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"Dial 988 +1: Examining the Operations of the Veterans Crisis Line"

House Veterans Affairs Committee, Health Subcommittee Hearing

September 18, 2024 (recording here)

HEARING INFORMATION

Witnesses & Written Testimony (linked):

• Dr. Matthew Miller: Executive Director, U.S. Department of Veterans Affairs, on behalf of Veterans Health Administration

• Dr. Christopher Watson: Executive Director, U.S. Department of Veterans Affairs, on behalf of Veterans Health Administration

• Mr. Brad Mills: Deputy Director, U.S. Department of Veterans Affairs, on behalf of the Office of Information & Technology

• Dr. Julie Kroviak, MD: Principal Deputy Assistant Inspector General for Healthcare Inspections, U.S. Department of Veterans Affairs, on behalf of the Office of the Inspector General

Keywords mentioned:

• Veteran suicide, mental health, continuity of care, confidentiality, staffing, responders, oversight, quality assurance, accountability, remote work, postvention support

IN THEIR WORDS

OPENING STATEMENTS FROM THE SUBCOMMITTEE

• Acting Chairwoman Jen Kiggans opened the hearing by acknowledging that it was being held during Suicide Prevention Awareness Month, stressing the urgency of addressing veteran suicides. She emphasized the importance of breaking the stigma around mental health and ensuring that veterans have access to support for conditions like posttraumatic stress disorder (PTSD). The Veterans Crisis Line (VCL) was established in 2007, and the Chairwoman expressed concern over recent outages and access issues affecting nearly 700 callers. She looked forward to hearing from the Department of Veterans Affairs (VA) and its efforts to improve the Crisis Line and make it fully accessible.

• Acting Ranking Member Greg Landsman reiterated that every call to the VCL is an opportunity to save lives and highlighted the importance of preparing responders to handle each interaction with the highest stakes. He praised the smooth transition to the 988 number and the VA’s transparency regarding outages, acknowledging the ongoing efforts to mitigate issues and ensure no veteran is left without support. Ranking Member Landsman pledged continued support for improving the Crisis Line and acknowledged the challenging but vital work of its responders.

SUMMARY OF KEY POINTS

• Dr. Matthew Miller shared that the VCL had grown from 14 responders in 2007 to over 1,000, providing 24/7 support via call, text, or chat. Since the launch of the 988 line, the VCL saw a significant increase in calls and interactions, which has saved lives. Dr. Miller acknowledged past outages but assured the Subcommittee that modernization efforts were underway to improve the system. He also affirmed that the VCL remains a critical resource for suicide prevention.

• Dr. Julie Kroviak recognized the importance of addressing veteran suicide during Suicide Prevention Awareness Month. She noted that the OIG provides oversight of clinical services aimed at reducing veteran suicide, including the Veterans Crisis Line. Dr. Kroviak pointed out several deficiencies in VCL services, such as incomplete risk assessments and missed rescue opportunities, which contributed to tragic outcomes. Despite these issues, she commended the VCL’s response to the 988 implementation and stressed the need for ongoing support for responders.

• Chairwoman Kiggans asked Dr. Miller how the VCL identifies the location of veterans who either do not provide that information or are calling from a different location than their phone's area code. Dr. Miller explained that while the VCL allows veterans to remain anonymous, in about 5-6% of cases involving emergency dispatch, location information is required. If a veteran cannot or will not provide their location, the VCL has ways to locate them based on various factors as a last resort in emergencies.

• The Chairwoman then asked how the VA ensures that VCL responders have postvention support, given the emotional challenges of the job. Dr. Christopher Watson explained that since May 2023, the VA has implemented postvention resources, including training, Employee Assistance Programs, and wellness activities like yoga and meditation to support responders.

• Chairwoman Kiggans inquired about the attrition rate for VCL responders. Dr. Watson stated that the turnover rate is low at around 15%, which aligns with industry standards. The turnover often includes advancement to supervisory roles, which the VA views as a positive indicator.

• Ranking Member Julia Brownley asked Dr. Watson about the VCL's efforts to provide culturally competent training, especially for interactions with the LGBTQ+ community and women. Dr. Watson outlined annual training programs that include a three-hour session for new employees focused on LGBTQ+, women veterans, and those with military sexual trauma. A resource SharePoint for special populations is also available.

• Ranking Member Brownley further inquired about remote work for VCL staff, expressing concerns over whether it is optimal for such sensitive work. Dr. Watson responded that remote work has been effective and that responders stay connected through daily virtual huddle meetings, which foster support and ensure performance metrics are met. Dr. Kroviak added that the remote option helped recruit quality supervisors, addressing a previous shortage.

• Rep. Amata Coleman Radewagen asked about the VA’s efforts to address geo-routing issues for crisis line calls. Dr. Miller confirmed that SAMHSA had announced a pilot implementation of geo-routing services, which links 988 callers to local crisis centers. He noted that geo-location is less of an issue for the VCL’s national operations, as the line connects veterans with local VA facilities and suicide prevention coordinators.

• Rep. Radewagen also asked about the VCL's follow-up procedures for dropped calls. Dr. Watson explained that the VCL attempts to reconnect with veterans by making three calls across different shifts. They successfully reconnect with 74% of those callers, with some not reached due to inoperable phone numbers or the veteran already calling back.

• Rep. Nikki Budzinski inquired about the VCL’s coordination with local law enforcement, especially in rural areas. Dr. Miller underscored that rural veterans have a higher risk of suicide, often due to firearm-related incidents, and that the VCL collaborates closely with law enforcement in these areas. The VA also offers training and resources to law enforcement and is exploring the use of broader response teams that include social workers and peer specialists.

• Rep. Budzinski also asked about improving the coordination of veterans' health records when they call the VCL. Dr. Miller explained that while the VCL maintains a separate documentation system from VA health records to preserve confidentiality, there are interoperable linkages through suicide prevention coordinators to ensure continuity of care when necessary.

• Rep. Derrick Van Orden asked the witnesses about who answers the phones at the VCL, to which Dr. Watson explained that crisis responders come from various social science backgrounds and work remotely.

• Rep. Van Orden expressed concern about the effectiveness of remote work and the qualifications of responders who may have never met a veteran in person. He questioned whether the higher suicide risk of veterans who call the VCL indicates the line may be contributing to the problem. Dr. Miller responded that veterans who call the VCL are already at high risk for suicide, but the service has reduced suicide rates significantly, with a 30% reduction in suicide from 2019 to 2020 and another 20% reduction in 2021.

• Rep. Van Orden pressed Dr. Miller on the apparent contradiction in the data, noting that veterans are 11 times less likely to engage in suicidal behavior after a call, yet have a higher risk of suicide within 12 months of contacting the VCL. He argued that remote work contributes to distractions and reduces accountability. Dr. Miller clarified that while the veterans remain high-risk after the call, immediate interventions are effective in reducing suicide attempts in the short term. Rep. Van Orden voiced his frustration, stating the current approach is not effective enough and emphasizing the need for personal accountability and higher engagement from staff.

• Acting Chairwoman Kiggans asked how many calls one responder may receive in a regular work shift. Dr. Watson mentioned that one crisis responder may receive about 2,500 calls per day on average.

• The Chairwoman followed up and asked about any future plans to return to an in-person setting for responders. Dr. Miller responded that the VA is open to the idea if it proves to be better for veterans.

• Ranking Member Brownley shared her colleagues’ concerns about the effectiveness of remote work for VCL staff, noting that working together in person might better support the team and improve outcomes. She stated that new staff could benefit from observing experienced colleagues, and she questioned whether working remotely truly serves veterans' needs. Dr. Miller acknowledged that while remote work helped the VCL quickly hire staff and avoid COVID-related service disruptions, he understood the value of in-person interaction, particularly the loss of "water cooler" moments where staff could connect informally. He affirmed that the option for in-person work should remain open for future consideration.

• Rep. Van Orden called for improved outcomes and greater accountability for remote workers. He criticized the existing structure, questioning whether remote work and the qualifications of VCL staff were sufficient to address the critical needs of veterans in crisis. He reiterated the need to strive toward "functional zero" for veteran suicides and demanded clearer, more logical explanations for the data presented.

• Chairwoman Kiggans asked whether there was any follow-up done after veterans reach out to the VCL. Dr. Watson explained that the VCL has implemented a peer support outreach call center where 100% veteran-certified peer support specialists provide follow-up. Additionally, the VCL uses monthly written outreach through a program called "Caring Contacts," which has been well-received by veterans.

• The Chairwoman acknowledged the importance of in-person interactions, sharing her experience from a recent in-person mental health provider roundtable. She agreed that in-person collaboration can be beneficial and suggested further exploration of in-person models at the VA. She concluded the hearing by reminding veterans and their families that the VCL remains available through 988, text, and chat services.

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