with 
an additional call to the 988 crisis line. Once the participant 
has received referrals and has been connected to support, we 
are required to then readminister the baseline assessments. We 
have only had 6 of our 180 Fox participants complete that 
entire process, and both Staff and veterans describe the 
assessments as both repetitive and exhausting.
    To eliminate redundancy, the psychosocial, Interpersonal 
Support Evaluation List-12 (ISEL-12), and General Self-Efficacy 
(GSE) assessments could be removed or combined and shortened 
with other assessments. We already know that depression, 
isolation, and financial hardships are risks for suicide. How 
does continually assessing known stressors better our 
prevention model?
    In addition, the amount of data gathered is significant. 
AWP has submitted thousands of forms to account for outreach 
efforts and Fox Grant requirements, necessitating the hiring of 
additional administrative staff to handle the load. We are in 
year two of the grant's lifecycle, and the data collection tool 
was made available to AWP just yesterday. We have not tested 
that system to see how it will work from here on.
    Finally, there is no clear measure of success for the Fox 
Program. Is it a number or an outcome? Does success come with 
potential increase in funding, and are those organizations 
unable to meet their metrics held to account, removed, or 
reduced? There is no bigger picture on how all this data will 
impact VA policy to improve the lives of our veterans. Thank 
you, subcommittee members, for the opportunity to testify 
today.

    [The Prepared Statement Of Missy Meyer Appears In The 
Appendix]

    Ms. Miller-Meeks. Thank you, Ms. Meyer. Mr. Falke, you are 
now recognized for 5 minutes to deliver your opening statement.

                     STATEMENT OF KEN FALKE

    Mr. Falke. Good morning. I want to begin by thanking this 
committee for its essential and hugely impactful work on behalf 
of our Nation's veterans and their families. Chairwoman Miller-
Meeks and Ranking Member Brownley, thank you for your 
leadership and the opportunity to speak to the subcommittee 
regarding the Staff Sergeant Fox Suicide Prevention Grant 
Program. I also want to thank Representatives Bergman and 
Houlahan, who as veterans themselves took the lead on the 
creation of this legislation with the assistance of so many 
others.
    I served in the U.S. Navy for 21 years as a Special 
Operations bomb disposal specialist. Since my retirement in 
2002, I have become an advocate for my brothers and sisters. A 
major driver of my work is the nearly unspeakable truth that 
since 9/11, we have lost more members of the bomb disposal 
community to suicide than we did on the battlefields. This 
truth is nearly unspeakable because the work that my community 
does on the battlefield is considered to be the world's most 
dangerous job. Sadly, this epidemic is not limited to the bomb 
disposal community.
    In response to these challenges, my wife Julia and I 
founded two nonprofit organizations, the Explosive Ordnance 
Disposal (EOD) Warrior Foundation in 2004 and Boulder Crest 
Foundation in 2010. Since then, our organizations have served 
over 100,000 program participants. Boulder Crest Virginia is 
the Nation's first privately funded wellness center dedicated 
to combat veterans and their families. Our vision was to create 
a place and programs where combat veterans could transform 
their struggles into strength and growth.
    Broadly speaking, our Nation's mental health system is not 
focused on accomplishing this goal. The mental health system is 
nearly exclusively focused on one thing when it comes to 
clients and patients, and that is managing and mitigating 
symptoms associated with times of struggle, often through a 
combination of medication and talk therapy. This approach is 
not working for far too many people, something made evident by 
the highly distressing statistics around veterans mental health 
and suicide.
    In 1995, Dr. Richard Tedeschi coined a term posttraumatic 
growth to describe how people reported growth in areas of their 
lives in the aftermath of traumatic events. In 2014, we 
partnered with Dr. Tedeschi in the development and delivery of 
our Warrior Progressive and Alternative Training for Helping 
Heroes (PATHH) program. Warrior PATHH is the first training 
program ever designed to enable our Nation's combat veterans to 
transform deep struggle into profound strength and lifelong 
post-traumatic growth. It is a 90-day program, 
nonpharmacological, peer delivered, and delivered at nine 
permanent locations in the United States and through two mobile 
training teams for a total of 11 Warrior PATHH programs per 
month. In short, we have developed a program that achieved the 
vision set forth to ensure that veterans could be as productive 
at home as they were on the battlefield and live extraordinary 
lives filled with passion, purpose, growth, connection, and 
service.
    In 2022, Boulder Crest was one of the 80 organizations 
awarded a grant from Staff Sergeant Fox Suicide Prevention 
Program. Our grant's for $725,000, which only covers the 
delivery of 12 Warrior PATHHs and the administration and 
reporting functions required by the grant. Boulder Crest and 
our partners have delivered over 465 Warrior PATHH programs to 
over 3,000 students. Across the more than 10 clinically 
validated measurement tools that we use to measure the impact 
of Warrior PATHH to include those required by the Fox Grant 
program, participants report experiencing symptom reduction and 
improved growth more than any other program.
    The establishment of the SSG Fox Grant Program is a 
realization of something I have long believed was necessary and 
that is a true public-private partnership based on the goals of 
ensuring at-risk veterans do not fall through the cracks and 
the identification of innovative and effective programs that 
are effectively and sustainably addressing the suicide epidemic 
amongst veterans.
    In light of the ongoing conversations with the VA and the 
data from the VA funded Warrior PATHH participants, we propose 
five key recommendations to enhance the program. The first one 
is to remove the funding caps. Today, only 24 of the 132 
annually delivered Warrior PATHH programs are funded under this 
grant. Revise the eligibility criteria. We need to rethink the 
use of the Columbia-Suicide Scale, primarily because we often 
see the Patient Health Questionnarire-9 (PHQ-9), which is a 
depression scale, scores out of sync with the Columbia scale. 
As you know, depression is a leading cause of suicide.
    We need to broaden the veteran eligibility. My personal 
belief is that all veterans should be eligible for this 
program, regardless of the score on a test that is only taken 
for one day. Number four, we need to include traumatic brain 
injury (TBI) centers. We need to expand the eligibility to 
include leading privately funded clinical TBI centers. TBI is a 
significant risk for veteran suicide and needs to be treated 
clinically.
    Finally, we believe that we need to expand the 
collaborative partnership between the VA. We believe that the 
more people that understand post traumatic growth, the better 
chance they will learn to thrive in the aftermath of trauma and 
help others do so. I believe these steps are vital to our 
united mission to support our veterans' well-being and reduce 
the veteran suicide epidemic. My team and I are committed to 
being active contributing partners in this mission. I am deeply 
thankful for the opportunity to address you today and look 
forward to any questions.

    [The Prepared Statement Of Ken Falke Appears In The 
Appendix]

    Ms. Miller-Meeks. Thank you, Mr. Falke. Ms. King, you are 
now recognized for 5 minutes to deliver your opening statement.

                    STATEMENT OF JOYCE KING

    Ms. King. I would like to begin by thanking the committee 
for this transformational work on behalf of our Nation's 
veterans and their families. I applaud Chairwoman Miller-Meeks 
and Ranking Chair Member Brownley for their leadership, and I 
greatly appreciate the opportunity to speak to the subcommittee 
regarding the Staff Sergeant Fox Suicide Prevention Grant 
Program.
    My name is Joyce King. I serve as the director of the Staff 
Sergeant Fox Suicide Prevention Grant Program at Sheppard 
Pratt. I am a board-certified mental health therapist and 
substance abuse counselor as well as a 16-year Air Force 
veteran with more than 25 years of mental health, substance 
use, and social services experience. Sheppard Pratt is the 
Nation's largest private, nonprofit provider of mental health, 
substance use, developmental disability, special education, and 
social services in the country. We provide specialized services 
for veterans, including supportive services for veteran 
families, SSVF, Homeless Veteran Reintegration program, HVRP, 
and clinically intensive grant per diem transitional housing. 
Many of these programs are funded by the U.S. Department of 
Veterans Affairs.
    Collectively, Sheppard Pratt's veteran services assists 
approximately 1,200 homeless veterans every year in urban, 
rural, and suburban communities across Maryland and in select 
counties in West Virginia. Many of our staff are veterans, 
including some staffs who were previous clients. The dedication 
and commitment of our team drives our impact. We have helped 
over 5,235 homeless veteran and veterans' families to obtain 
permanent housing. Our HVRP program helps homeless veterans to 
obtain employment with an average wage of just under $20 an 
hour.
    In 2022, the VA released a Staff Sergeant Fox Grant notice 
of funding opportunity. Its deep focus on community connection, 
well-being, and suicide prevention responded to a clear gap in 
the community-based services for veterans. Accordingly, we 
jumped at the opportunity to better serve our veteran 
community. The application process was well organized and 
transparent with significant flexibility and approach provided 
by the VA. The staff of the VA deserve credit for designing and 
implementing a disciplined, efficient application process.
    Sheppard Pratt was honored to be awarded the Staff Sergeant 
Fox Grant in September 2022. Our implementation strategy 
combines a comprehensive and holistic strategy set selected 
based on the best available evidence for the greatest potential 
to prevent suicide among veterans across Maryland. We leverage 
current programming in relationships with veterans that are 
high risk yet disengaged with the VA in mental health care. 
Peer support is a critical component of our Staff Sergeant Fox 
implementation strategy. Through this new funding, we have 
trained veterans with lived experiences related to suicide and 
mental health.
    Our peer support specialists work directly with the 
veterans and their families to promote connectedness, provide 
holistic case management, and reduce risk factors associated 
with suicide. In addition, case managers help veterans with a 
range of health, housing, employment, and other needs. As the 
Staff Sergeant Fox Grant Program was only recently launched, 
our data is preliminary, but suggestive. During enrollment, 95 
percent of our veteran clients indicate a need for mental 
health services, 75 require connection or reconnection to the 
VA services and supports, 65 percent report benefits 
challenges, 60 percent request peer support and connection, and 
another 60 percent report health, housing, employment, and 
other challenges best addressed through case management.
    The need, therefore, is clear. The impact of the Staff 
Sergeant Fox Grant Program is best demonstrated through 
stories. I would like to share a story of one of the 
participants. I will call her Alice. Alice's story illustrates 
the power of the Staff Sergeant Fox Grant Program as well as 
the way in which community-based veteran services, including 
SSVF and HVRP, combine to prevent suicide and promote well-
being more generally. Alice is a 48-year-old single veteran, 
single female Navy veteran with a history of post-traumatic 
stress disorder and traumatic brain injury.
    Alice recently experienced two traumatic events. In 2022, 
she was laid off. To make ends meet, she moved in with her 
sister. In 2023, her sister passed away unexpectedly. With the 
loss of both her job and her sister, she fell behind on her 
rent. She had to make a choice between paying her rent or 
buying food. In September 2023, she called Sheppard Pratt. Our 
Staff Sergeant Fox Program team collaborated with SSVF to help 
Alice find a more affordable housing option. To help Alice gain 
employment, our Staff Sergeant Fox and HVRP teams worked 
together to provide Alice with both a computer and 
technological training. Alice dedicated herself to her job 
search. Within a month of her calling Sheppard Pratt, she had a 
new job in the IT field.
    While Alice was working to obtain a new job and housing, 
she was simultaneously grieving the loss of her sister. The 
Staff Sergeant Fox peer support specialists were instrumental 
in modeling healthy and effective coping strategies. Today, 
Alice is working, living stably in safe housing and in a 
healthy home. She shared the impact of Staff Sergeant Fox in 
her exit survey. ``I can say for sure that the program and all 
of the team went above and beyond my expectation. I honestly 
never felt like I was alone during the process. In fact, the 
opposite almost. I literally felt like a team was assigned to 
me for different stages and aspects. I could not be more 
grateful.''
    Alice's comments about the Staff Sergeant Fox program are 
echoed by other participants. John Woodard, a former Marine, 
similarly was struggling with PTSD, a job loss, and eviction 
when he connected with the Staff Sergeant Fox program. John 
tells his story better than I can. He said, ``Sheppard's 
veteran services got me and my family out of a situation that I 
was in before where I was not appreciated and was not being 
supported for my mental illness. Now I am in a better location 
with my family, with a peaceful mind instead of a crime 
infested area where I could hardly sleep because of fear and 
hyper vigilance. I would like to thank the veteran services 
programs for coming to my rescue. I have been using this time 
to heal and to get help with my PTSD.''

    [The Prepared Statement Of Joyce King Appears In The 
Appendix]

    Ms. Miller-Meeks. Thank you, Mrs. King. We appreciate your 
testimony. We will now proceed to questioning. I will defer my 
questions to the end. I now recognize Ranking Member Brownley 
for any questions she may have.
    Ms. Brownley. Thank you, Madam Chair. Dr. Scavella, I 
wanted to ask you with regards to metrics and what the VA uses 
as metrics to measure the success of these grants.
    Dr. Scavella. Thank you for the question, Ms. Brownley. As 
you heard from our fellow witnesses, there are a number of 
metrics that we do use to assess how our veterans are doing. 
There are some that are required, some that are taking place 
later on in the process. I am going to ask Dr. Burnett to add 
the details on which ones are required at the beginning and 
which ones we conduct during the course of the care.
    Dr. Burnett. Thank you. There are three primary areas that 
we use to evaluate success of this program, the first being 
reduction in suicide risk factors. The second, of course, being 
perceptions of well-being. Hannon 201 requires that we make 
assessments not only of immediate suicide risk, but also 
overall well being to push the interventions as upstream as 
possible to prevent the escalation of people who are feeling 
suicidal. Third, is the connection to veterans who are most at 
risk and currently unconnected to services.
    Ms. Brownley. Certainly the first one is important. All 
three are important. In my opinion, the two and three are a 
little bit harder to actually assess and put into a metric. 
What about, I mean, one of the other objectives of this grant 
program is helping veterans who are not enrolled to enroll in 
VA healthcare. Is that something that you measure? Also, one of 
the other objectives of the program was to reach out to the 
approximately 60 percent of veterans who have had no connection 
to the VA at all. Are those metrics that you will be 
collecting?
    Dr. Burnett. Yes. We will provide information on both of 
those things to you in the interim report that is coming to you 
in the spring.
    Ms. Brownley. Okay. Can you speak to in the VA's testimony, 
they talked about the number of organizations and the amount of 
money that has been awarded so far. If you break that down on a 
per veteran basis, it is pretty expensive. Do you have any way 
to explain why the cost per veteran of this grant program seems 
to be so high?
    Dr. Burnett. Thank you for that question. It is not 
unexpected in the first year of this pilot program, as these 
grantees are establishing their services. The first half of 
last year, they were really getting their programs up. They 
were not required to begin seeing veterans until January 2023. 
What you have seen is that trend increase pretty dramatically. 
As of December, for example, we had approximately 100 veterans 
that were participating in the program, and by October 31, we 
had 3,500. You had just around 120 outreach events in December, 
and that reached 20,000 by the end of the year. We expect that 
trajectory to continue into the second year here. That does 
help give some context to why that cost was so disproportionate 
at the beginning of the year as they ramped services.
    Ms. Brownley. Thank you. Mr. Falke, I think in your 
testimony, I think it was you who mentioned that it does not 
cover all the costs. Am I quoting you correctly?
    Mr. Falke. I think in my written testimony, I talked about 
the cost. The Warrior PATHH program, it is a cohort-based 
program of eight veterans per program, and we deliver 11 of 
those programs a month. Only two of them are funded.
    Ms. Brownley. Two of them?
    Mr. Falke. Two of them are funded by the grant. The rest of 
it is all funded philanthropically through private donations. I 
would love to see it expand and cover all of them, you know, 
assuming that Warrior PATHH is, in fact, identified by the VA 
as one of the critical programs to solve this problem.
    Ms. Brownley. Thank you for that. I want to thank all the 
grantees who are here for the work that you do for our Nation's 
veterans. We appreciate it very, very much.
    I wanted to also ask, as I mentioned in my opening 
statement, that the age adjusted suicide rate among women 
veterans has increased significantly in 2021. If any of the 
grantees can speak to that and wondering if any of your 
organizations are specifically targeting programming toward 
women veterans.
    Mr. Falke. We run, our Warrior PATHH programs are run as 
male and female cohorts. Initially, we were doing, if you take 
Boulder Crest Virginia, we were running 12 programs a year, two 
of those were for women veterans, 10 for male, which is a 
little disproportionate to the amount of women who serve versus 
men. I think it is 90/10, and we were doing 80/20.
    In the last 3 years, we have had to increase the number of 
female programs because of the demand. That is kind of how we 
respond as a small nonprofit is based on the demand. We will 
transform one of the male cohorts into a female cohort. With 
the network we have created around the United States, 11 
programs now delivering it, we are at about 27 percent of the 
veterans who go through our program is female.
    Ms. Brownley. I know my time is up, but I would love to 
follow up with you and talk in greater detail about some of the 
differences between men, women, et cetera. It seems that there 
is a lot of good information in there. Thank you. I yield back.
    Ms. Miller-Meeks. Thank you Ranking Member Brownley. The 
chair now recognizes Representative Bergman for 5 minutes.
    Mr. Bergman. Thank you, Madam Chair. You know, when you 
turn on the evening news, they start with good evening, and 
then for the next 27 minutes, they tell you why it is not. Then 
for the last 3 minutes, they give you good feeling stories so 
to come back and take the abuse the next night.
    We are going to flip that on its backside. A couple of 
years back, Chairman Bost and I had the honor of visiting 
Boulder Crest Virginia. We are grateful, Mr. Falke, for your 
selfless efforts to serve so many in the mil vet community. 
Twenty-two years naval service, followed by the creation of two 
nonprofits that have served more than 100,000 folks is an 
incredible achievement and one you should be proud of.
    What we saw at Boulder Crest was, quite simply, visionary. 
In your testimony, you mentioned that traditional mental health 
is focused on one thing only, ``managing and mitigating the 
symptoms associated with times of struggle often through a 
combination of medication and talk therapy.'' If I were to 
appoint you as the new mental health tsar at VA, do you think 
you could spend that $16.5 billion in a more focused manner? I 
know you stated a lot of it in your comments, but if there are 
a couple of things you would like to share with us here, 
because we are still in the good news phase of my 5 minutes.
    Mr. Falke. Do you have any harder questions, sir? I served 
in the Navy 21 years. I was in the government contracting 
business for 10. I have been through this contracting process. 
I will say hands down, this VA process has probably been the 
smoothest thing I have ever seen. I am not just saying that 
because I am here. It has really been a great process, how the 
grant was rolled out, how the outreach programs work, the 
partnerships in Orlando.
    You are right. I think, you know, I tell people all the 
time, I have raised $200 million in the last 20 years for 
veteran causes, nearly $200 million. I have been shot at. I 
have disarmed bombs in the middle of the night. I have jumped 
out of airplanes, been diving in deep, dark waters. There is 
nothing harder than raising money.
    One of my frustrations with the VA, and I have been fairly 
outspoken, three of the last four secretaries have been to 
Boulder Crest Virginia. Bob McDonald is on our honorary board. 
One of the problems that I have seen, and we were instrumental, 
I think, in part of the lobbying efforts around this grant, is 
that there is not real good community partnerships, and there 
does not seem to be a sense of urgency that I saw in the 
Pentagon.
    Mr. Bergman. I am going to cut you right there.
    Mr. Falke. Yes, sir.
    Mr. Bergman. You just made the key phrase that in my 7 
years here on Veterans' Affairs, the idea of when--by the way, 
thank you. We have had countless testimonies here where we have 
asked the VA, how will you get a sense of urgency behind your 
efforts? You know, Dr. Scavella, there is growing frustration 
on both sides of the aisle because the news does not get 
better. We are still, even though we may have a dip from year 
to year, the overall rise is still unacceptable.
    Put bleakly, over $150 billion has been spent since 9/11 on 
this issue. When you look at the ratio of suicide in the 
community, it has only gone up, never down. In fact, in 
comparison to the general population, it only continues to get 
worse, not better despite significant resources spent.
    You know, in the 116th Congress, I, along with some of my 
colleagues, worked very hard because we had grown frustrated 
with the VA's lack of progress over time on this. Could you 
outline the VA's specific objectives to reduce veteran suicide 
over the next 5 years going forward, ideally broken down by 
year? What achievable metrics will you use to measure success? 
You have only got 20 seconds to do that. If you would like to 
take it for the record, I would really like to see a timeline, 
however you want to put it, because no results is just that, no 
results. We need to put the money where we are going to get the 
results for our veterans. With that, I yield back.
    Madam Chairwoman, may I have 30 seconds to say that to our 
Christine, you know, in naval terms, you have served honorably 
and fair winds and following seas we will see in the future.
    Ms. Miller-Meeks. So recognized. Is that it is better to 
ask for forgiveness than ask for permission? Dr. Scavella, if 
you will, please follow up with the question from 
Representative Bergman and send in that response, which would 
have taken much longer than 20 seconds. I, too, would like to 
see that data. If you could submit that in writing to the 
subcommittee, that would be greatly appreciated. The chair now 
recognizes representative Deluzio for 5 minutes.
    Mr. Deluzio. Thank you, Madam Chair, and good morning, 
everyone, and thank you for your commitment to helping solve a 
crisis in our veterans community.
    Dr. Burnett, I will start with you to follow up a bit on 
what Ranking Member Brownley was asking about the report that 
this committee and our counterparts in the Senate will see. 
What is most useful from where I sit is understanding are 
grantees effective and are they effective relative to VA? On 
the cost question, I heard you answer part that, you know, is 
this a cost effective, are we seeing cost effective performance 
again relative to VA? My first question on reducing suicide 
risk factors, do you plan to report to us that success or 
failure relative to how VA is doing here?
    Dr. Burnett. Preliminary indications are very good. 73 
percent of the people who have started and completed this 
program have seen an improvement in well-being or reported an 
improvement in well-being, which is a good first year start for 
this.
    Mr. Deluzio. Let me dig in a bit there then. Do you have 
that same data and have that same metric for those who are 
seeing care within the VA? Will you be reporting that data 
about grantees and/or VA to us in the report?
    Dr. Burnett. Keep in mind, many of these, so 80 percent----
    Mr. Deluzio. Some are not eligible.
    Dr. Burnett. Well, so you have 7,000 support 
recommendations or referrals that were submitted. Almost half 
of those are for nonemergency mental health care and 80 percent 
of those are coming to VA for services. When you look at 
emergency services, so when they are screened, as we talked 
about the screeners earlier, more than 300 are identified at 
the time of that screening as being at high immediate risk. 78 
percent of those are going to the VA or vet centers for care. 
About 22 percent are going to the community or other 
organizations. We can provide you with that information.
    Mr. Deluzio. You get the thrust of what I am interested in 
seeing there.
    Dr. Burnett. Yes, of course.
    Mr. Deluzio. Similarly, I heard the explanation on some of 
the high costs----
    Dr. Burnett. Yes.
    Mr. Deluzio [continuing]. per veteran. It will still be 
useful from where I sit to see how the financial performance is 
relative to what, you know, a similar cost per care metric is 
within VA.
    Dr. Burnett. Of course, understood. We evaluate that as a 
part of our business operations process in reviewing all 
grantees.
    Mr. Deluzio. Good. This could be either Dr. Burnett or Dr. 
Scavella, the grant recipient in my district and region, 
Veterans Leadership Program, they run the PA Serves Care 
Coordination Network across the Commonwealth. We say 
Commonwealth in Pennsylvania. They have a good relationship 
with the Pittsburgh VA. I have, you know, seen that 
coordination. I have seen the referrals that pass through both 
directions. I would like to know if VA is assessing and whether 
we have a way to assess whether that is happening elsewhere and 
if you have tools in place or you need different ones to 
encourage that kind of coordination for other grant recipients.
    Dr. Scavella. Yes. Thank you for that question. When our 
veterans are engaging with any of the grantees, they are 
required to try to get them in for services with us. That is 
one way we are doing that structurally as part of the program, 
part of the procedures. As far as data related to how many have 
actually done that and how many are engaged, we can get that 
information, and that is something that we are very interested 
in because we are trying to tackle that 60 percent, you know, 
group of veterans who are not enrolled engaged with us.
    Mr. Deluzio. Yes. I think it is another way for us to 
assess whether this is successful or not is to see that level 
of coordination reported to us. I would encourage you to 
include it as well. Madam Chair, I yield back.
    Ms. Miller-Meeks. Thank you, Representative Deluzio. The 
chair now recognizes Representative Van Orden for 5 minutes.
    Mr. Van Orden. Thank you, Madam Chair. Just to go over a 
couple of numbers here, $16.5 billion requested last year, $150 
billion since 9/11 applied to this problem set, and we have an 
increase in veteran suicide. As an enlisted guy who does not 
have the highfalutin degrees and whatnot, to me that is just 
abject failure. How much of this money have you guys given to 
faith-based programs? I am talking to you, ma'am.
    Dr. Scavella. I am going to defer to my colleague. I do not 
know the answer to that question.
    Mr. Van Orden. Very well. Dr. Burnett.
    Dr. Burnett. Nineteen percent of our current grantees 
report providing are faith-based service offerings, sir.
    Mr. Van Orden. Okay. I would like a list of those, please.
    Dr. Burnett. Mm-hmm.
    Mr. Van Orden. Are you familiar with the program called 
Mighty Oaks Foundation?
    Dr. Burnett. Yes, sir.
    Mr. Van Orden. Do you know what their success rate is?
    Dr. Burnett. Not off the top of my head.
    Mr. Van Orden. They have treated approximately 5,000 
veterans, two of which have committed suicide. That smokes any 
of your programs you got going on. I have some very basic 
questions here. You guys are failing. I am not going to 
sugarcoat anything. You are failing. You are failing my 
brothers and sisters. The master chief is not. Ms. King, you 
are not. Ma'am, sorry, I took my glasses off. I cannot read 
your name right now. Yes, you know who I am talking to. Anyway, 
you guys are doing God's work. I know you guys are trying, but 
you are just not pulling it off at all.
    If I understand this program correctly, you guys are 
failing completely. We are now giving you money to give to 
people that are succeeding. Is that right? I mean, that is what 
this is, right? We are cutting you checks through the 
chairwoman to give you money to give to people whose programs 
are succeeding. Did I miss something? I mean, that is what we 
are doing, right? The very basic question is, why does your 
office exist? It is like an incredibly expensive middleman? 
What can we do differently?
    My colleague Mr. Luttrell has got some language in for 
psychedelic treatments. I do not particularly agree with it 
completely. However, it works. Faith-based programs work. We 
have got to do something different. You have to do something 
fundamentally different because your treatment modalities are 
failing. With Senior Chief Mike Day, I have had 21 of my Navy 
Sea, Air, and Land (SEAL) friends commit suicide to date. I 
will guarantee you there are going to be more.
    This is a statement. You guys need to do something 
different. If that means we hack half your staff and take those 
salaries and benefits and give it to those three people, then 
that is what we need to do. It is not about me. It is not about 
you. It is not about your job. It is not about your career. It 
is not about an agency. It is about saving our brothers' and 
sisters' lives.
    Ms. Meyer, I want to thank you. Master Chief, thank you 
very much. Ms. King, thank you for your efforts. I appreciate 
it. I understand you are trying but it is not working. From our 
previous line of work, that means you got to go. With that I 
yield back.
    Ms. Miller-Meeks. Thank you, Representative Van Orden. The 
chair now recognizes Representative Landsman for 5 minutes.
    Mr. Landsman. Thank you, Madam Chair. Thank you all for 
being here and working on what is one of the most significant 
crises that we face as a country and getting at the question of 
what is working, what is not working, and where we go from 
here. Several members and I, in a bipartisan fashion, kicked 
off last week a What Works Caucus to help us as lawmakers and 
the administration do a better job at ensuring legislation, 
programming is evidence-based, that we are using data to not 
just see what is working, but getting better, continuous 
improvement. This is for everyone across the board. What are we 
measuring now? What are the inputs, outputs that you think are 
most important? What should we be measuring? You know, what is 
the best way forward for us to track this as a committee, 
because getting this right is so hugely important. I will just 
turn it over and maybe go right to left, left to right. In any 
event, what are the most important measures in your mind? Are 
we tracking them? How do we make sure that this committee has 
visibility into that and can be as helpful as possible?
    Dr. Scavella. Yes, thank you for that question. One of the 
main things we are tracking is going to be the looking at the 
number of the suicides. Not only has it risen within the 
Department of Veterans Affairs and our patients, but in the 
community as well. We want to keep track of all those instances 
that have been successfully avoided. We will be documenting and 
reviewing that data, and we will continue to do that.
    Also, you know, we know that this is a complicated problem. 
One of the concerns is that how do we make sure that we are 
looking at things that are not purely clinical? This program 
has been impactful and visionary in the fact that it is not 
only looking at clinical services, but also looking at 
community services, faith-based organizations that are helping 
us, as well as other innovations. That is really where we are 
pushing the needle into territory that is new. That is what I 
would offer. I will turn it over to Dr. Burnett.
    Dr. Burnett. Thank you for that question. Two things in 
particular. Are we reaching the right people, and are we making 
a difference for them? Your question earlier was about how do 
we know we are reaching women veterans, or American Indian, 
Alaskan Native veterans, or veterans 35 to 54? Those are three 
populations that you saw significant increases in the 2021 
report. 23 percent of the participants in this program are 
women, 40 percent are veterans or individuals who are 35 to 54, 
and about 10 percent are American Indian, Alaskan Native, Asian 
American, Pacific Islander, Native Hawaiian veterans.
    More than that, and the information you will see is what is 
the risk at the time that they are coming into this program? 
About 70 percent of each of those groups are coming into these 
programs as identified as being at high risk or moderate risk 
for suicide. Then what is the impact when they leave this 
program? Did we make a difference? Now, I shared with you about 
73 percent of those so far. We are just in our first year, so 
we do not have all the information we are going to have, but 
that is the information we need to be presenting to you and 
making decisions based on what works and how we know it works.
    Mr. Landsman. I have got a minute left, so maybe we could 
circle back or you could submit to the committee what measures 
that you all are using. Maybe you already have done that. I 
just wanted to say, as we think about this, and this may end up 
being something we work on as a committee. In Cincinnati, where 
I am from, we have one of the best children's hospitals in the 
country, and they will tell you that they got to be in the top 
two or three because they focused entirely on this idea of 
getting better, being the best at getting better, and using 
data and continuous improvement to provide the greatest 
possible care. With something so complicated as this, something 
so important as this reducing veteran suicide, I would love to 
see us do more, especially with this grant program, to ensure 
that every dollar is going to the highest impact program 
possible. Thank you. I yield back.
    Ms. Miller-Meeks. Thank you, Representative Landsman. The 
chair now recognizes Representative Luttrell for 5 minutes.
    Mr. Luttrell. Thank you, Madam Chairman. Veteran suicides, 
we have been parked on 6,000-plus veterans for about 20 years 
now. That is a fair assessment, correct? Anybody say yes 
because that is the number. You should be screaming, that one, 
which is 6,000 way too many. Dr. Scavella, you, previous just 
said we are moving into kind of a more innovative approach on 
how to address these things. Now, when people read these 
numbers, they see the number.
    Dr. Scavella. Yes, sir.
    Mr. Luttrell. I am a researcher by trade before I showed up 
to this place. You guys are researchers, too. We know the 
underlying factors. We do. For 20 years, we have known the 
underlying factors. Is that a fair assessment?
    Dr. Scavella. Yes.
    Mr. Luttrell. Why is it 20 years later, we are just now 
moving to an innovative approach? All right. I say this on just 
about every single committee I sit in front of the VA is I 
cannot imagine the rucksack that you are carrying every single 
day. You two sitting right there. It is unforgivable. It is. 
You should be the two people in this room that go to bed every 
night and get up every morning sick to your stomach because we 
have 6,000-plus veterans dying every year. It is not a fun job. 
I understand that.
    You have these three organizations that are pushing the 
envelope as best they can. If they did not exist, imagine what 
those numbers would be. To my colleague to my right here and he 
stated those faith-based and the organizations, they grow. I 
think there are more veteran service organizations in America 
than any other organizations possible, 40,000 or 400,000. It is 
crazy numbers.
    When the VA grants these nonprofits or for profits money, 
does the information that they gather annually come back to the 
VA and does the VA share that with other organizations so they 
can tailor their processes to be similar or to grow? Either one 
of you too.
    Dr. Scavella. Sure. I will start and then I will pass it on 
to Dr. Burnett. One of the important factors with this is that 
we are not being prescriptive to the T for every single 
program. We are allowing the programs to innovate and to set 
forth programs that they think will impact the actual community 
that they are taking care of.
    Mr. Luttrell. Does VA have a portal or an enclave of every 
single one of the facilities that exists? What is the 
turnaround time from a call to the VA hotline to Mr. Falke's 
organization?
    Dr. Scavella. Yes. If someone is calling a hotline, they 
are getting an answer on that call. That is not being called 
back. That is an actual answer. With regards to the reporting, 
our teams are getting regular engagement and information back 
from the organizations that are participating in the program on 
a monthly basis. Then we are also there for any technical 
questions and things like that that may arise. Is there 
anything I have missed, Dr. Burnett?
    Dr. Burnett. No, I think you captured it and I think what 
you are getting at is the foundation of a public health 
approach to suicide prevention, which is a big part of the 
difficulty.
    Mr. Luttrell. The VA should be leading the charge on that. 
You should not be able to walk across the United States and you 
should be able to ask somebody who is leading the charge on 
suicides in America? The first words out of the mouth should be 
the VA. That does not happen.
    Congress, I dare say this committee, subcommittee and 
committee would most likely give you as much rope as you needed 
to go out and take this from 6,000 to zero. I think what we are 
waiting on is for those, you individuals, to come to us and 
say, we hit 6,000 this year. I am going to promise that will 
not be the number next year. I have not heard that yet all 
year.
    Dr. Scavella. I did not hear a question there, but I do 
want to comment on your statement.
    Mr. Luttrell. That was more of a statement----
    Dr. Scavella. Yes.
    Mr. Luttrell [continuing]. but you can respond, if you 
would like.
    Dr. Scavella. I just want to just emphasize that this is 
our top clinical priority, our top priority, period, and that 
we are committed to this work.
    Mr. Luttrell. How long have you been in this position?
    Dr. Scavella. I have been in this position since 2020.
    Mr. Luttrell. Okay.
    Dr. Scavella. 2021, excuse me, sorry. I have been with the 
VA for my entire career as a physician. I have been committed 
to taking care of veterans from the time I became a physician. 
This is very important to us. We have gotten to this place 
because we have looked at the data and seen that despite all of 
our efforts, we do have a large component, 60 percent, who are 
not engaged with VA at all. We are trying to find ways to get 
to them to make sure that we are taking care of them as well.
    Mr. Luttrell. That is a perfect point. I will close with 
this statement but thank you. I do not think we are catching it 
early enough. By the time those broken bodies and brains show 
up to these organizations, the round is downrange. I would like 
to hear, after what the VA working by, with, and through 
Department of Defense (DoD) is doing to catch the members as 
they leave our services so we can get in front of it. 
Statistically, there have got to be numbers out there that say 
these problem sets, these characteristics, these mannerisms, 
will inevitably lead to. We are Artificial Intelligence (AI) 
based. There has got to be a way we can figure this out. I 
would like for a follow up, if we could get those numbers and 
know exactly how the VA is working with the DoD to decrease 
these numbers. I yield back, Madam Chair.
    Ms. Miller-Meeks. Thank you, Representative Luttrell. To 
correct for the record, when I thanked Mrs. Brownley, I meant 
to thank Representative Landsman. Thank you, Representative 
Landsman. I now recognize Dr. Murphy for 5 minutes.
    Mr. Murphy. Thank you, Madam Chairman. Apologize, this is 
one of those ping pong days, as we all know so very well. Thank 
you all for coming. This is an important, obviously, purpose, 
really, of our VA subcommittee. I do not know if there is 
anything necessarily greater, because these lives lost are 
tragedies that are absolutely, in my opinion, preventable.
    I am very fortunate. About a 10th of my district, actually, 
one in 10 constituents, is a veteran. Camp Lejeune, Cherry 
Point, several other places are well within my district. It is 
one of the largest constituencies and the fabric, really, of 
eastern North Carolina. I cherish our veterans, and whenever I 
am ever driving anywhere, if I am stopping off for gas or 
something, I always give somebody a challenge coin because it 
is just a small thing that we can do to always help our 
veterans.
    That said, I feel like we are failing these individuals, 
and I am going to pick up a little bit where Mr. Luttrell 
stepped. If we are not starting this from day one, day one 
being the day before they leave the service, we are failing our 
veterans. I have the Veterans Bridge Home in my district and 
the Bunkham Asheville Buncombe Community Christian Ministry. 
These agencies do a great job. We need to really, in my 
opinion, start this from day one. The fact that we cannot touch 
these folks is a big deal.
    Hyperbaric oxygen is a big deal for me. I think it has 
changed lives. We have had hearings on psychedelic medicine, 
which is innovative and interesting. There are a lot of 
research studies going now on mitochondrial injury, on whether 
how that can produce suicide.
    I just wonder if I could ask, and we theorize a little bit 
as we are encroaching now, literally a wheel formation in 
medicine and in technology with artificial intelligence. Where 
does the VA see that as being able to help our veterans, 
because so many times, I have been a physician now for 35 
years, I am able to buildupon my experience to help take care 
of patients. With AI, we are going to be able to take care to 
use the knowledge base essentially instantaneously of millions, 
if not billions or trillions of experiences. How are we going 
to be able to use that to help prevent veteran suicide?
    Dr. Scavella. Yes. Thank you for that question. As I am 
sure you are aware of, we are in the middle of a tech sprint 
where we are asking companies who have innovations that can 
help us to take care of our veterans, to give those proposals 
to us so that we can put things into place to make changes in 
how we are delivering care. We see artificial intelligence, as 
well as the entire spectrum of those technologies, as 
potentially instrumental and impactful in what we are doing for 
our veterans.
    Mr. Murphy. How does that process look like? What is the 
timeline?
    Dr. Scavella. I am not sure when the tech sprints close, 
when we get all the proposals back, but they are ongoing 
currently.
    Mr. Murphy. Do you expect to have to come back and ask for 
further funding, or is there funding within the VA to do that?
    Dr. Scavella. I cannot answer that question. I would have 
to talk to the finance team about that.
    Mr. Murphy. Okay.
    Dr. Scavella. I am not sure.
    Mr. Murphy. This is a critical issue. Despite the number 
being taken down statistically and really just by 
administrative change, being taken down from the number being 
taken from 22 to 17, it is still the same number. It is still 
the same number. I think it is, you know, a ruse on the 
American people that we all of a sudden dropped five suicide 
deaths per day. That is not really true.
    I applaud you all for what you are doing. This is critical. 
This is the life changing element that not only touches one 
lives, but it touches so many other lives. We cannot get caught 
in the bureaucratic nonsense either of outside the VA or within 
the VA. It is one life at a time. Thank you. With that, Ms. 
Chairman, I will yield back.
    Ms. Miller-Meeks. Thank you, Mr. Murphy. The chair now 
recognizes Representative Kiggans for 5 minutes.
    Ms. Kiggans. Thank you, Madam Chair. Thank you all for all 
your work you are doing here. I do not need to restate some of 
the, just the statistics, and we all say that one veteran 
suicide is too many. I know that many of you mentioned just 
some of the assessments that I think, Ms. Meyer, you mentioned 
that only six of 180 of the assessments were complete.
    Just reading the list of requirements of all the different 
scales and assessments you have to complete, I know we can get 
bogged down in some of these screenings, especially things 
like, I quickly reviewed the Columbia-Suicide Severity Rating 
Scale and can understand it. I am a nurse practitioner at a 
primary care, so really assessing patients mental health, I 
understand the importance of the scales, but there is a job 
that we are trying to do. Getting bogged down in that type of 
scales, it just seems like we have expanded government yet 
again and the requirements for you all.
    There is, I think, a discussion we had about, do we really 
need all of those scales, because, you know, pretty quick, if 
you are dealing with somebody who is in trouble and who is not. 
One of the things that is not listed on these scales that I am 
interested in just from talking to veterans in my district and 
understanding depression and suicide, is, are we ensuring, and 
I guess this is a question maybe for Dr. Scavella or Dr. 
Burnett, but ensuring that we are looking at their med lists 
and what these guys are taking? I know that you talked about 
talk therapy and all the other components and the scales and 
everything else, but there is so much that chemical imbalance, 
and I have seen firsthand time and time again, when we 
administer medication to these patients, and most of them carry 
black box warnings about the risk, increased risk of 
suicidality. I have seen it like, night and day, like flipping 
a switch. I usually would have my patients come back a week or 
two after we start a new medication. Are you feeling better? 
Are you feeling worse? Do we need to change course? Are we 
looking at that, too? Is that one of the assessments that we 
are doing? I do not feel like we have talked about that a lot.
    Dr. Scavella. Yes. Thank you for that question. One of the 
things we do at every visit is medication reconciliation. We 
are looking at the medications they are on. We are also 
questioning whether or not they need to remain on something 
they may have been on for a while. Can we reduce the strength? 
Can we reduce the frequency? Can we discontinue it altogether? 
Those are questions that our clinicians are asking at every 
visit. Looking at potential side effects from medications that 
they are currently taking, yes, that is something that is 
included. We do not just have our clinicians who are involved, 
but we have a group of clinical pharmacists who are also part 
of the care team who are also doing that look to assist our 
clinicians with those assessments and those reviews.
    Ms. Kiggans. Is that being done in some of our other care 
organizations? That the rest of you guys just not leaving out 
that medication component. I have heard even from Special 
Forces guys that say, we got a bag of medications. Their 
spouses would say, we found this bag of drugs. We do not know 
what it is. We do not know what it does, but this was given to 
them by their team doctor. Just making sure we are having those 
frank conversations about what medications you are ingesting. 
Do you know what they are for? Do you know what they are 
called? What side effects they carry. Are we looking at that 
from the other side, too?
    Ms. Meyer. That is not something that we are currently 
assessing. We do not employ any clinical staff.
    Ms. King. As a clinician, that is something that I look at, 
and our staff are trained to look at as well, because it is 
instrumental in determining risk factors associated with 
veteran suicides.
    Ms. Kiggans. How about you, Mr. Falke.
    Mr. Falke. We do look at medication as part of the intake 
summary, and it has been amazing to me. We had a colonel in one 
of our programs, a retired colonel who was on 34 different 
medications. It has been super disappointing to me. I think I 
know how it goes. I am a patient of the VA as well, so I know 
how it goes. You just get one drug after another and you start 
to store them up and take them. We do look at it very closely.
    Ms. Kiggans. In my perfect world, I shorten this assessment 
list that you guys are required, and I would put in a 
medication assessment by a clinical provider who can understand 
those interactions and some of those side effects profiles. 
Thank you for that.
    Let us see also for Dr. Scavella and Dr. Burnett, for just 
continuity of care, I feel like is a really important piece 
that I feel like when we have our initial assessments, it is a 
team effort by some of our other care organizations. Is the VA 
doing a good job with that continuity of care piece, because 
that is where we lose people. We get them either inpatient or 
these initial assessments, but then we lose them. Can you talk 
to me a little bit about what that looks like?
    Dr. Scavella. Yes. Care coordination is really important. 
We reach out both internally and externally when our veterans 
may receive care outside of our actual system to make sure that 
we have all the information, that we can do the proper follow 
up. Also, if it is vice versa, they are leaving us to go 
somewhere else to do the same thing. Is there anything you 
would like to add, Dr. Burnett?
    Ms. Kiggans. Do your other care organizations provide 
continuity of care pieces as long as needed?
    Mr. Falke. One of the things that we have really talked to 
the VA about is how do we get our, most of the people that come 
to us do not go to the VA. What we want to do is make sure that 
they get over there. That is really what we believe. I believe 
that we make our participants better patients. That is one of 
the things that happens, is you lose agency and you start to 
believe things, and that is why you take drugs that maybe you 
do not need. To put a patient who has been through our program 
into the VA with better agency and to be a better patient, I 
think it really creates a win-win for this program because it 
is going both ways.
    Ms. Kiggans. Very much so. It cannot be overstated. I am 
out of time but thank you very much for all that you do.
    Ms. Miller-Meeks. Thank you, Representative Kiggans. The 
chair now recognizes Representative Radewagen for 5 minutes.
    Ms. Radewagen. Thank you, Chairwoman Miller-Meeks and 
Ranking Member Brownley, for holding this hearing today. Thank 
you to all of the witnesses for your testimony. Dr. Scavella, 
how does the VA address organizations that are unable to meet 
established metrics of success within the Fox Grant Program? 
Are there accountability measures in place such as removal or 
reduction of funding?
    Dr. Scavella. I will start and I will pass on to Dr. 
Burnett eventually. We are still early in our process, so we do 
a lot of engagement in the support of the organizations who 
have applied to be part of our program, who are grantees. If we 
see something that is not going quite as expected as planned, 
we want to support those organizations to try to get them into 
compliance, but we do have a regular follow up with them. Dr. 
Burnett?
    Dr. Burnett. Yes. I would echo that. Most of these grantee 
sites are yet to complete a first full year of running their 
services, and so we are still evaluating those outcomes. Of 
course, we do operational oversight and business operation 
oversight to make sure that they are spending those funds 
appropriately, that they are using those funds for eligible 
veterans and partnerships that are within the scope of the 
legislation. As we get that information back, we will be happy 
to share that with you in the interim report that we will 
provide in the spring.
    Ms. Radewagen. Thank you. Dr. Scavella, how much 
flexibility do grantees have in using their funds? If, for 
whatever reason, the original grantee found themselves at risk 
of failing to execute the grant, could an otherwise qualified 
third party be designated to receive the grant so that funding 
remains within the target community?
    Dr. Scavella. That is a great question. I am actually going 
to look to my expert, Dr. Burnett, for this one.
    Dr. Burnett. Yes. If a grantee, if I understood your 
question correctly, if the grantee is underperforming or is 
unable to execute appropriate funding, can that funding be 
reallocated to another? There are a couple of answers there. 
Grantee site, of course, we want to promote innovation, and if 
they ask to change the scope of their grant to provide 
different services, they always have the ability to request a 
change in the scope of their services, which we will support 
them with. If they are unable to provide those services or 
something happens at their facility, we will then pivot those 
funds to others to cover the veterans in that area the Notice 
of Funding Opportunity process.
    Ms. Radewagen. All right. Well, that is it, Madam 
Chairwoman. I yield back the balance of my time. Thank you.
    Ms. Miller-Meeks. Well, thank you very much. I now yield 
myself 5 minutes. The advantage of being the chair is that you 
have to stay during the entire hearing, and so you get to 
listen to the questions and the answers by all of the Members 
of Congress. I am going to toss out what I thought were the 
questions that I was going to ask, and I am going to try to hit 
on some of the points made by our members. First and foremost, 
let me just say that I know that my colleagues, all of them 
here on the Health Subcommittee and on the Veterans Affairs 
Committee, are extraordinarily interested in this topic and 
want to see the number of veterans suicide and the brain health 
of veterans improve. They want to see the numbers decrease. 
They want to see brain health increase. I know that that, too, 
is the VA's priority and their mission.
    I am going to first say thank you for all of those efforts. 
However, we know that the number of veterans suicide remains 
high. It has not dropped. In the spirit of innovation, I think 
what we are trying to say to you is it should not be Members of 
Congress coming up and touring in their districts or elsewhere, 
innovative programs coming back, talking to the VA, and/or 
passing legislation to force the VA to do something that if 
this is your priority, please, I ask you to go outside of the 
box and find those programs and those entities that are doing 
that work in concert with you, whether or not they are being 
given a grant by the VA. Incorporate those, bring those to us. 
Let us know that you really are thinking about how to best 
address this issue.
    One of the things that we have heard today is the nine 
different assessments. As a physician and a veteran, I 
understand what the VA is trying to do. The VA is trying to 
standardize the entry process so that you have the data and 
metrics that members have asked you for so that we can assess 
the effectiveness of the program, and you are trying to apply 
the same standards done within the VA institution to these 
outlying organizations. I get it. I understand it. I do not 
fault you for that. Those assessments are not working.
    What we hear from our veterans in our district is I go to 
the VA, even if I am trying to make an appointment on the 
phone, I am asked all these questions. They do not have 
anything to do with what I am doing. Perhaps I would say one of 
the things, Dr. Scavella and Dr. Burnett, you can take from 
this hearing is tailor that, narrow it, find out what it is 
that you need to do in order to have metrics and data for 
effectiveness, but tailor it for our communities.
    Number two, the cost of medication. We are not figuring in, 
in the cost of all these programs. Dr. Scavella, how much is 
the VA spending per year on mental health and suicide 
prevention, all dollars?
    Dr. Scavella. I would have to get that information to you.
    Ms. Miller-Meeks. Please get that information to us. In 
this, if you have an individual who goes to Missy Meyer's 
program or goes to Ken Falke's program, or Joyce King gets 
someone to a program, or English River Outfitters in my 
district, or Heroes with Horses in Wyoming, if they go to one 
of those programs and they are on four or five medications and 
they are taken off, what is the cost of those medications, 
because that is also in the cost of success if an individual is 
off medications. I do not disagree with what Representative 
Kiggans, or Representative Luttrell said, or Ken Falke said. As 
a physician, I can tell you, and having worked with this and 
worked in the VA, someone comes in, they are prescribed a 
medication, they have a side effect or something else. Part of 
the medication's working, but something else has happened, they 
are prescribed another medication. We are not treating people 
holistically.
    I am just going to make a comment from one of my 
colleagues, the reason you have the assessments that you do is 
that we need to know that we are treating people the same 
severity, the same support groups, the same attempts at care, 
whether they are within the VA or outside of the VA. Saying 
that x number of people went into this program and only x 
number of people committed suicide does not really tell you the 
data. It is anecdotal. What you are trying to do is get real 
data. You are attempting to apply structure and standardization 
to this program to validate and determine effectiveness.
    We need to do better. That is what we are saying. We need 
to do better. We need to lower the rates of suicide. We have 
not seen that through the VA. I am going to also say that I 
actually support these programs. I have toured these programs. 
I have seen whether they are faith-based, non faith-based. We 
know that there is an individual, a holistic patient, and this 
includes the suicide risk and TBI, which should be included. 
This is a program that I think that we are all willing to 
support and see continue. It is really just in its infancy, 
even though it is three years. We would like to see the VA take 
greater steps, get more grants out there, simplify the 
assessment and the data so that we can determine effectiveness.
    With that, I thank you, and I yield back. Does Ranking 
Member Brownley, would you like to make any closing remarks, 
seeing no other representatives here to ask questions?
    Ms. Brownley. Thank you, Madam Chair. I just want to say 
that this is an important hearing. The topic is obviously 
important and complex. This is not an easy issue. I think that 
this particular grant program has great opportunities to be 
wildly successful. It could be wildly a failure as well if we 
are not doing the proper oversight.
    I feel as though the VA's role in terms of working with 
these grantees across the country is really to intervene with 
all of these grantees in a positive way to kind of check in to 
see how are you doing? Where are your metrics? What is driving 
your practices here? Maybe we need to adjust to get to where we 
are trying to get to. I just think that we have to approach 
this in a business model, if you will. That is very much a data 
driven, continuous improvement model, that every single 
grantee, you know, that we are funding is really focused in 
that way and knows that they have to be data driven. They have 
to be continually improving their program.
    I do not know whether the VA even has that capability to be 
overseeing all of these grantees across the country. I know you 
are there to provide a service for grantees who need and want 
your assistance and help, but I am not sure that you are 
closely, closely following each and every one of these 
grantees.
    That is what I think, if we do something like that, I think 
we can be wildly successful in this. I do not think the VA is 
going to solve this problem by itself, that we need the help of 
experts across the country to help us in this endeavor to help 
to solve this problem. We have got to be able to do it. I am 
not saying that we are doing it in a willy nilly way, but we 
have really got to approach it in a very serious business model 
and for it to succeed.
    I think the grantees here are grantees that we can look to 
that have been successful and can help others. We have got to 
really approach this, I think, in a very data driven way. I 
worry that we are not going to be collecting all of the data 
points that we should be collecting. With that, I yield.
    Ms. Miller-Meeks. Thank you, Ranking Member Brownley. I 
realize that in my question, I did not have a lot of questions 
that I asked, but I think that you understand the suggestions 
that I am making. In addition to the data that Representative 
Brownley and others suggested acquiring about medications, 
about sex, we also should be--and when you provide us the 
information, looking at active duty, National Guard, and 
Reserve broken down, i.e., members that are leaving active-duty 
military and transitioning, have a different transition out of 
the service than members of the National Guard or the Reserve 
who are deployed for a set period of time and then go back to a 
community. How they integrate back into their community.
    I would like to thank everyone for their participation in 
today's hearing and for the productive conversation, and I 
appreciate everyone's focus on such, it really is a critically 
important topic and also all of your dedication to decreasing 
the number of veterans suicide. It is important to me and my 
colleagues on both sides of the aisle that all veterans seeking 
help receive it in a timely manner. It is our responsibility, 
this committee, the VA, and our communities, to lift veterans 
at risk out of isolation, get them out of trouble, treat them 
as whole people within a family and a community, not just a VA 
hospital community, and we get them the care that can save 
their lives.
    If you are a veteran watching this right now who needs 
help, please know that help is available to you anytime by 
calling 988 and pressing 1 or texting 838255 or visiting 
veteranscrisisline.net.
    I would also like to just say, if I can, I have to pull 
this up on my phone, so I apologize for the delay. You have 
already heard this from Ranking Member Brownley. As a closing 
note, I want to take a moment to recognize our outstanding 
Staff Director, Christine Hill, who will be retiring at the end 
of this year and over 30 years of Federal service. I have not 
worked with her as long as Ranking Member Brownley has, but in 
the 3 years I have been on the Veterans Committee and the 
Health Subcommittee, she has just been outstanding. For her 
time here, from her time in the Air Force, to her work here as 
a Staff Director of the Health Subcommittee, Christine's life 
has been about service.
    I am grateful to have been able to work closely with her on 
the Health Subcommittee this year. While she will be sorely 
missed, we wish her the very best in retirement and know that 
she will continue to serve. Thank you so much, Christine.
    The complete record of statements of today's witnesses will 
be entered into the hearing record. I ask unanimous consent 
that all members have 5 legislative days to revise and extend 
their remarks to include extraneous material. Hearing no 
objections, so ordered. I thank the members and the witnesses 
for their attendance and participation today. This hearing is 
now adjourned.
    [Whereupon, at 11:58 a.m., the subcommittee was adjourned.]
     
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                         A  P  P  E  N  D  I  X

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                    Prepared Statements of Witnesses

                              ----------                              


                  Prepared Statement of Erica Scavella

    Good morning, Chairwoman Miller-Meeks, Ranking Member Brownley, and 
distinguished members of the Subcommittee. Thank you for the 
opportunity today to discuss the Department of Veterans Affairs' (VA) 
implementation of the Staff Sergeant Parker Gordon Fox Suicide 
Prevention Grant Program (SSG Fox SPGP). Accompanying me today is Dr. 
Todd Burnett, Senior Consultant for Operations, Suicide Prevention 
Program.
    The SSG Fox SPGP honors Veteran Parker Gordon Fox who joined the 
Army in 2014. He died by suicide on July 21, 2020. His obituary \1\ 
notes his legacy of ``loyalty, thoughtfulness, joy, compassion, and 
deep friendships.'' Section 201 of the Commander John Scott Hannon 
Veterans Mental Health Care Improvement Act of 2019 (P.L. 116-171; the 
Hannon Act) authorized this Program, which assists VA in implementing a 
public health approach that blends community-based prevention with 
evidence-based clinical strategies through community efforts, bringing 
personalized support and care to Veterans. The SSG Fox SPGP represents 
an important step in leveraging community networks and expertise in 
Veteran suicide prevention efforts beyond VA's systems.
---------------------------------------------------------------------------
    \1\ https://www.dignitymemorial.com/obituaries/johnson-city-tn/
parker-fox-9282651.
---------------------------------------------------------------------------
    The SSG Fox SPGP enables VA to provide resources toward community-
based suicide prevention efforts to meet the needs of Veterans and 
other eligible individuals, including their families, through outreach, 
suicide prevention services, and connection to VA and community 
resources. The impact of this Program has been meaningful. For 
instance, the following two examples are a brief sample of the 
incredible work SSG Fox SPGP grantees are rendering:

      A young, pregnant Veteran fled from a domestic violence 
situation and engaged in services provided by a grantee who helped her 
enroll in prenatal care at VA as well as other health care and mental 
health supports. She stated: ``I could not have survived without your 
help.''

      A Marine Corps Veteran presented to Boulder Crest 
Foundation, a grantee in Virginia, with suicidal thoughts and was 
seeking help for combat-related trauma. After getting connected to 
help, he confided that he had been engaged in preparatory behaviors to 
end his life prior to getting connected, and that the services he 
received saved his life.

    VA has collected and received many more examples: lifesaving 
engagements through the Healing Warriors Program in Colorado to the 
Warrior Wellness Program, meeting the needs of Choctaw Nation of 
Oklahoma Veterans, and the Aleutian Pribilof Islands Association in 
Alaska, as well as many more. The engagements within grantee 
communities are part of the critical community-based interventions 
needed across the Nation to prevent Veteran suicide.
    Congress authorized $174 million to be appropriated for fiscal 
years (FY) 2021 through 2025 to carry out the SSG Fox SPGP. 
Organizations can apply for grants worth up to $750,000 and may apply 
to renew awards from year to year throughout the length of the program. 
Grants are awarded to organizations that provide or coordinate suicide 
prevention services for eligible individuals at risk of suicide and 
their families, including but not limited to:

      Outreach to identify those at risk of suicide;

      Case management and peer support services;

      Baseline mental health screening for suicide risk and 
behavioral health conditions;

      Assistance in obtaining VA and public benefits;

      Assistance with emergent needs (e.g., personal financial 
planning, child care); and

      Non-traditional \2\ and innovative approaches and 
practices.
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    \2\ Nontraditional and innovative services that were included in 
grants funded include Adaptive Performance, Art Therapy, Creative Arts, 
Equine Therapy, Family Support Circles, Food Security, Healing Touch 
Therapy, Mindfulness, Moral Injury Education, Music Therapy, Native: 
Risking Connections (Hawaiian), Native: Alaska Native Cultural Health 
and Resilience Gathering, Outdoor Recreation, Recreation Therapy, 
Resilience Strength Training, Service Dogs, Warrior PATHH, Water 
Sports, and Yoga.

    VA first awarded grants in September 2022, to 80 awardees in 43 
states, Washington, DC, and American Samoa. In March 2023, VA prepared 
for the second round of grant awards by publishing a Notice of Funding 
Opportunity (NOFO) for renewal grants and new organizations to apply. 
The application period opened March 2, 2023, and closed May 19, 2023. 
On September 20, 2023, VA announced the award list for FY 2023 grants 
totaling more than $52 million to 80 community-based organizations; 
this included 77 current grantees and 3 new grantees in 43 states, the 
District of Columbia, Guam, and American Samoa. Twenty-one grantees 
serve tribal lands including Navajo Nation, Cherokee Nation, Choctaw 
Nation, Alaskan Native tribes, and others. Funding decisions prioritize 
the distribution of grants to rural communities, tribal lands, 
territories of the United States, medically underserved areas, areas 
with a high number or percentage of minority Veterans or women Veterans 
and areas with a high number or percentage of calls to the Veterans 
Crisis Line.
    As of September 30, 2023, grantees have completed over 20,000 
outreach contacts and engaged 3,500 participants. Grantees have 
successfully intervened for many who are on a pathway to risk, as the 
program takes an upstream approach to reach Veterans with some, but not 
necessarily acute, risk for suicide. The SSG Fox SPGP facilitates 
engagement with (and reduces barriers to) clinical mental health care 
but is unique in that most services are non-clinical. As the Nation 
continues to recognize, and as research evidence confirms,\3\ social 
determinants of health (e.g., economic hardship, unemployment, barriers 
to health care) are drivers of suicide risk; the SSG Fox SPGP takes a 
critical step to acknowledge and meet the need for suicide prevention 
services beyond just the clinical mental health continuum.
---------------------------------------------------------------------------
    \3\ U.S. Department of Veterans Affairs. (2023). 2023 National 
Veteran Suicide Prevention Annual Report. https://
www.mentalhealth.va.gov/docs/data-sheets/2023/2023-National-Veteran-
Suicide-Prevention-Annual-Report-FINAL-508.pdf.
---------------------------------------------------------------------------
    The grants are a core aspect of VA's 10-year National Strategy for 
Preventing Veteran Suicide. The SSG Fox SPGP also supports and aligns 
with the priority goals and cross-cutting implementation principles in 
the White House's strategy on Reducing Military and Veteran Suicide. 
Given the multiple factors that may lead to suicide death, preventing 
suicide requires a comprehensive public health approach that harnesses 
the full breadth of the Federal Government in close coordination with 
states, territories, tribes, and local governments, as well as 
collaboration with industry, academia, communities, community-based 
organizations, families, and individuals. Reducing suicide requires a 
long-term strategic vision and commitment designed to create and 
implement systemic changes in how we support Service members, Veterans, 
and their families across the full continuum of risk and wellness.
    The SSG Fox SPGP is uniquely positioned to help tailor resources to 
meet the needs of diverse Veterans in their communities, while also 
building community capacity to deliver suicide prevention services. The 
strength of the SSG Fox SPGP is that it allows for different approaches 
to fit diverse community needs and to reach those individuals at risk 
of suicide who choose not to receive care at VA. The program also 
engages families, which is critical to reaching and serving those at 
risk.

Eligibility Requirements

    Eligibility requirements are set forth by law through the Hannon 
Act. Eligible individuals are persons defined in section 201(q) of the 
Hannon Act who are at risk of suicide. For purposes of SSG Fox SPGP, 
risk of suicide means exposure to, or the existence of, any of the 
following factors, to any degree, that increase the risk for suicidal 
ideation and/or behaviors:

        1. Health risk factors, including mental health challenges, 
        substance use disorder, serious or chronic health conditions or 
        pain, and traumatic brain injury.

        2. Environmental risk factors, including prolonged stress, 
        stressful life events, unemployment, homelessness, recent loss, 
        and legal or financial challenges.

        3. Historical risk factors, including previous suicide 
        attempts, family history of suicide, and history of abuse, 
        neglect, or trauma, including military sexual trauma.\4\
---------------------------------------------------------------------------
    \4\ 38 C.F.R. 78.10(b).

    Grantees use non-clinical tools to assess these areas to determine 
the degree of risk of suicide for eligible individuals and the drivers 
of stress to focus support recommendations to facilitate the 
individual's (and family's) well-being. To assist grantees in 
determining risk of suicide (and thus an individual's eligibility for 
suicide prevention services), VA provides grantees with a Columbia 
Suicide Severity Rating Scale screening tool, which is a brief, 
evidence-based form that can be administered quickly by responders with 
no formal mental health training and applied in a wide range of 
settings for adults to detect the presence of suicide risk.\5\ VA has 
ensured that grantees are provided this tool before providing or 
coordinating suicide prevention services under the Program and have 
access to publicly available training materials to support their use of 
this tool.
---------------------------------------------------------------------------
    \5\ Posner, K., Brent, D., Lucas, C., Gould, M., Stanley, B., 
Brown, G., Fisher, P., Zelazny, J., Burke, A., Oquendo, M., & Others. 
(2008). Columbia-suicide severity rating scale (C-SSRS). New York, NY: 
Columbia University Medical Center.

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Grant Program Evaluation

    The SSG Fox SPGP evaluation plan has two components:

          The VA grant management program is evaluated using a 
        formative evaluation design to collect mixed methods data on 
        program-level impact using the Reach, Effectiveness, Adoption, 
        Implementation, Maintenance (RE-AIM) framework.\6\
---------------------------------------------------------------------------
    \6\ Fetters, M.D., Curry, L.A., & Creswell, J.W. (2013). Achieving 
integration in mixed methods designs-principles and practices. Health 
services research, 48(6 Pt 2), 2134-2156. https://doi.org/10.1111/1475-
6773.12117.

          The evaluation of the grantees uses a summative 
        evaluation design with standardized outcome measures for 
        community-based programs using a longitudinal and pre-and post-
        test survey methodology.\7\
---------------------------------------------------------------------------
    \7\ Stone, D.M., Holland, K.M., Bartholow, B., Crosby, A.E., Davis, 
S., and Wilkins, N. (2017). Preventing suicide: A technical package of 
policies, programs, and practices. Atlanta, GA: National Center for 
Injury Prevention and Control, Centers for Disease Control and 
Prevention.

    The reporting requirements in 38 C.F.R. Sec.  78.145 were designed 
to provide VA with the information required to assess the outcomes 
associated with grantee programs. Ultimately, evaluations of 
effectiveness are measured by one goal - reducing the number of 
Veterans at risk of suicide, which we evaluate through expectations 
laid out in every grant agreement, including but not limited to 
services provided, at-risk populations reached, and pre-and post-
service surveys. Our data collection specifically evaluates the effects 
of SSG Fox SPGP engagement on Veterans' financial stability, mental 
health status, well-being, suicide risk, social support, treatment 
engagement, and service utilization.
    Evaluation activities include demographic and geospatial analysis 
to ensure we are positioned to engage the broadest possible range of 
at-risk Veteran subpopulations. We will provide an overview of our 
outcomes to date in the interim 18-month report and final report.\8\ 
These reports will include information on population engagements 
overall and by specific at-risk groupings (such as the number of 
American Indian/Alaska Native, women, minority, LGBTQ, Asian American, 
Native Hawaiian and Pacific Islander, rural, or other target population 
members engaged), the services provided to Veterans, active-duty 
Service members, or family members; assessed risk pre-and post-
services, and the type of services. VA launched an online data 
collection tool in November 2023 to give grantees the ability to submit 
real-time information on the services they are providing. This allows 
VA and grantees to identify where service demands are expanding, the 
types of services needed, and where supports are needed to overcome 
barriers to engagement. The program is also positioned to identify, 
share, and scale emerging best practices for community-based suicide 
prevention.
---------------------------------------------------------------------------
    \8\ Beginning not later 18 months after the date of the first grant 
award (September 19, 2022), VA must provide an interim report to the 
Committees on Veterans' Affairs regarding the provision of community-
based grants to eligible entities through the SSG Fox SPGP. 
Additionally, VA is required to submit a final report no later than 3 
years from the date of first award and annually thereafter for each 
year in which the program is in effect (P.L. 116-171, section 201(k)).

---------------------------------------------------------------------------
Operation of the SSG Fox SPGP

    VA's collaborations with grantees are designed to facilitate 
eligible individuals' engagement in care, wherever, whenever, and 
however needed to reduce the risk of suicide. To ensure oversight of 
grants implementation, VA grants are subject to Federal laws, 
regulations, and VA policies. SSG Fox SPGP and grantees must comply 
with section 201 of the Hannon Act, VA's regulations (38 C.F.R. Part 
78), other applicable VA policies, and the grant agreement. To support 
grantees with implementing their programs, VA offers guidance and 
technical assistance on key elements of the Program and best practice 
sharing. This supports grantees in optimizing efficiencies and resource 
stewardship to maximum benefits to eligible individuals and their 
families. VA guidance and technical assistance includes the following:

      The SSG Fox SPGP Program Guide, which was initially 
issued October 2022 and was updated and distributed in July 2023;

      Recurring onsite technical assistance events for all 
grantees;

      Monthly technical assistance webinars; and

      Monthly Grant Manager meetings, weekly data technical 
assistance, and 1:1 Grant Manager support services.

    Prior to providing SSG Fox SPGP assistance to a participant, 
grantees enter into a written agreement between their agency and each 
participant. This agreement describes the grantee's SSG Fox SPGP 
services and any conditions or restrictions on the receipt of suicide 
prevention services by the participant. Agreements do not require 
sobriety, income limits, participation in suicide prevention services, 
or other unnecessary requirements as a condition of assistance to the 
extent practicable. Grantees work in coordination with the local VA 
medical center (VAMC), particularly around referral and linkage to 
VAMCs for clinical mental health assessment and services. The grantee 
must facilitate referral to an appropriate alternative, except in 
emergent situations. If all clinical mental health care is declined, 
individuals may still receive SSG Fox SPGP services, and grantees 
follow their policies and procedures for ongoing risk assessment and 
referral discussions.
    A critical goal of the SSG Fox SPGP is to ensure the safety of all 
participants and grantee and community staff. Grantees are required to 
develop a comprehensive plan to maintain the safety of participants and 
staff and the confidentiality of the Program's participants and their 
records. In developing such a plan, VA requires that grantees complete 
the following:

      Establish goals and objectives that reduce and eliminate 
accidents, injuries, and illnesses related to administering suicide 
prevention services to participants;

      Develop plans and procedures for evaluating the safety 
program's effectiveness, both at the grantee service location office 
and in the field;

      Develop priorities for remedying the identified factors 
that cause accidents, injuries, and illnesses;

      Ensure that participant records are secured with all such 
information password-protected;

      Ensure that all staff, students, and volunteers receive 
initial and annual training on how to respond to and report critical 
incidents; and

      Develop a clear written procedure for following up on any 
incidents that may occur to ensure that the Program evaluates how they 
responded and to ensure any party involved was connected to any 
services needed.

    VA conducts reviews of grantee programs that include an assessment 
of policies and procedures.

    Conclusion

    VA is grateful for Congressional support in advancing Veteran 
suicide prevention. The SSG Fox SPGP is just one tool that VA has 
rolled out in its public health approach to Veteran suicide prevention. 
We need everyone at the table and working in the same direction. This 
requires both moving away from a belief that suicide is solely a mental 
health problem and moving toward engaging within and outside of 
clinical health care delivery systems to decrease both individual and 
societal risk factors for suicide. Suicide is preventable, and each of 
us has a role to play in this mission. The public health approach 
reminds us that we each can and do make a difference. This concludes my 
testimony. My colleague and I are prepared to respond to any questions 
you may have.
                                 ______
                                 

                   Prepared Statement of Missy Meyer

    Chairwoman Miller-Meeks, Ranking Member Brownley, and other 
honorable members of the Subcommittee
    Thank you for the honor to testify before the House Veterans 
Affairs Subcommittee on Health. The issue of Fox Grants and ending 
veteran suicide means a lot to me personally, and my colleagues at 
America's Warrior Partnership (AWP).
    The SSG Fox Suicide Prevention Grant, from the original idea and 
inception in this Committee, had a singular goal: find veterans in the 
community that are in need and help them.
    While Congress has been very thoughtful and deliberate in crafting 
the law and providing generous funding, it is a big program that is 
still working through growing pains and in need of minor reforms and 
fixes to ensure it can meet the intended goal.
    As a Fox Grant recipient that has done extensive work in the 
community, the process for how the grant was awarded was complex, time 
consuming, and met with repeated delays by the VA.
    However, in September 2022, America's Warrior Partnership (AWP) 
began conducting outreach utilizing Fox Grant funds. This outreach is 
targeted at all veterans in each of our five communities across the 
country in alignment with AWP's upstream Community Integration (CI) 
Model. The idea behind CI is to find veterans that are not engaged in 
services and may have no connection to resources. This includes both 
veterans typically considered ``at risk'' which the Fox Grant has 
identified as primary candidates for outreach as well as community 
leaders, professionals, volunteers, etc. that may not currently need 
services or believe they do not qualify for benefits. Our mission is to 
partner with communities to prevent veteran suicide. Our programs 
accomplish this by starting at the community level and understanding 
the unique situations of veterans and their families. We connect local 
veteran-serving organizations with the appropriate resources, services, 
and partners that they need to support veterans, their families, and 
caregivers at every stage of veterans' lives. Our ultimate goal at AWP 
is to improve the quality of life for veterans and to end veteran 
suicide by empowering local communities to serve them proactively and 
holistically before a crisis occurs.
    In March 2023, AWP was able to begin fully assessing and enrolling 
active service members, veterans, veteran spouses and caregivers in the 
SSG Parker Gordon Fox Suicide Prevention Grant Program. Since that 
time, AWP has completed intakes and suicide risk assessments, as 
required by the VA, via the Psycho-Social Assessment and Columbia-
Suicide Severity Risk Scale for 1,057 warriors. 185 of those men and 
women have indicated some level of suicide risk. This means over 17 
percent of those 1,057 veterans had suicidal ideations ranging from 
wishing they could fall asleep and not wake up to having active 
thoughts of taking their own life with a plan and an intention to act 
on that plan and/or having made a previous attempt to end their own 
life.
    Once AWP knows a veteran or service member is in crisis, we must 
find them local mental health resources. In a crisis, this is achieved 
with a call to the ``988'' crisis line and a referral to their local 
counseling center. Veterans who do not wish to work with the VA are 
referred to community based mental health resources. There is no 
expedited care for Fox participants, there is no special number or 
intervention to get them services immediately.
    As an example, on November 13th a veteran called AWP's ``The 
Network'' with an active plan to take his own life. He was 
disillusioned with his care at the VA in New York but had an 
appointment with the Fort Meyers VA for a medical appointment the 
following morning. He was ``tired of taking so many pills for my PTSD 
and Bi-Polar that the VA doctors keep giving me.'' I called the Fort 
Meyers, FL Suicide Prevention Coordinator as required by the Fox Grant. 
I left several messages including the information that we had an 
actively suicidal individual that needed services. AWP was hoping to 
coordinate a mental health referral while the vet was in the VA for his 
other appointment. This call has still not been returned. The Network 
was able to connect with the 988 hotline and continued working with the 
veteran. He stated that he loved his girlfriend too much to kill 
himself, and we are still talking with him today to help improve his 
quality of life.
    This is one of the major shortcomings of the SSG Fox Suicide 
Prevention Grant Program. There is no ``program.'' It is a transaction. 
It is a VA-sponsored phone call and assessment with no plan on the 
backend for care, or funding for connected services. As stated before, 
AWP's mission is to assist veterans and end veteran suicide. We would 
serve these warriors exactly the same way even without Fox funding. 
However, these assessed veterans are not offered expedited care or a 
same day appointment for a mental health evaluation.
    The next step in the Fox Grant, following the intake and suicide 
risk assessment, is to create a holistic service plan based around the 
veteran's needs and wants. We set goals and connect each veteran to 
various services as needed. Then AWP is mandated to conduct a series of 
additional assessments with each participant. There are nine forms over 
all that must be complete for the participant to be enrolled. The 
Veteran (or Veteran Family Member) Intake Form, Columbia-Suicide 
Severity Rating Scale, Psycho-Social, Socio-Economic Status, Personal 
Health Questionnaire, Participant Communication Confirmation Form, 
General Self-Efficacy Scale, Interpersonal Support Evaluation and 
Warwick-Edinburgh Mental Well-Being Scale. In addition, there is a 
service attendance form, referral form and various others that are 
submitted monthly or as needed.
    The Columbia Scale has been a life saving measure since AWP 
integrated the questions into every warrior intake. This allows us to 
take a veteran reaching out for rental assistance and ensure they do 
not need immediate mental health support as well. In my opinion, this 
is the biggest success of the Fox Grant. All grantees are required to 
``ask the question.'' This gives our veterans the opportunity to 
express any ideations to someone they have already connected with.
    Once the participant has received support and been connected to 
referrals, AWP is required to readminister the baseline assessments: 
PHQ-9, ISEL-12, GSE, SES and Warwick. AWP has only successfully 
completed both sets of assessments with 6 of our 180 Fox Eligible 
participants largely due to lack of engagement.
    In addition, the program itself needs metrics and accountability. 
There is no clear measure of success for the Fox Grant program. The 
grantee has key performance indicators set forth in their grant 
agreement, but the Fox Program overall has no measurable indicator of 
success other than individual improvement that is supported solely by 
individual organizations. How will we use this data once we have it? 
What will the VA do differently with the knowledge from these 
assessments? We already know that depression, isolation and financial 
stressors are risks for suicide. How does continually assessing known 
stressors better our prevention model?
    With this in mind, there are several recommendations below that may 
be good to focus on during upcoming discussions about changes and fixes 
to the program.
    First, AWP is often asked about the Fox Program and what it 
entails. The honest answer is this program is a data gathering mission 
that gives the veteran the opportunity to share their feelings and 
experiences to help the VA improve future prevention measures. Yet 
there is no direct benefit to the veteran, and it may even be a 
detriment. These assessments ask people that are actively in crisis to 
elaborate on feelings of isolation, depression, and lack of resources 
with no licensed mental health professional present to assist in 
debriefing that individual. Many VA staff members have no idea what the 
Fox Grant is or why grantees are calling asking for assistance with a 
``Fox Participant.'' At the Fox Grantee Conference this past week there 
were several grantees that noted having an issue connecting with their 
local Suicide Prevention Coordinators. There needs to be more education 
that extends to frontline staff on the Fox Grant and what to do with 
those enrolled.
    The Fox Grant program cannot be transactional. It needs to have 
follow-up programs available for veterans in need. Calling and asking 
for information, with no infrastructure to assist, is defeating for 
many veterans opening up to Fox Grant recipient organizations in hopes 
of getting help. Several assessments ended with an additional call to 
the 988 Crisis line. There needs to be a better plan for how to help 
these individuals. Again, these participants receive no preferential or 
expedited care for their time and efforts.
    Next - the assessments need to be refined and slimmed down to 
eliminate redundancy. The Psycho-Social asks participants that have 
already indicated some level of suicide about suicide risk factors. The 
ISEL-12 and GSE ask questions already addressed in our holistic intake 
as far as support and self-efficacy. All three of these assessments 
could be done away with, as there are certainly similar assessments 
conducted as soon as the veteran enters the VA, or other resources, for 
mental health assistance.
    Both AWP staff and clients describe the assessments as repetitive 
and exhausting. The amount of data gathered is significant. AWP has 
submitted thousands of forms to account for both outreach efforts to 
find veterans not connected with resources and complete Fox mandated 
forms. Every AWP outreach event requires its own form submitted in a 
PDF form via email. The massive amount of paperwork has resulted in AWP 
having to hire additional administrative staff to handle the data entry 
load. We are in year two of the grant's life cycle, and the Data 
Collection Tool is not yet available to AWP to lighten the load of 
saving and emailing individual PDFs by the dozens every month.
    Finally, the VA needs to fully detail and expand their measures of 
success. Is it a number or outcome? Does success come with a potential 
increase in funding? And are those organizations that are unable to 
meet those metrics held to account and removed, or reduced? 
Organizations like AWP take this very seriously and believe the Fox 
Grant can be incredibly helpful for outreach to veterans that are 
otherwise not in the VA system. Accordingly, we want this program to be 
successful, and it takes metrics and accountability to determine that 
success.
    Metrics and goals with accountability build trust with veterans as 
well, but only if it fits the overarching aim of the program itself. 
Recently, during our in-person Fox Grant conference, VA staff outlined 
program goals: reduce suicide risk, improve mental health status and 
improve well-being of participants. However, the issue remains: there 
is no bigger picture on how the data grantees spend hours compiling and 
reporting will impact VA policy.
    Members of the Subcommittee, thank you again for the opportunity to 
testify today. We look forward to our continued work together and would 
like to thank each of you for all your hard work and dedication to 
those who served in our nation's armed forces.
                                 ______
                                 

                    Prepared Statement of Ken Falke
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

                    Prepared Statement of Joyce King

Introduction

    I would like to begin by thanking the Committee for its 
transformational work on behalf of our nation's Veterans and their 
families. I applaud Chairwoman Miller-Meeks and Ranking Member Brownley 
for their leadership, and I greatly appreciate the opportunity to speak 
to the Subcommittee regarding the Staff Sergeant Fox Suicide Prevention 
Grant Program.
    My name is Joyce King, and I serve as director of the SSG Fox 
Suicide Prevention Grant program at Sheppard Pratt. I am a Board-
certified mental health therapist and substance abuse counselor, as 
well as a military Veteran with more than 25 years of mental health, 
substance use, and social services experience.
    Sheppard Pratt is the Nation's largest private, nonprofit provider 
of mental health, substance use, developmental disability, special 
education, and social services in the country. We provide specialized 
services for Veterans including Supportive Services for Veteran 
Families (SSVF), Homeless Veteran Reintegration Program (HVRP), and 
clinically intensive Grant Per Diem (GPD) transitional housing. Many of 
these programs are funded by the U.S. Department of Veterans Affairs 
(VA).
    Collectively, Sheppard Pratt's Veterans services assist 
approximately 1,250 homeless veterans every year in urban, rural, and 
suburban communities across Maryland and in selected West Virginia 
counties. Many of our staff are Veterans, including some staff who were 
previously clients. The dedication and commitment of our team drives 
our impact: We have helped over 5,235 homeless Veteran and Veteran 
family members to obtain permanent housing. Our HVRP program helps 
homeless Veterans to obtain employment with an average wage of just 
under $20 per hour.

Joining the SSG Fox Program

    In 2022, the VA released the SSG Fox Grant Notice of Funding 
Opportunity. Its deep focus on community connection, well-being, and 
suicide prevention responded to a clear gap in community-based services 
for Veterans. Accordingly, we jumped at the opportunity to better serve 
our Veteran community.
    The application process was well-organized and transparent, with 
significant flexibility in approach provided by the VA. The staff at 
the VA deserve credit for designing and implementing a disciplined, 
efficient application process.
    Sheppard Pratt was honored to be awarded a SSG Fox Grant on 
September 19, 2022. Our implementation strategy combines comprehensive 
and holistic strategies selected based on the best available evidence 
for the greatest potential to prevent suicide among veterans across 
Maryland. We leverage current programming and relationships with 
veterans that are at high-risk yet disengaged with VA and mental health 
care.
    Peer support is a critical component of our SSG Fox implementation 
strategy. Through this new funding, we have trained Veterans with lived 
experiences related to suicide and mental health. Our peer support 
specialists work directly with Veterans and their family members to 
promote connectedness, provide holistic case management, and reduce 
risk factors for suicide. In addition, case managers help Veterans with 
a range of health, housing, employment, and other needs.
    As the SSG Fox Grant program was only recently launched, our data 
are preliminary but suggestive. During enrollment, 95 percent of 
Veteran clients indicated need for mental health services; 75 percent 
required reconnection to the VA for services and supports; 65 percent 
reported benefits challenges; 60 percent requested peer support and 
connection; and 60 percent reported health, housing, employment, or 
other challenges best addressed through case management.
    The need, therefore, is clear.

The Impact of the SSG Fox Program

    The impact of the SSG Fox Grant program is best demonstrated 
through stories. I would like to share the story of one participant: 
I'll call her Alice. Alice's story illustrates the power of the SSG Fox 
Grant program, as well as the way in which community-based Veterans 
services - including SSVF and HVRP - combine to prevent suicide and 
promote well-being more generally.
    Alice is a 48-year-old single female Navy Veteran, with a history 
of Post-Traumatic Stress Disorder (PTSD) and Traumatic Brain Injury 
(TBI).\1\
---------------------------------------------------------------------------
    \1\ Some details have been altered to protect confidentiality.
---------------------------------------------------------------------------
    Alice recently experienced two traumatic events. In 2022, she was 
laid off. To make ends meet, she moved in with her sister. In 2023, her 
sister passed away unexpectedly. With the loss of both her job and her 
sister, she fell behind on her rent. Alice had to choose between paying 
for her rent or buying food.
    In September 2023, she called Sheppard Pratt. Our SSG Fox program 
team collaborated with SSVF to help Alice find a more affordable 
housing option. To help Alice gain employment, our SSG Fox and HVRP 
teams worked together to provide Alice with both a computer and 
technology training. And Alice dedicated herself to her job search. 
Within a month of her calling Sheppard Pratt, she had a new job in the 
IT field.
    While Alice was working to obtain a new job and housing, she was 
simultaneously grieving her sister's death. The SSG Fox peer support 
specialist was instrumental in modeling healthy and effective coping 
strategies.
    Today, Alice is working and living stably in a safe, healthy home. 
She shared the impact of SSG Fox in her exit survey: ``I can say for 
sure that the program and ALL of the team went above and beyond my 
expectations. I honestly never felt like I was alone during the 
process. In fact, the opposite almost, I literally felt like a team was 
assigned to me for different stages and aspects. I couldn't be more 
(sic) greatful.''
    Alice's comments about the SSG Fox program are echoed by other 
participants.
    John Woodard, a former Marine, similarly was struggling with PTSD, 
a job loss, and eviction when he connected with the SSG Fox program.
    John tells his story better than I could. He said, ``Sheppard's 
Veterans Services got me and my family out of a situation that I was in 
before where I was not appreciated, and I was not being supported for 
my mental illness. Now I am in a better location with my family with a 
peaceful mind, instead of in a crime-infested area where I could hardly 
sleep because of fear and hypervigilance. I would like to thank the 
Veterans Services programs for coming to my rescue. I've been using 
this time to heal and get help with my PTSD, and I've been going back 
to school. Veterans Services made that possible.''
    Mr. Woodard adds, ``I would like to say thank you for keeping your 
word and coming through in my time of need. I wasn't getting any 
support from anywhere and they came in and saved me, saved my whole 
year. I was depressed, I was upset, I was thinking about suicide. And I 
just want to say thank you.''
    John has advice for Veterans across the Nation: ``To other vets who 
are where I was, I would say you can't get discouraged. You can find a 
way. Reach out for help when you need it. It takes a team, just like in 
the military. [Sheppard Pratt's] Veterans Services was part of my 
team.''
    John is better able to articulate the value of the SSG Fox Grant 
program than perhaps anyone.

Enhancing the Impact and Scale of the SSG Fox Program

    As both our qualitative and quantitative data illustrate, the 
strengths of the SSG Fox Grant program are undeniable: our team is 
reaching Veterans who are at high-risk of suicide; the program is 
connecting Veterans with critical resources that are both community-
based and VA-based; and this intervention is helping Veterans to 
improve their well-being and strengthen protective factors against 
suicide. Moreover, the VA has been responsive to community feedback and 
supported the evolution of the program based on both the community 
feedback and data analysis.
    Like every new initiative, SSG Fox will need to evolve to achieve 
greater impact - and further contribute to the end of Veteran suicides.
    How, then, can we enhance the impact of SSG Fox? What lessons have 
we learned thus far?
    First, we must expand access to life-saving clinical behavioral 
health services for SSG Fox participants. There are two primary 
challenges that SSG Fox participants face when we connect them to 
mental health and substance use treatment services.
    While 95 percent of Veterans enrolled in our SSG Fox program have 
requested mental health and other behavioral health services, we have 
experienced delays in connecting Veterans to outpatient services at the 
VA. We appreciate that the VA is working diligently to reduce wait 
times and recognize that significant progress has been made. In the 
meantime, we respectfully request a clear and direct path for high-risk 
SSG Fox clients to VA mental health services.
    Further, we respectfully request an improvement in rates for 
community behavioral health service providers serving Veterans.
    Sheppard Pratt is committed to providing behavioral health services 
to Veterans, but current rates for both Tricare and Community Care 
Network providers do not cover the cost of care. Raising rates to 
reflect provider costs is critical to expanding community-based mental 
health and substance use treatment services for Veterans across the 
Nation.
    Finally, I would like to recommend that we continue to invest in 
the SSG Fox Grant Program, expanding its scale and reach over time. 
Current funding restrictions limit our ability as providers to serve 
Veterans in every community. Additional resources will allow us to 
better engage Veterans across the nation, particularly Veterans who are 
reluctant to seek support.
    As John Woodard reminded us, ``it takes a team, just like in the 
military.'' The SSG Fox Grant Program is an essential part of the team 
working to prevent Veteran suicide across our Nation.

Conclusion

    Thank you again for the opportunity to speak to the Subcommittee 
regarding the Staff Sergeant Fox Suicide Prevention Grant Program. As a 
veteran and a clinician, my gratitude is both professional and 
personal.

About Sheppard Pratt

    Sheppard Pratt is the nation's largest private, nonprofit provider 
of mental health, substance use, developmental disability, special 
education, and social services in the country. A nationwide resource, 
Sheppard Pratt provides services across a comprehensive continuum of 
care, spanning both hospital-and community-based resources. Since its 
founding in 1853, Sheppard Pratt has been innovating the field through 
research, best practice implementation, and a focus on improving the 
quality of mental health care on a global level. Sheppard Pratt has 
been consistently recognized as a top national psychiatric hospital by 
U.S. News & World Report for nearly 30 years. Thanks to support from 
the U.S. Department of Veterans Affairs and the U.S. Department of 
Labor, Sheppard Pratt provides Supportive Services for Veteran 
Families, Homeless Veteran Reintegration Program, Grant Per Diem 
Clinically Intensive Transitional Housing, and SSG Fox Suicide 
Prevention Services to veterans in Maryland and, for some services, in 
West Virginia.

                       Statements for the Record

                              ----------                              


               Prepared Statement of Swords to Plowshares
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

             Prepared Statement of Wounded Warrior Project

    Chairwoman Miller-Meeks, Ranking Member Brownley, and distinguished 
members of the Committee on Veterans' Affairs Subcommittee on Health - 
thank you for inviting Wounded Warrior Project (WWP) to submit this 
written statement for the record of today's hearing on the Staff 
Sergeant Parker Gordon Fox Suicide Prevention Grant Program (SSG Fox 
SPGP). We share your commitment to easing the pain of veterans who are 
suffering from invisible wounds and appreciate the opportunity to offer 
our perspective on potential congressional action to improve how the 
U.S. Department of Veterans Affairs (VA) serves veterans through 
innovative mental health programming like the SSG Fox SPGP.
    For 20 years WWP has been committed to our mission to honor and 
empower wounded warriors. In addition to our advocacy before Congress, 
we offer more than a dozen direct service programs focused on 
connection, independence, and wellness in every spectrum of a warrior's 
life. These programs span mental, physical, and financial domains to 
create a 360-degree model of care and support. This comprehensive 
approach empowers warriors to create a life worth living and helps them 
build resilience, coping skills, and peer connection. Our reach extends 
to more than 200,000 veterans who are being served in various ways 
across the United States.
    In this context, assisting warriors with their mental health 
challenges has consistently been our largest programming investment 
over the past several years. In Fiscal Year 2022, WWP spent more than 
$82 million in mental and brain health programs - an investment 
consistent with the fact that more than 7 in 10 respondents to our 2022 
Annual Warrior Survey self-reported at least one mental health 
condition, and nearly the same amount (66.3 percent) reported visiting 
a professional in the past 12 months to help with issues such as 
stress, emotional, alcohol, drug, or family problems.\1\ Four WWP 
programs - Warrior Care Network, WWP Talk, Project Odyssey, and Complex 
Case Coordination - focus specifically on mental health; however, 
programs that focus on physical health, financial wellness, and social 
connection all play a critical role in improving quality of life and 
mitigating against mental health stressors like loneliness, financial 
insecurity, and chronic pain.
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    \1\ WWP's 2022 Annual Warrior Survey can be viewed at https://
www.woundedwarriorproject.org/mission/annual-warrior-survey.
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    Wounded Warrior Project has proudly delivered these life-changing 
programs while also appreciating that a single organization cannot meet 
the needs of post-9/11 veterans and their families alone. Collaboration 
is at the core of all we do and serves as a critical driver of the 
innovation, efficiency, and excellence we strive to reach. Since 2012, 
WWP has supported 212 military and veteran-connected organizations 
through grants. These targeted investments help to expand our reach, 
diversify engagement opportunities, augment our programs and services, 
and ultimately improve outcomes for all veterans and their families. In 
FY 2021 alone, WWP grants to partner organizations extended our impact 
to more than 36,000 veterans, caregivers, family members, and military-
connected children. These partnerships touched nearly every aspect of 
veteran well-being, targeting issues like social connection, support 
for the Special Operations community, brain health, family resiliency, 
emergency financial assistance, transitional housing, and many more.
    This background in partnership and program delivery was critical to 
our advocacy in support of the historic Commander John Scott Hannon 
Veterans Mental Health Care Improvement Act and its centerpiece now 
known as the Staff Sergeant Parker Gordon Fox Suicide Prevention Grant 
Program (P.L. 116-171 Sec.  201) (SSG Fox SPGP). The SSG Fox SPGP is a 
three-year pilot program that will provide up to $174 million to 
community-based organizations and state, local, and tribal governments 
that provide suicide prevention services for veterans and their 
families. Suicide prevention services have been broadly defined to 
permit healthy interventions before veterans reach mental health crises 
and allow for spending on activities like outreach, case management 
services, peer support, and assistance in obtaining VA benefits. After 
two funding cycles, VA has awarded $52.5 million in both 2023 and 2022 
to 80 community-based organizations, with only three organizations 
changing from year to year.\2\, \3\
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    \2\ Fiscal Year 2022 SSG Fox SPGP Awards List, available at https:/
/www.mentalhealth.va.gov/docs/SSG-Fox-SPSG-FY-2022-Grant-Awards-List-
508.pdf.
    \3\ Fiscal Year 2023 SSG Fox SPGP Awards List, available at https:/
/www.mentalhealth.va.gov/ssgfox-grants/docs/FY23-SSG-Fox-SPGP-Awardee-
List.pdf.
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    While VA's metrics and impact for this program are in the earliest 
stages of review, our perspective on the SSG Fox SPGP implementation to 
date is largely anecdotal and based on our organizational experience. 
We agree that no one organization - and no single agency - can fully 
meet all veterans' needs. We recognize that empirically supported 
mental health treatment works when it is available and when it is 
pursued, but the best results will be found by embracing a public 
health approach focused on increasing resilience and psychological 
well-being and building an aggressive prevention strategy. WWP is not a 
SSG Fox SPGP grantee, but we support and encourage others to 
participate. In this context, we offer two important considerations for 
the Subcommittee.
    First, organizations that WWP has worked with have expressed 
concern that the SSG Fox SPGP application and compliance requirements 
can be onerous. Although expectations were clearly laid out by VA \4\, 
some participants have shared with WWP that aligning a veteran's 
eligibility with delivery of specific services can be challenging. A 
veteran must meet definitions set out in Section 201(q)(4) of the 
Hannon Act, which includes consideration of a myriad of health, 
environmental, and historical risk factors for suicide. While 
acknowledging these predispositions are important in early and direct 
conversations about suicide, approaching such considerations without a 
foundation of trust can sometimes discourage veterans from being honest 
with their responses or willing to accept and engage in services. 
Allowing some time to foster a relationship enables engagement in 
difficult conversations that stem from place of care and compassion, 
rather than obligation. Navigating discussions in such a way can foster 
more immediate connection to services that mitigate their risk for 
suicide and reduce emergent needs while also making the delivery of 
those services ineligible for grant purposes. Others have noted that 
the high volume of veteran assessments required can induce incentives 
(like providing small gifts) for completion that may skew the quality 
of data gathered and what practices are sound under the premises of the 
grant. We encourage more investigation into how administrative 
practices can better align with the intended purpose of connecting more 
veterans with support.
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    \4\ Funding Opportunity: Staff Sergeant Parker Gordon Fox Suicide 
Prevention Grant Program, 87 Fed. Reg. 22630 (Apr. 15, 2022).
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    Second, the provision of clinical care under this grant program - 
generally not permitted beyond emergency treatment - should be more 
grounded in practical considerations for delivering veterans evidence-
based mental health care. Currently, when grantees are treating 
eligible individuals at risk of suicide or other mental or behavioral 
health conditions, the grantee must refer that individual to VA for 
follow-on care. If they do not, any care given is at the expense of the 
grantee.\5\ However, some veterans are not comfortable receiving care 
at VA for a variety of reasons. This puts the grantee in a difficult 
situation where they are forced to stop providing care or provide care 
at their own expense, something many programs may be unable to afford. 
Additionally, if a grantee is a part of VA's Community Care Network, 
they are still required to get additional VA authorization to provide a 
veteran follow-up care. We would ask the Subcommittee to consider if 
there are ways this process can be improved so that more veterans at 
risk of suicide can be connected to care they know and trust as soon as 
possible.
---------------------------------------------------------------------------
    \5\ Id.
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    As the Subcommittee continues its oversight of the SSG Fox SPGP, 
WWP remains supportive of this critical new asset to assist veterans 
and their families lead healthy and fulfilling lives. We appreciate the 
support that Congress has provided both in authorizing this program and 
continuing appropriations, and we are grateful for this opportunity to 
provide our perspective on how this program can be improved over the 
duration of the pilot period and beyond. WWP stands by as your partner 
in meeting the needs of all who served - and all who support them. We 
are thankful for the invitation to submit this statement for record and 
stand ready to assist when needed on these issues and any others that 
may arise.
                                 ______
                                 

  Prepared Statement of D'Aniello Institute for Veterans and Military 
                 Families (IVMF) at Syracuse University

Background

    Successfully addressing and preventing veteran suicide requires a 
comprehensive and holistic approach at the individual, community, and 
policy levels. This collective approach must include addressing the 
variety of upstream, non-medical drivers of mental health that 
contribute to a veteran's overall health outcomes and risk of suicide. 
Examples of non-medical drivers of health include socioeconomic status, 
financial strain, housing stability, food security, and access to 
reliable transportation. The complex nature and interactions of these 
contributing factors present multiple opportunities to intervene when a 
veteran is at risk of suicide. At each of these steps, community-based 
organizations and government agencies have the chance to prevent 
further deterioration of the veteran's health by providing resources to 
meet the veteran's material and non-material needs. Due to their long-
standing presence and trusted partnerships, non-profit community-based 
organizations (CBOs) are particularly well poised to intervene and 
assist veterans who are at risk of suicide.
    Established in 2020 with the passing of the Commander John Scott 
Hannon Veterans Mental Health Care Improvement Act, the Staff Sergeant 
Parker Gordon Fox Suicide Prevention Grant Program (SSG Fox SPGP) plays 
a vital role in addressing the pressing issue of veteran suicide in the 
United States. By providing funding to CBOs to address underlying 
causes of veteran suicide in addition to facilitating referrals for 
clinical care, the SSG Fox SPGP recognizes the complex nature of 
factors leading to veteran suicide and takes meaningful action to 
partner with and support communities in the prevention effort.
    In September, the D'Aniello Institute for Veterans and Military 
Families (IVMF) at Syracuse University hosted several events in 
recognition of National Suicide Prevention Month at the National 
Veterans Resource Center. In addition to local attendees, we invited 
our community partners that are recipients of the SSG Fox SPGP to join 
in person. During the gathering, we convened a roundtable where SSG Fox 
SPGP grantees had the opportunity to share valuable insights on both 
the program's successes and the challenges it faces. The feedback 
provided in this document represents the collective viewpoints of 
eleven grantees from across the country who actively engaged in this 
discussion.

Eligibility

    One topic the roundtable participants discussed related to 
eligibility was restrictions based around level of risk. Participants 
noted that these restrictions prevent them from potentially capturing 
high-risk individuals who don't meet the administrative eligibility, 
such as the 24-month requirement. The potential expansion of the SSG 
Fox SPGP to support additional populations.
    Participants also recognized instances where individuals scored 
within an eligible range for some assessment metrics but fell short in 
others, leading to disqualification from SSG Fox SPGP intervention. For 
example, grantees noted that individuals who score high on psychosocial 
assessments but not on the Columbia Suicide Severity Rating Scale (C-
SSRS) still present a potential risk and should be eligible. In a few 
more dire cases, despite exploring other avenues to assist these 
individuals, communities reported they had witnessed tragic outcomes, 
including suicide. Our discussion emphasized that understanding the 
motivations behind individuals declining assessments could lead to a 
more comprehensive approach.
    Grantees also highlighted constraints to eligibility regarding 
covered services. They raised significant concerns about barriers to 
entry into the SSG Fox SPGP, both in terms of outreach and getting to 
the point of screening. Many individuals struggle with transportation, 
as it isn't covered until a client becomes officially enrolled in the 
program. Others are more responsive to initial outreach efforts that 
are more social in nature, rather than focused specifically on mental 
health. Providing veterans with material resources such as food and 
transportation assistance simultaneously reduces risk factors and 
builds trust with individuals in their communities.
    Additionally, specific barriers were recognized as potentially 
addressable by non-SSG Fox SPGP funding, such as the Supportive 
Services for Veteran Families (SSVF) for housing. Still, these programs 
may have their own entry challenges, and keeping track of different 
federal funding sources for similar activities can be burdensome.
    One other topic that arose was the idea of expanding populations 
eligible for the program. These populations might include Reservists, 
National Guard members, and even family members. For example, if a 
veteran enrolled in SSG Fox SPGP dies by suicide, their spouse may 
subsequently experience suicidal ideations. However, the program is 
currently unable to provide the needed support.

Screening

    In addition to the eligibility side of screening, a range of 
crucial issues regarding screening tools and process emerged. While 
supportive of the selected assessments in general, as noted above, 
grantees want to eliminated situations where a veteran would be 
automatically disqualified despite the potential risk still present. 
This dilemma prompted discussions on how to make the screening process 
more comfortable and conducive to open conversations, as well as 
addressing its labor-intensive and formal nature. Suggestions included 
actively seeking feedback from grantees to enhance comfort, promoting 
organic and conversational interactions, involving non--clinicians in 
the screening process, and exploring ways to distill necessary 
information from more natural conversations.
    One of our presenters in another session (Joe Geraci, PhD, Director 
of the Transitioning Servicemember/Veteran and Suicide Prevention 
Center at the VISN 2 MIRECC) shared a 17-question screener used by his 
team, which includes the C-SSRS questions. Many participants seemed to 
believe this screener would be a valuable asset, relative to the host 
of other screeners currently part of SSG Fox SPGP.
    Participants acknowledged that screenings are subjective and 
contingent on a client's truthfulness, adding to the complexity of the 
process. There's also a culture clash between current military culture 
and openly discussing mental health. To overcome this hurdle, grantees 
stressed the importance of finding effective ways to communicate in the 
language of the service member and to reshape their perspective on 
mental health. In light of these challenges, participants and our team 
underscored the trusted standing that CBOs hold within their 
communities, and how they play a critical role in engaging with 
veterans and creating the space they need to obtain support and 
assistance.
    And last, while the Fox grantees' programs and interventions differ 
from one another, the screening tools and eligibility criteria are 
uniform. Many of the participants expressed interest in collaboration 
and efforts to share resources more effectively, particularly when a 
practice was working well in one community but not another.

VA Referrals & Process

    The process of referring eligible individuals to the VA has 
revealed both successful practices and areas necessitating improvement. 
One success reported was direct collaboration between the VA and the 
grantee, where they were able to work directly with the Suicide 
Prevention Coordinator (SPC) to create procedures for enrollment. These 
actions not only streamlined the referral process, but also enhanced 
understanding of the VA's capacity to accommodate these referrals.
    However, there have been notable challenges in the referral 
process. Though well-intentioned, the Office of Mental Health and 
Suicide Prevention has sometimes fallen short in ensuring local VA 
Medical Centers (VAMCs) follow programmatic guidance and intent. 
Successful collaboration with SPCs as described above was the 
exception, and levels of support seem to vary highly from VAMC to VAMC. 
Even where partnerships were strong, they were not stable in the event 
of turnover.
    Furthermore, VAMCs may not have the readiness to accommodate 
referrals through this channel. Suicide Prevention teams, often 
stretched thin, have cited capacity constraints. Another critical issue 
is the absence of a specific code in the intake to identify SSG Fox 
SPGP participants, leading to delays in care due to administrative 
hurdles. There is also a need for improved tracking of clients' 
treatment history across different systems to streamline the referral 
process and ensure seamless coordination between the VA and CBOs.
    Grantees also noted that the referral process would benefit from 
being more bidirectional, particularly at the point where patients may 
be discharged from VA care. Communities faced discrepancies in whether 
their local VA was willing to take the appropriate steps to authorize 
releases of information. They noted that the services they are able to 
provide can often make an enormous difference to veterans' experiences 
managing their mental health and day-to-day lives.
    Overwhelmingly, our partners remained positive about the potential 
of the SSG Fox SPGP. They believe that by continuing to buildupon the 
partnerships with CBOs through the program, the VA can continue to 
provide comprehensive care for veterans that aims to address root 
causes of health and wellness that allow veterans to thrive.

Data Collection & Sharing

    While grantees acknowledged ongoing improvements from the VA and 
MITRE, data collection remains a challenge. One prominent issue 
revolves around the lack of clarity on how the MITRE dashboard will 
display important and relevant information. Grantees agreed it feels as 
if they're sending data off without a clear sense of how it will be 
shared or utilized. Participants also emphasized the necessity for more 
immediate feedback and quicker turnaround on screening scoring. Others 
suggested more flexibility in the required data forms, depending on any 
changes that may come to screening process requirements.
    We also noted other missed opportunities to capture meaningful 
data. For example, while this program is in its early stages and 
therefore still improving, it would be beneficial to track individuals 
who score high on psychosocial assessments but zero on the C-SSRS 
screening, those who screen positive but face administrative-caused 
ineligibilities, and those who refuse assessments. There is also a 
desire for more comprehensive data on those screened but not deemed 
eligible, including insights into their circumstances. Participants 
have expressed a perception of limited interest from the SSG Fox SPGP 
data team regarding information on individuals who do not strictly meet 
the eligibility criteria. Additionally, they expressed concern over the 
omission in collecting information about why individuals withdraw from 
the program. There was a strong willingness to collect and share this 
type of information with the VA, if more data was available in return.
    As a final point on data collection and reporting, grantees 
conveyed the complexity with managing multiple federal grants that have 
specific coverage and measurement requirements. There was wide 
agreement that there is an opportunity to increase efficiency and 
consider the ways in which data can be standardized and aligned 
throughout the process of administering different programs.
    In response to data challenges, programs have undertaken their own 
tracking and documentation of program data to understand the broader 
context better, integrate into their other operations more effectively, 
and address the pain points described above. We know that robust and 
accessible data is necessary to effectively address the underlying 
causes of poor mental health and veteran suicide. Both the IVMF and our 
partners strongly hope that data from SSG Fox SPGP is collected 
thoughtfully, incorporated into meaningful analysis, and transparently 
shared.

Conclusion

    We thank the Committee for the opportunity to share these insights 
and for its continued focus on the target and shared goal of preventing 
veteran suicide. The SSG Fox SPGP provides the needed support to CBOs 
to address upstream factors of mental health that contribute to a 
veteran's risk of suicide. We look forward to seeing how veteran health 
continues to improve with the incorporation of this feedback to 
strengthen the SSG Fox SPGP and ensure its long-term viability and 
sustainability.

                                 [all]