STATEMENT OF
MICHAEL J. KUSSMAN, MD, MS, MACP
ACTING UNDER SECRETARY OF HEALTH
DEPARTMENT OF VETERANS AFFAIRS
BEFORE THE
HOUSE COMMITTEE ON APPROPRIATIONS
SUBCOMMITTEE ON MILITARY CONSTRUCTION, VETERANS' AFFAIRS AND RELATED AGENCIES

March 8, 2007

    Mr. Chairman and members of the subcommittee, I am pleased to be here today to discuss the ongoing steps that the Department of Veterans Affairs ( VA) is taking in order to meet the mental health care needs of our Nation's veterans. I am accompanied by Dr. Ira Katz, Deputy Chief Patient Care Services Officer for Mental Health, and Paul Kearns, VHA Chief Financial Officer. I would like to take this opportunity to describe a general overview of the mental health services provided by VA, explain what VA is doing to support mental health needs through its planning and budget processes, outline the services provided through our Vet Centers as well as our medical centers and clinics for our returning combat veterans, and outline our suicide prevention efforts.

Overview

     VA provides mental health services to veterans in all our patient care settings. General and psychogeriatric mental health services are being integrated into primary care clinics, VA nursing homes, and residential care facilities where many veterans receive mental health care. Veterans with a serious mental illness are seen in specialized programs, such as mental health intensive case management, day centers, work programs and psychosocial rehabilitation. VA employs full and part time psychiatrists and full and part time psychologists who work in collaboration with social workers, mental health nurses, counselors, rehabilitation specialists, and other clinicians to provide a full continuum of care for mental health services for veterans.

    We have seen that many returning veterans have injuries of the mind and spirit as well as the body. For veterans of prior eras, we have learned that mental disorders can increase the risk for certain physical illnesses, and vice versa. Our goal is to treat a veteran as a whole patient - to treat a patient's physical illnesses as well as any mental disorders he or she may also be facing.

Mental Health Strategic Plan and the Mental Health Initiative

    In 2004, the Veterans Health Administration ( VHA) developed its Comprehensive Mental Health Strategic Plan (MHSP). Our strategic plan includes multiple action items and reinforces that mental health is an important part of veterans' overall health. VA is committed to eliminating barriers separating mental health and the rest of health care.

    The Mental Health Initiative was established to provide funding to support the implementation of the MHSP outside of the Veterans Equitable Resource Allocation (VERA) model. To assist in planning the funding for the Mental Health Initiative, the MHSP was divided into four key areas-(1) enhancing capacity and access for mental health services; (2) integrating mental health and primary care; (3) transforming mental health specialty care to emphasize recovery and rehabilitation; and (4) implementation of evidence-based care. There are multiple funded programs in each of these areas. For example, we will be improving capacity and access by expanding mental health services in Community Based Outreach Clinics either with on-site staffing or by telemental health, as well as enhancing both Post Traumatic Stress Disorder ( PTSD) and substance abuse specialty care services. We will be fostering the integration of mental health and primary care by funding evidence-based programs in over 100 sites, and will be extending this principle to the care of older veterans by funding mental health positions in Home Based Primary Care. VA will be working to emphasize recovery and rehabilitation in specialty mental health services by funding additional psychosocial rehabilitation programs, expanding residential rehabilitation services, increasing the number of beds and the degree of coordination in homeless programs, extending Mental Health Intensive Case Management, and funding a recovery coordinator in each medical center.

The Mental Health Budget

    The anticipated spending for mental health services for FY 2007 is $2.80 billion and $2.96 billion for FY 2008. These amounts represent increases of $390 million and $545 million from actual spending of $2.42 billion in FY 2006 or an increase of 16 percent and 23 percent, respectively. These estimated increases are adequate to fund the Mental Health Initiative to implement the MHSP and to enhance and expand mental health services in the amount of $306 million in FY 2007 and $360 million in FY 2008. The estimated increases are also adequate to allow the regional networks to expand core mental health services where appropriate, and to address any gaps in mental health care.

     VHA is aware of concerns about spending of funds from the Mental Health Initiative in FY 2005 and FY 2006. To ensure that the available funds are utilized efficiently in FY 2007 and FY 2008, we have modified our processes to base them on a two-year planning period. We have staggered the implementation of many programs during the course of this year so that we are simultaneously preparing for the FY 2007 and FY 2008 initiatives. Because we recognize there may be some delays in hiring in certain geographic areas, we plan to closely monitor hiring, recover under-executed funds, and reinvest them in highly meritorious projects submitted by the Veteran Integrated Service Networks ( VISN) that would utilize non-recurring funds to enhance care and advance the Mental Health Strategic Plan.

Access To Mental Health Services Through Vet Centers

     VA's Vet Centers, located throughout the VA system, provide counseling and readjustment services to veterans. VA will be expanding the number of Vet Centers from 209 to 232 over the next two years. Some Vet Centers have established tele-health linkages with VA medical centers that extend VA mental health service delivery to remote areas to underserved veterans populations. Vet Centers also offer tele-health services to expand the reach to an even broader audience. Vet Centers are staffed by multidisciplinary teams that include psychologists, nurses, and social workers. Vet Centers address the psychological and social readjustment and rehabilitation process for veterans and support ongoing enhancements under the VA Mental Health Strategic Plan. Vet Centers provide an alternative to traditional access for mental health care some veterans may be reluctant to access in our medical centers and clinics.

    These Vet Centers provide the readjustment services to returning war veterans. It is now well established that rehabilitation for war-related PTSD and other military-related readjustment problems, along with the treatment of the physical wounds of war, is central to VA's continuum of health care programs specific to the needs of veterans. The Vet Center service mission goes beyond medical care in providing a holistic mix of services designed to treat the veteran as a whole person in his/her community setting.

    Vet Centers provided readjustment counseling services to over 228,000 all-era combat veterans in Fiscal Year 2006 and, of these, over 127,000 veterans were provided substantial face to face counseling services, and over 101,000 veterans were seen on outreach. The Vet Centers provide over one million visits to veterans in Fiscal Year 2006.

    The Vet Center program is the only VA program to address the veteran's full range of needs within family and community. The service functions provided to veterans by the Vet Center program are as follows:

• Community-based service units emphasizing post-war rehabilitation in an informal setting;
• Extensive community outreach activities;
• A varied mix of direct counseling and supportive social services addressing the holistic psycho-social needs of veterans in their post-war readjustment;
• Assessment for war-related readjustment problems to include PTSD in all cases;
• Assessment and treatment of military related sexual trauma; and
• Family counseling when needed for the readjustment of the veteran;

Since 2003, the Vet Centers also provide bereavement services to surviving family members of service men and women killed while serving on active duty. The Vet Center Strategy is to intervene early to facilitate a successful post-war readjustment in a safe and confidential setting. The bereavement program has seen over 1,200 family members of over 900 fallen warriors most of which were killed in action in Operation Iraqi Freedom/Operation Enduring Freedom.

    Care for Operation Iraqi Freedom and Operation Enduring Freedom ( OIF/ OEF) veterans is among the highest priorities in VA's mental health care system. For these veterans, VA has the opportunity to apply what has been learned through research and clinical experience about the diagnosis and treatment of mental health conditions to intervene early; and to work to prevent the chronic or persistent courses of illnesses that have occurred all too often in veterans of prior eras.

    Since the start of OIF/ OEF until the end of FY 2006, over 631,000 veterans have been discharged. Approximately 32.5% have sought care in VHA, and, of these, 35.7 percent have had a mental health condition or concern. This makes mental health second only to musculoskeletal conditions among the classes of conditions seen most frequently in these returning veterans.

    In response to the growing numbers of veterans returning from combat in OIF/ OEF, the Vet Centers initiated an aggressive outreach campaign to welcome home and educate returning service members at military demobilization and National Guard and Reserve sites. Through its community outreach and brokering efforts, the Vet Center program also provides many veterans the means of access to other VHA and Veterans Benefits Administration (VBA) programs. To augment this effort, the Vet Center program recruited and hired 100 OEF/ OIF veterans to provide the bulk of this outreach to their fellow veterans.

    Since the beginnings of hostilities in Afghanistan and Iraq, the Vet Centers have seen over 165,000 OIF/ OEF veterans, of which almost 116,000 were outreach contacts seen primarily at military demobilization and National Guard and Reserve sites. A similar outreach program conducted during the first Gulf War received the commendation of the President's Advisory Committee on Gulf War Veterans' Illnesses. In its final report of March 1997, the Committee cited the Vet Centers for providing exemplary outreach to contact and inform this veteran cohort about VA services. The utilization pattern for war veterans from other eras indicates that these veterans will require sustained services and will increase in numbers over time

Post Traumatic Stress Disorder

     VA's approach to PTSD is to promote early recognition of this condition for those who meet formal criteria for diagnosis and those with partial symptoms. The goal is to make evidence-based treatments available early to prevent chronicity and lasting impairment.

    Throughout VHA, there is a sense of urgency about reaching out to OIF/ OEF veterans, engaging them in care, screening them for mental health conditions, and making diagnoses when appropriate. Screening veterans for PTSD is a vital first step towards helping veterans become resilient and recover from the psychological wounds of war. Veterans are screened on a routine basis through contact in Primary Care Clinics. In instances when there is a positive screen, patients are further evaluated and referred to a mental health provider for further follow-up, as necessary. It can often be difficult to tell the difference between mild to moderate PTSD and normal reactions to highly abnormal situations. In fact, what is most striking about our service members and veterans is not their vulnerability, but their resilience. When people prefer treatment, we encourage it. When they are reluctant, we watch them over time, and urge treatment if symptoms persist or worsen.

Suicide Prevention

    Suicide prevention is a major priority for VHA and we are on the watch for suicide among our veterans. Research about suicides among OIF/ OEF returnees is currently under way to teach us more about how to address the issues surrounding this tragic event.

    We are presently implementing a comprehensive program based on the concept that prevention requires adequate capacity and ready access to a high quality mental health care system, as well as actions devoted specifically to prevention. VA's program is based upon education and training within the community as well as within VA facilities, the funding of a suicide prevention coordinator in each medical center, and the implementation of a national suicide prevention hotline to be completed by the end of FY 2007.

    I am pleased to announce that we set aside our first Suicide Prevention Awareness Day, which fell on March 1, 2007 this year. We plan on this becoming an annual event. During our first Suicide Prevention Awareness Day, VA staff members who come in contact with patients received training on how to assess and respond to crisis situations. Our goal is to make the point that in VA, suicide prevention is everyone's business-not just that of our mental health providers-everyone who comes into contact with our veterans and their families plays an important role.

Conclusion

    Thank you again Mr. Chairman for having me here today. I will answer any questions that you or other members may have.