Veterans Crisis Line: Further Efforts Needed to Improve Service
Published: 2017-04-04T00:00:00

Fast Facts:
The Department of Veterans Affairs started the Veterans Crisis Line to help support veterans in emotional crisis. From 2007 to 2015, call volume increased almost 700%. As VA tried to handle the volume, some veterans were dissatisfied with the service.
This statement for the record summarizes our 2016 report on VA oversight of the crisis line. Three of the 4 recommendations in that report have not been implemented. VA has not specified targets or timeframes for assessing its call center. Also, VA has not worked with its partners to identify or address why veterans reach the National Suicide Prevention Lifeline rather than the crisis line.

Highlights:
section_title: Why GAO Did This Study
paragraphs: VA established the VCL in July 2007 to provide support to veterans in emotional crisis. Between fiscal years 2008, its first full year of operation, and 2015, the number of calls received by the VCL increased almost 700 percent, exceeding VA's expectations. As VA began to address increasing numbers of requests for assistance, reports of dissatisfaction with VCL's service periodically appeared in the media.
This statement summarizes GAO's May 2016 report on VA's oversight of the VCL. Specifically, the statement describes (1) the extent to which VA met response-time goals for VCL calls and text messages, (2) how VA monitored VCL primary center call center operations, and (3) how VA worked with VCL service partners to help ensure veterans receive high-quality service. For the May 2016 report, GAO visited the VCL's primary center and two backup call centers; tested VCL response time through a generalizable sample of covert telephone calls and a nongeneralizable sample of text messages in July and August 2015; reviewed internal reports and policies and plans; and interviewed VA officials. GAO contacted VA and SAMHSA for an update on actions taken in response to the report's recommendations.
section_title: What GAO Found
paragraphs: In May 2016, GAO found that the Department of Veterans Affairs (VA) did not meet its call response-time goals for the Veterans Crisis Line (VCL), although extended call wait times were not common; issues with text messages were also found. VA's goal was to answer 90 percent of VCL calls at the VCL primary center within 30 seconds in the period GAO studied. Calls not answered within 30 seconds were to route to VCL backup call centers; however, for 5 months of fiscal year 2015, calls were routed to VCL backup call centers after 60 seconds. According to VA officials about 65 to 75 percent of VCL calls were answered at the VCL primary center in fiscal year 2015 within either 30 or 60 seconds. GAO's covert testing in July and August 2015 confirmed this. Specifically, 119 covert test calls showed that an estimated 73 percent of calls made during this period were answered within 30 seconds. GAO also covertly tested the VCL's text messaging services and found that 4 of 14 GAO test text messages did not receive responses. GAO recommended that VA regularly test the VCL's text messaging system to identify issues and correct them promptly. In response, VA developed and implemented procedures to regularly test the VCL's text messaging system, as well as its telephone and online chat systems.
In May 2016, GAO found that VA had taken a number of steps to improve its monitoring of the VCL primary center operations. For example, VA had established a permanent VCL call center evaluation team and created a mechanism for tracking complaints about the performance of the VCL primary center from VCL callers or external parties. However, GAO found that VA had not specified quantifiable or otherwise measurable targets and had not included dates for when it would expect the VCL to complete actions covered by each key performance indicator. This was inconsistent with guidance provided by the Office of Management and Budget. GAO recommended that VA document clearly stated and measurable targets and time frames for key performance indicators needed to assess VCL performance. Although VA agreed, as of March 2017, this recommendation remains open.
GAO also found that VA had established an interagency agreement with its service partner, the Department of Health and Human Services' (HHS) Substance Abuse and Mental Health Services Administration (SAMHSA), to manage the shared operations of the VCL and Lifeline (a public-private network that provides free and confidential support to people in suicidal crisis or emotional distress). Despite these efforts to coordinate, VA and SAMHSA did not collect information needed to assess how often and why callers intending to reach the VCL do not follow voice prompts and instead reach Lifeline local crisis centers. As a result, VA and SAMHSA did not know the extent to which this occurred and could not determine the underlying causes that may need to be addressed. GAO recommended that VA and SAMHSA (1) collect information on how often and why callers intending to reach the VCL instead reach Lifeline local crisis centers and (2) review the information collected and, if necessary, develop plans to address the underlying causes. Although VA and SAMHSA agreed, as of March 2017, these recommendations remain open.
section_title: What GAO Recommends
paragraphs: In its May 2016 report, GAO made four recommendations to VA and HHS to improve the VCL. VA and HHS concurred with the recommendations and while action has been taken on one, three remain open as of March 2017.

section_title: Letter
paragraphs: We are pleased to submit this statement on our May 2016 report  regarding the Department of Veterans Affairs’ (VA) Veterans Crisis Line  (VCL). Upon returning home from deployments in Afghanistan, Iraq,  Vietnam, and other locations, many servicemembers struggle with mental  health issues, including post-traumatic stress disorder, depression, and  substance abuse. Several of these mental health issues have been  identified as risk factors for suicide among veterans. As part of the  continuum of mental health services it provides, VA established the VCL  in July 2007.
The VCL supports veterans in emotional crisis and helps implement VA’s  goal of improving mental health outcomes for servicemembers, veterans,  and their families through a number of actions—including reducing  barriers to seeking mental health treatment and expanding access to VA  services. During the time of our review for the May 2016 report, the VCL  operated through a VA-operated primary center staffed with VA-employed  responders and five backup call centers that provided additional  responders and other services through a backup call coverage contract.  Veterans can access the VCL by calling a national toll-free number—1- 800-273-TALK (8255). The VCL and the National Suicide Prevention  Lifeline (Lifeline) share this national number through an interagency  agreement between the VA and the Substance Abuse and Mental Health  Services Administration (SAMHSA). In addition to responding to calls,  the VCL can also be accessed via online chat and text message.
Since it was established, demand for the VCL’s services has exceeded  VA’s expectations. The VCL received about 534,000 calls in fiscal year  2015, an almost 700 percent increase from the about 67,000 calls it  received in fiscal year 2008, its first full year of operation. In response, VA  steadily increased the VCL’s spending from about $3 million to $30 million  from fiscal year 2008 through fiscal year 2015, devoting additional staff  and resources to the VCL over time. As VA endeavored to address  increasing numbers of requests for assistance, reports of dissatisfaction  with VCL service periodically appeared in the media, and the VA Office of  Inspector General was asked to investigate complaints about the VCL’s  lack of timely response to callers. The Inspector General identified gaps  in the VCL quality-assurance process, including challenges associated  with supervisory review, tracking of issues, and collection and analysis of  data from VCL backup call centers. In addition, the Inspector General  found that in some cases callers did not receive immediate assistance  from responders.
Our statement discusses (1) the extent to which VA met response-time  goals for calls, online chats, and text messages received through the  VCL; (2) how VA monitored the performance of the VCL primary center  responders and call center operations; and (3) how VA worked with VCL  service partners—backup call centers and SAMHSA—to help ensure  veterans receive high-quality service from responders. This statement is  based on our May 2016 report on VA’s oversight of the VCL as well as  updates from VA and SAMHSA about efforts to address the report’s  recommendations.
For the May 2016 report, we made covert test telephone calls, text  messages, and online chats to assess the extent to which VA met its  response-time goals through the VCL. The test calls included a  generalizable sample of 119 calls that could be used to describe all  callers’ wait times when calling the VCL during July and August of 2015.  We also sent a nongeneralizable sample of 15 test online chats to the  VCL and 14 test text messages during the same time period. In addition,  we examined telephone call, online chat, and text message data and  summary reports from January 2013 through December 2015 that VA  maintained related to the timeliness of the VCL’s operations.
We reviewed VCL policies, procedures, and monitoring data and  interviewed VA officials. We also compared VA’s use of key performance  indicators to the Office of Management and Budget’s guidance on  performance goals, which are consistent with the Government  Performance and Results Modernization Act of 2010. We observed call  centers’ operations and interviewed officials and representatives of the  VCL primary center and two of the five VCL backup call centers to  examine the extent to which VA coordinates with the VCL’s service  partners in ensuring that veterans receive high-quality service from  responders. Further, we reviewed VA’s contract that provides backup call  coverage and VA’s interagency agreement with SAMHSA. We also made  34 covert calls in which we mimicked the experience of veterans who did  not follow the instructions of a voice prompt to press “1” to reach the VCL.  Finally, to examine the extent to which VA had plans to improve VCL  operations, we reviewed VA’s improvement plans and interviewed VA  officials responsible for planning and implementing those improvements.  More detailed information on our objectives, scope, and methodology for  this work can be found in our 2016 report.
We conducted the work on which this statement is based in accordance  with generally accepted government auditing standards. Those standards  require that we plan and perform the audit to obtain sufficient, appropriate  evidence to provide a reasonable basis for our findings and conclusions  based on our audit objectives. We believe that the evidence obtained  provides a reasonable basis for our findings and conclusions based on  our audit objectives. In addition, the related investigative work was  performed in accordance with the standards prescribed by the Council of  the Inspectors General on Integrity and Efficiency.
subsections: section_title: Background
paragraphs: In 2007, VA established the VCL, a 24-hour crisis line staffed by  responders trained to assist veterans in emotional crisis. Through an  interagency agreement, VA collaborated with SAMHSA to use a single,  national toll-free number for crisis calls that serves both Lifeline and the  VCL. Through this interagency agreement, VA and SAMHSA set up a  cooperative relationship between the agencies that would provide  consistent suicide-prevention techniques to callers.
The national toll-free number presents callers with choices. Callers are  greeted by a recorded message that explains the function of the crisis line  and prompts individuals to press “1” to reach the VCL. Callers who do not  press “1” by the end of the message are routed to one of Lifeline’s 164  local crisis centers. All callers who press “1” are routed first to the VCL  primary center. Calls that are not answered at the VCL primary center  within 30 seconds of the time that the caller presses “1” during the Lifeline  greeting are automatically routed to one of five VCL backup call centers.  If a call is not answered by the VCL backup call center that initially  receives it, the call may be sent to another VCL backup call center. VA  entered into a contract with a firm to oversee the operations of the VCL  backup call centers.
At the time of our 2016 report, there were a total of 164 Lifeline local crisis  centers, 5 of which also serve the VCL.
VA added online chat and text message capabilities to the VCL in fiscal  years 2009 and 2012, respectively. The number of online chats and text  messages handled by the VCL generally increased every year, though  the number of online chats decreased in fiscal year 2015.
section_title: Extended Call Wait Times Were Uncommon in July and August 2015, but VA Did Not Meet Its Call Response Time Goals and Some Text Messages Did Not Receive Responses
subsections: section_title: VA Responded to Most Calls within 30 Seconds in July and August 2015, but Did Not Meet Its Goal to Answer 90 Percent of Calls within 30 Seconds at the VCL Primary Center
paragraphs: In our covert testing of the VCL’s call response time in July and August  2015, we found that it was uncommon for VCL callers to wait an extended  period before reaching a responder since all of our calls that reached the  VCL were answered in less than 4 minutes. However, we also found VA  did not meet its goal of answering 90 percent of calls to the VCL within 30  seconds for test calls that we made. Our test calls included a  generalizable sample of 119 test calls that could be used to describe all  callers’ wait times when calling the VCL during this period. On the basis  of our test calls, we estimated that during July and August 2015 about 73  percent of all VCL calls were answered at the VCL primary center within  30 seconds. VA officials told us that, during fiscal year 2015, about 65 to  75 percent of VCL calls were answered at the VCL primary center and  about 25 to 35 percent of VCL calls were answered at the backup call  centers. These VA-reported results indicate that about 65 to 75 percent of  VCL calls were answered within either 30 or 60 seconds. These results  are consistent with our test results for July and August 2015.
During our 2016 review, VA officials told us that VA attempts to maximize  the percentage of calls answered at the VCL primary center because  these responders have additional resources—including access to  veterans’ VA electronic medical records—that are unavailable to VCL  backup call center responders. All responders—whether at primary or  backup centers—receive specialized training to assist callers in crisis.
section_title: To Help Achieve Response-Time Goals, VA Implemented Changes at the VCL Primary Center
paragraphs: To improve its performance toward meeting the goal of answering 90  percent of calls at the VCL primary center within 30 seconds, VA  implemented two changes in fiscal year 2015—namely, staggered work  shifts for responders and new call-handling procedures.
Staggered work shifts. VA implemented staggered shifts for responders  at the VCL primary center on September 6, 2015. Staggered shifts are  work schedules that allow employees to start and stop their shifts at  different times as a way to ensure better coverage during peak calling  periods. Specifically, it helps schedule more employees to work when call  volume is highest and fewer employees to work when call volume is  lowest. Additionally, staggered shifts help limit disruptions in service as  responders begin and end their shifts.
By comparing VCL telephone call data from September through  December of 2014 to that of September through December of 2015, we  found that VA’s implementation of staggered shifts at the VCL primary  center had mixed results. For example, the average percentage of calls  answered per hour at the VCL primary center from September through  December 2015—after staggered shifts were implemented—was 75  percent, slightly less than the average of 79 percent answered during the  corresponding period in 2014 before staggered shifts were implemented.  However, the VCL received an average of about 1.3 more calls per hour  during this period in 2015 than it received during the corresponding period  in 2014 and, according to VA officials, the VCL primary center employed  fewer responder staff in 2015 than 2014.
New call-handling procedures. VA implemented new call handling  procedures at the VCL primary center beginning in June 2015 that  provided responders with specific guidance to more efficiently handle  “noncore” callers—those callers who were not seeking crisis assistance  but rather seeking help with other issues, such as help with veterans’  benefits questions. For example, if a caller reached the VCL with a  question about VA disability benefits, the VCL primary center responder  would verify that the caller was not in crisis and transfer the caller to the  Veterans Benefits Administration to address the question.
VCL telephone call data provided by VA suggest that the average time  VCL primary center responders spent handling noncore calls decreased  by approximately 30 percent over a 5-month period after responder  training began on these new call-handling procedures. We would expect  that as the average time VCL primary center responders spent handling  noncore calls decreased, these responders would have more time  available to answer additional incoming calls.
section_title: In July and August 2015, Most of Our Test Online Chats Were Answered Within 30 Seconds, but VA Did Not Ensure That Veterans Received Responses through Its Text Messaging Service
paragraphs: To determine the timeliness of the VCL’s responses to online chats and  text messages, we conducted a covert test in July and August 2015 using  nongeneralizable samples of 15 online chats and 14 text messages. All  15 of our test online chats received responses within 60 seconds, 13 of  which were within 30 seconds. This result was consistent with VA data  that indicated VCL responders sent responses to over 99 percent of  online chat requests within 1 minute in fiscal years 2014 and 2015. During  our 2016 review, VA officials told us that all online chats are expected to  be answered immediately. Although this was an expectation, we found in  2016 that VA did not have formal performance standards for how quickly  responders should answer online chat requests and expected to develop  them before the end of fiscal year 2016.
However, our tests of text messages revealed a potential area of concern.  Four of our 14 test text messages did not receive a response from the  VCL. Of the remaining 10 test text messages, 8 received responses  within 2 minutes, and 2 received responses within 5 minutes.
As we reported in May 2016, VA officials stated that text messages are  expected to be answered immediately, but, as with online chats, VA had  not developed formal performance standards for how quickly responders  should answer text messages. VA data indicated that VCL responders  sent responses to 87 percent of text messages within 2 minutes of  initiation of the conversation in both fiscal years 2014 and 2015. During  our 2016 review, VA officials said that VA planned to establish  performance standards for answering text messages before the end of  fiscal year 2016. VA officials noted and we observed during a site visit  that some incoming texts were abusive in nature or were not related to a  crisis situation. According to VA officials, in these situations, if this is the  only text message waiting for a response, a VCL responder will send a  response immediately. However, if other text messages are awaiting  responses, VA will triage these text messages and reply to those with  indications of crisis first. This triage process may have contributed to the  number of our test texts that did not receive responses within 2 minutes.
The VCL’s text messaging service provider offered several reasons for  the possible nonresponses that we encountered in our test results. These  included: (1) incompatibilities between some devices used to send text  messages to the VCL and the software VA used to process the text  messages, (2) occasional software malfunctions that freeze the text  messaging interface at the VCL primary center, (3) inaudible audio  prompts used to alert VCL primary center responders of incoming text  messages, (4) attempts by people with bad intentions to disrupt the VCL’s  text messaging service by overloading the system with a large number of  texts, and (5) incompatibilities between the web browsers used by the  VCL primary center and the text messaging software.
At the time of our 2016 review, VA officials told us that they did not  monitor and test the timeliness and performance of the VCL text  messaging system, but rather relied solely on the VCL’s text messaging  service provider for such monitoring and testing. They said that the  provider had not reported any issues with this system. According to the  provider, no routine testing of the VCL’s text messaging system was  conducted. Standards for internal control in the federal government state  that ongoing monitoring should occur in the course of normal operations,  be performed continually, and be ingrained in the agency’s operations.  We concluded that without routinely testing its text messaging system, or  ensuring that its provider tests the system, VA cannot ensure that it is  identifying limitations with its text messaging service and resolving them  to provide consistent, reliable service to veterans.
We recommended that VA regularly test the VCL’s text messaging  system to identify issues and correct them promptly. In response, VA  developed and implemented procedures to regularly test the VCL’s text  messaging system, as well as its telephone and online chat systems. We  believe this change will allow VA to more reliably and quickly identify and  correct errors in the text messaging system and therefore help veterans  reach VCL responders in a timelier manner.
section_title: VA Had Taken Steps to Improve Its Monitoring of VCL Primary Center Performance but Had Not Established Targets and Time Frames for VCL Key Performance Indicators
subsections: section_title: VA Established a Call Center Evaluation Team, Implemented Revised Responder Performance Standards, and Analyzed VCL Caller Complaints
paragraphs: As we reported in May 2016, VA had sought to enhance its capabilities  for overseeing VCL primary center operations through a number of  activities—including establishing a call center evaluation team,  implementing revised performance standards for VCL primary center  responders, implementing silent monitoring of VCL primary center  responders, and analyzing VCL caller complaints.
Establishment of a call center evaluation team. In October 2013, VA  established a permanent VCL call center evaluation team that is  responsible for monitoring the performance of the VCL primary center.  As we reported in May 2016, the call center evaluation team analyzes  VCL data, including information on the number of calls received and the  number of calls routed to backup call centers from the primary center. VA  officials told us that they use these data to inform management decisions  about VCL operations.
Implementation of revised performance standards for VCL primary  center responders. In October 2015, VA implemented new performance  standards for all VCL primary center responders that will be used to  assess their performance in fiscal year 2016. According to VA officials, these performance standards include several measures of responder  performance—such as demonstrating crisis-intervention skills, identifying  callers’ needs, and addressing those needs in an appropriate manner  using VA approved resources.
Silent monitoring of VCL primary center responders. In February  2016, VA officials reported that they were beginning silent monitoring of  all VCL responders using recently developed standard operating  procedures, standard data collection forms, and standard feedback  protocols.
Analysis of VCL caller complaints. In October 2014, VA created a  mechanism for tracking complaints it receives from VCL callers and  external parties, such as members of Congress and veterans, about the  performance of the VCL primary and backup call centers. According to  VA officials, each complaint is investigated to validate its legitimacy and  determine the cause of any confirmed performance concerns. The results  and disposition of each complaint are documented in VA’s complaint  tracking database.
section_title: VCL Key Performance Indicators Lacked Measureable Targets and Time Frames
paragraphs: In 2011, VA established key performance indicators to evaluate VCL  primary center operations; however, in our May 2016 review, we found  these indicators did not have established measureable targets or time  frames for their completion.
VCL key performance indicators lacked measurable targets. We  found that VA’s list of VCL key performance indicators did not include  information on the targets the department had established to indicate their  successful achievement. For example, VA included a key performance  indicator for the percentage of calls answered by the VCL in this list but  did not include information on what results would indicate success for (1)  the VCL as a whole, (2) the VCL primary center, or (3) the VCL backup  call centers. As another example, VA had not established targets for the  percentage of calls abandoned by callers prior to speaking with VCL  responders. Measureable targets should include a clearly stated minimum  performance target and a clearly stated ideal performance target. These  targets should be quantifiable or otherwise measurable and indicate how  well or at what level an agency or one of its components aspires to  perform. Such measurable targets are important for ensuring that the  VCL call center evaluation team can effectively measure VCL  performance.
VCL key performance indicators lack time frames for their  completion. We found that VA’s list of VCL key performance indicators  did not include information on when the department expected the VCL to  complete or meet the action covered by each key performance indicator.  For example, for VA’s key performance indicator for the percentage of  calls answered by the VCL, the department had not included a date by  which it would expect the VCL to complete this action. As another  example, VA had not established dates by which it would meet targets yet  to be established for the percentage of calls abandoned by callers prior to  speaking with VCL responders. Time frames for action are a required  element of performance indicators and are important to ensure that  agencies can track their progress and prioritize goals.
Guidance provided by the Office of Management and Budget states that  performance goals—similar to VA’s key performance indicators for the  VCL—should include three elements: (1) a performance indicator, which  is how the agency will track progress; (2) a target; and (3) a period.  Without establishing targets and time frames for the successful  completion of its key performance indicators for the VCL, we concluded  that VA could not effectively track and publicly report progress or results  for its key performance indicators for accountability purposes.
We recommended that VA document clearly stated and measurable  targets and time frames for key performance indicators needed to assess  VCL performance. While VA officials have informed us that they have  created scorecards that track information related to calls answered,  staffing, and average handle times, as of March 2017, clearly stated and  measurable targets and time frames have not yet been developed.
section_title: VA Was Strengthening Requirements for VCL Backup Call Centers, but VA and SAMHSA Did Not Collect Information to Assess How Often and Why Callers Were Not Reaching the VCL
subsections: section_title: VA Was Enhancing Performance Requirements for Its Backup Call Coverage Contractor
paragraphs: As we reported in May 2016, VA’s backup call coverage contract,  awarded in October 2012 and in place at the time of our review, did not  include detailed performance requirements in several key areas for the  VCL backup call centers. Clear performance requirements for VCL  backup call centers are important for defining VA’s expectations of these  service partners. However, VA had taken steps to strengthen the  performance requirements of this contract by modifying it in March 2015  and was beginning the process of replacing it with a new contract.  According to VA officials, the new contract was awarded in April 2016.
October 2012 backup call coverage contract. This contract provided a  network of Lifeline local crisis centers that could serve as VCL backup call  centers managed by a contractor. This contractor was responsible for  overseeing and coordinating the services of VCL backup call centers that  answer overflow calls from the VCL primary center. This contract as  initially awarded included few details on the performance requirements for  VCL backup call centers. For example, the contract did not include any  information on the percentage of VCL calls routed to each VCL backup  call center that should be answered. Detailed performance requirements  on these key aspects of VCL backup call center performance are  necessary for VA to effectively oversee the performance of the contractor  and the VCL backup call centers. By not specifying performance  requirements for the contractor on these key performance issues, we  believe that VA missed the opportunity to validate contractor and VCL  backup call center performance and mitigate weaknesses in VCL call  response.
As we reported in May 2016, VA officials told us about several concerns  with the performance of the backup call centers operating under the  October 2012 contract based on their own observations and complaints  reported to the VCL. These concerns included the inconsistency and  incompleteness of VCL backup call centers’ responses to VCL callers,  limited or missing documentation from records of VCL calls answered by  VCL backup call center responders, limited information provided to VA  that could be used to track VCL backup call center performance, and the  use of voice answering systems or extended queues for VCL callers  reaching some VCL backup call centers. For example, VA officials  reported that some veterans did not receive complete suicide  assessments when their calls were answered at VCL backup call centers.  In addition, VA officials noted that they had observed some VCL backup  call centers failing to follow VCL procedures, such as not calling a veteran  who may be in crisis when a third-party caller requested that the  responder contact the veteran. According to VA officials, these issues led  to additional work for the VCL primary center, including staffing one to two  responders per shift to review the call records submitted to the VCL  primary center by backup call centers and to determine whether these  calls required additional follow-up from the VCL primary center. These  officials estimated that 25 to 30 percent of backup call center call records  warranted additional follow-up to the caller from a VCL primary center  responder, including approximately 5 percent of backup call center call  records that needed to be completely reworked by a VCL primary center  responder.
March 2015 backup call coverage contract modification. Given these  concerns, in March 2015, VA modified the October 2012 backup call  coverage contract to add more explicit performance requirements for its  backup call coverage contractor, which likely took effect more quickly  than if the department had waited for a new contract to be awarded.  These modified requirements included (1) the establishment of a 24- hours-a-day, 7-days-a-week contractor-staffed emergency support line  that VCL backup call centers could use to report problems, (2) a  prohibition on VCL backup call centers’ use of voice answering systems,  (3) a prohibition on VCL backup call centers placing VCL callers on hold  before a responder conducted a risk assessment, (4) documentation of  each VCL caller’s suicide risk assessment results, and (5) transmission of  records for all VCL calls to the VCL primary center within 30 minutes of  the call’s conclusion.
Development of new backup call coverage contract. In July 2015, VA  began the process of replacing its backup call coverage contract by  publishing a notice to solicit information from prospective contractors on  their capability to satisfy the draft contract terms for the new contract; this  new backup call coverage contract was awarded in April 2016. We  found that these new proposed contract terms included the same  performance requirement modifications that were made in March 2015,  as well as additional performance requirements and better data reporting  from the contractor that could be used to improve VA’s oversight of the  VCL backup call centers. Specifically, the proposed contract terms added  performance requirements to address VCL backup call center  performance—including a requirement for 90 percent of VCL calls  received by a VCL backup call center to be answered by a backup call  center responder within 30 seconds and 100 percent to be answered by a  backup call center responder within 2 minutes. In addition, the proposed  contract terms included numerous data reporting requirements that could  allow VA to routinely assess the performance of its VCL backup call  centers and identify patterns of noncompliance with the contract’s  performance requirements more efficiently and effectively than under the  prior contract. The proposed terms for the new contract also state that VA  will initially provide and approve all changes to training documentation  and supporting materials provided to VCL backup call centers in order to  promote the contractor’s ability to provide the same level of service that is  being provided by the VCL primary center.
section_title: VA and SAMHSA Did Not Collect Information Needed to Assess How Often and Why Callers Were Not Reaching the VCL
paragraphs: In May 2016, we found that when callers did not press “1” during the initial  Lifeline greeting, their calls may take longer to answer than if the caller  had pressed “1” and been routed to either the VCL primary center or a  VCL backup call center. As previously discussed, VA and SAMHSA  collaborated to link the toll-free numbers for both Lifeline and the VCL  through an interagency agreement. The greeting instructs callers to press  “1” to be connected to the VCL; if callers do not press “1,” they will be  routed to one of SAMHSA’s 164 Lifeline local crisis centers. To mimic the  experience of callers who did not press “1” to reach the VCL when  prompted, we made 34 covert nongeneralizable test calls to the national  toll-free number that connects callers to both Lifeline and the VCL during  August 2015 and we did not press “1” to be directed to the VCL. For 23  of these 34 calls, our call was answered in 30 seconds or less. For 11 of  these calls, we waited more than 30 seconds for a responder to answer— including 3 calls with wait times of 8, 9, and 18 minutes. Additionally, one  of our test calls did not go through, and during another test call we were  asked if we were safe and able to hold. VA’s policy prohibits VCL  responders from placing callers on hold prior to completing a suicide  assessment; Lifeline has its own policies and procedures.
According to officials and representatives from VA, SAMHSA, and the  VCL backup call centers, as well as our experience making test calls  where we did not press “1,” there are several reasons why a veteran may  not press “1” to be routed to the VCL, including an intentional desire to not connect with VA,  failure to recognize the prompt to press “1” to be directed to the VCL, waiting too long to respond to the prompt to press “1” to be directed to  calling from a rotary telephone that does not allow the caller to press  “1” when prompted.
As we found in May 2016, VA officials had not estimated the extent to  which veterans intending to reach the VCL did not press “1” during the  Lifeline greeting. These officials explained that their focus had been on  ensuring that veterans who did reach the VCL received appropriate  service from the VCL primary center and backup call centers. In addition,  SAMHSA officials said that they also did not collect this information.  These officials reported that SAMHSA did not require the collection of  demographic information, including veteran status, for a local crisis center  to participate in the Lifeline network. However, they noted that SAMHSA  could request through its grantee that administers the Lifeline network  that local crisis centers conduct a one-time collection of information to  help determine how often and why veterans reach Lifeline local crisis  centers. SAMHSA officials explained that they could work with the Lifeline  grantee to explore optimal ways of collecting this information that would  be (1) clinically appropriate, (2) a minimal burden to callers and Lifeline’s  local crisis centers, and (3) in compliance with the Office of Management  and Budget’s paperwork reduction and information collection policies. The  interagency agreement between VA and SAMHSA assigns SAMHSA  responsibilities for monitoring the use of the national toll-free number that  is used to direct callers to both the VCL and Lifeline. These  responsibilities include monitoring the use of the line, analyzing trends,  and providing recommendations about projected needs and technical  modifications needed to meet these projected needs. Using the  information collected from the Lifeline local crisis centers on how often  and why veterans reach Lifeline, as opposed to the VCL, VA and  SAMHSA officials could then assess whether the extent to which this  occurs merits further review and action.
Although the results of our test were not generalizable, substantial wait  times for a few of our covert calls suggested that some callers may  experience longer wait times to speak with a responder in the Lifeline  network than they would in the VCL’s network. We concluded that without  collecting information to examine how often and why veterans do not  press “1” when prompted to reach the VCL, VA and SAMHSA could not  determine the extent veterans reach the Lifeline network when intending  to reach the VCL and may experience longer wait times as a result. In  addition, limitations in information on how often and why this occurs did  not allow VA and SAMHSA to determine whether or not they should  collaborate on plans to address the underlying causes of veterans not  reaching the VCL. Standards for internal control in the federal  government state that information should be communicated both  internally and externally to enable the agency to carry out its  responsibilities. For external communications, management should  ensure there are adequate means of communicating with, and obtaining  information from, external stakeholders that may have a significant impact  on the agency achieving its goals.
We recommended VA and SAMHSA collaborate in taking the following  two actions: (1) collect information on how often and why callers intending  to reach the VCL instead reach Lifeline local crisis centers and (2) review  the information collected and, if necessary, develop plans to address the  underlying causes. We understand that VA and SAMHSA have been  coordinating on these issues. However, as of March 2017, both of these  recommendations remain open.
Chairman Roe, Ranking Member Walz, and Members of the Committee,  this concludes our statement for the record.
section_title: GAO Contact and Staff Acknowledgments
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