Statement of Melissa Bryant
Director of Intergovernmental Affairs of
Iraq and Afghanistan Veterans of America before the
House Veterans Affairs Committee
April 4, 2017
Chairman Roe, Ranking Member Walz, and Distinguished Members of the Committee:
On behalf of Iraq and Afghanistan Veterans of America (IAVA) and our more than 425,000 members, thank you for your time last week as IAVA introduced our She Who Borne the Battle Campaign. We look forward to working with you and your staff to fully recognize and improve services for women veterans. We also thank you for the opportunity to share our assessment of ongoing concerns with the Veterans Crisis Line (VCL) today. Mental health and suicide prevention remains one of the top concerns of our members, where an overwhelming 75% of respondents to our latest survey (to be published later this spring) still believe troops and veterans are not getting the care they need for mental health injuries.
I am here today not only as IAVA’s Director of Intergovernmental Affairs, but also as a former Army Captain and a combat veteran of Operation Iraqi Freedom. I was a military intelligence officer, a leader of men and women in combat, and I bore witness to the trauma and anguish several of my soldiers and friends endured when dealing with suicidal ideations or attempts. I bore the battle with these brave men and women, with two soldiers in particular–one male and one female– who were under my direct charge and I felt a special duty to protect and care for. And while I am eternally grateful these two soldiers were saved by mental health interventions, I mourn the loss of my sisters and brothers in arms who lost their battle and died by suicide. I am giving voice to all of us who served and the invisible wounds of war as I speak today.
In 2007, IAVA fought for and celebrated the passage of the Joshua Omvig Suicide Prevention Act, which among other things required the establishment of a hotline to provide information on and referrals to mental health services. This established the VCL. IAVA signed an Memorandum of Agreement with the VCL in 2012, and continues to partner with them today to both ensure our members are aware of the critical services the Crisis Line offers, as well as to provide crisis support to clients who are seeking support from IAVA’s Rapid Response Referral Program (RRRP). To date, our RRRP Veteran Transition Managers (VTMs) have referred nearly 200 clients to the VCL. These clients share both positive and negative stories of their experiences with the VCL. IAVA wants to get to a place where all of the feedback we get about the VCL is positive.
The Veterans Crisis Line provides a critical service to veterans and their loved ones. Since its inception, the crisis line has provided around the clock support to 2.8 million calls, engaged in 332,000 chats and answered 67,000 texts. IAVA recognizes the life-saving services the VCL offers every day. It is a vital resource for our community, and we are committed to ensuring that it continues to fulfill its mission to provide 24/7, world class suicide prevention and crisis intervention services to veterans, service members, and their family members.
Media reports covering the recent Department of Veterans Affairs Office of the Inspector General Report, Evaluation of the Veterans Health Administration Veterans Crisis Line focused on the finding that the Veterans Crisis Line could not handle call volume and had to rely on a backup call center to field these calls. The VA has addressed this specific piece in their press release and data that they’ve shared with the community. But they haven’t addressed the additional findings of the IG report that point to larger, more systemic issues. These findings point to institutional challenges with the VCL: its governance structure, operations, and quality assurance protocols. These are the deficiencies that still need to be addressed.
IAVA strongly urges the VA to reconsider its management structure of the Veterans Crisis Line. There must be a dual leadership structure in which an operations lead can oversee the functional aspects of the call line while a clinical lead oversees the clinical aspects. These roles must be complementary and cooperative to ensure the success and safety of the those both clients of the VCL and the responders who are answering their calls. Finally, the Office of Suicide Prevention must be heavily engaged with the operations, quality assessment, and oversight of the VCL.
IAVA already brought some of these concerns before the committee last year, particularly regarding the governance structure and quality control measures. In 2016, the VA moved the VCL from the directorship of the VA Suicide Prevention Office to VA Member Services. While VA Member Services oversees all of the call lines at VA, what makes the VCL different is it inherently requires a strong clinical component. We worried that the restructuring was discounting the clinical piece that is so critical to the success of the Crisis Line. Specifically, we raised the following questions:
- Understanding that there are existing quality standards in place at VCL, are these standards being enforced?
- Are they being met?
- Do these standards apply to contracted call centers, as well?
- Are the existing standards strict enough to ensure no call goes unanswered?
We recommended in 2016 the VA consider shifting management back to the Suicide Prevention Office, with consultation on operations from Member Services of another appropriate entity, to ensure appropriate operational management of the call line.
The IG report confirmed our concern that not enough is being done to manage quality across the VCL calls or more broadly, and define through data how the VCL accomplishes its mission. Some of our questions were answered in conversations with the VA. The VA shared with IAVA a quality management matrix that is being used to assess call quality. We feel this matrix does a decent job of setting baseline standards for each phone call, but does not go far enough to assess broader program effectiveness or implement a higher standard of clinical care for callers. The delay in implementing this in Atlanta is a real issue, but the VA assures us that delay has been remedied. We encourage the VA to share those data with the veteran community and Congress on a regular basis, as we all have skin in the game when it comes to ensuring the VCL is running efficiently and effectively. The IG report also highlights concern that the Atlanta call center was opened too quickly and the staff were ill prepared to handle the case load placed on them. IAVA agrees and hopes the VA will be transparent in sharing solutions to address these challenges. Finally, we understand that the VA continues to work to define expectation for the contracted call centers to ensure no call goes unanswered and to refine expectations for these centers, an absolutely critical aspect of this conversation.
IAVA implores the VA to also consider whether the level of clinical support provided to each call responder is appropriate, how the VCL is addressing self-care among responders, and what mechanisms are in place to prevent staff burnout and experienced responders from moving on. Appropriate and continued training is critical to ensure call quality, but training cannot be replaced with experience, and the VA must ensure that it has protocols in place to support its staff. Compassion fatigue is real. The employees answering the calls of veterans, service members, and families are dedicated and tireless advocates. We, and the VA, owe it to them to ensure they are being cared for and supported both emotionally and professionally. We strongly believe there is a robust way to silently monitor and review calls, both for quality management and clinical review, which would require an expansion of the current quality assurance protocol. Given the challenges the IG report highlights with training, particularly at the opening of the Atlanta call center, IAVA believes this is critical for both continued staff training and staff support.
We also believe that a strong clinical program will allow a ratio of one clinician to ten responders and will encourage weekly reviews of calls with rigorous review and critique of call responses. The current emphasis on business process and optimized workflow over individualized, clinical service to a veteran in crisis places already vulnerable veterans in peril. And applying a sterilized quality assurance protocol that could also be templated for determining a customer service rating for your home cable installer is woefully insufficient for our veterans.
While quality control is an important aspect of assessing the VCL, again, application of a larger program evaluation is critical. We would expect that the Veterans Crisis Line would fall under the purview of two bills championed by IAVA: the Clay Hunt SAV Act, which requires annual evaluation of VA’s mental health and suicide prevention program; and the Female Veterans Suicide Prevention Act, which goes a step further to require analysis of these programs by gender. IAVA’s She Who Borne the Battle Campaign is anchored in the fact that women veterans are the fastest growing veteran population, yet often go unrecognized. We don’t know how many women veterans use VCL, nor how effective VCL is at providing support for women, or even how they are welcomed by a responder that is answering their call. As part of our She Who Borne the Battle Campaign, we recognize that the motto of the VA functions as a symbolic barrier perceived by many women veterans like myself, emblematic of our lack of parity in care compared to our male counterparts; perhaps this culture is trickling down to the VCL, but a holistic program evaluation including gender-specific data should be conducted to know for certain.
We point to IAVA’s own best-in-class case management and referral program, the Rapid Response Referral Program, as a model. This high-tech, high-touch program provides one-on-one support, connecting veterans, service members and their families to a highly skilled and trained Veteran Transition Manager with a Masters in Social Work. We call it “RRRP/Rip” because it rips through the red tape and bureaucracy and meets the veteran where they are. It is supported without government funding–and functions solely thanks to generous private foundations like the Wonderful Foundation, The Annenberg Foundation, The Goldhirsh Foundation, the New York State Health Foundation, the Robin Hood Foundation, the May and Stanley Smith Charitable Trust, and the Schultz Family Foundation, among others–and by individual Americans nationwide who care. Since its inception in 2012, we have served over 7,800 clients, 20% of them women, connecting them quality resources and benefits. And many who have not be eligible for VA care due to their other-than-honorable discharge status. We have put a strong emphasis on client follow-up and customer satisfaction at RRRP. Programs like RRRP complement the VCL and are valuable partners by supporting veterans and their families who are not in immediate crisis, but are at risk if these types of services are not provided; support for these programs is critical. Often, veterans have seen bad news stories about VA, or had a bad experience, and come to us instead. And we often bring vets into VA that wouldn’t trust the VA alone. We’re often one of the best on-ramps for veterans into VA support.
RRRP’s VTMs engage in rigorous followup with clients prior to closing their case to ensure their needs have been met and referrals made are providing quality level of services and support. They also regularly follow-up with referral partners to ensure that they are connecting with RRRP clients and continuing to provide the standard of service that our program advertises. We believe the VCL could benefit from our model. To truly understand the impact of the VCL, the metrics must go beyond the number of calls or the number of emergency services dispatched. The VCL must conduct routine follow-up calls with clients and referral partners and regularly review VA data sources to ensure service delivery and better quantify the impact of the VCL.
I cannot emphasize enough on behalf of IAVA the gratitude that we have for those who staff the VCL call lines and are there to support the tens of thousands of calls received each year. In our 7th Annual Member Survey, nearly 20% of respondents had reached out to the VCL on their own behalf or on behalf of someone they loved. It continues to be a resource well known and highly recommended by IAVA members for mental health support. This is a critical, often life-saving resource for our community. 65% of respondents to our latest survey personally know a post-9/11 veteran who attempted suicide, while 58% of respondents to our survey personally know a veteran who died by suicide. And as one of those respondents to our survey who personally knows veterans who have either attempted or died by suicide, this issue is deeply personal to me, and one we must resolve swiftly.
It’s important to emphasize that these reports and conversations should not deter our community from reaching out, but rather reinvigorate Congress, the VA, the VSO community and private sector partners to work together to continue improving this critical program. I think this is best captured by a statement made by the VA OIG report in its opening pages, which highlights the inherent challenges facing the VCL and other programs like it, but also the critical benefit:
The VCL faces two major challenges. First is to meet the operational and business demands of responding to over 500,000 calls per year, along with thousands of electronic chats and text messages, and initiating rescue processes when indicated. Second is to train staff to respond to veterans and their family members in individual encounters… These complex and difficult challenges are not unique to the VCL as we observed other crisis hotlines that face similar issues. Although we made findings and recommendations concerning the VCL, we note an unwavering and impressive commitment by VCL staff who compassionately assist veterans in crisis.
Members of the Committee, thank you again for the opportunity to share IAVA’s assessment of the Veterans Crisis Line with you here today. We look forward to working with each of you and the VA in the months to continue to improve this essential resource. I look forward to answering any questions you may have.