on. one is first we have a working group that will report their summer on a new set of performance measures that includes providers on the ground assisting us with insuring that we develop measures in conjunction with support from the ig that are really veteran centered that are centered on the veteran's individual condition and one in which we can revamp and go forward. we fully embrace that our performance measures, measurement system needs to be revised and we will be doing that with the work of people on the frontlines 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 we're 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 mr. tolentino, and i really appreciate your willingness to come forward today and i believe your testimony is going to be very helpful to addressing many of the changes that are needed in a timely fashion. of in your testimony, you suggested that va institute more extensive oversight into how mental health care is actually delivered and funds are spent. given how adept many of the facility administrators are at getting around the current system without being caught, how do you think the va can most effectively perform that oversight? >> madame chairman, to be perfectly honest, i don't have a

very good answer for you because of the fact that the gaming is so prevalent. as soon as something is put out, it is torn part to look to see what the work around is. i feel that the reports, the reporting that is done is -- it's very redundant reporting that feels like it goes nowhere. there is no feed back loop. it's one way we're telling you exactly what you want 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 in 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 to be speak to what you said you've done. i remember in the short time that i worked there, many times we got vast amounts of financial

monies for different programs. but very, very seldom little did we ever get requests to verify what we've done with workload, with any kind of feedback reports or anything 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. >> mr. shown hard, i nim's up. i do want to address a very important issue here. the department has announced 1600 new mental health care providers and i appreciate that step. i think it's really needed. but i am concerned that va hospitals all across the country are going to run into the same hurdles that spokane va has been in not being able to hire a health staff. i hope that medical centers are doing everything including using all available hiring incentives to fill those vacancies. i assure you that is 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 will 1600 new mental health care providers that you announced don't become 1600 new vacancies? >> chairman murray, that's a very important question. and we have stood up in our human resources group and vha workforce two task forces to assist us with this. one is the recruitment and retention of mental health providers with particular focus on accessory. that's where our greatest need and problem is in retaining and recruiting mental health providers. the second task force is a hiring task force. that is, what can we be doing to expedite and make sure that we are having the process of recruitment as speedy as possible. the group has put together a number of good recommendations

that we will be implementing. part of what dr. d aig h spoesk 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. >> okay, that's one issue but then 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 20i6r director told senator begich and

i 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. so i want to ask you, how did you arrive at that number of 1600 and what makes you confident that it's going to be effective lili placed across the country? what is the staffing plan you used to do that? >> i'm sorry, i misunderstood the question. i'm going to ask dr. schohn who may want to embellish on this. but we used a model that looks at the volume of services and i wonder if dr. schohn might speak to this. we ref piloting this and i would be happy to answer further. >> thank you. yes, as part of our response to the committee in november, we planned to develop a staffing model. the staffing model -- >> i'm sorry, you planned to develop a staffing plan, it's not yet in place. >> no, no, we did develop the staffing model but we submitted

to you that that was part of our action plan in november. we developed the staffing model and we're in the process of implementing it in 14 and 22 to understand how to you interpret so we don't want to just simply say here's a number of staff without actually a plan for how this rolled out, is this right number of staff to really evaluate how well and how effective this method ol is. our plan, however, also is not to wait until we get a full evaluation of this plan but basically to staff up so that we'll be fully ready to implement this plan throughout the country by the end of the fiscal year. so we will have -- we are planning -- the plan itself is based on identification of existing staff at facilities, the veteran population, the range of services offered and the demand for services. our plan is to be able to use this to project the feed so that

we will have a standard pod del in the future that is empirically validated that we will all know how many staff we need into my time is up. i do want to come back to this because it's critically important but i will let senator brown and senator chester. >> thank you. so secretary, so you announced last week that the va will hire 1900 additional mental health staff, 1600 mental health providers and then 300 support staff. yet in response to a question for the record submitted by senator byrd, a poll of your facilities in december of 11 revealed that there were 1500 open mental health positions so 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 complement. >> i know but is it in addition to the 1500? >> it is in addition. these are additional positions in addition to those that we are searching to recruit for that are currently open. >> 3400 positions you're going to be filling? >> no, no, sir. these are additional positions on top of what we are currently recruiting in terms -- >> you said there were 1500 open positions and now you're saying you have 1900. >> 1500 vacancies and dr. schohn, you may want to comment to this, but i think it's important. >> who's in charge, you or her or what? >> well, for the committee, let me just clarify. these are not related to the number of vacancies. these are 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. >> so how long do you think it will take to fill these positions? >> well, it depends on the level of provider that we're searching for. but -- >> give me an idea. is it a week, is it a month, a year? >> it can take four or five months. >> okay. so how do you determine the number of additional staff and which type of clinicians were actually needed? how do you make that determination? >> we are allocating the ftee to the vizzen for its distribution to the facilities. we will be working with the facilities and the vizzens. part of what we have not described here that is in place now is a robust system by which dr. schohn is working with the bizzen mental held leads in the vizzens and with a new management information system that we have in place, we have

greater visibility to vizzen management of this opening going forward. >> so this is four to five months still are we talking about? >> well, sir, we are planning by mid-may to identify where the specifics go but want to do that in conjunction with the vizzen leadership. >> in the interim, you have soldiers that are killing themselves and people who are hurting and need services. and i know that the uniform mental health services handbook also says that you can actually on a fee basis you can actually refer out people who need help. >> yes. >> so i'm curious as to when you read about these things if there's such an overload and such a breakdown, why is it then only 2% per year of the total unique patient population in mental health send out for nonva care? why is it only 2%, yet the handbook says that you should and could do it. >> yes, we do that where we can.

often where we have shortages, the community has short ands. >> well, it seems like there are, based on what we've heard and the testimony we've been receiving that there is clearly a shortage. so 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 coverages right away? >> well, sir, first let me clarify for those who need urgent care, we are emphatic that we ensure that those are at risk are well treated and are suicide referred to a suicide prevention coordinator for immediate treatment. >> well, jack manning needed care and coverages and he didn't get any and he killed himself. there are others like that. what's the definition of critical care and immediate care. >> to me it means immediate, the guy calls and gets help right then and there. >> absolutely. anyone who brents any at risk factors should be seen and treated right away. >> but they're not.

>> with 24 hourtory and. >> they should be. >> but they're not. is that right in the. >> we very an obligation to ensure that they are. >> but they're not, correcting? so 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, we need to actually outsource and use these resources that we have, these other folks that are out there who want to try to help. we should be doing that. do you agree or disagree? >> sir. >> 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 -- >> sir with all due respect, that's not happening. that's why we're here. that's why the ig report said that there's a breakdown that you're meeting performance standards and actually not handling the individual needs of the individual soldiers who are killing themselves. so it's clearly not working. so my question is, do you think we should be sending out more people or not? yes or no, to these the

fee-based of outside the va system? >> we should send out where we do not have the capacity, but we should for those who are most at risk that can need urgent care, we should ensure that they receive treatment within the va. >> but you're not, correct? >> well. >> i'm not saying every time but there are instances where there's been a problem. is that a fair statement? >> and where we do that, we need to ensure that we have -- >> sir, listen, it's pretty simple. are there instances in which we, the va collectively everybody here we've let somebody fall through the cracks? yes or no. >> there are instances where veterans. >> we're not perfect, okay. in those instances should we then be making sure that we don't doe that again and if there is a problem that we refer them to the appropriate open agencies that can help right

away. is that a fair statement? >> yes, but -- >> but area only doing 2% of those folks actually are referred out. it's clear there may be some va sectors where there is a problem, not everybody and these for the people out there working their tails off each and every day. i get it. they're overworked. if that's the case, let's refer them out and get them coverages. >> dr. antonette zeiss and dr. schohn may want to comment on this. >> nick, if you will could just comment on the testimony you've heard and comment on the fact that based on your experiences in manchester, do you see -- what do you think of the testimony from the secretary first of all? number one, and number two, am i missing something? ing issing there an appropriate way toe refer people out like that? and is it being done and if it isn't, why not and should it be done? >> senator, 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 frontlines that aren't being heard at this l up here such as when these special purpose funds come in, therefore x number of years, one, two years whatever it may be. and a lot of facilities, many facilities not just manchester, those positions were then being listed as not too exceed two years or not to exceed one year. to be able to be go along with the special funding. so that they didn't have to worry about their budget in the future and instead, gave them the option to opt out. so if i'm a psychiatrist or a 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 even 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 frontlines are encountering in trying to get people in there. and secondly, when you're talking about the fee service,

tissue felt in where i was at, let me qualify that, it felt where i was at that the fee service was saying that our system was not adequate. so we're not going to send people out if we can't deliver this care that we're so very proud of that we offer. and then when they were feed out, the problem that says is in the uniform mental health handbook it says that the va is then responsible for ensuring the care management of those people out in the community. and that wasn't even evident either because we didn't even have the personnel to do that. >> thanks for that insight. i also want to -- so i'll stay all day, madame chair. this is an important issue. so i want to talk about the bonus program too, the fact that

you have people getting salary and bonuses on performance. i'd like to talk about that in the next round of questioning because i think it's important to note if somebody's getting a i salary to do their job and 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. >> absolutely. we'll have as many rounds as we need i assure you. senator chester. >> thank you. i want to thank everybody who's testified today just from a rural perspective, one of the reasons the va can't contract out in a rural state like montana is because the private sector doesn't have any more mental health professionals than the va has. pchb i want to point out that, it's professionals whether in the private sector or va getting these folks is a big problem. i very much appreciate mr mr. tolentino's be nobody's going to go to work for a year or two years in the va when in the private sector they have much more predictability in their jobs. we need to take that into

consideration when we start allocating dollars for the va to make sure that them have the advantage to be able to compete and i very much appreciate that perspective. along those same lines, i just want to ask, senator brown was right in the area of 1500 positions open and an additional 1900 so there is about 3400 positions. they might not all be psychiatrists. they might not all be clinicians but how you're going to fill thoses in an area where the private sector is sucking folks up because this is a big issue there too and the va is of interesting to me, do you have an allocation by vizzen of she was 1600 folks? and if you do, do you? >> could we get a list of those? >> yes, sir. >> how they're going to be allocated? i know you talked about metrics, number of veterans and that kind of stuff. could you give me list the metrics on why the number are there. how many are going to be psychiatrists, how many are

going to be nurses, clinicians. are any of them going to be skolss? >> sir, we are leaving to the vizzen and in discussion with the facilities it could be psychologists, they could be family -- they could be a variety of different mental health providers. >> when it comes to contracting out, do you guys typically only use psychiatrists or can you use skolss too? >> no, we can contract with others. >> super. that's good because there are some accessibility of those folks in a place. i like montana. i want tonight put 2000 things that mr. toe lentino said along winning major general jones. i want to thank you for what you're doing. i very much appreciate it march general jones. mr. toe lentino said when he was there, he said it was fairly common if somebody came in with a problem, don't ask if there's another issue. there's all sorts of correlations here that are wrong but i just want to tell you that

okay, so if that's done and i believe he's probably right because that then we can have a problem but if you combine that with what major jones said that the folks that he's working with, the major stressor is unknown, we've got a problem in our system here because the only way you're going to find out how to get to the real root of the problem when it comes to mental health and i'm not a mental health professional, is you've got to find out what that stressor is, find out what created that problem. does that kind of -- let me just ask you. if you had a va professional in one of the of see boks or in one of the hospitals tell their people that don't ask any questions because we don't want to know, i'm hoping to hell that doesn't come from your end. and why would they do that? >> sir, if that is being done, that is totally unacceptable.

and we will review the situation we have a review going on at manchester and we will continue to follow up anytime that that will occurs. >> i think, i'm going to tell you, i think you ought to do it in every vizzen you've got. that's just my opinion because that's totally unacceptable. we're not going to get our arms around this. you guys have been dealt this hand with multiple deployments so the mental health issue is a big issue. and it is an issue that quite honestly, if we don't get our arms around it, there are going to be more and more people slip through the cracks whether we want them to or not, that's the way it is. and i just, you know, our use in the private sector is important. our partnerships we develop are important. nobody wants to dismantle the va but when it comes to mental health issues i think it's all hands on deck. i think it's all hands on deck.

lastly, i just, and i've got a bunch of questions here that were written up. the metrics that are used and i nknow the access to care metric were the ones that one of you said, it might have been you dr. d aig h about those being flawed. if -- i don't know if this is the same thing or not but the report i read means that they were kind of jimmying the numbers to look like people were getting treatment in a timely manner when they weren't. >> i think that the, the problem is that the schedulers were inconsistency operating by business rule that said you should schedule account appointment to the date that was desired. and the desired date, what is the desired date in the desired date the patient wants, the doctor wants so that not to and

fro of scheduling, i think va created a metric, the business rules for which are not supportable in a systemic way. so when 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 of people you know trying to game the system. but i don't have evidence that i can give to you of gaming but i certainly can say that the data set we don't think the accurately reflects access as it is in the va. >> okay. well, one last thing and then this will be the last one. there's a stigma in this country and probably in the world but definitely in america the united states attached to mental health issues, injuries. there are i have multiple stories about folks who won't go get treatment because they're afraid it will be on the record, afraid they won't be able to get

a job, afraid it might impact the job they do have, 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 -- this is as major general jones says, it's increasing, it's present and it's growing and it's not uncommon and it's okay? is there -- is there some kind of cakes or outreach going on? yes, senator, there's make the 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 weep haven't mentioned today is the vet centers who are also ways in which veterans can approach for help if they have for whoever reasons 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 got a big job to do. but you've got to make sure that what's going on up here, what things that the chairman says and other people on this committee that it actually gets to the ground because we're hearing that thing 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. tolentino said about temporary dollars, hell, i wouldn't take a job like that. so let's figure out how to make it work and let's figure out also, by the way, because we've got healing waters in my state that goss a great job, we can

dove tail on to things like what major jones is doing because that can be an incredible, you know, whether you're fishing or leading a horse or whatever, i don't care, those can be incredible programs to get people back on their feet. thank you very much, madame chairman. >> thank you. >> thank au, chair woman. secretary shown hard, i was pleased to hear the va announce its plan to hire 1900 mental health workers. and then i was additionally pleased with the announcement yesterday about the family therapists and the licenses professional mental health counselors. my discouragement is how long it took for the va to implement. i have a history with particularly those twos professions that in 2006 congress passed the veterans benefits health care and information technology act. part of that act was a piece of legislation that i introduced to encourage authorize and insist that you hire those twos professionals within the va. and now five and a half years later, it's occurring.

and so while i think i'll stay on the positive note, i'm discouraged by how long it took but i'm very pleased at this point in time to see that you move in that direction and i encourage you to hire those people and put them to work as rapidly as possible. part of my interest in this topic is coming from a state as rural as kansas. in which our access to mental health professionals is perhaps even more limited than more urban and suburban states. and we need to take advantage of the wide array of professional services that are available at every opportunity. and so, i'm here to encourage you to now that you've made this announcement, let's bring it to fruition and thank you for reaching the conclusion and getting us to this point. i want to direct my question to general jones. i thank you very much for your semper fi odyssey efforts. i have a kansan visited with me

within the last month who has organized a program, i don't know that it's modeled after what you're doing but with the same kind of focus and effort. and it's somewhat related to the conversation or the questions of senator tester about kind of the stigma or lack of willingness to admit that one needs help. lack of perhaps knowledge about what programs are available, how to connect the veteran with what's there. and i wanted to give you the opportunity to educate me and perhaps others on what it is that you've been able to do to bring that veteran who is not likely to know of the existence of your program or programs like yours and secondly, what can you -- what can be done to overcome the reluctance of military men and women and veterans to access what is available such as your program? >> thank you, sir. well, first off, i