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, we're not perfect. and in those instances, should we then be making sure that we don't do that again? if there is a problem, we refer them to the appropriate open agencies that can help right away, is that a fair statement? >> yes, but -- >> we're only doing 2%. only 2% of those folks are referred out, it's clear in may be some sectors, some va sectors where there is a problem, not hev. these aren't for the people who are working their tails off every day, they're overloaded, they're overworked. if that's the case, let's refer them out and get care and coverage. >> well, dr. scohn --

>> i'll get to them. if you can comment on the testimony you heard, and comment on the fact based on your experiences in manchester, what do you think of the testimony from the secretary first of all, number one, and number two, am i missing something? is there an appropriate way to refer people out like that? if it's not being done, should it be done? >> listening to the testimony so far, there's a couple things i'd like to comment on, one is the hiring practices, saying it's hard to recruit and fill these positions. there's barriers on the front lines that aren't being heard at this level up here, such as, when these special purpose funds come in, they're for x number of years, 1, 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 two years, or not to exceed one year. to be able to go along with the

special funding, so they didn't have to worry about their budget in the future. instead, gave them the option to opt out. if i'm a psychiatrist or 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's not guaranteed that i'm going to be there in two years or that position is going to be there in two years, that's the reality. that's just one of many examples that the front lines are encountering in trying to get people in there. secondly, when you talk about the fee service. it felt, where i was at -- i mean -- it felt where i was at, that the fee service was saying that our system was not adequate. we're not going to send people out if we can't deliver this care that we're so proud of. and when they were feed out, the problem it says in the uniform

mental health handbook, it says that the va is then responsible for ensuring the care management of the people in the community. and that wasn't even -- we had no personnel do that. >> thanks for that insight. i also want to -- i'll stay all day, madam chair, this is an important issue. i want to talk about the barness program too. you have people getting salary and bonuses on performance. i'd like to talk about that in the next round of questioning. if somebody's getting a salary to do their job and they're just hitting numbers to get a bonus, i find that a little bit surprising. so i'd like to talk about that, and i'll refer to the next round. >> we'll have as many rounds as we need, i assure you. >> thank you, madam chair. >> i want to thank everybody who's testified today.

i will tell you that one of the reasons the va can't contract out in a reural state of montan is because the public sector doesn't have any more mental health professionals than the va has. whether it's in the private sector or the va, getting these folks is a big problem, i appreciate mr. -- no one's going to go to work for a year or two years. we need to take that into consideration when we start allocating dollars for the va, to make sure they have the advantage to be able to compete. i appreciate that perspective. i want to ask, senator brown was right in the area of 1500 positions open, and an additional 1900, there is about 3400 positions. they may not all be psychiatrists or clinicians.

but how you're going to fill those in an area where the private sector is sucking folks up because this is a big issue there. the va is interesting to me. do you have an allocation by visn of these 1600 folks -- if you do -- could we get a list of those, how they're going to be allocated? i know you talked about metrics, number of veterans and that kind of stuff. could you list the metrics on why the number are there? how many are going to be psychiatrists, nurses, clinicians? are any of them going to be psychiatri psychiatrists? >> we are leading to the visn, it could be psychologists -- >> when it comes to contracting out, do you guys use psychiatrists or can you use psychologists too? >> no, we can contract with others. >> that's good, there are some

accessibility for those folks. i like montana, i want to put two things that mr. tolentino said along with major jones. i want to thank you for what you're doing, i appreciate it. mr. tolentino said when he was there, if someone came in with a problem, don't ask if there's another issue. there's all sorts of correlations here that are wrong. okay, if that's done, and i believe he's probably right, because then we have a problem. the major stressor is unknown with the folks you're working with. we have a problem in our system. the only way you're going to find out the root of the problem when it comes to mental health is you have to find out what that stressor is, you have to

find out what created that problem. does that kind of -- let me just ask it, if you had a va professional in one of the hospitals, tell their people that -- don't ask any questions, because we don't want to know, i'm hoping that doesn't come from your end. and why would they do that? >> if that is being done, that is unacceptable. we will review the situation we have going on in manchester and continue to follow up any time that occurs. >> i think you ought to do it in every visn you've got, that's just my opinion. it's totally unacceptable. we're not going to get our arms

around this. you guys have been dealt this with multiple deployments. it's an issue that we don't get our arms around it, there are going to be more and more people slip through the cracks, whether we want it to or not, that's the way it is. and i just -- our use of the public sector is important. no one wants to dismantle the va. it's all hands on deck. lastly, and i have a bunch of questions written out by -- the metrics that are use d, it may have been you, dr. dave about those being flawed. i don't know if this is the same

thing or not, but the report i read means they were kind of jimmying the numbers to make it look like people were getting treatment in a timely manner when they weren't? >> i think that the problem is, that the schedulers were inconsistently operating by business resume that said you should schedule the appointment according to the date that was desired. and the desired date. what is the desired date, the date the patient wants, the doctor wants? in the to and fro of scheduling, i think va created a metric, the rules for which are not supportable in a systematic way. you look at the data set, it's 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. i don't have evidence that i can give to you of gaming, but i can certainly say the data set, we don't think accurately reflects access as it is in the va. >> well, one last thing, and this will be the last one. there's a stigma in this country and probably in the world. definitely in america, the united states attached to mental health issues. i have multiple stories about folks who won't go get treatment because they're afraid it will be on their record, 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's increasing, it's present it's growing, and it's not uncommon, and it's okay. is there -- is there some kind of education or outreach going

on? >> yes, senator, there's a connection initiative that has just been undertaken. i think it gets back to the primary care integration of mental health, where we're able to screen for ptsd, and the other aspect of care that we haven't mentioned today is the vet centers who are also ways in which veterans can approach for health if they have for whatever reason to be reluctant to access the traditional system. >> i agree, and before i go on, 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 a big job to do, but have you to make sure that what's going on up here, what things that the chairman says and other people in this committee, that it actually gets

to the ground because we're hearing that things aren't going so well, in some areas. we're hearing things are going fine in others, and mental health is a huge challenge, and it's not easy, and please do make sure that it gets to the ground and if there's stuff like mr. torentino said about temporary dollars, i wouldn't take a job like that if i was in demand. let's figure out how to fix that. let's figure out what we can dove tail on to things like what major jones is doing, that can be an incredible -- it's -- you know, whether you're fishing or riding a horse or whatever, those can be incredible programs to get people back on their feet. thank you very much. >> thank you, chairman, chair woman. secretary schoenhart, i was pleased to hear the va announce they planned