deep concerns of the the -- based on my experience as a va another minute straif officer as well as service on several va national work groups and a back ground in quality management that led to an mba degree. failure to provide immediate care ultimately led to my -- let me also acknowledge that va's recent announcements to add mental health workers to its workforce are problems you have had to uncover. but additional staff alone will not remedy the systemic problems in the va management of health care. i do not wish to discredit the va or its mental health staff, they 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 medical performance goals ahead of health care needs. it is too susceptible to gaming practices to make the facility look good. 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 was to immediate 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 best health care. it creates incentive to find loopholes that will allow the center to meet it's goals without offering the services. many factors including under staffing make it very difficult

to meet performance requirements, but administrators don't feel they can acknowledge that. instead as soon as new performance management books were published, va nlgt began to -- even with colleagues of mine across the country to find loopholes to gain requirements that couldn't be met. while i detailed multiple examples in my full statement. i would like to share two of them now. several performance measurings main date that mental health be seen during first -- demand for health care was great and staff limited. we got the order, focus only on the veterans' immediate problem, treat it quickly in that appointment, usually with medication and don't ask further questions about needs, because, and i quote, we don't want to know or we'll have to treat it. another directive requires that

a patient who's actively at risk for suicide or at high risk for suicide, should be seen at least once a week for four weeks. this is to ensure that the veteran is getting the health care needed to decrease the -- instead of providing these high risk patients individual therapy, manchester created a group for them, a group that was clinically inappropriate and veterans who refused to join the group were often labelled resistant to treatment. the idea that group therapy be substituted for menl health. the mental health committee promoted this idea as a so-called best practice. even though it was not clinical practice, it was a good way to meet performance measures, i i believe most va center -- va

lacks a methodology to know what health -- in a misguided attempt to justify more mental health staff at manchester, the head of our mental health service stated that the priority be quantity rather than quality. chief said and i quote, have contact with as many veterans as we can, even if we weren't able to help them. the outcome was that the facility continued to enroll a growing number of veterans, far more than our health clinicians could handle and as a result veterans fell through the cracks. every year at the -- office survey to assess facility compliance with the va's m to provide high quality services. many of our answers were changed to say that required services were being provided when they in fact weren't. 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 believe were unethical or violated va policy. those concerns largely fell on deaf ears. our staff also repeatedly brought concerns to our ethics kbhe, but they -- for me the final straw was the medical center's failure to take meaningful action upon discovery that a mental health physician was visibly intoxicated while providing mental health care to a vetd tran. i very much hope the va will make real changes to address the systemic problems i describe. i believe there are steps the va can take beyond adding staff. i humbly offer these suggestions. first the va should stop

monetarily rewarding -- they're not real measure -- the va should institute a much more extensive oversight as to exactly how the -- the funds actually go to the programs they are intended to supplement. finally i would urge this committee to implement and develop a very long overdue and periodically supported staff and health methodology. so there's no need to guess whether 1,900 more staff will be enough. i am happy to share my -- i would be very pleased to answer any questions you may have. thank you. >> thank you very much. major general jones. [ inaudible ] >> can you hear me now? >> move the mike up to you.

>> i'm thomas jones, i don't have any expertise in menl health, but i have a lot of experience dealing with those who have mental health issues. i have been visiting walter reed and 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 a special fund bring wives run by wives to deal with the families of the wounded. i also started, semper fi -- it started as a normal transition course, bethesda was grievously

wounded over several times the next several years. and in ---rj naturally started i -- patently obvious after a while that the mental health issues were really such that we got into the whole issue of z l dealing with mental health. because of my background, i was able to bring a lot of folks in from the outside, i noticed navy psychiatrist dr. bill nash, he was so moved by the experience that he had me be involved in a number of gathering of mental health professionals. from that i'm able to, becau st project looking at best practices on mental health. what we have done, we have run 30 sessions now, week-long sessions. chiefly used 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, work when you're dealing with veterans. 30 sessions, 35 or so on average attend each time, just had one last week. so we have dealt with over 1,000 not only veterans, but those soon to be discharged from the military. we work in con tsang -- so it gives us an index of what problems we're having in the military and precisely what we're having in the veteran community. and what we have found is that many if not most of the people who are undergoing clinics's care have not divulged even the

source of the stressor that's creating the problem. i don't think the numbers of additional mental health coordinators is soleably going to solve the problem, i think that the mental health coordinator has to have a better understanding of what the demands are of an individual awarded. one thing that we have learnedthrough our experience, which -- get a better per executive of what these individuals are facing through interaction with them so. i would encourage other folks here, even my panel members if they're so inclined to be involved. because i think the insights and the site picture it provides you is absolutely illuminating. what we have learned, i call them seeing outcoming. we can see the same things you get in a normal transition course, or we're getting break throughs where people are coming

forward and talking about demons that they had never talked about befo before. we built a trust that is lasting, not just 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, this is my opinion, but i think it's a pretty well founded opinion, that the numbers are going to be growing in the future. and i would think that we need experiences where folks that do deal with the setting of a clinician have a better understanding of what the issues are that they're dealing with. i'm very honored to be here, i thank you very much, i will answer any questions and i would certainly encourage any staff members of your staff to visit.

>> mr. schoenehart, first let me say that i'm very happy to say that the va is finally acknowledging there's a problem. when the department is saying there's near perfect compliance, but every other indication is 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 look at other areas of care for similar disconnects. what we have heard from the ig is very, very troubling. for months now we have been

questioning whether shall 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 are were not proactive about this promonacti about this months ago. >> mrs. chairman, we have been looking at this for many years, with the support of congress, we increased our capacity and hired about 800 new providers between 2007 and 2011. we relied primarily on a uniform mental health handbook which would be the way we would deliver care to our nation's veterans. that has been the focus of the department to ensure that we're getting evidence-based therapies

and a staffing model that is largely based on the handbook put out in 2009. i athink what we have learned i 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 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 assuring that we provide veteran centered performance measures. >> mr. schoenefelt with with all due respect, so my question is, how are you going to address that growing gapa we have seen,

what central office believes and what's actually happening in the field? >> as dr. day 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 centered on a veteran's 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 people on the front lines to assist us. we have the benefit of these mental health site visits that are assisting us, we're 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 solution, but to engage the field in a way that we need to in order to ensure we are veteran-centered and able to support our providers in delivering this care. >> i appreciate that. but it is very troubling to me that this didn't happen five, ten years ago, that we're just now, after months of this, years of this, that that disconnect is there. but we'll go back to that because i want to ask mr. tarantino and i really appreciate your coming forward today and i believe your testimony is going to be very helpful in 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. again how adept many of the facility administrators are at

getting around the current system without getting caught, how do you think the va ask most effectively perform that oversight? >> madam chairman, to be perfectly honest i don't have a good answer for you, because of the fact that the gaming is so prevalent. as soon as something is put out, it is torn apart to look to see what the work around is. i feel that the reports, the reporteding that is done is -- it's very redundant reporting, that it feels like it goes nowhere, there's no feedback loop, it's one way, we're telling you exactly what you in most times want to hear that we did. at the facilities and even at the network. but there's no coming back and rechecking or coming back and feedback to say, well, you said you spent this money on these services, but there's no workload to verify it.

there's nothing concrete to be able do speak to what you say you've done. i remember in the short time that i worked there, many times, we got fast amounts of financial moneys for different programs, but very, very seldomly did we ever get requests to verify what we have done with workload, with any kind of feedback reports or nick like that. so i think opening the lines of communication and developing a feedback loop would be very helpful and a very transparent feedback loop at that. >> my time's up, 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 health care providers and i appreciate that stechlt i think it's really needed. but i am concerned that va hospitals all across is country are going to 00 into the same hurdles that spokane va has been in not being able to hire a

health staff and i hope that medical centers are doing everything including using all available hiring incentives to fill those vacancies, and i'm sure that's 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 have announced become 1,600 new vacancies. >> madam chairman, that is a very good question. we have two task forces to assist us, one is the recruitment and retention of mental health providers. the second task force a hiring

task force, what can we do to expedite and having the prospect of recruitment as speedy as possible. the a number of good recommendations that we will be implementing. part of what dr. day 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 handoff for employment when they finish this. >> that's one issue. how you arrived at your staffing plan is really unclear to me. >> i'm sorry. >> the new 1600 mental health providers that you allocated. the information that we got from the department yesterday on where that was going to go isn't

supported by any concrete facts or evidence. in fact, yesterday the vision 20 director told us that she learned about the new positions only a couple days ago, didn't know if it was sufficient, and didn't know how the department even reached those numbers. i want to ask you, how did you arrive at that number, 1600, and how is it going to be effectively placed across the country? >> i'm sorry, i misunderstood the question, i'm going to ask mr. schoen to speak to this. we are piloting this in three visions and i would be happy to answer further. >> thank you. yes, as part of the response to the committee in november, we

planned to develop a staffing model. >> you plan to develop a staffing plan? it's not yet in place? >> no, we did. we submitted to you that was part of our actual plan in november. we developed the staffing model and we're in the process of implementing it in business one for 2022 to understand how to implement it. we don't went to say, here's the number of our staff without a plan for how this rolls out, is this the right number of staff to really evaluate how well and how effective this methodology ist is. our plan is not to wait to get a full evaluation of this plan, but to staff up so we'll be ready by the end of the fiscal year. the plan itself is based on

identification of existing staff at the facility, the veteran population. the plan is to use this to protect the need so we will have a standard model in the future that is imperically validated that we will all know how many staff we will need. >> my time is out. i want to come back to this, because it's critically important, but i will let others have their turn. >> you announced last week that the va will hire 1600 additional mental health staff, and 300 support staff. yet in response to a question for the record submitted by senator burr, a poll of your facilities in december, of 18 revealed that there were 1500 open mental health positions. i guess my question is, are these 1900 positions announced last week by the va in addition to those already identified to

senator burr as open? >> senator, the 1900 additional positions are based on what we believe are the needed compliment. >> i know, but is it in addition to the 15? >> it is in addition to those that we are searching to recr t recruit -- >> is it 3400 positions you will be fill something. >> no, these are additional -- >> you say you have 1900. >> 1500 vacancies. dr. schohn you may want to comment to this. >> who is in charge? is it her or what? >> for the committee, let me just clarify, these are not related to the number of vacancies, they're related to the number of positions that are needed in our facilities, and so

we will be adding 1900 positions, 1600 in clerical and provider support in addition to those that we are currently recruiting for. >> how long do you think it will take to fill these positions? >> it depends on the level of provider that we're searching for. but -- >> give me an idea, is it a week, a month, a year? >> it can take four or five months. >> and how do you determine the number of additional staff and which type of clinicians were actually needed? how do you make that determination? >> okay. we are allocating the fte to the visn for distribution to the facilities, we will be working with the facilities and the visns, part of what we had not described here that is in place now is a robust system in which

dr. scohn is working with the mental health leads in the visns. we have greater visibility to visn management of this opening going-forward. >> so this is four to five months then still? >> sir, we are planning by mid may to identify where the specific -- >> so in the earner um. >> we want to do that in conjunction with the visn leadership. >> in the interim you have soldiers killing themselves, and i know the handbook also says that you can actually -- on say fee basis, you can fully refer out people who need help. >> yes. >> i'm curious as to -- when you read about these things, if there's such an overload and such a breakdown, why is is it that only 2% per year of the total unique population were sent out for nonva care.

why is it only 2%, yet the handbook says you should and could do it? >> we do that where we can. often where we have shortages, the community has shortages. >> it seems like there are -- based on what we've heard and the testimony we've been receiving, that there is clearly a shortage. why don't you -- in the interim, before you work and upload these 1900 people, why don't you get these people out the door and get them care and coverage right away. >> sir, first, let me clarify, for those who need urgent care we are emfastic that we ensure that those who are at risk are well treated and are -- it's suicide pretension coordinator for immediate treatment. >> well, jackmaning needed care and coverage, and he didn't get, he killed himself. there are others like that, what's the definition of critical care and immediate care? i mean, to me immediate means,

the guy calls, he gets help right then and there. >> anyone who presents with any at-risk factors should be seen and treated right away. >> but they're not. >> within 24 hours -- >> but they're not. >> they should. >> but they're not. >> well, we -- >> is that right or not? >> we have an obligation to ensure that they are. >> but they're not, correct? if they're not -- i know the answer, so you can certainly just say, yes, they're not. we've had some people slip through the cracks. if that's the case, then, we need to outsource and use these resources that we have, these other folks who are out there who want to try to help. we should be doing that do you agree or disagree? >> sir, i -- >> do you agree or disagree? >> i think we should take them on in our system, because we can best serve their urgent needs by ensuring -- >> with all due respect, that's not happening, that's why we're here. that's why the i.g. report said there's a breakdown in meeting performance standards, and you're not handling the

individual needs of the individual soldiers who are killing themselves. it's clearly not working, my question is, do you think we should be sending out more people or not? yes or no, to these fee-based, outside the va system. >> we should send out where we do not have the capacity, but for those who are most at-risk, that need urgent care, we should ensure that they receive treatment within with the va. >> but you're not, correct? >> well -- >> because -- >> i'm not saying every time, but there are instance where's there's been a problem, is that a fair statement. >> where we do that, we need to ensure that we have -- >> sir, listen -- it's pretty simple. are there instances in which we've -- we, the va, checkedively, everybody here, we've let somebody fall through the cracks, yes or no? >> there are instances where swret rans -- >> all right,