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An Assessment of Ongoing Concerns at the Veterans Crisis Line
April 04, 2017
Kayda Keleher, Legislative Associate
National Legislative Service
Veterans Of Foreign Wars Of The United States
Committee On Veterans’ Affairs
United States House Of Representatives
With Respect To
“An Assessment of Ongoing Concerns at the Veterans Crisis Line”
Chairman Roe, Ranking Member Walz and members of the Committee, on behalf of the men and women of the Veterans of Foreign Wars of the United States (VFW) and its Auxiliary, I want to thank you for the opportunity to present the VFW’s views on the Department of Veterans Affairs (VA) Office of the Inspector General’s (OIG) report on the Veterans Crisis Line (VCL)
In 2007, the Department of Veterans Affairs Health Administration (VHA) established a suicide hotline. The hotline, which later became known as the VCL, was established to provide 24/7, suicide prevention and crisis intervention to veterans, service members and their families. This was necessary as a means of constant availability to individuals in need of crisis intervention. The VCL provides crisis intervention services to veterans in urgent need, and helps them begin their path toward improving their mental wellness. The VCL plays a critical role in VA’s initiative of suicide prevention, and ongoing efforts to decrease the estimated 20 veterans who die by suicide each day. The VCL answers more than 2.5 million calls, responds to more than 62,000 text messages and initiates the dispatch of emergency services more than 66,000 times each year. Yet, there is still more work that must be done to improve the VCL.
The VAOIG released a report on March 20, 2017. This report came after the United States Government Accountability Office (GAO) release of another VCL report in May 2016. Of the four objectives highlighted by VAOIG, there are 16 recommendations. The VFW applauds the VCL for the progress it has made since the reports were released. To continue improvements, the VCL must improve quality control, implement clinical oversight and increase collaboration.
From January 1 – March 11, 2017 the VCL received a total of 133,694 calls between their two locations in Canandaigua, New York and Atlanta, Georgia. Of those calls, 552 were rolled over to a backup call center. It is also worth noting VA does not have the capability of monitoring any calls which are sent to their Substance Abuse and Mental Health Services approved backup call centers. While 552 unanswered VCL phone calls may seem high, the VFW believes rollover calls cannot be completely eradicated. We believe the goal of VCL responders should be quality of crisis intervention, not quantity of calls answered. Though it should still be a priority for responders to answer as many calls as possible, the number one goal must be successful crisis intervention. Yet, without being able to promise every veteran it is completely practical for the employees in New York and Georgia to always have somebody available to answer the call, it is imperative VCL continues contracting backup call centers with oversight and monitoring of the quality of those calls. Since the mark of the New Year, VCL rollovers have decreased from 1.99 percent of calls to anywhere from .02 to .47 percent of calls. This is a huge improvement since November 2016, when 31.34 percent of calls were being sent to backup centers, and throughout much of the time VAOIG was doing its investigation. The consistent and dramatic decreases in amount of calls being sent to backup centers can be directly correlated with the second VCL location opening in Atlanta, Georgia, on October 1. Each individual employee at the VCL is answering an average of nine calls per day, and those calls are being answered quicker than 911 and the National Emergency Number Association standards. While these improvements compared to the past are commendable, the VCL must focus on quality of crisis intervention provided, not strictly on quantity of calls answered. The VFW believes with the right adjustments, VCL staff can maintain this quantity of service while also improving the quality.
Precise numbers of non-veterans and veterans not in a mental health crisis calling VCL are unknown. Last year it was publicized that four callers were calling and harassing VCL employees thousands of times –– estimates of four percent of incoming calls were to harass VCL responders. Other veterans admit to calling VCL when not in mental health crisis because it is the first phone number they see publicly available. They have called in hopes of being able to schedule appointments or to complain about unsatisfactory care they received. Completely screening these calls and assuring only individuals in crisis are calling the VCL is not practical, and most callers are in need of some level of intervention. Crisis is defined individually, and everyone in crisis deserves support. Yet, the VFW is concerned some of the calls not being answered by VCL responders may be due to non-crisis callers clogging the system.
The VFW believes expanding VA’s Office of Patient Advocacy would greatly benefit the VCL. By improving and expanding the patient advocacy offices throughout VA, employees of these offices would have better visibility and means to assist non-crisis patients. If veterans become more aware of the patient advocate mission and capabilities, non-crisis callers to the VCL would decrease.
The VFW has been working to expand and improve patient advocacy within VA and we will continue to monitor progress. The VFW urges this Committee to conduct extensive oversight of the VA Patient Advocate Program to ensure veterans are able to have their non-emergent concerns addressed without having to call the VCL.
Employees at VCL undergo extensive training before being allowed to answer calls, and it takes at least six months before they may begin training to also answer chat and text conversations with veterans in crisis. Yet, it was not until late December 2016 that the VCL had the capability to record and monitor their calls. Without this crucial technological capability, there was no way for calls to be truly monitored for quality control. Now that this capability is available, the technology must be properly utilized. Staff at VHA and the VCL monitor some ongoing calls for quality assurance, but a better, constant process must be implemented to ensure these recordings are being used to improve the training and capabilities of VCL responders. This would not only improve crisis intervention, but would assist with ending allegations of responders not understanding or following protocol, instructions, and resources.
Over the last six months, turnover rates for employees at both VCL locations have been far below the national average. Canandaigua currently has 361 employees. They have lost 15 employees since October 2016, with a turnover rate of 4.1 percent. In Atlanta, there are currently 275 employees. The Atlanta call center has lost 10 employees since October 2016, with a turnover rate of 3.6 percent. According to a 2015 study published by Nursing Solutions, Inc., the average turnover rate for health care employers was 19.2 percent. This may in part be due to increased morale thanks to the VCL employee wellness program. Leadership at the VCL took notice in the past to low morale amongst employees, which is completely reasonable given the nature of responders’ jobs. The employee wellness program provides responders at the VCL 15 minutes to prepare themselves mentally before and after their shifts. This allows them time to enter the mindset necessary for their emotionally demanding job, as well as time to decompress and adjust their mindset or talk with others before leaving their workplace. The employee wellness program also improved the supervisor to responder ratio. Prior to the program, there were 20 employees for every supervisor. The ratio was decreased to ensure the needs of employees are not overseen, so that now there are 11 employees to every one supervisor.
There is no doubt clinical oversight at the VCL is a necessity. Clinical decision making must be made by clinicians and not by operations and administrative staff. Leadership running the VCL must also have clinical background. This would ensure veterans in crisis who call the VCL receive the best clinical judgement and assistance possible. Clear guidelines must be established for the VCL so non-clinicians are not forcing a clinically based crisis line to operate as a business. This has a clear link to quality control as well. The VFW believes that while the number of calls going to backup centers decreasing at such a rapid rate is a positive, it is not a sign of the quality of work being provided. Veterans, service members and their families deserve the best clinical care available, and VA is known for outperforming the private sector in many areas of health care. In fact, of the estimated 20 veterans who commit suicide every day, only six of them are enrolled in VHA. This shows that clinicians within VA know what they are doing, and they do it well.
The VFW believes VHA must establish both clinical and operational policies specific to the VCL. This would allow for easier protocol standards to be understood and met on a regular basis, while establishing guidance and regulations to continue being followed by employees without clinicians stepping on the toes of operations, or operations stepping on the toes of clinicians.
In March 2016, the VCL established a Clinical Advisory Board at the request of VHA Member Services. This board was intended to assist and work with VHA Member Services, to assure no clinical necessities were being dismissed after VCL operations were moved to the non-clinical office within VHA. This group was intended to assist VHA Member Services in collective expertise of clinicians to improve the veteran experience, efficiencies of employees and increased access to the VCL. The charter for the advisory board was later changed by different leadership within VHA Member Services. The board now has one meeting per month where they call in for one hour. Call data is presented to the board members, but a monthly hour long meeting does not provide them with the means to effectively obtain clinical input for policy decisions to improve the VCL.
The VFW firmly believes the VCL has improved and will continue to improve. Though that improvement will continue to be slow, frustrating and life-endangering if the VCL does not begin collaborating with others. Aside from working with patient advocacy offices to cut down on non-crisis calls and VHA Member Services to readjust the advisory board and increase clinicians, the VCL must also work more closely with the Office of Suicide Prevention (OSP).
Member Services has undoubtedly assisted the VCL in quantity control, but OSP can also assist the VCL in quality control. If the goal of the VCL is to intervene for veterans in need of immediate assistance while they are in the middle of a mental health crisis, the VCL should be working with the subject matter experts and leaders in suicide prevention and outreach for VA. If all three offices could collaborate together, with better guidelines, Member Services must be able to continue improving the VCL call center expertise and business, while OSP can make sure the VCL is up-to-date with the most current clinical expertise on suicide prevention and outreach.
Information Required by Rule XI2(g)(4) of the House of Representatives
Pursuant to Rule XI2(g)(4) of the House of Representatives, the VFW has not received any federal grants in Fiscal Year 2017, nor has it received any federal grants in the two previous Fiscal Years.
The VFW has not received payments or contracts from any foreign governments in the current year or preceding two calendar years.