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74–334 PDF 2012

S. HRG. 112–508 

VA MENTAL HEALTH CARE: EVALUATING ACCESS 

AND ASSESSING CARE 

HEARING 

BEFORE THE

COMMITTEE ON VETERANS’ AFFAIRS 

UNITED STATES SENATE 

ONE HUNDRED TWELFTH CONGRESS 

SECOND SESSION 

APRIL 25, 2012 

Printed for the use of the Committee on Veterans’ Affairs 

( 

Available via the World Wide Web: http://www.fdsys.gov 

(II) 

COMMITTEE ON VETERANS’ AFFAIRS 

PATTY MURRAY, Washington, Chairman 

JOHN D. ROCKEFELLER IV, West Virginia 

DANIEL K. AKAKA, Hawaii 

BERNARD SANDERS, (I) Vermont 

SHERROD BROWN, Ohio 

JIM WEBB, Virginia 

JON TESTER, Montana 

MARK BEGICH, Alaska 

RICHARD BURR, North Carolina, Ranking 

Member 

JOHNNY ISAKSON, Georgia 

ROGER F. WICKER, Mississippi 

MIKE JOHANNS, Nebraska 

SCOTT P. BROWN, Massachusetts 

JERRY MORAN, Kansas 

JOHN BOOZMAN, Arkansas 

KIM LIPSKY, Staff Director 

LUPE WISSEL, Republican Staff Director 

(III) 

C O N T E N T S 

APRIL 25, 2012 

SENATORS 

Page 

Murray, Hon. Patty, Chairman, U.S. Senator from Washington ........................ 1 

Brown, Hon. Scott P., U.S. Senator from Massachusetts ..................................... 3 

Tester, Hon. Jon, U.S. Senator from Montana ...................................................... 57 

Moran, Hon. Jerry, U.S. Senator from Kansas ..................................................... 59 

WITNESSES 

Schoenhard, William, FACHE, Deputy Under Secretary, Health, Operations 

and Management, U.S. Department of Veterans Affairs; accompanied by 

Antonette Zeiss, Ph.D., Chief Consultant, Office of Mental Health Services; 

and Mary Schohn, Ph.D., Director, Office of Mental Health Operations ........ 5 

Prepared statement .......................................................................................... 7 

Response to posthearing questions submitted by: 

Hon. Patty Murray ........................................................................................ 11 

Hon. Bernard Sanders .................................................................................. 16 

Hon. Johnny Isakson .................................................................................... 18 

Hon. Roger F. Wicker ................................................................................... 20 

Halliday, Linda, Assistant Inspector General for Audits and Evaluations, 

Office of Inspector General, U.S. Department of Veterans Affairs; accompanied by Larry Reinkemeyer, Director, Kansas City Office of Audits and 

Evaluations ........................................................................................................... 27 

Joint prepared statement ................................................................................. 28 

Response to posthearing questions submitted by: 

Hon. Bernard Sanders .................................................................................. 32 

Hon. Johnny Isakson .................................................................................... 32 

Daigh, John, M.D., Assistant Inspector General for Healthcare Inspections, 

Office of Inspector General, U.S. Department of Veterans Affairs; accompanied by Michael Shepherd, M.D., Senior Physician, Office of Healthcare 

Inspections ............................................................................................................ 33 

Tolentino, Nicholas, OIF Veteran and Former VA Mental Health Officer ......... 34 

Prepared statement .......................................................................................... 36 

Jones, MajGen Thomas S., USMC (Ret.), Founder and Executive Director, 

Outdoor Odyssey Youth Development and Leadership Academy .................... 43 

Prepared statement .......................................................................................... 44 

APPENDIX 

Altman, Claire Haaga, Executive Vice President/Chief Operating Officer, 

HealthCare Chaplaincy; prepared statement .................................................... 69 

American Society for the Advancement of Pharmacotherapy; prepared statement ...................................................................................................................... 70 

(1) 

VA MENTAL HEALTH CARE: EVALUATING 

ACCESS AND ASSESSING CARE 

WEDNESDAY, APRIL 25, 2012 

U.S. SENATE, COMMITTEE ON VETERANS’ AFFAIRS, Washington, DC. 

The Committee met, pursuant to notice, at 9:35 a.m., in room 

SD–138, Dirksen Senate Office Building, Hon. Patty Murray, 

Chairman of the Committee, presiding. 

Present: Senators Murray, Tester, Brown, and Moran. 

STATEMENT OF HON. PATTY MURRAY, CHAIRMAN, 

U.S. SENATOR FROM WASHINGTON 

Chairman MURRAY. Good morning. This hearing will come to 

order. I would like to welcome all of you to today’s hearing to 

evaluate VA access to mental health care services. 

Today’s hearing builds upon two hearings held last year. At each 

of the previous hearings, the Committee heard from the VA how 

accessible mental health care services were. This was inconsistent 

with what we heard from veterans and the VA mental health care 

providers. So last year, following the July hearing, I asked the Department to survey its own mental health care providers to get a 

better assessment of the situation. 

The results, as we all now know, were less than satisfactory. 

Among the findings, we learned that nearly 40 percent of providers 

surveyed could not schedule an appointment in their own clinic for 

a new patient within the VA-mandated 14-day window; and 70 percent reported inadequate staffing or space to meet mental health 

care needs. 

The second hearing, held in November, looked at the discrepancy 

between what the VA was telling us and what the providers were 

saying. We heard from a VA provider and other experts about the 

critical importance of access to the right type of care, delivered 

timely by qualified mental health professionals. 

At last November’s hearing, I announced that I would be asking 

VA’s Office of Inspector General to investigate the true availability 

of mental health care services at VA facilities. I want to thank the 

IG for their tremendous effort in addressing such an enormous request. The findings of this first phase of the investigation are substantial and troubling. We have heard frequently about how long 

it takes for veterans to get into treatment, and I am glad the IG 

has brought those concerns to light. 

The IG will also discuss an entirely different and more useful 

way of understanding access to care. This model would give more 

2 

reliable data and reduce the rampant gaming of the system that 

we have seen thus far. The IG has also found the existing scheduling system is hopelessly insufficient and needs to be replaced. 

VA has struggled with developing a new scheduling system. I understand VA is working to get a replacement system in place. I 

would like the Department’s commitment that they will work to get 

this done right and get it done soon. 

The IG findings also show some serious discrepancies in what VA 

has been telling this Committee and veterans. VA stated that 95 

percent of veterans received mental health evaluation within 14 

days. In reality, it was only about 50 percent. VHA data reported 

that after the evaluation was completed, 95 percent of veterans received a treatment appointment within 14 days. In reality, it was 

only 64 percent. For those in treatment, 12 percent were scheduled 

beyond the 14-day follow up appointment window, with providers 

telling the IG that they were delaying follow up for months, not because of the veterans’ needs, but because their schedules were too 

full. 

VA is failing to meet its own mandates for timeliness and instead 

is finding ways to make the data look like they are complying. VA 

can and must do much better. Important steps have been taken in 

the right direction by the Department. Last week, VA announced 

the addition of 1,600 mental health providers. And late last year, 

VA announced an increase in staffing levels at the Veterans Crisis 

Line. 

As we will see today, the hard work remains in front of us at a 

time when veterans are dying by suicide at an alarming rate. We 

know that the sooner a veteran can get a mental health care appointment after they request it, the more likely they are to follow 

through with care. 

We cannot afford to leave them discouraged when trying to access care, and when in care, we must be getting veterans their next 

appointment in a clinically appropriate time. We need to be sure 

there are enough resources so providers do not have to delay treatment because their schedules are too full. 

While I commend VA for the decision to hire another 1,600 mental health providers, there is still no reliable staffing model to determine where these individuals are needed. Without that model, 

VA needs to explain how they will know where to place these additional providers. 

There are other challenges with getting the best providers into 

the system. I understand that nationally there are shortages of 

mental health providers, and it is even harder for VA because they 

cannot always pay the highest salaries in the community. There 

are still a large number of vacancies in VA’s mental health ranks. 

I want to hear from the Department how they will fill the existing gaps and ensure the new positions they have announced do not 

become 1,600 empty offices. Ultimately, what really matters is how 

long it takes for a veteran to start that first treatment session. 

What really matters is not abandoning that veteran. 

I recently saw Andrea Sawyer whose husband Lloyd suffers from 

PTSD and depression. Andrea bravely testified before this Committee last July about the tremendous difficulties she and her husband faced in getting him into care. Lloyd still faces challenges, but 

3 

he is now getting the care he needs. That is what matters. We cannot let our veterans down, especially when they have shown the 

courage to stand up and ask for help. 

I look forward to hearing from VA how they intend to address 

the issues the IG has found. Now more than ever is the time for 

action and for VA to show effective leadership. Let the hearing 

today serve as an unequivocal call to action. The Department must 

get this right. 

In closing, I do want to be clear that while we have discussed a 

number of problems with the system at large, none of this reflects 

poorly on VA’s providers. I believe I can speak for all of us in 

thanking VA’s many mental health providers for the incredible job 

that they do. Let there be no mistake, these individuals are incredibly dedicated to their mission. They choose to work harder than 

most of their peers, often for less lucrative benefits, all because 

they believe in what they do and because they have a deep and 

unshaking commitment to our veterans. 

To all of VA’s psychiatrists, psychologists, social workers, and 

other providers, and to all the administrative staff who support 

them, thank you so much for the good job, and keep up the good 

work. 

With that, I want to turn it over to Senator Brown who is standing in for Senator Burr today. 

STATEMENT OF HON. SCOTT P. BROWN, 

U.S. SENATOR FROM MASSACHUSETTS 

Senator BROWN. Thank you, Madam Chair. It is good to be here 

as the Ranking Member in place of Senator Burr. It is good to be 

back on the Committee serving with you. I want to thank you for 

holding this very important hearing. 

Some of these I am still serving, I see and hear of these types 

of situations regularly. $5.9 billion, that is the increase that VA 

got. And out of that, do you think we could hire some more people 

to address these very real concerns? $5.9 billion. 

To read some of the things that we have been reading about the 

suicidal veteran calling for help, gone unanswered, one more person killing themselves, and the veteran’s mental health care is delayed—put out by the Washington Post, actually yesterday, talking 

about how the system is being gamed by the VA, and not actually 

scheduling and following through with scheduling and providing a 

good opportunity for these soldiers to get the care and coverage 

that they need—it is mind boggling. 

I mean, I understand the delay. I understand that there are 

problems. I understand that claims go over a year. But for somebody who calls and says, ‘‘Hi, I’m thinking of killing myself.’’ 

‘‘Well, do you feel that way right now?’’ 

‘‘Well, not right in this moment. But I tried to hang myself yesterday. Does that count?’’ And then to be blown off; it just makes 

absolutely no sense to me at all. 

So I am glad you are holding this hearing. I want to continue to 

look into mental health services. Your insights in this Committee 

help perform the oversight to ensure that veterans get the services 

they need, and that is a good thing. 

4 

As you know, one of the several hearings regarding mental 

health services—this is another one—last year, I remember we did 

learn about the various serious mental health services that were 

needed and, quite frankly, lacking. I want to just say that today’s 

hearing will focus on evaluating the availability of these services 

and accessing the care that is delivered. 

The testimony we hear today will be from VA’s Inspector General, as well as Iraq veteran and former VA mental health officer, 

Nick Tolentino, who feels there is an ongoing cultural problem at 

the VA. 

Nick, I want to thank you for your testimony and pointing out 

where the loopholes are sought and openly shared to hide the fact 

that the facilities are not meeting their performance metrics. And 

I have got to tell you, it is unacceptable, as I said, for some of you 

who still serve and see and speak regularly with people that are 

affected by these various serious ailments. 

The gaming of the system has to stop. The IG found in their 

audit, and Nick confirmed in his testimony, that our veterans are 

not given the opportunity to actually offer a desired date for their 

next appointment. They were simply told when and where to show 

up and no consideration or compassion to address the very real 

concerns that they have. 

The scheduling system is not the only problem with delivering 

mental health care. Even though the VA has increased the staffing 

by 48 percent between 2006 and 2010, both the IG and Nick point 

out that it is understaffed and lacks a methodology to assess their 

staffing needs. And it is no surprise that just 1 week after this 

hearing, VA announced they are hiring 1,900 additional mental 

health staffers. 

Well, that is great. It is a good start. But, man, what have we 

been doing up to this point? We need to do it better. We have people’s lives depending on these decisions that we are making. And 

it is a good step, as I said, but how long will it take to actually 

fill these positions? And what happens to that soldier who calls, as 

been happening with Jacob Manning and others. 

We will hear today from community groups that are helping, 

General Tom Jones, founder of Semper Fi Odyssey, to help veterans from the current conflicts manage their mental health. And 

I want to thank you, sir, for that effort, going above and beyond. 

It will help veterans volunteer their time to help fellow soldiers 

cope with those invisible wounds of war, which we all know about. 

It is a great example of the community coming forward and addressing needs not currently being met. So thank you for that. 

In the end, simply hiring more staff and fixing VA’s broken 

scheduling system will not cure all the issues, but it will certainly 

take a combination of changes at the facility level and the VA office 

level. And the VA will use all available resources, including fee 

bases, care, staffing increases, and developing better performance 

metrics to fix a severely broken system. 

I concur with you that the individual people that are there, they 

are doing yeoman’s work, but it is still not enough. Is it you need 

more people? You need more computers? What is it? $5.9 billion 

should go a long way to addressing those issues. 

5 

Madam Chair, as I reference, I am heading upstairs just to give 

HSGAC a quorum, then I will be right back down. So I look forward to everybody’s testimony. Thank you. 

Chairman MURRAY. At this time, I would like to introduce the 

first panel. Representing the VA is Mr. Bill Schoenhard, VA’s Deputy Under Secretary for Health, Operations and Management. He 

is accompanied today by Dr. Antonette Zeiss, Chief Consultant for 

the Office of Mental Health Services, and Dr. Mary Schohn, Director of Mental Health Operations with the Veterans Health Administration at the Department of Veterans Affairs. 

From the Office of Inspector General, we have Dr. David Daigh, 

Assistant Inspector General for Healthcare Inspections, accompanied by Dr. Michael Shepherd, senior physician in the IG’s Office 

of Healthcare Inspections. Also from the Office of Inspector General, we have Ms. Linda Halliday, Assistant Inspector General for 

Audits and Evaluations, accompanied by Mr. Larry Reinkemeyer. 

Next, we will hear from Nick Tolentino. He is a Navy veteran of 

the Iraq War and a former mental health administrative officer in 

the VA. 

Finally, we will hear from the founder and executive director of 

Outdoor Odyssey, retired U.S. Marine Corps, Major General Thomas Jones. 

So, Mr. Schoenhard, we will begin with your testimony. We have 

a lot of answers we need from you, so please begin. 

STATEMENT OF WILLIAM SCHOENHARD, FACHE, DEPUTY 

UNDER SECRETARY, HEALTH, OPERATIONS AND MANAGEMENT, U.S. DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY ANTONETTE ZEISS, PH.D., CHIEF CONSULTANT, 

OFFICE OF MENTAL HEALTH SERVICES; AND MARY 

SCHOHN, PH.D., DIRECTOR, OFFICE OF MENTAL HEALTH 

OPERATIONS 

Mr. SCHOENHARD. Thank you. 

Chairman Murray, we appreciate the opportunity today to address the access to and the quality of mental health care services 

to our Nation’s veterans. And we appreciate so much discussion of 

a topic that is integral to the well being and full living out of a fulfilled life of our Nation’s veterans. 

Mental health is integral to the overall well being and physical 

health of a veteran. It is important, if there is underlying depression, problem drinking, or substance abuse, or other medical mental ailment, that this be diagnosed in order to ensure that those 

who have served our country have the full treatment of something 

that is so core to their overall well being and to their ability to also 

implement the physical health aspects of medication management, 

staying employed and the rest, which is so important to the quality-of-life of a veteran who has served this country. 

It is the sacred mission of VA to ensure that this very integral 

part of our care is well delivered. 

I appreciate so much your comments regarding the 20,500 providers who on the ground work so hard every day to serve our Nation’s veterans in this important mission. 

In the written statement, I have outlined three areas of improvement and concern, but I would like to first mention that we appreVerDate Nov 24 2008 16:59 Aug 22, 2012 Jkt 000000 PO 00000 Frm 00009 Fmt 6633 Sfmt 6633 H:\ACTIVE\042512.TXT SVETS PsN: PAULIN
6 

ciate so much your leadership, the Committee’s review, and the Inspector General’s review. This is an important aspect of care, and 

we appreciate all of the assistance. 

We will be working very closely with the Inspector General as we 

go forward with their report as it relates to the first recommendation that I would like to address. And that is that we agree with 

the Inspector General that our appointment measurement system 

should be revised to include a combination of measures that better 

capture the overall efforts throughout a course of treatment for a 

veteran, while maintaining flexibility to accommodate a veteran’s 

unique condition and phase of treatment. 

We must also continue our efforts to strengthen mental health 

integration into our primary care in order to ensure in the primary 

care settings that we are assessing mental health needs of our Nation’s veterans and also be able to address the stigma that is often 

associated with this, that can be discussed in a primary-care 

setting. 

The second point I would like to make, as announced by Secretary Shinseki last week, we are increasing staff to enhance both 

the access to and the quality of mental health care by hiring 1,900 

additional staff, more than 1,600 of those who are mental health 

clinicians. As I mentioned, this will augment the current complement of 20,500 mental health employees in our system and is 

designed to provide additional staff in our facilities. 

It is also designed to increase our staffing of our crisis line, 

which is so integral to the identification and treatment of people 

who are in crisis, as Senator Brown spoke of so eloquently. And it 

is also an important aspect of increase in that we will be adding 

additional examiners for compensation and pension examinations. 

It is an important transition from active duty to veteran status 

for those who are currently on active duty and for those who 

present with new conditions. We have a solemn responsibility to 

ensure that we increase our staff to ensure that we can handle this 

volume in a timely fashion, and that we can do this in a way that 

does not erode our capacity to serve our existing patients. 

I want to emphasize that this additional staffing will continue to 

be evaluating and assess data and refine the staffing model. We 

are currently piloting this in three VISNs, and this is a work in 

progress that will be continually improved as part of our comprehensive approach to ensuring that our facilities have the resources to ensure that we accomplish this mission. 

The third point I would like to make is that deploying evidencebased therapies to ensure veterans have access to the most effective methods for PTSD and other mental health ailments, we are 

making more widespread and improving our training for those who 

are receiving care and delivering care of evidence based treatments. We are shifting from a more traditional approach to one 

with newer treatments. 

We would acknowledge that we have not always communicated 

these changes as clearly as we might to our Nation’s veterans, so 

we are redoubling our efforts to improve communication not only 

to our providers but to our veterans to ensure that these evidence 

based therapies are implemented in a way that can be supported 

7 

by the veteran, and fully educated and trained personnel assuring 

that that is delivered. 

In summary, we just thank you again for your encouragement, 

for your support. This is an important part of care that is fundamental to the well being of our Nation’s veterans. We look forward 

to answering your questions and those of the Committee. 

[The prepared statement of Mr. Schoenhard follows:] 

PREPARED STATEMENT OF WILLIAM SCHOENHARD, FACHE, DEPUTY UNDER SEC- RETARY FOR HEALTH FOR OPERATIONS AND MANAGEMENT, VETERANS HEALTH AD- MINISTRATION (VHA), DEPARTMENT OF VETERANS AFFAIRS (VA) 

Chairman Murray, Ranking Member Burr, and Members of the Committee, I appreciate the opportunity to address access to, and quality of, VA’s mental health 

care. I am accompanied today by Mary Schohn, Ph.D., Director, Office of Mental 

Health Operations and Antonette Zeiss, Ph.D., Chief Consultant, Office of Mental 

Health Services. 

VA has testified twice within the past 12 months on its mental health programs, 

and values the feedback received from those hearings. From these hearings and subsequent field visits, VA has learned a great deal about the strengths of our mental 

health care system, as well as areas that need improvement. VA’s Office of Inspector 

General (OIG) also recently completed a review of VA’s mental health programs and 

offered four recommendations. The OIG cited a need for improvement in our wait 

time measurements, improvement in patient experience metrics, development of a 

staffing model, and provision of data to improve clinic management. VA is using the 

OIG results in concert with our internal reviews to plan important enhancements 

to VA mental health care. VA constantly strives to improve, and we will use any 

data and assessments—positive or negative—to help us enhance the services provided to our Veterans. 

Reviews have confirmed that Veterans seeking an initial appointment for a mental health evaluation generally receive the required rapid triage evaluation in a 

timely manner; this was confirmed by the OIG report on mental health access. 

While a mental health evaluation within 14 days of the triage referral generally occurs, we were concerned to learn from the OIG report that those evaluations do not 

always result in the full diagnostic and treatment evaluation required by VA policies. Further, Veterans seeking follow up appointments may experience waits of 

longer than 14 days, especially for some intensive services such as beginning a 

course of evidence-based psychotherapy. While the explanations for these findings 

are varied, none are satisfactory—we must do more to deliver the mental health 

services that Veterans need. My written statement will describe how we have traditionally evaluated access to mental health care and how we propose to evaluate access in the future. It will then explain how we assess the quality of care delivered 

and potential new considerations on this topic. Both sections will address the need 

for increased staffing and better data collection. 

ACCESS TO CARE

Ensuring access to appropriate care is essential to helping Veterans recover from 

the injuries or illnesses they incurred during their military service. Over the last 

several years, VA has enhanced its capacity to deliver needed mental health services 

and to improve the system of care so that services can be more readily accessed by 

Veterans. Mental health care must constantly evolve and improve as new research 

knowledge becomes available, as more Veterans access our services, and as we recognize the unique needs of Veterans—and their families—many who have served 

multiple, lengthy deployments. In addition, enhanced screening and sensitivity to 

issues raised by Veterans are also identified as areas for improvement. 

In an effort to increase access to mental health care and reduce the stigma of 

seeking such care, VA has integrated mental health into primary care settings. The 

ongoing transfer of VA primary care to Patient Aligned Care Teams will facilitate 

the delivery of an unprecedented level of mental health services. Systematic screening of Veterans for conditions such as depression, Post Traumatic Stress Disorder 

(PTSD), problem drinking, and military sexual trauma has helped us identify more 

Veterans at risk for these conditions and provided opportunities to refer them to 

specially trained experts. Research on this integration shows that VA is seeing 

many Veterans for mental health care who would not otherwise be likely to accept 

referrals to separate specialty mental health care. These are important advances, 

particularly given the rising numbers of Veterans seeking mental health care. In an 

8 

informal Mental Health Query administered by VA in August 2011, VA learned that 

many of its providers in the sites queried believe that Veterans’ ability to schedule 

timely appointments may not match data gathered by VA’s performance management system. These providers also identified other constraints on their ability to 

best serve Veterans, including inadequate staffing, space shortages, limited hours 

of operation, and competing demands for other types of appointments, particularly 

for compensation and pension or disability evaluations. In response to this query, 

VA took two major actions. First, VA developed a comprehensive action plan aimed 

at enhancing mental health care and addressing the concerns raised by its staff. 

Second, VA conducted external focus groups to better understand the issues raised 

by front-line providers. As part of this action, VA is visiting every VA facility this 

year to conduct a first-hand review of its mental health program. As of April 25, 

2012, 63 of 140 (45 percent) site visits have been completed, one to each VA health 

care system, with the remainder scheduled to be completed by the end of the fiscal 

year. 

As part of this ongoing review of mental health operations, Secretary Shinseki recently announced that VA will be adding approximately 1,600 mental health clinicians—including nurses, psychiatrists, psychologists, social workers, marriage and 

family therapists and licensed mental health professional counselors—as well as 300 

support staff to its existing workforce of 20,590 mental health staff. This addition 

was based on VA’s model for team delivery of outpatient mental health services, and 

as these increases are implemented, VA will continue to assess staffing levels. Further, as part of VA’s efforts to implement section 304 of Public Law 111–163 (Caregivers and Veterans Omnibus Health Services Act of 2010), VA is increasing the 

number of peer specialists working in our medical centers to support Veterans seeking mental health care. These additional staff will increase access by allowing more 

providers to schedule more appointments with Veterans. VA began collecting monthly vacancy data in January 2012 to assess the impact of vacancies on operations and 

to develop recommendations for further improvement. In addition, VA is ensuring 

that accurate projections for future needs for mental health services are generated. 

Finally, VA is planning proactively for the expected needs of Veterans who will separate soon from the Department of Defense (DOD) as they return from Afghanistan. 

We track this population to estimate the number of such Veterans, how many are 

anticipated to seek VA care, and how many who seek care are anticipated to need 

mental health evaluation and treatment services. These processes will continue, 

with special attention to whether patterns established up to this point may change 

with the expected increase in separations from active duty military. 

Historically, VA has measured access to mental health services through several 

data streams. First, VA defined what services should be available in VA facilities 

in the 2008 Uniform Mental Health Services in VA medical centers and Clinics 

Handbook and tracks the availability of these services throughout the system. Moreover, VA has added a five-part mental health measure in the performance contracts 

for VHA leadership, effective starting in fiscal year (FY) 2012. The new performance 

contract measure holds leadership accountable for: 

• The percentage of new patients who have had a full assessment and begun 

treatment within 14 days of the first mental health appointment; 

• The proportion of Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) Veterans with newly diagnosed PTSD who receive 

at least eight sessions of psychotherapy within 14 weeks; 

• Proactive follow-up within 7 days by a mental health professional for any patient who is discharged from an inpatient mental health unit at a VA facility; 

• Proactive delivery of at least four mental health follow-up visits within 30 days 

for any patient flagged as a high suicide risk; and 

• The percentage of current mental health patients who receive a new diagnosis 

of PTSD and are able to access care specifically for PTSD within 14 days of referral 

for PTSD services. 

VA policies require that for established patients, subsequent mental health appointments be scheduled within 14 days of the date desired by the Veteran. This 

has been a complicated indicator, as the desired date can be influenced by several 

factors, including: 

• The Veteran’s desire to delay or expedite treatment for personal reasons; 

• The recommendation of the provider; and 

• Variance in how schedulers process requests for appointments from Veterans. 

VA understands virtually every health care system in the country faces similar 

challenges in scheduling appointments, but as a leader in the industry, and as the 

only health care system with the obligation and honor of treating America’s Veterans, we are committed to delivering the very best service possible. As a result, 

9 

VA has decided to modify the current appointment performance measurement system to include a combination of measures that better captures overall efforts 

throughout all phases of treatment. VA will ensure this system is sufficiently flexible to accommodate a Veteran’s unique condition and the phase of treatment. Some 

Veterans may need to be seen more frequently than within 14 days (for example, 

if they need weekly sessions as part of a course of evidence-based psychotherapy), 

while others may not (for example, if they are doing well after intensive treatment 

and will benefit most from a well-designed maintenance plan with far less frequent 

meetings). A thoughtful, individualized treatment plan will be developed for each 

Veteran to inform the timing of appointments. 

VA has formed a work group to examine how best to measure Veterans’ wait time 

experiences and how to improve scheduling processes to define how our facilities 

should respond to Veterans’ needs. In the interim, the work group has recommended 

a return to the use of the ‘‘create date’’ metric, which will minimize the complexity 

of the current scheduling process. The ‘‘create date’’ refers to the date on which a 

Veteran requested an appointment, and the wait time will be measured as the numbers of days between the create date and the visit with a mental health professional. 

The work group is currently developing an action plan to be reviewed by the Under 

Secretary for Health by June 1, 2012. Performance measurement and accountability 

will remain the cornerstones of our program to ensure that resources are being devoted where they need to go and being used to the benefit of Veterans. Our priority 

is leading the Nation in patient satisfaction with the quality and timeliness of their 

appointments. 

Decisions concerning staffing and programs were determined historically at the 

facility level to allow flexibility based on local resources and needs. However, as evidence accumulates, it is clear that sites can benefit from more central guidance on 

best practices in determining needed mental health staff. Therefore, we recently developed a prototype staffing model for general mental health outpatient care using 

a methodology that considered findings in the academic literature, consultation with 

other health care systems, and productivity data. We are using these results to pilot 

this staffing model in Veterans Integrated Service Networks (VISN) 1, 4, and 22, 

and we anticipate national implementation of this new model by the end of the fiscal year. While the model may be refined as a result of the pilot testing, it provides 

a clear basis for assessing staffing for mental health services, and shows that currently there are shortfalls at some sites nationally. 

By adding staff, offering better guidance on appointment scheduling processes, 

and enhancing our emphasis on patient and provider experiences, we are confident 

we are building a more accessible system that will be responsive to the needs of our 

Veterans while being responsible with the resources appropriated by Congress. 

QUALITY OF CARE

VA has made deployment of evidence-based therapies a critical element of its approach to mental health care. Mental health professionals across the system must 

provide the most effective treatments for PTSD and other mental health conditions. 

We have instituted national training programs to educate therapists in two particularly effective exposure-based psycho-therapies for PTSD: cognitive processing therapy and prolonged exposure therapy. The Institute of Medicine and the Clinical 

Practice Guidelines developed jointly by VA and the DOD have consistently concluded the efficacy of these treatment approaches. 

Not everyone with PTSD who receives evidence-based treatment may have a favorable response. Although VA uses the most effective treatments available, some 

Veterans will need lifetime care for their mental health problems and may see slow 

initial improvement. Almost everyone can improve, but some wounds are deep and 

require a close, consistent relationship between VA and the Veteran to find the most 

effective individualized approaches over time. Veterans and their families should 

not expect ‘‘quick fixes,’’ but they should expect an ongoing commitment to intensive 

efforts at care for any problems. 

A recent analysis of data from VA’s large Cooperative Study (CSP# 494), a study 

on prolonged exposure to the stress factors associated with and contributing to 

PTSD symptoms among female Veterans and active duty Servicewomen, identified 

those factors that predict poor treatment outcome. This is the largest randomized 

clinical trial of prolonged exposure treatment ever conducted (284 participants), and 

the first one focusing solely on Veterans and military personnel. VA staff would be 

pleased to brief you in greater detail on the methodology and results of this study. 

Our analysis shows that Veterans with the most severe PTSD are least likely to 

benefit from a standard course of treatment and to achieve remission. Other factors 

that predicted poor response were unemployment, co-morbid mood disorder, and 

10 

lower education. In other words, those with the worst PTSD are least likely to 

achieve remission, as is true with any other medical problem. 

Even when Veterans are able to begin and sustain participation in treatment, 

timing, parenting, social, and community factors all matter a great deal. Treatment, 

especially treatment of severe PTSD, may take a long time. During this period, Veterans with PTSD are at risk for many severe problems including family and parenting issues, inability to hold a job or stay in school, and social and community 

function. Further, evidence also shows that whereas a positive response to treatment may reduce symptom severity and increase functional status among severely 

affected Veterans, the magnitude of improvement may not always be enough to 

achieve full clinical remission. This is no different than what is found with other 

severe and chronic medical disorders (such as diabetes or heart disease) where effective treatment may make a substantial and very important difference in quality of 

life without eradicating the disease itself. Thus, providing the best treatments with 

the strongest evidence base is crucial to care, but that must be placed within an 

ongoing commitment to recognize that initial care may need to be followed by ongoing rehabilitative care, for the major diagnostic problem, for other co-occurring mental health problems, and for the host of psychosocial problems that may accompany 

the diagnosis (or diagnoses). 

Outcome evidence generated from cases involving Veterans who are receiving 

these therapies in VA substantiate that they are effective for Veterans participating 

in ongoing clinical care not associated with research projects. Based on ongoing surveys, we know that all VA facilities have staff trained at least in either prolonged 

exposure or cognitive processing therapy, and usually both. In addition, one of the 

preliminary results of our site visits found that many facilities have a strong practice of training more staff in these and other evidence-based therapies for a wide 

array of mental health problems. 

As more providers are trained in these approaches to care, facilities are shifting 

from their more traditional counseling approach to these newer treatments. We 

have not always communicated well enough to Veterans the nature or reason behind 

these changes. These new programs emphasize a recovery model, which is 

strengths-based, individualized, and Veteran-centered. A recovery-oriented model 

does not focus exclusively on symptom reduction, but has as its goal helping Veterans achieve personal life goals that will improve functioning while managing 

symptoms. These efforts have been recognized as successful in the academic literature and through a Government Performance and Results Act review conducted 

by RAND/Altarum, which concluded that VA mental health care was superior to 

other mental health care offered in the United States in almost every dimension 

evaluated. 

Before the development of these evidence-based approaches, VA made every effort 

to offer clinical services for PTSD based on clinical experience and innovation. Some 

of these approaches have developed into the evidence-based approaches we have 

now, while others have not been shown to offer the help that was expected. Even 

those therapies that did not help in truly alleviating PTSD could come to feel like 

‘‘lifelines’’ to those receiving them. For example, some sites hold group educational 

sessions to help Veterans understand PTSD symptoms and causes, and these sometimes developed into ongoing groups. While group therapy for PTSD can be effective 

and is cited in the VA/DOD Clinical Practice guidelines, group therapy is understood (and validated) as possible only in fairly small groups—usually fewer than 10 

participants. Educational groups often have far more members, sometimes up to 50 

or more; while this can be an effective way to conduct psycho-education, it cannot 

be considered ‘‘group therapy.’’ 

Veterans who have used some of the PTSD services previously adopted by VA 

may not be familiar or comfortable with newer approaches, and we must continuously educate Veterans and others about what treatments are most likely to be effective and how Veterans can access them. Some of our own providers have not understood these changes. The National Center for PTSD has been providing guidance 

through the PTSD mentoring program to help facilities collaborate with providers 

and Veterans in the transition. We have developed educational processes to help 

clarify the need for and rationale behind efforts to change clinical practice patterns 

to ensure best possible care for VA. 

The Under Secretary for Health’s realignment of the Veterans Health Administration last year created an Office of Mental Health Operations with oversight of mental health programs across the country. This has aligned data collection efforts with 

operational needs and connected resources across the agency to bring the full picture of VA’s mental health system into focus. In fiscal year 2011, VA developed a 

comprehensive mental health information system that is available to all staff to support management decisions and quality improvement efforts. This year, a collaboVerDate Nov 24 2008 16:59 Aug 22, 2012 Jkt 000000 PO 00000 Frm 00014 Fmt 6633 Sfmt 6621 H:\ACTIVE\042512.TXT SVETS PsN: PAULIN
11 

rative effort between VA Central Office and field staff is underway to review mental 

health operations throughout the system and to develop quality improvement plans 

to address opportunities for improvement through dissemination of strong practices 

across the country. 

CONCLUSION

VA remains fully committed to delivering high quality, timely mental health care. 

VA defined this commitment in 2004 with the Comprehensive Mental Health Strategic Plan, which was fully implemented and evolved into the Uniform Mental 

Health Services Handbook in 2008. Efforts to implement the Handbook have been 

largely successful, but more effort is needed to ensure full implementation at every 

appropriate VA facility. In addition, new challenges and opportunities continuously 

require response. For example, OEF/OIF/OND Veterans have faced more and longer 

deployments than previous generations of Servicemembers, and their families have 

shared these challenges. Many of these Veterans also have survived battlefield injuries that previously would have been fatal. Other challenges are presented by Vietnam era Veterans who seek mental health care at far higher levels than prior 

generations of older adults. In part, that is because we did not have the effective 

treatments for them when they returned from service more than 40 years ago. We 

know that the therapies discussed previously are effective for this population, and 

we welcome their search for mental health care. As VA reaches out to serve all generations, and as our intensive, effective outreach programs bring in greater numbers 

of Veterans to VA’s health care system, we must constantly find ways to keep pace 

with the need for expanded capacity for mental health services and for those services to be based on the best possible known treatments. Secretary Shinseki’s recent 

announcement that VA will add approximately 1,600 mental health clinicians and 

300 support staff reflects VA’s continuing commitment to meet the needs of Veterans. As these increases are implemented, VA will continue to assess staffing 

levels. 

New technologies, staff, training, approaches to care, and data measurement will 

provide VA the mechanisms it needs to deliver the necessary quality and timely 

mental health care. VA is developing solutions in each of these areas or is currently 

implementing new efforts to offer better access to and quality of mental health care. 

Madam Chairman, we know our work to improve the delivery of mental health 

care to Veterans will never be done. We appreciate your support and encouragement 

in identifying and resolving challenges as we find new ways to care for Veterans. 

This concludes my prepared statement. My colleagues and I are prepared to respond 

to any questions you may have. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. PATTY MURRAY TO WILLIAM SCHOENHARD, DEPUTY UNDER SECRETARY FOR HEALTH FOR OPERATIONS AND

MANAGEMENT, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS

HEALTH CARE

Question 1. The Department has conducted several site visits to medical facilities 

across the country to get a better sense of what is happening at various points of 

access to mental health care. Please provide the Department’s assessment of the 

findings from these site evaluations. 

Response. Site visit teams review the implementation of the Uniform Mental 

Health Services Handbook (UMHSH) across 18 domains; these domains capture all 

components of the mental health program that are to be implemented nationally. 

The team identifies strengths and opportunities for growth in each of these domains 

based on facility data submitted as pre-work, data from the Mental Health Information System, information gathered at the site through interviews with facility and 

mental health leadership; information gathered during interviews with front-line 

staff; and finally information gathered from Veterans, Veterans’ family and friends 

and community stakeholders. Prior to the facility debrief at the end of the visit, the 

site visit team determines the top five strengths and opportunities for growth at the 

facility. Strengths are determined by the team as practices which exceed the 

UMHSH guidance in any of the 18 areas, while opportunities for growth are areas 

in which the facility would benefit from targeted approaches for improvement. 

An analysis of the initial 55 site visits completed through March 31, 2012, has 

been completed based on the summaries of the top five strengths and top five 

growth areas aggregated across facilities. 

12 

Common Strengths: 

• Identification of the mental health staff as hard working, mission-oriented individuals focused on the care of Veterans. • Numbers of staff trained in Evidence-Based Psychotherapy and supported by 

mental health leadership to complete all necessary training requirements. • Suicide prevention services, including providing education to staff on suicide 

prevention while simultaneously providing continuity of care services for Veterans 

at high risk for suicide. • Substance Use Disorder treatment. • Provision of services to Veterans who are homeless. • Development of excellent community partnerships to assist in providing the best 

care for Veterans. 

Common Opportunities for Growth: 

Identification of opportunities for growth does not mean it is not present at a facility, but rather that this area is in need of further development. The most common 

opportunities for growth identified were: 

• Expansion of recovery-oriented programming, especially in inpatient settings, 

and further developing Psychosocial Rehabilitation and Recovery Centers (PRRCs) 

while increasing the presence and role of Local Recovery Coordinators. • Expansion of peer support services. • Need to fill vacancies and/or address concerns related to staff members covering 

multiple roles related to covering for staff vacancies. 

• Need to expand the Primary Care-Mental Health Integration program to include both co-located collaborative care providers and care management services 

within primary care. 

• Need to continue to improve transitioning of Veterans between different levels 

of care, including tracking and follow-up of Veterans as care is transferred from various settings such as inpatient to residential, residential to outpatient, and outpatient to inpatient. 

• Need to improve wait times, access, and scheduling of appointments for Veterans. 

Question 2. OIG found VA’s performance measures do not accurately convey 

whether patients are being provided timely access to mental health care. How will 

VA ensure medical centers are reliably and accurately reporting whether they are 

providing patients timely access to mental health care service, as well as verify 

those reports? 

Response. The Department of Veterans Affairs (VA) has formed a workgroup, including leadership from VHA clinical operations, mental health operations, systems 

redesign, and field representation, to make recommendations on methods to measure Veterans’ wait time experiences and to improve scheduling processes based on 

Veterans’ needs. The Veterans Health Administration (VHA) has piloted the use of 

metrics that will simplify the interactions required between a scheduler and a Veteran as well as increase the number of measurement points to include the full continuum of care. In the interim, the workgroup has recommended using the ‘‘create 

date’’ metric for new patients, which minimizes the complexity of the current scheduling process. The ‘‘create date’’ is captured ‘‘automatically’’ by the computer when 

an appointment is made. VHA has also developed and successfully piloted a proposed standard process to more reliably capture ‘‘desired date’’ for established patients. The work group recommendations were accepted by the Under Secretary for 

Health (USH) on July 1, 2012. To support implementation of the new metrics, VHA 

has established a workgroup to develop training materials and processes to educate 

clinicians and schedulers about the new requirements. As part of implementation, 

an auditing process will be developed to assess reliability and accuracy with the new 

reporting requirements. In addition, VHA will continue to use the site visit methodology to verify the process. Full implementation of the new metrics is anticipated 

by the start of fiscal year (FY) 2014. 

Question 3. OIG indicated VA’s mental health care measures for evidence based 

therapies are not valid. How will VA hold medical centers accountable to ensure evidence based therapies are being provided as treatment guidelines state? 

Response. The measure evaluated by the VA Office of Inspector General (OIG) as 

the evidence-based psychotherapy measure was still in draft form at the time of the 

audit. This measure is not directly a measure of evidence-based practice, but is a 

proxy measure to assess the percent of patients receiving an intensity of treatment 

(eight sessions in fourteen weeks) deemed as adequate for effective provision of psychotherapy. A software development project is underway to develop templated 

progress notes that will more directly measure implementation of evidenced-based 

13 

therapies. These templates provide a mechanism of tracking utilization of evidencebased psychotherapies (EBP), currently not available in our system, and will be required for use whenever EBPs are employed. Once these become available, Veterans 

Integrated Service Network (VISN), facility and VA Central Office Leadership will 

be able to review the data to follow-up on practices that do not meet the treatment 

guidelines. 

Question 4. How will OMHS ensure a non-clinical encounter with veterans related 

to the mental health care services is not recorded as a session of treatment for performance measure purposes? 

Response. Encounters which are entered in the Electronic Health Record (EHR), 

include information about the clinic where a visit occurred (documented with a stop 

code), the provider who met with the Veteran, and a Current Procedural Terminology (CPT) code. CPT codes describe what medical and diagnostic services occurred during a particular visit. Certain CPT codes are used to reflect the delivery 

of mental health treatment. If an encounter is non-clinical in nature, it would be 

reflected in the CPT code utilized, and it would not include a CPT code that is reflective of treatment. Based on the logic of the mental health metrics, non-clinical 

encounters would not be recorded with treatment CPT codes, and thus would not 

be recorded as a session of treatment for performance measure purposes. 

Question 5. Psychotherapy session note templates were proposed by VA’s Office 

of Patient Care Services, Mental Health Services to help clinicians consistently document use of evidence-based psychotherapies and accurately track use of these 

treatments, as well as allow program evaluators to monitor treatment outcomes. 

Please provide the Committee with the status of the implementation of these session note templates. 

Response. Mental Health Services has developed session-by-session documentation 

templates for evidence-based psychotherapies being nationally implemented in VHA. 

The first set of evidence-based psychotherapy documentation templates is on the 

current Work Plan of the Office of Information and Technology for planned distribution to the field by the end of fiscal year (FY) 2013. 

Question 6. Please describe the methodology used to allocate special funding for 

mental health initiatives. What steps is VA taking to hold recipients of such funding 

accountable for its targeted use and to prevent recipients from reallocating the 

funds to be used for other priorities set forth by VISN or medical center leadership? 

Response. VHA, through the offices of Workforce Management and Consulting 

(WMC) and the Office of Mental Health Operations (OMHO) is closely tracking the 

hiring of the additional staff recently funded as well as the filling of existing vacancies to ensure the monies are being spent for mental health staff. WMC and OMHO 

are providing biweekly reports and as needed to VHA senior leadership on the hiring status. 

Question 7. After the Department concludes its site visit reviews of mental health 

care services, how will VA ensure systematic surveillance efforts are carried out to 

better understand care trends, links between care processes and treatment outcomes, and facility-by-facility differences in performance? 

Response. OMHO is currently completing site visits at all 140 VHA facilities this 

fiscal year. Upon receipt of the site visit report, the facility schedules a meeting with 

Director of OMHO, the OMHO technical assistance specialist, facility leadership, facility mental health leadership, and VISN mental health leadership. On this call, 

the findings are reviewed and the facility is asked to submit an action plan to address the recommendations. OMHO provides ongoing consultation, at a minimum on 

a quarterly basis, with the facility to ensure implementation of the action plan. VHA 

is aggregating the data across facilities to look for systemic areas that require improvement across the system. 

Question 8. In 2005, and again in 2007, OIG released reports highlighting problems with VA’s patient scheduling system, including the calculation of wait times 

and inconsistent practices used by schedulers to capture appointment information. 

Despite the identification of these issues nearly seven years ago, the most recent 

IG report again identified these same issues as significant challenges. Please explain how recommendations issued by OIG and concurred with by the Under Secretary for Health remain unresolved for so long, and discuss the lessons learned. 

Response. In response to problems identified by OIG in 2005 and again in 2007, 

VHA stepped up its efforts to systematically train schedulers on correct scheduling 

practices and to audit their performance. These requirements were outlined in VHA 

policies published in 2008 and 2009. Internal VHA surveys show that compliance 

with VHA policy, especially in the area of entering desired date correctly has improved from the 60 percent range when OIG first studied the problem to the current 

90 percent range in Mental Health. Because of the large number of employees 

14 

scheduling appointments (50,000+) and the large number of appointments made 

each year (over 80 million), even a small rate of error will result in a large absolute 

number of desired date inaccuracies. While the problem is not completely solved, 

performance has improved. VHA has learned that training alone will not solve the 

problem, and is working to improve the reliability of Desired Date entry again by 

piloting efforts to standardize communication processes and electronically audit desired date accuracy. 

Additional Information: 

VHA has, over the years, attempted to improve and strengthen the policy direction, measure, display, and report waiting times, and respond to all known issues. 

Appendix 1 and 2 provide detailed timelines of significant activities. The following 

table is a brief summary of major events: 

Events VHA Responses 

Timeline GAO/IG Report Findings VHA Waiting Time Metric Directives

1999 Third Next Available 

2000-2004 Next Available 2002-028 

Jan-03 Audit of Veterans Health Administration’s Reported Medical Care Waiting Lists Electronic Waiting List 

Jan-04 Beginning of Time Stamp Measures 

Create Date for New Patients 

Desired Date for Established 

Patients 

2005 Audit of Outpatient Scheduling Procedures 

2007 Audit of the Veterans Health Administration’s 

Outpatient Waiting Times 

Access List 

2008 Audit of Efforts to Reduce Unused 

Appointments 

Consult Wait Time Measures 

Started 

2008-056 

Audit of Alleged Manipulation of Waiting Times 

in Veterans Integrated Service Network 3 

Review of Alleged Manipulation of Waiting 

Times, North Florida/South Georgia Veterans 

Health System 

2009-070 

2009 Recall Scheduling System 

Oct 1 2009 

(FY 2010) 

Veterans Health Administration Review of Alleged Use of Unauthorized Wait Lists at the 

Portland VA Medical Center 

Desired Date for New and 

Established Patients 

2010-027 

Audit of VA’s Efforts To Provide Timely Compensation and Pension Medical Examinations 

2012 Review of Veterans’ Access to Mental Health 

Care 

Specific Explanation of Issues: 

• Appointment waiting times are a negotiation between patients, providers, and 

the schedule capacity considering a number of factors. Experience has taught that 

there is no one perfect way or ‘‘solution’’ to the measurement of waiting times. 

• Private sector waiting time methods focus on capacity measures such as time 

to the third next available open appointment slot. VHA possesses and uses third 

next (and first next available) capacity measures and has since 1999. 

15 

• Because of the weaknesses in capacity measures to show the individual patient 

experience, beginning in 2004, VHA went well beyond other healthcare systems to 

measure 4 time stamps for every one of the approximately 80 million appointments 

per year. 

• Each one of the time stamp points (Desired Date, Create Date, Scheduled (future) Appointment and Completed Appointment) has its strengths and weaknesses. 

Appendix 4 provides a comprehensive explanation of these strengths and weaknesses. The challenges in measuring waiting times exist for every healthcare system, not just VHA. 

• Based on VA commissioned research studies that have just recently become 

available, VHA has new information on which measures are best associated with patient satisfaction and patient outcomes. VHA has learned: 

– Create Date has the strongest association with New Patient Satisfaction and 

outcomes 

– Desired Date (prospective) has the strongest association with Established Patient Satisfaction and outcomes 

• Limitations of the Desired Date (DD) measure include reliance on schedulers 

to accurately determine Desired Dates. Multiple OIG reports since 2005 found the 

DD was not entered correctly in some cases. Internal audits of VA’s scheduler performance in 2005 found DD correctly entered about 60 percent of the time. VHA 

agreed with the OIG finding and undertook mandatory scheduler training, yearly 

scheduler audits and feedback, facility certification of scheduling directive compliance, nationally hosted educational sessions, etc. The most recent audit of 43,643 

appointments, done about 54 months ago, indicated that Mental Health Schedulers 

correctly entered the DD 91.61 percent of the time. 

• It should be pointed out that there is yet another approach to measure wait 

times and that is from one completed appointment to another completed appointment. This is the method used in the widely debated Mental Health access performance measure looked at by the OIG recently where the time from completion of initial evaluation to completion of final evaluation was used. This method attempted 

to ‘‘zero in’’ on the experience of these specific mental health patients, required complex programming of the system, and does not measure the entire waiting time experience of the patient. The OIG attempted to combine the wait time methods of 

measuring one completed appointment to another completed appointment combined 

with DD wait times. The system was not designed to make this connection limiting 

the ability of the system to see the patient experience accurately. 

• As stated earlier, wait time measurements are only one piece of information 

that a clinic needs in order to manage their clinic operations. In addition to wait 

time, the clinic needs to know at a minimum, the panel size (or case load), the appointment demand, supply and activity, the no-shows, the cancel and reschedule 

rate, and the appointment continuity. This information is used to manage day-today clinic flow to optimize access. 

Lessons Learned: 

(1) There is no perfect measure of waiting times in the VA, or probably in private 

sector for that matter. 

(2) With more than 50,000 people making appointments in VHA, many of whom 

are entry level employees and with the high turnover in that job, it is probably unrealistic to expect DD will be entered correctly in every case. 

(3) VHA should use different methods for measuring wait times in different subpopulations of patients (see appendix 4 and above). This is the best information on 

the ‘‘correct’’ methods to measure wait times that is known to exist at this point. 

(4) It is important to clearly understand the method used to measure wait times 

when interpreting actual patient experience. For example, Mental Health measure 

reflects only a portion of the entire patients wait time, but was reported as reflecting the entire patient wait time. 

(5) Management of wait times would be enhanced by a better scheduling system. 

Question 9. Following the November 30, 2011, hearing on mental health care, VA 

indicated in questions for the record that off-hours care for mental health is available widely available. Based on completed site visits, has VA found discrepancies 

with what facilities have reported and what the site visits discovered regarding offhours availability? Are facilities meeting the Extended Hours Access for Patients 

policy requirements? 

Response. The Mental Health After Hours Report was reviewed through the second quarter of FY 2012. All medical centers visited through April 2012 have confirmed mental health clinic activity in off-hours as confirmed by medical record encounters. However, the site visits have identified three large CBOCs that had no 

16 

confirmed off-hours services in the first two quarters of FY 2012. These CBOCs are 

associated with two medical centers visited by OMHO through April 2012. Final site 

visits reports for these facilities have not yet been generated. However, overall, 

there does not appear to be a discrepancy between the Mental Health After Hours 

Report and what has been found on the site visits to date. As part of the site visit 

feedback, some facilities have been encouraged to expand the utilization of extended 

hours to assist with increasing access and reaching out to meet particular needs of 

Veterans. 

Question 10. An OIG report identified that VA does not have a scheduling system 

that works. VA is replacing the medical scheduling software but will not be available for full implementation until 2014 at the earliest. Given VA has a scheduling 

system that is simply insufficient, what steps is the Department taking to expedite 

the replacement of this system so that veterans who need access to mental health 

care services can be scheduled for appointments in a timely and reliable way? 

a. What steps is the Department taking to expedite the replacement of this system? 

Response. In February 2009, the previous effort to replace VHA’s 25-year-old 

scheduling system was ended without success. Work to examine the reasons for failure, including a comprehensive risk assessment concluded in 2010. At that point, 

VA reactivated the project with a decision to pursue a Commercial Off-The-Shelf 

software package to replace VistA Scheduling and be compatible with the current 

open source version of VistA. 

In December 2011, VA published a Request for Information about scheduling software and received 35 responses from a broad range of industry sources. These responses validated the assumption that commercial products can meet most of our 

needs. 

VA is in the process of designing a contest under the America Competes Act to 

address the most difficult component of the scheduling module: the ability to schedule across all facilities in the system. 

In April 2012, Information Technology leadership led a joint VHA/OIT/CTO 

workgroup which defined the projected outcomes from conducting a contest under 

the America Competes Act. A draft integrated project team (IPT) charter was completed and an OIT project manager was assigned full-time to the project in 

May 2012. 

b. What is VA doing now to make immediate access improvements for Veterans? 

Response. In the interim, VA is contracting to develop two near term improvements to the current scheduling system. The first is a Veteran-facing application intended to reside on handheld devices that would allow a Veteran to request an appointment within a Veteran-specified date range. The second is a scheduler-facing 

application which would change the scheduler’s view from the current blue-screen 

roll-and-scroll to a more user friendly calendar view of the schedule. Both of these 

short term improvements would provide significant improvements as the Veteran 

would be able to express their desired appointment date (improving the reliability 

of wait time measurement) and the scheduler would be able to much more efficiently find an available clinic slot. These improvements are being pursued along 

with the ultimate solution of replacing the scheduling system. 

In addition to software efforts, VA continues to train key staff in ‘‘Advanced Clinic 

Access’’ principles through multiple internal venues. An initiative focused on improvements in Specialty Care, including access improvements was piloted in every 

network in 2012. This initiative will expand in 2013. VA is also working to decrease 

the rate of no-shows through system-wide initiatives including network and facility 

collaborations, virtual phone educational sessions, change strategies customized to 

individual facility problems. These initiatives are working to enhance the information available to local managers to pinpoint problematic clinics. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. BERNARD SANDERS TO

WILLIAM SCHOENHARD, DEPUTY UNDER SECRETARY FOR HEALTH FOR OPERATIONS

AND MANAGEMENT, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF

VETERANS AFFAIRS

Question 1. As of today, how confident are you that schedulers are fully complying 

with the 2008 Uniform Mental Health Services in VA medical centers and Clinics 

Handbook with regard to performance compliance standards? 

Response. We are confident that schedulers correctly establish Desired Date more 

than 90 percent of the time. In the first quarter of FY 2012, VA conducted an internal audit of a sample of mental health schedulers at each VA facility and the results 

17 

demonstrated that schedulers were accurately capturing the Veteran’s Desired Date 

91.61 percent of the time. 

Question 2. Can you explain why the performance compliance standards could be 

so universally ‘‘misunderstood’’ or ‘‘misinterpreted’’ throughout the VA health care 

system? 

Response. We believe the question refers to the performance standard regarding 

scheduler entry of Desired Date. Desired Date is a time-stamp used to measure 

waiting times. VA has the experience of many approaches to the measurement of 

wait times. The table below shows the high level timeline of these events and measures for the past 11 years. In response to congressional and oversight bodies, VHA 

has gone well beyond other healthcare systems (that measure access at the ‘‘clinic’’ 

level) in implementing a measurement of ‘‘Desired Date’’ in order to understand access at the individual patient level. ‘‘Desired Date’’ means the date which the patient or provider wants the patient to be seen. The definition is necessarily broad 

in order to accommodate all scheduling situations. For example an established patient scheduling an agreed-upon future appointment with their provider is very different than a new or established patient requesting an out-of-cycle appointment for 

a new problem. Training 50,000 people who schedule appointments to enter Desired 

Date correctly for each situation for over 84 million appointments per year is a 

daunting task. The turnover of schedulers alone requires constant vigilance and 

training. However, internal VHA reviews show the performance has improved from 

correct entry about 60 percent of the time (in 2005) to more than 90 percent currently. VHA is currently taking steps to improve the reliability of Desired Date 

entry by piloting standard communication and electronic audit processes. The aim 

of these efforts is to improve the reliability of Desired Date information even more. 

Question 3. Were any schedulers reprimanded or fired because they were accurately reporting lower percentages in performance compliance standards than their 

counterparts who deviated from the VA Directives? 

Response. Although VHA’s Office of Workforce Services maintains data regarding 

adverse employee actions for senior staff, they do not have data regarding whether 

schedulers were reprimanded or fired due to inaccurate reporting of lower percentages in performance compliance standards. 

Question 4. Do you have any idea how many veterans decided not to participate 

in VA Mental Health Care programs because they didn’t want to wait beyond 14 

days to be evaluated or have an appointment? Would the veteran’s decision be documented as ‘‘resistant to treatment’’ or ‘‘denied treatment’’ or ‘‘no show’’ in his or her 

medical record? 

Response. VHA does not currently collect data on Veterans who have decided that 

they did not wish to be evaluated due to having to wait beyond 14 days for a full 

evaluation appointment. If a Veteran decided that they did not wish to engage in 

VA mental health programs, the clinician who met with the Veteran should document an accurate reflection of the interaction with the Veteran. In the situation described in your question, such a statement might be ‘‘Veteran did not wish to engage 

in mental health care programs due to an extensive wait for an appointment.’’ Such 

electronic health record entries cannot be readily pulled at a national level. 

If a Veteran had an appointment scheduled and did not attend, they would be 

identified as a ‘‘no show’’ and attempts would be made to reschedule the appointment. The requirement is to attempt at least three times to reach the patient to 

reschedule or determine that they no longer are requesting services. There would 

never be a presumption of ‘‘resistance to treatment.’’ 

Question 5. Who is responsible for quality control assurance of the Performance 

and Accountability Report (PAR)? Knowing that clinical scheduling has been identified as a problem by VA’s Office of Inspector General since 2005, how did the flawed 

data get past quality control reviews? 

Response. There is no recognized ‘‘gold standard’’ in the health care industry for 

calculating appointment timeliness, and no best way to capture the needs of patients and clinicians in a single access number. The metrics used in the Performance 

Accountability Report were developed with the input of subject matter experts and 

approved by senior agency leadership. VA made the decision to calculate waiting 

times using the ‘‘Desired Date’’ methodology after several options were assessed by 

an internal working group. At the time, we believed this approach, while imperfect, 

would provide the most patient-centered perspective possible within our decades-old 

scheduling system, and that the improvement trends in the metrics, rather than 

their absolute values, would help gauge VA efforts at improving access. 

Although the metrics themselves were calculated electronically from automated 

data systems, we were aware that over 50,000 staff across VA had the capability 

of scheduling appointments and that their individual actions would impact the vaVerDate Nov 24 2008 16:59 Aug 22, 2012 Jkt 000000 PO 00000 Frm 00021 Fmt 6633 Sfmt 6621 H:\ACTIVE\042512.TXT SVETS PsN: PAULIN
18 

lidity of the data. Taking that into account, we thoughtfully designed staff education 

and a process of periodic auditing to assure our numbers were as accurate as humanly possible. Seven years ago, compliance with policy was assessed at approximately 60 percent; a level of performance that we recognized was insufficient. As 

a result of continued education and feedback, the most recent audits of mental 

health scheduling have indicated over 90 percent compliance with the capture of 

‘‘Desired Date’’ as dictated by VA policy. 

In order to eliminate any ambiguity about our intent or our performance, we will 

report to Congress from this point forward appointment times calculated using the 

‘‘create date’’ entered into our scheduling package, while continuing to internally 

track waiting times based on Desired Date of appointment as well. We now have 

evidence from internal research that, for Veterans seeing us for the first time, waiting times calculated using ‘‘create date’’ may be overall more predictive of patient 

satisfaction. The same research also suggests that for established patients, waiting 

times calculated using ‘‘Desired Date’’ is the better predictor of satisfaction. 

It is important to point out, however, that we capture only an incomplete picture 

of access with such measured waiting times. Holistic mental health care requires 

the engagement of a team of professionals, including psychiatrists, psychologists, social workers, advanced practice nurses, and primary care providers to assure access 

to appropriate evaluation and treatment. VA has done considerable work over the 

past decade to integrate mental health evaluation and treatment into team-driven 

primary care settings, including collaborative care models and the extensive use of 

telemedicine. These modalities assure that Veterans experiencing emotional distress 

can be seen immediately, without the additional step of scheduling a separate consultation or appointment and waiting for a response. While such approaches are 

truly Veteran-centered and appreciated by patients and clinicians, ironically, they 

are not captured in our scheduling system, which was designed decades before such 

approaches were made part of our clinical routine. 

Question 6. If an active-duty servicemember is diagnosed with PTSD by a military 

behavioral health care professional and is subsequently medically discharged from 

the Armed Forces, is there a formal process between the Military Health Care System and VA to make sure the veteran’s treatment plan is successfully transferred 

between the two Federal agencies? 

Response. VA has a formal process in place to transition ill and/or injured Servicemembers from DOD to VA. VA has 33 VA Liaisons for Healthcare, registered nurses 

or licensed social workers, stationed at 18 Military Treatment Facilities (MTFs) 

with concentrations of recovering Servicemembers returning from Iraq and Afghanistan. These staff transition ill and/or injured Servicemembers from DOD to the VA 

system of care. VA Liaisons are co-located with the DOD case managers at the 

MTFs and provide onsite consultation and collaboration regarding VA resources and 

treatment options. Each referral from the DOD treatment team, including referrals 

for Servicemembers being medically discharged with PTSD, utilizes a standardized 

referral form completed by the DOD Nurse Case Manager identifying the ongoing 

treatment needs. In addition, each referral to a VA medical center (VAMC) includes 

supporting medical documentation such as progress notes and narrative summaries. 

At MTFs without an onsite VA Liaison, DOD Case Managers can refer Servicemembers directly to the Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) Program Manager at the Servicemember’s home 

VAMC. These referrals also utilize the standardized referral form identifying the ongoing treatment needs as well as the supporting medical documentation. As part of 

this process, a Servicemember’s treatment plan is transferred from DOD to VA, 

though the Servicemember/Veteran has a choice whether or not to enroll and participate in the VA health care system. 

Question 7. Did the VA pay any bonuses to employees based on the 95 percent 

compliance rate for new patients receiving an evaluation within 14 days or appointments within 14 days of their desired date? 

Response. This information is local information that is not available centrally. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. JOHNNY ISAKSON TO

WILLIAM SCHOENHARD, DEPUTY UNDER SECRETARY FOR HEALTH FOR OPERATIONS

AND MANAGEMENT, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF

VETERANS AFFAIRS

Question 1. The OIG has reported several times on inappropriate and inconsistent 

scheduling practices in 2005, 2007, and now again in 2012. VHA has taken steps 

to address these issues, however, the problem persists. 

19 

(a) Why does this continue to be an issue and what is contributing to the inappropriate practices? 

Response. Establishment of Desired Date (DD) requires knowledge of the patient 

and provider negotiation (for return appointments) and an understanding of what 

the patient wants under IDEAL circumstances (for new appointments, or for established patients who request a new appointment). Schedulers must enter the correct 

date in a roll-and-scroll line in the middle of a complex computer appointing process. 

If they are pressed with other duties (checking in, checking out, answering phones 

and questions from staff and patients), it is easy for the scheduler to be expedient 

and accept the default on the DD question. 

(b) Is it simply a lack of training for schedulers? 

Response. Not entirely. The process of establishing DD can be difficult. VHA is 

pushing to simplify and standardize the parts of the communication between the 

provider and patient so the establishment of DD in that situation (which is the majority of the cases) should be simpler and more reliable. 

(c) Are the schedulers receiving the required annual trainings and taking the annual tests to ensure they are properly carrying out VHA directives? 

Response. The schedulers are required to successfully complete the scheduler 

modules and Soft Skills training at the time they are hired. The scheduler supervisors are responsible for conducting a yearly audit on their performance, and addressing performance gaps. Additional training is available and should be undertaken by those schedulers who are uncomfortable with the scheduling protocols. 

Question 2. According to the OIG, this is leading to skewed data that is not helpful to key decisionmakers from the managerial level to the administrative level to 

Congress. 

(a) Do these inconsistencies occur in all the VISNs, or some performing better 

than others? 

Response. The inconsistencies in question are the correct entry of the Desired 

Date (DD) into the VistA scheduling system. The latest VHA self-study on entry of 

DD, completed December 23, 2011, looked at 43,643 mental health records from the 

five busiest Mental Health Clinics in all VISN’s. Overall, VHA found DD was entered accurately 91.67 percent of the time. Since most appointments made are for 

established patients rather than new patients, this study is thought to include predominately established patients; therefore, VHA is less certain about the accuracy 

of DD for new patients. 

No VISN enters DD correctly all of the time. This is because of several factors, 

including: the difficulty associated with determining the DD (as noted in the examples below); reliance on humans who may make mistakes to enter the DD; variation 

in systems and processes within and between clinics; and high turnover rates of 

scheduling clerks, resulting in less experienced staff performing the task at times. 

Some examples of different approaches to determining the Desired Date follow: 

• If the patient has an established relationship with the provider and agrees to 

return for a future appointment, the date the patient and provider agree upon as 

the desired return date is the DD. This situation is often called ‘‘internal demand’’ 

in the Advanced Access literature and comprises the majority of appointments in 

VHA. For example, a patient with diabetes may be due for a return visit in 6 

months, in which case the Desired Date for the follow-up appointment would be the 

date 6 months from the present appointment, regardless of when the follow- up appointment is ultimately scheduled. 

• Alternatively, if an established patient requests a previously unanticipated appointment, or a new patient requests their first appointment, the scheduling clerk 

is instructed to ask the patient when they would like to be seen (regardless of when 

they are able to be seen in an open slot). The answer to this question establishes 

the DD for this ‘‘external demand’’ situation. For example, if a Veteran calls on a 

Monday requesting an appointment right away and says Thursdays are good, the 

following Thursday (e.g., 3 days from the appointment request) is entered as the Desired Date. The appointment is then negotiated and created without changing the 

Desired Date, even if there is no appointment availability on the date the patient 

initially requested. 

(b) What is VHA doing to correct this problem? 

Response. VHA chartered a workgroup to make recommendations to the USH on 

developing new metrics to better measure the Veteran waiting experience. The 

workgroup made a number of recommendations that were accepted by the USH on 

July 1, 2012. These recommendations are in the process of being implemented. 

Question 3. In the discussion on metrics, VHA mentioned that the work group recommended they return to using the ‘‘create date’’ metric to help give a better picture 

of veterans’ waiting times. 

20 

(a) When the use of this was metric abandoned? 

Response. VHA still collects the data on Create Date (CD), but stopped using it 

as a performance measure in 2010. 

(b) Why did VHA stop using it? 

Response. VHA stopped using it because field facilities indicated there were multiple case of patients who wanted to make appointments earlier than 14 or 30 days 

from the time they wanted the appointment to occur. It was an attempt to make 

the waiting time measure more patient-centric. 

Question 4. In light of Sec. Shinseki’s announcement of the addition of 1600 mental health clinicians and 300 support positions, how will these positions be distributed amongst the VISNs? 

(a) How did VHA determine the numbers of needed clinicians and support staff? 

Response. VHA is piloting a staffing model to ensure consistent staffing patterns 

for outpatient mental health services based on numbers of patients served, the 

range of services available at a facility, characteristics of the facility, and complexity 

of services. A projection for national implementation of the model showed that many 

sites would need additional staff. This need was also suggested by data from site 

visits, providers and Veterans. The initial projection was then modified in conjunction with VISNs/facilities to correct for local practices such as the use of tele-mental 

health or contracting. 

(b) Is this number an appropriate reflection of the need for mental health providers throughout the VA system? 

Response. VHA is piloting the staffing model, which is based on Veteran population in the service area, mental health needs of Veterans in that population, and 

range and complexity of mental health services provided in the service area. VHA 

will be assessing the adequacy of the model based on access, Veteran and provider 

satisfaction, use of evidence-based psychotherapy among other therapies, and will 

continue to adjust staffing as needed to meet the mental health needs of Veterans. 

(c) What will VHA do in the interim to help veterans receive timely mental health 

services? 

Response. As part of the site visit process, VHA is working with facilities to re- duce barriers to access as they are identified. In FY 2012, VHA provided $12 million 

in funding to expand the use of tele-mental health for PTSD and is continuing to 

work with sites to identify opportunities to use this technology to provide expanded 

services. VHA is also expanding the implementation of mental health in primary 

care which allows Veterans to have access to mental health services within the primary care setting. Sites are also able to use fee and/or contract services to provide 

timely services. 

Question 5. The VHA Action Plan states that the work group will provide the 

Under Secretary for Health with an action plan to create new metrics no later than 

July 1, 2012. 

(a) How long will the review process take? 

Response. The review process began with the July action plan deadline and will 

continue, with expected refinements, and initial piloting of the new metrics by the 

first quarter of FY 2013. 

(b) What is the timeframe for implementation of the work group’s action plan? 

Response. It is anticipated that the action plan will be implemented by December 31, 2012. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. ROGER F. WICKER TO

WILLIAM SCHOENHARD, DEPUTY UNDER SECRETARY FOR HEALTH FOR OPERATIONS

AND MANAGEMENT, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF

VETERANS AFFAIRS

POST-TRAUMATIC STRESS DISORDER

Over the years, the public has seen an increase in Veterans who suffer from 

PTSD. With the recent withdrawal of U.S. combat forces from Iraq and the administrations announcement to end combat operations in 2014 in Afghanistan, I expect 

that there will be an increasing number of veterans that will be diagnosed with 

PTSD. I am concerned about the process to determine how benefits are given to 

those who suffer from PTSD amid this backlog. 

Question 1. My office has received complaints about doctors at VA hospitals in 

Mississippi who are skeptical of accepted science regarding PTSD. What actions will 

be taken to ensure that certain doctors, who receive a large number of complaints, 

over an extended period of time, will be properly vetted by the VA and that appropriate action will be taken? 

21 

Response. VHA is invested in ensuring that Veterans receive evidence-based care 

for PTSD and appreciates being informed when concerns are identified about PTSD 

treatment. Complaints about any provider that are reported to the patient advocates 

locally are recorded in a complaint tracking file. Supervisors are notified when a 

complaint is made and the supervisor follows up with the concern at that time. Additionally, all VA credentialed and privileged providers are required to be reviewed 

on a variety of performance standards twice a year through the Ongoing Professional Practice Evaluation (OPPE). Quality monitors are reviewed with providers by 

their supervisor. If there is a continued pattern of complaints regarding a provider, 

this would be reviewed at that time as well as with the mid-year performance and 

end-of-year performance evaluations. If improvements are not made, the supervisor 

may pursue disciplinary actions and/or dismissal if no progress is made on written 

goals. 

Question 2. What is the number of denials for PTSD claims at the Jackson Regional Office based on the doctor’s recommendations? Additionally, what is the number of claims which were initially denied, but later reversed on appeal? 

Response. VBA does not track claims by physician. In FY 2011, service-connection 

for PTSD was granted on approximately 11,500 appeals nationally. Of these, 1,573 

were granted by the Board of Veterans’ Appeals. 

Question 3. Can you please provide the statistical data on the denial rate at the 

Jackson VA Regional Office in comparison to other VA Regional Offices? 

Response. In FY 2011, the average percentage of claims denied nationwide was 

23.2 percent for claims for PTSD, to include original claims, claims for increase, and 

claims that were previously denied. The Jackson Regional Office’s (RO) denial rate 

was 33.4 percent. 

In 2006 and 2009, the Institute for Defense Analyses (IDA) conducted studies to 

determine factors that contribute to differences in disability compensation awards. 

One factor they found was that claims approval rates vary significantly based on 

the population served. For example, ROs processing high volumes of pre-discharge 

claims and claims from recently separated Servicemembers have higher grant rates. 

Pre-discharge claims and claims from recently separated Servicemembers usually 

have service treatment records readily available and up-to-date medical information 

and have a higher number of issues claimed. IDA also found that other factors that 

contribute to the differences include median family income, percentage of the general population with a mental disability, length of service, and population density 

(urban, rural, and highly rural). In areas experiencing difficult economic conditions, 

Veterans are more likely to submit first-time claims, claims for an increase in benefits, and to resubmit claims that were previously denied, also impacting grant and 

denial percentages. 

Question 4. Why is the VA Form 9 processed at Regional Offices before they reach 

the Board of Veteran Appeals? 

Response. VA Form 9s are processed at ROs prior to going to the BVA because 

it provides additional opportunities to resolve the appeal at the lowest possible level. 

ROs must ensure the following actions take place after a VA Form 9 is filed: 

• Determine if the VA Form 9 was timely filed 

• Obtain clarification of appealed issues if VA Form 9 is incomplete 

• Consider additional evidence submitted by the appellant 

• Accommodate appellant requests for a local hearing at the RO 

• Consider any new issues raised by the appellant 

These prerequisite steps to certifying an appeal are in place to ensure ROs have 

done everything possible to resolve the appeal prior to sending the claim to the 

Board of Veterans’ Appeals. 

Question 5. Describe how the VA conducts quality control of PTSD, C&P Exam 

Results, and C&P Examiner Performances? 

Response. The Systematic Technical Accuracy Review (STAR) program assesses 

the accuracy of disability benefit determinations and is administered by VBA’s Compensation Service. It utilizes employees well-versed in the claims adjudication process to review and analyze claims data nationwide. Although there is no special review for PTSD claims, a percentage of them are reviewed along with other categories of claims. The STAR reviews focus on nationwide rating consistency by reviewing RO rating decision variance across frequently rated medical diagnostic 

codes, including those for PTSD and other mental disorders. In addition, earlier this 

year VBA implemented the Quality Review Team’s transformation initiative that 

will result in improvements in the service VBA provides. Dedicated teams of quality 

review specialists at each RO evaluate decision accuracy at both the RO and individual employee level, and perform in-process review to eliminate errors at the earVerDate Nov 24 2008 16:59 Aug 22, 2012 Jkt 000000 PO 00000 Frm 00025 Fmt 6633 Sfmt 6621 H:\ACTIVE\042512.TXT SVETS PsN: PAULIN
22 

liest possible stage in the claims process. The teams are comprised of personnel 

trained by our national quality assurance review staff to assure local reviews are 

consistently conducted according to national standards. 

VHA’s Office of Disability and Medical Assessment (DMA) conducts quality reviews of VA Compensation and Pension (C&P) examination requests made by VBA 

and examinations completed by VHA clinicians. The Quality Management section, 

an integral component of DMA’s quality and timeliness mission, is responsible for 

the collection and evaluation of VA disability examination data to support recommendations for improvement throughout the VHA and VBA examination process. 

The quality review program incorporates a three-dimensional approach consisting of 

an audit review process to assess medical-legal completeness, performance measures, and a review process to assess clinical examination reporting competence. 

A mix of staff knowledgeable in both the clinical protocol/practices of the C&P examination process and staff with VBA rating experience perform the reviews. This 

monthly random sample can include all potential exam types. This quality review 

process started in October 2011, replacing the former C&P Examination Program 

that was discontinued in October 2010. Ongoing enhancements to data collection 

will provide VBA and VHA with detail data to support process improvement. 

DMA is charged with improving the disability examination process by monitoring 

the quality of examinations conducted. Quality is monitored monthly using an audit 

review tool and the results are reported on a quarterly basis. This intense audit is 

conducted on all types of disability examinations, assessing consistency between the 

medical evidence and the examination report. 

DMA monitors disability examiner registration and certification and designs and 

conducts continuous education and training. DMA, in conjunction with the Employee Education System, oversees the program for mandatory registration and certification as outlined by VHA Directive 2008–05, ‘‘Certification of Clinicians Performing Compensation and Pension Examinations,’’ (below). This program provides 

all compensation and pension (C&P) clinicians with a common resource of essential 

knowledge about the C&P process and ensures that all Veterans’ disability examinations are performed by clinicians who are specially trained to conduct C&P examinations. 

23 


425VHA85a.eps
24 


425VHA85b.eps
25 


425VHA85c.eps
26 

Chairman MURRAY. Thank you very much. 

Ms. Halliday? 


425VHA85d.eps
27 

STATEMENT OF LINDA HALLIDAY, ASSISTANT INSPECTOR 

GENERAL FOR AUDITS AND EVALUATIONS, OFFICE OF INSPECTOR GENERAL, U.S. DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY LARRY REINKEMEYER, DIRECTOR, 

KANSAS CITY OFFICE OF AUDITS AND EVALUATIONS 

Ms. HALLIDAY. Madam Chairman, Members of the Committee, 

thank you for the opportunity to discuss the results of our recent 

report on veterans access to mental health care services in VA facilities. We conducted the review at the request of the Committee, 

the VA Secretary, and the House of Veterans’ Affairs Committee. 

Today I will discuss our efforts to determine how accurately the 

VHA reports wait times in mental health services to both new and 

established patient appointments. Dr. Daigh, the assistant Inspector General for the Office of Healthcare Inspections, will address 

whether the wait times data VHA collects is an accurate depiction 

of the veterans’ ability to access those services. 

We are accompanied today by Dr. Michael Shepherd, a senior 

physician in the Office of Healthcare Inspections, and Mr. Larry 

Reinkemeyer, the Director of the Kansas City Office of Audits. 

Our review found that inaccuracies in data and inconsistent 

scheduling practices diminished the usability of information needed 

to fully assess current capacity, resource distribution, and productivity across the VA system. In VA’s Fiscal Year 2011, in the performance accountability report, VHA reported 95 percent of first 

time patients received a full mental health evaluation within 14 

days. However, we concluded that that 14-day reported measure 

has no real value as an access to care measure because VHA measured how long it took to conduct the mental health evaluation, not 

how long the patient waited to receive that evaluation. 

We calculated the number of days between the first time patient’s initial contact with mental health and the completion of 

their evaluation. We projected that VHA provided only 49 percent 

or approximately 184,000 of these evaluations, within 14 days of either the veterans’ request or referral for mental health care. On average, it took VHA about 50 days to provide the remaining patients 

their full evaluation. 

Once VHA provides the patient with their evaluation, VHA 

schedules the patient for an appointment to begin treatment. In 

Fiscal Year 2011, we determined that VHA completed approximately 168,000 or 64 percent new patient appointments for treatment within 14 days of their desired date. Thus, approximately 

94,000 or 36 percent of the appointments nationwide exceeded 14 

days. 

In comparison, VHA data showed that 95 percent received timely 

care. We also projected that VHA completed approximately 8.8 million or 88 percent of the follow up appointments for treatment in 

14 days. Thus, approximately 1.2 million or 12 percent of the appointments nationwide exceeded 14 days. In contrast, VHA reported 98 percent received timely care for treatment. 

We based our analysis on the dates documented in VHA’s medical records. However, we have concerns regarding the integrity of 

the date information because providers told us they used the desired date of care based on their schedule availability. 

28 

1The desired date of care is defined as the earliest date that the patient or clinician specifies 

the patient needs to be seen. 

I want to point out that we reported concerns with VHA’s calculated wait time data in our audits of outpatient scheduling procedures in 2005 and outpatient wait times in 2007. During both audits, we found schedulers were entering an incorrect desired date, 

and our current review show these practices continue. For new patient appointments, the schedulers frequently stated they used the 

next available appointment slot as the desired date of appointment 

for new patients. This practice greatly distorts the actual waiting 

time for appointments. 

To illustrate, VHA showed 81 percent or approximately 211,000 

new patients received their appointments on their desired appointment date. We found the veteran could still have waited two to 3 

months for an appointment, and VHA’s data would show a zero day 

wait time. 

Based on discussions with medical center staff and our review of 

the data, we contend it is not plausible to have that many appointments scheduled on the exact day the patients’ desired. 

I offer the rest of my time to Dr. Daigh, who will provide the 

overall OIG conclusion. 

[The prepared joint statement of Ms. Halliday and Dr. Daigh follows:] 

PREPARED STATEMENT OF THE OFFICE OF INSPECTOR GENERAL, 

U.S. DEPARTMENT OF VETERANS AFFAIRS

INTRODUCTION

Madam Chairman and Members of the Committee, thank you for the opportunity 

to discuss the results of a recent Office of Inspector General (OIG) report, Veterans 

Health Administration—Review of Veterans’ Access to Mental Health Care, on veteran access to mental health care services at VA facilities. We conducted the review 

at the request of the Committee, the VA Secretary, and the House Veterans’ Affairs 

Committee. The OIG is represented by Ms. Linda A. Halliday, Assistant Inspector 

General for Audits and Evaluations; Dr. John D. Daigh, Jr., Assistant Inspector 

General for Healthcare Inspections; Dr. Michael Shepherd, Senior Physician in the 

OIG’s Office of Healthcare Inspections; and Mr. Larry Reinkemeyer, Director of the 

OIG’s Kansas City Office of Audits and Evaluations. 

BACKGROUND

Based on concerns that veterans may not be able to access the mental health care 

they need in a timely manner, the OIG was asked to determine how accurately the 

Veterans Health Administration (VHA) records wait times for mental health services for both initial (new patients) and follow-up (established patients) visits and if 

the wait time data VA collects is an accurate depiction of veterans’ ability to access 

those services. 

VHA policy requires all first-time patients referred to or requesting mental health 

services receive an initial evaluation within 24 hours and a more comprehensive 

mental health diagnostic and treatment planning evaluation within 14 days. The 

primary goal of the initial 24-hour evaluation is to identify patients with urgent 

care needs and to trigger hospitalization or the immediate initiation of outpatient 

care when needed. Primary care providers, mental health providers, other referring 

licensed independent providers, or licensed independent mental health providers can 

conduct the initial 24-hour evaluation. 

VHA uses two principal measures to monitor access to mental health care. One 

measure looks at the percentage of comprehensive patient evaluations completed 

within 14 days of an initial encounter for patients new to mental health services. 

Another method VHA uses is to calculate patient waiting times by measuring the 

elapsed days from the desired dates1 of care to the dates of the treatment appointments. Medical facility schedulers must enter the correct desired dates of care in 

29 

the system to ensure the accuracy of this measurement. VHA’s goal is to see patients within 14 days of the desired dates of care. 

REVIEW RESULTS

Our review focused on how accurately VHA records wait times for mental health 

services for initial and follow-up visits and if the wait time data VA collects is an 

accurate depiction of the veterans’ ability to access those services. We found: 

• VHA’s mental health performance data is not accurate or reliable. • VHA’s measures do not adequately reflect critical dimensions of mental health care access. 

Although VHA collects and reports mental health staffing and productivity data, 

the inaccuracies in some of the data sources presently hinder the usability of information by VHA decisionmakers to fully assess current capacity, determine optimal 

resource distribution, evaluate productivity across the system, and establish mental 

health staffing and productivity standards. 

VHA’s Performance Data Is Not Accurate or Reliable 

In VA’s fiscal year (FY) 2011 Performance and Accountability Report (PAR), VHA 

reported 95 percent of first-time patients received a full mental health evaluation 

within 14 days. However, the 14-day measure has no real value as VHA measured 

how long it took VHA to conduct the evaluation, not how long the patient waited 

to receive an evaluation. VHA’s measurement differed from the measure’s objective 

that veterans should have further evaluation and initiation of mental health care 

in 14 days of a trigger encounter. VHA defined the trigger encounter as the veteran’s contact with the mental health clinic or the veteran’s referral to the mental 

health service from another provider. 

Using the same data VHA used to calculate the 95 percent success rate shown 

in the FY 2011 PAR, we conducted an independent assessment to identify the exact 

date of the trigger encounter (the date the patient initially contacted mental health 

seeking services, or when another provider referred the patient to mental health). 

We then determined when the full evaluation containing a patient history, diagnosis, and treatment plan was completed. Based on our analysis of that information, 

we calculated the number of days between a first-time patient’s initial contact in 

mental health and their full mental health evaluation. Our analysis projected that 

VHA provided only 49 percent (approximately 184,000) of first-time patients their 

evaluation within 14 days. 

VHA does not consider the full mental health evaluation as an appointment for 

treatment, but rather the evaluation is the prerequisite for VHA to develop a patient-appropriate treatment plan. Once VHA provides the patient with a full mental 

health evaluation, VHA schedules the patient for an appointment to begin treatment. We found that VHA did not always provide both new and established patients 

their treatment appointments within 14 days of the patients’ desired date. We reviewed patient records to identify the desired date (generally located in the physician’s note as the date the patient needed to return to the clinic or shown as a referral from another provider) and calculated the elapsed days to the date of the patient’s completed treatment appointment date. 

We projected nationwide that in FY 2011, VHA: 

• Completed approximately 168,000 (64 percent) new patient appointments for 

treatment within 14 days of their desired date; thus, approximately 94,000 (36 percent) appointments nationwide exceeded 14 days. VHA data reported in the PAR 

showed that 95 percent received timely care. • Completed approximately 8.8 million (88 percent) follow-up appointments for 

treatment within 14 days of the desired date; thus, approximately 1.2 million (12 

percent) appointments nationwide exceeded 14 days. VHA data reported in the PAR 

showed that 98 percent received timely care for treatment. Although we based our 

analysis on dates documented in VHA’s medical records, we have less confidence in 

the integrity of this date information because providers at three of the four medical 

centers we visited told us they requested a desired date of care based on their schedule availability. 

Scheduling Process 

Generally, VHA schedulers were not following procedures outlined in VHA directives and, as a result, data was not accurate or reliable. For new patients, the 

scheduling clerks frequently stated they used the next available appointment slot 

as the desired appointment date for new patients. Even though a consult referral, 

or contact from the veteran requesting care, may have been submitted weeks or 

months earlier than the patient’s appointment date, the desired appointment date 

30 

was determined by and recorded as the next available appointment date. For established patients, medical providers told us they frequently scheduled the return to 

clinic date based on their known availability rather than the patient’s clinical need. 

Providers may not have availability for 2–3 months, so they specify their availability 

as the return to clinic timeframe. 

OIG first reported concerns with VHA’s calculated wait time data in our Audit 

of VHA’s Outpatient Scheduling Procedures (July 8, 2005) and Audit of VHA’s Outpatient Wait Times (September 10, 2007). During both audits, OIG found that schedulers were entering an incorrect desired date. Nearly 7 years later, we still find that 

the patient scheduling system is broken, the appointment data is inaccurate, and 

schedulers implement inconsistent practices capturing appointment information. 

Workload and Staffing 

According to VHA, from 2005 to 2010, mental health services increased their staff 

by 46 percent and treated 39 percent more patients. Despite the increase in mental 

health care providers, VHA’s mental health care service staff still do not believe 

they have enough staff to handle the increased workload and to consistently see patients within 14 days of the desired dates. In July 2011, the Senate Committee on 

Veterans’ Affairs requested VA to conduct a survey that among other questions 

asked mental health professionals whether their medical center had adequate mental health staff to meet current veteran demands for care; 71 percent responded 

their medical center did not have adequate numbers of mental health staff. 

Based on our interviews at four VA medical centers (Denver, Colorado; Spokane, 

Washington; Milwaukee, Wisconsin; and Salisbury, North Carolina), staff in charge 

of mental health services reported VHA’s greatest challenge has been to hire and 

retain psychiatrists. We analyzed access to psychiatrists at the four visited medical 

centers by determining how long a patient would have to wait for the physician’s 

third next available appointment. Calculating the wait time to the third next available appointment is a common practice for assessing a provider’s ability to see patients in a timely manner. On average at the four VA medical centers we visited, 

a patient had to wait 41 days. 

VHA’s Measures Do Not Adequately Reflect Critical Dimensions of Mental Health 

Care Access 

The data and measures needed by decisionmakers for effective planning and service provision may differ at the national, Veterans Integrated Service Network, and 

facility level. No measure of access is perfect or provides a complete picture. Meaningful analysis and decisionmaking requires reliable data, on not only the timeliness 

of access but also on trends in demand for mental health services, treatments, and 

providers; the availability and mix of mental health staffing; provider productivity; 

and treatment capacity. These demand and supply variables in turn feed back upon 

a system’s ability to provide treatment that is patient centered and timely. 

Decision makers need measures that: 

• Are derived from data that is reliable and has been consistently determined system-wide. 

• Are based on reasonable assumptions and anchored by a reasonable and consistent set of business rules. 

• Are measurable in practice given existing infrastructure. 

• Are clinically or administratively relevant. 

• Provide complementary or competing information to other measures used by 

decisionmakers. 

• Measure what they intend to measure. 

Measuring Access to VHA Mental Health Care 

Included in the FY 2012 Network Director Performance Plan are the following 

measures: the percentage of eligible patient evaluations documented within 14 days 

of a new mental health patient initial encounter; a metric requiring a follow-up encounter within 7 days of discharge from inpatient hospitalization; a measure requiring four follow-up encounters within 4 weeks of discharge from inpatient treatment 

for high risk patients; and a measure of the percentage of new Operation Enduring 

Freedom/Operation Iraqi Freedom (OEF/OIF) veterans receiving eight psychotherapy sessions within a 14-week period during one year period. 

VHA’s 14-day measure calculates the percentage of comprehensive patient evaluations documented within 14 days of an initial encounter for patients new to mental 

health services. In practice, the 14-day measure is usually not triggered until the 

veteran is actually seen in a mental health clinic and a comprehensive mental 

health evaluation is initiated. For example, a new-to-VHA veteran presents to a primary care clinic, screens positive for depression, and the primary care provider reVerDate Nov 24 2008 16:59 Aug 22, 2012 Jkt 000000 PO 00000 Frm 00034 Fmt 6633 Sfmt 6621 H:\ACTIVE\042512.TXT SVETS PsN: PAULIN
31 

fers the veteran for further evaluation by a mental health provider. The ‘‘clock’’ for 

the 14-day follow-up measure will start when the veteran is actually seen in a mental health clinic and a comprehensive mental health evaluation is initiated, not at 

the time of the primary care appointment. Consequently, the data underlying this 

measure only provides information about the timeliness within which comprehensive new patient evaluations are completed but not necessarily the timeliness between referral or consult to evaluation. 

Veterans access VHA care through various routes, such as VA medical center 

emergency departments, primary and specialty care clinics, women’s clinics, or mental health walk-in clinics. Alternatively, they may seek services at community based 

outpatient clinics or Vet Centers in their communities. They may also initiate mental health services with private providers and later come to VA seeking more comprehensive services. The 14-day measure does not apply to veterans who access 

services through Vet Centers or non-VA-based fee basis providers. 

A series of complementary and competing timeliness and treatment engagement 

measures that better reflect the various dimensions of access would provide 

decisionmakers with a more comprehensive view of the ability with which new patients can access mental health treatment. 

The timeframe immediately following inpatient discharge is a period of high risk. 

The 7-day post-hospitalization and the four follow-up appointments in 4 weeks for 

high-risk patient measures are clinically relevant. The eight psychotherapy session 

in 14 weeks measure attempts to be a proxy for whether OEF/OIF patients are receiving evidence-based psychotherapy. The measure is clinically relevant but the 

utility is presently marred by inaccurate data or unreliable methodology. 

Beyond measures of timeliness (or delay) to mental health care, user friendly 

measures that incorporate aspects of patient demand, availability and mix of mental 

health clinical staffing, provider productivity, and treatment capacity, anchored by 

a consistent set of business rules, might provide VHA decisionmakers with more information from which to assess and timely respond to changes in access parameters. 

Recommendations 

Our report contained four recommendations for the Under Secretary for Health: 

• Revise the current full mental health evaluation measurement to ensure the 

measurement is calculated from the veterans contact with the mental health clinic 

or the veteran’s referral to the mental health service from another provider to the 

completion of the evaluation. 

• Reevaluate alternative measures or combinations of measure that could effectively and accurately reflect the patient experience of access to mental health appointments. 

• Conduct a staffing analysis to determine if mental health staff vacancies represent a systemic issue impeding the Veterans Health Administration’s ability to 

meet mental health timeliness goals, and if so, develop an action plan to correct the 

impediments. 

• Ensure that data collection efforts related to mental health access are aligned 

with the operational needs of relevant decisionmakers throughout the organization. 

The Under Secretary for Health concurred with our recommendations and presented an action plan. We will follow-up as appropriate. 

CONCLUSION

VHA does not have a reliable and accurate method of determining whether they 

are providing patients timely access to mental health care services. VHA did not 

provide first-time patients with timely mental health evaluations and existing patients often waited more than 14 days past their desired date of care for their treatment appointment. As a result, performance measures used to report patient’s access to mental health care do not depict the true picture of a patient’s waiting time 

to see a mental health provider. 

While no measure will be complete, meaningful analysis and decisionmaking requires reliable data. A series of paired timeliness and treatment engagement measures might provide decisionmakers with a more comprehensive view of the ability 

with which new patients can access mental health treatment. 

Madam Chairman, thank you for the opportunity to discuss our work. We would 

be pleased to answer any questions that you or other Members of the Committee 

may have. 

32 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. BERNARD SANDERS TO

THE OFFICE OF INSPECTOR GENERAL, U.S. DEPARTMENT OF VETERANS AFFAIRS

Ms. Linda Halliday 

Question 1. During your investigation, did you observe any obvious trends, such 

as an influx of National Guard servicemembers recently discharged from active-duty 

that helps explain why some veterans are scheduled appointments within the performance standards while others are not? 

Response. We did not identify any trends specific to particular groups of veterans. 

As part of our review, we interviewed key personnel involved in the scheduling process at four VA medical centers located in Spokane, Washington; Milwaukee, Wisconsin; Salisbury, North Carolina; and Denver, Colorado. None of the personnel 

interviewed stated that a recent influx of National Guard servicemembers recently 

discharged from active-duty caused any of their access issues. 

Question 2. Did any scheduler or scheduler’s supervisor explain why there was 

such a deviation from VA Directives with regards to mental health appointments? 

Response. The schedulers that we interviewed received the required annual training that clearly shows how the appointments should be scheduled. However, at two 

of the locations (Salisbury and Denver), schedulers indicated that supervisors told 

them not to follow the Directive. Instead, schedulers access the software to see when 

the next appointment is available. The scheduler then backs out of the scheduling 

package and goes back in to enter the date of the available appointment as the desired date. An audit trail is not created in Veterans Health Administration’s (VHA) 

records that documents and captures these actions. 

Dr. John Daigh 

Question 1. Would you consider group therapy for ‘‘high risk’’ mental health patients as ‘‘clinically inappropriate’’ if it is not, at minimum, done in concert with individual therapy? 

Response. ‘‘High risk’’ is a term that can have a variety of meanings. Patients 

may over a short period of time transition from ‘‘high risk’’ to ‘‘low risk’’ and back 

to ‘‘high risk.’’ Mental health providers need to consider all forms and combinations 

of therapy when constructing a treatment plan. A more specific answer requires the 

facts and circumstances of a specific patient. 

Question 2. During your investigation, did you discover any group therapy for 

‘‘high risk’’ mental health patients who were not at the same time receiving individual therapy? If so, how frequently was this group therapy done in lieu of a more 

individuated or comprehensive plan of therapy? 

Response. The scope of our review did not include this issue. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. JOHNNY ISAKSON TO

OFFICE OF INSPECTOR GENERAL, U.S. DEPARTMENT OF VETERANS AFFAIRS

Question 1. The OIG has reported several times on inappropriate and inconsistent 

scheduling practices in 2005, 2007, and now again in 2012. VHA has taken steps 

to address these issues, however, the problem persists. 

A. Why does this continue to be an issue and what is contributing to the inappropriate practices? 

Response. The required management oversight is not effective. Schedulers told us 

that supervisors focused their attention on the appointments where schedulers were 

not able to schedule the patient within 14 days of the desired date of care rather 

than the integrity/accuracy of the appointments they were able to schedule within 

14 days. 

B. Is it simply a lack of training for schedulers? Are the schedulers receiving the 

required annual trainings and taking the annual tests to ensure they are properly 

carrying out VHA directives? 

Response. We do not think it is lack of training, but more that the oversight is 

not effective and the lack of focus on ensuring the data integrity of the scheduling 

information. At the sites we visited, the training and competency records were up 

to date and schedulers stated they were receiving training on proper scheduling procedures. Scheduling supervisors also stated they evaluated schedulers’ competency 

annually, as required. The training provided to schedulers aligns with VA’s Directives. 

Question 2. According to the OIG, this is leading to skewed data that is not helpful to key decisionmakers from the managerial level to the administrative level to 

Congress. 

33 

A. Do these inconsistencies occur in all the Veterans Integrated Service Networks 

(VISNs), or are some performing better than others? 

Response. For our review, we visited four VA medical centers located in four different VISNS, and confirmed inappropriate scheduling practices occurred at three 

of the four centers. Our analysis did not attempt to draw a conclusion between 

VISN performance so we cannot offer an opinion in this area. 

B. What is VHA doing to correct this problem? 

Response. VHA has indicated they are changing the way new patient appointment 

timeliness will be evaluated by using the ‘‘appointment create date’’ instead of the 

‘‘desired date’’ to evaluate appointment timeliness. VHA agreed with our concerns 

that the ‘‘desired date’’ is ambiguous and that a simpler methodology will improve 

the reliability of scheduling data. 

Chairman MURRAY. Dr. Daigh. 

STATEMENT OF JOHN DAIGH, M.D., ASSISTANT INSPECTOR 

GENERAL FOR HEALTHCARE INSPECTIONS, OFFICE OF INSPECTOR GENERAL, U.S. DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY MICHAEL SHEPHERD, M.D., SENIOR PHYSICIAN, OFFICE OF HEALTHCARE INSPECTIONS 

Dr. DAIGH. Madam Chairman, Ranking Member, and Members 

of the Committee, it is an honor to testify before you today. I and 

my staff from the Office of Health Care Inspections on a daily basis 

deal with clinical care issues in VA, and we know that both the employees and leadership within VA strive to provide the highest 

quality care. And despite the subject of this meeting, I do believe 

VA provides very high quality health care to its veterans. In fact, 

with respect to quality metrics, I believe VA leads the Nation with 

respect to both the use of data and the publication of that data on 

the Web site. 

With respect to access to care metrics, I believe it is quite a different story. I believe those metrics are flawed. I believe, as our report indicates, Dr. Petzel has indicated that he will put together a 

group to try to resolve the issue and get the access to care metrics 

in line so that they do accurately reflect the business processes 

that are ongoing at VA. 

I plan to talk about some of the access to care metrics in the private sector, but I think what I would like to make are two different 

statements after hearing your opening statement, ma’am. 

The first would be I think VA has a number of missions. They 

have a mission to provide health care. They have a mission to do 

research. They have a mission to train individuals who will work 

in the United States and elsewhere in the health care industry. 

They have a mission to be available in times of national disaster. 

And I think as individuals out there in hospitals they decide how 

they are going to spend their time, those missions are generally accepted as being equal—there is not a directive that says the primary mission is the delivery of health care, and we will address 

those requirements first as professionals schedule their time or allocate their time. 

So, I think when we have a crisis like we have, that a prioritization of mission, again, stated clearly from top to bottom, would 

allow individuals across the system to rethink how they are spending their time. 

The second issue I think is important is to set a standard of productivity. I realize that health care cannot be numbers driven. I realize it is a personal interaction between a patient and a provider. 

34 

But at the same time, there has to be some method to determine 

that you are getting enough work or productivity from the people 

that are working for you. 

So, I think although VA has worked on these issues for a while, 

that there just has to be a clear, measurable, and in my view, productivity standard that is easily relatable to the work done in the 

private sector by a similar provider, so that one can decide whether 

the money spent is actually being effectively used. The other issues 

that are brought forward in terms of the kind of access to care 

standards we could use, I think that Mr. Schoenhard and others 

well understand those, and I think we can work with them in order 

to improve the standards that they currently have in place. 

With that, I will end my comments and be happy to answer any 

questions. 

Chairman MURRAY. Thank you very much. 

Mr. Tolentino. 

STATEMENT OF NICHOLAS TOLENTINO, OIF VETERAN AND 

FORMER VA MENTAL HEALTH OFFICER 

Mr. TOLENTINO. Madam Chairman, Senator Brown, Members of 

the Committee, as and OEF/OIF combat veteran, I am honored to 

appear here today to share deep concerns about the administration 

of VA’s mental health care system. 

My testimony is based on my experience as a VA mental health 

administrative officer, as well as service on a VA network executive 

committee, membership on several VA national work groups, and 

a background in quality management that led to an MBA degree. 

Deep concerns about the Manchester, NH, VA medical center’s failure to provide needed care ultimately led to my resignation last 

December. 

I want to commend this Committee for your vigilant oversight of 

VA mental health care. Let me also acknowledge the VA’s recent 

announcement and plans to add positions to its mental health 

workforce and address problems you have helped to uncover. But 

I want to emphasize that additional staffing alone will not remedy 

the systemic problems in the VA management of mental health 

care. 

Let me be clear. I do not wish to discredit the VA or its mental 

health staff who work diligently to help veterans. But for all it 

strives to do, the VA’s mental health system is deeply flawed. The 

system is too open to putting numerical performance goals ahead 

of veterans’ mental health care needs. It is too susceptible to gaming practices and making the facilities look good and too little focus 

on overseeing the effectiveness of care it promises to provide. These 

systemic problems compromise the work of a dedicated mental 

health staff and fail our veterans. 

Like many VA medical centers, the overriding objective at our facility, from top management on down, was to meet our numbers, 

meaning to meet our performance measures. The goal was to see 

as many veterans as possible, but not necessarily to provide them 

the treatment they needed. Performance measures are well intended, but they are linked to executive pay and bonuses, and as 

a result, create incentive to find loopholes that allow the facility to 

meet its numbers without actually providing the services. Far too 

35 

often, the priority is to meet a measure rather than meet the needs 

of the veteran. 

Many factors, including understaffing, make it very difficult to 

meet performance requirements. But administrators do not feel 

that they can acknowledge that. Instead, as soon as new performance management program manuals were published each year, network and facility leadership began planning how to meet those 

measures. That led to brainstorming, even with colleagues of mine 

across the country, to find loopholes to game requirements that 

could not be met. 

While I have detailed multiple examples in my full statement, I 

would like to share two of them now. 

Several performance measures mandate that veterans in mental 

health treatment be seen within certain timeframes. At Manchester, where demand for mental health was great and staffing 

very limited, the facility director demanded a plan to get better and 

seen at any cost. We got the order: focus only on the veteran’s immediate problem. Treat it quickly in that appointment, usually 

with medication, and do not ask further questions about needs because, ‘‘We don’t want to know, or we’ll have to treat it.’’ 

Another directive requires that a patient who is actively suicidal 

or high risk for suicide should be seen at least once per week for 

4 weeks after an inpatient discharge. This is to ensure the veteran’s receiving the intensity of care needed to reduce the risk of 

readmission and to increase the success of treatment. 

Instead of providing these high-risk patients individual therapy, 

Manchester instead created a group for them, a step that was both 

clinically inappropriate and contrary to the directive’s intent. Veterans who refuse to join the group were often labeled resistant to 

treatment. 

The idea that group therapy could be substituted for individual 

psychotherapy spread throughout the network. In fact, the network 

mental health executive committee actually promoted this idea as 

a so called best practice. Even though it was not at all good clinical 

practice, it was seen as a good way to meet performance measures. 

I believe that most VA facilities have an understaffed mental 

health service because the VA lacks a methodology to determine 

what mental health staffing is needed at an individual facility. In 

a misguided attempt to justify more mental health staff at Manchester, the head of our mental health service stated that the priority needed to be quantity rather than quality. She said, and I 

quote, ‘‘Have contact with as many veterans as we can, even if we 

aren’t able to help them.’’ 

The outcome was that the facility continued to enroll a growing 

number of veterans, far more than our mental health clinicians 

could handle. And as a result, veterans fell through the cracks. 

Tragically, there was no effective oversight, even to detect those 

deep systemic problems we faced. 

For example, every year, the medical center would complete a 

mandatory central office survey to assess facility compliance with 

the VA’s mandate to provide uniform mental health services, but 

each year our network told us we were never to answer that services were not provided. Many of our answers were actually changed 

36 

to say that required services were being provided when they in fact 

were not. 

During my years at Manchester, other members of the mental 

health staff and I repeatedly raised concerns with both facility and 

network leadership regarding practices we believed were unethical 

or violated VA policy. Those concerns largely fell on deaf ears. Our 

staff also repeatedly brought the concerns to our facility’s ethics 

committee. And to our great frustration, however, the ethics committee consistently declined to take up these issues because they 

felt they were clinical matters. 

For me, the final straw was the medical center’s failure to take 

meaningful action upon discovery that a mental health clinician 

was visibly intoxicated while providing care to our veterans. Ultimately, I could not continue to work at a facility where veterans’ 

well being seemed secondary to making the numbers look good. 

I very much hope the VA will make real changes to address the 

systemic problems I have described. I believe that there are steps 

the VA can take beyond adding staff. I humbly offer these suggestions. 

First, the VA should stop monetarily rewarding leadership for 

meeting numerical and process requirements that are not real 

measures of effective mental health care. 

Second, the VA should institute a much more extensive oversight 

into how care is actually being provided and how program funding 

is deployed to ensure the funds actually go to the programs they 

are intended to supplement. 

Finally, I would urge this Committee to press the VA to develop 

and implement a very long overdue empirically supported mental 

health methodology so that it is no longer necessary to guess 

whether 1,900 more mental health staff will be enough. 

In closing, I am honored to have had the opportunity to share 

both my experience and assessment of problems that I hope you 

can help to resolve. I would be very pleased to answer any questions you may have. Thank you. 

[The prepared statement of Mr. Tolentino follows:] 

PREPARED STATEMENT OF NICHOLAS TOLENTINO, OIF VETERAN AND FORMER VA 

MENTAL HEALTH ADMINISTRATIVE OFFICER

Chairman Murray, Ranking Member Burr and Members of the Committee: I am 

honored to appear before you today to share my experience, perspective and resultant concerns about the delivery of timely, effective mental health care in the VA 

system. I want to begin by sharing with you that I am myself an OIF/OEF combat 

veteran, medically retired after nearly 14 years of service in the United States 

Navy. 

In April 2009 I took a position as the Mental Health Administrative Officer of the 

Mental Health Service Line at the Manchester VA Medical Center (VAMC) in Manchester, NH. While working in the Navy as an Independent Duty Hospital Corpsman, I earned my MBA and developed a deep interest in the quality-management 

of medical facilities. An opportunity to support VA efforts to aid my brothers and 

sisters, was for me, an ideal transition into civilian work and service. As the Mental 

Health Administrative Officer I was responsible for a vast number of the administrative functions of the Mental Health Service Line. In addition to those duties and 

responsibilities, I served as a member of the VISN 1 Mental Health Executive Committee which worked to address network-wide mental health service issues, and also 

as chairman of the Manchester VAMC Mental Health Systems Redesign Team, 

which worked to address local issues specific to the function and design of our mental health services. Deep concerns about needed care we were NOT providing at 

Manchester ultimately led me to resign last December. 

37 

ADDITIONAL MENTAL HEALTH STAFFING ALONE IS NO PANACEA

As a combat veteran, I want to commend this Committee for your vigilant oversight into VA mental health care. Let me also acknowledge Secretary Shinseki’s announcement of plans for additional staff to supplement VA’s over-stretched mentalhealth work force and address the problems your oversight helped uncover. But additional staffing alone will not remedy fundamental national problems in VA’s administration and management of mental health care. The problems I will highlight 

in this testimony—problems I have seen at the medical center, VISN level, and on 

multiple national work groups—are significant enough to derail and undermine the 

Secretary’s well-intentioned effort. 

HOW VACO MENTAL-HEALTH PERFORMANCE MEASURES DISTORT CARE DELIVERY

It is important for me to make clear that in sharing these concerns, I do not intend to discredit the VA, an organization with a critical role. I know from experience 

that many VA mental health staff—clinical and administrative—work tirelessly to 

help the veterans they serve. But I also know from experience that that system is 

deeply flawed. The system is too open to putting numerical performance goals ahead 

of veterans’ mental health care needs—too susceptible to ‘‘gaming’’ practices to make 

facilities ‘‘look good’’—and too little focused on overseeing the effectiveness of the 

mental health care it promises to provide. I have seen just how easily these systemic 

problems can compromise the important work of dedicated VA mental health staff, 

and fail our veterans. 

By way of context, the Manchester VAMC serves some 12,000 veterans in the 

state of New Hampshire. We are the only VA in New Hampshire and we are a small 

facility with no inpatient services. The mental health service line staffing has itself 

grown exponentially over the past five years with increased national attention and 

funding for mental health, and is now comparable in size to many of the other services provided on site; however demand for mental health care has grown faster. 

Historically, but even more so during the almost four years that I worked at Manchester, the overriding medical center objective—from top management on down was 

to ‘‘meet our numbers,’’ that is, to meet performance measures and to see as many 

veterans as possible. Performance measures play a significant but troubling role in 

VA mental health care. While it is not unreasonable to expect a facility to want to 

meet numerical performance objectives and provide needed care to as many veterans as possible, VA Central Office’s well-intentioned performance requirements 

often prove antithetical to providing appropriate care. 

First and foremost, the achievement of performance measures is linked to pay and 

bonuses for Executive Career Field (ECF) employees, most commonly, upper management (myself included). The financial incentive to meet these measures too easily 

creates a perverse administrative incentive to find and exploit loopholes in the 

measures that will allow the facility to meet its numbers without actually providing 

the services or meeting the expectation the measure dictates. The upshot of these 

all too widespread practices is that meeting a performance target, rather than meeting the needs of the veteran, becomes the overriding priority in providing care. 

You might ask: Why not provide the services the way the measure dictates and 

simply ‘‘make the numbers’’ in that way, why employ loopholes? While most performance measures are intended to ensure that care is provided in ways that are 

effective (based on empirical research), timely, and relevant to the needs of the population, they do not necessarily take the following operational realities into account: 

1. Staffing: Most facilities’ mental health services are understaffed, and mine was 

no exception. Without solid means to measure the relative needs of each facility, 

given its size, population served, etc., staffing levels are haphazard. (For example, 

White River Junction VAMC in Vermont, our neighboring facility, serves half the 

number of veterans in their mental health service, but has double the staff). Performance measures, rightfully, are not flexible as they relate to VA facility capabilities, as a veteran does not deserve lesser treatment because his local facility is 

small. However, the expectations reflected in VA’s performance measures often far 

exceed the capabilities of the staff that must meet them. In my experience, it was 

a routine matter for facility and VISN administrators to find and use loopholes to 

‘‘meet their numbers’’ whenever they were confronted with a gap between a performance requirement and a facility’s limited capabilities that had adverse implications 

for their paychecks. Tragically, though, this kind of ‘‘gaming’’ of the system meant 

that veterans too often weren’t getting needed mental health services. 

2. Mandated services are not always relevant to a facility: By way of example, in 

a well-intentioned effort to improve rural veterans’ access to mental health care, VA 

Central Office set mandates, and accompanying performance requirements, that 

called for providing certain percentages of veterans with telehealth services. HowVerDate Nov 24 2008 16:59 Aug 22, 2012 Jkt 000000 PO 00000 Frm 00041 Fmt 6633 Sfmt 6621 H:\ACTIVE\042512.TXT SVETS PsN: PAULIN
38 

ever, not all facilities have this need. While our facility in particular, did not have 

much demand for this service, the requirement led us to place many veterans in 

telehealth treatment whether they wanted it or not, and in circumstances where it 

was not clinically relevant or of any use to the veteran. Additionally, group therapy 

and other services not otherwise needed or indicated for such technology were forced 

to adapt their treatments to fit this new initiative. The upshot was that precious 

staff time was devoted to a mode of treatment that veterans neither needed nor 

wanted. 

One might think that administrators whose facilities are truly incapable of meeting a performance requirement would simply acknowledge that they cannot meet a 

target and request additional staff or other needed support. Unfortunately the system does not encourage that behavior, and facility administrators generally don’t 

wish to ‘‘look bad.’’ Moreover ‘‘failing to meet’’ a performance measure has adverse 

implications: 

1. The first and most obvious is that failing to meet a performance measure has 

a direct impact on administrators’ personal paychecks. 

2. When a facility fails a measure, it must take on a significant amount of administrative work. Action reports must be generated and submitted to the VISN, data 

must be tracked and analyzed and a tremendous amount of attention is brought 

onto the administration. No one likes that. (The irony is that there are loopholes 

around even this administrative requirement.) 

3. And finally, unlike the VA Primary Care Service Lines, for example, that have 

a well-defined staffing methodology, VA lacks a good method for establishing individual facility mental health staffing needs. While on paper a facility can appear 

‘‘fully staffed’’ based on VACO’s determination for that region, in reality the veteran 

workload and needs far exceed the man hours available to serve them. In my experience, when a service line manager does submit a request for additional staff, often 

the request doesn’t make it past the facility director because he or she will want 

data to support the need before taking it higher up the chain. Gathering data takes 

a great deal of work, and the data gathered rarely depicts the demand in a way 

that translates into man hours needed. This takes us back to why even VACO has 

difficulty establishing a good method for establishing staffing needs for individual 

facilities. 

Manchester offers a troubling case in point. Failure to meet a performance measure has not historically resulted in staffing needs being addressed. Instead, failure 

has resulted in more work for an already stretched staff, and a leadership response 

that has insisted that ‘‘we are already fully staffed,’’ and therefore any failure to 

meet measures must be an indication of inefficient use of resources, not a lack of 

resources. The mental health service line manager translated the call for ‘‘improved 

efficiency’’ to mean ‘‘find more loopholes.’’ 

GAMING THE SYSTEM

I know from my experience on the VISN 1 Executive Committee and on various 

national VA workgroups that these problems are not unique to Manchester VAMC. 

Unfortunately, most VA facilities struggle to fit into the highly uniform expectations 

of VA performance measures. While the goal of expecting all facilities to provide 

uniform quality care is laudatory, the rigid one-size-fits-all approach contributes to 

systemic problems. 

As soon as the new ECF Performance Management Program manual and performance measure technical manuals are published each year, even in draft form, planning among VISN leaders, facility leaders, Quality Management staff, and Service 

Line staff begins regarding how to meet the measures for that year. Staff analyze 

those measures that are determined not likely to be met by a facility due to either 

low demand, lack of resources, etc., and the group brainstorms to find loopholes that 

can be exploited to game the requirement. The group will also ask other facilities 

in the region and nationally for their ‘‘solutions’’ to similar problems. Let me offer 

some examples: 

Desired Date of Appointment: VACO’s performance measures include a requirement that a veteran treated by the mental health service is to be scheduled for a mental health appointment within 14 days of his or her ‘‘desired 

date’’ for service. 

At Manchester, despite the fact that effective treatment requires a level of intensity and frequency determined by the veteran’s symptoms, limited staffing 

(and other problems) made it impossible to offer veterans the frequency of psychotherapy appointments to meet their clinical needs. While a veteran and his 

or her clinician might agree that the veteran should return next week to conVerDate Nov 24 2008 16:59 Aug 22, 2012 Jkt 000000 PO 00000 Frm 00042 Fmt 6633 Sfmt 6621 H:\ACTIVE\042512.TXT SVETS PsN: PAULIN
39 

tinue his progress, the appointment availability was simply not there. Nevertheless our service ‘‘met’’ this measure by simply eliminating the opportunity for 

the veteran to give us a desired appointment date. Instead, the veteran was told 

when the next appointment with his provider was available and that appointment (often weeks, even months away) was entered as his ‘‘desired’’ date, thus 

‘‘meeting’’ the measure. 

(Veterans who are unable to be scheduled for their actual desired date should 

be placed on an Electronic Wait List (EWL) developed for this purpose and 

meant to track the demand versus the availability of services. (But facility leadership ‘‘unofficially ordered’’ that the EWL was NOT to be used under any circumstances.) 

Meeting frequency measures for clinical contact: Several different performance 

measures mandate that veterans in mental health treatment be seen within 

certain timeframes and frequencies based on such classifications as whether the 

veteran was new to treatment, a high risk for suicide, etc. At Manchester, 

where demand for mental health care was great and the resources were very 

limited, the facility director pressed the mental health service line manager to 

develop a plan to ‘‘get the veterans seen’’ at any cost. The plan that was ultimately developed ‘‘gamed’’ the system so that the facility ‘‘met’’ performance requirements but utterly failed our veterans. Specifically, instead of conducting an 

assessment of veterans’ mental health needs and scheduling and providing the 

appropriate intensity and frequency of services, the plan called for providing 

only the most limited mental health services (such as medication management 

or a mental health check-in from time to time) through the facility’s primary 

mental health clinic. The service line manager’s order was to focus only on the 

immediate problem with which the veteran presented in that moment, treat 

that quickly in that appointment (this meant only medication) and not to ask 

further questions about needs because, ‘‘we don’t want to know or we’ll have 

to treat it.’’ 

This perverse approach reduced the need to schedule appointments in an already backlogged scheduling system. (When appointments aren’t scheduled 

there is no evidence that the facility is NOT getting the veterans in for appointments in a timely way that meets the measures. Thus, the facility succeeds in 

appearing to meet the measure.) Veterans were encouraged and often required 

to make use of the walk-in service, despite clinical contraindications. This fundamentally unethical approach meant that veterans who needed much more intense care made no progress toward symptom remission and achieving treatment goals. 

High Risk Patients: By VHA directive, a patient who is actively suicidal or 

identified to be at high risk for completing suicide should be seen, at minimum, 

on a once-weekly basis for four weeks after being discharged from an inpatient 

unit. This is to ensure the veteran is receiving the intensity of care necessary 

to reduce the likelihood of readmission to the inpatient ward and to increase 

the success of the treatment provided. Manchester’s response to this requirement was to create a group for these high-risk veterans to attend, instead of 

providing individual therapy. Not only was this clinically inappropriate and in 

direct conflict with the intent of the directive, but if a veteran refused to be in 

a group, that veteran was often labeled ‘‘resistant to treatment.’’ 

Group therapy to meet intense-therapy requirement: Another performance requirement mandates that a certain percentage of OEF/OIF veterans who have 

a primary diagnosis of PTSD are to receive a minimum of 8 psychotherapy sessions within a 14-week period. While the clear intent of that measure is based 

on research that emphasized immediate, intense individual psychotherapy as 

the best clinical approach to combating PTSD, the technical wording of the 

measure did not effectively restrict the nature of appointments to the clinically 

indicated individual psychotherapy. Manchester took advantage of that lack of 

‘‘guidance’’ in the technical wording and once again used group therapy sessions 

as a means to meet the measure. And once again, veterans who refused to attend group therapy were labeled as non-compliant with treatment. So while the 

facility looked ‘‘on paper’’ as though it had met this VA performance measure, 

the vast majority of the patients in fact were not getting the intensity of care 

that the measure intended. 

Group therapy as ‘‘best practice:’’ Despite clinical contraindications, the idea 

that group therapy could be substituted for individual psychotherapy spread 

throughout the VISN. Manchester was certainly not the first facility to use this 

strategy. In fact, the VISN Mental Health Executive Committee, which met annually to discuss how individual facilities were meeting performance measures, 

actually fostered this idea as a so-called ‘‘best practice.’’ While the idea of subVerDate Nov 24 2008 16:59 Aug 22, 2012 Jkt 000000 PO 00000 Frm 00043 Fmt 6633 Sfmt 6621 H:\ACTIVE\042512.TXT SVETS PsN: PAULIN
40 

stituting group therapy for individual therapy for any and all patients is not 

at all good clinical practice, it was looked on as a good way to meet requirements. The VISN actually brought that so-called ‘‘best practice’’ to a national 

level, promoting this practice at a national VA mental health conference. 

(While I am not a clinician, I am aware of the various methodologies for treating many mental health disorders and symptoms relevant to the veteran population. Group therapy is a very effective and important aspect of mental health 

service. The problem with its use in these instances is the lack of choice and 

intensity in the treatment. Group therapy is by its nature a less intense form 

of psychotherapy, generally speaking. In addition, the veterans were given no 

choice over whether they would receive individual therapy or group therapy. Instead, at many facilities they are directed into a mode of care many do not 

want, need, or with which they are uncomfortable, because the facilities’ need 

to meet the associated performance measure is the overriding priority.) 

Targeted populations: Some performance measures identify target populations, and result in assigning certain classes of patients’ priority and access 

to preferred treatment modalities. The obvious result is that veterans of other 

eras or demographics may receive less than desirable or not-so-clinically indicated treatments to create space for the preferred population. Under these circumstances the individual’s clinical needs are not considered. A Vietnam veteran in crisis with significant symptoms would be passed over for that all-toorare appointment spot with a psychotherapist, if an OIF veteran also seeks that 

appointment. The fact that the OIF veteran may not be in urgent need for services is not considered. He would get the appointment because a performance 

measure dictates that he get a more timely appointment than all others. While 

the intent of fostering early intervention is a good one, the drive to meet the 

measure impedes exercise of good clinical judgment. 

BUDGET GAMING CONFOUNDS PROVISION OF GOOD MENTAL HEALTH CARE

I’m well aware that this Committee has been instrumental in increasing VA mental health care funding over the years. But ‘‘disconnects’’ between VA Central Office 

and VA medical facilities have in some instances stood in the way of special funding 

(to enhance mental health services) actually reaching the veterans. (Such ‘‘special 

funding’’ was intended to support the implementation of the Uniform Mental Health 

Services policy in VA medical centers and Clinics (VHA Handbook 116.01), which 

aims to ensure that a uniform set of mental health services would be accessible to 

veterans across the country.) Despite a clear directive, Manchester did not actually 

use special funding as intended or fully implement the Uniform Services Package 

(the ‘‘USP’’). 

On numerous occasions, VA Central Office would establish a new initiative related to the USP, and provide special funding for a particular mental health staff 

position to carry out that initiative. Most times a VHA or VACO Memorandum 

would be sent out to the facilities stating that the posting and hiring of the position 

was mandated and to be done ‘‘ASAP.’’ However, Manchester’s leadership would 

mandate that the position go through various administrative approval boards (despite the Memorandum having specifically stated that the position is not to be subjected to such processes). This process would greatly increase the amount of time 

taken to post and hire for the position. During this time—often 3–6 months in duration—the position would be caught up in meetings awaiting ‘‘approval’’ and the salary dollars received by the facility would go unspent, creating a substantial excess 

(often referred to as lag funds). At the end of the fiscal year, these lag funds would 

be converted to cover salary expenses of regular staff or converted into facility General Purpose (GP) funds to reduce overall facility debt accrued over the course of 

the year. I can recall many instances, across several fiscal years, where Manchester 

acquired hundreds of thousands of dollars of special mental health funding without 

fulfilling the actual intent of the funding. 

In FY 2011, for example, approximately $500 thousand in mental health funds 

were converted to general operating funds. As a result, we were not able to hire the 

specialty mental health staff we needed or provide the initiative-programs with the 

tools required to perform effectively. But because VA Central Office directed all 

medical centers to carry out a number of new initiatives, including expansion of 

Geriatric Psychiatry services, substance abuse services and expansion of homeless 

programs, for example, clinicians at the facility were forced to take those titles on 

as a collateral duty, or the services were simply not offered. While concerns over 

the situation were raised at both the facility and VISN level, they received only 

minimal attention for a short time, without resultant change. 

41 

(By assigning collateral duties to clinicians who already held important titles and 

functions, Manchester was able to appear fully staffed without having to hire additional clinicians. On paper we were able to say that we had an ‘‘Military Sexual 

Trauma (MST) Coordinator,’’ for example, despite the fact that that clinician was 

also carrying other mandated titles and responsibilities. This gamesmanship impacted appointment availability and further stretched limited resources. Moreover, 

most titled positions come with many administrative duties (weekly or monthly conference calls, data tracking, etc.). So when a clinician carries several titles, much 

of his or her time is consumed by those administrative tasks, resulting in less appointment availability for veterans). 

Good mental health care, of course, requires that we provide veterans privacy, 

and the necessary office space to make that possible. We had a need for additional 

mental-health-service space at Manchester, and a project was submitted to VACO 

to remodel a storage area so that we could co-locate multiple mental health offices 

with primary care. VACO provided us mental health special funds to perform the 

work. But after the work was completed, the facility leadership decided that the 

space would not in fact be used for mental health offices, but would instead be used 

to expand Primary Care. Mental health received no additional space and was informed that the facility priority was now Primary Care, given the identification of 

the upcoming Primary Care expansion. This scenario was repeated with the submission of a project to add an additional wing to the medical center specifically for the 

expansion of mental health. After the project received initial VACO approval, the 

facility leadership once again chose to use it for Primary Care, though not altering 

the project-intent statements to reflect this fact. 

MENTAL HEALTH BUDGET: DISTORTIONS IN PROVIDING CARE

Manchester’s Mental Health Service Line Manager’s response to our staffing dilemma was made clear to us in a meeting in which she emphasized that the service 

line priority needed to be ‘‘quantity’’ rather than ‘‘quality.’’ By that she meant to 

‘‘have contact with as many veterans as we can, even if we aren’t able to help 

them.’’ The strategy was an attempt to show workload numbers as a way to justify 

requests for adequate resources. The upshot, though, was that the facility was enrolling growing numbers of veterans with very real mental health needs, but the 

mental health clinicians were reporting ‘‘we already have more patients than we can 

handle.’’ As a result, veterans began to fall through the cracks. 

Under such circumstances where demand for needed treatment far exceeds the 

services available, VHA’s Uniform Mental Health Services Handbook dictates that 

mental health services ‘‘must be made accessible when clinically needed’’ either inhouse or under contract arrangements. But despite that mandatory language, the 

VISN’s Mental Health Service Line Manager took the position that ‘‘these are more 

guidelines than rules.’’ There was, in theory, a process through which to get feebasis care authorized—that required going through the service-line manager to get 

approval from the chief of staff—but I was told requests for approving fee-basis 

mental health care were very rarely approved. And even if they were approved, the 

facility lacked any effective means to case-manage these patients, as required under 

the directives regarding fee-services. Similarly, it was often a battle to even send 

a patient to another facility for needed care. 

Let me share just one horrific example to illustrate how the mindset at Manchester turned good patient care on its head. A psychiatrist assigned to the Substance Abuse Treatment Team, on more than one occasion was faced with a veteran 

seeking treatment to end his opioid addiction. Because the psychiatrist believed that 

he didn’t have time to assist the patient, he prescribed the very opioids to which 

the veteran was addicted. He tried to justify this by stating that he needed to ‘‘hold 

the patient over,’’ and went on to schedule him an appointment to return sometime 

in the future. The psychiatrist said ‘‘they are going to get the drugs from somewhere 

so we might as well just go ahead and give them to them.’’ 

LACK OF EFFECTIVE OVERSIGHT

It is heartbreaking to reflect on the many, many barriers staff encountered to getting patients the mental health care they needed and deserved. While patients truly 

fell through the cracks, there was no effective oversight to detect that and to address the deep systemic problems we faced. Every year our medical center took part 

in a Central Office survey to assess medical facilities’ compliance with the Uniform 

Mental Health Services Handbook; as part of that surveying we were asked to delineate the services we provided. Each year, however, the VISN Mental Health Office 

gave the facilities the guidance that we were never to answer that services were 

not provided. Many of the answers were changed to say that specific (required) servVerDate Nov 24 2008 16:59 Aug 22, 2012 Jkt 000000 PO 00000 Frm 00045 Fmt 6633 Sfmt 6621 H:\ACTIVE\042512.TXT SVETS PsN: PAULIN
42 

ices WERE being provided when they weren’t. Specifically, we were instructed that 

the ‘‘fallback’’ answer was that the services were provided by fee-service, although 

this was never actually the case. 

During my years at Manchester, other members of the mental health staff and 

I repeatedly raised concerns with facility leadership as well as at the VISN level 

regarding practices and decisions which were either frankly unethical or violated VA 

policy. Those concerns largely fell on deaf ears. 

Internally, our medical center has an ethics committee, and staff often brought 

concerns regarding the compromises to mental health care to that committee. To our 

great frustration, however, the ethics committee consistently declined to take up 

these issues on the basis that they were ‘‘clinical matters’’ beyond its purview. 

Manchester is located in relatively close proximity to the National Center for 

PTSD headquartered at the VA Medical Center in White River Junction, Vermont. 

The National Center is not an oversight body, but its director, Dr. Matt Friedman, 

did visit Manchester on one occasion during my tenure and advised on various requirements the facility needed to meet. He was simply told, ‘‘we don’t have the staff’’ 

to meet those requirements, and was not invited back. 

UNETHICAL PRACTICES: THE LAST STRAW

I could detail other instances of unethical practice at the Manchester VAMC that 

contributed to my decision to resign, but the final straw occurred when the medical 

center failed to take meaningful action in response to the discovery that a VA clinical psychopharmacologist was intoxicated while providing patient care. On October 31st, 2011 the Mental Health Service Line Manager discovered that a 

psychopharmacologist at our facility was noticeably intoxicated and slurring his 

speech. The Service Line Manager became aware of this situation when a veteran 

reported that the clinician had failed to appear for an appointment. Looking into 

the matter, I discovered that he had written numerous prescriptions during that 

day, presumably during the period of his intoxication. The very next day, while the 

clinician was again treating patients, a water bottle was found hidden in that clinician’s personal office refrigerator that was filled with a brown fluid clearly smelling 

of alcohol. An internal panel was convened, but the panel seemed to be more of a 

formality than an actual investigatory board. I was disturbed to learn that the incident did not lead to the clinician’s removal, and instead he was simply transferred 

to work in the pharmacy. To make matters worse, the service line manager’s response to my protest regarding the lack of action was to imply that, as a combat 

veteran, I was likely also vulnerable to substance-abuse. That implication, notwithstanding my impeccable employment history, was not only personally insulting, but 

unfathomable coming from a psychiatrist responsible for the facility’s mental health 

service. A similar attempt to imply that my combat veteran status is a personal liability was made after my resignation, when I provided voluntary testimony to an 

internal investigative board. The board attempted to discredit my testimony by stating that my responses to incidents I’d reported were simply magnified by my combat 

experiences and resulting emotional instability. 

RECOMMENDATIONS

Ultimately, I could not continue to work at a facility where the well-being of our 

patients seemed secondary to making the numbers look good. I do care deeply that 

the VA health care system not only makes our veterans’ mental health a real priority, but that it institutes the kinds of changes needed to make VA mental health 

care timely and effective. I believe there are steps that can be taken—beyond adding 

additional staff—to make this happen. Let me offer three recommendations: 

1. VA must stop measuring and monetarily rewarding administrators for meeting 

numerical and process requirements that are simply not sound proxies for effective 

mental health care. 

2. VA must institute much more extensive oversight into how care is actually provided and how program funding is deployed to ensure the funds actually go to the 

programs that they are intended to supplement. 

3. Finally, I would urge that this Committee press the VA to develop and implement a very long overdue mental health staffing methodology, so that it is no longer 

necessary to guess whether, for example, 1900 more mental health staff will be 

enough. 

In closing, I’m honored to have had the opportunity to share with you my ‘‘on the 

ground’’ experience and assessment of problems that I hope you can help resolve. 

I’d be pleased to answer any questions you may have. 

Chairman MURRAY. Thank you very much. 

43 

Major General Jones. 

STATEMENT OF T.S. JONES, MAJGEN, USMC (RET.), FOUNDER 

AND EXECUTIVE DIRECTOR, OUTDOOR ODYSSEY YOUTH DEVELOPMENT AND LEADERSHIP ACADEMY 

General JONES. I am Tom Jones, retired Marine, founder and director of Outdoor Odyssey, which is a camp for at-risk youth. I do 

not have any expertise in mental health. I have a lot of experience 

dealing with those who have mental health issues. 

I have been visiting Walter Reed in Bethesda every week since 

the start of the war in Afghanistan in 2001. I have met thousands 

of folks. I have been privileged to be on the board of the Semper 

Fi Fund, started by wives, run by wives, that deals with families 

of the wounded. 

I also started Semper Fi Odyssey as an outgrowth of Outdoor 

Odyssey. While it started as a normal transition course, I met a 

Marine Corps captain in Bethesda who was grievously wounded, 

visited him many times over the next year. And while he is in therapy, he asked me to help him to start a 501(c)(3), since I had already done so, a nonprofit. 

We originally started as a normal transition course, however, it 

was patently obvious after a while that the mental health issues 

were such that we really got into the whole issue of dealing with 

mental health. Because of my medical background, I was able to 

bring a lot of folks in from the outside. I noted Navy psychiatrist, 

Dr. Bill Nash. And he was so moved by the experience that he had 

me be involved in a number of gatherings of mental health professionals. From that, I was able to—because I am an adjunct at the 

Institute for Defense Analysis here in D.C., I was able to start a 

project looking at best practices on mental health. 

What we have done, we have run 30 sessions now, week long sessions, of Outdoor Odyssey. I chiefly used Outdoor Odyssey because 

I had the facilities. What we have done is build on a volunteer 

strategy with team leaders. And almost all the people involved are 

in voluntary category. 

What has transpired is this whole issue of trust, cohesion and 

bonding, which works in the military when you are dealing with 

veterans. Of our cohort, 30 sessions, 35 or so, we attend each time. 

Just had one last week. So we have dealt with over a thousand not 

only veterans but those soon to be discharged from the military. 

We work in conjunction with the Wounded Warrior Regiment, so 

it gives us a pretty good index not only of the problems we are having in the military, but also, most strikingly, the problems we are 

having in the veteran community. And what we have found is that 

many, if not most, of the people who are undergoing clinician’s care 

have not divulged even the source of the main stressor that has 

created the problem. 

I agree with several of the panelists here. I do not think the 

numbers of additional mental health coordinators is solely going to 

solve the problem. I think the mental health coordinator has to 

have a better understanding of what the demands are of the individual warrior. I think the one thing that we have learned through 

our experience with bringing mental health professionals to these 

44 

experiences is that many of them can get a better perspective of 

what these individuals are facing through interaction with them. 

So I would encourage other folks here, even my panel members, 

if we are so inclined to be involved, I think the insights and the 

site picture provided to you is absolutely illuminating. What we 

have learned—I call them salient outcomes. We can see the same 

things you get in a normal transition course, and we are getting 

breakthroughs where people are actually coming forward and talking about demons that they heretofore have never talked about before. We build a network of trust that is lasting, not just a network 

in the sense of a transition course, but a network that will follow 

them after they leave the experience. 

Most importantly what we have learned is the fact that a large 

percentage and a growing percentage of folks are having mental 

health issues. And I would say—it is an opinion, but I think it is 

a pretty well-founded opinion—that the numbers are going to be 

growing in the future. I would think that we need experiences 

where folks that do deal in the setting of a clinician have a better 

understanding of what the issues are that they are dealing with. 

I am very honored to be here. I thank you very much. I will answer any questions, and I will certainly encourage any members of 

your staff to visit. We have got plenty of chow and a place to put 

you down. Thank you very much. 

[The prepared statement of General Jones follows:] 

PREPARED STATEMENT OF T.S. JONES, MAJGEN, USMC (RET.), FOUNDER/EXECUTIVE

DIRECTOR, OUTDOOR ODYSSEY YOUTH DEVELOPMENT AND LEADERSHIP ACADEMY

Dear Chairman Murray and Members of the Senate Committee on Veterans’ Affairs: Good morning. My name is Tom Jones, and I serve as the Executive Director 

of Outdoor Odyssey as well as an Adjunct Staff Member of the Institute for Defense 

Analyses (IDA). In 1998, I founded Outdoor Odyssey and have served as its Executive Director in a voluntary capacity since that time. I am very pleased to have the 

opportunity to appear before the Committee this morning on this very critical subject. Although, unlike other speakers this morning, I have no certified expertise in 

mental health, I have been privileged to gain a great deal of experience in dealing 

with servicemembers who continue to struggle with mental health issues and have 

witnessed countless examples of success, attributed in no small measure to the 

power of the team, cohesion and one-on-one genuine concern. My experiences are 

the by-product of my involvement with wounded warriors as an active-duty officer, 

reinforced after my retirement through my role as a Board Member of the Semper 

Fi Fund and the fact that I founded and oversee the activities of Outdoor Odyssey. 

I will briefly outline my perspectives on the issue at hand in the following sections: 

Background; Semper Fi Odyssey; Cadre of Support; Salient Outcome, Lessons 

Learned and Opinions. 

BACKGROUND

Although I have visited wounded Marines and Sailors weekly since the initiation 

of combat action soon after 9/11, and have certainly gained key perspectives from 

those same visits, my insights have been honed in large measure by the approximately thirty (30) weeklong sessions I have hosted at Outdoor Odyssey designed to 

assist wounded warriors make the transition from the military to the civilian sector. 

These sessions, now known as Semper Fi Odyssey, represent the collaborative efforts of two nonprofits, working with the Wounded Warrior Regiment of the United 

States Marine Corps. 

As mentioned above, I founded Outdoor Odyssey in 1998, geared to identify and 

impact at-risk youth; at-risk in this context are those elementary-age youth identified by educators as those who face significant challenges to successful achievement 

in school. The focus of Outdoor Odyssey identifies strong, potential leaders among 

high school juniors and seniors and prepares these youth through a Leadership 

Academy to engage, bond with and then provide follow-on care to at-risk youth from 

their own community through an aggressive mentoring program. These high school 

45 

mentors are themselves mentored by community leaders, serving as Umbrella Mentors. Leveraging the success of this program with 38 school districts in western 

Pennsylvania, programs have been created over the past 14 years to engage countless other educational institutions to provide leadership development and team 

building opportunities. At the risk of appearing arrogant, I have been blessed at 

Outdoor Odyssey, as the success of these programs has allowed Outdoor Odyssey 

to expand both facilities and programs to become a high adventure leadership academy rivaled by few and surpassed by no other similar organization that I have had 

the opportunity to visit. I offer this information, as programs incorporated at Outdoor Odyssey associated with mentoring, bonding, goal setting, etc., represent the 

by-products of my lengthy Marine Corps experience and set the stage for development of the Semper Fi Odyssey experience. 

Due to my involvement with Outdoor Odyssey, I was able to assist a wounded Marine Corps’ Captain pursue his dream of building a transition program for wounded 

warriors who could not remain in the military. I met this young man during my 

visits to what was then known as Bethesda Naval Hospital and discussed his dream 

with him on numerous follow-on visits. Due to my experience with starting a 501(c)3 

nonprofit, I helped him create a nonprofit and agreed to host the first session at 

Outdoor Odyssey and later assisted him by traveling to other sites in the United 

States to hold follow-on sessions. The original concept was to have quarterly sessions in different regions of the country; follow-on sessions were held in Vail, Colorado; Tampa, Florida and New York City. While the plan was conceptually sound, 

it precluded development of continuity of effort and the creation of a cadre of volunteer support; moreover, it soon became apparent that the costs associated with such 

a concept were staggering and, therefore, prohibitive to success. Due to the potential 

that I saw in the program and the obvious and compelling need of the wounded warriors, I went to my fellow board members of the Semper Fi Fund to assist with certain of the financial requirements. In an effort to significantly reduce financial demands, I offered to host the next four sessions at Outdoor Odyssey. The initial 

weeklong program, then known as COMPASS, gained immediate traction with those 

who oversaw the Wounded Warrior Regiment and visiting mental health professionals. I was able to recruit significant help from associates within the Washington, 

DC, and Pittsburgh regions, and the weeklong programs evolved from one solely oriented on transition from the military into one providing the participant bona fide 

skill sets in all aspects of his/her life. Most important, the sessions became a vehicle 

to identify and deal with a growing number who were struggling with mental health 

issues. A noted Psychiatrist, Dr. William Nash, along other mental health professionals, visited the sessions regularly and requested my support in sharing the 

power of these sessions with others at major mental health gatherings; the aforesaid 

led to my involvement in a major project sponsored by OSD (P&R) and connected 

to the Institute for Defense Analyses (IDA). 

Unfortunately, the nonprofit inspired by the young Marine Corps Captain did not 

survive for a variety of his (Captain) professional and personal reasons. Key lessons 

acquired during the weeklong sessions, however, provided ample evidence of significant success, and the Semper Fi Fund and Outdoor Odyssey collaborated to form 

Semper Fi Odyssey, with approximately thirty (30) sessions now having been held. 

To remove even a hint of any conflict of interest, I stepped down from the Board 

of Directors of the Semper Fi Fund and am now on the Board of Advisors of the 

Fund and maintain an Emeritus Status on the Board of Directors. 

SEMPER FI ODYSSEY

As mentioned above, Outdoor Odyssey and the Semper Fi Fund, have collaborated 

to develop Semper Fi Odyssey, working in conjunction with the Wounded Warrior 

Regiment for the identification of the majority of the participants. The vast majority 

of the participants are combat wounded, with a few struggling with illnesses such 

as cancer or undergoing recovery from injuries sustained in activities other than 

combat. With the exception of staff members of the Wounded Warrior Regiment who 

routinely participate, all of the participants will soon be medically discharged from 

the Marine Corps. Additionally, a growing number of veterans have been identified 

for involvement by case workers of the Semper Fi Fund; this cohort is exclusively 

comprised of those struggling to overcome mental health issues. Most of this later 

group have been clinically diagnosed with PTSD and/or TBI, and almost ALL diagnosed with PTSD are currently under a clinician’s care. Moreover, and of significance, many of the participants who have been diagnosed with PTSD have not 

shared with the clinician the source of the stressor that ultimately led to the PTSD. 

For a variety of reasons, many struggling with PTSD have a very difficult time of 

developing a covenant of trust with the mental health provider. 

46 

Albeit it’s virtually impossible to briefly describe Semper Fi Odyssey, suffice it to 

say that the weeklong session is a holistic approach to engage the Marine and 

through a covenant of trust help him/her build a realistic plan for the future. Rest 

assured, my use of holistic approach does NOT connote esoteric pabulum laced with 

lofty phrases but one-on-one, eye-ball level leadership, inspiring the participant to 

come to grips with the mental, emotional, physical and spiritual aspects of his/her 

life. Participants form teams and are led by very successful, volunteer veterans who 

are assisted by active-duty officers and senior noncommissioned officers who themselves have fought alongside the participants in Iraq and/or Afghanistan. The imperative to include the active-duty component became patently obvious as the evidence 

of operational stress grew in significance. All of the veterans who serve as Team 

Leaders have made a successful transition into the civilian sector, with the majority 

of this cohort having entered the business world; moreover, a sizable percentage of 

these veterans have experienced combat. 

While the syllabus of Semper Fi Odyssey ranks as taxing and quite challenging, 

the underlying objective is the development of both professional and personal goals, 

supported by definitive, understandable and usable tools to reach these goals. Participants are LED to examine themselves VERY closely and are invariably inspired 

to share innermost thoughts and ‘‘demons.’’ In general, participants arrive skeptical 

and somewhat tentative; however, the genuine concern of the Team Leader invariably ‘‘breaks the ice,’’ leading to team cohesion and trust among team members. 

While the course includes the obvious pieces of any typical transition course, the 

focus of effort is to provide the participant the ability to know and talk about himself/herself, without falling victim to the commonly-known habit of building a resume that doesn’t reflect in ANY manner the individual described. Without question, by the final day of the Semper Fi Odyssey session, the participant has grown 

immeasurably in his/her ability to understand and share insights about his/her 

strengths, while being armed with the ability and assistance to tackle weaknesses 

and challenges. More important, the participant leaves the experience with the 

skills to build and follow a plan to succeed, reinforced by the knowledge that he/ 

she now has a cadre of supporters (read network) for the future. 

I simply couldn’t adequately outline all of the elements of the week’s experience 

but will now offer but one vignette from our most recent weeklong event which concluded this past Saturday, the 21st of April 2012. We reinforce the classroom work 

and Team Leader time with physical activities to the degree possible, based on the 

physical challenges of the participants. As noted above, Outdoor Odyssey offers a 

wide variety of high adventure activities and facilities that enable sessions in activities such as yoga and physical fitness, using equipment usable to those with physical challenges. The participants thrive on events such as the zip line, high ropes 

course and climbing, obviously tempered by physical limitations. This past week, 

two Marines, having but one leg between them, executed the long staircase of our 

indoor facility, with the Marine with an artificial leg carrying the Marine with NO 

legs up to the high ropes course on his back. These two Marines then negotiated 

a VERY tough and rigorous ropes course in tandem; there was not ONE dry eye 

in the building. A Senior Staff Non-commissioned Officer, deathly afraid of heights 

and heretofore declining to undertake the high ropes course, was SO inspired by the 

experience that he scaled the stairs and negotiated the course. Without exaggeration 

or any sort of hyperbole, the Marine without legs felt ten-feet tall and bullet proof 

upon completion of the experience. Everyone (and I mean everyone) saw a stark example of the power of the mind—regardless of the body. This particular event will 

impact not only those involved last week but many others as well in the days ahead, 

as it was chronicled by camera in the form of pictures and film. 

The final, collective event of the week is the visit to the crash site of Flight 93 

that came down in a western Pennsylvania farm field, roughly a 20-minute drive 

from Outdoor Odyssey. Without question, the emotional release ranks as palpable; 

Marines, most for the first time, are able to come face-to-face with the reality of 9/ 

11. As the VAST majority of these young folks joined the military in large part due 

to the events of that fateful day, the experience reinforces key messages shared relative to survivor’s guilt and other stressors associated with the trauma of combat. 

CADRE OF SUPPORTERS

It would be virtually impossible to accurately chronicle all of the volunteer support that goes into the weeklong Semper Fi Odyssey session. However, it is critical 

to note that the word volunteer ranks as KEY to any and all success of the sessions 

held thus far at Outdoor Odyssey. Folks routinely arrive skeptical of the worth of 

the experience, as many, if not MOST, have listened to many folks offer assistance 

that has eventually fallen short of advertised pedigree. Without question, though, 

47 

the power of the week rests on the two most important words in leadership: genuine 

concern. The one-on-one sessions and interpersonal dynamics with those who freely 

give of themselves and their time set the experience aside from all others the participant has encountered. Moreover, and critical from my perspective, the nature of the 

volunteer, able to convey genuine concern, truly sets the stage for the covenant of 

trust that is developed; this can NOT be overemphasized!! To provide an illustration 

of the utility of the volunteer, I will use the most recent Semper Fi Odyssey as an 

example; this event was conducted last week, concluding this past Saturday, the 

21st of April. While not all-inclusive, I’ll show certain positions that played integral 

roles in the weeklong session, coupled with examples of the various backgrounds of 

those filling the respective roles: 

• Team Leader: clearly the key to the success of Semper Fi Odyssey; most Team 

Leaders (TLs) volunteer for the entire week, with a small percentage sharing the 

responsibility, changing at midweek; eleven teams were used during the recent session, with TLs coming from such locations as Oregon, Wyoming, New York, Virginia 

and, of course, Pennsylvania. The TLs from Oregon, Wyoming and New York were 

all Vietnam veterans; the gent from Oregon was an infantry officer in the USMC, 

followed by a stint as a F–4 pilot in the Corps; he is now CEO of his own company; 

he has traveled to Outdoor Odyssey six times to serve as a Team Leader; his brother was a company commander killed in Viet Nam in an epic battle experienced by 

one of our local Team Leaders from Pittsburgh who has now served in that capacity 

for 20 weeklong sessions. The gent from Wyoming is an Orthopedic Surgeon, who 

served in Vietnam as a Battalion Surgeon of the same battalion as the brother of 

the gent from Oregon and the aforementioned TL from Pittsburgh. Several of the 

Team Leaders hail from Pennsylvania—all former Marine Officers and/or Senior 

Non-commissioned Officers and serving in leadership positions in various businesses. Additionally, two retired Colonels from the DC area served as TLs during 

this recent session: both retired Colonels and CEOs of their own companies (one 

from the Air Force and one female retired from the Army—both having served multiple times as TLs). During this recent session, we were blessed with the support 

of several active-duty Marines to serve as TL or Assistant TL: two Majors, two Captains and two Gunnery Sergeants—all with multiple combat deployments to Iraq 

and Afghanistan. Previous sessions have seen TLs from Texas (Professor at Texas 

A&M and former Marine), Alabama (former enlisted squad leader in Viet Nam and 

successful businessman) and Florida (former Navy SEAL and financial advisor). 

Team Leaders coming from the Washington D.C. area are simply too numerous to 

list, with the vast majority being retired Colonels, LtCols and Senior Non-commissioned Officers—most with combat experience. • Mental Health Professional: During this session, we were supported by a psychiatrist (retired Navy Captain) who had served as the 1st Marine Division Psychiatrist in Iraq and, upon his retirement, played a key role in the development of the 

Marine Corps’ program of record for dealing with mental health injuries known as 

OSCAR (Operational Stress Control and Readiness). We vigorously follow the tenets 

of OSCAR, working hard to identify those struggling to overcome stress injuries, 

while working to support the mental health professional for those clinically diagnosed to be struggling with illnesses. This particular psychiatrist has been with us 

many times and strongly endorses our work, while providing significant reinforcement to the Team Leader. During this recent session, we were also supported by 

a psychologist from a prominent university, located in Pittsburgh; this gent had 

learned of Semper Fi Odyssey from a fellow mental health professional and actively 

sought the opportunity to partake and assist. I am confident that we will benefit 

from his services for many sessions in the days ahead. • Representatives from the University of Pittsburgh and Penn State: One of the 

most popular, and I would state most successful, presentations of the week has routinely been one oriented on dealing with stress management. Clearly, the sessions 

at Semper Fi Odyssey have identified that day-to-day stressors significantly exacerbate the incidence of operational stress or post-traumatic stress that many, if not 

most, servicemembers face after a combat deployment. We have been blessed for approximately twenty (20) sessions with a representative from the University of Pittsburgh who provides a striking and most stimulating presentation that includes tools 

that can be immediately implemented to address stress levels and improve sleep 

habits. Many participants have offered compelling testimony relative to the power 

of this two-hour block of instruction. Additionally, during this most recent weeklong 

session, we had seven representatives from Penn State and the University of Pittsburgh form a panel to address any and all questions posed by the participants, focusing on post-secondary education, veteran benefits, Vocational Rehab and any 

area related to education and training sought and/or required following departure 

from the military. This group consisted of college professors, specialists in veterans 

48 

programs and benefits, department heads and overseers of various programs associated with the matriculation to higher learning. As many of the participants face 

some level of physical challenge upon departure from the military, this session has 

proved to be MOST beneficial, providing insights into learning aids available to the 

veteran. The session takes approximately two hours, with panel members but rarely 

unable to answer the specific questions proffered by the participants; however, for 

those queries that stymy the group, an answer is invariably provided by one of the 

representatives later in the week. • Yoga Instruction: Semper Fi Odyssey has been supported by the nonprofit Exalted Warrior for approximately the last twenty (20) sessions. The key instructor 

hails from Tampa, Florida, and routinely spends the entire week at Outdoor Odyssey. Sessions are incorporated into the daily routine during at least four days of the 

weeklong schedule, with voluntary sessions held each evening after completion of 

scheduled events. This recent session was supported by two instructors, one of 

whom a Navy Admiral (retired career SEAL) who was instrumental in the founding 

of the Exalted Warrior nonprofit organization. Instruction is modulated according to 

the physical capabilities of the participants, and MANY extol the virtues of these 

sessions to assist in relaxation and meditation, while helping to address problems 

with sleep. • Fitness Instruction: For the last three plus years, we have been supported by 

the Fitness Anywhere Corporation via the involvement of a former Navy SEAL who 

is an exercise physiologist, chiropractor and bona fide fitness expert of the first 

order. Instruction orients on the use of a device known as the TRX, and, simply put, 

it can be used by virtually anyone regardless of physical challenge. The addition of 

several periods of this instruction into the weeklong syllabus has been HUGELY 

popular, with every session having one or more participant opining that use of the 

TRX was the first time the participant felt like a warrior since being wounded. The 

Fitness Anywhere Corporation, founded by a retired Navy SEAL, offers a TRX free 

to every participant, based on the recommendation of those overseeing the Semper 

Fi Odyssey. • Professional Assessment: A company owned by the father of a wounded Marine 

Captain offers his company’s service during each session of Semper Fi Odyssey to 

conduct a computerized assessment of each participant in the manner of the Meyers 

Briggs personality assessment. The evaluation provides the participant insight into 

his/her personal makeup, principally focused on elements of the individual’s personality, strengths and orientation relative to occupational fields. Fortunately, during 

this recent session, the Marine Corps’ Captain, an above-the-knee amputee from 

combat in Iraq and a recent returnee from Afghanistan where he served as a company commander, represented his father for the presentation of the assessment 

results. • Numerous Instructors: Quite a variety of other professionals, too numerous to 

list, visit Semper Fi Odyssey during the weeklong session to provide various periods 

of instruction. Many of these individuals are former military; however, we work 

hard to recruit, train and incorporate talent without military experience, as it serves 

to better educate the populace of the staggering sacrifices borne by today’s servicemember. Moreover, involvement by those without military experience provides the 

participant the opportunity to learn more from those he/she will likely encounter 

after departure from the military. Many of the instructors utilized for the weeklong 

sessions, be they former military or not, have been responsible for the creation of 

actual job opportunities for a number of the participants. An example of the periods 

of instruction provided by these instructors are as follows: goal setting; operational 

planning skills; resume building; interview skills and techniques; opportunities in 

the Federal Government; business 101 perspectives; STAR techniques for articulating accomplishments, etc. Of additional note, EVERY weeklong session has included presentations oriented on bona fide job opportunities; several sessions have 

had participants linked to his/her future employer. 

• Interviewers: Our most seasoned Team Leader, a former Marine Corps Infantry 

Officer with considerable combat experience, hails from Pittsburgh. This gent trains 

the new Team Leaders and plays an integral role in virtually anything and everything that goes on at Semper Fi Odyssey. He owned his own computer company for 

over three decades in Pittsburgh and knows virtually everyone in the city. He has 

built an inventory of over seventy potential interviewers, and personally coordinates 

the involvement for approximately 15–20 interviewers for the final day of instruction for each session of Semper Fi Odyssey. Each interviewer ranks as a leader in 

his/her field, and the variety of fields represented covers virtually any occupation 

one could pursue. The interview session provides each participant the opportunity 

to undergo at least three or more mock interviewers by folks they have never met, 

instilling a level of stress and offering an opportunity to evaluate the participant’s 

49 

ability to talk about his/her skills, experiences and passion to serve. A number of 

the interviewers are military veterans; many, if not most, routinely hold interviews 

for actual positions within their respective organizations. Without question, those 

interviewers recruited for this experience are passionate about the unique opportunity that they themselves have in helping the participant transition into the civilian sector. It is NOT uncommon for an interviewer to become a mentor for one of 

the participants he/she has had the privilege of interviewing. This particular session 

ranks as one of the most, if not the most, popular of the week, greatly instilling confidence in virtually every participant. The following is a snapshot of the interviewers 

from the most recent session: former Vietnam Army Officer and former CEO of largest Electrical Construction Company in US; President of manufacturing firm; 

Human Resource Manager of major bank; Senior Franklin Covey Facilitator; West 

Point Grad and Vietnam Infantry Officer and President and CEO of major construction company; President of Performance Consulting; President of company that provides host of services to small businesses; Director of Systems Engineering of KEYW 

Corporation; lawyer and owner of Law Office; former Marine Sergeant in Vietnam 

and owner of nine restaurants in Pittsburgh; President and CEO of prominent technology company in Pittsburgh; Superintendent of one of Pittsburgh’s School Districts; former Marine enlisted infantryman in Vietnam and high level labor negotiator; Director of three assisted living homes; former infantry Sergeant with experience in Iraq who owns a major construction company; former Army Engineer with 

service in Vietnam who is now a TV and radio talk show host in Pittsburgh; Orthopedic Surgeon in Pittsburgh who served as a battalion surgeon supporting Marines 

in Vietnam; Assistant VP of Federal Reserve Bank in Cleveland; Manager of Recruitment at the University of Pittsburgh Medical Center. 

Salient Outcomes, Lessons Learned, and Opinions: As I pen this written testimony, we have now been privileged to engage approximately 30–35 participants for 

30 weeklong sessions. Without any exaggeration, trust, cohesion and team building 

represent the major by-products of the Semper Fi Odyssey experience, helping the 

participant share, learn and grow during the week while setting the stage for future 

success. Participants build relationships that are lasting and depart with the assurance that they are armed with connecting files to people who will indeed follow up 

with them in the days ahead. Obviously, those who choose to break contact can; 

however, those who elect to remain connected and gain follow-on support have a vehicle to do so. FORTUNATELY, the vast majority of past participants remain connected. I offer the following insights from the Semper Fi Odyssey experiences: 

Salient Outcomes: 

• Conduct self assessment and built definitive plan for improvement 

• Gain bona fide skills in application of life-planning tools 

• Identify and connect to people in their lives that they can count on and trust 

• Build a honest network of support among fellow participants and volunteer support 

• Make commitments that lead to accountability and likelihood of noble pursuits 

• Experience trust and cohesion, inspiring participants to share ‘‘demons’’ 

• Made significant breakthroughs relative to mental health issues that pave the 

way to improve follow-on care 

• Develop SMART (specific; measurable; attainable; realistic; time bound) Goals 

• Hone interview skills and STAR techniques that reinforce a TRUE resume 

• Build a tentative network of support in the eventual geographical location of 

residence 

• Enjoy being treated as a warrior and inspired by useful, workable skills 

• Learn that others with similar experiences have grown and prospered greatly 

Lessons Learned: 

• Vast majority of wounded warriors require some level of assistance in preparation for transition 

• A growing % of wounded warriors struggle with operational stress issues, and 

a growing number are being diagnosed with PTSD and/or TBI 

• Trust, team building and cohesion pay REMARKABLE dividends in preparing 

Marines for eventual departure 

• Many, many programs, based on sound concepts and procedures, simply DO 

NOT connect to the individual warrior, lacking one-on-one, eye-ball level leadership 

and understanding 

• Many diagnosed and under a clinician’s care do NOT disclose stressor at root 

of the problem 

• Team building and cohesion led to significant number of breakthroughs among 

those diagnosed with PTSD but heretofore unable to disclose nature of stressor 

50 

• Experiences at Semper Fi Odyssey paid huge dividends in project sponsored by 

OSD designed to identify best practices; OSCAR is truly a winner if presented correctly • Individuals who care and possess genuine concern for the wounded warrior are 

essential • Key personnel within OSD are working to provide a grant that would enable 

support to be provided to members of any branch of the service 

Opinions: 

• Any cohort of combat veterans who have served in Iraq and/or Afghanistan 

would provide indications of stress levels roughly equivalent to those observed in 

wounded Marines • A very large percentage of mental health professionals DO NOT remotely connect to combat vets and are presently unable to establish the necessary covenant 

of trust • Semper Fi Odyssey could easily serve as a prototype for programs within the 

active-duty services • Many, many veterans will be identified to be struggling with combat stress 

issues in the near future—and for many, many months to follow • There exist too many disparate programs that DO NOT connect to the individual servicemember • The Semper Fi Odyssey model stands to greatly assist mental health professionals engage veterans with mental health issues 

• We need to build a mechanism of support that would permit the inclusion of 

members from any branch of the service 

Very Warm Regards and Semper Fi. 

Chairman MURRAY. Thank you very much. 

Mr. Schoenhard, first let me say that I am very happy to hear 

that the VA is finally acknowledging there is a problem. When the 

Department is saying there is near perfect compliance, but every 

other indication is that there are major problems, I think it is an 

incredible failure of leadership that no one was looking into this. 

In fact, when you sit at that table before this Committee, we expect 

you to take seriously the issues that are raised here. It should not 

take multiple hearings, and surveys, and letters, and ultimately an 

IG investigation to get you to act. 

I also would like to suggest that if the reality on the ground 

could be so far off from what Central Office thought was happening 

as it relates to mental health, then you better take a very hard 

look at some of the other areas of care for similar disconnects. 

Now, what we have heard from the IG is very, very troubling. 

For months now, we have been questioning whether Central Office 

had a full understanding of the situation out in the field, and I believe the IG report has very clearly shown you do not. So I want 

to start by asking you today, after hearing from this Committee, 

from veterans, from providers, and from outside experts, why you 

were not proactive about this problem months ago? 

Mr. SCHOENHARD. Chairman Murray, we have been looking at 

mental health for many years. As you know, with the support of 

the Congress, we increased our capacity and hired about 8,000 new 

providers between 2007 and 2011. We relied primarily on a uniform mental health handbook that would be the source of the way 

in which we would deliver care to our Nation’s veterans. That has 

been the focus of the Department, to ensure that we are getting 

evidence based therapies and a staffing model that was largely 

based on the handbook put out in 2009. 

I think what we have learned in this journey, and we have been 

wanting to work very closely with our providers, is a number of 

things. As I mentioned in my opening statement, the way in which 

51 

we measure these performance measures is not a good measure of 

wait time. We want to work very closely with the IG and with any 

other resources that are available to assist us in ensuring that we 

provide Vet Centered performance measures going forward. 

Chairman MURRAY. Mr. Schoenhard, with all due respect, I think 

back in 2005, the IG said this information was there. So that is a 

long time with a lot of veterans in between. So my question is, how 

are you going to address that growing gap that we have seen, what 

Central Office believes, and what is actually happening in the 

field? 

Mr. SCHOENHARD. As Dr. Daigh described in our response to the 

IG report, we have a number of things going on. One is first we 

have a working group that will report this summer on a new set 

of performance measures that includes providers on the ground assisting us with ensuring that we have developed measures in conjunction with support from the IG that are really Vet Centered, 

that are centered on the veterans’ individual condition, and one in 

which we can revamp and go forward. 

We fully embrace that our performance measurement system 

needs to be revised, and we will be doing that with the work of people on the front lines to assist us. We have the benefit of these 

mental health site visits that are assisting us. We are learning as 

we go on other issues having to do with scheduling. And all of this 

effort is assisting us in not just having people at Central Office develop proposed solutions, but to engage the field in a way that we 

need to in order to ensure we are Vet Centered and we are able 

to support our providers in delivering this care. 

Chairman MURRAY. I appreciate that, but it is very troubling to 

me that this did not happen five, 10 years ago; that we are just 

now—after months of this, years of this, that that disconnect is 

there. But we will go back to that, because I want to ask Mr. 

Tolentino—and I really appreciate your willingness to come forward today. And I believe your testimony is going to be very helpful to addressing many of the changes that are needed in a timely 

fashion. 

In your testimony, you suggested that VA institute more extensive oversight into how mental health care is actually delivered and 

funds are spent. Given how adept many of the facility administrators are getting around the current system without being caught, 

how do you think the VA can most effectively perform that oversight? 

Mr. TOLENTINO. Madam Chairman, to be perfectly honest, I do 

not have a very good answer for you because of the fact that the 

gaming is so prevalent. As soon as something in put out, it is torn 

apart to look to see what the work around is. 

I feel that the reporting that is done is—it is very redundant reporting that feels like it goes nowhere. There is no feedback loop. 

One way we are telling you exactly what you in most times want 

to hear that we did at the facilities and even at the network, but 

there is no coming back and rechecking, or coming back and feedback to say, well, you said you spent this money on these services, 

but there is no workload to verify it. There is nothing concrete to 

be able to speak to what you say you have done. 

52 

In the short time that I worked there, many times we got vast 

amounts of financial monies for different programs, but very, very 

seldom did we ever get requests to verify what we have done with 

workload, with any kind of feedback reports, or anything like that. 

So I think opening the lines of communication and a very transparent feedback loop at that. 

Chairman MURRAY. Mr. Schoenhard, my time is out. I want to 

turn it over to Senator Brown, but I do want to address a very important issue here. 

The Department has announced 1,600 new mental health care 

providers, and I appreciate that step. I think it is really needed. 

But I am concerned that VA hospitals all across the country are 

going to run into the same hurdles that Spokane VA has been in 

not being able to hire health staff. And I hope that medical centers 

are doing everything, including using all available hiring incentives 

to fill those vacancies. By the way, I assure you that is the next 

question this Committee is going to look at. 

But I want to ask you specifically how are you going to make 

sure that 1,600 new mental health care providers that you announced do not remain 1,600 new vacancies? 

Mr. SCHOENHARD. Chairman Murray, that is a very important 

question. And we have stood up in our human resources group in 

VHA workforce two task forces to assist us with this. One is the 

recruitment and retention of mental health providers with a particular focus on psychiatry. That is where our greatest need and 

problem is in retaining and recruiting mental health providers. 

The second task force is a hiring task force; that is, what can we 

be doing to expedite and make sure that we are having the process 

of recruitment as speedy as possible. The group has put together 

a number of good recommendations that we will be implementing. 

Part of what Dr. Daigh spoke of earlier in terms of our four part 

mission, one of the great assets, having been in the private sector 

for many years before coming to VA, is that many mental health 

providers, including hundreds of trainees, currently today get part 

of their training in VA and have the opportunity to experience this 

going forward. We need to better link with these trainees and ensure that we have a warm hand off for employment when they finish this. 

Chairman MURRAY. OK. That is one issue. But then how you arrived at your staffing plan is really unclear to me. 

Mr. SCHOENHARD. Oh, I am sorry. 

Chairman MURRAY. The new 1,600 mental health providers that 

you allocated and the information that we got from the Department 

yesterday on where that was going to go is not supported by any 

concrete facts or evidence. In fact, yesterday the VISN 20 director 

told Senator Begich and me that she learned about the new positions only a couple days ago, did not know if it was sufficient, and 

did not know how the Department even reached those numbers. 

So I want to ask you, how did you arrive at that number of 

1,600, and what makes you confident that it is going to be effectively placed across the country? What is the plan, staffing plan 

you used to do that? 

Mr. SCHOENHARD. Thank you. I am sorry. I misunderstood the 

question. I am going to ask Dr. Schohn if she may want to speak 

53 

on this. But we used a model that looks at the volume of services. 

We are piloting this in three VISNs, and I would be happy to answer further. 

Ms. SCHOHN. Thank you. Yes. As part of our response to the 

Committee in November, we plan to develop a staffing model. The 

staffing model—— 

Chairman MURRAY. I am sorry. You plan to develop a staffing 

plan that is not yet in place? 

Ms. SCHOHN. No, no. We did develop a staffing model, but we 

submitted to you that that was part of our action plan in November. We developed a staffing model, and we are in the process of 

implementing it in VISNs 1, 4 and 22, to understand how to implement it. So we do not want to just simply say here is the number 

of staff without actually a plan for how this rolls out, issues the 

right number of staff, to really evaluate how well and how effective 

this methodology is. 

Our plan, however, also is not to wait until we get a full evaluation of this plan, but basically to staff up so that we will be fully 

ready to implement this plan throughout the country by the end of 

the fiscal year. So we will have—we are planning—the plan itself 

is based on identification of existing staff at facilities, the veteran 

population, the range of services offered, and the demand for services. And our plan is to be able to use this to project the need so 

that we will have a standard model in the future that is empirically validated, that we all know how many staff we need. 

Chairman MURRAY. My time is up. I do want to come back to 

this because it is critically important. But I will let Senator Brown 

and Senator Tester first speak. 

Senator BROWN. Thank you. 

So, Mr. Secretary, you announced last week that the VA will hire 

1,900 additional mental health staff, 1,600 mental health providers 

and then 300 support staff. Yet in response to a question for the 

record submitted by Senator Burr, a poll of your facilities in December 2011 revealed that there were 1,500 open mental health 

positions. 

So I guess my question is, are these 1,900 positions announced 

last week by the VA in addition to those already identified to Senator Burr as open? 

Mr. SCHOENHARD. Senator, the 1,900 additional positions are 

based on what we believe are the needed complement—— 

Senator BROWN. I know. But is it in addition to the 1,500? 

Mr. SCHOENHARD. It is in addition—these are additional positions, in addition to those that we are searching to recruit for, that 

are currently open. 

Senator BROWN. So is it 3,400 positions you are going to be 

filling? 

Mr. SCHOENHARD. No, sir. These are additional positions on top 

of what we are currently recruiting in terms—— 

Senator BROWN. You said in 2011, there are 1,500 open positions. 

And now you are saying you have 1,900—— 

Mr. SCHOENHARD. Fifteen hundred vacancies. And Dr. Schohn, 

you may want to comment to this. But I think it is important for 

this—— 

Senator BROWN. Who is in charge? Is it you or her, or what? 

54 

Mr. SCHOENHARD. Well, for the Committee, let me just clarify. 

These are not related to the number of vacancies. These are related 

to the number of positions that are needed in our facilities. And so 

we will be adding 1,900 positions, 1,600 in clerical and provider 

support, in addition to those that we are currently recruiting for. 

Senator BROWN. All right. So how long do you think it will take 

to fill these positions? 

Mr. SCHOENHARD. Well, it depends on the level of provider that 

we are searching for. But—— 

Senator BROWN. Give me an idea. Is it a week? Is it a month, 

a year? 

Mr. SCHOENHARD. It can take four or 5 months, sir. 

Senator BROWN. Four or 5 months. OK. And how do you determine the number of additional staff and which type of clinicians 

are actually needed? How do you make that determination? 

Mr. SCHOENHARD. We are allocating the FTEE to the VISN for 

its distribution to the facilities. We will be working with the facilities in the VISNs. Part of what we have not described here that 

is in place now is a robust system by which Dr. Schohn is working 

with the mental health leads in the VISNs. And with a new management information system that we have in place, we have greater visibility to VISN management of this open and going forward. 

Senator BROWN. So this is four to 5 months, then, still, that we 

are talking about? 

Mr. SCHOENHARD. Sir, we are planning by mid May to have identified where the specific positions go. 

Senator BROWN. But in the interim—— 

Mr. SCHOENHARD. But we want to do that in conjunction with 

the VISN leadership. 

Senator BROWN. Thank you. But in the interim, you have soldiers that are killing themselves and people who are hurting and 

need services. I know that the Uniform Mental Health Services 

Handbook also says that you can actually—on a fee basis, you can 

actually refer out people who need help. 

Mr. SCHOENHARD. Yes. 

Senator BROWN. So I am curious as to—you read about these 

things. And if there is such an overload and there is such a breakdown, why is only 2 percent per year of the total unique patient 

population in mental health sent out for non-VA care. Why is it 

only 2 percent, yet the handbook says that you should and could 

do it? 

Mr. SCHOENHARD. Yes. We do that where we can. Often where 

we have shortages, the community has shortages. 

Senator BROWN. Well, it seems like there are—I mean, based on 

what we have heard and the testimony we have been receiving, 

there is clearly a shortage. So in the interim, before you work and 

upload these 1,900 people, why don’t you get these people out the 

door and get them care and coverage right away? 

Mr. SCHOENHARD. Sir, first let me clarify, for those who need urgent care, we are emphatic that we ensure that those who are at 

risk are well treated. And it is referred to as suicide prevention coordinator for immediate treatment. 

Senator BROWN. Well, Jack Manning needed care and coverage, 

and he did not get it. And he killed himself. I mean, there are othVerDate Nov 24 2008 16:59 Aug 22, 2012 Jkt 000000 PO 00000 Frm 00058 Fmt 6633 Sfmt 6601 H:\ACTIVE\042512.TXT SVETS PsN: PAULIN
55 

ers like that. So what is the definition of critical care and immediate care? I mean, to me it means immediate, like the guy calls; 

he gets help right then and there. 

Mr. SCHOENHARD. Absolutely. Anyone who presents with any at 

risk factors should be seen and treated right away—— 

Senator BROWN. But they are not. 

Mr. SCHOENHARD [continuing]. Within the 24-hour triage. 

Senator BROWN. But they are not. 

Mr. SCHOENHARD. They should be. 

Senator BROWN. But they are not. 

Mr. SCHOENHARD. Well—— 

Senator BROWN. Is that right? They are not. 

Mr. SCHOENHARD [continuing]. We have an obligation to ensure 

that they are. 

Senator BROWN. But they are not. Correct? So if they are not— 

I mean, I know the answer. So you can certainly just say that, yes, 

they are not. We have had some people slip through the cracks. If 

that is the case, then, we need to actually outsource and use these 

resources that we have, these other folks that are out there, who 

want to try to help. 

We should be doing that. Do you agree or disagree? 

Mr. SCHOENHARD. Sir—— 

Senator BROWN. Sir, do you agree or disagree? 

Mr. SCHOENHARD. I think we should take them on in our system 

because we can best serve their urgent needs by—— 

Senator BROWN. Sir, with all due respect, that is not happening. 

OK? That is why we are here. That is why the IG report said that 

there is a breakdown with you meeting performance standards and 

actually not handling the individual needs of the individual soldiers who are killing themselves. So it is clearly not working. 

So my question is, do you think we should be sending out more 

people or not—yes or no—to the fee based—outside the VA system? 

Mr. SCHOENHARD. We should sent out where we do not have the 

capacity, but we should—for those who are most at risk that need 

urgent care, we should ensure that they receive treatment within 

the VA. 

Senator BROWN. But you are not. Correct? 

Mr. SCHOENHARD. Well—— 

Senator BROWN. I am not saying every time, but there are instances where there has been a problem. 

Is that a fair statement? 

Mr. SCHOENHARD. And where we do that, we need to ensure that 

we have—— 

Senator BROWN. Sir, listen. It is pretty simple. Are there instances in which we, the VA, collectively, everybody here, we have 

let somebody fall through the cracks. 

Yes or no? 

Mr. SCHOENHARD. There are instances where veterans—— 

Senator BROWN. OK. All right. We are not perfect. So in those 

instances, though, should we then be making sure that we do not 

do that again. And if there is a problem, that we refer them to the 

appropriate open agencies that can help right away. 

Is that a fair statement? 

Mr. SCHOENHARD. Yes, but—— 

56 

Senator BROWN. We are only doing 2 percent. Only 2 percent of 

those folks actually are referred out. And it is clear that there may 

be some sectors, some VA sectors, where there is a problem. Not 

everybody. And these are not for the people who are out there 

working their tails off each and every day. I get it. They are overloaded. They are overworked. If that is the case, let us refer them 

out and get them care and coverage. 

Mr. SCHOENHARD. Dr. Schohn or Dr. Zeiss may want to comment. 

Senator BROWN. I will. I will get to them. 

I just want to say, Nick, if you could just comment on the testimony you have heard, and comment on the fact that, based on your 

experiences in Manchester, do you see—or what do you think of the 

testimony from the Secretary, first of all? Number 1. 

Number 2, am I missing something? Is there an appropriate way 

to refer people out like that? And is it being done? And if it is not, 

why not, and should it be done? 

Mr. TOLENTINO. Senator, listening to the testimony so far, there 

are a couple of things I would like to comment on. One is the hiring 

practices, saying it is hard to recruit and fill these positions. 

There are barriers that are on the front lines that are not being 

heard at this level up here, such as when these special purpose 

funds come in, they are for X number of years—1 or 2 years, whatever it may be. And a lot of facilities, many facilities—not just 

Manchester—those positions were then being listed as not to exceed 2 years, or not to exceed 1 year, to be able to go along with 

the special funding, so that they did not have to worry about their 

budget in the future, and instead gave them the option to opt out. 

So if I am a psychiatrist or a mental health clinician, why, especially in this economy, am I going to leave a full time position to 

go to work for the VA if it is not even guaranteed that I am going 

to be there in 2 years, or that position is going to be there in 2 

years? That is the reality. That is just one of many examples that 

the front lines are encountering in trying to get people in there. 

Second, when you are talking about the fee service, it felt, where 

I was at—let me qualify that. It felt where I was at that the fee 

service was saying that our system was not adequate. So we are 

not going to send people out if we cannot deliver this care that we 

are so very proud of, that we offer. And when they were fee’d out, 

the problem that—in the Uniform Mental Health Handbook, it says 

that the VA is then responsible for ensuring the care management 

of those people out in the community. And that was not even evident either, because we did not have even the personnel to do that. 

Senator BROWN. Thanks for your answer. 

I also want to—— 

[Pause.] 

Senator BROWN. I will stay all day, Madam Chair. I mean, this 

is an important issue. 

I want to talk about the bonus program, to the fact that you have 

people who are getting salary, and then they are getting bonuses 

on performance. I would like to talk about that in the next round 

of questioning because I think it is important to note that if somebody is getting a salary to do their job, and they are just hitting 

57 

numbers to get a bonus, I find that a little bit surprising. So I 

would like to talk about that, and I will refer to the next round. 

Chairman MURRAY. OK. Absolutely. And we will have as many 

rounds as we need, I assure you. 

Senator Tester. 

STATEMENT OF HON. JON TESTER, 

U.S. SENATOR FROM MONTANA 

Senator TESTER. Thank you, Madam Chair, and thank you for 

holding this hearing. I want to thank everybody who has testified 

today. 

Just from a rural perspective, I will tell you that one of the reasons the VA cannot contract out in a rural State like Montana is 

because the private sector does not have any more mental health 

professionals than the VA has. And I just want to point that out 

because mental health professionals, whether it is in the private 

sector or in the VA, getting this to these folks is a big problem. 

I very much appreciate Mr. Tolentino’s—about nobody is going to 

go to work for a year or 2 years in the VA when in fact in the private sector, they have much more predictability in their jobs. And 

we need to take that into consideration when we start allocating 

dollars for the VA, to make sure that they have the advantage to 

be able to compete. I very much appreciate that perspective. 

Along those same lines, I just want to ask—Senator Brown was 

right in the area of 1,500 positions opened and an additional 1,900. 

So there are about 3,400 positions. They may not all be psychiatrists, and they may not all be clinicians. But how you are going 

to fill those in an area where the private sector is sucking folks up? 

Because it is a big issue there, too. And the VA—it is interesting 

to me. 

Do you have an allocation by a VISN of these 1,600 folks? Do 

you? 

Mr. SCHOENHARD. Yes, sir. 

Senator TESTER. Could we get a list of those? How they are they 

going to be allocated? 

Mr. SCHOENHARD. Yes, sir. 

Senator TESTER. I know you talked about metrics, number of veterans and that kind of stuff. Could you give me a list of metrics 

on why the numbers are there, how many are going to be psychiatrists, how many are going to be nurses, clinicians? 

Are any of them going to be psychologists? 

Mr. SCHOENHARD. Sir, we are leading to the VISN and in discussion with the facilities, it could be psychologists. It could be family—it could be a variety of different mental health providers. 

Senator TESTER. Thank you. And when it comes to contracting 

out, do you guys typically only use psychiatrists, or can you use 

psychologists, too? 

Mr. SCHOENHARD. No. We can contract with others. 

Senator TESTER. Oh, super. That is good, because there are some 

accessibility of those folks in a place like Montana. 

I want to put two things that Mr. Tolentino said along with 

Major General Jones. And, Major General Jones, I want to thank 

you for what you are doing. I very much appreciate it. 

58 

Mr. Tolentino said when he was there, it was clearly common if 

somebody came in with a problem, do not ask if there is another 

issue. There are all sorts of correlations here that are wrong. But 

I just want to tell you that—OK. So if that is done—and I believe 

he is probably right because that then became a problem. But if 

you combine that with what Major Jones said, that the folks that 

he is working with, the major stressor is unknown, we have a problem in our system here. Because the only way you are going to find 

out how to get to the real root of the problem when it comes to 

mental health—and I am not a mental health professional—is you 

have got to find out what that stressor is. You have got to find out 

what created that problem. 

Does that kind of—well, let me just ask you. If you had a VA professional in one of the CBOCs or at one of the hospitals tell their 

people do not ask any questions because we do not want to know, 

I am hoping the hell that does not come from your end. And why 

would do they do that? 

Mr. SCHOENHARD. Sir, if that is being done, that is totally unacceptable. And we will review the situation we had to review going 

on in Manchester. And we will continue to follow up any time that 

that occurs because—— 

Senator TESTER. I am going to tell you, I think you ought to do 

it in every VISN you have. That is just my opinion because that 

is totally unacceptable. We are not going to get our arms around 

this. You guys have been dealt this hand with multiple deployments. So the mental health issue is a big issue. And it is an issue 

that, quite honestly, if we do not get our arms around it, there are 

going to be more and more people who slip through the cracks, 

whether we want them to or not. That is the way it is. 

Our use in the private sector is important. Our partnerships we 

develop are important. Nobody wants to dismantle the VA, but 

when it comes to mental health issues, I think it is all hands on 

deck. I just think it is all hands on deck. 

Last, I just—and I have a bunch of questions here. They were 

written out. The metrics that are used—and I know the access to 

care metrics were the ones that one of you said—and it might have 

been you, Dr. Daigh, about those being flawed. 

I do not know if this is the same thing or not, but the report I 

read means that they were kind of jimmying the numbers to look 

like people were getting treatment in a timely manner when they 

were not. 

Dr. DAIGH. I think that the problem is that the schedulers were 

not consistently operating by a business rule that said you should 

schedule the appointment according to the date that was desired. 

And the desired date, what is the desired date? The desired date 

the patient wants, the doctor wants? 

So in the to and fro of scheduling, I think VA created metrics 

which are not supportable in a systematic way. Then you look at 

the dataset. It is not usable from my point of view. So I think that 

is, in large measure, part of the problem with the access measures 

across the system. 

We also hear reports of gaming and people trying to game the 

system. But I do not have evidence that I can give to you of gamVerDate Nov 24 2008 16:59 Aug 22, 2012 Jkt 000000 PO 00000 Frm 00062 Fmt 6633 Sfmt 6601 H:\ACTIVE\042512.TXT SVETS PsN: PAULIN
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ing, but I certainly can say that from the dataset, we do not think 

it accurately reflects access as it is in the VA. 

Senator TESTER. OK. Well, one last thing, and this will be the 

last one. There is a stigma in this country, and probably in the 

world, but definitely in America, the United States, attached to 

mental health issues, injuries. I have multiple stories about folks 

who will not go get treatment because they are afraid it will be on 

their record, afraid they will not be able to get a job, afraid it 

might impact the job they do have, perception by family, friends, 

colleagues. 

Does the VA have an active education program to try to reach 

out to those folks to let them know that this is part of—as Major 

General Jones says, it is increasing, it is present, and it is growing. 

And it is not uncommon, and it is OK. 

Is there some kind of educational outreach going on? 

Mr. SCHOENHARD. Yes, Senator. There is Make the Connection 

initiative that has just been undertaken. I think it gets back to the 

primary care integration of mental health, where we are able to 

screen for PTSD. 

The other aspect of care that we have not mentioned today is the 

Vet Centers, which are also ways in which veterans can approach 

for help, for whatever reasons they would be reluctant to access a 

traditional system. 

Senator TESTER. I agree. And before I go—and I want to thank 

the Chairman for the length—I just want to say thank you for all 

you do. Look, I put myself on the line for the VA every day because 

you guys have got a big job to do. But you have got to make sure 

that what is going on up here, things that the chairman says and 

other people on this Committee, that it actually gets to the ground, 

because we are hearing that things are not going so well in some 

areas. We are hearing things are going fine in others. And mental 

health is a huge challenge, and it is not easy. And please do make 

sure that it gets to the ground. 

If there is stuff like Mr. Tolentino said about temporary dollars, 

temporary money, hell, I would not take a job like that if I was in 

demand. So let’s figure out how to fix that, figure out how to make 

it work. And let’s figure out also—by the way, because we have 

Healing Waters in my State that does a great job, and there are 

some others. Let’s figure out how we can dovetail onto things like 

what Major Jones is doing because that can be an incredible paradox—I mean, you know, whether you are fishing or riding a horse, 

or whatever, I do not care. Those can be incredible programs to get 

people back on their feet. 

Thank you very much, Madam Chair. 

Chairman MURRAY. Thank you. 

Senator Moran? 

STATEMENT OF HON. JERRY MORAN, 

U.S. SENATOR FROM KANSAS 

Senator MORAN. Thank you, Chairman, Chairwoman. 

Secretary Schoenhard, I was pleased to hear the VA announce its 

plan to hire 1,900 mental health workers. And then I was additionally pleased with the announcement yesterday about the family 

60 

therapist and the licensed professional mental health counselors. 

My discouragement is how long it took for the VA to implement. 

I have a history with particularly those two professions, that in 

2006, Congress passed the Veterans Benefits Health Care and Information Technology Act. And part of that act was a piece of legislation that I introduced to encourage, authorize, and insist that you 

hire those two professionals within the VA. And now five and a 

half years later, it is occurring. 

So while I think I will stay on the positive note, I am discouraged 

by how long it took, but I am very pleased at this point in time 

to see that you moved in that direction. I encourage you to hire 

those people and put them to work as rapidly as possible. 

Part of my interest in this topic is coming from a State as rural 

as Kansas, in which our access to mental health professionals is 

perhaps even more limited than more urban and suburban States. 

And we need to take advantage of the wide array of professional 

services that are available at every opportunity. And so I am here 

to encourage you, now that you have made this announcement, let’s 

bring it to fruition. And thank you for reaching the conclusion and 

getting us to this point. 

I want to direct my question to General Jones. I thank you very 

much for your Semper Fi Odyssey efforts. I had a Kansan visit 

with me within the last month who has organized a program—I do 

not know that it is modeled after what you are doing, but the same 

kind of focus and effort. And it is somewhat related to the conversation or the questions of Senator Tester about kind of the stigma or lack of willingness to admit that one needs help; lack of perhaps knowledge about what programs are available; how to connect 

the veteran with what is there. 

I wanted to give you the opportunity to educate me and perhaps 

others on what it is that you have been able to do to bring that 

veteran, who is not likely to know the existence of your program 

or programs like yours. And second, what can be done to overcome 

the reluctance of military men and women and veterans to access 

what is available, such as your program. 

General JONES. Thank you, sir. Well, first off, I think that the 

Semper Fi Fund that I have been a board member of provides the 

ability for these veterans to come. Admittedly, most of the veterans 

that come back to their case workers of the Semper Fi Fund have 

some problems, or they would not be there, and they have had a 

difficult time making a transition. 

So when they arrive in Western Pennsylvania for one of the week 

long sessions, they arrive with a major degree of skepticism and 

very tentative. And we try to restore them to the strength of their 

experience in the Marine Corps, the team, the cohesion, team 

building, and basically restoring their trust. I would say trust in 

the system and trust in others. 

I think that my work through the Semper Fi Odyssey, because 

of the mental health professionals that have come in and really 

bought in to the program, and have really advertised the program 

and allowed me to speak to other groups, led to a project I am 

doing with the Institute of Defense Analysis, sponsored by OSD, 

that looks at best practices. 

61 

So for a long time, we never talked much about mental health 

issues until recently. As a Vietnam platoon commander, we never 

talked about it. But now there are programs in the Marine Corps, 

and I would say the Army, too, Comprehensive Soldiers Fitness, in 

the Army. The Marine Corps’ program is Operational Stress Control and Readiness. 

It is a great program, but it is not easy to overcome the stigma. 

And the program really rests on the strength of the NCO. No major 

general is going to ride into a link, or squad, or platoon, or company, and build immediate trust. It is going to come from the NCO. 

So overcoming that skepticism, overcoming that chasm of trust 

is difficult, but it is happening, especially those units that have 

deployed four and five times; young NCOs, young officers, who are 

seeing the power of what a squad leader or platoon commander can 

do to identify problems when they are still in the category of combat stress injuries and have not migrated to combat stress 

illnesses. 

I think that is the strength of the Marine Corps’ program. I 

think the problem with—mind you, this is only my opinion now— 

the Army program is that it is very well built. The application is 

not focused on the young NCO as is the Marine Corps’ program. 

I am not saying this because I am a Marine, but I just sense the 

NCO identifying in Iraq or Afghanistan if there is a problem. 

You can start the dialog right there. You can start the reconciliation process right there. You do not have to wait 6 months after 

he returns and he has got this problem in his metal wall locker he 

pulls out then, when he is by himself. 

So we try to restore, and very successfully restore, because all 

these veterans come in and actually volunteer their services. This 

past week, we did 35 Marines. We had an individual travel all the 

way from Oregon six times. His brother was killed in Vietnam as 

a company commander. He himself was a Marine Corps officer. He 

is a CEO of a very successful business, but he is giving up a week 

of his time. 

We had an orthopedic surgeon come in as a team leader from 

Wyoming. Well, it does not take a Phi Beta Kappa very long to tell 

that, hey, these people are giving themselves for me, so that chasm 

of trust is taken care of pretty quickly. I would say by Wednesday 

of a 7-day program, these people start realizing these people care 

about me. Then you are on the road to identification. That is when 

the demons start coming out. That is when you find out that a guy, 

when the company commander was killed, feels guilty—irrationally 

but true—and he has never shared that with a clinician. That is 

when you find out a guy has been behind curtains of his own apartment in Racine, Wisconsin, for 21⁄2 years, and the only person he 

has talked to is his clinician. He has never divulged to his clinician 

that he killed a Marine accidentally because their sectors aligned 

with each other. 

So I think we have no full-proof system, but I think the power 

of the Corps and the power of the Army clearly has team, clearly 

has cohesion, clearly has trust. And if you can restore that to what 

degree you can restore that, then you are on the road to a good 

program. 

62 

There is no shortage of people that come and chronicle their experience with a clinician. And they are not damning the clinician 

at all, but the clinician simply does not understand the individual 

adequately enough to build that bond of trust. 

Senator MORAN. General, thank you, for your service to our country and to the veterans. And thank you all for your interest and 

well being of our Nation’s service men and women. 

Thank you, Chairman. 

Chairman MURRAY. Thank you very much. 

Dr. Daigh, let me turn to you. As you well know, it is hard 

enough to get veterans into the VA system to receive mental health 

care. Once a veteran does take a step to reach out for help, we need 

to knock down every potential barrier to care. Clearly, the report 

your team produced shows a huge gap between the time that the 

VA says it takes to get veterans’ mental health care and the reality 

of how long it actually takes them to get seen at facilities across 

our country. 

Now, VA has concurred with all of your recommendations, but I 

think it is clear we all have some real concerns because some of 

these issues have been problems for years. So can you address a 

question of what you think it would take to get the VA to get this 

right this time? 

Dr. DAIGH. I think, to begin with, the veteran population is dispersed across the country, and the VA is not evenly dispersed 

across the country. So those veterans that go to fixed facilities to 

receive their care, the VA, I am guessing, probably is trying to address in this current plan for 1,600 people. I have not seen the details of the plan, so I do not know. 

So I think the first issue is to realize that you have a problem 

where you have facilities and where you do not have facilities. And 

I think the second problem is that, as has been stated here, there 

simply are not enough mental health providers to hire off the street 

in a timely fashion, I believe. 

I mean, we looked at the other day—I think there is something 

like 1,200 psychiatry graduates a year in this country, from our 

medical schools. So there is a limited pool, and there is a great deal 

of demand for mental health providers. In our discussions with private sector, they said that because of the downturn in the economy 

and other facts, that the non VA, non military demand had also 

gone up, in their experience, 10, 20 percent the last couple of years. 

We were asked several years ago to look at access to mental 

health care in Montana. And it was a very interesting review for 

me, in that Montana VA had linked up with the community mental 

health centers in Montana. 

I believe that—I may be out of date by a couple years since we 

did it a couple of years ago—but there was an organization of community mental health centers. And by allowing veterans to go to 

those mental health centers, which are usually staffed by psychologists and social workers and usually not by physicians, they were 

able to dramatically improve the access time to get folks to talk to 

competent people in their neighborhood, in their city, to get some 

care. 

63 

I think in order to make that care cohesive, as Mr. Tolentino 

said, you have got to be able to get medical records back and forth 

so that there is a coordination of care. 

So I think the all hands on deck idea is one that I wholly endorse 

and one where, if I look at some of the cases—tragic cases we have 

looked at in the past—it was not infrequent for veterans to show 

up at a community mental health center in their town. And because they were veterans, they were then sent to the VA, and there 

was not a link. They were not accepted, or there was no payment 

mechanism, or there was no authority. So I think that would be a 

useful step. 

Second, I think you really do have to sit down—and as bad as 

metrics are, I think you just do have to sit down and model what 

you are going to do, and figure out what demand is, and try to lay 

out a business case for what you are doing. 

Chairman MURRAY. Is that in place at the VA today? 

Dr. DAIGH. I do not believe that they have for mental health the 

level of business plan that I think they should have, nor do I think 

they have it for most medical specialties. 

Chairman MURRAY. Ms. Halliday, do you want to comment on 

that? 

Ms. HALLIDAY. No. However, I would like to say, though, to your 

original question, where you said what is needed to fix this, I really 

believe VA needs to focus on the data integrity of the information 

they are collecting, along with the new set of metrics. And I think 

they need to hold the medical facility directors accountable to ensure that data integrity. 

We have seen scheduling practices that resulted in gaming the 

system to make performance metrics look better at the end of the 

day, over the past 7 years, they need a culture change. To get that 

culture change, I think they really need to hold the facility directors accountable for how well the data is actually being captured. 

The auditors that actually did the work in the field at the sites 

for this review had general observations, that the focus was always 

on the outliers, who was not getting care outside of, say, the 14- 

day window, but there really was very limited focus on how well 

the schedulers were capturing that information. 

That is the information that starts to identify demand. It starts 

to tell you what type of services you are going to need and whether 

you need to address emergent care; or to strategically address care 

over the long term, you have to have reliable information. So coupled with I think a positive step to increase the staffing, that is 

clearly very important. 

Chairman MURRAY. OK. Thank you very much. 

Senator Brown? 

Senator BROWN. Thank you very much. 

So, Mr. Secretary, I want to get back to, obviously, the bonus 

issue. This year’s budget for 2012 is $5.9 billion; next year, 2013, 

$6.2 billion, an obvious increase. And the VA gave out in 2011 $194 

million to senior executive service employees. 

Do you think that is appropriate? 

Mr. SCHOENHARD. Well, sir, we have—at VA, under Secretary 

Shinseki’s leadership—run an extensive review of performance boVerDate Nov 24 2008 16:59 Aug 22, 2012 Jkt 000000 PO 00000 Frm 00067 Fmt 6633 Sfmt 6601 H:\ACTIVE\042512.TXT SVETS PsN: PAULIN
64 

nuses and have reduced those in both the number of outstanding 

ratings and the dollar amount that has actually been implemented. 

Senator BROWN. So the number was actually higher at one point 

than—— 

Mr. SCHOENHARD. It was, sir. 

Senator BROWN [continuing]. $100 million? 

Mr. SCHOENHARD. Yes. We have taken this very much to heart. 

So let me just offer that the integrity of our performance measures, 

and the integrity of our scheduling system, and the fidelity with 

which we implement these and adhere to them that are veteran 

centric is extremely important to the Department. So we take very 

seriously the comments that have been made by the IG, and we 

will be rigorously following up. 

We have been emphasizing the integrity of the system. And it is 

obvious that some of what we have put in, in my opinion, in performance measures, particularly as it relates to desired date, may 

get us into a discussion where it leads to this kind of confusion. Because what sometimes happens is that a scheduler will say I want 

to schedule you for when you want to next come in. And the veteran might say, ‘‘When are you next available? I will be happy to 

take whatever is there.’’ And that is a trick bag we need to get out 

of, by going back, in our view—— 

Senator BROWN. Sir, listen. I understand that. But my question 

is really focusing on bonuses now. I understand that there are 

holes and we need to fix them. The Chairwoman brought up that 

this has been an issue since the mid 2000s, 2005, 2008, whatever, 

and it is something you are going to continue to obviously work on. 

And I get that. It is not perfect. I understand that as well. 

But I am a little curious. What is the average salary for these 

people that are actually getting these bonuses? 

Mr. SCHOENHARD. Sir, can we take that for the record? 

Senator BROWN. Yes. I would like to—I am going to get you 

some—what is the salary? What are the bonuses based on? How do 

you justify $194 million of the tax dollars to go to pay for bonuses? 

This should be part of their job. I just want to make sure I understand it. And maybe if not, then I will stand corrected. 

Nick, what do you think about the opinion of tying these bonuses 

to quality rather than quantity? What do you think about that possibility? 

Mr. TOLENTINO. Senator, my opinion with the bonuses is that I 

think he already mentioned it. It is bonuses for doing your job. So 

if you are doing your job up to par, you are rewarded for that. And 

what I was always taught from my 14 years in the military is your 

bonus is your reward for going above and beyond. And clearly, I am 

not seeing that, in the treatment of veterans and the care that they 

need. 

So my opinion is, I truly do not agree. 

Senator BROWN. Do you think that money could be used somewhere better? 

Mr. TOLENTINO. Beg your pardon? 

Senator BROWN. Do you think that $194 million could be used 

somewhere better? 

Mr. TOLENTINO. I do. 

Senator BROWN. Thank you. 

65 

Mr. TOLENTINO. I do, Senator. 

Senator BROWN. First of all, thank you once again. I enjoyed the 

testimony from Senator Moran. 

Why do you think the veterans are reluctant to share their experiences with a clinician and that you are finding that during your 

situation in Semper Fi Odyssey and during that week, you have 

found that so many folks have actually opened up? Why do you 

think that—is it a trust issue? Is it just being in the military? Or 

what is it? 

General JONES. Yes, sir. It is clearly a trust issue. The issue— 

the combat—obviously, there is operational stress. There is—— 

Senator BROWN. Can I just add one thing to that? And what do 

you think the VA could do to establish that bond that apparently 

you have? 

General JONES. I think that the issue is a lot of—it is a trust 

issue, the lack of trust. And it is a fact that, quite honestly, many 

clinicians do not understand the nuances of combat stress. In fact, 

some of the tools that are being built now are much like a wreck 

on 95 in a traumatic event. 

Combat stress is very different. It is very personal. And it is 

something that people have a fear and then trust with somebody 

else to share those experiences. And the longer the person waits for 

the reconciliation process, the more difficult the problem may be. 

The answer to that, what I think they could do, is I think that 

we need to provide more opportunities, like we are doing at Semper 

Fi Odyssey, for some of these people in the mental health community. As mentioned before, I do not think that 1,900 more people, 

or 3,400 more people, are going to solve the problem unless you are 

hiring the person that really can, in fact, connect to the individual 

that will inspire him or her to share their perspective. 

Senator BROWN. Great. Thank you. Thank you all very much. 

Chairman MURRAY. Dr. Schohn, at this Committee’s November 

mental health hearing, you said you were not aware of any facilities that were gaming the system and not fully reporting waiting 

times. You heard Mr. Tolentino’s testimony about the Manchester 

VA regularly using loopholes to artificially meet their mental 

health performance measures, often at the direct expense of veteran care. 

So now that you have read the IG report and performed your 

own audit of mental health practices at various VA facilities, and 

you have listened to his testimony, I want to ask you the same 

question today that I asked you in November. 

Do you believe that VA facilities are gaming the system and now 

fully reporting wait times? 

Mr. SCHOENHARD. Senator, I would say that we have zero tolerance for that. We are going to continue our audits and reviews to 

ensure, with additional training of scheduling practices, that this 

is not occurring. This is certainly not a practice that can be 

condoned. 

Chairman MURRAY. Well, you heard Mr. Tolentino. He talked 

about the Manchester VA increasing their mental health workload 

numbers in order to get additional resources, despite not having 

enough staff to support that growth; the quantity over quality, I believe that you stated. And the result is veterans not getting the 

66 

care that they need. I am really shocked that the VA allowed providers to be put in that kind of dilemma, where they have to choose 

between following directions from the leadership and following the 

ethics of their profession. 

So let me ask you, what are you going to do to ensure that the 

quality of care is not being sacrificed as you continue to meet these 

timeliness standards? 

Mr. SCHOENHARD. I think it is a multifold approach going forward, that we are underway and have been implementing here. 

First, we need to ensure a staffing model that we will continue to 

perfect, that we have sufficient staffing on board to serve the veterans’ needs. We also need to look, as Dr. Daigh said earlier, at the 

productivity of that. And there is a productivity directive that is 

being developed to ensure that care is being rendered in a productive way. 

Second, we need to make sure that we have the measures in 

place to ensure that the veterans are receiving timely care in accordance with their condition. 

If I might just go back to an earlier discussion with Senator 

Brown. As we were discussing those veterans who are most critically at need, who are urgently in need of crisis, I feel so strongly 

that we should be sure to respond to those. But certainly in the 

case where we would not have, say, an inpatient psychiatric bed 

available, we would fee that out to the private community. And 

that is something that should happen in order to ensure the veteran is cared for. But it is fundamentally important that we get 

visibility for this. 

In the conversation with Senator Brown, what I was trying to 

emphasize is that we must have visibility, and we must respond to 

those who are most in crisis. And if that requires that we fee out 

because we do not have a bed available or something, we would do 

that. We do do that. But we would only do that after making sure 

we do not have the capacity because, candidly, part of the risk is 

the handoff to the private sector. And it is important we get visibility, we bring those veterans in, and we take care of them. 

Chairman MURRAY. Let me go back to the scheduling issue because that is a critically important piece of all this. Back in 2005 

and again in 2007, the IG released reports that highlighted problems with the patient scheduling, including the calculation of wait 

times, inconsistence practices by schedulers, all that. And despite 

having heard about this for 7 years now, here we are today. 

So why is it so difficult to address these problems, and should 

we be more optimistic it is going to happen this time? 

Mr. SCHOENHARD. Well, VHA has established needs, Madam 

Chairman, for scheduling, including a vision of a modern scheduling package that would, among other things, provide patients the 

ability to make their own appointments. 

Chairman MURRAY. And the implementation date? 

Mr. SCHOENHARD. We published an RFI in December 2001. We 

would like to take, for the record, when we will be implementing 

because we are underway in this new initiative. 

Chairman MURRAY. Dr. Daigh, do you believe that is going to 

happen? 

67 

Dr. DAIGH. I do not have enough information to comment, 

ma’am. I would have to check and see where they are with this. 

I would just say this has been an issue for a number of years, and 

it has not been solved. So I am not aware of the specifics of what 

they are talking about. 

Chairman MURRAY. OK. I have several other questions I am 

going to submit for the record. 

But I do want to say, I want to thank all of you for being here 

today and sharing your views. Critically, access to VA health care 

in a timely fashion is absolutely essential, especially as we have a 

growing number of men and women who are returning from the 

war, where this is a signature wound that we are very cognizant 

of, and we need to be prepared. And this Committee is focused on 

this, wants answers and follow up, and not just this to be another 

hearing, but wants real action taken. 

So, Mr. Schoenhard, I appreciate the VA stepping up to this 

today. I appreciate them accepting the IG report. I really appreciate the IG for all the work you did in a short amount of time. 

A large number of your resources were focused on this. 

Of course, to our other witnesses, thank you very much for being 

here today. 

I want to make it very clear: this is not something we are going 

to have a hearing on, and leave, and go do something else tomorrow. This has to be taken care of. We owe it to these men and 

women. I do not want to continue to hear that anybody is gaming 

the system. I want to know that the action plan is being put in 

place to make sure that the hiring you have announced is actually 

taking place. If there are barriers to that, we want to know about 

it. 

And I want to know how you decided which VISNs are going to 

get the practitioners that you plan to recruit. I want VA to know 

that this is not just another hearing here in Washington, DC. 

So this is very critical. I think we have made some progress, but, 

boy, do we have a lot of work ahead of us. And I think the Nation 

expects that of us. I intend to stand up to it, and I expect all of 

you to stand up to it as well. 

I do want to just take a second and congratulate Ms. Halliday 

on her recent promotion to Assistant Inspector General. We do look 

forward to working with you. 

With that, this hearing is adjourned. Thank you. 

[Whereupon, at 11:12 a.m., the Committee was adjourned.] 

(69) 

A P P E N D I X 

PREPARED STATEMENT OF CLAIRE HAAGA ALTMAN, EXECUTIVE VICE PRESIDENT/ 

CHIEF OPERATING OFFICER, HEALTHCARE CHAPLAINCY

Madam Chairwoman and Committee Members: Thank you for this opportunity to 

present the testimony of HealthCare Chaplaincy, Inc. My name is Claire H. Altman 

and I represent HealthCare Chaplaincy, a New York City based nonprofit organization founded in 1961, whose mission is to improve the effectiveness and efficiency 

of health care through the innovative ways chaplains promote and advance palliative care research, education, and practice. Fully understanding that the distress in 

a health care setting involves the mind, the body and the spirit, board-certified 

multi-faith chaplains serve as the spiritual care expert on medical teams. Our chaplains, employed in clinical settings alongside doctors, nurses and other health care 

professionals, work closely with patients and families, religious or otherwise, to help 

find comfort in difficult times. 

With minor exceptions, every veteran who enters the VA has seen active duty in 

military, naval or air service. During their tours, they have worked side by side with 

chaplains. Chaplains in a military setting provide care to the spirit to servicemembers of any faith or no faith. Chaplaincy is a well-established and trusted institution in the Armed Forces. When a servicemember wants to have a confidential 

conversation about crisis of meaning and purpose, he or she is often more comfortable approaching the chaplain who has been in the trenches with them, as opposed to the social worker or psychologist. Off the battlefield, this attitude carries 

into civilian life. Chaplains are an understood and trusted presence. 

Many veterans suffer from serious spiritual and mental distress; 22% of N.Y. Afghanistan and Iraq war veterans have probable diagnoses of Post Traumatic Stress 

Disorder (PTSD) and/or depression. It is difficult for them to discuss their issues 

with their families and friends, often exacerbating their distress and isolation. This 

distress can manifest itself in a number of ways—suicide, substance abuse, strained 

familial ties, difficulty finding or retaining a job, and the list goes on. As we are 

also seeing now, PTSD and/or depression are reemerging as older veterans confront 

age-related illness and loss. 

Unfortunately, many veterans fear utilizing the more standard support services 

due to a potential stigmatization and loss of confidentiality, as well as not wanting 

to be perceived as ‘‘weak.’’ However, veterans generally trust chaplains and speaking with them is not perceived as a sign of weakness. In addition, the confidential 

nature of the chaplain visit will not affect future deployment or career considerations. 

Another barrier to service delivery is that veterans and their families who are experiencing crises of meaning and purpose often go unrecognized in civilian hospitals 

where otherwise chaplains and other health care professionals would be available 

to help them. We know of no civilian hospitals that ask patients or their family 

about their affiliation with military service. 

HealthCare Chaplaincy recommends two actions: 1) include chaplaincy services in 

VA funded outposts/clinics to provide services that servicemembers know and trust; 

and 2) ensure that civilian hospital systems across the country include admissions 

questions asking if a patient is a veteran, has seen military combat or is a family 

member of a veteran. 

We applaud the work of this Committee and are encouraged that these hearings 

are taking place to shine a much needed light on the critical needs of our servicemembers. 

70 

PREPARED STATEMENT OF AMERICAN SOCIETY FOR THE ADVANCEMENT OF

PHARMACOTHERAPY


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