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[House Hearing, 113 Congress]
[From the U.S. Government Publishing Office]

 
  MAKING A DIFFERENCE: SHATTERING BARRIERS TO EFFECTIVE MENTAL HEALTH 
                           CARE FOR VETERANS

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

                             FIELD HEARING

                               before the

                         SUBCOMMITTEE ON HEALTH

                                 of the

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                    ONE HUNDRED THIRTEENTH CONGRESS

                             FIRST SESSION

                               __________

                      TUESDAY, SEPTEMBER 17, 2013

             FIELD HEARING HELD IN ANDERSON TOWNSHIP, OHIO

                               __________

                           Serial No. 113-36

                               __________

       Printed for the use of the Committee on Veterans' Affairs

                                 ______

                   U.S. GOVERNMENT PRINTING OFFICE 
82-896                     WASHINGTON : 2014
____________________________________________________________________________ 
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                     COMMITTEE ON VETERANS' AFFAIRS

                     JEFF MILLER, Florida, Chairman

DOUG LAMBORN, Colorado               MICHAEL H. MICHAUD, Maine, Ranking 
GUS M. BILIRAKIS, Florida            Minority Member
DAVID P. ROE, Tennessee              CORRINE BROWN, Florida
BILL FLORES, Texas                   MARK TAKANO, California
JEFF DENHAM, California              JULIA BROWNLEY, California
JON RUNYAN, New Jersey               DINA TITUS, Nevada
DAN BENISHEK, Michigan               ANN KIRKPATRICK, Arizona
TIM HUELSKAMP, Kansas                RAUL RUIZ, California
MARK E. AMODEI, Nevada               GLORIA NEGRETE MCLEOD, California
MIKE COFFMAN, Colorado               ANN M. KUSTER, New Hampshire
BRAD R. WENSTRUP, Ohio               BETO O'ROURKE, Texas
PAUL COOK, California                TIMOTHY J. WALZ, Minnesota
JACKIE WALORSKI, Indiana

            Helen W. Tolar, Staff Director and Chief Counsel

                                 ______

                         SUBCOMMITTEE ON HEALTH

                    DAN BENISHEK, Michigan, Chairman

DAVE P. ROE, Tennessee               JULIA BROWNLEY, California, 
JEFF DENHAM, California              Ranking Minority Member
TIM HUELSKAMP, Kansas                CORRINE BROWN, Florida
JACKIE WALORSKI, Indiana             RAUL RUIZ, California
BRAD R. WENSTRUP, Ohio               GLORIA NEGRETE MCLEOD, California
VACANCY                              ANN M. KUSTER, New Hampshire

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.

                            C O N T E N T S

                               __________

                           September 17, 2013

                                                                   Page

Making A Difference: Shattering Barriers To Effective Mental 
  Health Care For Veterans.......................................     1

                           OPENING STATEMENTS

Hon. Dan Benishek, Chairman, Subcommittee on Health..............     1
    Prepared Statement of Hon. Benishek..........................    33
Hon. Brad R. Wenstrup, Subcommittee on Health....................     3
    Prepared Statement of Hon. Wenstrup..........................    34

                               WITNESSES

Howard Berry, Father, Joshua Berry (deceased)....................     5
    Prepared Statement of Mr. Berry..............................    35
Nate Pelletier, Executive Director, Joseph House, Inc............     6
    Prepared Statement of Mr. Pelletier..........................    38
Rodger Young, Clermont County Veteran Service Commission.........    10
    Prepared Statement of Mr. Young..............................    40
Paul Worley, Adams County Veterans Service Commission............    12
    Prepared Statement of Mr. Worley.............................    42
Kristi D. Powell, Scioto County Veterans Service Commission......    14
    Prepared Statement of Ms. Powell.............................    42
Linda D. Smith, FACHE, Medical Center Director, Cincinnati VA 
  Medical Center, Veterans Health Administration, U.S. Department 
  of Veterans Affairs............................................    22
Prepared Statement of Ms. Smith..................................    46
    Accompanied by:

      Kathleen M. Chard, Ph.D., Director, Cognitive Processing 
          Therapy Implementation, Director, Trauma Recovery 
          Center, Cincinnati VA Medical Center, Veterans Health 
          Administration, U.S. Department of Veterans Affairs

      Emma Bunag-Boehm, MSN, APRN, BC, Primary Care Provider, 
          OEF/OIF/OND Clinic, Clinician, Persian Gulf Registry, 
          Cincinnati VA Medical Center, Veterans Health 
          Administration, U.S. Department of Veterans Affairs

      Chadwick Watiker, MSW, LISW-S, BCD, Cincinnati Vet Center 
          Team Lead, Readjustment Counseling Service, U.S. 
          Department of Veterans Affairs

  MAKING A DIFFERENCE: SHATTERING BARRIERS TO EFFECTIVE MENTAL HEALTH 
                           CARE FOR VETERANS

                      Tuesday, September 17, 2013

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                                    Subcommittee on Health,
                                                   Washington, D.C.
    The Subcommittee met, pursuant to notice, at 10:00 a.m., at 
7850 Five Mile Road, Anderson Township, Ohio, Hon. Dan Benishek 
[Chairman of the Subcommittee] presiding.
    Present: Representatives Benishek and Wenstrup.
    Also Present: Representative Massie.

           OPENING STATEMENT OF CHAIRMAN DAN BENISHEK

    Mr. Benishek. Please remain standing for the Pledge of 
Allegiance, led by Commander Rick Simpson.
    [Pledge of Allegiance.]
    Mr. Benishek. Good morning. Thank you all for joining us 
this morning. It is a pleasure for us to be here in beautiful 
Cincinnati with all of you.
    To start, I would like to ask unanimous consent for our 
friend and colleague from Kentucky, Congressman Thomas Massie, 
to sit at the dais and participate in today's proceedings.
    Without objection, so ordered.
    I am honored to serve as the Chairman of the House 
Veterans' Affairs Committee, Subcommittee on Health, and to be 
joined on the Subcommittee by your Congressman and my friend, 
Dr. Brad Wenstrup. As -
    [Audio Disturbance.]
    Mr. Benishek.--lieutenant colonel. In the spring of 2005, 
he was deployed to Iraq for a year, and while there he served 
his fellow soldiers, sailors, airmen and Marines, as well as 
prisoners and civilians, in the Abu Ghraib prison as Chief of 
Surgery and Deputy Commander of Clinical Services. For his 
brave and loyal service there, he earned numerous awards and 
accolades, including the Bronze Star. Brad is a doctor of 
podiatric medicine and former small-town business owner.
    Needless to say, the immense wealth of knowledge, 
experience and insight that Brad brings to the Subcommittee is 
very invaluable. I am extremely grateful to work side by side 
with him and with his leadership on behalf of our Nation's 
veterans and their families.
    So when Brad asked me to come to Cincinnati, his hometown, 
to address an issue of such importance to us all, the provision 
for high-quality and effective mental health care to veterans 
in need, I was happy to take the opportunity.
    Yesterday, Brad and I paid a visit to the Cincinnati 
Department of Veteran Affairs Medical Center. While there, we 
had an in-depth discussion with medical center leaders and 
toured the facility. Having worked myself as a surgeon in the 
Iron Mountain VA Medical Center, I most enjoyed the meeting 
with some of our hard-working Ohioans who strive day in and day 
out to provide the best possible care and services to the 
veterans in this community.
    I would like to take a moment to thank each of those health 
care providers, administrative personnel and support staff for 
their dedication to our servicemembers, veterans and their 
families. It is clear that there are some very special things 
going on here in Cincinnati for our heroes, and you have much 
to be proud of here in Ohio.
    However, where the health care and services provided for 
our veterans is concerned, exercising our responsibility for 
oversight and policy in Congress is paramount. This past 
February, the VA issued a sobering report which showed that for 
the last 12 years there have been 18 to 22 suicide deaths among 
our veterans every single day.
    Ladies and gentlemen, we have lost far too many of our 
veterans on the battlefield of mental illness. We have to do 
better, and we have to do it now. Key to that effort is 
breaking down barriers to care that veterans in the midst of 
struggle often face when attempting to access the care they 
need to successfully transition home and maintain happy, 
healthy and productive lives. No veteran should be reluctant to 
ask for help because they are ashamed or embarrassed; and no 
veteran who takes the brave step of seeking care should be told 
they have to wait for an appointment that is weeks or months 
away, or travel long distances from their home and family to 
receive the services that they need.
    Today, we will discuss the actions we must take to reduce 
the stigma and improve the accessibility and availability of 
mental health care for veterans here in Ohio and across the VA 
health care system. We will also discuss the increasingly vital 
role that faith-based and community groups play in helping our 
veterans and what we need to do to increase and improve 
meaningful partnerships between the VA and these community 
resources, who are often the first and most trusted point of 
contact for veterans and families in need.
    Finally, we will also discuss the critical part that family 
members and other loved ones play in the healing of our heroes 
and the need to increase family awareness, involvement, and the 
integration of mental health services, particularly for those 
veterans most in need of support.
    I look forward to hearing from the local Ohioans, many of 
them veterans, who will testify today. I thank you for being 
here and for your devotion to improving the lives of Ohio's 
veterans. With the help of communities like Cincinnati and 
discussions like the one we were having here this morning, I am 
hopeful that we will shatter the mistaken perceptions that 
mental health care is not available, not appropriate, or not 
effective, and there will come a day when no veteran is 
discouraged from reaching out and seeking care, and no family 
suffers alone.
    With that, I now recognize your Congressman and my 
colleague and friend, Dr. Brad Wenstrup, for his opening 
statement.

    [The prepared statement of Hon. Benishek appears in the 
Appendix]

           OPENING STATEMENT OF HON. BRAD R. WENSTRUP

    Mr. Wenstrup. Thank you, Mr. Chairman.
    If you would, everyone, I would like for us to bow our 
heads and let us take a moment to remember those who lost their 
lives in yesterday's tragic Washington Navy Yard attack. Their 
service and sacrifice will forever be remembered by their 
families and loved ones.
    [Moment of silence.]
    Mr. Wenstrup. Good morning, everyone, and welcome to the 
House Committee on Veterans' Affairs, Health Subcommittee field 
hearing entitled, ``Making a Difference: Shattering Barriers to 
Effective Mental Health Care for Veterans.'' I want to formally 
and officially welcome you to Cincinnati.
    As you have seen in the past few days, this district is a 
district that I am privileged and proud to represent. I want to 
thank you for the leadership you have shown on the issue of 
veterans' mental health care and for hosting this field hearing 
today. I am also grateful that Representative Thomas Massie, a 
strong supporter of our military and our Nation's veterans, has 
taken time out of his busy schedule to be here with us as well. 
Congressman Massie, thank you.
    To the witnesses on our panels, to each person in the 
audience, and especially to every veteran present today, thank 
you for joining us. It is important for us all to be engaged in 
this issue if we are going to truly improve the care that our 
veterans receive.
    A field hearing is an opportunity to bring Congress to 
Cincinnati, and I am pleased that the Subcommittee on Health 
will hear directly from the veterans, the family members of 
veterans, the service officers, and the community providers of 
this region, who will provide a valuable perspective on the 
common barriers to mental health care that our veterans face.
    Veterans of Southern and Southwest Ohio are a diverse 
group. They were raised on farms, urban high-rises, and in 
suburban neighborhoods. But they share a common bond. They made 
the voluntary commitment to serve our Nation. Only 1 percent of 
Americans have served in uniform. Their accomplishments have 
been amazing and truly unmatched by the rest of the world.
    As a veteran of the war in Iraq and a member of the Army 
Reserve, I have witnessed the heroism of my fellow veterans and 
have deep respect for them. We can never repay them for their 
sacrifice, but we can honor it by ensuring that they and their 
families receive the care that they deserve.
    In Ohio, we have a robust system of veteran service 
commissions that serve our veterans with zeal and dedication. I 
am grateful to have representatives from commissions in three 
different counties present to testify here today.
    There is a growing recognition that we must develop better 
treatment for the invisible wounds that veterans bring home, 
including depression, post-traumatic stress disorder, substance 
abuse, and traumatic brain injury. These wounds effect veterans 
of all our past wars, but the veterans of Operations Enduring 
Freedom and Iraqi Freedom face unique mental health challenges. 
Because of technology and advances in that, more soldiers are 
surviving physical combat injuries, but they present 
disproportionate neurological and psychological wounds.
    Studies suggest that 1-in-5 veterans of the wars of Iraq 
and Afghanistan have PTSD. A decade of war with frequent and 
extended deployments have made it more critical than ever 
before to create a quality mental health care system for our 
veterans.
    There are many challenges in our current system that do not 
allow veterans to get the care they need. Sometimes veterans 
are simply unable to access care. They have difficulties in 
scheduling timely appointments, or the office is simply too far 
away. Other times, veterans are unwilling to ask for or accept 
help. They feel ashamed of their mental injuries. Each veteran 
has unique struggles and needs, and we need a mental health 
care system that is able to provide effective individualized 
care.
    But today, we will discuss how the Department of Veterans 
Affairs can better improve its approach to and delivery of 
mental health care. Truly effective care, however, will extend 
beyond the VA. It will require the involvement of veterans' 
families and their communities, including veteran service 
organizations, community health care providers, and faith 
organizations. Each of us has a role to play in improving 
veterans' access to mental health care.
    Again, I want to thank each and every one of you for being 
here today for this important discussion.
    Mr. Chairman?

    [The prepared statement of Hon. Brad R. Wenstrup appears in 
the Appendix]

    Mr. Benishek. Thank you, sir.
    We will start with our first panel who are already seated 
today at the tables.
    Doctor, would you please introduce the panelists?
    Mr. Wenstrup. Yes. On our first panel joining us today is 
Mr. Howard Berry, the father of Army Staff Sergeant Joshua 
Berry. Josh served in Afghanistan and was stationed at Fort 
Hood during the shooting on November 5, 2009. Josh suffered 
from PTSD and ultimately took his own life on February 13, 
2013. Howard is here to tell his son's story, as well as his 
own.
    Barriers to effective mental health care exist not only for 
our servicemembers, but for their loved ones as well. I 
sincerely appreciate Mr. Berry's willingness to share his 
experiences as a way to improve outcomes for veterans and their 
families.
    Also with us today is Mr. Nate Pelletier, Executive 
Director of the Joseph House here in Cincinnati. Mr. Pelletier 
is an Army veteran of Operation Iraqi Freedom.
    Mr. Rodger Young, veteran service officer at Claremont 
County Veterans Service Commission. He is an Air Force Master 
Sergeant with 20 years of service.
    Paul Worley, Army veteran who has agreed to represent the 
Adams County Veterans Service Commission here today. He has 
served three tours in the global war on terror.
    Ms. Kristi Powell, veteran service officer at the Scioto 
County Veterans Service Commission, Air Force veteran.
    Thanks to each of you for your service to our Nation and 
for the work you do every day to help your fellow veterans. I 
look forward to your input on this important issue.
    On the second panel, I will be pleased to welcome Ms. Linda 
Smith, the Director of Cincinnati VA Medical Center, here to 
testify on behalf of the VA. She is accompanied by Dr. Kathleen 
Chard, Director of Trauma Recovery Center at the Cincinnati VA 
Medical Center, Professor of Clinical Psychiatry at the 
University of Cincinnati; and also accompanied by Ms. Emma 
Bunag-Boehm, primary care provider for the OIF/OEF/OND Clinic 
and the Persian Gulf Registry clinician at the Cincinnati VA 
Medical Center; and also by Mr. Chadwick Watiker, an Air Force 
veteran, Cincinnati Vet Center Team Leader. I want to thank you 
all for being here today.
    Mr. Benishek. Thank you, Doctor.
    Once again, thank you all for being here.
    Mr. Berry, I think we will begin with you. Please proceed 
with your testimony.
    We are trying to keep it around 5 minutes each, so I 
appreciate your consideration there.
    Please begin.

 STATEMENT OF HOWARD BERRY, FATHER OF JOSHUA BERRY (DECEASED); 
NATE PELLETIER, EXECUTIVE DIRECTOR, JOSEPH HOUSE, INC.; RODGER 
   YOUNG, CLERMONT COUNTY VETERANS SERVICE COMMISSION; PAUL 
  WORLEY, ADAMS COUNTY VETERANS SERVICE COMMISSION; KRISTI D. 
       POWELL, SCIOTO COUNTY VETERANS SERVICE COMMISSION

                   STATEMENT OF HOWARD BERRY

    Mr. Berry. Good morning. My name is Howard Berry. I am the 
father of the late Staff Sergeant Joshua Berry. My son was 
injured both physically and mentally during the shooting at 
Fort Hood in 2009. I am not an expert on the diagnosis and 
treatment of PTSD, but I am an expert on the pain and suffering 
of the surviving family members of soldiers who turn to suicide 
as a final solution to their problems.
    Please read what I submitted for the record. Some of the 
observations and possible solutions to consider are not just my 
thoughts. I solicited input from family, friends, soldiers who 
served with my son, veterans and caregivers. All have 
contributed to what I hope you will read.
    The reason I am humbly asking you to read what I wrote is 
simple. I am skeptical due to the fact that I have already 
written the President twice, all 100 senators, and all Members 
of the House of Representatives. To date, I have received eight 
responses. That is less than 2 percent.
    I had the opportunity to attend some of the trial at Fort 
Hood several weeks ago. I was fortunate to stay with my son's 
former commanding officer and his family. I learned that Josh's 
captain sustained a traumatic brain injury during a subsequent 
deployment to Afghanistan. He also suffers from PTSD. He 
described what it is like to live with PTSD to members of 
Senator Cornyn's staff during a meeting I scheduled while in 
Texas.
    He said, ``I have a wonderful wife and three children. I 
retired from the Army after 21 years of service. I have a good 
job and a house and two cars. I am living the American Dream. I 
have PTSD. I don't know where, when, or how long an episode 
will last when it starts. When it does, I cannot see the wife, 
kids, career, job, home. All I feel is pain, guilt, and shame. 
I should have died in Afghanistan. I have no worth. I should 
take my life. The PTSD I have is mild compared to what Staff 
Sergeant Berry had. His was severe.''
    Stigmas encountered by soldiers with PTSD start in the 
military, continue through treatment at the WTUs, the VA, and 
into society. Current perceptions are that PTSD-affected 
soldiers are different or messed up. We need to keep them at 
arm's length. We need to watch them.
    I recently spoke with a director from a local company. I 
asked him if he had one job to fill and two equally qualified 
applicants, one a veteran with a Purple Heart, which one would 
he hire? He replied, ``The veteran.'' I then asked him to 
consider the same scenario, only the veteran has PTSD. He did 
not respond.
    I understand that he has a responsibility to look out for 
the company's interest, that he must look out for the welfare 
and the safety of all the people employed there. That is his 
job. The society we live in has to change. PTSD-affected 
soldiers deserve better treatment, like all of us.
    The suicide rate is still rising among our veterans. I hope 
my coming here today to speak to you is not a waste of our 
time. I hope this is the beginning of better days for veterans 
with PTSD. After all, we are all responsible.
    Please read what I submitted.
    Thank you; God bless.

    [The prepared statement of Howard Berry appears in the 
Appendix]

    Mr. Benishek. Thank you very much, Mr. Berry. I truly 
appreciate your testimony. I am so sorry for the loss of your 
son. Thank you for telling some of us his story.
    Mr. Pelletier, please go ahead.

                  STATEMENT OF NATE PELLETIER

    Mr. Pelletier. Thank you, Mr. Chairman, and thank you, Mr. 
Berry, for being here. I would first like to say that on behalf 
of all veterans, this is why we continue to serve our 
population, so that your son is remembered and so others do not 
follow in his footsteps.
    I would first like to say that in my testimony, I am very, 
very proud of our VA Medical Center that we have here in 
Cincinnati and the work that has been done. I personally 
received best-in-class care here as a disabled veteran. As a 
veteran leader here in the community, I have a vested interest 
in ensuring that our Federal and community resources enable our 
warriors that are in transition to soon be veterans and that 
our current veterans successfully reintegrate into our 
communities.
    I have recently conducted research that studied the impact 
of transitioning veterans and drafted a proposal to assist not 
only the VHA, which is the main effort post-transition, but the 
Departments of Defense, Labor, HUD, Human Resources, and all 
supporting agencies within our community to make sure that we 
improve and implement a sustainable transition system for our 
veterans or before they become veterans.
    As the executive director of a local agency supporting 
veterans' needs, I am in the fight every day. I have witnessed 
what can happen if those who have served our country fall into 
what I call the ``distrust gaps'' of an inefficient transition 
and support network within the veteran community. I lived that 
on the very first day of the Joseph House on April 1st. One of 
my War on Terror clients overdosed on heroin and nearly died in 
his room. Thankfully, his roommate, who was also there for 
addiction reasons, was EMT-certified and saved his life that 
day. That day, I knew it was real.
    Over the next three years, roughly 300,000 new veterans are 
going to return to our communities, and we want to make sure 
that we utilize their talents in every way that we can. To this 
end, I want to show the interconnected ways that draw attention 
to this Committee on the VHA side. We need to address the scope 
of expansion of our local VHAs, and also address the 
administrative leadership's ability to support community 
partnerships.
    During the transition of new veterans into the community, 
the VHA currently feels the burden to fill gaps in the process 
due to the absence of a seamless transitioning system. I define 
this as ``scope creep.'' The DoD, VA, all parts of the VA, 
including benefits and health, the Department of Labor, as well 
as other agencies and community organizations have acknowledged 
that the transition process is inefficient and that the 
responsibilities of each organization are unclear.
    With this in mind, some examples of VHA scope creep 
include, but are not limited to employment assistance, which 
can be handled in our community, as well as education 
assistance, benefits assessment, family supportive services, 
and some maybe unrelated medical tasks that can be handled 
through the partnerships in our communities.
    As we attempt to define these responsibilities, I feel it 
is necessary to look at the process in the three different 
categories: the processes that the VHA can fund and own 
responsibility to execute; processes that the VHA funds and 
outsources to the community partners to execute; and finally, 
processes that the VHA outsources to the community partners who 
are either VA or privately funded and can own the 
responsibility to execute on their own.
    In addition to addressing the systems and process 
responsibility to reduce scope creep, I think it is important 
for the VA administrative leadership to empower and leverage 
VHA and community partnerships.
    In an attempt to fully assess the effectiveness of the VHA 
in our community and scope creep, we really need to say what 
are the primary responsibilities of our local VAMCs. In my 
mind, the purpose of the VHA is very focused and clear: support 
the medical needs of veterans who qualify for medical services 
post military service. Any services in addition to these 
primary responsibilities should be assessed according to those 
three categories that I previously mentioned.
    The first step to effectively optimize the veteran support 
administration is to take an active role in partnering and 
oftentimes leading the convening of mobilized community efforts 
in our community. We are doing this right now in Cincinnati. We 
need more involvement from the VHA.
    We can assess two areas of concern nationally and locally, 
particularly locally here as it concerns us, one being 
employment and chemical dependency, that we are seeing real 
difficulty among our returning veterans. In my mind, employment 
is a critical node in the process. If you look at all the 
different nodes to ensure the ecosystem is best for our 
veterans, sustaining income and having a job that not only 
provides that income but a sense of purpose is vital to their 
successful reintegration.
    Often, what I have talked from the sources at the Joint 
Chiefs of Staff Office for Warrior and Family Support, that it 
is not just PTSD. Not having that stability to be able to 
provide for yourself and your family can also trigger symptoms 
of depression, self-esteem, a sense of purpose, other things 
that may not be directly related to combat-related issues.
    Too frequently, these breakdowns lead to the use of 
unhealthy coping mechanisms, which then leads to things such as 
substance abuse. This is what I call the downward spiral of the 
veteran's reintegration or lack of reintegration back into our 
communities.
    To really access the importance of employment again, the 
Joint Chiefs of Staff Office for Warrior and Family Support 
said they are accountable for $960 million in unemployment 
compensation to veterans without the ability to fix the problem 
because in the transition to the community, those veterans are 
no longer a part of the Department of Defense.
    I feel that we see that the first access the VHA has, that 
veterans have, is to our local VHA, and they feel the burden to 
meet some of these gaps. I think this is an example of scope 
creep within the VHA due to the inefficiencies related to who 
owns what in the transitional process.
    Besides veteran employment efforts, I think the VA 
administration can optimize the partnerships with the community 
agencies to provide clinical treatment for our veterans. This 
is a very specific topic here. As the director here of the 
Joseph House, my clients are prime examples of the system 
breakdown within the ecosystem of support. I have currently 
identified that 12 out of 27 of my clients are not only 
suffering from chemical addiction, but also from a co-occurring 
disorder related to mental health, most of them from PTSD.
    Recently, we just reassessed those numbers, and it is 78 
percent of my current clients from yesterday suffering from co-
occurring disorders related to chemical addiction and mental 
health. Subsequently, those are broken down to family support, 
employment, and all those other things that they need to be 
able to successfully reintegrate.
    I would also like to mention that although the VA 
administration has provided exceptional support through their 
VHA Community Outreach Division to fund and evaluate current 
programs like the Joseph House, VA has been reluctant to 
partner in the community-based veteran mobilization efforts or 
the community action team effort here in Cincinnati. We can 
really do better by having participation in there, not just to 
figure out what they can do to support us, but what we can do 
to relieve the burden of their scope creep.
    Local agencies such as the Joseph House, Talbert House, 
Volunteers of America in the region provide services and 
treatment for veterans that are suffering from chemical 
dependency. The majority of these programs are actually funded 
by VA Grant Per Diem programs. Although the VA provides a 
series of measures to validate funding each year, they also 
operate their own internal substance clinic within the 
hospital. Again, a very action item where we can look at what 
can the VA do internally, and what can we do externally to 
serve our veterans. We are already funded to do it in our 
communities.
    Also we have seen, although it is not true everywhere, but 
that the private agencies or funded agencies in the VA and the 
community require certifications of their clinical counselors. 
We are not often seeing the same at the VA hospital, where it 
is not part of the hierarchy to actually have an LICDC or a 
CDCA certification to be a clinical counselor. Just a couple of 
examples of things we can look at.
    And then also related back to chemical dependency locally 
here, we are seeing an increasing rise in the use of opiates in 
our community versus alcohol. This is an alarming effect, and 
we have power within our community agencies to really partner 
to do that very well, to relieve the burden on our local VAs.
    Just in summary, I would like to reiterate the 
opportunities to optimize VHA scope creep and the VA 
administrative leadership for the community are not a 
reflection of the dedicated staff and those that are leading 
them, but an opportunity to optimize our processes.
    If I could, in closing, just give you an example of how I 
experienced the stress of a veteran who recently was discharged 
from our local VA. In 2011, I received a call from a soldier on 
a Wednesday, a weekday night. I believe it was a Wednesday at 
10:30 p.m. Actually, the call came from the local VA hospital, 
to see if I could house a War on Terror veteran for the night. 
He was no longer able to stay in the hospital because his time 
was up.
    At around 11:30 he arrived at the house, at my house, and 
for the next two hours he tearfully told me his story. Like 
many soldiers, he signed up to serve his country and suffered 
severe trauma related to combat that came home with him post 
deployment. If I recall correctly, his father had also recently 
passed away, and his mother was suffering from chemical 
dependency as well.
    Despite the breakdown of his support, he soldiered on and 
secured a meaningful job, but was later laid off like so many 
other Americans. Without stable housing or employment, he found 
solace on the streets and had built a relationship with local 
law enforcement to allow him to just spend a few nights on the 
street while he reached out for help during the day. And 
unfortunately, like many homeless citizens in distress, he 
turned to alcohol and other drugs as his coping mechanism.
    While he fortunately found his way to the VA where he 
completed their chemical dependency program, he did not have 
the support network to sustain his sobriety post treatment, and 
my home became his last resort that night.
    This story, like so many others, is simply unacceptable. We 
must think strategically, we must act operationally, and 
continue to identify opportunities to improve the system while 
always keeping the end-state in mind, ensuring our veterans 
thrive and are productive members of our society. One veteran 
left behind is one too many.

    [The prepared statement of Nate Pelletier appears in the 
Appendix]

    Mr. Benishek. Thank you, Mr. Pelletier.
    Mr. Young, you are up.

                   STATEMENT OF RODGER YOUNG

    Mr. Young. Good morning. My name is Rodger Young. I am a 
Veteran Service Officer for the Clermont County Veterans 
Service Commission. Veteran Service Officers assist veterans in 
obtaining their VA benefits. This can include enrolling into 
health care, applying for compensation or pension, education 
benefits, burial benefits--can you hear me now?
    Mr. Benishek. Pull the microphone closer.
    Mr. Young. Can you hear me now? How is that?
    Good morning. My name is Rodger Young. I am a Veteran 
Service Officer for the Clermont County Veterans Service 
Commission. Veteran Service Officers assist veterans in 
obtaining their VA benefits. This can include enrolling into 
health care, applying for compensation or pension, education 
benefits, burial benefits, VA home loans, and financial 
assistance programs. We are also charged with aiding veterans 
with their appeals and dealing with the overpayments and 
billing issues at the VA. We are pretty much the proverbial 
one-stop-shopping for VA benefits.
    Our office was invited here today for this Committee to 
provide feedback on the services the Veterans Healthcare 
Administration provides and also comment on the programs and 
stigmata associated with the PTSD programs.
    To start off, I would like to give some positive feedback 
first. I have noticed--I have been with the Veterans Service 
Commission for five years, and within the last couple of years, 
the VA has transitioned into nursing teams. The nursing teams 
have been very well organized, and it opened up the 
communications between the veterans and their doctors.
    Along with that, they also opened up the MyHealthyVet Web 
site, which is a great way again to open up communication 
channels between the veterans and their doctors, and also for 
them to download some of their medical information.
    Coupled with that, VBA, the Veteran Benefit Administration, 
also has their own Web site, and the E-Benefits Web site also 
is a major hub for VA benefits and downloading of VA 
correspondence.
    I want to personally commend the staff, especially at the 
CBOC Clermont County. They always have great service, great 
nursing teams, very cooperative and friendly with the VSOs, and 
they treat every veteran with the utmost care and respect.
    The quick reference flipbooks are also a great way of 
passing on information concerning health care, and I have seen 
the Ohio Department of Veterans Services is also tagged on to 
that.
    The areas I feel that we need to improve on over at the VA 
as far as health care goes, non-VA health care--fee basis is 
what it used to be called--it is not as easy as it sounds. Many 
veterans are confused about the program and when VA will 
actually pay for the emergency or care and transportation. VHA 
needs to be clear on what VA will pay and the requirements 
before the health care is covered. Again, the handout makes it 
sound easy. There should also be a claim form to send in to VHA 
along with the hospital bills.
    The processing time is another big concern. It takes so 
long for the veteran to even receive an answer if the VA is 
going to cover their bills or not. And by this time, the bills 
are handed over to collections, and the veteran, of course, 
their credit is going to go bad and everything else.
    VHA also needs, I feel, a call center for billing specific 
non-VA care alone. Normally, you are going to get an answering 
machine when you call, and very rarely will we get a call back 
on that.
    Another problem that they are having down there, especially 
at the medical center, is average wait time for surgeries, 
anywhere from six months to a year. I feel personally if the VA 
does not have the facilities available for surgeries, they 
should fee base it out somewhere, to one of the local 
hospitals.
    Still getting complaints about the professionalism down 
there at the VA Medical Center. I know there are a lot of great 
folks down there, but there are a lot of angry folks down there 
also, which concerns me. A lot of the angry folks we have 
identified. As one veteran put it to me, some of those folks 
down there at the medical center need to go to Happy College.
    [Laughter.]
    Mr. Young. I get little to no complaints over at the 
Georgetown facilities or the Clermont CBOC.
    Another problem that we have, disability questionnaires. I 
know we are looking for a way to expedite some of these claims. 
That is the key. That is probably the best idea I have heard 
since I have been a service officer, is to bring in these DBQs, 
which the doctors can fill out there at the CBOCs and at the VA 
medical centers. Matter of fact, the central office there in 
Washington, Tom Moe--I'm sorry, Tom Murphy; I misspoke there. 
Tom Murphy actually told us that they are supposed to be doing 
that. The CBOCs, we have no problem with this, with the medical 
centers.
    We are having an issue with filling out the DBQs, and these 
disability questionnaires, once filled out--take a diabetes 
claim, for instance. You have a Vietnam vet in-country. These 
disability questionnaires will clearly identify that he has a 
diagnosis of diabetes, what he is doing for the diabetes, 
medication. That is a 20 percent rating. That is easy. Versus a 
claim that is going to take eight months to a year-and-a-half 
just to identify the same things.
    Also, another thing that we run into, if doctors refer 
veterans to file a claim, especially to our office, please 
ensure the diagnosis and notes are annotated in CAPRI or in 
their systems. It makes everybody's life much easier. I get a 
lot of veterans coming into the office, and I will file a claim 
for PTSD, no problem there, especially if a psychiatrist sends 
a veteran over there. But please, if you send a veteran over 
there under the impression he has PTSD, please annotate that he 
has PTSD. There are times when we get claims back. The claim 
was denied because there was no diagnosis.
    Veterans endure many adjustments when returning home from 
deployment to include indoctrination back into family life, 
adjusting back into their home station and their rules, and 
trying to process what has happened while deployed. In general, 
many veterans are reluctant to seek help for mental issues due 
to the stigmata associated with PTSD. Employment is a big issue 
to include separation from the military if they self-identify. 
Also, they may run into problems with their family, and also 
with current gun laws. Many veterans will not self-identify as 
having PTSD or won't seek help because of these things.
    Feedback from the CBOC staff indicate cognitive therapy is 
working on many veterans, and I will vouch for that. It does 
work. Success stories, to be honest, though, I don't have any. 
PTSD, folks, you can get treated for that, but it does not go 
away.
    Many veterans who seek help for PTSD receive some relief 
through medications to tone down the symptoms, but I have never 
seen a veteran completely cured of it. Realize in past wars, 
veterans would endure one to two deployments in the warzone. 
Contemporaneously, it is not uncommon to see five to eight 
deployments nowadays.
    PTSD programs have prevented many suicides, but I think we 
still have a long road ahead of us in treating PTSD. In my 
opinion, we need to fix the stigmatas associated with PTSD so 
more veterans will seek help, and then we need to rehabilitate 
them to function in today's society outside the military.
    Veterans, they feel disconnected when they come home. They 
are totally disconnected from the civilian society. They are 
programmed for military.
    Our office appreciates the invitation today to outline some 
of the hurdles VA faces and the vast improvements it has made 
to ensure the veterans are taken care of. Partnerships within 
VHA, VBA, and the VSO offices will solidify a smooth transition 
for the returning veterans and their families. Standardization, 
consistency and communication within these agencies is the key 
element to minimize the confusion within the veteran 
communities.

    [The prepared statement of Rodger Young appears in the 
Appendix]

    Mr. Benishek. Thank you very much, Mr. Young.
    Mr. Worley, could you begin, please?

                    STATEMENT OF PAUL WORLEY

    Mr. Worley. Good morning, Mr. Chairman, Members of the 
Committee. It is an honor to testify before you today. Thank 
you for allowing me the opportunity to speak this morning about 
mental health care for veterans.
    My name is Paul Worley, and I am an Army veteran. I served 
as an infantry rifle platoon leader and scout platoon leader in 
the 2nd Battalion, 502nd Infantry Regiment, 101st Airborne 
Division in Iraq in 2005 to 2006. In 2008, I went to 
Afghanistan and served as an operations officer for Regional 
Command South in Kandahar. In 2010, I went back to Iraq as a 
company commander and saw the drawdown and was there for 
Operation New Dawn.
    At times and places few will ever know, we fought for each 
other against an unseen enemy. I was honored to serve my 
country and privileged to lead the best soldiers in the world. 
Today, I am equally proud to represent my fellow veterans and 
to talk about the issues we face in regards to mental health.
    When it comes to mental health care for veterans, the major 
issues are access and availability. The VA is the largest 
integrated health care system in the country. There are going 
to be issues, as there are in every health care system, but 
that does not mean that the system is broken.
    In Adams County, Ohio, our veterans are faced with the 
issue of getting reliable transportation to their mental health 
appointments. The nearest clinics are located in Portsmouth and 
Chillicothe, which are at least a 45-minute drive for the 
majority of our veterans. For those who receive services in 
Cincinnati and Columbus, the task of getting to their 
appointments is even more daunting.
    Our local veteran service commission and our local veteran 
service organizations, including our VFW Post 8327 and our 
Disabled Veteran Chapter 71, currently provide transportation, 
but it is not enough to meet the demands of our veterans and 
their families. I believe it is essential that we provide more 
mobile veteran centers to provide access to our rural 
residents.
    Another access issue we face in southern Ohio is Internet 
availability. Our Internet infrastructure in Adams County is 
extremely limited due to the terrain and the financial 
challenges of our local population. Many veterans do not have 
ready access to fill out forms online or to obtain the 
information they need about mental health services. As more and 
more information is shared online, it is critical that we 
provide our veteran population with this essential basic modern 
need.
    I believe that the military as a whole has made positive 
progress to reduce the stigma of post-traumatic stress disorder 
within its ranks over the past 10 years. However, I believe 
that there is still a great amount of work to do to reduce the 
stigma of PTSD among the American people. Young veterans 
seeking civilian jobs are extremely reluctant to seek help 
because of the risk of an employer not hiring them. All 
veterans deal with the stigma that seeking help for mental 
health is a sign of weakness. More education is needed to make 
sure that the American public comprehends the issues associated 
with PTSD.
    It is very encouraging that the VA has recently hired an 
additional 1,300 mental health care workers that will 
potentially alleviate some of the availability issues. I 
believe that the VA employees and leadership want nothing but 
the very best care and benefits for our veterans. However, we 
need to continue to improve the mental health care system. We 
need to be prepared to pay for veteran health care services as 
readily as we were to fund the wars that caused these issues. 
The price tag may be great, but that truth does not take away 
the Nation's duty to care for its veterans.
    The country sent us to war. Now is the time to make sure 
that this country is delivering on the solemn promise made to 
our veterans for their voluntary service. No one gets left 
behind. Thank you.
    [Applause.]

    [The prepared statement of Paul Worley appears in the 
Appendix]

    Mr. Benishek. Thank you, Mr. Worley.
    Ms. Powell, please begin.

                 STATEMENT OF KRISTI D. POWELL

    Ms. Powell. Good morning. Thank you for this opportunity.
    My name is Kristi Powell. I work with Scioto County 
Veterans Service Office. It is through my job there that I get 
the opportunity to work with my fellow veterans, and it is 
through this job that I will be their voice today for victim 
survivors of military sexual trauma, as I will refer to as MST 
throughout.
    The Department of Veterans Affairs Web site states that 
about 1-in-5 women and 1-in-100 men seen in VHA respond ``yes'' 
when they are screened for MST. This is a very high rate, and 
it is very alarming and concerning.
    The veterans in my county are struggling with the services 
that the VA can provide. Although a disabled vet myself, I do 
go to the VA, and I strongly advocate for veterans to utilize 
the VA, but we need to recognize that we are struggling with 
programs for specialized things like PTSD, TBI, and MST.
    The veterans in my community, when they do raise their hand 
and address themselves as being a survivor of MST, they are not 
getting the care that they received in the cases that I 
provided in my testimony. What I would like to see is that we 
recognize this as an ongoing problem, a current problem, and 
one that is not going away. It would be great if we could see 
every VA develop a plan to help these veterans.
    Currently, veterans have to travel very far distances. 
There is not a lot of facilities to treat women survivors of 
MST. Currently, one of my veterans had to go all the way to New 
York State just for the care that she deserves. So there is not 
care locally being provided.
    In the cases that I did give you, the women were subjected 
to being in all-men counseling groups and around individuals 
that they should not have been around when trying to struggle 
with a rape and the scars that it has left on them.
    A survivor and a victim of MST should be able to go to 
their local VA with confidence that they are going to receive 
the care that they deserve, and that care should be available, 
like I said, at every VA that is around. For my veterans, a 
drive one way to get care is over an hour.
    The VA is responsible for serving the needs of veterans by 
providing health care, rehabilitation, and this just is not 
being done. I would like to just raise awareness on this 
subject today, and I won't go into detail. I hope that 
everybody received a copy and can read the cases that I 
provided on the veterans in my community. Thank you.

    [The prepared statement of Kristi D. Powell appears in the 
Appendix]

    Mr. Benishek. Thank you very much for your testimony, Ms. 
Powell.
    I really appreciate you all being here today.
    I think I am going to start by yielding myself 5 minutes 
for questions. I think I want to start with a question for Mr. 
Berry.
    I think you have some very compelling testimony there 
concerning the loss of your son, of course. Were you able to 
talk to a veteran service coordinator at the VA? Were you 
involved at all with your son getting care from the VA? Were 
you a part of it?
    Mr. Berry. PTSD?
    Mr. Benishek. Yes.
    Mr. Berry. For his care?
    Mr. Benishek. Well, apparently they have a family services 
coordinator that helps families of veterans with veterans that 
have to deal with the VA. So were you involved with a family 
service coordinator?
    Mr. Berry. No, I wasn't. None of my family members nor I 
were ever approached in any way to learn about PTSD or 
participate in what needed to be done as far as the care for my 
son, what we could do, what to look out for, anything. And when 
I did try to ask questions, they always kept tossing the HIPAA 
laws up, ``We can't communicate with you because of the HIPAA 
laws.''
    These soldiers are brittle. We need to surround them with a 
circle of care, and the door was closed. Even after his death, 
I found out that a lot of the things that--the HIPAA law 
doesn't go away. I am, like, well, I don't understand. But, 
see, I don't understand a lot of things that took place 
regarding my son's care, and all I have had have been questions 
since the day he died. I still haven't had any answers.
    Mr. Benishek. Well, I hope today that the second panel will 
review your testimony and maybe come up with some answers for 
us regarding that question. I brought up the veterans service 
coordinator and making sure we try to have the family and 
friends of the veterans more involved with the care. So, I 
appreciate that.
    Mr. Pelletier, I have a question for you, too. You told me 
about a veteran that showed up at your house at 11 o'clock at 
night after being discharged from the VA hospital. Is that 
correct?
    Mr. Pelletier. That is correct.
    Mr. Benishek. Didn't they have a discharge plan for the 
patient? I mean, how is it that the guy ended up on your 
doorstep?
    Mr. Pelletier. What I know, Mr. Chairman, is only what he 
told me, that he had finished the program and was not allowed 
to be there for another night based on, I guess, the 
regulations of the program. Now, he was able to go back the 
next day, so it was more or less a one-night event where he 
needed a place to sleep.
    Mr. Benishek. All right. It just seems to me that, as a 
physician, I know when the patient has a discharge plan to be 
going the same day. We know where the patient is going that 
day, and it seems odd that there would be no plan for his 
discharge or a place for him to be, and then he would call you. 
So I was just wondering if there was a plan, it wasn't carried 
out or the patient wasn't satisfied with that plan, or he just 
didn't have anything else to do and he finally showed up at 
your door.
    And how often has that occurred? Where do you get your 
people from? Are they from discharges, or are they just from 
people finding homeless people on the street?
    Mr. Pelletier. That relates to Joseph House, your first 
question. I was contacted by a staff member at the VA hospital 
in reference to him and his need, and I talked to him on the 
phone. So it was from VA. Now, I don't know--and I won't speak 
on what I don't know. So if he had a program aligned for him, 
he may have. I was not aware of it. All I know is that I felt 
the need for it to happen.
    Mr. Benishek. Right. Does it turn out that many of your 
patients come from discharges from the hospital?
    Mr. Pelletier. Are you referring to the Joseph House?
    Mr. Benishek. Yes.
    Mr. Pelletier. That house was actually my personal house 
where he came to stay with me, not at the Joseph House.
    Mr. Benishek. Right.
    Mr. Pelletier. He stayed in my own home. It was not until 
about a year-and-a-half I took over the Joseph House.
    So at the Joseph House, we do receive clients from the VA. 
We receive clients from multiple sources. Given our location, 
we are right in the middle of the area, we have a lot of walk-
ins because they are literally sleeping a block away from where 
we exist.
    But we do have a lot of referrals from the VA to the 
program, and keep in mind that a lot of clients that I serve 
have chemical dependency. It requires them to go through 
multiple programs. That doesn't mean that one is better than 
the other, but it will take maybe a few different attempts to 
find the right fit, which also establishes, I think, why we 
need to have a great partnership, to understand the needs of 
each client to make sure we try to get them in the right place 
the first time.
    Mr. Benishek. All right. Thank you.
    Ms. Powell, let me just take another moment here and ask 
you a question. This military sexual trauma issue, I am very 
interested in this issue. It is my understanding that many 
people don't report the fact that they have been a victim of 
military sexual trauma because of the fact that they are just 
afraid as to what is going to happen to them or if they are 
going to be discharged, are they going to be segregated. I am 
working on legislation to take the reporting and the 
prosecution of offenders out of the military chain of command.
    Do you feel that that would be helpful, removing the 
prosecution from the military chain of command? Are you 
familiar with that?
    Ms. Powell. Yes, sir, I am. In the cases with the female 
veterans I am currently dealing with, that is an issue. None 
have reported. They did not report while they were active duty 
due to being afraid of reprimand, and also being afraid to 
testify against their perpetrator.
    Mr. Benishek. You mentioned a circumstance where a victim, 
a female victim of military sexual trauma was in a treatment 
program that was all men involved. Is that a frequent 
circumstance?
    Ms. Powell. When it happened the second time with the 
second case, a female, then I realized that it was a problem, 
and it is due to there not being separate wings or 
individualized treatment plans available for care. If there 
were separate female units, then they definitely would not have 
been put in the group counseling with the men.
    But, yes, this is occurring frequently, and that was the 
issue that I addressed. As soon as they identify themselves as 
MST, the red flag should go up and they should not be subjected 
to that type of group counseling.
    Mr. Benishek. Well, yes. All right. Well, I am hoping that 
the next panel will address some of these questions that you 
all have brought up here this afternoon.
    I will now yield the floor to my colleague, Mr. Wenstrup, 
for his questions.
    Mr. Wenstrup. Thank you, Mr. Chairman.
    Mr. Berry, I want to again thank you for being here today. 
I think that your testimony clearly depicts the challenges that 
so many face when they return from war, and I think that it 
clearly depicts our need for a greater transition for our 
soldiers as they exit the military and go to the VA side. There 
seems to be a wall there and a disconnect, and I think that 
attention will be focused more on transitioning as we move 
forward, and I think it is very important, and your story 
clearly depicts that, and I thank you for bringing that out for 
us today.
    On that front with transition and support, I have a 
question for you, Mr. Pelletier. You identified the need for a 
stronger referral system between the VA and the community 
providers. Would you clarify some of the weaknesses in the 
current referral system and ways that maybe we can make it 
better?
    Mr. Pelletier. Right. I think to sum up, if you have seen 
one VA, then you have only seen one VA. Speaking locally here, 
given that we have a very robust community effort to mobilize 
our sources externally from the VA, what we found in these 
convening sessions that we have is that there are vital people 
in the VA who could be part of those groups, whether it is 
around--particularly around health, but housing and chemical 
dependency are very interconnected when it comes to health 
issues, that they are not allowed to participate, period, due 
to restrictions on the administrative side, to participate in 
those convening sessions.
    We have five active teams right now in our community. They 
are focusing on the--well, every community is different, but 
five major efforts to support our veterans who don't have that 
support. We are here to help because, like I said, the VHA has 
taken on so much responsibility that it is hard to do the 
primary tasks. But it is hard to help if we can't interact in 
an effective way, and they have the most access to our clients.
    I am a big fan of the OIF/OAF clinic and Operation New Dawn 
and Karen Cartwright's leadership there. She says that she has 
access to the majority of the new veterans coming in. We need 
to be able to understand the landscape and for them to be 
involved.
    Mr. Wenstrup. Thank you.
    Mr. Young, I believe you mentioned about the disability 
questionnaire. Were you speaking to that? And are those claims 
done electronically or hand-written?
    Mr. Young. Hand-written.
    Mr. Wenstrup. They are hand-written, the questionnaires?
    Mr. Young. Right.
    Mr. Wenstrup. Just one thought that I had on that. 
Sometimes with an electronic type of form, if they are 
obligated to fill it out, it won't let them complete it if 
there are missing portions of it, and I think that that might 
be a solution for us. Does that sound like it may work? Because 
you commented on parts not being there, like the diagnosis, 
which is key. So if you can't complete the form without having 
all the boxes checked, might that be of help?
    Mr. Young. That could be one solution. Actually, the 
diagnosis would show up in CAPRI, which they could see up there 
at the VA regional office. The disability questionnaires we 
will actually expedite, and those are normally hand-written. I 
am not sure how we would get that integrated to their system so 
they could do that.
    Mr. Wenstrup. Thank you.
    Ms. Powell, this has been a very major issue for us. I am 
on the Armed Services Committee as well as Veterans' Affairs 
Committee, and the sexual trauma, military sexual trauma has 
been highlighted.
    One question I have is when you are seeing some of these 
victims, are they mostly clearly recent incidents, or are some 
people from 20 years ago that are now coming forward? What are 
you seeing?
    Ms. Powell. Okay, sir. Yes. When I had the roundtable 
discussion in case number 3, I was really taken aback that the 
different eras of women that served were all survivors of MST. 
There is a woman who served in the `80s, one from the `90s, and 
then others from currently today. So it has been going on for 
some time now.
    The women from the past are misled and don't have current 
information as well because they think that to receive care, 
that they have to provide information about their specific 
incident, so they stay silent.
    And I would like somehow to make that--they have to become 
aware of the services that can be provided and they don't have 
to stay silent anymore, because that is a long time that she 
has been the way she is, where she cannot even leave the house, 
she cannot work, she self-medicates, just to deal.
    Mr. Wenstrup. For those in uniform today that are victims, 
I just returned from Madigan Army Medical Center in Washington, 
and they started a new program that I hope is successful and 
that can carry on throughout the military, and it is a sexual 
assault response team where people can come in anonymously and 
start to engage, usually with a legal team and social workers, 
on what their options are. So when they take this step, they 
don't have to be afraid because it is not anything that goes on 
their record, and they get better guidance through that.
    Through the National Defense Authorization Act, this year, 
we put in many whistle-blower protections and things like that. 
So it is being addressed very seriously, and hopefully that 
will have long-term benefits.
    It doesn't change your challenge for today on the VA side, 
but hopefully it will, and maybe some of the models of what we 
are seeing with that program can reap some benefits. I 
appreciate you taking that on.
    Ms. Powell. Thank you.
    Mr. Wenstrup. Thank you.
    Mr. Chairman, I yield back.
    Mr. Benishek. Now I will yield to Mr. Massie for questions. 
Thank you.
    Mr. Massie. Thank you, Chairman Benishek. I want to thank 
you for your work on the recent bill, the first appropriations 
bill that we passed, reallocating priorities so that we can try 
and get rid of the backlog in the VA filings, and that did pass 
the House of Representatives. Hopefully, we can get that 
through as part of the latest budget and continuing resolution.
    Also, I want to thank you for traveling such a long 
distance to come and help us in our region on this issue.
    Mr. Wenstrup, I appreciate you organizing this hearing. I 
think among all the congressmen, you are probably the most 
qualified to cover this issue given your service in the 
military, and also in the health care profession.
    What strikes me today is that we are trying to ameliorate 
or work on an issue for people that starts in the military. It 
starts sooner than when they are discharged. So the question 
that I have for really anybody on the panel here is, what 
policies could our military adopt during active service to 
reduce the onset of mental illnesses or to mitigate the effects 
of mental illness after military discharge? For instance, you 
mentioned one of the nodes was employment. Are we doing enough 
in the military to prepare people for employment, or are there 
ways that we can prevent MST by preventing the acts? Would 
anybody like to speak to that?
    Mr. Pelletier. Congressman, I would be happy to. There are 
several ways to address it. The way I have been addressing it 
is looking at the holistic picture of someone who is about to 
get out of the service, who is about to sign that paperwork, 
and the next step will be to reintegrate into society.
    So if you look at kind of a TedX model, there are all kinds 
of things that could break down within transitioning warriors, 
as we like to call them, and it relates to employment, it 
relates to mental health. I just want to bring attention to 
that PTSD is certainly a diagnosis. It can go beyond what 
happens in combat. It can happen within the community. 
Something can trigger it after you get out that may not have 
been picked up. Or it could just be mental health issues 
related to combat stress, which is not always PTSD, 
transitional stress that can relate to mental health.
    So, yes, I do think it needs to be addressed before they 
get out and that we figure the accountability for it. I think 
what we need to do is when those soldiers or warriors have 
decided to make the next step and sign the paperwork, they 
don't get out the next day. There is a period of time. We need 
to figure out how long that period of time we can invest in 
their transition.
    My proposal is an actual recommendation of a process we 
could look at. It is not an answer, but it is a process where 
we address all those things that we need to look at with our 
veterans or soon-to-be veterans. We do a very good job right 
now, at least where I came from at Fort Stewart, in addressing 
the mental health. PTSD, I had gotten out in '08. Employment is 
not addressed, but it is also not the responsibility.
    So what we need to look at is where do the responsibilities 
lie in the system and that overlap of where, even before the 
DoD hands over, when can we bring in community or national 
partnerships to begin that work. The Joint Chiefs of Staff 
Family and Warrior Support Command is absolutely where I think 
the discussion can happen, because they overlap from DoD and 
community partnerships, but they are only facilitators. They 
are not the leaders.
    Mr. Massie. Thank you very much.
    Mr. Berry, along the lines of that question, do you think 
that multiple deployments or extended deployments contributed 
to your son's condition?
    Mr. Berry. My son served in Afghanistan, was only deployed 
one time. Ultimately, the incident that led to his taking his 
life, making that choice, was what took place at Fort Hood, and 
then the subsequent--I call it pussyfooting around for the next 
three-and-a-half years, or whatever.
    There were so many things that I couldn't understand, and 
his skill sets were compromised. So how could I expect him to 
understand what decisions were being made regarding the trial 
and how it was being handled? I couldn't wrap my brain around 
them. How could I expect him to?
    And I even actually have letters that were written on 
numerous occasions by doctors that were involved in his care, 
and I asked permission to use them, and I was told that if I 
did, that his physicians would terminate from their positions.
    I just thought that that was--I wasn't doing anything to 
disparage anyone. It was just a statement that was made that 
just said that the decision that my son made to end his life 
was based on what happened at Fort Hood, and I am not allowed 
to share that.
    Mr. Massie. I also share your concern over how that 
incident was characterized in the official story, and I 
appreciate you coming today to testify.
    Mr. Young, you mentioned something that I don't want to let 
it be swept under the rug. You said you are still getting 
complaints about the VA in Cincinnati. What are veterans 
telling you about the professionalism there, and are you 
concerned that they don't seek treatment because of the stigma 
or something associated with that particular center? Can you 
elaborate on your comment?
    Mr. Young. I will address the OEF/OIF clinic, very 
professional. I have heard nothing but good things come out of 
the OEF/OIF clinic. But there are other physicians down there 
that I hear they either tell them or kind of disregard of, 
``No, you don't have that.'' They kind of give them the brush-
off, is what I normally hear, or ``I don't believe in that.'' I 
have heard that one more than once. ``I don't believe in 
PTSD.'' Coming from a VA, that is ridiculous.
    Mr. Massie. Is there a system or a method to report those 
incidents?
    Mr. Young. Yes, there is. There is patient advocacy, and 
that is usually who we refer them to first. If we hear many 
incidents coming out of there, typically we will address the 
director on what is going on.
    Mr. Massie. Thank you.
    I yield back.
    Mr. Benishek. Thank you.
    Brad, do you have any other questions?
    Mr. Wenstrup. I just have one question.
    We talked a lot today about transitions, deployment 
actions, things like that, and I do hear the DoD side trying to 
take part in that. I hope that that comes to fruition.
    My question to each of you is, for those that you serve, 
when they come to you, especially veterans that are new 
veterans, just leaving the military, do you feel that they come 
to you with any guidance before they get to you on how to 
navigate the VA system?
    We can go down the line.
    Ms. Powell. My answer is no. The new veterans that are 
getting out today are not receiving any kind of beneficial 
information on what to do next. So they are getting out, and 
they experience a lot of separation anxiety. They don't know 
what to do next. They weren't told to copy their medical 
records, and now we are having problems locating those for when 
they got hurt in service. They know nothing about the VA at all 
until someone, an older person they see on the street tells 
them to come into our office, basically.
    Mr. Worley. And I just recently got out two years ago, and 
I left from Fort Stewart, Georgia. I saw a big transition when 
I first came in the Army from 2004 to where we were in 2011. I 
think these soldiers are armed with--everyone is armed with the 
right information, but a lot of times they are out processing 
when they get back from a deployment, and all that is on their 
mind is, I'm getting out, I have to show up to these mandatory 
classes, but they are not paying attention until when they get 
out and it has been a year and their unemployment has ran out, 
and then all of a sudden, well, I probably should have paid 
attention, but then they don't have leadership in place. They 
can't go to their team leader or squad leader and say, 
``Sergeant, can you tell me what I need to do?''
    So it is tricky, but at least in Adams County, we have made 
strides to make our veterans service office more available to 
our veterans. It is just hard with younger veterans because 
they are starting their lives when they get back. They are 
concentrating on their family, and it may be, like you said 
earlier, they may not get those issues until something triggers 
it later on.
    But I do believe that they are armed with the information. 
They just don't pay attention. They are focused on other things 
when they leave.
    Mr. Young. I concur with Mr. Worley there. I think the TAPS 
briefs are very good, and they have a lot of information, but I 
think the veterans with the--I think mine was a week-and-a-half 
long, and I think they are just inundated with so much 
information, and they are more concentrating on family and 
employment upon discharge.
    The VA, I know back when I had a TAPS brief, they lightly 
touched on VA and moved on. The first thing that went through 
my mind is VA health care, I am thinking a guy is missing 
limbs. I am not thinking that is a health care for me.
    But I think they need to touch more on the VA and the VA 
benefits available to them. I think the employment information 
was good that they gave us, but they need to hit on a little 
more about the VSO offices so we can kind of guide them on 
where to go when they get out. I think that would definitely 
help.
    Mr. Wenstrup. Thank you.
    I yield back.
    Mr. Benishek. I want to thank you all so much for appearing 
here this morning. It is very, very helpful for this Committee 
to hear this input.
    You all are now excused, and I will ask the second panel to 
come forward.
    Dr. Wenstrup introduced the second panel a bit earlier, and 
we were fortunate enough to meet with most of the panel 
yesterday in our visit to the medical center. I want to thank 
you all for being here today. I know that, Ms. Smith, you are 
going to be the one testifying, but I would hope that maybe you 
would address some of the issues that the first panel brought 
up in your testimony. We have your written testimony already, 
what you are prepared to say, but I think that some of the 
testimony that we heard in the previous panel is pretty 
compelling, and I know that we will later on, if you don't 
address those or if I can't think of all the things, we are 
going to submit questions to you later to try to address the 
issues that that panel brought up so that I don't forget any of 
those details later, so we would appreciate that.
    But in saying that, please proceed with your testimony.

 STATEMENT OF LINDA D. SMITH, FACHE, MEDICAL CENTER DIRECTOR, 
 CINCINNATI VA MEDICAL CENTER, VETERANS HEALTH ADMINISTRATION, 
U.S. DEPARTMENT OF VETERANS AFFAIRS, ACCOMPANIED BY KATHLEEN M. 
      CHARD, PH.D. DIRECTOR, COGNITIVE PROCESSING THERAPY 
IMPLEMENTATION; DIRECTOR, TRAUMA RECOVERY CENTER, CINCINNATI VA 
MEDICAL CENTER, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT 
    OF VETERANS AFFAIRS; AND EMMA BUNAG-BOEHM, PRIMARY CARE 
PROVIDER, OEF/OIF/OND CLINIC; CLINICIAN, PERSIAN GULF REGISTRY, 
 CINCINNATI VA MEDICAL CENTER, VETERANS HEALTH ADMINISTRATION, 
  U.S. DEPARTMENT OF VETERANS AFFAIRS; AND CHADWICK WATIKER, 
   CINCINNATI VET CENTER TEAM LEAD, READJUSTMENT COUNSELING 
          SERVICE, U.S. DEPARTMENT OF VETERANS AFFAIRS

                  STATEMENT OF LINDA D. SMITH

    Ms. Smith. Thank you for the privilege of being here, for 
all those in the audience who are attending, and in particular 
for the previous panel. We definitely will follow up on every 
issue that was raised earlier this morning.
    Good morning, Chairman Benishek, Dr. Wenstrup, and 
Representative Massie. Thank you for the opportunity to discuss 
the Cincinnati VA Medical Center's efforts to provide high-
quality care, specifically mental health care, to veterans in 
our catchment area, and our pilot Veterans Transportation 
Service.
    I am accompanied today by Dr. Kathleen Chard, Director of 
the Trauma Recovery Division of our Mental Health Care Line, 
and Professor of Psychiatry and Behavioral Science at the 
University of Cincinnati's College of Medicine; Emma Bunag-
Boehm, a primary care provider for the Post-Deployment Clinic, 
Cincinnati VAMC; and Mr. Chad Watiker, Cincinnati Vet Center 
Team Leader.
    The Cincinnati VAMC is a two-division campus located in 
Cincinnati, Ohio, and Fort Thomas, Kentucky. The medical center 
serves 17 counties in Ohio, Kentucky and Indiana, with six 
community-based outpatient clinics. We are a highly affiliated 
teaching hospital, providing a full range of patient care 
services, with state-of-the-art technology, medical education 
and research capabilities. The Medical Center provides primary 
care, the full range of mental health services, and tertiary 
and medical surgical care.
    Over 42,000 veterans are enrolled in VA health care through 
our facility. This number includes about 3,600 female veterans 
and 3,500 OIF/OEF veterans. The medical center has 15 full-time 
staff in our OEF/OIF/OND clinic providing primary care, mental 
health care, social work services, pain management care, and 
other services for military personnel returning from all recent 
combat theaters.
    The Cincinnati VAMC's Trauma Recovery Center consists of an 
outpatient PTSD clinical team and a residential PTSD program 
which offers eligible individuals family education, medication 
management, and evidence-based PTSD treatments in a variety of 
formats. These unique programs have been featured in national 
media for their patient-centered, evidence-based treatment 
programs for PTSD. The VAMC also provides care and services to 
veterans who have experienced military sexual trauma.
    Mental health services at the Cincinnati VAMC are unified 
under a multidisciplinary Mental Health Care Line. A 
comprehensive variety of mental health services is offered by 
the seven divisions of the Mental Health Care Line through 303 
staff members. To date, the Mental Health Care Line provides 
care to an additional 1,482 unique veterans that were seen over 
the same period in Fiscal Year 2012.
    VHA has developed many metrics to monitor performance in 
the delivery of our health care services. Cincinnati VAMC 
consistently scores above targets set by VHA regarding key 
areas of mental health treatment, including follow-up rate for 
veterans discharged from acute inpatient mental health 
treatment and percentage of qualifying veterans receiving 
evidence-based psychotherapy sessions.
    The Cincinnati VAMC has also seen tremendous success in 
improving patients' access to care, receiving an outstanding 5-
star quality rating under the category ``Mental Health Wait 
Time.''
    Recognizing that increasing access to care improves health 
care outcomes, the Cincinnati VAMC began operation of the 
Veterans Transportation Service in May of 2012, offering 
mobility management and transportation services. Mobility 
management guides veterans to the most medically appropriate 
and cost-effective means available through a private, veteran-
focused agency or public transportation services. VTS fills in 
the remaining gaps, providing door-to-door, wheelchair-
accessible transportation for those veterans living in the 
medical center's catchment area who have no other viable 
transportation options.
    In August 2013, the Cincinnati VAMC hosted its first 
Community Mental Health Summit, where facility leadership and 
staff met with 66 individuals from 36 community agencies. At 
the summit there was an open exchange of detailed information 
about mental health programs and services available through VA 
and the community.
    In conclusion, VHA and the Cincinnati VAMC are committed to 
providing the high-quality care that our veterans have earned 
and deserve, and we continue to improve access and services to 
meet the mental health care needs of veterans residing in 
Cincinnati and the local surrounding area. We appreciate the 
opportunity to appear before you, and we appreciate the 
resources Congress provides VA to care for veterans. We are 
happy to respond to any questions you have.

    [The prepared statement of Linda D. Smith appears in the 
Appendix]

    Mr. Benishek. Thank you very much for your testimony.
    Mr. Berry's testimony is pretty compelling. He lost his son 
while the son was being treated for PTSD as an out-patient. How 
many patients in the last two years under your care have 
committed suicide?
    Ms. Smith. In the last year, a total of three veterans in 
Fiscal Year 2013 actually committed suicide that were receiving 
our health care services. In Fiscal Year 2012 it was five, and 
in Fiscal Year 2011 it was nine. So we are seeing, I believe, 
improvements in our outreach for veterans at risk for suicide. 
We have a full-time suicide prevention coordinator. The month 
of September is designated as a special month to recognize the 
suicide risk, and we will be outreaching in the community and 
to all veterans who come to our medical center with a 
comprehensive package of information about suicide and ways to 
avoid it.
    Mr. Benishek. Mr. Watiker, you are with the veterans 
center, so it is somewhat different than the VA hospital. Tell 
me about your program and are you seeing an increasing number 
of patients, and is your staffing adequate to get people in on 
a regular basis, what is your wait time. Give me a little bit 
of an example of the challenges that you have and what could be 
better about your system.
    Mr. Watiker. Yes, sir. Thank you for that question, Dr. 
Benishek. The vet center program is geared toward readjustment 
counseling services for war-zone veterans and their families to 
help them with the transition from military life to civilian 
life. There is no time-limit restriction, and the cost is free 
because they have paid for the service already with the time 
that they served, being in a deployment status.
    We have well-trained clinicians that provide individual 
counseling, group intervention, couples, marital counseling, 
military sexual trauma, and bereavement counseling for those 
who have had loved ones die while in active duty service.
    Mr. Benishek. How long does it take to get in to see you?
    Mr. Watiker. Our access to our services, if a veteran comes 
into our office today, they are going to be seen by a 
clinician, assessed, develop a plan, and coordinate a follow-up 
that meets the best to their schedule.
    Mr. Benishek. Is there like a suicide notation made on the 
initial visit?
    Mr. Watiker. We definitely do it as part of our ----
    Mr. Benishek. Your evaluation?
    Mr. Watiker. Yes, sir. As part of our initial assessment we 
do a comprehensive assessment, a bio-psychosocial assessment 
with the individual. But with everyone we screen, we screen any 
type of suicidal ideation or homicidal ideation.
    Mr. Benishek. Dr. Chard, we were talking earlier, but I 
don't quite remember your answer to how long does it take for 
someone to call and get into an outpatient evaluation in your 
setting.
    Ms. Chard. Thank you, sir. If someone called today for an 
outpatient appointment in the PTSD division, we can get them in 
within the week. So if you called me today, we can get them in 
within this week to see both an individual therapist and a 
psychiatrist or a nurse-practitioner for a medication consult.
    Mr. Benishek. And is there any sort of a suicide evaluation 
done on the phone when somebody calls in? Because to me, even a 
week seems like a long time if somebody is calling in desperate 
for help.
    Ms. Chard. Exactly. When we do our initial phone screen, we 
do a suicide assessment, and we actually complete a suicide 
assessment on every visit that the patient has within the PTSD 
and the Mental Health Care Line.
    Mr. Benishek. All right.
    Mr. Wenstrup?
    Mr. Wenstrup. Thank you, Mr. Chairman.
    A couple of questions. We saw a lot of things yesterday 
when we visited, and that is the Cincinnati VA. Can you share 
with us some of the differences from state to state? Do you 
feel that every VA is the same? Obviously, there are some 
differences. And how do you think we are dealing with that on a 
national level compared to what we have here in Ohio?
    Ms. Smith. I really can't comment nationally. I can comment 
on what we do, and I know that we get a lot of direction from 
VA central office through our network about changes and 
improvements in the ways that we provide care. It seems that 
the changes are evolving even more and more quickly. I have 
been with VA almost 33 years now, and the pace of change and 
the pace of improvement in services is really remarkable, just 
from Dr. Chard's program as an example, and the ongoing 
improvements that have been made in the treatment provided for 
PTSD, including now the three separate programs, Emma Bunag-
Boehm's program where we have gone from two staff and in our 
OIF/OEF clinic to now 15. So I would say the pace of change is 
just incredible and driven by, in large part, the interest that 
Congress has had in continuing to improve VA health care 
services, and I thank you for that.
    Mr. Wenstrup. Thank you. You know, I know when I returned 
from the war, I got notices from the VA saying you need to get 
in and get enrolled. The outreach was there, and I think it 
continues, and I do give the VA tremendous credit for that.
    On the lines of suicide prevention, in the Army there is a 
lot being done proactively in what to look for, how to watch 
out for your buddy, don't be afraid to say, hey, I'm taking you 
in, you need help. That is great. We know that most of the 
suicides are occurring after they are out of uniform. How do we 
build that type of system once they are out, as opposed to when 
they are in?
    Ms. Smith. And this is part of what I see as a really 
increased sophistication and improvement in the mental health 
care at Cincinnati, and I am sure at other facilities. I will 
let Dr. Chard provide details.
    Ms. Chard. So with a team of three people in the suicide 
prevention office, we are able to do a lot more outreach than I 
think ever before. We do attend a lot of civic activities 
locally. We make sure that we attend all of the NAMI meetings 
that we are invited to. We always have our staff at the PDHRAs, 
and they are there to do the vesting visits because sometimes 
they don't want to come to the VAs, as you spoke about. We do 
need to vest them early and let them see a face that they can 
see when they come to the VA. So we do a lot of outreach there.
    One of the things that I love that VA has created is a peer 
support technician program where we actually hire veterans as 
peer supporters so that you can attend a group that is not run 
by clinicians, but is run by a trained peer support person so 
they can have that private environment to share their 
experiences, talk about their needs with someone who has 
already been through the program and can speak about what it 
was like to go through it, what obstacles they encountered, 
what they found to be helpful, and I think that has been a 
really strong success throughout the VA and the Nation.
    Mr. Wenstrup. That is something that comes with the length 
of time that this has been going on. You have alumnus, if you 
will, who can participate and help.
    I know it is sometimes difficult, too. I will ask you, 
Emma. You see patients for the first time, often. And as we 
talked about before, there are people who don't want to come 
forward to mention what they are struggling with, and sometimes 
they refuse to go there.
    I can remember in Iraq, we had to do a physical on Saddam 
Hussein, who was on a hunger strike, and he wouldn't let us 
evaluate his mental status. He refused psychiatry or 
psychology. So we had to use a little psychology and work 
within his physical exam to ask questions to really assess 
where he was mentally.
    So have you found that over the time of doing this, that 
you are able to sort of break through that, when you sense 
somebody doesn't want to tell you something, that you can break 
that down a little bit? And how do you do that? And if you do 
feel like you have gotten through and detect something, where 
do you go from there?
    Ms. Bunag-Boehm. Thank you, Representative or Dr. Wenstrup, 
for this opportunity to come and speak with you. I thank you 
for your service to our Nation.
    To answer your question, we, in our clinic, we have a team 
of nurses who does the initial intake, and we have those 
clinical reminders that we need to complete. Now, a lot of 
times, the servicemembers or veterans will not answer those 
questions. So when they come to my office and I develop this 
rapport with them, then along the way I go back in and ask them 
the same questions, and a lot of times they will be honest with 
me and start opening up more.
    In our clinic, after they see me as the primary care 
provider, we have a psychologist and social workers who are 
trained mental health providers as well. So if I identify that 
something is going on with this veteran, I also want to say 
that our clinic is like a medical home and it is a one-stop 
visit store or something. So they are aware that they might be 
there for a while because we want to make sure that everything 
that they need we give to them on that same day.
    Now, if they cannot do it because they are busy, then they 
have the option of coming back. But we try to do everything at 
that one visit, and a lot of times they will agree to that. So 
then it is handed off to the psychologist, and then we go from 
there.
    As you are aware, our clinic is--I mean, it has been very, 
very effective, and our clinic has really gone far. And thank 
you again to Congress for giving us those resources. Thank you.
    Mr. Wenstrup. I think you have made a lot of strides. I 
know servicemembers that have been treated by you that have 
been very grateful for the care that they have received, and I 
know it is a difficult challenge. And this somewhat addresses 
Mr. Berry's concerns today on how we get the families engaged, 
because I think that is important, and I hope that we can 
continue to do that.
    I just have one last question. So, we have been at war for 
12 years, and we have a lot of returning veterans, especially 
to this area of the country. What would you say are some of the 
major things that you have changed since, say, 2001, 2002, 
2003, 2004, compared to today?
    I will ask both of you, all three of you actually.
    Ms. Chard. Certainly. I think some of the most significant 
changes have actually been in the increase in mental health 
staff. So we have had an exponentially larger number of staff 
hired. Thank you, obviously, to your efforts.
    Speaking more specifically to the PTSD program, we have 
grown by three-fold. We have opened a women's program, which we 
did not have until 2007, and now we have the Traumatic Brain 
Injury PTSD Residential Program, and we are currently the only 
one in the Nation. So we are able to serve veterans in our area 
with both male issues, female issues, or TBI/PTSD issues in 
that program, both residential and outpatient.
    Mr. Benishek. I would just ask that the speakers use the 
microphone because we have had some comments that it has been 
difficult to hear your testimony.
    Ms. Smith. There are so many changes, it is hard to think 
through what has just happened in the last few years. 
Certainly, construction funding has allowed us, and also money 
for additional lease space has allowed us to really expand. We 
moved our eye program off campus, which opened up additional 
space for clinical care. We have, I think, four concurrent 
construction projects going on at every corner of the hospital 
to not only increase our capacity to provide care, but also to 
make that care more convenient and easier to get to.
    Probably the biggest improvement in terms of ease of access 
is the parking garage that is just now in the process of 
opening that should make it very easy for veterans to get into 
our health care services.
    We are building a brand-new community living center, what 
used to be called our nursing home care unit, and this is in 
recognition of the fact that moving veterans back and forth 
from Fort Thomas, Kentucky across the river to Cincinnati 
creates a lot of unnecessary trips for many of those nursing 
home residents, and now we will be able to have them located 
closer to clinical care and at the same time give them private 
rooms and immediate access to all health care services.
    We have done a lot to renovate our domiciliary and PTSD 
programs in recognition of the large number of veterans 
returning needing mental health care, and also those veterans 
who either have substance abuse or homeless issues and need 
some residential treatment. I see us significantly expanding 
those services at Fort Thomas and really make that a real 
state-of-the-art and evidence-based program that I believe will 
rival any in the VA Nation in terms of the types and quality of 
services provided there.
    And again, this has all been done with funding that 
Congress has given us, and we are very appreciative that we 
have been able to add all those services.
    Ms. Bunag-Boehm. And with the increase of our staff in our 
OIF/OEF/OND clinic, we are able to do more outreaching. We have 
partnered up with units in and around the greater Cincinnati 
area, Reserve and Guardsmen units. So we are often invited into 
their 30-day, 60-day and 90-day family gatherings.
    So on the 30th day, or actually whenever they come home, 
our program manager, Karen Cartwright, or our outreach 
coordinator, Mary Plummer, who is herself a veteran, they go 
into the units to give briefings. So with those briefings, they 
talk about the VA and what the VA offers them, from medical 
health care to benefits to everything else that they need to 
do.
    We have a mobile van which you saw yesterday, and we go 
outreaching to places where we are invited. So we take the 
opportunity to enroll veterans and at the same time get them 
vested into the VA health care, and then get them started. So 
if they need to be referred to a specialty clinic, then we get 
them referred, and these are from counties, and a lot of our 
community-based outpatient clinics offer those specialty 
clinics.
    Another thing that we would like to highlight is that we 
have the VITALS program wherein our psychologist is the liaison 
between our local universities in and around greater Cincinnati 
again, and a lot of times my veterans go back to school, and 
Dr. Jessica Theed is my liaison. So if they cannot come to me 
right away, they will seek her out, and then Dr. Theed will 
notify me if we need to see the patient, if I need to do more 
for the patient.
    And again, we would like to thank you for giving us the 
resources to do what we are doing now. Thank you.
    Mr. Watiker. First of all, I would like to thank you on 
behalf of the Readjustment Counseling Service for the resources 
that you provided for us, because one of the biggest changes 
for RCS is that you have allowed us, with the resources you 
have provided, to purchase 70 mobile outreach vet centers 
across the Nation. We have two here in Ohio. This allows us to 
do, not only mobile outreach to the local community, but 
outreach to the whole community to provide clinical and veteran 
services if we don't have a community access point. It also 
allows us to work with our VA counterparts for emergency 
response teams to national crises, as needed, to support the 
veterans and families outside of the State of Ohio, or within 
the state as well.
    When I talk about the community access points, it is one of 
the things that, with our outreach efforts, we were able to 
provide face-to-face connections with our veterans and families 
to easily engage them into vet center and VA resources. For 
example, we have outreached now to Highland County where it is 
a rural community. I heard earlier about the difficulty in 
accessing mental health care. One of my clinicians goes up 
there to a community access point through the veterans service 
office and provides mental health care to those veterans and 
families and helps them get linked up to VA resources.
    I thank you for the question.
    Mr. Benishek. Thanks.
    Mr. Massie?
    Mr. Massie. Thank you, Mr. Chairman.
    Dr. Chard, we heard from Mr. Berry that no one from the VA 
reached out to him to help the family understand the effects of 
PTSD or to participate in care. And then he later also stated 
that the HIPAA laws were an impediment to learning about his 
son's condition.
    Can you respond to Mr. Berry's testimony and also share 
with us how you have to work within the HIPAA laws, and if 
there is anything that Congress can do to change those laws, or 
do they strike the right balance of privacy for the patient, or 
do they restrict you too much from involving the family?
    Ms. Chard. Thank you. And, of course, any loss of any 
individual is one loss too many. It was very tough for me to 
hear that story because of my desire to always want to help 
every veteran that comes in our door.
    And the sad truth is exactly what you said. HIPAA laws 
prevent us. If an individual veteran does not want us to talk 
to their family members, they can invoke that right, and we are 
therefore not allowed to provide education, answers, support, 
any information at all to that person's family.
    Now, you asked about the balance, and I think the hard part 
is the situations where the veteran wants to be protected. I 
can't tell you the number of situations where I have had 
veterans going through custody hearings, going through 
difficult divorces, having difficult bosses who have asked for 
information from us and we have been able to protect them as 
they are going through those custody hearings where someone is 
trying to take away their child, saying they have PTSD and they 
cannot be trusted.
    So it is a very difficult situation that we are in, in that 
we do have to have a balance where we both protect the rights 
or personal care of an individual, but also try to get as much 
information out to family members as we can.
    Mr. Massie. Is that a right they have to assert? Do they 
invoke it, or is it an opt-in?
    Ms. Chard. HIPAA is a standard thing that all of us are 
given when we go to the doctor's office. There is HIPAA 
information that we are given, and we sign a statement saying 
we understand the HIPAA law. It is a standard for every one of 
us every time we go to a doctor's office.
    Mr. Massie. So it is basically an opt-in.
    Ms. Chard. You can opt out of HIPAA and give someone 
rights. You actually have to sign that you agree to let me talk 
to someone.
    Mr. Massie. So it is opt-out.
    Ms. Chard. Yes.
    Mr. Massie. By default, you can't share that. They would 
have to voluntarily ask you to do that.
    Ms. Chard. Correct. But I do encourage everyone here to 
talk about the National Center for PTSD Web site. We have one 
of the best Web sites, funded by Congress, for information for 
family members and veterans and civilians about PTSD, and it is 
the National Center for PTSD Web site at VA.gov, and there is 
great information for family members there.
    Mr. Massie. Can you encourage the veterans to engage their 
families? I mean, do you do that?
    Ms. Chard. We certainly do.
    Mr. Massie. And let them know about their HIPAA rights, 
that they can be waived, that they can share that information?
    Ms. Chard. We actually try in all the cases that I can ever 
remember to engage the family literally from step 1, because we 
do, at our orientation group, ask that the veteran bring a 
family member to our orientation group. We then, in addition to 
our psychosocial history, we ask if they have any family 
members that they are willing to have involved in their care. 
And then finally, we offer couples and family-based treatments 
that are evidence-based where we actually encourage the veteran 
to not just have them informed about their care but be a part 
of their weekly care, if they are willing.
    Mr. Massie. Thank you.
    Ms. Smith, Mr. Berry testified that his son was upset about 
the hassles involving going to the Cincinnati VA Medical 
Center, up to and including having to answer the same questions 
over and over. He felt that that caused him to relive his 
experience at Fort Hood. And then also, I think perhaps in his 
written testimony he stated that having doctors in residency 
treating vets kind of breaks this tendency that the patient 
would like to have the same doctor every time they go so they 
don't have to answer the same questions, because you want to 
build a connection with the doctor and trust.
    Do you agree with Mr. Berry why or why not should folks who 
are undergoing treatment for mental illness see doctors in 
residency, or should there be some continuity?
    Ms. Smith. Let me try to answer that question as broadly as 
I can. Every one of our mental health veterans will eventually 
have a mental health treatment coordinator, and I believe we 
are close to achieving that, somebody that can kind of navigate 
their care through the various areas where they get care or 
treatment.
    Our veterans, when they come to clinic, whether it is to 
one of Dr. Chard's PTSD clinics or with Emma, do have an 
attending physician or an attending provider responsible for 
their care. We are a site for training, and we have a large 
number of training programs which we are very proud of. But it 
is not the responsibility of a medical student or a psychiatric 
resident or a clinical social work trainee to provide care for 
our veterans. That responsibility resides with the individual 
provider, as in the case with Emma in our clinic, or the 
physician that also covers the OIF/OEF clinic, and also for Dr. 
Chard's clinic. Those are permanent providers.
    Now, it may be true if a veteran is seen at a specialty 
clinic, especially med surge specialty clinics, where their 
first contact may be with a medical resident or surgical 
resident. But there is always an attending physician at those 
clinics.
    I will let Dr. Chard just briefly talk about how we assign 
mental health providers.
    Ms. Chard. Certainly. So when someone comes into the VA, 
they are immediately attached to a provider, whether it is a 
psychiatrist, a psychologist, or a social worker, and whoever 
they first meet is attached as their mental health treatment 
coordinator. That person's name is on the front page of their 
chart. So if that individual calls in the middle of the night, 
if that person comes into our psychiatric emergency room saying 
``I don't remember who that person is, I have walked away from 
the VA for six months, but I need somebody,'' we have a name on 
the very front cover page that everyone can see, including the 
vet center, and call that individual and say Mr. Jones, Mr. 
Smith is back and he needs care, where did he leave off, what 
can we do for him, and that individual will reinitiate care 
with him and get him to the best environment, or her to the 
best environment.
    Mr. Massie. Thank you. I yield back.
    Mr. Benishek. Mr. Watiker, I just have one more question. I 
understand that you have authority for bereavement counseling 
for families. Were you made aware of Mr. Berry's son's suicide, 
and do you reach out to families that have suicide that you are 
aware of?
    Mr. Watiker. As far as in the specific case of Mr. Berry, 
we get referrals from a variety of different organizations.
    Mr. Benishek. I'm sorry, I can't understand what you are 
saying.
    Mr. Watiker. I'm sorry, sir. As far as speaking to Mr. 
Berry's case, we get referrals from a variety of different 
organizations, whether that is through family members or 
through veteran service officers, or even from our national 
organization or our national bereavement headquarters out of 
Colorado. And from there, once we get a referral, for whatever 
family member is requesting services, we make contact with that 
family member and engage them for services.
    Mr. Benishek. So you have to be notified by the family, 
then.
    Mr. Watiker. The family member or another representative, 
an organization who is acting on behalf of the family members. 
And once we get that referral, then we will make contact with 
that specific family member to offer bereavement services.
    Mr. Benishek. All right. Thank you.
    Mr. Watiker. Thank you.
    Mr. Benishek. Well, I appreciate you all being here this 
morning. I know you are very proud of the service that you 
provide there. As you said, Dr. Chard, even one suicide is one 
too many. You all know that there is definitely room for 
improvement despite the statistics that you have shown us that 
you are doing well.
    It is our job really to be sure that the system works as 
efficiently as possible. With 18 to 22 suicides a day among our 
veteran population, you can understand our concern as to what 
the VA is really doing to make it better. Despite your 
statistics that look good, it is very distressing to me and, 
I'm sure, my fellow Members here on the panel, that our 
veterans deserve the absolute best, and we want to make sure 
that your agency is doing the best they can.
    So I really want to thank all of our witnesses and members 
of the audience for joining us today. It has been a pleasure 
for me to spend time in southern Ohio and see the medical 
center and some of the other great medical facilities here in 
town.
    Before we conclude, are there any veterans in the audience? 
Could any veterans in the audience please stand up or raise 
their hands so we can recognize them?
    [Applause.]
    Mr. Benishek. Thank you. Thank you. I want to thank you 
very much for your service. We owe you a great debt that we 
still remain a free country. It has been an honor for us to be 
here with you this morning.
    And with that, I ask unanimous consent that all Members 
have 5 legislative days to revise and extend their remarks and 
include extraneous material, and we may submit further 
questions for the panel, which we will expect answers to. So, 
without objection, I will order that.
    The hearing is now adjourned.

    [Whereupon, at 11:53 a.m., the Subcommittee was adjourned.]

                            A P P E N D I X

                              ----------                              

              Prepared Statement of Hon. Dan Benishek M.D.

    Good morning and thank you all for joining us this morning. It is a 
pleasure for us to be here in beautiful Cincinnati, Ohio, with all of 
you.
    I am honored to serve as the Chairman of the House Veterans' 
Affairs Committee Subcommittee on Health and to be joined on the 
Subcommittee by your Congressman and my friend, Dr. Brad Wenstrup.
    As I am sure you know, Brad has served for the last fifteen years 
as a member of the U.S. Army Reserves, where he has achieved the rank 
of Lieutenant Colonel.
    In the spring of 2005, he deployed to Iraq for a year. While there, 
he served his fellow soldiers, sailors, airmen, and marines - as well 
as prisoners and civilians - in Abu Ghraib as the Chief of Surgery and 
the Deputy Commander for Clinical Services.
    For his brave and loyal service there, he earned numerous awards 
and accolades, including the Bronze Star.
    Brad is also Doctor of Podiatric Medicine and a former small 
business owner.
    Needless to say, the immense wealth of knowledge, experience, and 
insight that Brad brings to the Subcommittee is invaluable. I am 
extremely grateful to work side by side with him and for his leadership 
on behalf of our Nation's veterans and their families.
    So, when Brad asked me to come to Cincinnati - his hometown - to 
address an issue of such importance to us all - the provision of high 
quality and effective mental health care to veterans in need - I seized 
the opportunity.
    Yesterday, Brad and I paid a visit to the Cincinnati Department of 
Veterans Affairs (VA) medical center. While there, we had an in-depth 
discussion with medical center leaders and toured the facility.
    Having worked myself as a surgeon at the Iron Mountain VA Medical 
Center, I most enjoyed meeting with some of the hard working Ohioans 
who strive day-in and day-out to provide the best possible care and 
services to the veterans in this community.
    I would like to take a moment to personally thank each of those 
health care providers, administrative personnel, and support staff for 
their dedication to our servicemembers, veterans, and their families.
    It is clear that there are some very special things going on in 
Cincinnati for our heroes and you have much to be proud of here in 
Ohio.
    However, where the health care and services provided to our 
veterans is concerned, exercising our responsibility for oversight of 
policy and practice is paramount.
    This past February, VA issued a sobering report which shows that - 
for the last 12 years - there have been 18 to 22 suicide deaths among 
our veterans every single day.
    Ladies and gentleman, we have lost far too many of our veterans on 
the battlefield of mental illness. We have to do better. And we have to 
do it now.
    Key to that effort is breaking down barriers to care that veterans 
in the midst of struggle often face when attempting to access the care 
they need to successfully transition home and maintain happy, healthy, 
and productive lives.
    No veteran should be reluctant to ask for help because they are 
ashamed or embarrassed. And, no veteran who does take the brave step of 
seeking care should be told they have to wait for an appointment that 
is weeks or months away and/or travel long distances away from their 
homes and families to receive the services they need.
    Today, we will discuss the actions we must take to reduce stigma 
and increase the accessibility and availability of mental health care 
for veterans here in Ohio and across the VA health care system.
    We will also discuss the increasingly vital role that faith-based 
and community groups are playing in helping our veterans and what we 
need to do to increase and improve meaningful partnerships between VA 
and these community resources, who are often the first and most trusted 
point of contact for veterans and families in need.
    Finally, we will also discuss the critical part that family members 
and other loved ones play in the healing of our heroes and the need to 
increase family awareness, involvement, and integration in mental 
health care services, particularly for those veterans most in need of 
support.
    I look forward to hearing from the local Ohioans - many of them 
veterans - who will testify today. I thank you for being here and for 
your devotion to improving the lives of Ohio's veterans.
    With the help of communities like Cincinnati and discussions like 
the one we are having this morning, I am hopeful that we will shatter 
mistaken perceptions that mental health care is not available, not 
appropriate, or not effective and there will come a day when no veteran 
is discouraged from reaching out and seeking care and no family suffers 
alone.

                                 
                Prepared Statement of Hon. Brad Wenstrup

    Good morning, and welcome to the House Committee on Veterans' 
Affairs Health Subcommittee field hearing, ``Making a Difference: 
Shattering Barriers to Effective Mental Health Care for Veterans.''
    Mr. Chairman, I want to formally and officially welcome you to 
Cincinnati! As you have seen these past two days, this district - a 
district I am so privileged to represent - has an incredibly rich 
tradition of military service. I want to thank you for the leadership 
you have shown on the issue of veterans' mental health care and for 
hosting this field hearing here today. I am also grateful that 
Representative Massie, a strong supporter of our military and our 
Nation's veterans, has taken time out of his schedule to be here. 
Congressman Massie, thank you.
    To the witnesses on our panels, to each person in the audience, 
and, especially, to every veteran present today: thank you for joining 
us. It is important for us all to be engaged in this issue if we are 
going to truly improve the care our veterans receive.
    This field hearing is an opportunity to bring Congress to 
Cincinnati. I'm pleased that the Subcommittee on Health will hear 
directly from the veterans, the family members of veterans, the service 
officers, and the community providers of this region. They will provide 
a valuable perspective on the common barriers to mental health care 
that our veterans face.
    The veterans of Southern and Southwest Ohio are a diverse group. 
They were raised on farms, in urban high-rises, and in suburban 
neighborhoods. But they share a common bond: they made the voluntary 
commitment to serve our Nation. Only one percent of Americans have 
served in uniform. Their accomplishments have been amazing and truly 
unmatched by the rest of the world. As a veteran of the war in Iraq and 
a member of the Army Reserve, I have witnessed the heroism of my fellow 
veterans and have deep respect for them.
    We can never repay them for their sacrifice, but we can honor it by 
ensuring that they and their families receive the care that they 
deserve. In Ohio, we have a robust system of Veterans Service 
Commissions that serve our veterans with zeal and dedication. I am 
grateful to have the representatives from commissions in three 
different counties present to testify today.
    There is growing recognition that we must develop better treatment 
for the ``invisible wounds'' that veterans bring home, including 
depression, posttraumatic stress disorder, substance abuse, and 
traumatic brain injury. These wounds affect veterans of all our past 
wars, but the veterans of Operations Enduring Freedom and Iraqi Freedom 
face unique mental health challenges. Because of technological 
advances, more soldiers are surviving physical combat injuries, but 
they present disproportionate neurological and psychological wounds. 
Studies suggest that one in five veterans of the wars in Iraq and 
Afghanistan has PTSD. A decade of war with frequent and extended 
deployments has made it more critical than ever before to create a 
quality mental health care system for our veterans.
    There are many challenges in our current system that do not allow 
veterans to get the care they need. Sometimes, veterans are simply 
unable to access care: they have difficulties in scheduling timely 
appointments or the office is simply too far away. Other times, 
veterans are unwilling to ask for or accept help. Each veteran has 
unique struggles and needs, and we need a mental health care system 
that is able to provide effective, individualized care.
    Today, we will discuss how the Department of Veterans Affairs can 
better improve its approach to and delivery of mental health care.
    Truly effective care, however, will extend beyond the VA: it will 
require the involvement of veterans' families and their communities, 
including veterans service organizations, community health care 
providers, and faith organizations.
    Each of us has a role to play in improving veterans' access to 
mental health care.
    Again, thanks to each of you for being here for this important 
discussion.

                                 
                   Prepared Statement of Howard Berry

    My name is Howard Berry. I am the father of the late SSG Joshua 
Berry. He was wounded both physically and mentally as a result of the 
shooting at Fort Hood on 5 Nov 2009. My son suffered terribly from 
PTSD. He chose to end his life on 13 February 2013. I am not an expert 
on PTSD. I am however an expert on the pain that this disorder places 
on the surviving family members of soldiers who do not respond to 
treatment, soldiers who look to suicide as the solution to end their 
suffering.
    I am left with a lot of questions, many that will only be answered 
by the passage of time. Please bear with me as I attempt to share with 
you some of the experiences my son had while being treated for PTSD. I 
will also share some of the changes I believe will give other soldiers 
a better chance to find success in their recovery.
    Soldiers suffering from PTSD have skill sets that have been 
compromised. The simple things that we encounter in our day to day 
lives were extremely difficult, if not impossible, for my son. He had 
tremendous difficulty adjusting to civilian life. We do a marvelous job 
taking a civilian and turning him into a soldier. We do a lousy job 
helping that soldier make the transition back to civilian life. My son 
was one of those who could not successfully return to civilian life, as 
he was given limited training to transition, which was combined with 
the damage done to his skill sets.
    The invitation to this symposium listed four topics for discussion, 
and I will attempt to share my thoughts on each.
    (1) The impact of patient waiting and travel times on veterans' 
ability to receive mental health care and actions needed to increase 
the accessibility and availability of mental health care services for 
veterans.
    Josh travelled by car to get to his appointments. During his 
treatment, he had valid concerns about travel time and fuel cost. He 
had to consider how long it would take to find a parking space at the 
Cincinnati VA, and if he would have enough gas left to go home after 
his appointment. Josh was upset about the hassles involved in going to 
the Cincinnati VA, up to and including having to answer the same 
questions again and again, resulting in reliving the horror he 
experienced at Fort Hood. He saw no benefit in answering the same 
questions repeatedly.
    Josh was even involved in an accident one afternoon when leaving 
the VA to go home. This was another excuse that he would give to not go 
to the VA. It was just one more bad experience, added to a list of bad 
experiences, to, in his mind, deter him from seeking treatment. His 
skillsets were so broken that he also failed to maintain auto insurance 
coverage, which created yet another financial obstacle. When I asked 
him why he had not paid his bills, I discovered that he was not opening 
mail, period. He said he only got bad news whenever he did, so he 
didn't see the point.
    I am sure Josh's story of broken skillsets is similar to the 
stories of other soldiers. It must be difficult to admit the need for 
help. Our goal is to find a way to improve their skillsets, and their 
ability to seek treatment for their injuries.
    One way to improve the accessibility of treatment is to consider 
the needs of the soldiers themselves. A lot of folks are parents. How 
many appointments are missed, or aren't even scheduled, because vets 
cannot find someone to watch their children? Is there childcare 
available on site for veterans' children while they are receiving 
healthcare?
    Many of these soldiers are busy people. Transitioning into life as 
a civilian includes taking on financial and family responsibilities. 
Are appointments currently consolidated, so the veteran makes one trip 
instead of several to get treatment? For instance, can a vet schedule 
appointments back to back to see a physical therapist and a 
psychiatrist?
    Many soldiers who suffer from PTSD also miss appointments. If they 
stop calling and stop coming in, does anyone take notice? Do they fall 
through the cracks?
    I believe taking a battle buddy approach to making sure their 
fellow soldiers are OK will greatly improve the care they ultimately 
receive. This will also work well in rural areas where vets have 
limited access to care. Just talking with another person makes a world 
of difference. When my son enlisted, he told me that if something bad 
happened to him, someone had his back. After returning from deployment 
and trying to transition to civilian life, I asked him the same 
question. For him the answer was no. I could see and hear the pain he 
felt before he died. He felt that his country had wiped its feet on 
him. He felt that he had gone from a hero to a zero. I'm sure a battle 
buddy/mentor would have given him a better chance at recovering. I bet 
lot of soldiers returning home would jump at the chance to continue to 
be of service to their brothers and sisters in arms.
    Essentially, there needs to be a mentoring program, a pairing of a 
vet with a similarly ranked veteran. Consider the Alcoholics Anonymous 
concept of a sponsor/sponsee relationship. They meet as equals, the 
sponsor listening to the sponsee and sharing their experience, strength 
and hope with him, simply showing what he did to recover. I know this 
works. I cannot explain why. I do know we are only as sick as our 
secrets. I wish Josh had someone to share his secrets with; knowing 
that he wouldn't be judged or looked down upon would have helped him.
    In addition to a sponsor, there needs to be support groups where 
veterans can freely speak to one another anonymously, removing the 
fears and stigma that a person with PTSD suffers from.
    Furthermore, there needs to be a review of practices in all VA 
locations. Are the standards of care used to treat PTSD affected 
soldiers the same in all 50 states? If not, why? Are successful 
programs copied and less effective ones phased out? Do VA facilities 
across our country freely communicate with one another in a timely and 
consistent manner? What programs will result in a reduction of the 
suicide rate? We must determine what works and what doesn't work. After 
all, the goal is to reduce the number of service men and women who take 
their own lives when they feel they have no other option.
    Another area in need of improvement is the early identification of 
warning signs in soldiers who are likely to take their lives due to the 
severity of their PTSD. We need to identify these brittle soldiers as 
soon as possible. This group of combat soldiers has a disproportionate 
suicide rate when compared to other groups of servicemen and women. 
Those who need additional attention, due to the severity of their PTSD, 
should subsequently receive a higher level of care. Can resources be 
allocated to provide for their needs?
    Although accessibility, timeliness, and availability are important, 
continuity is just as crucial. Having doctors in residency treating 
vets with PTSD inhibits the development of strong doctor/patient 
relationships. A vet may begin to build a connection with a doctor, 
someone he is starting to trust, only to have that person replaced on 
the next visit. Having to start over from square one only forces our 
vets to relive painful experiences. How many times would you be willing 
to tell your story before it felt futile? I have been telling my son's 
story for over six months now. I know how it feels.

    (2) The effect of stigma on veterans' willingness to seek mental 
health care and actions needed to eliminate it in the veteran 
community.
    The stigma placed on our veterans starts in the military. My son 
was trained to suck it up and roll on, as I'm sure countless others 
have and are currently taught to do. If there is not bone or blood 
showing, you don't speak up, as it is looked on as a sign of weakness. 
Josh was told on one particular occasion by a superior that he was 
nothing but an old, broken down NCO, who needed to get out of this 
man's army. This was after he had experienced the horror at Fort Hood 
and was getting treatment for his PTSD. I know he felt that he was 
betrayed by some of the people put in place to help him.
    Why don't we begin by calling PTSD what it is? It is a wound. We 
need to give veterans a reason to hold their heads high and not be 
ashamed by the perceived weakness associated with PTSD.
    My son felt that he was as expendable as a broken rifle or a worn 
out pair of boots. I'm sure there are other veterans who are silently 
suffering and feel the same way. I believe that one way to help 
soldiers suffering from PTSD sustained in combat is to award them with 
a Purple Heart. They should be given the same considerations as 
servicemen and women who have shed blood for our country. This would 
help to even out the playing field in civilian life. Giving them the 
same benefits, including points towards employment, education and 
healthcare would be proof that their country acknowledges the 
sacrifices they have made to protect others' freedom. Their injuries 
merit equal treatment.
    I know there is a lot of resistance to this. I have been 
disappointed to hear from older veterans who are reluctant to support 
this change. They feel their sacrifice will be diluted by the inclusion 
of those with PTSD. I thought soldiers were trained to look out for one 
another. Why aren't they included in this Band of Brothers?
    If Purple Hearts are not awarded, then Congress needs to step up 
and create a separate award, one with equal benefits, one that will 
give these vets the recognition they deserve, one that honors the 
sacrifice they have made. Give these veterans a reason to hold their 
heads up high. It is the right thing to do.
    I recently had a discussion with a director where I work. I gave 
him a scenario: ``you have one position to fill with two equally 
qualified candidates. One of them is a veteran with a Purple Heart. Who 
would you hire?'' He responded with, ``The veteran.'' I then asked him 
to consider the same scenario, only this time, the veteran has PTSD. He 
did not immediately respond. I apologized for putting him on the spot. 
After all, he has an obligation to protect the company's interests, 
including the other employees' wellbeing and safety. If society puts 
these veterans at a disadvantage, it is no wonder that many don't seek 
treatment for PTSD. I'll bet many do not take their medication as 
directed or at all, fearing this may have an impact on their 
employability if their medication is discovered on a drug screen.

    (3) The role of faith-based and community providers in assisting 
veterans in need and actions needed to increase and improve meaningful, 
collaborative partnerships between VA and these critical community 
resources.
    One way we can support these veterans is through media coverage. 
Our society is driven by what we hear and see. Positive media coverage, 
starting from within the military, will help to remove the stigma 
associated with PTSD. Sharing the successes of programs that have 
proven to be effective as well as success stories of soldiers who have 
transitioned to civilian life will show the nation that vets with PTSD 
deserve a fair shake.
    We must strive to create connections, emotional bonds, with the 
rest of Americans, showing them that the veterans in their community 
are just like them. The difference is that they stand up in the face of 
danger and fight for our freedom. PTSD should not be a reason for fear 
in our society. Soldiers being treated for PTSD should be looked up to, 
not down on. We need to show our nation that they are not broken by the 
violence they have seen. We need to show them that they have worth and 
are included in the pursuit of happiness, something that is currently 
out of reach for many of them. The media can help create a bridge to 
bring churches and non-profit organizations together to support our 
vets. By including stories of success in our media outlets, we can 
change how society looks at PTSD affected veterans.
    I know I could not continue to speak for my son and others like him 
without a deep sense of faith. If a guy like me can learn how to do 
this, I believe anyone can.

    (4) The role of family in mental health care treatment and actions 
needed to increase family awareness, involvement, and integration in 
mental health care services.
    Families are directly and indirectly affected by soldiers returning 
home with PTSD. The anger, resentments and hopelessness carried by 
these returning vets are often carried over to civilian life. If 
nothing changes, the family suffers their own version of PTSD. We love 
them, but we don't understand what to do. We don't want to make things 
worse, yet we have no solution to work towards. We learn to suffer as 
silently as the veteran.
    Neither I nor any of my family members were ever asked if we wanted 
to learn how to help someone with PTSD. I could not communicate freely 
with anyone regarding my son's care due the HIPAA laws. These laws were 
enacted to protect the individual. However, I see compliance to this 
law as a major contributing factor in the death of my son.
    I also feel the law is currently used to protect the agency, not 
the individual. Letters that were written on my son's behalf could not 
be used by me without putting those who authored them at risk. The 
bottom line is this: if I choose to use them, the people responsible 
for authoring them would be dismissed. I don't understand the reasoning 
behind this. It must be fear. If more administrators spend less time 
covering their backsides and use a common sense approach instead, more 
would be accomplished.
    My son felt that the PTSD he suffered from was acquired through 
such a unique experience, the shooting at Fort Hood, that no one could 
ever understand. He could not focus on any of the similarities between 
his experiences and those of other soldiers--all he could see were the 
differences. In his eyes, he could have managed the PTSD from his tour 
in Afghanistan, but that going eye to eye with a superior officer who 
was shooting to kill amplified his trauma to another level, a terminal 
uniqueness that grew from the fact that his injuries were sustained in 
the center of a military installation, and not in a war zone.
    I am sure that there are other soldiers who feel just like Josh 
did, that their unique set of circumstances can't be understood, that 
their experiences are too traumatic for others to comprehend. And to a 
degree, we don't understand because we have not really tried to. But we 
have to find a way to break down these walls. We have to convince them 
that we want to understand, that they are not alone as we support them 
in their recovery. We need to make these soldiers feel like they're a 
part of the solution, and not a part of the problem. Their ability to 
succeed begins with creating a circle of care that includes the 
military, the VA, the family, and our society as a whole.
    Families need the opportunity to work with the medical 
professionals, social organizations, both religious and non-profit. 
PTSD affected soldiers need to see support in every direction they 
look. If we work together to make their burdens lighter, we have a 
chance to have the kind of country my son fought for.
    The suicide rate is still rising among our veterans. I hope my 
speaking to you today was not a waste of our time. I hope it is the 
beginning of positive changes. After all, we are all responsible.

                                 
                  Prepared Statement of Nate Pelletier

    The Cincinnati VAMC is a best in class medical center; and, as a 
disabled Veteran, I've personally received outstanding care. As a 
Veteran leader, I have a vested interest in ensuring our federal and 
community resources enable all Warriors in transition and Veterans to 
successfully reintegrate. I've conducted research that studied the 
impact of transitioning Veterans and drafted a proposal \1\ to assist 
not only the VHA, but the Departments of Defense, Labor, HUD and HHS 
\2\, as well as supporting agencies and community partners on how to 
improve and implement a sustainable transition system. As an Executive 
Director of a local agency supporting Veterans in need, I've witnessed 
what can happen if those who have served our country fall into the 
``gaps'' of an inefficient transition and support network. On my very 
first day of work at the Joseph House, Inc., one of our War on Terror 
clients overdosed on heroin and nearly died in his room. Thankfully, 
his roommate was EMT certified and saved his life that day.
---------------------------------------------------------------------------
    \1\ Clifford, P., Fischer, R. & Pelletier, N. (2013). Exploring 
Veteran disconnection: Using culturally responsive methods in the 
evaluation of Veterans Treatment Court services. Unpublished 
manuscript.
    \2\ Pelletier, N. (2012). Successful Warrior to Successful Veteran. 
Cincinnati, OH: Author.
---------------------------------------------------------------------------
    Over the next 3 years, more than 300,000 new Veterans will return 
to civilian society. Our communities need to be ready to serve them and 
utilize their talents in the community and in the workforce. To this 
end, there are two topics that are interconnected and deserving of this 
Committee's attention- VHA's scope expansion and VA administrative 
leadership's support for community partnerships.
    During the transition of new Veterans into the community, the VHA 
currently feels the burden to fill ``gaps'' in the process due to the 
absence of a seamless transitioning system. I define this as ``scope 
creep''. The DOD, VA (VBA/VHA), DOL, as well as other agencies and 
community organizations have acknowledged that the transition process 
is very inefficient and that the responsibilities of each organization 
are unclear. With this in mind, some examples of VHA scope creep 
include but are not limited to: employment assistance, education 
assistance, benefits assessment and family supportive services 
unrelated to medical services. As we attempt to define the 
responsibilities of the VHA during this process, we can categorize the 
decision making process into three groups - 1) processes that VHA funds 
and owns responsibility to execute, 2) processes that VHA funds and 
outsources to community partners to execute, 3) processes that VHA 
outsources to community partners who are VA or privately funded and can 
own the responsibility to execute. In addition to addressing the 
systems and process responsibility to reduce scope creep, it is 
important for the VA administrative leadership to empower and leverage 
VHA and community partnerships.
    In an attempt to fully assess the effectiveness of our VHA and 
recommend areas to partner with the community to reduce scope creep, we 
must define ``what are the primary responsibilities of the VHA?'' The 
purpose of the VHA is very focused and clear- support the medical needs 
of Veterans who qualify for medical services post military service. Any 
services in addition to their primary responsibilities should be 
assessed according to the three process categories mentioned 
previously.
    The first step to effectively optimize the system of Veteran 
support is for the VA administration to take an active role in 
partnering and often time leading the convening of mobilized community 
action teams to collectively meet the needs of our Veterans. To 
quantify and provide some examples of how the VA administration could 
partner more effectively in Cincinnati in order to reduce scope creep, 
we can assess two areas of concern nationally and locally- employment 
and chemical dependency, as well as their potential relation to co-
occurring mental health disorders.
    Employment is a critical ``node'' that a Veteran must attain and 
sustain to successfully reintegrate (with the exception of those who 
are 100% disabled and unable to work). If this node collapses, it is 
most often the catalyst that dissolves secondary nodes within the 
ecosystem of support for a Veteran such as mental health stability 
(i.e. triggers PTSD symptoms- depression, self-esteem, sense of 
purpose, etc.) and can cause a Veteran to retract from social 
reintegration as well as lead to even further breakdowns in the 
ecosystem of support such as family relations, and sustainable housing. 
Too frequently, these breakdowns lead to the use of unhealthy coping 
mechanisms such as a reliance on drugs and alcohol. This is often the 
beginning of the ``downward spiral'' and collapse of a Veteran's 
sustainable reintegration. So where does the responsibility lie for 
disconnection in Veteran employment during the transition from Warrior 
to Veteran?
    According to sources at the Joint Chief of Staff's Office for 
Warrior and Family Support, the DOD is accountable for more $960 
million dollars in unemployment compensation to Veterans (unfortunately 
without the ability to fully evaluate their progress due to the fact 
Veteran's are no longer tracked in the DOD system post out-process). 
However, more often than not, the VHA receives the primary burden of 
responsibility to assist unemployed Veterans given that they usually 
have the most access to the Veteran population in the region. This is 
an example of scope creep within our local VHA due to the 
inefficiencies related to ``who owns what'' in the transitional process 
from Warrior to Veteran. Therefore, the VA administration should 
emphasize the importance of engaging with the private sector and 
community partners who focus entirely on job placement. More often than 
not, this will be supported under category 3 mentioned above and 
secondarily, could reduce both the DOD and VHA scope creep.
    Besides Veteran employment efforts, the VA administration can also 
optimize their VHA partnerships with the community agencies providing 
clinical treatment for Veterans with addictions. As the Executive 
Director of the Joseph House, Inc. for homeless Veterans with 
addictions, my clients are prime examples of the systematic breakdown 
of a Veteran's ecosystem of support. My clinical team has 
conservatively identified that 12 out of our 27 clients in our 
treatment program as of September 2013 have also been prescribed 
psychotropic medication for a co-occurring mental health disorder. It 
is important to note, that up to 78% or more of my senior clients 
(post-Vietnam) are suffering from co-occurring mental health and 
addiction disorders that are either unrelated to military service, 
possibly caused by socio-economic struggles, childhood adversity or 
other past experiences. However, a majority of our younger clients (War 
on Terror) are suffering from disorders related to PTSD, combat stress, 
and/or transitional anxiety in addition to these past experiences that 
have either led to chemical dependency or enhanced a pre-service 
addictive behavior. As it relates to our clients, mental health and 
chemical dependency are the primary nodes that have broken down within 
their ecosystem of support that likely caused their current state of 
homelessness.
    Although the local VA administration has provided exceptional 
support through their VHA Community Outreach Division to fund and 
evaluate current programs like the Joseph House, Inc., it has been 
reluctant to support VHA participation in community-based Veteran 
mobilization efforts or ``community action teams.'' The VHA could 
optimize the impact of Veterans recovering from chemical addiction with 
effective engagement in both the housing and health sub-committees of 
the local Veteran community action team. VHA participation at an 
operational level will allow them to better assess funding support for 
community agencies according to the three process categories mentioned 
above. Furthermore, a more interactive relationship with community 
agencies will enable them to share and assess best practices so that 
they can not only help improve the local agencies they currently fund, 
but their internal treatment program as well.
    Local agencies such as the Joseph House, Inc., Talbert House 
Parkway Center, Volunteers of America to name a few in our region, 
provide services and treatment for Veterans suffering from homelessness 
and chemical dependency. The majority of our funding is provided 
through the VA Grant Per Diem program. Although the VA provides a 
series of measures to validate our funding each year, they also operate 
their own internal substance use program within the VAMC hospital. 
After reviewing their internal hospital program compared to local 
agencies, it is evident that they fund a higher percentage of staff 
treating a smaller percentage of Veterans compared to our external 
agencies. It is important to note that the qualifications and 
certifications per ODMHAS (Ohio Dept. of Mental Health and Addiction 
Services) for our cliental programs and staff are parity to the VAMC's 
program. Also, many of our clients have been referred to us from the 
VAMC hospital program due to negative discharges or time limitations of 
the program. Thus, a more collaborative partnership could potentially 
enable a more effective program match as soon as a Veteran is 
identified for treatment. Moreover, it is important to acknowledge the 
changing landscape in chemical addictions.
    More Veterans, particularly the War on Terror Veterans are choosing 
opiates such as heroin vs. alcohol. It is important that we address the 
treatment options for opiate addiction vs. alcoholism and which 
programs are more qualified to provide treatment services - VHA or 
community agencies, or at minimum, create a stronger referral system 
between the two to ensure that the Veteran receives the proper care in 
a timely manner as soon as they are diagnosed. Recent studies have 
pointed out that, while substance use remains a key issue for Veterans, 
there has been a decline in specialized programs. Clients often respond 
better and stay engaged longer with specialized drug treatment 
programs. Therefore it is beneficial for the VHA and local agencies to 
partner to meet the treatment needs of new Veterans. \3\ This is why it 
is essential that the VA administration encourage their VHA teams to 
partner with the community in order to channel resources into one of 
the three process categories mentioned above, optimize internal and 
external treatment programs, and ensure that a Veteran is referred to 
the most relevant program to meet their treatment needs.
---------------------------------------------------------------------------
    \3\ Eggleston, M., Straits-Troster, K. & Kudler, H. (2009). 
Substance use treatment needs among recent Veterans. North Carolina 
Medical Journal, 70(1), 54-58.
---------------------------------------------------------------------------
    In summary, it is important to reiterate that the opportunities to 
optimize VHA scope creep and VA administrative leadership's support for 
community engagement are not a reflection of the dedicated VA/VHA/VAMC 
leadership and staff, but the opportunity to optimize internal 
processes in order to sustain their primary responsibility of providing 
medical care for Veterans who qualify for benefits and treatment. To 
this end, it is the responsibility of all us who have ``skin in the 
game'' to operate more collaboratively to improve the transitional 
system and process of new Veteran reintegration and community efforts 
to sustain the well being of all our Veterans and their families.
    In 2011, I received a call from the local VAMC at 10:30pm on a 
weekday to see if I could house a War on Terror Veteran for the night 
that had. Although he had just completed the chemical dependency 
program at the VAMC, he now had nowhere to go, no friends to call, no 
family to help and his time was up per the VA program guidelines. At 
around 11:30pm he arrived at my home, and for the next 2 hours he 
tearfully told me his story. Like many Soldiers, he signed up to serve 
his country, and suffered severe trauma related to combat that came 
home with him post deployment. If I recall correctly, his father had 
also recently passed away, and his mother was suffering from her own 
chemical dependency. Despite the breakdown of his support system, he 
``Soldiered on'' and secured a meaningful job, but was later laid off 
like so many other Americans. Without stable housing or employment, he 
found solace on the streets and had built a relationship with local law 
enforcement to allow him to just spend a few nights on the street while 
he reached out for help during the day. And unfortunately like many 
homeless citizens in distress, he turned to alcohol as his coping 
mechanism. While he fortunately found his way to the VA where he 
completed their chemical dependency program, he did not have the 
support network to sustain his sobriety post treatment, and my home 
became his last resort that night. This story like so many others is 
simply unacceptable. We must think strategically, act operationally and 
continue to identify opportunities to improve the sytem while always 
keeping the end-state in mind- ensuring our Veterans thrive in our as 
productive members of our society. One Veteran left behind is one too 
many.

                                 
                   Prepared Statement of Rodger Young

    My name is Rodger Young, I'm a Veteran's Service Officer for the 
Clermont County Veteran Service Commission. Veteran Service Officers 
assist veterans in obtaining their VA benefits. This can include 
enrolling into healthcare, applying for compensation/pension, education 
benefits, burial benefits, VA Home Loans, and financial assistance. We 
are also charged with aiding veterans with their appeals and dealing 
with overpayments and billing issues. We are the preverbal ``one-stop-
shopping'' for VA benefits.
    Our office was invited to attend this Committee to provide feedback 
on the services Veteran Healthcare Administration (VHA) provides and 
also comment on the programs/stigmata associated with Post Traumatic 
Stress (PTSD).

    1) Positive Feedback:

    a) The nursing teams are working well; open communications is the 
key to successful healthcare.

    b) MyHealtheVet is a great way to open the communication channels 
from veteran to doctor.

    c) Love the Ebenefits website which is the main hub for VA 
benefits/downloading VA correspondence ect . . .

    d) I commend the staff at CBOC Clermont County Ohio . . . great 
service, great teams, very cooperative/friendly with VSOs and they 
treat every veteran with the utmost respect.

    e) The quick reference flipbooks are great for passing on 
information concerning healthcare

    2) Areas to improve upon (our feedback from the veterans):

    a) Non-VA care (FEE Basis) - I attached the handout VHA mailed 
concerning paying for outside medical care due to a medical emergency. 
Many veterans are confused about the program and when VA will pay for 
emergency care/transportation. VHA needs to be clear on what VA will 
pay and the requirements before the care is covered; the handout makes 
it sound easy. There should also be a claim form to send to VHA along 
with the hospital bills. The processing time is another concern. It 
takes so long to obtain an answer many veterans are turned over to 
collections/credit ruined while waiting for an answer; appeal take even 
longer. VHA needs a call center for billing/non VA care alone; normally 
will get an answering machine and no return call.

    b) Average wait time for surgeries

    c) Still getting complaints about the professionalism at VAMC 
Cincinnati (friendliness), little to no complaints on Georgetown/
Clermont CBOCs

    d) DBQs

    e) If doctors refer veterans to file a claim, please ensure 
diagnosis/notes are annotated in CAPRI. Makes everyone's life much 
easier when filing a claim.

    Veterans endure many adjustments when returning from deployment to 
include indoctrination back into family life, adjusting back into their 
home station and their rules, and trying to process what had happened 
while deployed. In general, many veterans are reluctant to seek help 
for mental issues due to the stigmata associated with PTSD (employment 
to include separation from the military, family and current gun laws). 
Feedback from the CBOC staff indicate cognitive therapy is working on 
many veterans. Success stories to be honest I don't have any.
    Many who seek help for PTSD receive some relief through medications 
(to tone down the symptoms) but I've never seen a veteran completely 
cured. Realize in past wars veterans would endure 1-2 deployments into 
the
    warzone; contemporaneously, it's not uncommon to see 5-8 
deployments. PTSD programs have prevented many suicides but I think we 
still have a long road ahead in treating PTSD. In my opinion, we need 
to fix the stigmatas associated with PTSD so more veterans will seek 
help and then we need to rehabilitate them to function in today's 
society outside the military.
    Our office appreciates the invitation today to outline some of the 
hurdles VA faces and the vast improvements it has made to ensure the 
veterans are taken care of. Partnerships within VHA/VBA/VSO will 
solidify a smooth transition for the returning veterans and their 
families. Standardization, consistency and communication within these 
three agencies are essential to minimizing the confusion within the 
veteran communities.

    Rodger Young, MSgt, USAF(Ret)
    Veterans' Service Officer
    Clermont County Veterans Service Commission
    76 South Riverside Drive, 3rd Floor
    Batavia, OH 45103
    (513)-732-7363

                                 
                  Prepared Statement of Paul D. Worley

    Mr. Chairman and Members of the Subcommittee, it is an honor to 
testify before you today. Thank you, for allowing me the opportunity to 
speak this morning about mental health care for veterans. My name is 
Paul Worley and I am an Army veteran. I served as an infantry rifle 
platoon leader and scout platoon leader in 2nd Battalion, 502nd 
Infantry Regiment, 101st Airborne Division (AASLT) in Iraq in 2005-
2006. In 2008, I served as an operations officer at Regional Command 
South, NATO Headquarters in Kandahar, Afghanistan. My last tour of duty 
in Iraq was from 2009-2010, where I served as a mechanized infantry 
company commander for 3rd Battalion, 69th Armor Regiment, 1st Brigade 
Combat Team, 3rd Infantry Division. At times and places few will ever 
know we fought for each other against an unseen enemy. I was honored to 
serve my country and privileged to lead the best soldiers in the world. 
Today, I am equally proud to represent my fellow veterans and to talk 
about the issues we face in regards to mental health.
    When it comes to mental health care for veterans the major issues 
are access and availability. The VA is the largest integrated health 
care system in the country. There are going to be issues, as there are 
in every health care system, but that does not mean that the system is 
broken.
    In Adams County, Ohio, our veterans are faced with the issue of 
getting reliable transportation to their medical and mental health 
appointments. The nearest clinics are located in Portsmouth and 
Chillicothe, which are at least a forty five minute drive for most 
veterans. For those who receive services in Cincinnati and Columbus the 
task of getting to appointments is even more daunting. Our local 
veterans' service commission and veteran service organizations, 
including VFW Post 8327 and DAV Chapter 71, currently provide 
transportation, but it is not enough to meet the demands of our 
veterans and their families. I believe it is essential that we provide 
more mobile veteran centers to provide access to our rural residents.
    Another access issue we face in southern Ohio is internet 
availability. Our internet infrastructure is extremely limited due to 
the terrain and the financial challenges of our local population. Many 
veterans do not have ready access to fill out forms online or to obtain 
the information they need about mental health services. As more 
information is shared online it is critical that we provide our veteran 
population with access to this basic modern need.
    I believe that the military as a whole has made positive progress 
to reduce the stigma of post-traumatic stress disorder within its ranks 
over the past ten years. However, I believe there is still a great 
amount of work to do reduce the stigma of PTSD among the American 
people. Young veterans seeking civilian jobs are reluctant to seek help 
because of the risk of employers not hiring them. All veterans deal 
with the stigma that seeking help for mental health is a sign of 
weakness. More education is needed to make sure the American public 
comprehends the issues associated with PTSD.
    It is very encouraging that the VA has recently hired an additional 
1300 mental health care workers that will potentially alleviate some of 
the availability issues. I believe that the VA employees and leadership 
want nothing but the very best care and benefits for our veterans. 
However, we need to continue to improve the mental health care system. 
We need to be prepared to pay for veteran health care services as 
readily as we were to fund the wars that caused these issues. The price 
tag may be great, but that truth does not take away the nation's duty 
to care for our veterans. The country sent us to war.
    Now is the time to make sure that this country is delivering on the 
solemn promise made to our veterans for their voluntary service.

                                 
         Prepared Statement of Kristi D. Powell - USAF Veteran

    I would like to thank the panel for this opportunity to discuss the 
issues that veterans face when seeking mental health care services 
through the VA, especially for MST (Military Sexual Trauma). I will 
touch on the four particular topics of discussion that cause barriers 
for the veteran when trying to receive mental health and other care and 
also of specific cases/examples of these barriers that we have in my 
county and with the VA's in our area. I would like to begin by 
introducing myself and giving you the specific examples of problems 
that veterans are currently facing when trying to receive treatment for 
MST.
    My name is Kristi Powell, I am a United States Air Force Veteran. I 
hold a Bachelor's Degree in Substance Abuse Counseling and a Masters 
Degree in Criminal Justice. I am currently employed at a job which 
allows me to assist in the needs of veterans. It is through my job and 
outside involvement with veterans' activities that I am able to hear 
veterans' stories, hold roundtable discussion groups, and help aid in 
their healthcare. I have also been blessed to have the opportunity to 
be their voice today. These examples are of different veterans of 
different ages, different eras served in the military and all separate 
times frames of when they experienced their problems within the VA as 
far as their health care.

    Case/Example 1: A female veteran in her late 40's came into the 
office very distraught. She showed signs of anxiety; she was crying and 
it was very apparent that something was wrong. After talking for 
awhile, she confided in me what had happened that was making her so 
distraught. She began to tell me how she was raped in the military by 
an officer and that it has impacted her life so severely that she can 
hardly function. She cannot work, she doesn't leave her apartment very 
often and she is on numerous medications just so she can get through 
the day and also to be able to sleep at night. Through the VA she 
learned of a program referred to as PRRTP (Psychosocial Residential 
Rehabilitation Treatment Program) that could possibly help her with her 
MST. She also felt that if she went to this program that it would help 
her in getting her service-connected claim for MST/PTSD so atleast the 
VA would know that she has severe problems with the MST that she was 
trying to address. She entered the PRRTP program at the VA hoping to 
receive the care that the VA claimed that they could give her and that 
they advertise. (Note: when referring to the care that the VA 
advertises I am specifically referring to the Department of Veterans 
Affairs website on MST in which it gives the following information that 
I copied and pasted):

Outpatient
      Every VA health care facility has providers knowledgeable 
about treatment for problems related to MST. Because MST is associated 
with a range of mental health problems, VA's general services for 
posttraumatic stress disorder (PTSD),depression, anxiety, substance 
abuse, and others are important resources for MST survivors.
      Many VA facilities have specialized outpatient mental 
health services focusing specifically on sexual trauma.
      Many Vet Centers also have specially trained sexual 
trauma counselors.

Residential/Inpatient Care
      VA has programs that offer specialized MST treatment in a 
residential or inpatient setting. These programs are for Veterans who 
need more intense treatment and support.
      Because some Veterans do not feel comfortable in mixed-
gender treatment settings, some facilities have separate programs for 
men and women. All residential and inpatient MST programs have separate 
sleeping areas for men and women.
How can I get more information about services?
      Knowing that MST survivors may have special needs and 
concerns, every VA health care facility has an MST Coordinator who 
serves as a contact person for MST-related issues. He or she can help 
Veterans find and access VA services and programs.

    So the veteran enters the VA PRRTP program as inpatient treatment 
for MST/PTSD. The veteran's anxiety began immediately upon arriving. 
After being admitted to the program the VA told her she was done for 
the day and that she go get chow. Upon entering the chow hall, she 
noticed that she was the only female veteran in the dining facility 
with all males. The veteran returned to her floor where she immediately 
found a VA nurse. She told the VA nurse she was having extreme anxiety 
and that she was told that the VA could help her with her MST/PTSD. The 
veteran felt betrayed that the VA would enter her in a program and then 
put her around all males throughout the day. On her first day of the 
program, she reported to where they told her to go, again she walked in 
the room to discover that she was the only female. Although confused 
and very uneasy about the situation she told herself that she had to 
stay because the VA briefed her that if she left the program early then 
she would not be allowed to be readmitted later and she still believed 
at the time she had to do it for her pending claim. In these group 
sessions she was told to participate, participation including stating 
the reason that you are there. She stated, when it was her turn, that 
she was there for MST. The males in the group automatically started in 
on insults and taunting her with comments about MST. A male in the 
group even stated to her ``why would you put yourself in that position 
by joining the military knowing that would happen.'' The same male then 
started bashing homosexuals by calling them derogatory names. This 
veteran responded by saying that it offended her and he responded back 
by saying ``you don't get excited by men?'' The facilitator of that 
group allowed this to go on and did nothing to stop or correct the 
conversation. After the group session was over, the female veteran went 
over to the facilitator and asked if there was a female psychologist 
that she could speak to. The facilitator gave her a name and so the 
female veteran immediately went and told the psychologist what 
transpired in group. The psychologist said that she would refer the 
veteran to the PCT program ( PCT programs I was told specialize in the 
treatment of combat-related PTSD). Even after this horrific event, the 
veteran still continued on with group. She completely isolated herself 
and refused to participate anymore while suffering severe anxiety 
attacks from being surrounded by all men. The same male from the group 
started following her around and making comments to her. He triggered 
her anxiety associated with her rape so much that the psychologist and 
the social worker stated that maybe this was not the program for her. 
The next morning the social worker came and talked to the veteran about 
what had transpired and what some options were. The comments continued 
by the male in the group in front of everyone, these comments were 
usually sexual in nature and as before, the facilitator did nothing to 
object to it. Finally the veteran had enough, she checked herself out 
of the VA and came back home. While at home, the veteran could not get 
the male or his comments to leave her mind. Something told her to 
Google his name, when she did numerous things came up. She noticed one 
was a mug shot so she clicked on it and it was that same male that 
taunted her in her group. He was listed as a convicted sex offender. He 
had raped a woman in Mansfield, Ohio and had his address listed on the 
website as the VA's. This VA allowed an MST survivor who suffers from 
severe mental health conditions associated with her rape to be in a 
group counseling session and freely around a convicted rapist. This 
veteran is now so traumatized that she refuses to go back to the VA for 
any type of healthcare. This event has completely set her back in any 
progress that the veteran had made prior to entering the VA for help.

    Case Example 2: A female veteran in her 20's came into the office. 
After talking to her, she disclosed that she was living in the homeless 
shelter and that she had a substance abuse problem. She was crying and 
stating that she did not know what she was going to do. I told her 
about the programs that are being offered at the VA and asked her if 
she would like me to help her see if one of the programs was open for 
her to enter treatment. She told me that she was already in a program 
up there and left and that she was not allowed back into any of them 
because of leaving. I asked her which one and what happened. She told 
me that she was raped while deployed to Afghanistan by her Lt. After 
being raped and her being harassed continually by him she started self 
medicating when she returned to the states. Her performance declined at 
work and she was eventually discharged from the military. When she came 
home, her substance abuse continued as she tried to mask her pain. She 
started using harder drugs such as heroin just to deal with life. Her 
parents did not know how to handle her so they kicked her out which 
forced her into the homeless shelter. She entered the VA in hopes of 
getting help with her MST and substance abuse problem. While at the VA, 
she also was put into an all male group session in which the taunting 
began immediately with name calling. They would call her ``princess'' 
and tell her to sit down when she told the group that she was there for 
MST. The taunting from the males became so bad that she left treatment 
and immediately got high to deal with pain that resurfaced from being 
raped. It was with this second veteran that I realized that this is not 
a coincidence; this is an on-going and unchanging issue at the VA. 
Since this vet was going through withdraws I took her back to the VA. 
While waiting for her to be admitted through Urgent Care, I took her 
with me to talk to the patient advocate. My first stop was the OEF/OIF 
patient advocate since she was from that era. I told the patient 
advocate that this was the second case that I knew of and that it was a 
severe problem. I asked him because I wanted to know what I personally 
had to do or who I had to talk to for this issue to be addressed and so 
it would not happen to another veteran trying to receive care. The 
patient advocate looked at me and asked ``at what point do you feel 
that these MST veterans would be able to attend group sessions?'' I 
honestly looked at him in disbelief, I could not believe that this was 
his first question and only concern. My reply was ``probably never. It 
would only be when the veteran states for themselves that they are 
ready.'' I then got up, left his office and went to the next person in 
line which was the Women's Health Social Worker. The social worker 
listened to my concerns and complaints about how MST veterans are being 
treated and the lack of care that they are receiving; she could not 
however give me any explanation to why this was happening but more or 
less said that the VA does not have the space or resources to have an 
all-female area. I stated to her although I completely understood 
budget restraints, as soon as a veteran discloses that they are a MST 
victim/survivor that should be the red flag for the VA to do an ITP 
(Individualized Treatment Plan). Under no circumstances should the 
veteran be subjected to the same sex and/or race of the person that 
sexually harassed and/or assaulted them. The social worker agreed and 
said she would definitely let the director of the VA know. The social 
worker gave me her word that she would find the appropriate care for my 
fellow young veteran that was suffering from so many mental health and 
substance abuse issues. The catch to waiting for new treatment would be 
that it might take some time to find something so she would be stuck at 
the VA in the same scenario with all men until then. I talked to my 
veteran and I asked her what she wanted to do, she agreed stating it's 
either this, the homeless shelter or die. Since I admitted her through 
the urgent care, the standard rule from what I understand is that the 
veteran goes to the psych ward for 3 days. I escorted this vet up to 
the psych ward and it was filled again with all male vets that were in 
their for numerous different types and levels of mental illness with no 
separate section for female and/ or male vets that were survivors of 
MST. I informed the staff on the ward that she was suffering from MST. 
The one guy that was working that floor did not even know what MST was. 
I told the vet to call me at anytime if she felt she could not handle 
it and it was triggering her anxiety or want to use drugs or anything 
else. She did call me but she also made it through her three days. The 
social worker did keep her promise to me and this vet by later 
transferring her to New York State where she has been referred to an 
all-female treatment facility with other female vets where she gets to 
stay for a year. In her correspondence she tells me that I saved her 
life by being active in her health care and being her voice when no one 
cared. She loves the facility where she is at and she celebrates every 
day that she is alive and sober and getting help for all the pain that 
she has hide within herself. This worked out for this particular 
veteran but not all veterans are given this opportunity for treatment.

    Case/Example 3: Due to the problems that I have seen within the VA 
when it comes to women's healthcare, I had participated in a Roundtable 
discussion with an Ohio Senator. Again I voiced my concerns about what 
was taking place and what I was witnessing at the VA when it came to 
treatment for MST. Months later, a representative from his office 
called and asked if I would be interested in hosting another roundtable 
in which she could come down and sit with me and about 10 other women 
veterans to discuss problems they are having in receiving care. I 
started calling women veterans from the area. I picked one (the veteran 
from case #1) to join me to discuss MST. The other four female veterans 
were random and I had never met them nor knew anything about their time 
in service or if they even utilized the VA. I called random women 
veterans in hopes of creating a roundtable full of different women to 
voice their concerns about VA healthcare. After meeting and talking for 
awhile, I brought up MST to the representative and started voicing my 
concerns. As soon as I opened this discussion up and the other women 
veterans knew that this was my passion and my new fight, they began to 
open up and all five women veterans were MST victims/survivors. As I 
listened to what they were willing to share, it occurred to me that 
this problem has been present for quit sometime and although progress 
is occurring, the VA is still not where it should be with the number of 
MST statistics that they are reporting on their website. According to 
the Department of Veterans Affairs website, ``About 1 in 5 women and 1 
in 100 men seen in VHA respond ``yes'' when screened for MST. Though 
rates of MST are higher among women, there are almost as many men seen 
in VA that have experienced MST as there are women. This is because 
there are many more men in the military than there are women.''
    With the statistics that the VA has provided and from what I have 
witnessed in my county alone, I am in hopes that positive changes 
occur. Men and women who served their country and are victims/survivors 
of MST/PTSD should not be left to fight this battle alone. The VA 
should do the necessary steps to develop Individualized Treatment Plans 
and separate wings/facilities that are specially staffed to meet the 
needs of MST victims/survivors. Women veterans should not have to worry 
about encountering all men when they go to the VA for treatment; with 
separate wings/facilities a female could feel more confident in 
choosing to get care through the VA without fear. The services provided 
for MST/PTSD should be available at every VAMC. At the present time, 
only certain locations throughout the United States have all-female 
treatment areas and the wait time for a veteran to get into the program 
is very lengthy (6 months or more). The veteran also has to apply and 
be accepted into the program and they are then placed on a waiting 
list. Even in the cases I mentioned above, the drive one way to this 
particular VA is one hour. In some areas of Ohio, a female veteran is 
expected to drive 3 plus hours one way for a gynecology exam.
    The VA is the federal agency responsible for serving the needs of 
veterans by providing health care, disability compensation and 
rehabilitation, education assistance, home loans, burial in a national 
cemetery, and other benefits and services. The VA bears the words, ``To 
care for him who shall have borne the battle and for his widow, and his 
orphan.'' Not only are these words a reminder to the VA of the 
commitment they made to care for those injured in our great nation's 
defense but I am here as well to remind them and let them know that 
more needs to be done to fulfill their commitment to the veterans of 
this country.
    I thank you again for allowing me this opportunity to speak before 
you.

    Sincerely,
    ///SIGNED///
    Kristi D. Powell

                                 
              Prepared Statement of Linda D. Smith, FACHE

    Good morning, Chairman Benishek, Ranking Member Brownley, and 
Members of the Committee. Thank you for the opportunity to discuss the 
Cincinnati VA Medical Center's (VAMC) efforts to provide high quality 
care, specifically mental health care, to Veterans in our catchment 
area and our pilot Veterans Transportation Service. I am accompanied 
today by Dr. Kathleen Chard, Director of the Trauma Recovery Division 
of our Mental Health Care Service Line, and Professor of Psychology and 
Behavioral Neuroscience at the University of Cincinnati, College of 
Medicine; Emma Bunag-Boehm, Primary Care Provider for the Post-
Deployment Clinic, Cincinnati VAMC, and Mr. Chad Watiker, Cincinnati 
Vet Center Team Leader.
    I will begin my testimony with an overview of the Cincinnati VAMC. 
I will then focus on our comprehensive mental health programs and end 
with a brief overview of the Veterans Transportation Service, which has 
improved access to care for many of our Veterans.
Cincinnati VAMC Overview
    The Cincinnati VAMC is a two-division campus located in Cincinnati, 
Ohio and Fort Thomas, Kentucky. The Medical Center serves 17 counties 
in Ohio, Kentucky, and Indiana with six Community-Based Outpatient 
Clinics, located in Bellevue, Kentucky; Florence, Kentucky; 
Lawrenceburg, Indiana; Hamilton, Ohio; Clermont County, Ohio; and 
Georgetown, Ohio. The Cincinnati VAMC is a tertiary referral facility. 
We are a highly-affiliated teaching hospital, providing a full range of 
patient care services, with state-of-the-art technology, medical 
education and research capabilities. The Medical Center provides 
comprehensive health care through primary care, dentistry, specialty 
outpatient services, and tertiary care in areas of medicine, surgery, 
mental health, physical medicine and rehabilitation, and neurology.
    Our facility is the Veterans Integrated Service Network (VISN) 10 
referral site for a number of surgical and medical programs and a 
regional referral center for posttraumatic stress disorder (PTSD). The 
PTSD program at the Fort Thomas division of the Cincinnati VAMC in 
northern Kentucky also provides training to practitioners from various 
active duty military branches and other VAMCs. Our Inpatient Mental 
Health Unit is frequently visited by other VA facility staff to learn 
about our Recovery Model of Care.
    The Cincinnati VAMC has an active affiliation with the University 
of Cincinnati College of Medicine and is connected both physically and 
functionally to the University. Over 500 fellows, residents, and 
medical students are trained at the Cincinnati VAMC each year. In 
addition, there are also over 85 other academic affiliations involving 
dentistry, pharmacy, nursing, social work, physical therapy and 
psychology.
    The Cincinnati VAMC is fully accredited by The Joint Commission, 
the College of American Pathologists, the Commission on Cancer of the 
American College of Surgeons, the Commission on Accreditation of 
Rehabilitation Facilities, the Accreditation Council on Education, the 
Accreditation Council for Graduate Medical Education, the American 
Association of Cardiovascular and Pulmonary Rehabilitation and 
accrediting bodies for residencies in Optometry, Pharmacy and 
Radiology. Our research programs are also fully accredited.
    Over 42,000 Veterans are enrolled in VA health care through our 
facility. This number includes over 3,600 female Veterans and 3,500 
Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) 
Veterans. Growth in terms of enrolled Veterans has increased by over 4 
percent this fiscal year (FY) and approximately 25 percent over the 
past 5 years. We also have seen a 13percent increase (322 cases) in 
surgeries performed and a 15 percent increase in referrals from other 
VAMCs this fiscal year compared to FY 2012.
    The Cincinnati VAMC recently volunteered for the first VA survey of 
our Patient Aligned Care Team (PACT)/Medical Home Program by The Joint 
Commission and was commended for the quality of care and services we 
provide. Seventeen out of 43 four-person teams (physician, nurse, 
licensed practical nurse, and clerk) received national PACT recognition 
from the Veterans Health Administration. We also recently implemented a 
Hospital in Home Program that has enrolled over 100 Veterans since 
February 2013. This program has allowed us to avoid admission of 
Veterans to an inpatient unit by providing daily services in the home, 
thus avoiding some health care expenses. Since the program began in 
February 2013, we estimate a cost savings of over $700,000 and a 245-
day reduction in Bed Days of Care.
    Our facility continues to grow in order to meet increased demand 
for services. Construction projects include a recently-completed 
parking garage, a new imaging center, patient-centered renovations to 
our first floor, a new research building which will break ground in 
September 2013, an off-campus, state-of-the-art Eye Center, an 
ambulatory surgery center, and an expansion of our operating rooms. We 
also have a number of construction projects of interest to include: a 
Sleep Study Center, a new Traumatic Brain Injury (TBI) Clinic and new 
Community-Based Outpatient Clinics in Florence, Kentucky and 
Georgetown, Ohio.
    The Cincinnati VAMC has 15 full-time staff in the OEF/OIF/Operation 
New Dawn (OND) clinic providing primary care, mental health care, 
social work services, and pain management care for military personnel 
returning from Iraq, Afghanistan, and all recent combat theatres. 
Efforts to reach returning military personnel involve redeployment 
briefings, post-deployment briefings, family readiness meetings, local 
Veterans Service Organizations meetings/functions, community events and 
letters, and personal phone calls to recently-discharged 
Servicemembers. Our pilot Veterans Integration to Academic Leadership 
Program (VITAL) places a psychologist on local college and university 
campuses with the sole task of connecting with student Veterans and 
providing services on-site. The Post Deployment Integrated Clinic model 
of care and outreach efforts by the Cincinnati VAMC staff for the OEF/
OIF/OND population are considered best practices within VA. As a 
result, we have been able to enroll approximately 65 percent of 
eligible OEF/OIF/OND Veterans in our catchment area.
    One of the most exciting new initiatives at the Medical Center is 
our Tele-Intensive Care Unit (ICU), which allows the delivery of 
critical care services across a geographic distance through the use of 
electronic devices and connections. Critical care nurses and physicians 
perform sophisticated 24/7 remote monitoring of Veterans in VA critical 
care units throughout the State of Ohio and soon will be monitoring 
critically-ill Veterans in the VA Southeast Network (VISN 7).

Trauma Recovery Center
    The Cincinnati VAMC's Trauma Recovery Center consists of an 
outpatient PTSD clinical team (PCT) and a Residential PTSD Program. The 
PCT offers eligible individuals individual family education, medication 
management, and evidence-based PTSD treatments in individual, group, 
and couples formats including Prolonged Exposure and Cognitive 
Processing therapy (CPT), Couples-Based PTSD treatment, Virtual Reality 
Therapy and Dialectical Behavior Therapy.
    The Residential PTSD Program, described in Veterans Health 
Administration (VHA) Handbook 1162.02, Mental Health Residential 
Rehabilitation Treatment Program, is a 7-week, cohort-based program for 
men and women and an 8-week program for Veterans with PTSD and a 
history of TBI. The Residential programs are unique and highly-
successful programs that have been featured in national media for their 
patient-centered, evidence-based treatment programs for PTSD. In 
addition to utilizing CPT, the residential groups focus on anger, 
communication, distress tolerance, life skills, interpersonal 
effectiveness, nutrition, communication, and sleep. The women's 
residential program was identified as a best practice, and the TBI/PTSD 
residential program is the only one of its kind in the Nation.
    The Cincinnati VAMC also provides care and services, including 
counseling, to Veterans who have experienced military sexual trauma 
(MST) and come to VA for care. Under Title 38 United States Code, 
Section 1720D, VA is authorized to provide counseling and appropriate 
care and services, as required, to Veterans to overcome ``psychological 
trauma, which in the judgment of a mental health professional employed 
by the Department, resulted from a physical assault of a sexual nature, 
battery of a sexual nature, or sexual harassment which occurred while 
the veteran was serving on active duty or active duty for training.'' 
Section 1720D defines sexual harassment as ``repeated, unsolicited 
verbal or physical contact of a sexual nature which is threatening in 
character.''

Mental Health Care
    Mental health services at the Cincinnati VAMC are unified under a 
multidisciplinary Mental Health Care Line (MHCL). A comprehensive 
variety of mental health services is offered by the seven divisions of 
the MHCL. The divisions are Outpatient Mental Health, Substance 
Dependence, Assessment and Intensive Treatment, Trauma Recovery Center, 
Domiciliary Care for Homeless Veterans, Community Outreach, and Special 
Services. Presently, the MHCL employs 30 psychiatrists, 53 
psychologists, 72 social workers, and 83 nursing personnel. The total 
number of staff working for the MHCL is 303. From FY 2007 to FY 2012, 
our MHCL staffing grew approximately 74 percent, and the number of 
Veterans treated grew 55 percent. In the first 10 months of FY 2013, 
the MHCL provided care to approximately 15.5 percent more Veterans than 
were seen over the similar period in FY 2012. That amounts to an 
additional 1,482 unique Veterans. During this period of growth, the 
Cincinnati VAMC has been successful in recruiting highly-qualified, 
mental health staff in all professions.
    VHA has developed many metrics to monitor performance in the 
delivery of mental health services. These monitors include the 
following:

    1) Patients who are discharged from acute inpatient mental health 
treatment have follow up within 7 days. VHA's goal is that 75 percent 
of Veterans in this category should have contact. This year, the 
Cincinnati MHCL has successfully contacted approximately 85 percent of 
Veterans discharged from acute inpatient mental health treatment for 
follow up.

    2) Qualifying Veterans should have a Mental Health Treatment 
Coordinator (MHTC) assigned to them. VHA's goal is that 75 percent of 
qualified Veterans should be assigned an MHTC. The Cincinnati MHCL 
currently has approximately 85 percent of qualifying Veterans assigned 
to an MHTC. As new Veterans access Mental Health services, assignment 
of an MHTC is part of the treatment planning process.

    3) In the OEF/OIF/OND clinic, Veterans diagnosed with PTSD who 
agree to treatment are expected to have 8 evidence-based psychotherapy 
sessions over a 14-week period. VHA's target is that 67 percent of 
Veterans who agree to treatment receive 8 sessions in a 14-week period. 
The Cincinnati MHCL is currently at approximately 72 percent.

    4) In FY 2013, VHA began using two measures to evaluate Veteran 
access to mental health care. For Veterans who have established mental 
health treatment, the Medical Center tracks the percentage of Veterans 
who are able to schedule an appointment within 14 days of their desired 
date, which is VHA's goal. The Cincinnati MHCL has achieved that goal 
approximately 99 percent of the time. For Veterans who are new to 
seeking mental health care, the Medical Center tracks VHA's goal of 
having Veterans complete an initial appointment in 14 days or less of 
when the appointment was made. For FY 2013, the Cincinnati MHCL has 
provided this level of access approximately 83 percent of the time. In 
July 2013, the average wait time for a new mental health care patient's 
first appointment was 8 days, and approximately 85 percent of Veterans 
had their first appointment within VA's goal of 14 days. In the most 
recent VA Strategic Analytics for Improvement and Learning report, the 
Cincinnati VAMC received an outstanding 5-star quality rating which 
included the category ``Mental Health Wait Time.''

    While these metrics are important, we realize they tell only part 
of the story of Cincinnati VAMC's mental health accomplishments. In 
addition to the aforementioned Trauma Recovery Center, Cincinnati has 
an array of strong mental health services. For example, the acute 
inpatient mental health ward has 20 beds and has received multiple 
national recognitions for its patient-centered, recovery-oriented 
program. The Substance Dependence Division is also strong as a leader 
in tobacco cessation treatment and ambulatory detoxification. Our 
opiate substitution program is an important resource for local 
Veterans. Our Primary Care Mental Health Integration Program has one of 
the highest rates of utilization in the Nation. For 2013 to date, the 
VAMC had 1,717 tele-mental health encounters, an 89 percent increase 
over FY 2012, and as a result, increased access to care for Veterans 
and reduced requirements for travel.
    The Cincinnati MHCL has had a Family Services Coordinator for many 
years, supporting the families of Veterans with severe mental illness. 
We are responding to the new generation of OEF/OIF/OND Veterans with 
programs such as brief family consultation, Support and Family 
Education, Behavioral Family Therapy, and couples counseling. A VHA-
funded research project, Couple-Based Treatment for Alcohol Use 
Disorders and PTSD, is investigating the effects of couple-based 
counseling for alcohol dependency, PTSD, and partner relationships. The 
Cincinnati VAMC has also been chosen as a site for the Practical 
Application of Intimate Relationship Skills (PAIRS) program. This is a 
9-hour, intensive weekend training program to improve a Veteran's 
relationship with their partner.

Homeless Programs/Initiatives
    The Cincinnati VAMC is also working actively with many other 
Federal, state, and local entities to meet Secretary Shinseki's goal of 
ending homelessness among Veterans in 2015. The homeless programs at 
the Cincinnati VAMC are robust, consisting of strong outreach/community 
partnerships, Grant and Per Diem (GPD), Housing and Urban Development/
Veterans Affairs Supportive Housing (HUD/VASH), Health Care for 
Homeless Veterans (HCHV) contract beds, and Veterans Justice Outreach 
(VJO) programs. We have developed a Homeless/Low Income Resource Guide 
and the HUD/VASH Quarterly Newsletter that VA Central Office recognized 
as best practices. Our VJO program was featured in a recent 
rehabilitation accreditation newsletter, CARF International's 
``Promising Practices Innovation in Human Services,'' April 2013.
    On May 3, 2013, the Cincinnati VAMC held its 4th Annual Homeless 
Summit, which was attended by a broad base of community partners, 
including Joseph House, Greater Cincinnati Behavioral Health, Talbert 
House, Drop Inn Center, and Strategies to End Homelessness. 
Additionally, the Cincinnati VAMC works closely with numerous faith-
based organizations, such as City Gospel Mission, Interfaith 
Hospitality Network, St. Francis/St. Joseph Catholic Worker House, 
Mercy Franciscan at St. John's, and the Mary Magdalen House.
    The Community Outreach Division of the MHCL, under which the 
homeless programs fall, will be moving to Downtown Cincinnati this 
month to a strategic location allowing increased access and walk-in 
service. A portion of the division will remain in Fort Thomas, Kentucky 
to allow access for homeless Veterans in Northern Kentucky. Listed 
below are the homeless programs and initiatives available through the 
Cincinnati VAMC:

    GPD - We have 173 beds, including seven beds for female Veterans. 
Our programs run at capacity and have a high success rate, short length 
of stay, and low cost per episode.

    HUD/VASH - We have 275 vouchers in Hamilton and Clermont counties 
in Ohio and Northern Kentucky and were awarded an additional 40 
vouchers for FY 2014. The Cincinnati VAMC was among the first medical 
centers in the Nation to incorporate Housing First principles within 
HUD/VASH by piloting a 25-voucher program in October 2010 and retooling 
the entire program to incorporate Housing First principles in March 
2011. According to the Homeless Operations Management Evaluation 
Systems (HOMES) Database, our chronically homeless housed rate is 
approximately 89.26 percent, among the highest in the Nation. We 
finished FY 2012 with a 94.84 percent housed rate and the Medical 
Center is on target to exceed that rate in FY 2013.

    HCHV Contract Beds - We have 12 beds (six, two-bedroom apartments) 
under this program. Each bedroom is private and locked, ensuring 
safety, security, and privacy.

    Veterans Justice Outreach - We actively collaborate with four 
operational Veterans Treatment/Diversion Courts and look forward to 
collaborating with a fifth court in the planning stages moving towards 
implementation. The addition of this fifth court will give us 
partnerships with Veterans Treatment Courts in all three states within 
our catchment area, providing Veterans with help in meeting treatment 
goals instead of incarceration.

Veterans Transportation Service (VTS)
    Recognizing that increasing access to care improves health care 
outcomes, the Cincinnati VAMC began operation of the VTS in May 2012, 
offering both mobility management and transportation services. Mobility 
management guides Veterans to the most medically-appropriate and cost-
effective means available through a private, Veteran-focused agency or 
public transportation resources. VTS fills the remaining gaps, 
providing door-to-door, wheelchair-accessible transportation for those 
Veterans living in the Medical Center's catchment area who have no 
other viable transportation options. VTS has served 750 unique 
Veterans, approximately 40 percent of whom are wheelchair-bound, 
providing nearly 10,000 rides, since its inception.

Community Partnerships
    The Cincinnati VA has been building community mental health 
partnerships by holding annual homelessness prevention summit meetings 
for the past 4 years. Those summit meetings inspired our development of 
the Cincinnati Homeless/Low Income Resource Guide. In addition to 
having been cited by VHA as a best practice, the guide has become a 
highly valued document for community agencies. Based on events like the 
homelessness summits, VHA has been holding Community Mental Health 
Summits during the Summer of 2013.
    In August 2013, the Cincinnati VAMC hosted its first Community 
Mental Health Summit. At the Summit, facility leadership and staff met 
with 66 individuals from 36 community agencies. The facility was joined 
by staff from the local delegation of Members of Congress, one state 
agency, one county agency, and six universities.
    Presentations were made on the following topics:

    University Liaison. The Cincinnati VAMC has a well-established 
outreach program which partners with local colleges and universities to 
ease the transition of Veterans seeking higher education.

    PTSD Treatment. Cincinnati MHCL discussed its programs with Dr. 
Chard speaking on this topic.

    Suicide Prevention. Each VAMC has been allocated at least one full 
time suicide prevention coordinator. The MHCL has 3 full time social 
workers devoted to this task. VHA works steadily to reduce stigma 
associated with receiving mental health care. VHA has declared that 
September 2013 is Suicide Prevention Month, and VHA is sponsoring the 
public service announcement ``Talking About It Matters''. During 
September 2013, the Cincinnati MHCL Suicide Prevention team will give 
11 presentations in the community focusing on eliminating the stigma 
that complicates preventing suicides.
    At the Mental Health summit, there was considerable open exchange 
of detailed information about mental health programs and services 
available through VA and in the community. This was an opportunity to 
share ideas and promote further collaborations. Particular suggestions 
that emerged included annual follow-on summit meetings and for MHCL to 
develop a simple telephone access to respond to Community Agency 
queries about MHCL services.

Conclusion
    VHA and the Cincinnati VAMC are committed to providing the high-
quality care that our Veterans have earned and deserve, and we have 
continued to improve access and services to meet the mental health 
needs of Veterans residing in Cincinnati and the local surrounding 
area. We appreciate the opportunity to appear before you today, and we 
appreciate the resources Congress provides VA to care for Veterans. Dr. 
Chard, Ms. Bunag-Boehm, Mr. Watiker, and I are happy to respond to any 
questions you may have.

                                 
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