Answering the Call: Examining VA’s Mental Health Policies

1[House Hearing, 119 Congress]2[From the U.S. Government Publishing Office]34                   ANSWERING THE CALL: EXAMINING VA'S5                         MENTAL HEALTH POLICIES67=======================================================================89                                HEARING1011                               BEFORE THE1213                        SUBCOMMITTEE ON OVERSIGHT AND14                              INVESTIGATIONS1516                                 OF THE1718                     COMMITTEE ON VETERANS' AFFAIRS1920                     U.S. HOUSE OF REPRESENTATIVES2122                    ONE HUNDRED NINETEENTH CONGRESS2324                             FIRST SESSION2526                               __________2728                       WEDNESDAY, APRIL 30, 20252930                               __________3132                           Serial No. 119-183334                               __________3536       Printed for the use of the Committee on Veterans' Affairs3738[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]3940                    Available via http://govinfo.gov4142                                __________4344                   U.S. GOVERNMENT PUBLISHING OFFICE4561-151                    WASHINGTON : 20254647-----------------------------------------------------------------------------------4849                     COMMITTEE ON VETERANS' AFFAIRS5051                     MIKE BOST, Illinois, Chairman5253AUMUA AMATA COLEMAN RADEWAGEN,       MARK TAKANO, California, Ranking54    American Samoa, Vice-Chairwoman      Member55JACK BERGMAN, Michigan               JULIA BROWNLEY, California56NANCY MACE, South Carolina           CHRIS PAPPAS, New Hampshire57MARIANNETTE MILLER-MEEKS, Iowa       SHEILA CHERFILUS-MCCORMICK,58GREGORY F. MURPHY, North Carolina        Florida59DERRICK VAN ORDEN, Wisconsin         MORGAN MCGARVEY, Kentucky60MORGAN LUTTRELL, Texas               DELIA RAMIREZ, Illinois61JUAN CISCOMANI, Arizona              NIKKI BUDZINSKI, Illinois62KEITH SELF, Texas                    TIMOTHY M. KENNEDY, New York63JEN KIGGANS, Virginia                MAXINE DEXTER, Oregon64ABE HAMADEH, Arizona                 HERB CONAWAY, New Jersey65KIMBERLYN KING-HINDS, Northern       KELLY MORRISON, Minnesota66    Mariana Islands67TOM BARRETT, Michigan6869                       Jon Clark, Staff Director70                  Matt Reel, Democratic Staff Director7172              SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS7374                   JEN KIGGANS, Virginia, Chairwoman7576AUMUA AMATA COLEMAN RADEWAGEN,       DELIA RAMIREZ, Illinois, Ranking77    American Samoa                       Member78JUAN CISCOMANI, Arizona              TIMOTHY M. KENNEDY, New York79KEITH SELF, Texas                    HERB CONAWAY, New Jersey8081Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public82hearing records of the Committee on Veterans' Affairs are also83published in electronic form. The printed hearing record remains the84official version. Because electronic submissions are used to prepare85both printed and electronic versions of the hearing record, the process86of converting between various electronic formats may introduce87unintentional errors or omissions. Such occurrences are inherent in the88current publication process and should diminish as the process is89further refined.90                         C  O  N  T  E  N  T  S9192                              ----------9394                       WEDNESDAY, APRIL 30, 20259596                                                                   Page9798                           OPENING STATEMENTS99100The Honorable Jen Kiggans, Chairwoman............................     1101The Honorable Delia Ramirez, Ranking Member......................     2102103                               WITNESSES104                                Panel I105106Dr. Ilse Wiechers, Deputy Executive Director, Office of Mental107  Health, Veterans Health Administration, U.S. Department of108  Veterans Affairs...............................................     4109110        Accompanied by:111112    Dr. Anthony Stazzone, Chief Medical Officer, Veterans113        Integrated Service Network 9, Veterans Health114        Administration, U.S. Department of Veterans Affairs115116Dr. Julie Kroviak, MD, Principal Deputy Assistant Inspector117  General in the Role of Acting Assistant Inspector General for118  Healthcare Inspections, Office of the Inspector General, U.S.119  Department of Veterans Affairs.................................     6120121                                APPENDIX122                    Prepared Statements Of Witnesses123124Dr. Ilse Wiechers Prepared Statement.............................    23125Dr. Julie Kroviak, MD Prepared Statement.........................    27126127                       Statements For The Record128129NeuroFlow Prepared Statement.....................................    43130American Psychological Association Services, Inc. Prepared131  Statement......................................................    46132Documents for the Record Submitted by The Honorable Delia133  Ramirez, U.S. House of Representatives, (IL-3).................    49134135       ANSWERING THE CALL: EXAMINING VA'S MENTAL HEALTH POLICIES136137                              ----------138139                       WEDNESDAY, APRIL 30, 2025140141             Subcommittee on Oversight and142                            Investigations,143                    Committee on Veterans' Affairs,144                             U.S. House of Representatives,145                                                    Washington, DC.146    The subcommittee met, pursuant to notice, at 10:06 a.m., in147room 360, Cannon House Office Building, Hon. Jen Kiggans148[chairwoman of the subcommittee] presiding.149    Present: Representatives Kiggans, Ramirez, and Kennedy.150151          OPENING STATEMENT OF JEN KIGGANS, CHAIRWOMAN152153    Ms. Kiggans. Good morning, everyone. The subcommittee will154come to order.155    I would like to welcome our witnesses, my fellow members,156and the audience to this hearing of the Subcommittee on157Oversight Investigations. Today we will dig deeper into U.S.158Department of Veterans Affairs' (VA) mental health policies to159gain insight into the processes and quality of care decisions160regarding veterans' mental healthcare. From speaking with161veterans in my district, it is clear that we have a lot of162ground to cover to fix the mental health crisis in the veteran163community.164    Of the concerns I hear most from veterans is how long it165takes to schedule their appointments for mental health166treatments. Delay in mental healthcare in the age of telehealth167is well within our ability to address. Veterans deserve timely168care.169    Despite the VA investing billions into Post-Traumatic170Stress Disorder (PTSD) treatment, suicide prevention, and171alternative approaches to mental health, we continue to lose172too many veterans to suicide. One veteran suicide is too many.173In 2022, 6,407 veterans died by suicide. That is 17 veterans a174day. Unfortunately, it does not stop there. An additional 20175veterans died by self-injury mortality, which generally means176overdose. I have heard horror stories from constituents who177have been prescribed pain medication and told to take more when178they feel bad and less when they feel better. As a provider, I179would not feel comfortable for prescribing two medications that180might interact with one another without first consulting a181psychiatrist. This is unacceptable.182    It is impossible to cover every detail of every case, but183we know that we are losing veterans. Despite a seemingly184endless amount of resources spent, these numbers have failed to185substantially decline. One veteran's suicide, again, is too186many.187    These men and women volunteer to serve their country in a188variety of roles throughout our armed services. They have189answered the call to serve. As a veteran and a nurse190practitioner, it is alarming that we have allowed VA to fail to191move the needle for this long. We must do better. We have tried192to throw more money at the problem; the VA's budget has risen193479 percent since 2001. Yet, despite a shrinking veteran194population, the veteran suicide rate has remained virtually195stagnant. Unfortunately, the VA's own numbers have only shown196that they are doing less with more.197    This is not a question of spending more taxpayer dollars,198but getting veterans what they need when they need it. Making199progress means that we must take a closer look into the VA's200bureaucracy and improve our oversight of the processes and201policies that determine the quality of veteran mental202healthcare. Suicide prevention and veteran mental health are203bipartisan issues. Losing these veterans impacts red states and204blue states.205    I hope this hearing will yield results to important206questions about VA mental healthcare. How are these policies207developed? What steps has the VA taken to adjust this approach?208How does the VA use science and data to improve veteran care?209Most importantly, how can the VA better serve the veteran?210    The answers that we hear today will inform our next steps211to address these urgent issues. Veterans should not have to212wait for mental healthcare and it is our bipartisan213responsibility to ensure the VA has up-to-date policies and is214enforcing these policies to ensure no veterans slip through the215cracks. Again, this is a bipartisan issue and we cannot let216politics stand in the way of making progress.217    There was spirited conversation during our last full218committee hearing on the VA's workforce reform efforts--that219the impact of VA's workforce reform efforts would have on220delivering mental healthcare to veterans. The Secretary has221addressed this misinformation and, let me reiterate, no222mission-critical employees, including those at the Veterans223Crisis Line, have been terminated from the VA.224    I am committed to ensuring that the VA works for veterans225and their caregivers with a functioning, quality workforce.226That being said, I look forward to hearing from our witnesses.227    I now recognize our Ranking Member Ramirez for her opening228comments.229230       OPENING STATEMENT OF DELIA RAMIREZ, RANKING MEMBER231232    Ms. Ramirez. Thank you, Chair Kiggans.233    For many years I worked at a homeless shelter where I saw234case of veterans confronting alone, without anyone to turn to,235mental health challenges. Imagine, after wearing a uniform and236serving our Nation, these veterans were dealing in silence with237the pain of PTSD, depression, substance abuse, and the risk of238self-harm. I am really glad that today we are having this239hearing to truly discuss the necessity of adequate mental240health and suicide prevention screening for veterans.241    The topic of today's hearing really gets to the crux of why242VA and this committee specifically exist. Our responsibility is243to ensure that when veterans need help they are connected to244the clinicians who can provide the care and the services that245they need so that no veteran has to confront these challenges246alone. That is why we cannot have a complete conversation about247mental health and suicide screening at the VA if we are248unwilling to also address the cuts to personnel and the249resources the agency and the work environment clinicians are250currently operating in. We have to look at the entire picture.251    You see, the mental health and well-being of veterans does252not exist in a vacuum, especially when upwards of 30 percent of253the impacted workforce are veterans themselves. The Musk-Trump254fueled uncertainty and the chaos being created for veterans and255VA staff impact the mental health and the well-being of256veterans. We are hearing directly from veterans who are worried257about losing their VA care because of the Musk-Trump cuts. We258know veterans have lost their jobs across the Federal259Government and are now facing the trauma of unemployment due to260this administration. Research shows that unemployment and job261loss puts individuals at increased risk of suicide.262    Let me tell you, being someone that ran a homeless shelter,263who saw veterans who were unemployed, who had no housing264security, I can attest to this. It is really clear to me that265we cannot have a conversation about adequate screening without266also discussing adequate staffing across the VA enterprise. We267cannot talk about adequate intervention without talking about268adequate investment.269    Psychiatrists, psychologists, primary care physicians, and270medical support assistance have long been on the VA Inspector271General's severe occupational staffing shortage list. It is272easy to see how shortages of these positions, which directly273coordinate and provide mental healthcare to veterans, would274affect VA's ability to adequately screen veterans for suicide.275We had a talk about the work environment in which clinicians276are now forced to provide mental health screenings and277treatment.278    Since Department of Government Efficiency (DOGE) and279Trump's April 15 Return to Office order that left facilities280scrambling to find space for physicians, we have heard report281after report from providers who are conducting telehealth282appointments in compromised conditions, from open spaces to283closets to even showers. I can tell you, as someone who served284as the executive director of a social service organization that285served people experiencing trauma and struggling with suicidal286ideation, a shower is not the appropriate place to have these287conversations. Providers are worried about the privacy of288veterans, about the comfort of the veteran in disclosing their289needs, and about having delicate conversations in unfit290environments, and they have every single right to be worried.291It is unacceptable that clinicians are taking their screenings292in a closet.293    Sadly, a VA spokesperson dismissed the concerns about294veteran privacy as nonsensical, saying that the VA will make295accommodations as needed so employees have enough space to work296and comply with industry standards for privacy. We are hearing297directly from clinicians that those accommodations are just not298happening.299    Hypocrisy is a word I feel like I am using a lot these300days. My colleagues do not act concerned about the mental301health of veterans, while ignoring the mental health toll that302the Musk-Trump agenda is taking on them and cheering that303agenda on from the halls of Congress.304    I will close with this. I believe we have an obligation to305ensure that every single veteran access the care they need and306they earned. Secretary Collins and President Trump have turned307their back on LGBTQ+ veterans by shutting the VA's door to308gender-affirming care, which in many cases includes mental309healthcare. That, too, is unacceptable.310    If we want to talk about threats to veterans' mental311health, we have to have an honest conversation about one of the312biggest threats, and that is the Trump administration. Through313their actions, they are creating the kind of anxiety, the314uncertainty, the trauma, and stress that directly and315negatively impact veterans' mental health, their well-being,316and their care. With that, I look forward to this hearing, to317truly forgetting about R and D and putting our veterans first.318That also requires the veterans that are part of the workforce319that protects our veterans.320    With that, Chairwoman, I yield back.321    Ms. Kiggans. Thank you, Ranking Member Ramirez.322    I will now recognize our witnesses on our first panel323testifying before us today. We have Dr. Wiechers, deputy324executive director of the Office of Mental Health of the325Veterans Health Administration (VHA), the Department of Veteran326Affairs. She is accompanied by Dr. Anthony Stazzone, the chief327medical officer of Veterans Integrated Service Network (VISN) 9328at the Veterans Health Administration, Department of Veterans329Affairs. We also have Dr. Julie Kroviak, acting assistant330inspector general for the Office of Healthcare Inspections of331the Office of the Inspector General.332    All the witnesses, please stand and raise their right hand.333    [Witnesses sworn.]334    Ms. Kiggans. Thank you. You may be seated. Thank you. Let335the record reflect that the witnesses answered in the336affirmative.337    Dr. Wiechers, you are now recognized for 5 minutes to338provide VA's testimony.339340                   STATEMENT OF ILSE WIECHERS341342    Dr. Wiechers. Good morning, Chairwoman Kiggans, Ranking343Member Ramirez, and distinguished members of the subcommittee.344I am honored to speak on behalf of the Department of Veterans345Affairs about our work in providing high-quality mental346healthcare for our veterans. My name is Ilse Wiechers and it347has been my honor to serve the past 3 years as the deputy348executive director of the Veterans Health Administration Office349of Mental Health. Joining me today is Dr. Anthony Stazzone,350chief medical officer of the VA MidSouth Healthcare Network.351    I have had the privilege of working with and caring for352veterans as a practicing board-certified adult and geriatric353psychiatrist for the past 15 years. VA's Mission to Care for354our veterans drives us to improve daily. Veterans face unique355mental health challenges, including higher rates of PTSD,356depression, and substance use disorders, all of which357significantly elevate their risk of suicide. Currently, 17.6358veterans die by suicide every day, reflecting a grave public359health crisis that impacts communities nationwide.360    While many veterans are successful and fully integrate back361into society, some experience invisible wounds of war.362Conditions like PTSD, depression, and substance use disorder,363combined with the challenges of life after military service364contribute to an elevated risk of suicide. In response, VA has365developed a broad continuum of mental health services to ensure366veterans receive the help they need. This includes crisis367intervention, same-day access for urgent needs, outpatient,368residential, and inpatient care across VA medical centers,369community-based outpatient clinics, vet centers, the 24/7370Veterans Crisis Line, and a nationwide network of suicide371prevention coordinators, or SPCs.372    VA's Mental Health Services are designed to be accessible,373evidence-based, and recovery-oriented. We emphasize early374intervention, continuous support, and seamless integration of375mental health into overall healthcare. Most veterans utilizing376VA services report positive experiences and satisfaction,377appreciating the availability of essential services, the378privacy of medical records, ease of access, and the379professionalism and courtesy of our VA staff.380    In 2018, VA published the National Strategy for Preventing381Veteran Suicide, emphasizing a public health approach to382suicide prevention. This combines community prevention and383clinical intervention actions to directly serve veterans. Our384commitment to preventing veteran suicide is integrated385throughout all mental health programs and supported by enhanced386staff education and suicide prevention.387    The Secretary has made preventing veteran suicide a top388priority for VA. VA leadership is closely examining all current389suicide prevention efforts and we are committed to challenging390the status quo in order to find new and better ways of helping391veterans. We cannot continue approaches that have failed to392produce meaningful improvements despite substantial resource393investments. Recent reports by the Office of Inspector General394(OIG) have highlighted VA's efficiencies in VA's mental395healthcare intake process and adherence to suicide risk396identification screening. These findings underscore the need to397strengthen initiatives and ensure high-quality care.398    VA has implemented a standardized suicide risk screening399and assessment process known as the Suicide Risk Identification400Strategy, or RISK ID. Completed annually for all veterans401receiving VA care, this process includes a primary screening402using a standardized questionnaire and a comprehensive suicide403risk evaluation for any positive screen. This determines the404severity of suicide risk and helps develop a risk mitigation405plan. To ensure adherence, VHA issued a memorandum requiring406all Veterans Integrated Service Networks to implement RISK ID407requirements by April 7, 2025. In Fiscal Year 2024, VA408completed over 2.6 suicide risk screenings.409    To stay at the forefront of suicide prevention VA410continually updates clinical guidelines and training programs.411In 2024, VA and U.S. Department of Defense (DOD) released a new412Joint Clinical Practice Guideline for the assessment and413management of patients at risk for suicide. Additionally, all414VHA staff must complete suicide prevention training. VA has415also implemented specialty training for SPCs and mental health416clinicians on topics like lethal means safety counseling,417ensuring high-quality care for at-risk veterans.418    VA is taking decisive action to transform the Department's419mental healthcare system for veterans. The path forward420requires VA to embrace innovation, accountability, and proven421practices across every facet of its operations. Meaningful422change requires collaboration within VA and with partners423across government, private healthcare, and veteran424organizations. This whole of society approach is essential to425reach veterans wherever they may be. The oversight from this426committee strengthens VA's work and helps ensure our focus427remains on what matters most: providing veterans the428exceptional care they have earned.429    The VA looks forward to continuing to work with this430committee and we look forward to answering any questions you431may have. Thank you.432433    [The Prepared Statement Of Ilse Wiechers Appears In The434Appendix]435436    Ms. Kiggans. Thank you, Dr. Wiechers.437    Dr. Kroviak, you are now recognized for 5 minutes to438provide your testimony.439440                   STATEMENT OF JULIE KROVIAK441442    Dr. Kroviak. Thank you, Chairwoman Kiggans, Ranking Member443Ramirez. I am grateful for this opportunity to discuss the444OIG's independent oversight of VA's and mental health services.445    The OIG recognizes that meeting the complex needs of446veterans requiring mental healthcare comes with extraordinary447challenges. The Office of Healthcare Inspections routinely448assesses VHA's services and how well they address those449challenges. Our clinical teams regularly make recommendations450to improve VA's delivery of healthcare through reviews of451mental health and suicide prevention programs, inpatient mental452health units, reports of harm to patients at individual medical453centers, as well as inspections of vet centers. OIG454recommendations for corrective action are based on identified455deficiencies and noncompliance with VA policies and established456standards of care.457    As my written statement details, deficiencies can be458grouped into three steps stages of suicide risk reduction459interventions, with the first focused on screening and460assessing veterans' risk. A December 2024 OIG review of VHA's461suicide risk compliance found that in Fiscal Year 2023, the462annual adherence rate was just 55 percent. Interviews revealed463that the reasons for noncompliance included staff feeling464uncomfortable with initiating screening and lack of clarity who465should be overseeing staff compliance. A tragic example of a466failure to properly assess a veteran was documented in an OIG467report that found a veteran's crisis line responder did not468fully assess a caller's alcohol impairment and access to lethal469means. Shortly after the call, the veteran died by suicide.470    The second stage of risk reduction is the effective471management of acute care needed after a veteran's suicide472attempt or ideation. In two separate 2024 hotline reports, our473teams found noncompliance with mandates to remove belongings474from a patient that could be used in a suicide attempt and with475requirements for staff's one-to-one observation for a patient476with suicidal ideation. In both instances, the veterans477attempted suicide during their hospitalization and, tragically,478one died.479    Our mental health inspection teams consistently review the480environment and care practices of VHA's Acute Inpatient Mental481Health Units, repeatedly finding lapses in preparing patients482for discharge. Because the highest risk for suicide occurs483within the first 30 days after hospitalization, VHA staff484should unfailingly carry out activities such as pre-discharge485screening, determinations of access to lethal means, and a486suicide prevention safety plan to confirm that a hospital487discharge is appropriate and safe for each patient.488    Third, while the tragedy of a veteran's suicide can489overwhelm survivors and healthcare teams, lessons learned can490and must support efforts to reduce future suicides. Our work491has identified numerous delays and deficiencies in important492internal VA reviews after a veteran completes suicide,493including root cause analyses, peer reviews, institutional494disclosures, and family interviews. Such delays not only impede495improvements, but also deprive loved ones of important grief496management resources.497    The last report in my statement was published just last498month on the role of VISN chief mental health officers. Across499these 18 regional networks, the chief mental health officers500reported they lack clarity about their role and the authority501to effectively address staff noncompliance. In effect, VHA's502governance structure may contribute to problems with503performance and hinder opportunities for processing504improvements.505    There will never be a single solution to the devastating506problem of veteran suicide. Still, we must continue to work507toward saving every life. That means not losing sight of what508needs to happen today and every day: providing wraparound509services that treat known risk factors for suicide, from510prevention, such as anxiety and depression management,511substance use disorder interventions, PTSD and military sexual512trauma treatments, and grief counseling. VHA providers must513meet veterans where they are and be ready to effectively514intervene during their greatest moments of need. The OIG is515committed to conducting oversight to ensure all veterans have516access to the high-quality and compassionate care they need and517deserve.518    Madam Chair, this concludes my statement. I would be happy519to take any questions.520521    [The Prepared Statement Of Julie Kroviak Appears In The522Appendix]523524    Ms. Kiggans. Thank you, Dr. Kroviak. We will now move to525questions and I yield myself for 5 minutes.526    I just wanted to start with you. You spoke a little bit,527Dr. Kroviak, about staff noncompliance and about the VISN528mental health chiefs being kind of frustrated with their529ability to understand what their role is. Could you expand on530that just a little bit, because I know we have talked about531that in different parts of this committee, and what that looks532like?533    Dr. Kroviak. Yes, I think there is this poorly defined or534lack of clarity in what these critical leaders' roles should be535in place of to being a consultative arm. We just repeatedly536find that when we are in a facility, if there is an issue537brought up, and we go to the VISN to understand their knowledge538of interventions, they either were not aware or felt they could539not intervene because that was not in their authority to do so.540    Ms. Kiggans. Would it be helpful to clarify that authority?541    Dr. Kroviak. We think so. We very much think so. The one542report on the chief mental health officer is one example. We543published other individual hotlines where we really tried to544get that message across, that it was concerning that the545facility was undergoing such trauma and the VISN either did not546know about it or did not effectively intervene or monitor the547events that were occurring.548    Ms. Kiggans. The monitoring is there, but just the549enforcement of what to do once they identify a problem, what550they can--what is the next step they can take?551    Dr. Kroviak. Yes, it becomes unacceptable for this regional552source of expertise to just serve in a consultative role,553waiting to hear about an issue, and we have repeatedly554identified that in the reports.555    Ms. Kiggans. Thank you. Thank you very much for clarifying556that. Then we have all heard the saying if you have seen one557VA, you have seen one VA. My concern here is that all VA558facilities operating off agencywide standardized policies for559mental health. How is it that interpretation and adherence to560VA's mental health policies varies so much between VISNs and561facilities? Either Dr. Wiechers any of you can answer.562    Dr. Wiechers. Thank you for the question. We do have563national standards and policies in place for mental health and564for suicide prevention. The question of why is there variation,565there are several possible causes for that.566    One could be that our policy needs to be better clarified567and written more clearly. That is something that I take568personally to heart and that I am working with my team as we569constantly review and update our policies to ensure that we570have clear language.571    The other could be about ensuring that there is clear572training to help educate the field staff and our colleagues at573the VISN level about that. We work hard to ensure we have those574trainings available and that they are consistent across the575system. We work closely, also, with our VISN partners and our576facility leaders with open communication. We have regular577meetings with our VISN chief mental health officers every week.578Then the VISNs, and I will let Dr. Stazzone say more about the579communication that they have regularly between facility580leadership and VISN leadership.581    I think it is a matter of ensuring we have clear policies582with standard trainings and clear lines of communication. We583are working on all of those things, thanks to the OIG providing584us some opportunities in areas where we may have gaps to focus585on.586    Ms. Kiggans. Could that clarification include role587clarification at the VISN level, what Dr. Kroviak was just588talking about?589    Dr. Wiechers. Yes. I am pleased to report that Office of590Mental Health has already drafted a functional statement and591roles and responsibilities with our partners in the VISN chief592mental health officer role. We look forward to having that role593clarity for everybody across the system in each of the VISNs594very soon.595    Ms. Kiggans. Thank you. Thank you.596    Dr. Stazzone, do you have anything to add?597    Dr. Stazzone. No. I appreciate Dr. Wiechers' comments and,598as she said, at the VISN level our role is to make sure we have599the policies from Office of Mental Health and Office of Suicide600Prevention. We meet regularly with them as well as in the VISN601we have regular huddles, and also meetings regularly with the602facility leadership to make sure those things are going603forward.604    I think it is important that there is some standardization605and understanding authorities across the network. As any606healthcare network, you need to have standard processes and607policies to follow through and our goal is to make sure those608are being followed through to the front lines. Healthcare is a609very complex system and trying to make sure we have the right610processes in place to follow the policies, to make sure our611frontline staff can do the right things and follow through with612those is critically important. Communication across the network613also up to central office and down all the way to facilities is614key. I will speak with VISN 9, we try to do that as much as615possible. Our chief medical health officer reports directly to616me.617    Ms. Kiggans. I am just curious about the communication618flow. I know in my district in Hampton Roads, Virginia, has one619of the largest veteran populations and just practicing in620primary care there, and I know we have many patients who would621receive some level of care at the VA because it entailed great622services that they enjoyed: cheap hearing aids, eyeglasses,623medications, this type of thing. Then they would come to624receive community care from different civilian providers.625    One of my biggest frustrations was just trying to get626patient notes and documents related to my patients, especially627on the mental healthcare side, which I know there is certain628privacy issues with mental health. Even from the civilian629provider side it was challenging to get notes and an accurate630prescribing record, which I thought was perhaps most important,631too.632    How does the VA work with community providers to make sure633that information is shared so providers are making informed634decisions about a veteran's especially mental healthcare?635    Dr. Wiechers. Thank you for that question. The office at636oversees Community Care works with our third-party637administrators in helping manage the network of providers in638the community, and working together to get that information639back is a key area that we need to focus on and I am sure for640the reasons that you have mentioned, because that continuity of641care and that information is really valuable for the providers642back at VA to understand what is happening in the community.643    Ms. Kiggans. Is there a person that goes behind and is644doing that personal follow up, too, with the veteran ensuring645that once they have left the office--just talking about646continuity of care again, that that pace I feel like is where647we lose people a lot of times, especially when we get them in648the door. We them seen, we have a plan of care, we start a new649medication or have a follow-up visit. Who goes behind and makes650sure that, on the compliance side, that that is actually651happening. Is there a process in place for that?652    Dr. Wiechers. I will have to take that back so that I can653make sure I get the most up-to-date information about it.654    Ms. Kiggans. I have always been a proponent, just on the655personal side of it, using home health nurse, especially. I656mean, there is a lot of benefit to a visitor, too, in people's657homes. We have tried to mandate that or make that--it is hard.658We do not have home health providers either, but I just think659that piece or what are we doing with that continuity of care660piece, because they go home and I mentioned in my opening661statements just about veterans who are taking multiple psych662meds.663    I know you all understand what that interaction piece looks664like. It frustrates me when I have surviving family members665that will show me bags of medication that they do not know what666this is. It was a combination of things that they would, again,667take more if they felt worse and less if they felt better.668There was some disconnect between when these medications--a lot669of disconnect between when these medications were prescribed,670how they got to be lumped together, you know. Then it just goes671back to the communication flow, which is a source of672frustration for me673    Again, on the civilian provider side, I think an, you know,674electronic health record may be a helpful thing. We will keep675working through that. Just that communication piece, that676follow-up piece, that continuity and care piece, along with677moral clarification and all the other things that I know you678all are focused on in talking about, that piece is just679important to me personally.680    My time has expired. I will yield to my ranking member.681    Ms. Ramirez. Thank you, Chair. I want to thank you all for682being here again. Really appreciate it.683    Dr. Wiechers, I want to specially thank you for being here684today. Behind me in a moment you will see are the instructions685that accompanied a rubric VA supervisors were required to fill686out justifying why their employees should not be subject to the687agency's planned reduction in force, or what we call the RIF.688Supervisors, who are clinicians themselves and who manage689employees providing mental healthcare, were obligated to fill690out this rubric. As I look at it, having been a manager myself,691I find it absurd that the VA could measure mental health692providers' value and justification through these very limited693scales.694    Dr. Wiechers, these instructions require supervisors to695provide one to two sentences explaining their special skills,696their competencies, and their institutional knowledge for Their697positions. How would you fill out this for a mental health698provider and the support staff the provider relies on?699    Dr. Wiechers. Thank you for that question. I cannot really700speak to a hypothetical. I would have to have an example of a701specific individual provider to be able to answer the question.702I am just seeing the information that you are providing now in703terms of the details. I would respectfully like to take that704back and would be happy to take any specific questions you have705and report back afterwards.706    Ms. Ramirez. Thank you for that. Let me just be clear, Dr.707Wiechers, this was provided to supervisors already, so this708rubric is already available and I am concerned that you would709not have seen it prior. Let me ask you this. Do you think one710to two sentences fully capture a provider or their support711staff importance to the mental health and well-being of712veterans?713    Dr. Wiechers. I think that our mental health providers are714invaluable resources to our veterans. Obviously the work that715they do is complex and is something that is hard to capture in716one to two sentences. Nonetheless, I can appreciate the need to717have a rubric to make decisions.718    Ms. Ramirez. Following up on that, the rubric is there.719Supervisors have to take time to fill this out. Can you explain720to me why supervisors, many of whom are clinicians themselves,721were required to take time away from patient care to fill out722this rubric?723    Let me add a little more. Some providers reported they had724to fill this out for over 300 employees, this rubric, and725spending some time trying to figure out how in one sentence at726most, they could be able to explain the negative service impact727of letting that staff person go. I just do not understand.728    Tell me, do you think it is a good use of a clinician's729time to perform administrative tasks that justify the critical730nature of their employees' jobs instead of using their time to731provide mental healthcare for veterans?732    Dr. Wiechers. I think putting veterans first is the most733important thing that any one of our employees does. Putting the734ongoing and sustaining mission and the work that we do is what735is most important.736    Ms. Ramirez. I agree, Dr. Wiechers. We are also here to737discuss ways that VA can better screen veterans to ensure that738no veteran dies by suicide. I have another follow-up question739for you. Will the VA provide gender-affirming care if it saves740a veteran from suicide?741    Dr. Wiechers. The Department has made changes to a742provision of hormone therapy related to transgender patients,743but those who have been receiving that service and continue to,744as well as servicemembers who are transitioning into veteran745status who are eligible for VHA healthcare. All of our mental746health services and preventive health services remain available747for all veterans who are eligible for VHA care.748    Ms. Ramirez. What you are saying, Dr. Wiechers, is that the749VA will provide that gender-affirming care if it saves a750veteran from suicide?751    Dr. Wiechers. I am saying that the VA is providing services752based on the new policy and that mental health services and753preventive medical services remain available to all eligible754veterans.755    Ms. Ramirez. Okay. Well, let me pivot for a second here. I756know my time is up soon.757    Dr. Kroviak, what are the top five clinical severe758occupational staffing shortages the Inspector General759identified last year?760    Dr. Kroviak. Offhand I do not know the top five, but I do761believe the top ones were nurses, physicians, mental health, in762particular, psychologists, and psychiatrists.763    Ms. Ramirez. Got it. Since I only have 15 seconds, Dr.764Wiechers, are you aware of the VA barring staff in the field765for performing their assigned duties to do veteran outreach766within their community? Yes or no?767    Dr. Wiechers. I am not personally aware of that. If you768have examples, please share and I would be happy to look at it.769    Ms. Ramirez. Okay. Just to wrap up, just to put on record,770in Chicago, we know that the VA staff are told to no longer go771out to the ward offices to do veteran outreach. I guess my last772question to you is, do you agree that meeting veterans where773they are is a central component to suicide prevention?774    Dr. Wiechers. Yes.775    Ms. Ramirez. Thank you. With that I yield back.776    Ms. Kiggans. Thank you. We are going to do another round of777questions. I just have a couple more since we have a little bit778of time.779    Dr. Wiechers, could you please explain what policies the VA780has reviewed since January to ensure better communication and781procedures for servicemembers transitioning to VA care? I know782we had a change of administration. We have a new VA Secretary.783What improvements have been made to care coordination between784the DOD and VA? What do you feel like we should be focused on785moving forward?786    Dr. Wiechers. Thank you for that question, ma'am. The VA is787working closely with our partners in DOD on transitioning788servicemembers. That is work that is been ongoing for some time789and continues to this day. I think ensuring seamless transition790from servicemember to veteran status is important. In791particular, ensuring that we have continuity of mental792healthcare, especially for those who may be receiving793medications or therapy, treatment as servicemembers, and794ensuring that we get them transitioned as smoothly as possible795to receiving those services at VA.796    Ms. Kiggans. Is that happening? Is that happening where797there is a flawless transition or a seamless transition with798charting and records?799    Dr. Wiechers. We are working to ensure that it happens800smoothly for everyone. We have lots of folks working together801with out colleagues in DOD to help ensure that that is taking802place.803    Ms. Kiggans. Okay. Tell us what you need and what we can be804helpful with to make that happen. I think that transition piece805is critical and challenging in so many ways, but I think with806the mental healthcare case we should prioritize that and we owe807that to our veterans, especially now.808    Can you talk to me, Dr. Kroviak, about just staffing?809Staffing. Do you feel like there are issues with staffing810shortages? There is a lot of talk, a lot of misinformation, a811lot of fear mongering. I do not believe that.812    Then, also, could you talk to me a little bit about your813use of advanced practice nurses and if you feel like they are814being best utilized in the mental health environment?815    Dr. Kroviak. In terms of staffing, you are right. We have816not seen the Secretary's plan for what the actual final817staffing cuts or decreases in staff will be, but we report818annually on clinical staffing shortages. That is a819congressionally mandated report. We are doing our work on that820now and that will be published probably by the end of the821summer. Those are perceptions at each individual facility level822as to what the most critical clinical and nonclinical shortages823are.824    A reminder that it is so important the staff member that825meets with the patient, but in that arrangement there are826multiple backstage staff who are coordinating so many827activities to ensure the effectiveness of that meeting between828the provider and the patient.829    The work we do on our cyclical reviews, hotlines,830nationals, we will capture when there are staffing concerns. We831might go in for an allegation specific to substandard care and832find out that the staff are reporting ineffective staff, too833few staff, prolonged vacancies. Our work will continue to ask834those questions, and we will absolutely report the findings.835    Then your question about nurse practitioners, we have not836looked specifically at their use or barriers to using them more837so in mental health arena, but we know they are used across the838system. With the shortages of providers within VA and without,839I cannot imagine that there is not an increased need to840encourage their participation in that care.841    Ms. Kiggans. Yes, and they are a great source of, if I842might add, of being able to fill those gaps in care. Please843make sure we are utilizing all of our advanced practice nurses844as well. Hampton VA, which is the VA facility near my district,845a lot of challenges we are working through, but when I have had846the opportunity to visit and on the mental healthcare side, I847think they do a great job and I hear great things about that848piece. There are some other pieces we could work to do better,849but I am thankful for that and I hope that all VA facilities850are prioritizing that care. I know it takes a team. This is not851just a provider. That is an important piece and making sure our852providers are supported is important, too, when we think about853staffing. That is good.854    Providing that reassurance, and I know Secretary Collins855has done a good job throughout the country really. He has been856down to Hampton Roads, but other places as well, just857reassuring people that we are focused on staffing. We have858picked up the phone, make sure we are focused. We are going to859be protective of the actual provider piece, the nurses, the860physicians, the allied heart health partners, who touch our861patients. Just, again, providing that reassurance piece I think862is important.863    I wanted to have each of you, if you do not mind, talk864about just alternative treatments for mental health. I think865that everyone responds differently and we need to meet the866veteran where they are at. We have done some discussions in867this committee talking about alternative treatments from868psychedelics to Electroconvulsive Therapy (ECT) to different--869you know, there are a variety of treatments out there.870    Can each of you respond just about how you feel that is871going in the VA? Is there room for improvement? I feel like we872need to do more and probably quicker about, again, meeting the873veteran where they are at, what do they respond to? but I am874just curious as to your opinions.875    Dr. Wiechers. Thank you for that question. The VA has been876growing its use of what we call the somatic treatments. Those877are things like ECT, transcranial magnetic stimulation,878ketamine infusions, and intranasal S ketamine. Over the last 5879to 7 years we have seen growth and expansion across the system.880Could we do more? Yes. We continue to try to expand access to881those, both in direct care and also through referral to882community providers.883    We have, as I know you are aware, we have announced an884Request for Application (RFA) for funding of psychedelic885research and that is something that continues moving forward at886VA. We also have studies ongoing for stellate ganglion block,887excuse me, and other kind of emerging therapies as well. I888think we are doing a lot in the research space and the889innovation space. Then in terms of our existing standards of890care for difficult to treat depression or other types of mental891health conditions that fail to respond to initial courses of892treatment, we have a menu of options available to veterans and893we are working on expanding access to those.894    Ms. Kiggans. Good. Thank you.895    Dr. Stazzone. Thank you, Madam Chair. As Dr. Wiechers said,896we look at evidence-based therapies to make sure we are doing897the right things for the veterans that has been proved898effective. There is lots of research in the VA as well. I will899say our geriatric research centers also have research into900dementia and psychosis as well for mental illness in geriatric901populations, which is important.902    At this time, treatment-resistant depression, I will speak903for VISN 9. We are try to implement three modalities of904treatment, ECT, transcranial magnetic stimulation, and ketamine905infusion, at all of our sites. All veterans have access to the906most up-to-date and evidence-based treatments. I know there is907much research going on, as Dr. Wiechers already spoke about,908and as those new studies come forward with possibilities, you909know, we will adapt those with evidence-based treatment.910    Dr. Kroviak. I will say from an oversight perspective911nobody does mental healthcare like VA. They are absolutely912pioneers in this field, and we are very encouraged by the913previous, ongoing, and forward-looking research that continues.914I hate to say it, but we look forward to doing oversight work.915    Ms. Kiggans. Yes, and I appreciate you are just always916working to expand the treatment options for veterans and on the917geriatric side, too. I mean, I think that is a whole other918discussion probably for a whole other committee. I feel like919there is not enough focus on that. Our veterans are older920adults usually and geriatrics is technically over the age of92165. That is a large, probably, percentage of our veteran922population. I know at the Hampton VA, we had one geriatrician923on staff and that was not enough and she had some great nurses924working with her. Focus on that piece and thank you.925    I think we could always have more when we talk about926studying dementia as a cognitive impairment. That was my927specialty as a geriatric nurse practitioner. But I just in my928perfect world, yes, we have a whole other section of the VA929that focuses on geriatrics. We talk a lot about mental health930and another just personal passion project of mine, but on the931geriatric side we do not have advocates for older adults and932their specific needs for the patient and for their families and933caregivers. We will table that for now, but look forward to934future discussions about taking care of our older adults.935    With that, I will move to my ranking member if she has any936last questions.937    Ms. Ramirez. Thank you. I just want to follow up.938    Dr. Wiechers, as the chair mentioned in her opening,939overdoses claim too many veterans' lives. Do you think that940Narcan saves lives?941    Dr. Wiechers. Yes.942    Ms. Ramirez. Will the Trump administration cuts to Narcan943funding lead to more overdose deaths, including veteran deaths?944    Dr. Wiechers. I cannot speak to hypotheticals.945    Ms. Ramirez. You do agree that Narcan saves lives and we946should have adequate funding to be able to continue to provide947it?948    Dr. Wiechers. I agree that Narcan saves lives and the VA's949overdose education and naloxone distribution program has been950award-winning and has saved many veteran lives.951    Ms. Ramirez. All right. Well, let me shift here then for a952second to talk more about it. Can you please describe the953partnership between the Substance Abuse and Mental Health954Service Administration, or what we call SAMHSA, and the VA?955Follow up with the second part of it. How does that partnership956improve mental health treatment and support services for957veterans?958    Dr. Wiechers. What I can speak to is the partnership that I959personally have been engaged with colleagues at SAMHSA in as it960relates to ongoing work in our development of strategic plans961for psychedelic treatments. I believe that our partnership is962strong and the connection between our two agencies helps both963SAMHSA and our veterans at VA.964    Ms. Ramirez. Are you concerned that cuts at SAMHSA will965affect the VA's ability to provide services to veterans966suffering from substance abuse disorder and other mental health967challenges?968    Dr. Wiechers. I believe that the VA will continue to969provide high-quality access to substance use disorder drug970treatments and for mental health treatments for its veterans.971    Ms. Ramirez. Okay. Let us get a little bit more into that.972I want to know how you are going to do that. How will the VA973fill in the gaps if SAMHSA is gutted?974    Dr. Wiechers. I will have to wait and see. Again, I cannot975provide response to hypotheticals. We will adapt and ensure976that all of our veterans continue to have access to Substance977Use Disorder (SUD) treatment and mental healthcare.978    Ms. Ramirez. Yes, but, Dr. Wiechers, I hear you say that979you cannot work on hypotheticals. You should be planning. As980you are already hearing, there is going to be cuts to981particular programming. For me, if we are having real982conversations about ensuring that veterans have the resources983they need, then you should already be planning on coordinating984what you are going to do to fill those gaps. You are telling me985that you will be prepared to be able to ensure that veterans986continue to get the resource they need. It is hard for me to987hear you say you are prepared to ensure that we continue to988provide the resources, we have the partnerships we have, but989you are not doing any planning.990    I think that is part of the challenge that we have seen,991particularly in this committee, is that there is no adequate992planning or even real strategic consideration when we are993talking about letting staff go. We really have to be asking994ourselves, when we are making these major decisions and shifts995and changes, what will the impact, in fact, be for our veterans996and what are we doing in advance to ensure that the veterans997that we say that we serve are not impacted by it? I have to say998that as you say that, it is really difficult for me because you999can keep saying I cannot really plan a rhetorical, but if you1000are not actually planning for things you already know that are1001coming, then that is a concern for me, especially as we know1002how critical the work of this committee is in oversight.1003    Let me come back to something real quick that I started1004talking about at the end and, with that, I will yield back to1005the chair. I mentioned to you that the VA is barring staff in1006the field from performing their assigned duties to do veteran1007outreach within their community in a number of locations. We1008have invited the VA to come to some of the outreach events that1009we do, particularly around housing, healthcare, and other1010resources. I submitted a letter March 6, asking why this is1011happening. You said you were not aware that this was happening.1012I want to make sure that on the record I know that I submitted1013a letter over a month ago and I have not received the response.1014I wonder if, by any chance, do you know that a letter was sent1015and if you know there is an update on when I can expect a1016response?1017    Dr. Wiechers. Thank you for the question. I will take that1018back and we will get into it for an answer as to when you can1019expect your response.1020    Ms. Ramirez. Thank you. Appreciate that.1021    With that, I yield back to the chair.1022    Ms. Kiggans. Thank you. I have no further questions.1023    Ranking Member Ramirez, do you have any closing remarks?1024    Oh, I am sorry. Well, we have a new member just joining us,1025so we will recognize Congressman Kennedy for 5 minutes and then1026we will close.1027    Mr. Kennedy. Thank you very much. Thank you all for being1028here today, for your service to this country, for your1029testimony.1030    Before entering public service, I served as an occupational1031therapist. My work focused on helping people navigate the1032challenges of daily life and understanding that health is not1033just about physical recovery, but it is also about mental and1034emotional well-being. I saw firsthand how addressing mental1035health is just as critical as treating physical conditions.1036Without quality mental healthcare, true healing is incomplete.1037Our veterans deserve no less, as we know.1038    I am deeply concerned that VA's and mental health services1039are not meeting the rising demands of veterans. Because of1040reckless cuts by this administration, instead of much-needed1041investment in our bravest, veterans are facing long wait times,1042workforce shortages, and barriers to accessing a full range of1043services that they need. If we are truly committed to honoring1044our veterans' service and sacrifice that they have made, we1045have to ensure quality, timely mental health support at the1046gold standard level of care alongside their physical care.1047    With that, I have a few questions. You know, first and1048foremost, the VA and this administration are now forcing1049employees, many of whom were hired as remote workers, to return1050to office. Dr. Wiechers, was the VA aware of the space1051constraints for mental health providers before ordering them to1052work in the office?1053    Dr. Wiechers. Thank you for the question, sir. We have a1054process in place to review at each of the local facilities the1055space available before any Return to Office orders are1056submitted to employees to return. The space available is being1057considered as we return people to office.1058    Mr. Kennedy. Is the agency concerned about the Health1059Insurance Portability and Accountability Act (HIPAA) violations1060as providers of reported staff overhearing sessions and the1061lack of privacy after being placed in congregate settings?1062    Dr. Wiechers. All of our facilities and providers are held1063to the highest legal and ethical standards related to privacy1064and we have processes in place. Should people be concerned that1065the space they have available is not suitable for privacy1066concerns for the care that they are providing, we have1067processes at each of the facilities that allow other those1068staff to report those concerns so that they can be addressed1069and ensure that privacy of our veterans is held sacred, as it1070should be.1071    Mr. Kennedy. Thank you. Dr. Wiechers, on March 4th it was1072announced that the VA planned to eliminate over 80,000 jobs,1073which would certainly include mental health providers.1074Thankfully, that directive is now on hold. Since the VA is1075already facing a shortage of mental health providers, how does1076the Department plan provide responsive mental health services1077in light of these cuts? Were you consulted before the1078announcement of these cuts?1079    Dr. Wiechers. Thank you for the question, sir. There are108030,000 frontline provider and staff positions that are exempt1081from the hiring freeze and other actions. Included on the list1082of those 300,000 staff providers are all of our different types1083of mental health providers. Psychologists, psychiatrists,1084social workers, marriage and family therapists, Licensed1085Professional Mental Health Counselor (LPMHCs), peers, all of1086those folks and our frontline mental health providers are on1087the exemption list.1088    Mr. Kennedy. Is there hiring taking place right now?1089    Dr. Wiechers. There is hiring taking place right now. I1090believe Dr. Stazzone can speak explicitly about VISN 9.1091    Dr. Stazzone. Thank you, Dr. Wiechers. Thank you,1092Congressman. Yes. As Dr. Wiechers said, 300,000 positions were1093exempted from the hiring freeze. There is ongoing hiring for1094those positions. In VISN 9 we have a dashboard for workforce1095management that list the vacancies. We follow through with1096those and continue recruitments for all the frontline positions1097that are exempted.1098    Mr. Kennedy. While there is hiring that is taking place,1099are these folks being onboarded?1100    Dr. Stazzone. Yes, Congressman.1101    Mr. Kennedy. Can you commit to sending this committee data1102on the number of employees and occupations that have been1103onboarded since January of this year?1104    Dr. Stazzone. Yes, I will take that back Congressman for1105all employees. I can only speak to VISN 9, but there is a1106dashboard from workforce management. I believe they can get you1107those numbers.1108    Mr. Kennedy. I think it is vitally important that we have1109that data. It is one thing to make an argument that there are1110exemptions while there are tens of thousands of potential cuts1111and we need to know what those exemptions are, where they are.1112If there is an argument that there is hiring that is taking1113place, we need to know if those people are actually being hired1114and onboarded and put to work rather than just put into a1115process and not to be brought onboard. It is very important1116information. We would appreciate you bringing that to us.1117    Madam Chair, I yield back.1118    Ms. Kiggans. Thank you. Now we will move to our closing.1119    Ranking Member Ramirez, do you have any closing remarks?1120    Ms. Ramirez. Thank you, Chair. I want to ask as we are1121wrapping up unanimous consent and to a few of news articles1122related to veterans' mental health into the record: from1123Reuters, on democracy, the New York Times, NPR, The Hill,1124Military.com, and NBC News.1125    Ms. Kiggans. So ordered.1126    Ms. Ramirez. Thank you. I would also like to ask for1127unanimous consent to enter six testimonials from veterans whose1128mental health is being affected by the cuts to the VA workforce1129and their ability to receive care.1130    Ms. Kiggans. So ordered.1131    Ms. Ramirez. Thank you. I want to end by reminding my1132colleagues that in order to honor our veterans' service with1133action we must defend and protect their access to mental health1134services. That starts by making sure that mental health1135providers are available.1136    I look forward to our work and the follow ups we will get1137from the witnesses today. Thank you.1138    With that, I yield back.1139    Ms. Kiggans. Thank you. For my closing remarks I just want1140to thank the witnesses for coming in to testify today. We have1141gained better insight into the VA's mental health policies, the1142effectiveness of the services they provide to veterans, and how1143you are working to improve these processes. Thank you very much1144for clarifying about the mental health providers and partners1145that are exempt from the cuts and hiring freezes.1146    We have said this time and time again, straight from the1147Secretary's mouth, thank you very much for your presence here1148today and to clarify that. We will continue to clarify that and1149to remind our veterans that mental healthcare and their health1150care in general remains a priority. I have personally picked up1151the phone multiple times to ensure that these positions are not1152being cut so I can provide some personal validation to them as1153well. Thank you very much for putting that on the record.1154    We all know that while the VA has worked hard to provide1155support for mental health challenges, our veterans continue to1156struggle. We also know that providers are working hard. I1157wanted to say a special thank you to them because they are1158often an underappreciated group; our physicians, our nurses and1159all of our allied health partners and their staff who work so1160hard every single day.1161    We cannot let fearmongering or partisan politics get in the1162way of achieving results for our veterans. It is one of the1163reasons I love working in the healthcare space. I feel like it1164should always be a nonpartisan issue. I think that we should1165work to hopefully remember that and hopefully we can get there.1166    The VA must continue to prioritize a quality workforce that1167can deliver world-class mental health services and meet1168veterans where they are. We can no longer ask the veterans to1169navigate the VA's bureaucracy when what they need is help. I1170know we are all working hard and have the same objectives here.1171It is essential that we have our veterans' backs and we reform1172our approach to improve the policy and services that the VA1173provides to veterans.1174    Thank you all so much for taking the time to be here today.1175    I ask unanimous consent that all members should have 51176legislative days in which to revise and extend their remarks1177and include any extraneous material.1178    Hearing no objections, so ordered. This hearing is now1179adjourned.1180    [Whereupon, at 11:03 a.m., the subcommittee was adjourned.]11811182=======================================================================11831184                         A  P  P  E  N  D  I  X11851186=======================================================================11871188                    Prepared Statements of Witnesses11891190                              ----------11911192                  Prepared Statement of Ilse Wiechers11931194    Chairwoman Kiggans, Ranking Member Ramirez, and distinguished1195Members of the Subcommittee. Joining me today is Dr. Anthony Stazzone,1196Chief Medical Officer of the VA MidSouth Healthcare Network. It is an1197honor to be here on behalf of VA to discuss the critical work we are1198doing to ensure our Veterans receive the high-quality mental health1199care they deserve.12001201Introduction12021203    Veterans face unique mental health challenges. While many Veterans1204are very successful and fully integrated back into society, some1205invisible wounds of war have manifested in conditions like1206posttraumatic stress disorder (PTSD), depression, and substance use1207disorders (SUD). These issues, combined with life transitions after1208military service, contribute to an elevated risk of suicide. In1209response, VA has developed a broad continuum of mental health services1210intended to ensure Veterans receive the help they need. This continuum1211ranges from crisis intervention and screening to same-day access for1212urgent mental health needs, as well as outpatient, residential, and1213inpatient care across the country. VA medical centers, community-based1214outpatient clinics, Vet Centers, the 24/7 Veterans Crisis Line, and a1215nationwide network of Suicide Prevention Coordinators (SPC) all serve1216as points of access.1217    VA's mental health services are designed to be accessible,1218evidence-based, and recovery-oriented, ensuring that all Veterans1219receive the mental health support they need, regardless of where they1220access care. By emphasizing early intervention, continuous support, and1221the seamless integration of mental health into overall health care, VA1222is committed to enhancing the well-being and resilience of Veterans1223nationwide.1224    Most Veterans who utilize VA health care services report positive1225experiences and satisfaction with VA mental health care, including the1226availability of essential services, the strong emphasis on the privacy1227and confidentiality of medical records, the ease of accessing VA mental1228health services, the expertise and professionalism of the mental health1229care staff, and the courtesy and respect demonstrated by the staff1230toward patients.1231    In 2018, VA published the National Strategy for Preventing Veteran1232Suicide \1\ which emphasized the need to develop and implement of a1233public health approach to suicide prevention. The public health1234approach combines both community prevention and clinical intervention1235actions that directly serve Veterans. The National Strategy focuses on1236preventing suicide for all Veterans, as well as selective and indicated1237strategies for reaching Veterans at higher risk for suicide. VA Suicide1238Prevention has fueled ongoing work with our partners in the Department1239of Defense (DoD) to support transitioning Service members. VA's1240commitment to preventing Veteran suicide is also interwoven throughout1241all mental health treatment programs and bolstered by enhanced staff1242educational requirements in suicide prevention.\2\1243---------------------------------------------------------------------------1244    \1\ https://www.mentalhealth.va.gov/suicide_prevention/docs/Office-1245of-Mental-Health-and-Suicide-Prevention-National-Strategy-for-1246Preventing-Veterans-Suicide.pdf1247    \2\ VHA Directive 1071, Mandatory Suicide Risk and Intervention1248Training, dated May 11, 2022.1249---------------------------------------------------------------------------1250    Let me be clear: the Secretary has made preventing Veteran suicide1251a top priority for VA. We face a sobering reality that demands1252acknowledgement: Since 2008, the number of Veterans who died by suicide1253each year has remained essentially unchanged at roughly 6,500 per year.1254Yet over that same period, VA spending on suicide prevention has1255increased by more than 11,000 percent, from $4.4 million per year in12562008 to $522 million per year in 2022. In other words, VA spending on1257suicide prevention is now more than 100 times what it was in 2008, but1258we're getting the exact same results. This status quo is unacceptable.1259    This new Administration and VA leadership are committed to1260challenging the status quo in order to find new and better ways of1261helping Veterans. We cannot continue approaches that have failed to1262produce meaningful improvements despite substantial resource1263investments.1264    Recent reports by the Office of Inspector General (OIG) have1265highlighted deficiencies in VA's mental health care intake process and1266adherence to suicide risk identification screening guidance, among1267other issues. These findings underscore the urgent need for concerted1268efforts to address policy adherence and to strengthen our initiatives1269to provide high-quality health care to our Veterans. Despite these1270challenges, VA is committed to our mission: promoting, preserving, and1271restoring Veterans' health and well-being; empowering them to achieve1272their life goals; and to provide state-of-the-art mental health1273treatments. We are accelerating efforts to enhance access to care,1274whether delivered in VA facilities or through VA community care when1275eligible.1276    This is not simply an organizational priority; it is VA's sacred1277obligation to those who served. The Secretary has established this as1278the standard by which the Department's effectiveness will be measured,1279and VA leadership will accept nothing less than transformative1280improvement in suicide prevention and mental health care.12811282Suicide Risk Identification Strategy (Risk ID)12831284    VA staff play an important role in supporting the Department's top1285clinical priority to prevent Veteran suicide. VA has implemented a1286standardized suicide risk screening and assessment process, providing1287Veterans with a high standard of preventive care. This process, known1288as the Suicide Risk Identification Strategy, was introduced in May12892018. As a population health effort, Risk ID is completed annually for1290all Veterans receiving VA care. Risk ID is also completed for Veterans1291receiving care in a VA emergency department and for Veterans seeking1292mental health services. Additional suicide screening occurs in certain1293health care settings, such as during intake at an outpatient mental1294health visit. Risk ID processes ensure that all VA health care systems1295are equipped to identify Veterans at risk for suicide and connect them1296to life-saving resources and interventions. Risk ID consists of a1297primary screen (using a standardized questionnaire such as the Columbia1298Suicide Severity Rating Scale), followed by a Comprehensive Suicide1299Risk Evaluation, a templated clinical assessment, for any patient who1300screens positive. The goal of the evaluation is to determine the1301Veteran's severity of suicide risk and collaboratively develop a plan1302for risk mitigation.1303    VA is the largest health care system in the United States to1304implement universal screening for suicide risk, highlighting the1305Department's commitment to comprehensive suicide prevention. To ensure1306adherence to the Risk ID screening process, VHA issued a memorandum1307requiring all Veterans Integrated Service Networks (VISN) to confirm1308that facilities within each network have established procedures for1309implementing Risk ID requirements across clinical services. This1310attestation must align with each facility's standard operating1311procedures and conform to national policy and guidelines by April 7,13122025.\3\ In Fiscal Year (FY) 2024, VA completed over 2.6 million1313suicide risk screenings.1314---------------------------------------------------------------------------1315    \3\ For Action: Suicide Risk Screening and Evaluation Requirements1316and Implementation Update (VIEWS 12521544)1317---------------------------------------------------------------------------1318    In addition to broad screening efforts, VA also wants all Veterans1319and former Service members to know that they can access emergent1320suicide care, no matter where they are. Under 38 U.S.C. Sec.  1720J, as1321added by section 201 of the Veterans Comprehensive Prevention, Access1322to Care, and Treatment (COMPACT) Act of 2020 (P.L. 116-214), any1323Veteran - whether enrolled in VA or not - and certain former Service1324members can go to a VA or non-VA facility to access emergent suicide1325care If you're a Veteran in crisis or concerned about one, contact the1326Veterans Crisis Line to receive, confidential support 24 hours a day, 71327days a week. You don't have to be enrolled in VA benefits or health1328care to connect. To reach responders, Dial 988 then Press 1, chat1329online at VeteransCrisisLine.net/Chat, or text 838255.13301331Enhanced Training and Clinical Guidance13321333    To stay at the forefront of suicide prevention, VA continually1334updates its clinical guidelines and training programs to support best1335practices. In 2024, VA and DoD released a new joint Clinical Practice1336Guideline (CPG) for the Assessment and Management of Patients at Risk1337for Suicide, which compiles evidence-based strategies for evaluation,1338safety planning, and treatment of suicidal individuals. VA providers1339are encouraged to familiarize themselves with this critical guidance.1340Additionally, all VHA health care staff must complete suicide1341prevention training. In recent years, VA has updated these trainings1342by, for example, creating improved education for all staff related to1343the steps to take to save Veterans lives, formerly known as ``Operation1344S.A.V.E.'' VA tracks and monitors these courses to ensure training1345compliance.1346    Additionally, VA has implemented specialty training for SPCs and1347mental health clinicians on topics like lethal means safety counseling1348- such as how to talk with Veterans (and their families) about safely1349securing firearms or medications during a suicidal crisis. By1350institutionalizing such training and guidance, VA has worked to1351standardize the quality of care delivered to at-risk Veterans, no1352matter which facility they visit.1353    Another enhancement to our suicide prevention infrastructure is1354assigning dedicated SPCs across all VA medical facilities. SPCs1355actively monitor Veterans flagged as high-risk, coordinate follow-up1356care, facilitate safety planning, and ensure compliance with suicide1357prevention protocols. Regular contacts from a dedicated suicide1358prevention team during a high-risk period may reduce the risk of new1359suicidal behavior over time. During times of personal or community1360crisis, the SPC program provides a model for addressing risks related1361to mental health and for recovery enhancement. A 2021 study showed that1362additional SPC contact reduced the odds, between 4-5 percent, of1363suicide attempt, suicidal behavior, and reactivation of high-risk1364status within the next year.\4\ Our enhanced safety planning practices1365now involve comprehensive, individualized safety plans collaboratively1366developed and documented clearly in electronic health records.1367---------------------------------------------------------------------------1368    \4\ Doran et al. (2021). Associations between veteran encounters1369with suicide prevention team and suicide-related outcomes. Suicide &1370Life-threatening Behavior.1371---------------------------------------------------------------------------1372    VA and DoD also have written CPGs for Bipolar Disorder, Management1373of First Episode Psychosis and Schizophrenia, Major Depressive1374Disorder, PTSD, and SUD. VA encourages mental health care providers to1375familiarize themselves with these guidelines.1376    With regard to training staff in recommended therapy dissemination,1377VHA is a recognized leader in ensuring that staff are trained in VA/DoD1378CPG-recommended therapies. VHA has done this through the National1379Evidence-Based Psychotherapy and Psychosocial Interventions (EBP)1380Provider Training Program, which advances access to VA evidence-based1381mental health through the provision of high-quality, competency-based1382provider training in VA/DoD CPG-recommended evidence-based1383psychotherapies and psychosocial interventions. In Fiscal Year 2024,\5\1384the National EBP Provider Training Program included 14 training1385initiatives for depression, PTSD, SUD, insomnia, chronic pain, severe1386mental illness, and suicide risk management treatments. The program1387trained 2,781 VA mental health providers in 128 workshops and1388consultation trainings across the full range of mental health1389discipline professions and mental health work settings in Fiscal Year13902024. The current VHA workforce has nearly 9,000 providers trained to1391competency, through the program.1392---------------------------------------------------------------------------1393    \5\ https://www.healthquality.va.gov/guidelines/MH/srb/VADoD-CPG-1394Suicide-Risk-Full-CPG-2024_Final_508.pdf1395---------------------------------------------------------------------------1396    All VHA mental health care staff are also mandated to complete1397training about Military Sexual Trauma and Prevention and Management of1398Disruptive Behavior. In recent years, the Office of Mental Health has1399provided staff with numerous additional trainings, for example,1400trainings on military cultural competence and trainings on how to treat1401Veterans with comorbid PTSD and SUD. In Fiscal Year 2024, the Office of1402Mental Health and Mental Illness Research Education and Clinical1403Centers provided over 1,000 training sessions to VA staff.14041405Mental Health Policy and Governance14061407    As a program office, the Office of Mental Health provides policy1408and operational guidance for delivering mental health services across1409the continuum of care. The Office of Mental Health also provides1410ongoing monitoring and makes data available to aid VISNs and facilities1411in implementing mental health programming in accordance with policy and1412developing action plans to address non-compliance. VISNs are1413responsible for ensuring the implementation of such action plans,1414resolving implementation and compliance challenges in the VA medical1415facilities within the VISN and providing oversight of VISNs to ensure1416compliance with mental health directives and their effectiveness. The1417Office of Mental Health works closely to support such operational1418implementation efforts and develops and maintains dashboards that1419provide facilities and VISNs with easily accessible and regularly1420updated program performance information. Weekly forums between Office1421of Mental Health leaders and VISN Chief Mental Health Officers offer1422opportunities for compliance-related discussion and planning, as1423needed. To further support VISNs and facilities with their1424implementation efforts, the Office of Mental Health has National Mental1425Health Quality Improvement and Implementation Consultants, assigned to1426specific VISNs and facilities, who complete scheduled and for-cause1427site visits and are available to work closely with sites in developing1428action plans to address non-compliance and ensure those plans are1429informed by best practices and implementation science.14301431Conclusion14321433    VA is taking decisive action to transform the department's mental1434health care system for Veterans. The path forward requires VA to1435embrace innovation, accountability, and proven practices across every1436facet of its operations.1437    Meaningful change requires collaboration, within VA and with1438partners across government, private healthcare, and Veteran1439organizations. This whole-of-society approach is essential to reach1440Veterans wherever they may be. The oversight from the Committee1441strengthens VA's work and helps ensure our focus remains on what1442matters most: providing Veterans with the exceptional care they have1443earned. VA looks forward to continuing to work with this Committee and1444we look forward to answering any questions you may have.14451446                  Prepared Statement of Julie Kroviak1447[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]14481449                       Statements for the Record14501451                              ----------14521453                    Prepared Statement of NeuroFlow1454[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]14551456Prepared Statement of American Psychological Association Services, Inc.14571458    Chairperson Kiggans, Ranking Member Ramirez, and Distinguished1459Members of the Committee:14601461    American Psychological Association Services, Inc. (APASI) submits1462the following statement for the record in advance of the House Veterans1463Affairs Committee Oversight and Investigations Subcommittee hearing1464entitled Answering the Call: Examining VA's Mental Health Policies. We1465appreciate the Committee's willingness to examine challenges1466surrounding the critical delivery of mental health care for our1467Nation's veterans. Demand for VA mental health care has increased1468steadily over the past 20 years and continues to outpace other care1469within the VA. Meeting this demand while maintaining the VA's high1470level of clinical excellence is a priority.1471    American Psychological Association and its companion organization1472APA Services, Inc. (APA/APASI) serve as the Nation's largest scientific1473and professional nonprofit organization representing the discipline and1474profession of psychology, as well as over 173,000 members and1475affiliates who are clinicians, researchers, educators, consultants, and1476students in psychological science. Psychologists and the profession1477have a rich history within the VA, serving veterans since World War II.1478As such, today we would like to address three policy areas important to1479the delivery of quality mental health care: maintaining clinical1480excellence and care coordination, protecting veteran privacy and1481confidentiality, and ensuring adequate mental health provider training1482and staffing.14831484Maintaining Clinical Excellence and Care Coordination14851486    APASI is grateful that VA Secretary Collins is making preventing1487veteran suicide a top priority. Over many years, the VA has made1488tremendous strides in universal suicide prevention risk assessments and1489required training for providers of care on topics including but not1490limited to suicide prevention, lethal means safety, military culture,1491and military sexual trauma. The demand for mental health care is1492growing across our entire nation's health care system, also1493highlighting the unique role and mission within the VA to train much of1494our Nation's healthcare workforce.1495    Increased investments in veteran suicide prevention have been1496impactful, and veteran outcomes are improved when interacting with the1497VA. The 2024 National Veteran Suicide Prevention Annual Report1498demonstrates the suicide rates for veterans receiving only VA care are149950 percent lower than even those receiving all their care in the1500community care program. However, one veteran suicide death is one too1501many and now is not the time to let our foot off the gas on VA1502investments in mental health staffing, care coordination, and best1503practices that could be applied everywhere a veteran in crisis might1504receive care.1505    As Congress reviews the VA's internal mental health policies, it is1506important to highlight that the VA continues to provide veterans with a1507gold standard of care in mental health treatment. Whether leading the1508way in post-traumatic stress disorder (PTSD) or requiring access to1509evidence-based psychotherapy, the VA maintains a high bar \1\ and1510consistently outperforms non-VA care in both quality of care and trust1511among veterans \2\,}\3\.1512---------------------------------------------------------------------------1513    \1\ https://www.mentalhealth.va.gov/providers/sud/docs/1514uniformserviceshandbook1160-01.pdf1515    \2\ https://news.va.gov/press-room/va-outperform-non-va-facilities-1516cms-ratings/1517    \3\ https://www.va.gov/initiatives/veteran-trust-in-va/1518---------------------------------------------------------------------------1519    Strong internal clinical standards, oversight by the VA Office of1520Inspector General (VA OIG) and other agencies, and the existence of1521reporting and compliance mechanisms within the VA all play a role in1522maintaining exceptional clinical excellence in mental health care. It1523is worth noting that such high clinical standards and oversight is1524lacking or nonexistent in VA community care. For example, the mandatory1525risk assessments and required trainings referenced above are optional1526in the community. APASI would like to see policies such as adoption of1527risk assessments and mandatory training applied regardless of site of1528service for the veteran and agrees with a recent Government1529Accountability Office report \4\ that stronger oversight of community1530care contracts is necessary to ensure high quality care.1531---------------------------------------------------------------------------1532    \4\ https://www.gao.gov/assets/gao-24-106390.pdf1533---------------------------------------------------------------------------1534    We encourage the Committee to support evidence-based treatments,1535measurement-based care, and the VA's critical role in care1536coordination, as each is so important to maintaining the high standards1537that are at the core of the VA's mental health program. Lessening care1538coordination and clinical standards does nothing to improve the health1539of America's veterans. We are concerned, for example, that the recently1540introduced Veterans' ACCESS Act, H.R. 740, which will allow access to1541outpatient private treatment without any VA authorization or referral,1542could adversely impact the quality of care. Care coordination and1543oversight ensures quality care for veterans. We are also concerned that1544this bill lessens the current VA facility requirement that mental1545health residential rehabilitation treatment programs (RRTPs) be1546accredited by both the Commission on Accreditation of Rehabilitation1547Facilities (CARF) and The Joint Commission to requiring only one of1548those accreditations. While improving access to care is critical and1549community care is a necessary complement to VA direct care, exacting1550standards for clinical excellence should be applied equally in each1551setting. Access to ``any'' care is not necessarily access to1552``quality'' care.15531554Ensuring Veteran Privacy and Confidentiality15551556    A recent issue of significant concern for us is ensuring veteran1557privacy and confidentiality when delivering mental health care within1558the VA. The recent policy change requiring most Federal employees to1559return to the office, including VA psychologists and other mental1560health care providers, is significantly impacting the delivery of1561confidential mental and behavioral health services. Many VA facilities1562lack sufficient private spaces to accommodate the influx of mental1563health providers who previously worked remotely. This has resulted in1564providers being asked to conduct sensitive therapy sessions in open1565office environments, cubicles, or shared spaces that fail to meet basic1566HIPAA confidentiality and privacy requirements for the delivery of1567mental health care services.1568    The VA has long used telehealth to reach isolated, rural, and1569disabled veterans in need of mental health services and it further1570expanded access to telehealth services between 2020-2024 which allowed1571more mental health care providers to deliver care from private home1572offices. This enabled the VA to expand to meet a growing demand.1573Unfortunately, the return-to-office mandate undermines access and1574confidentiality essential to effective mental health care. This needs1575to be addressed as plans are put into effect. Without ensuring adequate1576space to absorb the return of mental health providers, those providers1577face the difficult choice between violating ethical and legal patient1578confidentiality requirements or suffering disciplinary action for non-1579compliance with return-to-office mandates.1580    In light of these serious concerns regarding the timing and1581implementation of return-to-office mandates and other policies1582impacting delivery of mental health services, we encourage the1583Committee to consider waivers for all mental health providers that1584would return to a shared space until veteran privacy and access to care1585concerns are addressed. Our concerns currently center on several key1586issues:15871588      Ethical and practice standards: Both the APA Ethics Code1589and VA professional standards require that psychotherapy be conducted1590in private settings that protect patient confidentiality. In many1591facilities, the current implementation of return-to-office orders1592without adequate office space availability appears inconsistent with1593these requirements.15941595      Patient confidentiality and trust: A strong therapeutic1596relationship depends on confidentiality. Veterans dealing with1597sensitive mental health issues require assurance that their disclosures1598remain confidential. Conducting therapy in shared spaces fundamentally1599compromises this trust.16001601      HIPAA compliance risks: Arrangements in some facilities1602may violate HIPAA privacy and security requirements if patient1603information can be overheard in shared spaces. This not only presents1604individual providers with legal liability and ethics concerns but would1605also constitute a HIPAA violation by the Veterans Health Administration1606itself.16071608      Veteran care impact: These challenges threaten to disrupt1609ongoing care relationships and may deter veterans from seeking or1610continuing needed mental health treatment in their preferred setting.16111612      Workforce retention concerns: Reports indicate that some1613mental health professionals are considering resignation rather than1614practicing under conditions they view as unethical and below an1615acceptable standard of care. This could worsen existing staff shortages1616in VA mental health services.16171618    Many veterans experience trauma and sensitive mental health1619conditions. APASI supports long-standing policies that ensure the1620protection of patient confidentiality and privacy, including adequate1621physical space within VA facilities to provide private mental health1622services that prioritize patient needs.16231624Ensuring Adequate Mental Health Provider Training and Staffing16251626    Finally, APASI continues to be concerned about adequate staffing to1627serve veterans of today and tomorrow. Psychology is again the number1628one clinical workforce shortage area within the VA, with 85 of 1391629facilities reporting psychology shortages \5\. The demand for mental1630health care continues to increase both within the VA and throughout our1631Nation's healthcare system. With well over 400,000 new PACT Act1632Veterans Health Administration (VHA) enrollees, and 754,000 new1633enrollees overall since August 2022, continued investment into the VA1634mental health workforce is more important than ever.1635---------------------------------------------------------------------------1636    \5\ https://www.vaoig.gov/sites/default/files/reports/2024-08/1637vaoig-24-00803-222.pdf1638---------------------------------------------------------------------------1639    The VA provides healthcare training, residencies, and fellowships1640to more than 120,000 trainees each year in over forty disciplines. Even1641today, 65 percent of all U.S. psychologists and 70 percent of1642physicians receive training in the VA. As Congress faces current1643Administration plans to reduce the size and scope of the VA, we ask1644that it not lose focus on one of VA's foundational missions dating back1645nearly 80 years--``To educate for VA and the Nation''. Our nation's1646veterans and every American depends on this critical health care1647workforce pipeline.1648    Thank you again for your focus on mental health and the VA policies1649necessary for quality delivery of care. APASI stands ready to work with1650the Committee to ensure the best care for veterans.1651    For more information, contact K. Conwell Smith, APA Deputy Chief1652for Military and Veteran Policy at csmith@apa.org or (301) 875-8923.16531654          Documents for the Record Submitted by Delia Ramirez1655[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]16561657                                 [all]