UNITED STATES DEPARTMENT OF VETERANS AFFAIRS ...YESSENIA CASTILLO, Senior Consultant, Sigma Health Consulting, LLC KATHRYN FAUSTMANN, Support Staff JOHN KLOCEK, Subject Matter Expert;

(202) 234-4433 Washington DC www.nealrgross.comNeal R. Gross and Co., Inc.

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UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

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CREATING OPTIONS FOR VETERANS' EXPEDITED RECOVERY (COVER) COMMISSION

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OPEN SESSION

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THURSDAY SEPTEMBER 12, 2019

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The Commission met in Suite 150A atthe VHA National Conference Center, 2011 CrystalDrive, Crystal City, Virginia, at 9:00 a.m., JakeLeinenkugel, Chair, presiding.

PRESENT JAKE LEINENKUGEL, Chair; Senior White House Advisor, Veterans AdministrationCOLONEL MATTHEW F. AMIDON, USMCR, Director, Military Service Initiative, George W. Bush InstituteTOM HARVEY, U.S. Army (Ret.), Board Member, Milbank Memorial FundWAYNE JONAS, M.D., Executive Director, Samueli Integrative Health ProgramsJAMIL S. KHAN, U.S. Marine Corps (Ret.)MATTHEW KUNTZ, U.S. Army (Ret.), Executive Director for the Montana National Alliance on Mental Illness (NAMI)SHIRA MAGUEN, Ph.D., Mental Health Director of the OEF/OIF Integrated Care Clinic, San Francisco VA Medical CenterMICHAEL POTOCZNIAK, Ph.D., Captain, U.S. Army Reserve, Team Lead for Addiction Recovery Treatment Services, Martinez, California


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JOHN M. ROSE, Captain, U.S. Navy (Ret.), Board Member, National Alliance on Mental Illness (NAMI)

STAFF PRESENT

JOHN GOODRICH, Designated Federal Official (DFO)CASIN SPERO, Executive DirectorSHANNON BEATTIE, MPH, Senior Project Analyst, Sigma Health Consulting, LLCFERNANDA CARRION, Management Analyst, Sigma Health Consulting, LLCYESSENIA CASTILLO, Senior Consultant, Sigma Health Consulting, LLCKATHRYN FAUSTMANN, Support StaffJOHN KLOCEK, Subject Matter Expert; Alternate DFO

WENDY LARUE, Alternate DFO; Writer

NICK MAJIE, Senior Consultant, Sigma Health

Consulting, LLC

LAURA McMAHON, Contracting Officer

Representative; Alternate DFO

HANIFAH MOHAMED, Project Analyst, Sigma Health

Consulting, LLC

STACEY POLLACK, Ph.D., Subject Matter Expert;

Alternate DFO

SALMAN SHAMSI, Program Manager, Sigma Health

Consulting, LLC

TRACY SHEWMAKE, Support Staff


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CONTENTS

Call to Order. . . . . . . . . . . . . . . . . . . 4

Introduction of Commission Members . . . . . . . . 4

Remarks Regarding Congressional Visit. . . . . . . 6

COVER Commission Next Steps. . . . . . . . . . . .11

Final Phase - Writing the Report . . . . . . . . .43 Wendy LaRue

Workgroup 1 Update . . . . . . . . . . . . . . . .59 Wayne Jonas

Workgroup 3 Update . . . . . . . . . . . . . . . 102

Shira Maguen

Boston Site Visit. . . . . . . . . . . . . . . . 202

Wayne Jonas

Adjourn. . . . . . . . . . . . . . . . . . . . . 229

Atlanta Site Visit 190

Discussion by Commissioners


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1 P-R-O-C-E-E-D-I-N-G-S

2 9:08 a.m.

3 CHAIR LEINENKUGEL: Good morning,

4 everybody. Welcome to the COVER Commission

5 meeting that is officially now in session.

6 At this time, I would like

7 Commissioner Khan to lead us in the Pledge of

8 Allegiance.

9 DR. KHAN: Please join us.

10 (Pledge of Allegiance.)

11 DR. KHAN: Thank you.

12 CHAIR LEINENKUGEL: I would like to

13 begin by introducing, to the general public and

14 to attendees, the Commissioners that are

15 currently present. And I'll start with myself,

16 and we'll go around the table.

17 Jake Leinenkugel, Chairman, COVER

18 Commission, Marine Corps veteran, family of

19 Marines, and also a Marine and veteran advocate,

20 and very proud to be part of this Commission.

21 MR. ROSE: Jack Rose, a Navy veteran,

22 26 years. I've also spent the last 19 years with


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1 the National Alliance on Mental Illness, both at

2 the state and local level. And we have two adult

3 children who have lived with mental illness. And

4 I, too, am very proud to be a part of this

5 Commission.

6 Thank you, and good morning.

7 DR. POTOCZNIAK: Mike Potoczniak. I'm

8 an Army veteran and currently the Mental Health

9 Director at the Santa Rosa Clinic of the San

10 Francisco VA. Yes, happy to be on this

11 Commission. And thanks.

12 DR. MAGUEN: Hi. I'm Shira Maguen.

13 I'm a clinical psychologist by training.

14 Currently work at the San Francisco VA. I've

15 been with the VA system since 2001, and, in

16 addition to that, Workgroup 3 lead.

17 MR. HARVEY: My name is Tom Harvey.

18 I'm a veteran. I'm an Army veteran. I spent two

19 and a half years in Vietnam as an infantry

20 officer. I also spent much of my career working

21 on issues relating to veterans as Staff Director

22 of the Senate Veterans Affairs Committee, Deputy


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1 Administrator of the VA, and Assistant Secretary

2 of the VA for Congressional Relations. It's an

3 honor to serve on this Commission with all of

4 you.

5 COLONEL AMIDON: Good morning. Matt

6 Amidon, Marine Corps, still serving as a

7 Reservist, 27 years. And in my civilian

8 capacity, I'm the Director of the Military

9 Service Initiative at the George W. Bush

10 Institute in Dallas, Texas. Thank you.

11 DR. KHAN: Good morning. Jamil Khan,

12 United States Marine, Vietnam through Desert

13 Shield/Desert Storm. It's an honor to be part of

14 this Commission, and thank you very much.

15 DR. JONAS: So, I'm Wayne Jonas. I'm

16 a family physician, an Army veteran, 24 years. I

17 still see military and veterans in the clinic,

18 and I'm very interested in whole-person care,

19 which includes their mental health. And I've

20 said this before, but I'll say it this time. I'm

21 actually a four-generation veteran. My great-

22 great-grandfather was a veteran, my grandfather,


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1 my father. So, a long way for them, all Army, by

2 the way.

3 (Laughter.)

4 MR. KUNTZ: I'm Matt Kuntz. I am a

5 peacetime Army veteran. Got into mental health

6 after losing a family member that was a

7 servicemember to post-traumatic stress. And I am

8 the Director of NAMI Montana, the National

9 Alliance on Mental Illness for Montana, and then,

10 also, the Director of the Center for Mental

11 Health Research and Recovery at Montana State.

12 I'm excited to be here.

13 CHAIR LEINENKUGEL: Thank you,

14 Commissioners.

15 And I also want to note that Admiral

16 Tom Beeman, another Commissioner, is the only

17 Commission member that has been excused from this

18 meeting, as six months ago he had a planned visit

19 to see a good friend outside the country. So, he

20 will be made aware of all the findings and

21 discoveries and other further action items in

22 relation to milestones and outputs that are


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1 required coming out of this particular meeting.

2 So, that being said, I want to start

3 with what happened yesterday with five

4 Commissioners. We had the opportunity, through

5 the diligence of our support staff and Staff

6 Director and Hill representative, to be able to

7 go up and meet for the first time directly with

8 SVAC-HVAC staff, and also some key Members of

9 Congress, in order to see their awareness

10 situational updates as far as COVER, which came

11 out of the CARA legislation of 2016, and

12 certainly have an opportunity for the five

13 Commissioners to explain to them where we

14 currently are and where we need to go.

15 And also, we were delighted to learn

16 that there was a high receptivity, higher than

17 anticipated, into the outputs and outcomes of the

18 COVER Commission. And I would like to turn to

19 those Commissioners to give a brief synopsis of

20 their view and take from that particular day.

21 So, I'll start with Dr. Shira Maguen. Thank you.

22 DR. MAGUEN: Thank you.


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1 I thought it was a very productive

2 meeting. It was excellent to meet with both HVAC

3 and SVAC staff. And I thought that everyone

4 asked excellent questions. They were well-

5 prepared. And it was also very good to hear

6 about how they are thinking several steps ahead

7 about the recommendations that we are going to

8 make. I also heard loud and clear that they are

9 ready for our recommendations and are hoping to

10 get our deliverables as soon as possible. So, I

11 think we will live up to that.

12 CHAIR LEINENKUGEL: Commissioner

13 Harvey?

14 MR. HARVEY: I missed the afternoon

15 meetings with the House Veterans Affairs

16 Committee. I was there for the meeting with the

17 State Veterans Affairs Committee. And obviously,

18 they have two staff persons who are very much

19 engaged in what we're doing, to include one young

20 woman who recently joined their staff from the

21 National Alliance on Mental Illness, who's very

22 knowledgeable about that. And I was pleased to


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1 see they were as engaged in what we are doing as

2 we are.


4 Amidon?

5 COLONEL AMIDON: Again, I thought it

6 was a very valuable and rewarding experience, the

7 day on the Hill. I was also taken with their

8 level of precise knowledge to Commissioner

9 Maguen's comments on the questions they were

10 asking, even specific to your Workgroup. So, I

11 mean, I was very aware of their deep knowledge in

12 what we're doing.

13 In addition to that, I think it was

14 important to say that the way that some of the

15 five legislative mandates are written can allow

16 for scope and scale of many, many years of great

17 effort. And so, they were accepting of some of

18 the constraints that we are going to declare and

19 are operating under as a Commission and seemed

20 very accepting of that. So, it was good to hear

21 that as well.



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1 Kuntz?

2 MR. KUNTZ: So, from my perspective,

3 I just want to start out by thanking Casin Spero

4 and Dan Hanlon for their work in setting up the

5 meetings. I've been to the Hill for quite a few

6 times as a veterans advocate, and you can tell

7 when your staff sets you up to succeed. And I'm

8 really grateful for their work.

9 And it was obvious that our efforts

10 are important to current legislative

11 expectations, and they expect us to deliver a

12 quality product. And they were also excited by

13 the team that we brought before them. So, I'm

14 really looking forward to where we go in the next

15 few months to meet those expectations.

16 CHAIR LEINENKUGEL: Yes, and after

17 that meeting -- and I thank you, Commissioners,

18 for attending -- I thought it would be very

19 beneficial for next month in October, and we'll

20 get into more specifics as far as milestones and

21 some deadline issues that we need to discuss as a

22 Commission in this particular general session,


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1 that it would behoove us and for HVAC-SVAC

2 members to have the Workgroup leads. And I would

3 certainly ask our Staff Director and, also, Hill

4 representative, both Casin and Dan, to set up the

5 Workgroup leads Commissioners to probably make

6 that October visit, and then, also their overall

7 leads to attend as well.

8 So, I think that that would make a lot

9 of sense for further updates, because we were

10 asked by both SVAC and HVAC, and a couple of also

11 Congressionals, if we were going to be able to

12 meet the deadline, which I, as the Chairman, told

13 them that that is certainly our full intent. We

14 know that we have a lot of things to discuss

15 today that are probably pending. And I think

16 that the general public needs to be aware of a

17 couple of the issues that we have. Later in the

18 day, we will be talking to each Workgroup lead as

19 to the status and updates as to the current state

20 of where they are with each of their particular

21 Workgroup statuses; and also, how we need to get

22 to outcomes.


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1 So, it's a good time to talk about

2 milestones to completion because, as a group of

3 Commissioners, we came up with guiding principles

4 that we talked about way back in April, of how we

5 were going to operate together. And as Chairman,

6 I think that we have done an exceptional job as a

7 group of 10 to work in partnership in a very

8 partisan way to actually tackle the subject of

9 veteran mental health care within the VA and,

10 also, looking at those veterans that are not

11 currently being served by the VA, and how are

12 their mental health care issues being met or

13 served.

14 So, with that, we know that we set

15 dates, saying that most of our data collection

16 and work would be completed by the end of summer.

17 Looking at my calendar, that's about two weeks

18 away, officially, as the end of summer. We are

19 getting close, but we do have gaps. And I know

20 that it would be a pretty good time, after I sort

21 of prefaced for the general public and for those

22 on the call what the COVER Commission was


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1 actually mandated as far as a time point.

2 We started back in July of 2018, and

3 we were given 18 months to complete our outputs

4 and final report, which would put us in the

5 middle of January 2020 for that draft to be

6 presented to the White House, the Secretary of

7 Veterans Affairs, the Senate Veterans' Affairs

8 Committee, and the House Veterans' Affairs

9 Committee. Those are our key constituents.

10 And so, with that original mandate,

11 the Commissioners agreed that we would be on time

12 and on budget, and we're pretty much on track for

13 that in most all cases. And we'll further talk

14 about that in the October meeting.

15 So, as a group of Commissioners, we

16 have been talking about some of the gaps, the

17 data, the research that's required for us to get

18 to solid recommendations that are going to make

19 an impactful difference to each one of our

20 constituents, that they can take and either say,

21 boy, that's a great idea, a great suggestion; we

22 need to legislatively mandate this, or get it


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1 into a better practice mode, within the VA and

2 maybe looking at outside partners to help our

3 veterans in assistance with better mental health

4 care.

5 So, I would like to open it up at this

6 time, and I think just an open floor because we

7 did talk earlier offline that the end of summer

8 is now. It is September. We have meetings

9 scheduled for October, November, December to

10 complete and finalize and write and draft the

11 work for presentation to our constituents, which

12 really is not a lot of time, when you're looking

13 at about 100 days to completion. And there's

14 still a lot of moving parts within each one of

15 the Workgroups.

16 So, for the general public's sake, we

17 know that coming in October we have meetings

18 scheduled that I cannot, I don't believe, give

19 the time to because I'll have to ask our DFO if

20 that's been in The Federal Register or not yet.

21 MR. GOODRICH: Not as of yet.

22 CHAIR LEINENKUGEL: Not as of yet, but


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1 there will be an October meeting, and those dates

2 will be forthcoming as well as November and

3 December, with more than likely open general

4 public sessions as well.

5 So, we know that there's a lot of

6 things that have to be completed, and I would

7 like to have some open discussion for the general

8 public, so that they are aware of not only the

9 amount of work, but the context and sometimes the

10 difficulty of compiling this much data and

11 research, and getting to solid recommendations

12 and suggestions that each one of our Workgroup

13 leads deals with. So, I would like to have an

14 open session about some of the gaps in our

15 research and data collection, so that our

16 partners that are in the room, whether they're

17 our VA subject matter experts or our outside

18 contract groups that help us, and namely, Sigma,

19 in research data collection and extrapolation,

20 are well aware of what some of our gaps are, and

21 just so that it's out in the open.

22 Because we're going to have to stop at


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1 some point with the research, the analysis, and

2 come up with the recommendations. And when I say

3 that, that has to start now, if we're going to

4 meet the writing time schedule that we'll talk

5 about later in the general open session as well

6 on writing the report.

7 So, I'll open it up. I'll start with

8 Workgroup 1 at this point, just a top over line,

9 because they all will be presenting specific

10 proposals and recommendations and a deeper dive

11 into each one of their Workgroups later in the

12 session. But this is mainly for our partners in

13 the room to understand what some of our issues

14 are or some of our worries are at this point of

15 what needs to be done in order for us to get to

16 the recommendation and deliberation stage.

17 So, with that, if I may start with

18 you, Wayne? Commissioner Jonas.

19 DR. JONAS: Okay. Great. Thank you

20 very much, Chairman.

21 Yes, so, later today, I'll give sort

22 of an overview of where we are in Duty Group 1


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1 and sort of what our core questions are to

2 address the duty. Just as a reminder, we're

3 looking at models, models of care, the efficacy

4 of that for mental health, and specifically at

5 wellness-based outcomes. So, that's the charge

6 of that.

7 And we've laid out a research pathway

8 that involves several steps and several

9 components. And I think on the top line is that

10 we will be more than 80 percent collected in

11 terms of the data and information that we need,

12 even with some of the gaps that I think will

13 still remain after that, which will be fine.

14 So, we're moving along in actually

15 answering those questions and filling in the

16 information. I think the hope originally that we

17 wanted to do, to really cover what services,

18 models, and approaches that were available for

19 all veterans, both inside and outside the VA.

20 We've had a great overview of what's in the VA.

21 We've made many trips. We've met with

22 individuals. We've had expert presentation,


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1 especially from the VA. So, we're pretty good on

2 that. We've got that information around the

3 models that are being used for mental health,

4 around approaches for complementary and

5 integrative medicine or health, about integration

6 components of that within the VA.

7 However, as has been pointed out many

8 times, the vast majority of veterans are taken

9 care of outside the VA. And so, one of the

10 questions is, are those types of services

11 available and is there a capacity for the

12 delivery of those types of things, and what types

13 of models are there out there?

14 So, the ideal way to do this would be

15 to survey the entire health system around these

16 areas. And that is a pretty massive task. We

17 explored that, but given the resources and

18 constraints, and, also, just trying to define it

19 clearly, so that you can actually ask the right

20 questions. We actually went to several top-level

21 systems, civilian systems, and had presentations

22 from them from around the country and got a


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1 pretty good idea of what they were doing. And

2 so, we have formulated a survey that could begin

3 to get at that, but it's still not been

4 completely tested and validated and seen whether

5 it could be done in those areas.

6 And so, one of the gaps that I think

7 we will have is a difficulty in being able to get

8 a comprehensive evaluation. We would like to

9 send it out to a few of the top-level systems.

10 We've already sent it out to one, and they're in

11 the process of looking at it, providing

12 information back. And then, we'll send it out to

13 a few more after that.

14 I think that will be the cherry on the

15 cake. I think we already actually have a pretty

16 good idea of what's out there, what we are doing,

17 and filling in information using internet

18 research in a more systematic assessment of top

19 quality systems in different categories around

20 the country. So, we will have all of that

21 information. And we are, then, evaluating sort

22 of the wellness-based outcomes, using a fairly


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1 systematic evaluation, systematic review method,

2 literature review method in those areas.

3 So, it would be, the ideal component,

4 the 100 percent solution would be to survey the

5 entire country, find out what they're doing in

6 this area. And maybe that's something that can

7 be done in the future, and we may make a

8 recommendation that that be done, to get a better

9 idea of that. And we will be able to offer

10 examples so far of the types of questions that

11 need to be asked in order to get that

12 information. So, that will be good, and then, we

13 will have, like I said, the 80 percent solution

14 in those areas.

15 I think one of the challenges that we

16 found in looking at models is especially around

17 wellness-based outcomes, because most of the

18 quality models don't do that. Most of the

19 quality models in health care, including the

20 Quadruple Aim, measure things like outcomes, like

21 cost, like satisfaction, and the outcomes are

22 usually clinical outcomes. They're disease-


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1 based. They're not wellness-based. So, it's

2 sort of hard to find those.

3 And so, one of the things we're going

4 to be looking for is what wellness-based outcomes

5 are there that look like they could be useful and

6 point to some examples of that. We've got

7 several of those. And then, getting some expert

8 input on that.

9 And so, part of our plan is, very soon

10 actually, the beginning of October, is heading up

11 to Boston where we're not only going to look at

12 some of the clinical integration at the Boston VA

13 there, but also talk with the folks doing that

14 evaluation up there, both in the VA and, then,

15 get some input from outside experts who do this

16 all the time; for example, from the Institute for

17 Healthcare Improvement, which developed the

18 Triple Aim from which the Quadruple Aim came, and

19 some other experts in these areas that are

20 around. So, that will help us fill in that

21 particular area.

22 And so, I think, by the time we're in


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1 the process of filling in the writing and that

2 type stuff, we will have more than enough.

3 CHAIR LEINENKUGEL: Yes, I would like

4 to ask you, Commissioner Jonas, to explain to the

5 general public and some others that may be

6 unaware of the difference between clinical

7 outcomes and wellness outcomes, why you believe

8 from your career as being a doctor and really

9 focusing on wellness, what the difference is

10 between clinical and wellness and why you believe

11 wellness outcomes would be a critical component

12 for us moving forward.

13 DR. JONAS: Yes, I would be happy to

14 do that.

15 So, one of the long-time

16 recommendations that's been around by the

17 National Academy of Medicine and others has been

18 to do more patient-centered or person-centered

19 care. The original "Crossing the Quality Chasm,"

20 a landmark study that came out in 2001, said put

21 the patient in the center of the decision-making

22 process.


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1 And that's not what we do in medicine.

2 Okay? In medicine we have a very medical-centric

3 approach, where the disease and the diagnosis are

4 in the middle, and then, we try to figure out

5 what's the matter and what to do about it. And

6 if it happens to align with patients' goals and

7 interests, and if it doesn't happen to align,

8 then we try to make them do it anyway. And

9 that's called compliance issues.

10 And that's a challenge. When you

11 break your leg, you want that. When you get an

12 infection, when you have a heart attack, it's

13 like, you know, don't tell me whether I want to

14 come in the hospital; please take me into the

15 hospital and save my life, right? And we've got

16 a great system for that, and we do a lot of that.

17 For current complex, chronic

18 illnesses, it's not so easy and applying that

19 model is actually producing some problems in our

20 country in terms of costs, increasing costs,

21 declining outcomes, et cetera. So, we need to

22 actually adopt more of a person-centered model,


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1 like was recommended by the IOM and many other

2 folks since then.

3 And the VA has been doing that over a

4 period of decades. They've been actually, you

5 know, adopting person-centered outcomes through

6 the PACTs, the Patient-Aligned Care Team, by

7 incorporating more and more mental health

8 components, which have traditionally neglected

9 within health care, and integrating that into

10 primary care, where a lot of mental health issues

11 come up. And so, they have been moving that

12 along. And now, with the whole-health effort,

13 they're just going the next step further to try

14 to do that.

15 And so, the wellness-based outcomes,

16 the well-being-based outcomes, which is a way

17 better term, are ones that actually put the

18 patient, put the person in the center, find out

19 what's important for them, and then, identify

20 their particular determinants of health, you

21 know, whether they're mental and social or

22 emotional issues, whether they're behavior and


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1 lifestyle issues, whether they're social need

2 issues. And then, facilitating that process, so

3 that they can be successful in improving quality

4 of life and actually fulfill what they're here to

5 do, their mission and purpose.

6 And so, that's the kind of direction

7 that health care in general has been trying to

8 move towards. The VA has been doing it. And I

9 think we're going to look at that and say, you

10 know, can we do that in a more robust and

11 accelerated way? Can we make some

12 recommendations that can be useful and practical

13 to the VA and to those who take care of veterans

14 outside the VA, to be able to do that better?


16 Commissioner Jonas. It was helpful.

17 I would like to transition to

18 Commissioner Potoczniak at this time for a brief

19 update as far as some of his status and gaps.

20 DR. POTOCZNIAK: Sure. So, we've gone

21 around and kind of visited, similar to what Dr.

22 Jonas just said, we've gone around and we've hard


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1 informally what veterans' experience with mental

2 health has been in the VA, in the different

3 areas, whether it be rural or urban. So, we've

4 informally heard their experience with VA.

5 And we've heard some pretty good

6 themes, even on the reservation also, about

7 different themes that people had with seeking

8 care for mental health in the VA. And so, that's

9 been very helpful.

10 We've also gone through a process of

11 kind of incorporating data from other research

12 that looks and discusses veterans' experience.

13 So, that's been something that's been ongoing

14 through this process, and specifically looking at

15 veterans' experience with CIH and their general

16 experience with the different empirically-based

17 treatments in the VA.

18 So, we've heard a lot over the past

19 year, and I think now we're currently involved in

20 conducting focus groups with veterans in the

21 different VISNs within VA to hear kind of in a

22 more formal way what their experience is. And


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1 we've started to identify themes. Thank you to

2 Casin Spero and Wendy, going out and collecting

3 that data, as well as Sigma for doing some of the

4 virtual and in-person focus groups. There are

5 some themes that we're going to be picking up on

6 and making recommendations from. So, I think

7 we're on track to do that.

8 And I think that's where we're at

9 right now.

10 CHAIR LEINENKUGEL: Thank you.

11 Appreciate it.

12 DR. POTOCZNIAK: No problem.

13 CHAIR LEINENKUGEL: Dr. Maguen, if you

14 would, Workgroup 3.

15 DR. MAGUEN: Great. So, just as a

16 reminder to the public, Workgroup 3 is looking at

17 examining the existing research on complementary

18 and integrative health treatments, and

19 specifically for mental health. And we're

20 looking at how that applies to veterans

21 specifically.

22 We are in the process of doing several


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1 reviews for eight different mental health

2 outcomes. And so, we're well underway in doing

3 those reviews. Four of those reviews have been

4 completed and discussed. One was actually

5 delivered yesterday. So, we're going to be

6 looking at that over the next few days. And the

7 remaining three reviews will be delivered by

8 October 15.

9 So, our hope is -- and you'll be

10 hearing a lot more about this today -- to start

11 discussing some of the recommendations that have

12 come out of Workgroup 3. We will be doing that

13 after lunch to get everyone's feedback

14 specifically on those recommendations.

15 So, that's, in a nutshell, where we

16 are at.

17 CHAIR LEINENKUGEL: Thank you very

18 much, Commissioner.

19 Commissioner Rose, Workgroup 4?

20 MR. ROSE: Yes, sir. We are looking

21 at the sufficiency of the resources within the

22 Department to ensure the delivery of good mental


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1 health care to our veterans. So, actually, I

2 think this really kind of encapsulates the entire

3 Commission and the duties that we're trying to

4 accomplish.

5 And so, in doing so, we have

6 approached, as Dr. Jonas said, the Quadruple Aim

7 Program, and we have gone out and visited

8 different facilities. We've had numerous experts

9 come in, both inside and outside the VA, to take

10 a look at just the level of mental health.

11 We have started to provide some

12 recommendations. We have an analytical plan that

13 we are working with. And I think it's extremely

14 important for us all to look, as, again, Dr.

15 Jonas had mentioned. But each one of the

16 veterans are individuals. So, if we can work

17 with the individual, and especially with mental

18 health, deal with a recovery program that gives

19 the veteran a better life and a better reason to

20 be alive and go forward with that life.

21 And I think we are gathering a great

22 deal of information. I think some of the things


31

1 that we have seen in our studies so far, and one

2 of those is the extreme importance of the veteran

3 peer support. Here you have a person who is in

4 recovery who has walked the walk, so to speak,

5 and they have been a tremendous outreach to help

6 the veteran, and not only those veterans that are

7 currently in the VA, but also to bring veterans

8 that are not in the VA into that system of care.

9 So, I think we're all working

10 together. We've got a common goal. We have a

11 target, and we are going to achieve that target.

12 Thank you, sir.


14 Commissioner Rose.

15 Commissioner Kuntz, Duty 5.

16 MR. KUNTZ: All right. I've been

17 really grateful for the staff that has supported

18 Duty 5 and all of the Commissioners.

19 We have a multi-pronged task, which I

20 have to repeatedly check the COVER Commission's

21 notes to make sure that I get it right, word for

22 word. But it is, it has been a lot of different


32

1 angles that we've had to explore, the first one

2 being suicide prevention. And I think that the

3 reality in the field, as we've seen it, is that

4 it is very hard to research suicide prevention

5 because of the numbers, and just there are

6 statistical challenges that make it hard to

7 research suicide prevention.

8 And we've explored that and the

9 systematic data. We kind of looked at -- there's

10 a number of different models that people think

11 about with suicide. So, I think that that's

12 probably something that we were fortunate to be

13 able to explore. Because of the statistic and

14 scientific challenges of doing broad-scale

15 research on just suicide prevention, then you've

16 got to think about your model and you've got to

17 think about other ways to analyze it. So, we've

18 worked hard on that.

19 And we are having audio difficulties.

20 So, I apologize for anyone on the call.

21 And three of our tasks have also been

22 a little bit more of really deep dives with the


33

1 data. And we've worked closely with Dr. John

2 Klocek to come up with some rough starting points

3 for where we're at. And I'm excited about what

4 he's developed and running them by the

5 Commissioners to see what we need to do to maybe

6 do a little bit deeper dive. But I do think that

7 the white paper process that we began in January

8 has come to fruition and will guide Duty 5

9 forward on those.

10 We also had a white paper done on what

11 is one of the more challenging pieces. Let me

12 make sure I get it right. Analyzing the efforts

13 of the Department to expand complementary and

14 integrative health treatments viable to the

15 recovery of veterans with mental health issues.

16 So, how has the VA been rolling out these

17 complementary and integrative treatments?

18 And we worked to have a white paper

19 done looking specifically at how the VA has

20 rolled out those treatments for outpatients,

21 because the majority of VA care is provided with

22 outpatients. And then, also, the funding has


34

1 actually been spent on, with the idea that either

2 VA staff or outside contractors, you know, if

3 you're paying for it, it's valuable. That's how

4 you're showing the value. So, we're working

5 towards that with a white paper that is almost

6 complete, and that's been really helpful in

7 seeing what is out there in scope.

8 And so, there are two kind of gaps

9 that I would like to tackle, like two more people

10 to come have talk, and what level they should be

11 at. One is Dr. David Gordon, the Director of the

12 National Institute of Mental Health. I've been

13 involved with inviting him to come present to us,

14 because that was one of the things that Congress

15 asked, is: how does this relate to what NIMH is

16 doing? And we heard that a number of times

17 yesterday.

18 And I do think it would be valuable

19 for us to hear it directly from the Director,

20 what they're looking at for mental health and

21 diagnostics, and the challenges, because this

22 isn't just a VA challenge. It's not just


35

1 something that the VA should be blamed for. Some

2 of them are kind of states of the science, and

3 it's nice to get an outside party with a lot of

4 money involved in research on that.

5 The other one is, in trying to compare

6 how the VA has made practices like yoga and tai

7 chi available, I think it will be important to

8 compare them to another health system that has

9 done it in terms of millions of people, not just

10 thousands or hundreds. So, I've been chasing

11 that down for several months, finding a group

12 that can do that.

13 The Medicare Advantage plans seem to

14 be very dialed in at making exercise, yoga, tai

15 chi, available to millions of people. It's part

16 of how they do business, whether it's Silver

17 Sneakers or UnitedHealthcare. And

18 UnitedHealthcare is willing to present to us

19 about how they make that available to millions of

20 their beneficiaries, if we're interested.

21 I certainly think it's important for

22 Duty 5 to get that, just so we can look at how


36

1 the VA is doing. But if that is part of what the

2 broader group wants to consider, we can have

3 that.

4 CHAIR LEINENKUGEL: Yes, I think

5 that's a real good recommendation, Commissioner

6 Kuntz, and something that certainly for the

7 October session we could certainly block an hour

8 or two. And I'm looking over at Casin and John

9 at this point, but I think that, as

10 Commissioners, it would be beneficial.

11 Does anybody not agree?

12 COLONEL AMIDON: It would just be to

13 learn the scope and scale with which they're

14 delivering that? And would it be to hear the

15 take rates from their patient population as well?

16 MR. KUNTZ: The take rates, I think if

17 we can get an in-depth on what you want to hear,

18 and that was one of the things that UnitedHealth

19 moved away from Silver Sneakers because they

20 weren't happy with the take rates.

21 COLONEL AMIDON: Yes, it would be

22 great to learn what they thought they knew, what


37

1 they knew along the way, how they've adjusted,

2 and what their programmatic -- you know, can you

3 tie it to other health outcomes, the whole

4 Quadruple Aim concept?

5 MR. KUNTZ: Right. And it's nice

6 because they are in a position where they are the

7 health care entities, so they have a reason to

8 want to reduce costs for health care. This is

9 part of what they do for that, and they do it in

10 a really big way. Because I don't think it's

11 fair to compare the VA to something that has a

12 thousand members. You know, you need apples to

13 apples at some level.

14 COLONEL AMIDON: I was just thinking

15 in terms of additive value to the workers as

16 well. You mentioned yoga and tai chi. You all

17 have a list of things. Would you need to know if

18 United does --

19 MR. KUNTZ: Yes, they --

20 COLONEL AMIDON: In other words, a

21 portfolio of delivery that correlates to their

22 applications?


38

1 MR. KUNTZ: Yes. Yes, I think it's

2 really interesting. And as you've added,

3 exercise, so they do have all of those different

4 studios that people can subscribe to. So, it

5 would be helpful to give them the list that Dr.

6 Maguen's been working on.

7 COLONEL AMIDON: Conservation of the

8 space, too. I think Humana had their Bold Gold.

9 I don't know how that interrelates.

10 DR. JONAS: Yes, we had a presentation

11 on that. We have to add on a summary of that,

12 actually. Maybe we can get it to you or

13 something.

14 CHAIR LEINENKUGEL: Are you okay with

15 that, then, Commissioner Amidon, as far as the

16 intent with it?

17 COLONEL AMIDON: Yes.

18 CHAIR LEINENKUGEL: And, yes, we

19 should be looking at each one of these additional

20 requests as, is it going to have the additive

21 value that we're seeking for the outcomes and

22 recommendations? And I would say that, in this


39

1 case, that Dr. Gordon and, also, your follow-up.

2 Dr. Jonas?

3 DR. JONAS: Well, as you just

4 mentioned, I like the idea very much of having

5 Dr. Gordon come and talk about that. We might

6 want to also ask -- and maybe it could be done at

7 the same time -- Dr. Helene Langevin, who is the

8 Director of the National Center for Complementary

9 and Integrative Health at NIH, to ask the same

10 questions.

11 They have just come out with an $80

12 million RFA where they're funding, jointly with

13 the VA and the DoD, on an integrative health care

14 focused on pain. It would be nice to find out,

15 do they have any plans or are there any

16 discussions --

17 CHAIR LEINENKUGEL: That would be

18 nice.

19 DR. JONAS: -- in mental health,

20 right?

21 CHAIR LEINENKUGEL: Right. That makes

22 sense. So why don't you add that on as a follow-


40

1 up for the October session as well?

2 Anything else? Yes, Commissioner

3 Rose?

4 MR. ROSE: Yes, I think that that's an

5 important part to share with the public, that we,

6 as a Commission, talk to each other. We have

7 conference calls. We participate in maybe three

8 different groups going through in this process.

9 And so, as we learn something, we share

10 something. And again, it's important to get to

11 the final product that we are trying to do. It's

12 extremely important.

13 Thank you.

14 CHAIR LEINENKUGEL: Commissioner Rose,

15 thank you. And thanks for clarifying that. That

16 should have been part of the beginning. But, no,

17 this work, this group of Commissioners has been

18 highly integrative, highly collaborative, and

19 very supportive of each Workgroup phase, and

20 there's a lot of mixing in between Workgroups of

21 Commissioners as well. So, it's good to note to

22 the general public and staff members.


41

1 At this point in time, I think what I

2 would like to do is take a quick, 15-minute

3 break.

4 I know we're having some audio

5 problems. Maybe they've been corrected. But if

6 we could work further on that? And I apologize

7 on behalf of the Commission. I thought that the

8 audio would be well set up in the particular

9 facility that we are in. We'll continue to work

10 on that.

11 And we'll do a break until 10:05 a.m.

12 We'll come back with further discussion on next

13 steps and we'll talk and discuss about writing

14 the report, so that there's a clear vision for

15 each one of the Commissioners of what it's going

16 to take in the next 100 days to get there. And

17 we'll also ask the writer at the time to give us

18 some more in-depth as to the timeframe and the

19 crunch that we're currently under in order to

20 meet our objectives.

21 So, 10:05 a.m. Break.

22 (Whereupon, the above-entitled matter


42

1 went off the record at 9:51 a.m. and resumed at

2 10:22 a.m.)

3 CHAIR LEINENKUGEL: All right. I'll

4 call the COVER Commission back in session at this

5 point. Thank you.

6 I think that we are now up on a better

7 audio system. So, we'll get that input back from

8 the general public.

9 And we just talked about milestones

10 for report completion, how we're going to be

11 addressing gaps in our research and data

12 collection; and also, now that it's time to speed

13 up the process as far as changing gears from

14 going from research analysis to actually make our

15 suggestions/strong recommendations for VA mental

16 health care.

17 I thought it would behoove all of us,

18 and the general public, to have Dr. Wendy LaRue

19 at this time, who was brought onboard by the

20 Commission to be our head writer, give the

21 Commissioners and the staff members and support

22 staff, and also the general public on the call,


43

1 how to go about writing a Commission-type report

2 and what it's going to take; and also, the time

3 crunch that we're under, so that there is a sense

4 of urgency gained not only from us, but also our

5 support staff.

6 So, at this point, Dr. LaRue?

7 DR. LaRUE: Thank you.

8 So, I think probably the best place to

9 start when talking about this topic is the end

10 and work about from there to think about what

11 that looks like.

12 With a late January report, we would

13 need to have a generally-approved report, the one

14 that you all raise your hand and say, "Yes, I

15 support his," at the December meeting. So, it's

16 easy to think, oh, we have until January, but we

17 really don't. So, automatically, you can cut off

18 a month of time from that.

19 To get to that report that you approve

20 in December, ideally, you would see a good part

21 of it, and not necessarily final content, but

22 some solid drafts at the November meeting. So,


44

1 you might be thinking now it's almost the middle

2 of September. And so, we're really talking about

3 six weeks from now, which is not very much time,

4 or maybe eight weeks from now. It's not very

5 much time. And so, there's a lot of work that

6 needs to be done between now and then.

7 Ideally, a good starting place would

8 be figuring out what we think our recommendations

9 will be. And I realize that we're still

10 collecting some data, and we can backfill where

11 we need to with data. But if we don't have a

12 roadmap for where we're going, we're not going to

13 get there by December.

14 With that in mind, I have a request

15 that Jake has said he will back. And that is, if

16 all the Workgroups could send a list of your

17 current thoughts on recommendations by next

18 Friday, close of business next Friday, so that I

19 can start to look at them? My guess is that

20 there will be a lot of overlap from Workgroup to

21 Workgroup, just based on my experience of sitting

22 in on Workgroup calls.


45

1 CHAIR LEINENKUGEL: Wendy, let me

2 interrupt for a minute, if I could.

3 DR. LaRUE: Sure.

4 CHAIR LEINENKUGEL: You're on a roll.

5 I also see Casin, and I was going to ask him to

6 start time-lining this on the white board, which

7 he is currently doing, for those that can't see.

8 But we will have that. It will also be

9 transcribed in our notes. And then, we'll

10 discuss as a Commission about actionable items

11 and reasonable standards, as far as the timing,

12 once you're finished.

13 DR. LaRUE: Okay.

14 CHAIR LEINENKUGEL: So, keep going,

15 Wendy.

16 DR. LaRUE: So, I think where I was

17 is, by next Friday, if all of the Workgroups

18 could provide tentative recommendations, and just

19 send whatever is on your mind. Because what I

20 will do with them in the next few days after that

21 is look to see where there is overlap. For

22 example, I know that several Workgroups have


46

1 talked about the need for further research on

2 various topics. And so, getting everybody's

3 recommendations, I'll be able to see where

4 there's overlap and help consolidate.

5 Our ultimate goal should be somewhere

6 in the neighborhood of 20 to 25 overarching

7 recommendations. And you should think of those

8 as very broad commandments of what should be

9 done. So, recommendations start with verbs, as

10 we've talked about before, because we want action

11 from the recommendations.

12 And then, the implementation part of

13 the recommendations will be in line with what

14 some might consider sub-recommendations. So,

15 those will be the nitty-gritty these are the

16 things that you need to do, Congress, VA,

17 whomever the recommendation is geared toward, to

18 make this big, overarching thing happen.

19 My guess is that, as I'm seeing the

20 things that you send me, I'll be able to take

21 some groups' recommendations and pull something

22 out to put over them, and some of those things


47

1 that you've sent as recommendations will actually

2 become sub-recommendations.

3 MR. GOODRICH: Wendy, this is John

4 Goodrich, the DFO.

5 Just to clarify, when you're asking

6 for the recommendations, those would be

7 recommendations from the subcommittees directly

8 to you, not to be shared amongst all

9 Commissioners --

10 DR. LaRUE: Correct.

11 MR. GOODRICH: -- because we would,

12 then, discuss those in October.

13 DR. LaRUE: Correct.

14 MR. GOODRICH: So, please, when the

15 Workgroup leads send those recommendations, they

16 should only go to Casin, Wendy, and myself. We

17 can distribute them among the staff, but please

18 don't send them to the entire Commissioner group,

19 just so that we avoid the appearance of

20 deliberations until we're back in a public

21 meeting.

22 DR. LaRUE: Thank you.


48

1 CHAIR LEINENKUGEL: Thank you for

2 that, John. It's very necessary to point out

3 that there's rules and regulations under FACA

4 that this Commission has to adhere to, and well-

5 pointed.

6 DR. POTOCZNIAK: I'm just wondering

7 from a Workgroup 2 standpoint, it's going to be

8 very hard for us to come up with recommendations

9 by Friday.

10 DR. LaRUE: My guess would be that you

11 might have some things on your mind --

12 DR. POTOCZNIAK: Correct.

13 DR. LaRUE: -- and really have to

14 shift as we get more data in. But the general

15 topics I think we probably know right now. And

16 there's writing that can be done even if we don't

17 know what the specific recommendation is. So, if

18 we know we need a recommendation on how VA does

19 outreach to veterans to get them in to get mental

20 health care, we may still be collecting data on

21 what veterans say would be the best way to

22 communicate with them, but we can still do some


49

1 of the background writing for a recommendation

2 that will talk about that. So, even if you don't

3 know specifically what you are going to

4 recommend, if you could even say, "We'll need a

5 recommendation on how VA contacts or reaches out

6 to veterans to get them in for mental health

7 care," that would be correctly sufficient.

8 DR. POTOCZNIAK: Well, we'll talk

9 about that.

10 DR. LaRUE: Is that helpful?

11 MR. SPERO: And, Wendy, I mean, you

12 can't write all the Workgroups' recommendations

13 at once, too. So, maybe Workgroup 2, because of

14 the challenges we've had --

15 DR. LaRUE: Right, right.

16 MR. SPERO: -- is pushed, but

17 generally --

18 DR. LaRUE: I can only write one page

19 at a time.

20 (Laughter.)

21 That said, if everybody waits -- a lot

22 of people are perplexed with the idea of that


50

1 limitation -- if everyone waits until the last

2 minute, you see where that gets to be a problem.

3 And we talked earlier about the

4 possibility of getting some staff that would be

5 sort of as needed part-time, possibly a graphic

6 designer. We've talked previously about getting

7 some additional writing help. But, even with

8 that, we're under a pretty serious time crunch.

9 So, the more we can put together, the better.

10 Also, this exercise will just help us

11 make sure that we're not producing things in a

12 vacuum and, then, realizing that we either have

13 conflicting recommendations or multiple groups

14 are working on the very same recommendation.

15 I will be doing a lot of writing. I

16 would hope that I will be doing even more

17 editing. And so, I know that the Workgroups have

18 been -- I see all the email traffic -- the

19 Workgroups have been collecting lots of research

20 studies, articles that support the directions

21 that they seem to be going. And I am aware of

22 all of that. Think about one person processing


51

1 that times five groups, not just the ones that

2 you're working on.

3 So, once we figure out what the

4 recommendations should be, anything that's

5 already written is going to be helpful, even if

6 it's chunks of material. And then, having the

7 actual articles or links to them to go with the

8 recommendations is going to be key. We can't

9 start from scratch on that.

10 So, just keep those things in mind.

11 But the starting point is, what do you plan to

12 recommend?

13 COLONEL AMIDON: Is the plan, to avoid

14 redundancy in recommendations and efficiency in

15 communication, that we will spend some time

16 looking at those overlaps, percolating what would

17 be recommendations into under thematic

18 delineations? Like, to your point, outreach is a

19 subcomponent of strategy communications. A lot

20 of what we're talking about could be enterprise

21 efficiency, bureaucratic barriers. Are we

22 thinking of top-line themes that would, then,


52

1 have cascading recommendations, so we have

2 efficiency in sort of context?

3 DR. LaRUE: That is what I would hope

4 to do from getting this information next week.

5 COLONEL AMIDON: Okay.

6 DR. LaRUE: Because until we can see

7 where everybody is heading, it's hard to know

8 what the big categories are.

9 COLONEL AMIDON: Right.

10 DR. LaRUE: I would think, ideally, we

11 have a few categories into which our 20 to 25

12 recommendations fall.


14 DR. LaRUE: So that there are arms of

15 VHA that do different things.

16 COLONEL AMIDON: Right, right.

17 DR. LaRUE: And this arm can, then,

18 cherry-pick what they care about in our report.

19 COLONEL AMIDON: And we can create a

20 one-pager.

21 DR. LaRUE: Right. Well, and

22 actually, past Commission experience, that is


53

1 exactly what we've done --


3 DR. LaRUE: -- is taken -- or the last

4 Commission that Jennifer and I worked where we

5 published about 3,000 pages worth of content,

6 nobody is going to read all 3,000 pieces. They

7 could read what they care about. So, we did a

8 lot of repackaging in different ways for

9 different interest groups.

10 And somebody mentioned this earlier,

11 but the most important part of our report, when

12 it's all done, will be the executive summary.

13 And we can produce like fold-over brochure-type

14 things that have the executive summary with

15 enumerated recommendations, just easy things to

16 go out and socialize what the recommendations

17 are.

18 DR. KHAN: Dr. LaRue, you already have

19 recommendations from 4 and 5 and partly from 1.

20 How can the rest of the Commissioners can see it,

21 so they're not rewriting the same subject?

22 DR. LaRUE: So, that gets tricky with


54

1 what John was mentioning earlier. You can't do

2 deliberation outside of a public meeting. But

3 that's why I'm asking to collect all of the

4 recommendations. And I will take the time to

5 categorize them, to see where there is overlap.

6 And then, at the October meeting we can go

7 through whatever structure seems to arise from

8 all I get.

9 DR. KHAN: I think the question is,

10 there are already about eight or nine

11 recommendations written that have been submitted

12 to you through -- at that particular time, John,

13 you were not in for it -- I think Wendy was and

14 maybe Casin. Yes, so did you see my

15 recommendation? If you didn't see it, but at

16 that time we were told to send it to --

17 MR. SPERO: Yes, we have them, Jamil.

18 DR. LaRUE: Right.

19 DR. KHAN: I think what I'm sharing

20 is, if Mike sees it, something that Jamil has

21 already written, then he will not be writing

22 about it. That's what I'm asking about.


55

1 MR. SPERO: So, Jamil, that has to be

2 shared in open sessions when we do that. And so,

3 I think today's some of that is probably going to

4 get shared, where we are already at, when the

5 Workgroups do their individual updates later.

6 The problem is, as you develop new ones --

7 DR. KHAN: Sure. Got it.

8 MR. SPERO: -- you know, we have to be

9 together and open and transparent.

10 CHAIR LEINENKUGEL: And there's

11 nothing wrong with having redundancy within the

12 Commissioners' recommendations. Because, by

13 September 20th, at that time we will know what is

14 redundant and what needs to be streamlined, and

15 we'll get back in open session and discuss those

16 or individual Workgroups, to say that you have

17 some commonality with another Workgroup. So,

18 we'll be able to figure that out once we get to

19 that September 20th.

20 And thank you for bringing that date

21 out. You know, it's like tomorrow. But I think,

22 Wendy, this is helpful. We need to continue the


56

1 discussion and questions because it's very

2 important about workflow and timing.

3 Just so the general public knows, the

4 majority of these folks have day jobs and are

5 extremely busy doing numerous other things in

6 relationship to that. So I just want everyone to

7 be aware that there are a lot of extra hours

8 going into this process outside of their general

9 practitioner jobs or duties that they have in the

10 civilian world.

11 So, Wendy, thanks, number one, for

12 clarifying the Friday date.

13 Any other comments from the

14 Commissioners about that particular date? Any

15 consternation or concerns?

16 Also, do you need to be more

17 definitive? I think it's pretty clear. You gave

18 us that, by November, we're looking at a solid

19 draft. And the November timeframe meeting,

20 again, can't be discussed publicly at this point

21 because it's not in The Federal Register, but the

22 earlier in November, the better. Right?


57

1 DR. LaRUE: Right. Well, I would

2 think at each of those reviews in November and

3 December that Commissioners would want to have a

4 week or so to actually read the report before

5 they have to comment on it.

6 (Laughter.)

7 So, you can think about those dates,

8 back up a week, and then, you see what the actual

9 work time is, because there's no work time while

10 you're reviewing.

11 CHAIR LEINENKUGEL: Right. How much

12 time is actually spent on the development of a

13 very clear, concise, actionable executive

14 summary?

15 DR. LaRUE: Once we have a solid

16 report, a good executive summary is easy.

17 CHAIR LEINENKUGEL: Okay.

18 DR. LaRUE: And because that's the

19 most important part -- you know, if we have good,

20 solid recommendations, we move forward as quickly

21 as possible on that, then that part writes

22 itself.


58


2 Commissioners, any other questions of

3 Dr. LaRue at this point? Comments?

4 Thank you very much, Wendy. That was

5 helpful.

6 DR. LaRUE: All right. Thank you.

7 MR. ROSE: Thanks so much, Wendy.

8 CHAIR LEINENKUGEL: So, we are ahead

9 of schedule. And obviously, the audio system is

10 much better than what it was during the first

11 hour, or we would have been pinged by the general

12 public that did that earlier. So that is good.

13 I think everybody is speaking up.

14 Tom, is it better from the

15 Commissioners' standpoint?

16 (Laughter.)

17 I think that let's do the start,

18 because what I'm trying to do, if we have the

19 opportunity, is to leave more time at the end of

20 the day, since now there is this sense of urgency

21 to get the recommendations, to actually get

22 through the updates on Workgroup 1 and 3. And


59

1 there's a lot of meat on the bone for both Dr.

2 Jonas and Mr. Maguen to discuss with us today.

3 So, I'm thinking that's going to be a couple of

4 hours.

5 So, Wayne, I don't know if you are

6 prepared or ready to begin at this point to go

7 through the Workgroup 1 update and all of your

8 requests and needs. If you are ready, thumbs-up,

9 let's do that. And then, let's plan on breaking

10 for lunch, and then, coming back with, Shira, if

11 you would, Workgroup 3.

12 DR. MAGUEN: Absolutely.

13 CHAIR LEINENKUGEL: Because, again,

14 all these are very important, but I know Wayne

15 has a large deck here for us to review and it's

16 all very pertinent material.

17 So, Dr. Jonas?

18 DR. JONAS: Thank you. I appreciate

19 that.

20 And, yes, I asked to print out a lot

21 of materials in it, just so that people have the

22 full materials there. But I can do a pretty good


60

1 summary of it for our discussion here and sort of

2 where we are. I already talked a little bit

3 about some of the gaps, but let me put the

4 context around what we're doing and sort of where

5 those fit in.

6 So, I think, first of all, just to

7 orient people around what this duty is, unlike

8 some of the others that have multiple subsections

9 of what they're doing, this is a single duty,

10 right, although there are subsections built into

11 it, if you look at it. But I just want to show

12 it's a single duty. It really is in many ways

13 sort of an overarching one.

14 I am hoping what I can do is -- and

15 I've heard this already this morning, as folks

16 have gone around and talked about their gaps --

17 I've seen immediate overlaps between the types of

18 recommendations around models of care, which this

19 duty is about, and things that other folks have

20 said. And so, that kind of synergistic

21 integration I think will be a part of what we

22 want to make sure happens, so that the report


61

1 comes out and it's both coherent, clear, and that

2 type of thing.

3 And so, this Duty Group is really to

4 look at the efficacy -- that is, how well it

5 works -- around the evidence-based therapy model.

6 So, this is the framework. A model is a

7 framework that organizes your thinking around

8 delivery of a service. And then, look at how

9 that's being done for mental health for veterans,

10 and then, identify how to improve those. So, how

11 do you improve those models? What are some of

12 the recommendations that can be made, and

13 especially around wellness-based components,

14 which is the last part of that phrase we talked a

15 little bit about?

16 Thank you for your question, Chairman,

17 about what's the difference between a clinical

18 outcome and a wellness outcome. We've been

19 discussing that, describing that. Actually, Tom

20 Beeman and others on that group, and Shira and I,

21 have had, I think, some very nice discussions

22 about what does it mean actually to do this.


62

1 So, those are the tasks. We have sort

2 of split that up into three, maybe four, major

3 types of information that we need to gather.

4 Much of it we've already seen, but just to

5 clarify, when you look at mental health and

6 integrative health or whole health, there are

7 basically three main models that exist.

8 One in mental health is the stepped

9 care or the comprehensive care model. It goes by

10 different names, but we've seen that presented a

11 number of times. That currently is in operation

12 for mental health.

13 There is the integration of mental

14 health into primary care. So, there's the PACT

15 model, which is the primary care delivery model,

16 and then, there's the integration of the mental

17 health into that, the Primary Care-Mental Health

18 Integration Model, and we've heard that.

19 And then, there's sort of the new kid

20 on the block, which is the whole health-

21 complementary, which is the community-based whole

22 health kind of approaches in those areas.


63

1 So, those are the three ones that

2 we're looking at. All of those have moved more

3 really -- again, not to confuse terminology --

4 but all of those have been moving more and more

5 toward taking care of the whole person. Mental

6 health, by bringing the mental health component

7 into the actual regular and routine care of

8 patients, whether they have a diagnosis or not --

9 and many in primary care and outside of the

10 formal mental health services need behavior and

11 mental health support in some way, even though

12 they might not hang around with a diagnosis. We

13 saw that in suicide prevention. Half of the

14 people never saw a mental health professional or

15 never got an actual mental health diagnosis. So,

16 it's beyond that.

17 And so, those are the three models

18 we're looking at, and there are some nice

19 descriptions of those. There's some graphics of

20 those. It's fairly easy to describe those. That

21 will be background kind of material.

22 The other thing we've been looking at


64

1 is the Quadruple Aim, is the framework for that,

2 and to what extent do health systems utilize

3 those. That really is largely the national

4 model, both inside and outside the VA, for

5 determining quality in health care. And I think

6 it's a challenge to actually find systems that

7 actually look at all four of those things.

8 Usually, quality improvement things will look at

9 one aspect of it or another aspect of it, but

10 very rarely are there systems that actually put

11 them all together and analyze them in a way where

12 you can actually look the offsets of one aim

13 against another.

14 It's easy to do costs, right? You

15 just stop paying for stuff, right? So, you can

16 lower costs; just don't provide the services, but

17 that doesn't have a very good impact on the other

18 aims. And so, balancing those aims out is sort

19 of key.

20 We talked about the wellness-based

21 outcomes. And so, this is an area right now that

22 I think we still have some gaps in, but we've got


65

1 a plan to kind of fill that in. This has to do

2 with putting the flourishing of the veteran in

3 the center of the care model, and then,

4 surrounding health care as supportive aspects to

5 help make that happen. Obviously, in chronic

6 illness and in mental health, that's key in those

7 areas.

8 So, that's the basic sort of approach

9 that we're taking to these areas. We're, again,

10 looking at inside and outside that.

11 I'll pause right there and see if

12 there's any questions. Because, then, I'll go on

13 to the method, the methodology that we're doing

14 and what data we're actually collecting. But

15 maybe I should stop right there and just ask if

16 there's any comments/questions from that now.

17 MR. ROSE: Dr. Jonas, just one thing,

18 as mental health advocate. If you look at the

19 diagnoses of mental illness, that can be a very

20 touchy situation, and it's not like having some

21 type of medical disorder -- heart, liver,

22 whatever. So, that's kind of a different animal.


66

1 DR. JONAS: It is. No, that's right,

2 and it's been widely acknowledged and there's

3 lots of data out there to show that, in general,

4 our health care system neglects mental health.

5 We pay for and do things to the body very

6 effectively and we'll do that type of thing, but

7 when it comes to mental health, we're just not

8 very good at it. You know, it's because it's

9 more difficult. It's more difficult to measure.

10 It's more difficult to know what it is. Frankly,

11 I think we have a habit of physicalizing

12 everything and sort of ignoring the social and

13 emotional parts of the human being and the mental

14 and spiritual parts of a human being.

15 And part of what we heard over and

16 over and over again from veterans for sure,

17 patients, family members, and providers is that

18 you've got to take whole-person modeling. You've

19 got to incorporate those things and acknowledge

20 them, and not make them sort of secondary types

21 of things or optional things in terms of looking

22 at them.


67

1 So, that clearly has to be strongly

2 embedded in one of our recommendations around

3 what does a new model look like. What does a

4 full-person model look like?

5 MR. ROSE: Thank you.

6 DR. JONAS: So that's great. Other

7 thoughts on that?

8 I will just add, just before I get

9 into the methodology thing, just even this

10 morning I could see immediate links to a lot of

11 what other folks were talking about. The

12 recovery model that you talked about in those

13 areas was key.

14 Methodologies for getting evidence, I

15 mean, qualitative evidence is as important for

16 getting information to make decisions around

17 clinical delivery as randomized control trials

18 are and clinical conditions. And yet, we have an

19 approach that uses a hierarchy of evidence, that

20 puts the randomized control trial at the top, and

21 then, because of that, tends to ignore other

22 things like good qualitative evidence. And so


68

1 it's harder to get that evidence because we don't

2 value it as much, and it's just not out there

3 when we're looking.

4 So we need to have not only more

5 whole-person or a more whole-person-oriented

6 approach, person-oriented approach in terms of

7 delivery, we need also to have a whole-person-

8 oriented approach for collecting evidence and

9 analyzing the evidence. And there are some great

10 things out there. We've actually talked about

11 other ways to do that, external validity issues,

12 qualitative evidence, that type of thing,

13 implementation science, person-centered evidence,

14 like what PCORI is doing and others that we've

15 heard from, AHRQ, and that type of thing.

16 So, again, I think that dovetails in

17 on the evidence recommendations, and we've

18 started to put some of those discussions into the

19 -- evidence component.

20 DR. MAGUEN: I just want to add,

21 too --

22 DR. JONAS: Yes.


69

1 DR. MAGUEN: -- I think that the point

2 you made is quite important. And I think just

3 big picture, what we're doing in this Commission

4 with all the Workgroups and our work as a whole

5 is really collecting data on both sort of the

6 qualitative and quantitative end. So, really,

7 we're utilizing as a whole Commission very much a

8 mixed-methods approach --

9 DR. JONAS: That's right.

10 DR. MAGUEN: -- and doing that in

11 unison. So, in between Workgroup 2, actually, 1

12 through 5, we're giving a lot of thought to that.

13 DR. JONAS: Right.

14 DR. MAGUEN: So, I think that's a

15 critical component to acknowledge --

16 DR. JONAS: Exactly.

17 DR. MAGUEN: -- the work we're doing

18 as a whole.

19 DR. JONAS: No, I agree, and you've

20 said the right term there. That's the term of

21 art right now that's used, is mixed methods. And

22 I think we should, you know, say yes on that, but


70

1 we actually should say, well, what are those

2 methods and how are they integrated; how are they

3 put together? What are some of the analytical

4 approaches and frameworks -- again, thinking of

5 research models -- that are doing that? And

6 there's a number of good examples out there. We

7 should just point to them and say, hey, VA needs

8 to take its evidence evaluation if it's going to

9 be consistent with these kind of delivery

10 approaches and evolve that in the direction of

11 that kind of mixed methods, where we value

12 evidence that is specific to the use of different

13 populations that are making decisions about

14 health care that aren't just payers, right, and

15 that kind of thing. Hopefully, that will come

16 out of that and be consistent with those.

17 So, any other thoughts or comments?

18 And then, I'll tell you about the methodology

19 that we're using.

20 CHAIR LEINENKUGEL: It's always

21 interesting, Dr. Jonas. You know, as the Chair,

22 I'm sitting here, now that there's a sense of


71

1 urgency to write recommendations, and just from

2 your 10-minute overview, about two

3 recommendations popped into my head, although

4 I'll keep them mute at this point. But, I mean,

5 it's an interesting evolution of conversation now

6 as far as what can we do differently when you're

7 looking at efficacy of the Secretary of VA model

8 with evidence-based.

9 DR. JONAS: Right.

10 CHAIR LEINENKUGEL: And then, also,

11 including there's that very important note that I

12 stopped you earlier on about the wellness-based

13 outcomes.


15 CHAIR LEINENKUGEL: I mean, there's a

16 lot going on with just your small one task there.

17 DR. JONAS: Right. Yes, and

18 hopefully, this will help. Hopefully, what we

19 can do can help.

20 We haven't written or proposed in our

21 Duty Group any draft recommendations at this

22 point because we've been kind of both collecting


72

1 information, but also stepping back and saying,

2 wait a minute; we need to know what's going on in

3 other areas to make what we say valuable and

4 consistent with what's going on in those areas.

5 So, I feel, given the timeline that's

6 going on, I feel a little bit nervous about

7 saying, God, we've got to get them out. And

8 then, I'm thinking, well, wait a minute; let's

9 get them right. And once they get out, I think

10 we'll be able to write them pretty easily, but I

11 haven't even done that yet.

12 CHAIR LEINENKUGEL: Yes, I didn't say

13 that they would be two solid recommendations.

14 (Laughter.)

15 DR. JONAS: No, but I think now

16 sharing those, those kinds of drafts and others,

17 it's time to do that.


19 DR. JONAS: So, part of my task, and

20 our task, over the next month is to really begin

21 to stick those together and, then, look how they

22 dovetail with other groups in a consistent way,


73

1 so that they are supportive and useful in those

2 areas. So, that would be one of the things.

3 I know, Shira, you and Tom and Jamil

4 and others around the group. So, I'm going to

5 put that now more upfront in terms of let's start

6 doing that, okay, even as we finish collecting

7 the data.

8 Now, in terms of the data collection,

9 if I can move on to that, I think I talked a

10 little bit about that, but just to give a summary

11 of that. There's several things that we're doing

12 to collect data. No. 1, there's a number of

13 reports that have been out there. I mean,

14 obviously, the one that the Institute of Medicine

15 did on mental health, a massive one that is still

16 pretty fresh and new, that's an example of one.

17 I just gave the Chairman a book from

18 the Institute of Medicine that was published in

19 2009 that was an overview of complementary and

20 integrative health. There's others out there.

21 So, we've look at a lot of the major

22 ones that relate to mental health and whole


74

1 health especially. And I have asked Sigma, and

2 they have done this. Those are available. I

3 think they've all been released, but we'll make

4 sure they get around or they are loaded on that.

5 They're doing sort of a structured

6 summary of all of those, because some of them are

7 huge and they're very difficult to go through.

8 So, they're doing a structured summary. So,

9 those would be available for people to look into.

10 And also, Wendy, you will be able to

11 tap into it in order to do some of your writing,

12 because it is new writing around that, but it's

13 linked directly back to that data, those areas.

14 So, that's one thing that they're doing.

15 The second thing is that we've talked

16 about how do we get information around the models

17 that are out there and the outcomes that are

18 being used in the VA and outside the VA. We

19 received most of the stuff from the VA, but one

20 of the major gaps was what's going on out in the

21 community for community care.

22 And so, I mentioned the challenges


75

1 around trying to get that comprehensively in the

2 country, and that really isn't possible in the

3 timeline, what we have. But what we did do is we

4 have developed a methodology for internet

5 assessment of selective top systems from around

6 the country.

7 And so, we used an objective approach

8 to identify those groups and classify them into

9 different types of hospital systems. When people

10 talk about, oh, where are the best systems in the

11 world, I always think about the ones that are

12 these major systems that are listed every year as

13 the top-ranked systems using one methodology.

14 Usually U.S. New & World Report is what they use.

15 There's other more objective

16 methodologies that are out there. IBM Truven has

17 been doing those for years that's based on CMS

18 and other quality measures. They rank the top

19 100 hospitals and they put them into categories

20 from large to small, to rural, to medium, et

21 cetera.

22 And so, we went through those, and


76

1 then, selected five in each of the five

2 categories that they have that are in that. And

3 then, Sigma is now going through and doing an

4 internet collection of the information around

5 that.

6 I think the internet collection will

7 be valuable because it's the kind of thing that

8 the public could theoretically do, or at least

9 they're publicly-available information sources.

10 When you ask a health system to tell us all the

11 great stuff they're doing, they'll be happy to

12 tell us all the great stuff they're doing. That

13 doesn't mean they're actually doing it.

14 (Laughter.)

15 And so that is not necessarily helpful

16 in terms of knowing is that a place I can go.

17 It's not available to your average veteran or

18 family member or provider that wants to find out,

19 is this available, or even the VA, when they're

20 trying to assess systems that are out there that

21 they might want to contract with community care.

22 Most of the time they have to go to publicly-


77

1 available sources to do that. It's very

2 difficult to collect it separately.

3 And so, we thought this would actually

4 provide a useful biopsy of what's available in

5 those areas. The initial ones we've looked at,

6 we can already see quite a bit of gaps in there,

7 but that's the state of the data, right? It's

8 still what you get when you go out there.

9 And so, that will be completed. It's

10 in the process of being done right now. That

11 will be completed. We'll have a nice hierarchy.

12 We did develop a pretty comprehensive

13 survey, and it had a lot of input in it from a

14 variety of people. It's big. It's complex.

15 It's something, if you said to somebody, if they

16 weren't forced to do, they probably wouldn't do

17 it. And Geisinger was kind enough to say they're

18 actually going to do it. And that was about a

19 month ago, and they still haven't gotten it back

20 from them. That just tells you immediately that

21 it's probably unlikely we're going to get a whole

22 lot of other systems to do that. So, it will


78

1 have to be simplified.

2 But the nice thing about it, it is an

3 overview of the kind of information that we want

4 to see systems collecting and doing to provide

5 this kind of whole-person care. So, I think it

6 will be useful later, and we may get some

7 information out of that. It would need to be

8 refined, solidified, validated.

9 One of the things that we might

10 suggest that the VA at some point do is actually

11 refine that and actually begin to do that, or

12 somebody else in the --

13 CHAIR LEINENKUGEL: Wayne, could I

14 make a recommendation? And I should have done

15 this earlier when I saw your list. To possibly,

16 now that you're struggling because it is so -- I

17 call it "an intense survey" --

18 DR. JONAS: Yes, intense.

19 CHAIR LEINENKUGEL: -- but very well

20 done and necessary for what I think you're

21 looking for, and we are as a Commission. To

22 include possibly Marshfield Clinic --


79

1 DR. JONAS: Uh-hum.

2 CHAIR LEINENKUGEL: -- because, again,

3 I have an affiliation; I'll disclose that to the

4 general public. I'm a former Board member. And

5 also, that is my clinic of choice outside of VA

6 care, which I am not eligible for.

7 So, that being said, I think that they

8 would be responsive and it will also give you,

9 give us, a pretty good aspect of rural northwest

10 and now expanded eastern Wisconsin and the UP of

11 Michigan --

12 DR. JONAS: Uh-hum.

13 CHAIR LEINENKUGEL: -- which they have

14 clinicians and providers in.

15 DR. JONAS: Okay.

16 CHAIR LEINENKUGEL: And also, I know

17 that they would be very receptive if the

18 Commission were to participate, if you find it of

19 value.

20 DR. JONAS: I think that would be

21 valuable. I think, instead of just sending it

22 sort of randomly out, which we talked -- not


80

1 randomly, but we had had actually proposed to do

2 this to some of the larger systems. I think we

3 still need to have it refined, evaluated. We

4 need volunteer systems that are willing to spend

5 the time to help us develop it further. And if

6 by the end of the report we've done that a few

7 times, that will actually move it along very

8 nicely.

9 So, if there are groups that are

10 willing to do that -- Geisinger already is doing

11 that. If Marshfield gives us that kind of

12 another test case on that, it would be helpful.

13 So, if you wanted to put me in touch with that, I

14 could contact them.

15 CHAIR LEINENKUGEL: I'll help you out

16 with that.

17 DR. JONAS: We can do that in a break.

18 So, that I think is where we will

19 continue to fill in that information. We won't

20 get the ideal thing, the ideal thing without a

21 dilatory aspect. But we will get, I think, what

22 we need, and the public will know what we intend


81

1 to do.

2 The final dataset that we're looking

3 at is a summary of quality of the VA and non-VA

4 care for veterans. There has been a number of

5 studies doing that kind of quality assessment,

6 most of them not in mental health actually. But

7 there are some others that have done that.

8 An example, I think, Matt, you put

9 this in the Commissioners' thing, this recent

10 summary from the RAND, research from the RAND

11 which is "Improving the Quality of Mental Health

12 Care for Veterans" that actually does that. So,

13 these are excellent. These are rigorous,

14 systematic evaluations of that information.

15 And we have done a literature search

16 and collected all of these types of studies that

17 are there. We're now going through, with Sigma's

18 help, in terms of doing summary analyses of those

19 studies, so that we'll actually have an up-to-

20 date biopsy of all the current studies that have

21 been done doing this kind of comparative

22 evaluation in all areas of health care, including


82

1 mental health.

2 And then, a second part of that, there

3 have been studies that have looked specifically

4 at outcome differences, looking at things like

5 satisfaction, for example, access, that type of

6 thing. So, that's a second category that we're

7 going to be doing a summary table on.

8 So, we will be able to provide sort of

9 a current update of the recent research that's

10 been done on quality in those areas. All that I

11 think will be, should be completed in the next

12 month, except the survey part, which is a

13 developmental item. Hopefully, we'll have that

14 towards the end.

15 And that's sort of where we're at.

16 DR. KHAN: We need to give the

17 recommendations by the 20th?

18 DR. JONAS: We do. So, like I say,

19 I'm going to be getting our group to really start

20 focusing on recommendations, and we'll try to

21 collect the ones that are out there in the other

22 groups, and then, try to make sure what we're


83

1 doing has consistency in terms of supporting

2 those types of recommendations. We'll be doing

3 that in the next month, although I am gone for

4 the next two weeks. So, I'll be doing some of

5 that while I'm on the planes, in those areas, and

6 then, hopefully, bring it back in a coherent way

7 for the Working Group to begin to look at in

8 those areas.

9 I think that kind of does it for me.

10 I could talk a little bit about the Boston visit,

11 if you would like. That might be helpful.

12 CHAIR LEINENKUGEL: Yes.

13 DR. JONAS: Do we have time for that?

14 CHAIR LEINENKUGEL: I'd find it

15 helpful.

16 DR. JONAS: So let me stop there for

17 a minute before I switch gears here. Are there

18 any thoughts and comments for this?

19 I actually do have a question on our

20 writing the recommendations for my group. Would

21 you like to see them as developed as possible or

22 would you like to see them in small snippets? It


84

1 sounds to me, given the urgency of the timeline,

2 it might be better to kind of deliver the whole

3 thing, and then, ask you to take the time to kind

4 of do a deep dive and have a discussion of that

5 over several of our meetings, if that's okay. I

6 mean, I think that would accelerate it, if that's

7 okay.

8 I could spend a fair amount of time

9 looking at the other recommendations, coming up

10 with some for models, for the model components,

11 kind of flesh out the action items or the

12 subcomponents the best I can do them at this

13 point, then bring that as a whole to the group,

14 the Working Group, for our discussion and that

15 kind of thing. Would that be a useful approach

16 to doing this?

17 DR. LaRUE: So, I think something to

18 keep in mind is --

19 CHAIR LEINENKUGEL: Dr. LaRue, hold

20 on. This is Dr. Wendy LaRue responding to

21 Commissioner Jonas' query, again, concerning

22 timing of recommendations.


85

1 DR. LaRUE: Yes, so something to keep

2 in mind about the structure of the report is that

3 there will be two main sections. One section

4 will be the recommendations and the backup of

5 those recommendations that's very specific to the

6 precise language of the recommendations. And the

7 other major section will be, in essence, the

8 research report by Workgroup.

9 So, it sounds like what you're talking

10 about will largely be that second part, the sort

11 of research behind everything.

12 DR. JONAS: No, I'm not talking about

13 that.

14 DR. LaRUE: Oh, okay.

15 DR. JONAS: I just did a summary of

16 that research that's going on. But, right now,

17 what I'm talking about is, what's the best

18 approach to begin the process of doing the

19 recommendations? Okay? So, the research is

20 going on, but we haven't done any of the

21 recommendations.

22 DR. LaRUE: Right. So, I would go


86

1 back to what I said earlier, which is you

2 probably at least know the areas where you need

3 to have recommendations, even if you don't know

4 the precise direction.

5 DR. JONAS: No, we've got a lot of

6 information already. I mean, a lot of the

7 research that we're filling the gaps in with that

8 I just summarized is going to be helpful in terms

9 of justifying some of what we're doing. It may

10 alter some of what we're doing, but we've got

11 enough now that I think we can begin the process

12 of doing the recommendations.

13 But my question was what would the

14 best process for doing that be to try to

15 accelerate it? To write all of those and some of

16 the sub-recommendations in as much detail as

17 possible for our deliberation, okay, or just send

18 the top-level ones out, and then, come back again

19 for the sub-recommendations? I mean, I think if

20 we did them as a -- I don't want to overwhelm the

21 group with --

22 CHAIR LEINENKUGEL: I think Wendy is


87

1 saying that, if by September 20th, you could do

2 and/or, it would be great.

3 DR. JONAS: That's what I was

4 thinking, given the timeline, yes.

5 DR. LaRUE: Yes.

6 DR. JONAS: Okay. Great.

7 DR. LaRUE: If all you can give me on

8 September 20th is these are the big ideas, that's

9 fantastic. If you can give me, these are the big

10 ideas and these are the ones that fall under it,

11 that's even more fantastic, because it will help

12 me see the overlap.

13 DR. JONAS: All right.

14 DR. LaRUE: The more, the better.

15 DR. JONAS: However, I would like to

16 make sure the Workgroup, the Duty Group, actually

17 has seen them, has the ability to have input and

18 everything before I send them.

19 DR. LaRUE: Well, then, that's why I'm

20 thinking close of business Friday. That gives

21 everybody a full week to have their regular

22 meetings.


88

1 DR. JONAS: So, you want them by

2 September 20th?

3 (Laughter.)

4 DR. LaRUE: I really do.

5 DR. MAGUEN: So, we're going to be

6 able to be on a call before they get sent out.

7 CHAIR LEINENKUGEL: You may, as

8 Commissioner Workgroup leads, actually need

9 multiple calls the following week. They may be

10 for half an hour each. I don't know. But, with

11 the condensed timeframe and with six business

12 days basically to do the "writer's ask," which we

13 concurred with, at least in a simplistic form, to

14 use Dr. LaRue's context, I think that approach

15 can be done. But I know, Wayne, you're talking

16 about travel.

17 DR. JONAS: Yes.

18 CHAIR LEINENKUGEL: You may have to

19 certainly probably have someone fill in. But I

20 would use the time in closed session today and

21 tomorrow to answer those questions.

22 DR. JONAS: Okay. That's great, and


89

1 we can have that discussion.

2 So, we usually have our calls or do

3 these calls on Friday. Okay? We're not doing it

4 this time because we're having this meeting on

5 Friday. We'll have discussion around that. Next

6 Friday, which is the 20th, that would be next

7 Friday. So, there was no time on our current

8 schedule when we could actually have a Duty Group

9 discussion about this before the deadline she

10 just said.

11 DR. MAGUEN: Unless we do that, and

12 then, it gets sent. So, we can meet on a call,

13 and then, it gets sent by close of business. So,

14 we'll have a chance to touch base, and then, you

15 send it later in the day.

16 DR. POTOCZNIAK: Let me just ask, I

17 know you can only write one page at a time.

18 There are some people here that have

19 recommendations that have probably already

20 written up. Is there any way that it could be

21 like a two-phase thing where those people get you

22 all those by Friday, and then, the next set of


90

1 people who aren't quite ready to do that would be

2 by the next Friday?

3 DR. LaRUE: That's an interesting

4 question.

5 DR. POTOCZNIAK: Because you can't,

6 like you said, you can't really write it all --

7 DR. LaRUE: What that would preclude

8 is the ability to see all of it in a big picture,

9 and that's really what I think is vital.

10 MR. SPERO: Can I jump in here? So,

11 I wasn't aware of the September 20th plan before.

12 I don't really know where that came from, but I

13 actually agreed with Mike's point. Even with

14 Workgroup time today, I don't see how that gives

15 us enough time.

16 DR. LaRUE: So, if we said Tuesday the

17 next week, would that --

18 MR. SPERO: If we had asked three

19 weeks ago for them to schedule calls next week --

20 as you said, Jake, everybody has full-time jobs

21 here. So, I just don't think a September 20th

22 date -- if you have recommendations, I think we


91

1 should try to get them in. But I think we need

2 to be understanding of people's time and --

3 CHAIR LEINENKUGEL: I did ask, and

4 Wayne rose it, and Mike replied to it. And now

5 you interjected. But I did ask earlier in the

6 meeting if everybody was fine with September

7 20th. And so, now is round two in the debate

8 deliberation to come up with a firm date that all

9 Commissioners will agree to.

10 (Laughter.)

11 So, that is back in play right now.

12 We will, as the Commissioners, make that

13 decision, and then, let Dr. LaRue know that. But

14 I would say, since we're on that topic, what do

15 the rest of the Workgroup leads, besides Dr.

16 Jonas at this point and Dr. Potoczniak,

17 recommend?

18 Commissioner Rose?

19 MR. ROSE: Yes. Group 4, and we will

20 do our best to make that September 20th deadline.


22 MR. ROSE: And we've already got some


92

1 in the works. And so, we will do our best to

2 meet that.

3 COLONEL AMIDON: Acknowledging that

4 this is the first phase of recommendation

5 development, so we have our Workgroup call

6 Monday-Tuesday-ish.

7 CHAIR LEINENKUGEL: So, Workgroups 4

8 and 5, which is Commissioner Kuntz -- and I

9 think, Matt, would you agree September 20th would

10 be doable for the initial recommendations?

11 MR. KUNTZ: Yes, we've been pushing

12 this out and getting Duty 5 ready for two months.

13 CHAIR LEINENKUGEL: And Commissioner

14 Amidon is the lead of Group 4 and 5 as well. So,

15 do you concur with September 20th?

16 COLONEL AMIDON: To get initial stuff?

17 Yes.

18 CHAIR LEINENKUGEL: Okay. So, 4 and

19 5 have got concurrence on September 20th. So,

20 Wendy, that's helpful, right?

21 Let's go 1, 2, and 3. And Admiral

22 Beeman is not here, but, Dr. Jonas, what date


93

1 would make sense with you? And certainly you've

2 got the two other Commissioners, Maguen and

3 Potoczniak, right across from you. So, let's get

4 a preferred date, a test date.

5 DR. JONAS: Well, I mean, my concern

6 is time for us to discuss it. That's my concern.

7 Right now, there's no time to discuss it.

8 CHAIR LEINENKUGEL: Amongst your

9 Workgroup?

10 DR. JONAS: Among our Workgroup, yes.

11 That's my concern.


13 DR. JONAS: I mean, I can put them out

14 as a preliminary thing for our discussion by next

15 week, okay, especially after these couple of

16 days. They will not have yet incorporated the

17 kind of cross-tabulation that we've been talking

18 about here. We don't have time to do that

19 because we haven't actually seen them.

20 MR. KUNTZ: And we didn't do that.

21 I'll just say, like what I requested from Duty 5

22 was everybody submit. We're expecting overlap.


94

1 Let's fire them downrange, and we can get working

2 on them after that.

3 DR. LaRUE: I would suggest that this

4 first around is not about -- you don't need to

5 edit things out. This is the brainstorm; these

6 are all our ideas. And at the October meeting is

7 the paring things out, if that's helpful.

8 DR. JONAS: So, I cannot do the call

9 on the 20th because I'm actually running an all-

10 day meeting in Europe on the 20th, unless it's --

11 I don't know what the time difference is, but

12 maybe I can do that on the 20th, but it will

13 probably be 3:00 in the morning or something.

14 Nine o'clock California time is six o'clock.

15 Anyway, I'll look at that, but I don't think I

16 can do it on the 20th. I'm running an all-day

17 meeting on the 20th.

18 CHAIR LEINENKUGEL: Dr. Jonas, could

19 you do some of this over email and get consensus

20 through email?

21 DR. JONAS: Sure. Yes. But what I'm

22 saying is that I might --


95

1 CHAIR LEINENKUGEL: Then, you can have

2 discussion, if you want, right?

3 DR. JONAS: We can have a discussion

4 actually when we're doing our deliberation at our

5 subgroup tomorrow or later this afternoon, and

6 we'll try to figure that out. So, I can't

7 actually answer the question right now, but I can

8 get it to you.

9 MR. SPERO: So, can we table the date

10 until tomorrow morning for the final date for all

11 Workgroups?

12 CHAIR LEINENKUGEL: I think that's

13 smart, yes. I think it's the right thing to do

14 because we'll go through Workgroup sessions later

15 this afternoon in closed. And that's a good

16 idea.

17 DR. JONAS: All right. And then, we

18 can get a date.

19 MR. SPERO: I mean, from the staff's

20 perspective, I think this thing is for you guys

21 all to be comfortable, but also --

22 CHAIR LEINENKUGEL: You're also


96

1 looking at your workload as well. We understand

2 that.

3 MR. SPERO: Well, Wendy's workload,

4 working with the staff. But I think we want to

5 be sensitive to Wayne's point that he doesn't

6 want to put up recommendations on behalf of

7 Workgroup 1, even if they are just for

8 deliberation. You know, the Workgroup does need

9 agreement. So, I think that's a fair point that

10 we need to consider.

11 And to Mike's point, we're just

12 finishing collecting the basic information. He

13 needs to really add that last piece in. I

14 definitely want to make sure we're -- you know,

15 you are all comfortable as a group. We'll do

16 what we can to get you there.

17 DR. POTOCZNIAK: I think just to add

18 for Workgroup 2, because I know we are going

19 around, for Workgroup 2, what I would need, at

20 least to even come up with potential kind of

21 recommendations is what themes we're seeing from

22 you guys that are out there in the field right


97

1 now. And then, we can always refine it as you do

2 the coding and stuff like that. But I'd be okay

3 with making those recommendations, the potential

4 kind of recommendations, because I have an idea

5 of what we're probably going to hear, but I don't

6 know how it's coming out in your focus groups,

7 right?

8 DR. LaRUE: I can probably get that to

9 you before we leave for today.

10 MR. SPERO: And I was going to suggest

11 to you, actually, something. If you like during

12 your Workgroup time tomorrow in open meeting,

13 Wendy and I would be happy to have a discussion

14 with all of this of the themes that we picked up

15 over the past month, as we've been going through

16 these.

17 COLONEL AMIDON: That would be the

18 best idea.

19 MR. KUNTZ: I have one other request I

20 guess on just kind of procedurally. I would like

21 for any of the recommendations that Commissioners

22 in a group to move forward, I mean, if there is


98

1 one Commissioner that the rest of their Duty

2 doesn't agree, that should still come to the rest

3 of us. If that group doesn't like it, that

4 doesn't mean that it doesn't go forward. So, if

5 a Commissioner has a recommendation, I want to

6 make sure that it at least gets to the Board and

7 the rest of us have the chance to vote on it, if

8 a Commissioner cares about it that much.

9 CHAIR LEINENKUGEL: I don't think any

10 Commissioners have any concerns with what you're

11 requesting.

12 COLONEL AMIDON: My assumption was,

13 yes, the first tranche is all captured and the

14 recommendations, however precise or defined, to

15 Mike's point. We may not know the data to drive

16 the recommendation, but we have a delete button.

17 (Laughter.)

18 CHAIR LEINENKUGEL: Like I said

19 earlier to Dr. Jonas, I have two potential

20 recommendations. I don't know if they're good or

21 not.

22 (Laughter.)


99

1 I think to your point, Commissioner

2 Kuntz, I think that we would all agree that this

3 first go-round, as Commissioner Amidon said, is a

4 free-for-all grab bag. Throw them out there, and

5 then, we're going to get back and have the

6 debate, discussion, deliberation, and all.

7 DR. JONAS: I think that's great. I

8 just want to make sure my Workgroup has the time

9 to have the first grab at the grab bag.

10 CHAIR LEINENKUGEL: Understand.

11 DR. JONAS: That's all.

12 CHAIR LEINENKUGEL: And it makes it

13 much clearer, as we said earlier, and Casin

14 stated again that we all have other jobs, except

15 for me, which is golf, obviously.

16 (Laughter.)

17 Wayne, thank you very much.

18 DR. JONAS: Thank you. I'm finished.

19 CHAIR LEINENKUGEL: Any other order of

20 business at this point in time?

21 If not, what I thought we would do is

22 break for an early lunch, seeing that we are


100

1 ahead of schedule.

2 I think we've made great progress as

3 a Commission in a very short amount of time here

4 as far as concurrence and, also, a little bit of

5 pushback as far as timing to Dr. LaRue's request,

6 which I appreciate and I wanted it to get out in

7 the open, so that there is that sense of urgency,

8 but also clarity as far as 100 days is not a long

9 period of time to do the amount of work that we

10 have to do. So, I think all the Commissioners

11 are well aware of that. I think that, once

12 closed session meetings go into place, it will

13 become much clearer.

14 And to other Commissioners' request,

15 in particular, Dr. Jonas, we'll come back with a

16 better time period for the initial

17 recommendations by tomorrow morning. Is that

18 agreed upon by all the Commissioners?

19 So, at this point, I would like to

20 officially break at 11:25 and have us back

21 here -- Casin, John, 12:45? Give everybody a

22 good hour-plus to chat, decompress, catch lunch.


101

1 And we'll do a 12:45 startup in open session

2 again to go on to Duty 3 and Commissioner Maguen.

3 MR. SPERO: I'll just say, did we get

4 through the Boston --

5 CHAIR LEINENKUGEL: We didn't. I'd

6 like to do that.

7 MR. SPERO: Do we want to just start

8 with that after lunch then?

9 CHAIR LEINENKUGEL: Let's do Wayne's

10 overview of Boston, because it's a full one-page

11 coverage, if you don't mind doing that.

12 DR. JONAS: Okay.

13 CHAIR LEINENKUGEL: And we can do that

14 after lunch.

15 DR. JONAS: After lunch is fine.

16 CHAIR LEINENKUGEL: Yes. Great.

17 MR. SPERO: And then, we'll go into

18 Workgroup 3?

19 CHAIR LEINENKUGEL: Correct.

20 MR. SPERO: Okay. Perfect.

21 CHAIR LEINENKUGEL: All right.

22 Thanks.


102

1 We are presently closed and on lunch.



4 12:50 p.m.)

5 CHAIR LEINENKUGEL: Good afternoon,

6 everybody. This is the COVER Commission open

7 session meeting of September 12th in Washington,

8 D.C., and at this point in time coming out of a

9 lunch break.

10 As we noted in the morning session we

11 were going to go to Workgroup 3, which is led by

12 Commissioner Shira Maguen.

13 And, Shira, if you would, please begin

14 the update on Workgroup 3.

15 DR. MAGUEN: Thank you so much,

16 Chairman.

17 So, as a reminder for those on the

18 call, I know that the Commissioners are all aware

19 of Duty 3's scope, but I wanted to just read it

20 one more time. So, our duty is going to "Examine

21 the available research on complementary and

22 integrative health treatment therapies for mental


103

1 health issues and identify what benefits could be

2 made with the inclusion of such treatments for

3 veterans."

4 In order to accomplish this, we're

5 examining several different mental health

6 modalities as well as several different mental

7 health conditions. And so, we're examining PTSD,

8 opioid use disorder, alcohol use disorder,

9 suicidal behavior, depression, bipolar disorder,

10 generalized anxiety disorder, and insomnia.

11 I want to also remind people of the

12 Workgroup membership here. Thomas Beeman is the

13 subcommittee lead for Duties 1, 2, and 3,

14 including ours. In addition to myself, the

15 Commissioners are Mike Potoczniak, Jack Rose,

16 Wayne Jonas. Alison Whitehead is our ADFO. Our

17 mental health subject matter experts are John

18 Klocek, Kendra Weaver, Stacey Pollack, and Sigma

19 support, Shannon Beattie and Hanifah Mohamed.

20 I want to just update everyone on what

21 we have completed up to date. After I do that,

22 I'm looking forward to sharing some of the


104

1 working recommendations that have come out of

2 this Workgroup and want to get Commissioners'

3 feedback on those that we have been discussing on

4 the call for Workgroup 3.

5 So, first, I wanted to just remind

6 people that the post-traumatic stress disorder

7 systematic review and executive summary was

8 completed on April 4th, 2019. The opioid use

9 disorder systematic review and executive summary

10 was completed June 5th, 2019. Alcohol use

11 disorder was completed on June 14th, 2019, and

12 the suicide risk systematic review was completed

13 on August 24th, 2019.

14 We currently have the major depressive

15 disorder systematic review and executive summary

16 completed. I mean, we just received that

17 yesterday, so the Workgroup is going to be

18 reviewing those findings and discussing working

19 recommendations for that on our next call.

20 I want to now move, given that we have

21 four finished reports and executive summaries and

22 have working recommendations, I want to move to


105

1 those for the Commissioners to discuss and

2 review. Again, I want to emphasize that these

3 are working recommendations that we're now going

4 to put up for deliberations.

5 Embedded in these recommendations are

6 some of the findings. So, you'll see that I'm

7 going to summarize for all of you where we found

8 evidence, where we did not find evidence, as well

9 as the strength of the evidence, for each of

10 these mental health conditions.

11 Okay. So, the first condition, as I

12 mentioned -- this is the one that we started with

13 -- is post-traumatic stress disorder. I'm just

14 going to read the recommendations out loud.

15 To provide a frame, we have made four

16 different recommendations that are specific to

17 mental health disorders and related behaviors.

18 And then, we also have recommendations that we've

19 made that really fall under the umbrella of

20 applicable to all disorders. I'm going to be

21 going over all of those with you today.

22 First, for post-traumatic stress


106

1 disorder, I'm going to specifically highlight the

2 areas in which there were not any randomized

3 control trials. And so, our first recommendation

4 is "To conduct and fund research related to

5 complementary and integrative health treatment

6 interventions." And PTSD, in particular, and

7 then, particularly multi-site trials.

8 Again, we want to conduct or fund

9 research in these areas, and specifically, we

10 think that multi-site trials are the way to do

11 this. So that we're not only looking at one

12 specific area of the country, but really doing a

13 deeper dive and looking at how these treatments

14 might affect people at different parts of the

15 country within different cultures.

16 So, more specifically, we found that

17 there were not any RCTs for PTSD outcomes with

18 the following modalities: art therapy,

19 cannabinoids -- and I will say here that, with

20 cannabinoids, an RCT was conducted, but never

21 published. So, we saw and we found that that RCT

22 was conducted, but we can't get those results to


107

1 date.

2 COLONEL AMIDON: Do we know who

3 conducted them?

4 DR. MAGUEN: We do, yes, and I have

5 that information.

6 COLONEL AMIDON: Oh, okay. Thanks.

7 Great.

8 DR. MAGUEN: Yes. Music therapy, tai

9 chi, service dogs, chiropractic care, hyperbaric

10 oxygen therapy. There were two RCTs containing a

11 small percentage of PTSD patients, but the PTSD

12 subgroups were not separately analyzed. So, we

13 really don't have any information about the PTSD

14 outcomes, in particular. And then, massage

15 therapy.

16 Again, these are the conditions in

17 which there were not any RCTs. And now, I'm

18 going to move to the conditions where there were

19 some trials. Now this is, again, part of that

20 first recommendation.

21 The following modalities had low

22 strength of evidence with respect to PTSD


108

1 outcomes due to methodological and study design

2 issues. So, further studies may be required.

3 And just as a reminder to Commissioners, what we

4 did, when we found studies that existed, we

5 evaluated each study based on the Cochrane 2.0

6 Rules of Bias. And so, we wanted to really find,

7 is the quality of the study strong or are there

8 problems, both methodological and study design

9 issues, that might lower our extent of what we're

10 willing to resolve about some of these studies?

11 Basically, what we found: low

12 strength of evidence for accelerated resolution

13 therapy, acupuncture, equine therapy, exercise,

14 healing touch, relaxation therapy, and TMS.

15 Then, there were additional studies

16 that were done. I'll just read the

17 recommendation. "To conduct/fund research

18 studying CIH modalities as an adjunct treatment

19 to evidence-based PTSD psychotherapies and

20 medication, since these trials would mirror how"

21 -- sorry, let me just go back for one second --

22 "since these trials would mirror how treatment is


109

1 generally provided in clinics."

2 What we have done in the searches is

3 we have looked at these CIH modalities as both a

4 monotherapy -- so, if it's used alone in looking

5 at whether or not it improves PTSD -- as well as

6 an adjunctive therapy, which means that people

7 were able to receive evidence-based treatments

8 for psychotherapy related to PTSD or medications

9 related to PTSD.

10 And so, what we really recommend, and

11 what we really believe should happen, is that

12 these studies really will mirror what happens in

13 our clinics. We know that when someone comes in

14 for PTSD, we want them to receive what we know

15 works best. And so, we envision CIH being used

16 in conjunction with those treatments that we know

17 work best, rather than as a monotherapy.

18 And so, we want the studies that are

19 done to mirror that because, otherwise, it's not

20 reflecting what actually happens in clinical

21 care. So, there are different ways to do that,

22 including pragmatic trials, but we really


110

1 strongly believe that that should mirror what

2 happens in our clinical work. As an example,

3 acupuncture could be studied as an adjunctive

4 treatment to the standard of PTSD clinical care;

5 i.e., PTSD psychotherapy plus acupuncture.

6 Any questions about those first two

7 recommendations so far?

8 Okay. Maybe what I can do is go

9 through all of the PTSD ones, and then, open it

10 up for questions. And then, we'll just keep

11 going as we move along. But, hopefully, you are

12 getting a sense of what we found in the

13 systematic reviews: that, overall, there were

14 few studies that were actually RCTs and that

15 those that we did find, the strength of the

16 evidence was low.

17 Yes?

18 MR. KUNTZ: Shira, this looks great.

19 I think it's really solid, I guess. Just kind of

20 wondered, do you think that this kind of

21 recommendation is similar to what you would do if

22 you were to take PTSD out and just say mental


111

1 health conditions? I mean,

2 transdiagnostically --

3 DR. MAGUEN: Yes. And so, I think

4 that the way that we've structured it, the way

5 that we have for the conditions initially, I

6 think that when we sit down with Wendy, there

7 will be a big umbrella about conducting research,

8 for the research and what that will look like,

9 and it will be specified by each condition. But

10 the way that I've done it this way initially is

11 for us to really get an understanding of, by

12 disorder, where the studies exist and where

13 they're lacking.

14 But I do see us having a larger

15 umbrella under which -- so, you will see, for

16 each disorder that I go through, there's a

17 parallel structure, and I'm thinking ahead to

18 being able to consolidate under one general --

19 MR. KUNTZ: Yes, that is what I was

20 guessing. So, okay. Great.

21 DR. MAGUEN: That's right, yes. So,

22 yes.


112

1 MR. KUNTZ: Thank you.

2 DR. MAGUEN: Yes. Thanks for

3 highlighting that.

4 And that's going to be for each

5 disorder that I go through, I'm going to review

6 with all of you where there was no data, where

7 there was some data, but the strength of the

8 evidence was either low or medium.

9 MR. KUNTZ: Okay. Thank you.

10 DR. MAGUEN: Good question.

11 Any other questions at this point?

12 COLONEL AMIDON: I just wanted to make

13 sure it was clear to me. So, the threshold

14 within which you decided whether there was data

15 or no data was based on whether an RCT had been

16 applied to the combined conditions, not the

17 monotherapy? And I know that this would make it

18 probably an infinite project, but other --

19 DR. MAGUEN: Yes.

20 COLONEL AMIDON: -- call is

21 "research"; I may be misusing the word -- that

22 were more qualitative in their approach, per Dr.


113

1 Jonas previously, that just would make it too

2 much scope and scale?

3 DR. MAGUEN: That's right.

4 COLONEL AMIDON: Okay. Volumes --

5 DR. MAGUEN: Right. Originally, when

6 we came up with the PICO tables, that's right, we

7 wanted to do something that was manageable.


9 DR. MAGUEN: We already felt like

10 five, and then, extended to eight conditions --


12 DR. MAGUEN: -- would have been a lot

13 of work, which it was. And so, if you should

14 look at the reports, they're between 100 and 150

15 pages for each condition.


17 DR. MAGUEN: So, it's a tremendous

18 scope of work.


20 DR. MAGUEN: So, yes, the PICO tables

21 really specify that we would look at RCTs and

22 highlighted each of, you know, the population


114

1 that we were going to look at, the interventions,

2 et cetera. Those interventions, again, were all

3 based on VA/DoD guidelines or other organizations

4 that had guidelines, if the VA/DoD did not have

5 any.

6 COLONEL AMIDON: Thank you.

7 DR. MAGUEN: You're welcome.

8 DR. POTOCZNIAK: But, basically, what

9 you are seeing is that there's almost no like

10 solid support for any of those modalities? Even

11 though there are some that have low quality

12 research done, there's no like big kind of study

13 that kind of has found that acupuncture, for

14 example, is really effective with PTSD? The VA

15 offers all these things, but --

16 DR. MAGUEN: Yes.

17 DR. POTOCZNIAK: Yes.

18 DR. MAGUEN: Yes, and I will say, too,

19 I know we had part of this conversation

20 yesterday, too. But I think the studies that

21 don't exist are, for example, using CIH

22 modalities to get people engaged in PTSD care.


115

1 So, if they're not willing to do the evidence-

2 based treatment for PTSD, we heard when we went

3 to some of the VAs, "Well, I went on a veterans'

4 biking trip. I heard about treatments that

5 veterans were engaged in. I was more open to

6 doing those treatments as a result."

7 So, that was an example of how CIH led

8 to that veteran being more open to mental health

9 treatment. So, those studies also don't really

10 exist. And I know that that's a way in which

11 many veterans get involved in CIH treatments.

12 So, yes.

13 MR. ROSE: I mean, this brings up the

14 point, though, that having these, quote,

15 "modalities," that you can offer and treat the

16 individual veteran. It's not one-size-fits all.

17 It may get the veteran in the door to additional

18 treatment, but you've got it out there.

19 DR. MAGUEN: Yes.

20 MR. ROSE: And you get more people

21 involved.

22 DR. MAGUEN: Yes, that's right. And


116

1 so, I mean, that's a very important point.

2 That's why we're looking at large-scale RCTs,

3 because it allows us to kind of compile the data.

4 Because it's not going to be -- one veteran may

5 benefit from one treatment and not from the

6 other.

7 MR. ROSE: Right.

8 DR. MAGUEN: So, we're kind of looking

9 at the larger scope now and seeing what does the

10 research tell us. But, yes, a very important

11 point.

12 DR. POTOCZNIAK: Was exercise in

13 there?

14 DR. MAGUEN: Yes, it is. Yes.

15 DR. POTOCZNIAK: Wow. That's

16 surprising.

17 DR. MAGUEN: Yes. Yes. Again, there

18 were, with PTSD, there are some studies for

19 exercise, but there were some methodological

20 issues with some of those studies.

21 DR. POTOCZNIAK: That's surprising,

22 though, there's not more done on that with


117

1 veterans because veterans all love when you tell

2 them to go exercise to cure something.

3 DR. MAGUEN: Yes. And again, that

4 doesn't mean that there's not pilot trials.

5 There are several pilot trials out there.


7 DR. MAGUEN: But it just means that

8 they haven't gotten -- and I know of one trial

9 that's actually ongoing right now that's

10 specifically looking at exercise and PTSD. But,

11 again, this is the drawback to doing it at one

12 point in time, is that you're not getting all the

13 moving pieces necessarily, but just getting a

14 flash in time, so up to the point where we're

15 doing the search.

16 DR. POTOCZNIAK: It almost seems that

17 would need to be almost longitudinal research for

18 exercise because people do it for short periods,

19 and then, give up on it. Is it, in fact,

20 sustained over time, and all that other stuff?

21 DR. MAGUEN: Right. There are all

22 kinds of methodological issues when you're trying


118

1 to conduct an exercise study, too. For example,

2 with a treatment, oftentimes if it's an

3 individual therapy, you have the person come in

4 once a week for that individual therapy, or if

5 it's mass, maybe more. But, in general, it's not

6 more than once a week. With exercise, you're

7 hoping that they're going to do it at least three

8 times a week, ideally, right? And so, there are

9 all kinds of design issues that make this kind of

10 research extremely complicated. And then, you

11 have to have a matching condition where you're

12 asking veterans to come in three times a week for

13 something. And we know, with scheduling and busy

14 lives and barriers to coming in the first place,

15 that becomes very complex. So, yes.

16 Good, very good discussion. Any other

17 thoughts before we move on to the next

18 recommendation?

19 Okay. Great.

20 I do want to say that Recommendation

21 3 is about specific treatments, including

22 mindfulness-based stress reduction, MBSR, or


119

1 mantra meditation. In our searches we did find

2 that there was more evidence for those two

3 specific modalities. So, our recommendation is

4 to include structured or manualized forms of

5 meditation as a routinely available adjunctive

6 treatment intervention for PTSD, such as

7 mindfulness-based stress reduction or mantra

8 meditation.

9 I will say that I know that in a lot

10 of clinics this is already happening. So, again,

11 if we look at implementation, that is something

12 that is happening on some level across some

13 clinics, but, then, it, again, varies from VA to

14 VA.

15 Recommendation No. 4 is "To conduct or

16 fund implementation science studies that focus on

17 how to best integrate CIH modalities into current

18 standard practice in mental health and primary

19 care." Multi-site trials would be particularly

20 helpful.

21 So, this recommendation is

22 specifically about how do we take the knowledge


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1 that we have and understand how we implement it

2 within a system. And so, for example, when CPT

3 and PE were rolled out to the VA, it was very

4 important for implementation scientists to come

5 in and say, "Here's a system that currently

6 exists. We're taking these modalities and

7 introducing them into the system."

8 In many clinics it was already

9 happening during the time of the rollout, but the

10 implementation scientists were able to come in

11 and say: here's how we can create a system that

12 will be accepting of these treatments. Here are

13 the things that would need to be treated. Let's

14 evaluate not only what happens when you introduce

15 this to a system, but how we can help support the

16 continued implementation of these particular

17 modalities into a system.

18 So, it's really about how this gets

19 integrated/implemented; what are the barriers to

20 doing so? And so, we have to understand not only

21 what should be implemented, but also how to do

22 that within the system.


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1 So, in the same way that whole health

2 has been rolled out, and there have been studies

3 about how to implement that in the system, the

4 same way we would want to do that for CIH

5 modalities within the whole health system. As we

6 have heard about a lot of those studies from Ben

7 Kligler, a lot of those studies are ongoing.

8 Yes?

9 MR. ROSE: Shira, when you talk about

10 CIH modalities, would it not be better to kind of

11 bring those in a little bit or keep it open and

12 say, "CIH modalities," or should it be specific

13 which ones would be maybe, based on your research

14 to date, which ones might be better to start at?

15 DR. MAGUEN: Yes. Yes.

16 MR. ROSE: I don't know. Just --

17 DR. MAGUEN: No, absolutely, yes. I

18 think that, again, once we get into

19 deliberations, we're going to get into the nitty-

20 gritty of that. I think, right now, what I'm

21 trying to do is kind of give a broad overview of

22 the directions and get feedback and get sort of


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1 input from the Commissioners, just like what you

2 are giving. And so, I think our goal is, as

3 we're working with Wendy LaRue, is to also get

4 more and more specific. So, that is very much

5 what we're -- I think the ultimate

6 recommendations will be very specific in their

7 scope. So, yes.



10 Okay. Good. Any other questions

11 about that implementation size piece, in

12 particular?

13 Okay. Okay. Great. So

14 Recommendation No. 5 is "To address barriers in

15 conducting CIH research to accelerate information

16 that can be gleaned from these studies." For

17 example, logistical and systematic barriers and

18 stigma. So, it is somewhat related to

19 Recommendation No. 4, but, again, I think that

20 this is really related to, once we get the CIH

21 research out there and what's effective and

22 what's not effective, we want to also make sure


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1 that we're really, really aware of what the

2 barriers are to sort of implementation, but also

3 to just using these treatments.

4 We're learning a lot from the focus

5 groups, for example, about what are some of the

6 system-level barriers, but also some of the

7 personal-level barriers. And so, I think

8 barriers can be both at the individual as well as

9 the systemic level. So, logistical sometimes can

10 be a huge barrier as well for people to make it

11 to a yoga class or to make it to an acupuncture

12 session. And so, all of those are important to

13 look at. So, we can't do this in a bubble. We

14 really have to be aware of some of the barriers

15 that exist in conducting both the research and

16 the information that can be gleaned from the

17 studies as well.

18 So, I think that if there are no

19 questions about that, in particular, I'm going to

20 move to Recommendation 6. "Make results of CIH

21 studies more accessible to providers and

22 patients, so that it can easily be disseminated


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1 and linked to shared decision-making."

2 So, I think this is one that we have

3 been talking about quite a bit in our Workgroup.

4 And so, we're doing all of this hard work. And

5 if we don't get it into a form that is digestible

6 and accessible to providers and patients, then

7 it's not going to get out to the very people that

8 we're hoping to serve.

9 And so, we have had a lot of

10 discussion about creating bubble maps, so that

11 those can be used as a tool to say, like you can

12 sit down with your patient and say, "Look, here

13 is where the strength of the evidence is. Here

14 is the modality that you want to use. Here is

15 where it falls on our bubble map. Let's have a

16 conversation about whether that could be helpful

17 for you and what that means."

18 And so, bringing the patient into the

19 conversation about the evidence that exists for a

20 particular CIH modality as well as personal --

21 right, because I think patient preferences is

22 always a part of that conversation. Certainly


125

1 within the whole health model, it's tailored to

2 that individual. So, we want to learn -- we want

3 them to have all of the information about what

4 their preferences are, what the strength of the

5 evidence is, what their barriers are to

6 participating in a particular modality. So, all

7 of that can get discussed with any particular

8 patient. And so, from our end, we have to make

9 sure that those materials are accessible and

10 translatable to providers and patients.

11 Okay. So, I think that that, in a

12 nutshell, is six recommendations just for PTSD.

13 Any thoughts about those? Any concerns? Yes?

14 MR. KUNTZ: I guess I was just

15 wondering if we could just -- do you think it

16 would be accurate to say we are in just kind of a

17 low science area with these? There just hasn't

18 been that much research in some basic level. Is

19 that accurate? Maybe we'll have to come out with

20 that kind of a statement --

21 DR. MAGUEN: Yes, I think that --

22 MR. KUNTZ: -- to be able to explain


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1 why these recommendations make sense?

2 DR. MAGUEN: Yes. So, I think that

3 that is going to be in the first part of the

4 report. So, there's going to be a lot leading up

5 to these recommendations in terms of framing our

6 findings, framing the scope of what we did. And

7 then, the recommendations will come after that.

8 And so, hopefully, the context will be

9 extremely helpful. But, yes, I would say that

10 most modalities, more often than not, there is no

11 research on a particular CIH modality. And so, I

12 think that that statement that you made is

13 accurate.

14 And so, as you know, part of these

15 were listed in the legislation, and then, part of

16 these were also ones that we believed were

17 important to look at because of a number -- you

18 know, they're important to veterans. We believed

19 from our own work that these were important to

20 look at. And so, those were ones that were added

21 as well. So, it's both the legislation as well

22 as the ones that the Commissioners added, too.


127

1 So, yes. If you take those as a whole, more

2 often than not, there are not RCTs that

3 specifically look at those modalities.

4 COLONEL AMIDON: And your

5 recommendation, just from sort of a broader

6 context, is that, after we deliver the report,

7 maybe it would be wise to go do, in the 30

8 subsequent days after the report is delivered,

9 kind of key stakeholder engagement, wherein you

10 could chat about this recommendation with the

11 NIHs and the DoDs of the world to see if there is

12 collaborative research opportunity? This isn't

13 necessarily a VA problem set. It could be --

14 DR. MAGUEN: Yes.

15 COLONEL AMIDON: -- an entirety of the

16 system problem set?

17 DR. MAGUEN: Yes, and that is exactly

18 -- you'll see that in the recommendations for all

19 disorders that we make, that is exactly the

20 direction that we're headed. And so, we can

21 recommend all of the studies that we want, but

22 until we kind of set up and recommend an


128

1 infrastructure for that to happen -- and that

2 necessarily involves cross-system collaboration

3 because this can't be done by any one system, any

4 one bubble.


6 DR. MAGUEN: So it really has to be

7 across systems. And I think there are good

8 models for that. So the good news is that the

9 Pain Collaboratory --


11 DR. MAGUEN: -- has forged really good

12 ground with how to do some of those studies. So,

13 we will definitely be getting to that. So, thank

14 you for that. We're on the same page.


16 DR. POTOCZNIAK: So when we make these

17 recommendations that more research be done, the

18 question is where does that go? Because it's

19 like you would go to -- because we're really

20 recommending this, right, to --

21 CHAIR LEINENKUGEL: It's a great

22 question, and I think that that comes with the


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1 follow-up Workgroup discussions, especially what

2 we heard from Wendy this morning about being more

3 specific as to implementation and verbalizing

4 with key verbs who we want to own that. In

5 particular, saying --

6 MR. SPERO: Congress should direct --

7 CHAIR LEINENKUGEL: Correct. VA

8 should --

9 MR. SPERO: These government agencies

10 conduct --

11 DR. LaRUE: That's the implementation

12 steps. It's like budget, $5 million to go to

13 something rather --

14 CHAIR LEINENKUGEL: Mike, to your

15 point, we'll get to much more specific

16 recommendations, but these are just great step-

17 builders that you're presenting right now, Shira,

18 right on the mark.

19 DR. MAGUEN: Okay. Good. Yes,

20 exactly. Right. I think, again, keeping in mind

21 that these are working. The way that I view this

22 is just that way, that these are building blocks


130

1 to be able to get us to discuss the specificity

2 that we need in a recommendation, guided by

3 someone who has, by people who have a lot of

4 experience in this area in how to make our

5 recommendations digestible.

6 CHAIR LEINENKUGEL: Right.

7 DR. MAGUEN: Okay. Great. Okay. So,

8 moving on, if no one else has questions about

9 PTSD, I want to share our opioid use disorder

10 recommendations. Again, as I mentioned,

11 Recommendation 1 is structured in a very similar

12 way. We are recommending "To conduct/fund

13 research related to CIH treatment interventions

14 and OUD, particularly multi-site trials." That's

15 going to be a theme throughout.

16 More specifically, we found that there

17 were not any randomized control trials for OUD

18 with the following modalities. And again, you

19 see here that this is really the majority of the

20 modalities. There was very little research with

21 OUD.

22 I want to specifically point out here


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1 that there are studies, for example, on pain,

2 which is reason why many people start using

3 opioids. But we are, again, looking at

4 conditions. And so, that's important to note

5 here.

6 COLONEL AMIDON: Will there be any

7 attempt, just I guess yes or no, to prioritize

8 those modalities below in order to sort of live

9 life in the research lane?

10 DR. MAGUEN: Yes, I think that that is

11 something --

12 (Simultaneous speaking.)

13 DR. MAGUEN: That's right. That's

14 right. So, eventually, I think we have to, for

15 budgetary reasons, be able to kind of prioritize

16 these. But I think that's going to require

17 further deliberation/discussion amongst the

18 Workgroup and the Commissioners as a whole.

19 Okay. So, these are areas in which

20 there was some evidence. So, exercise and some

21 acupuncture studies have low strength in evidence

22 with respect to OUD outcomes due to


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1 methodological and study design issues. Again,

2 further studies might be required. So, there

3 were some studies with exercise, and there were

4 some acupuncture studies as well that were done.

5 However, acupuncture in those with

6 OUD, there were some studies that had moderate

7 evidence with reducing depression, but not any of

8 the OUD-specific outcomes. Okay. So this is,

9 again, just as a reminder, in our tables we

10 looked at OUD-specific outcomes, like cravings,

11 methadone consumption, but we also looked at,

12 because we know that comorbidity is an issue,

13 does it reduce depression? Or do some of these

14 modalities increase well-being and quality of

15 life? And so, we looked at a number of different

16 outcomes. But what we did find was that

17 acupuncture was helpful with reducing depression,

18 but not any of the OUD outcomes. So, I want to

19 make sure that that's clear to people because

20 it's a bit of an indirect relationship in terms

21 of what we were hoping to see, in particular.

22 Okay. Again, take-home message here: very few


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1 studies with OUD and CIH modalities.

2 This was a recommendation that I think

3 is important because we don't only want to focus

4 on treatment, but also prevention as well. And

5 so, you'll see this echoed when we talk about

6 alcohol use disorder as well. "Conduct more

7 research with OUD patients to ensure prevention

8 of overdose." So, looking at naloxone and CIH

9 modalities. Really thinking about this, not only

10 from a treatment, but from a prevention

11 perspective as well.

12 DR. POTOCZNIAK: Meaning naltrexone or

13 buprenorphine?

14 DR. MAGUEN: So, basically, if we're

15 thinking about this from a prevention

16 perspective, to think about how --

17 DR. POTOCZNIAK: Yes, so prevention of

18 overdose. Got it. Okay.

19 DR. MAGUEN: Yes, that's right.

20 DR. POTOCZNIAK: Okay.

21 DR. MAGUEN: So, we want to be

22 thinking about not only how we are treating


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1 people when there's already a problem, but how

2 are we going to think about preventing overdose

3 and more difficult problems.

4 DR. POTOCZNIAK: Got you.

5 DR. MAGUEN: Yes. So, good. Any

6 questions about that?

7 So Recommendation No. 3, and I think

8 this goes back to the point that I was making

9 before. There are pain management studies that

10 are out there. So we want to leverage pain

11 management research that exists and conduct

12 studies with these modalities that include

13 patients with OUD. For example, while yoga has

14 shown to be helpful with pain management, there

15 are no studies that focus on yoga and OUD.

16 So, this goes back to, Matt Amidon,

17 your question about how we prioritize. I think,

18 with OUD, here is some information about how we

19 might want to prioritize those studies by looking

20 at what's been done in pain, and then, really

21 increase the studies with this particular

22 population, so we can make sure it impacts those


135

1 people, in particular.

2 Okay. And then, finally,

3 Recommendation No. 4, "Conduct studies with

4 medication-assisted treatment and CIH

5 modalities." This is where, Mike, the question,

6 that's the one that you were looking for, right?


8 DR. MAGUEN: So, again, naltrexone,

9 suboxone, building on the services that VA is

10 already delivering. We want to look at -- again,

11 this is not a monotherapy, but in combination

12 with what we already are doing in the VA, and

13 focus in on specifically those types of studies

14 that look at medication-assisted treatment.

15 All right. Any thoughts about OUD?

16 Are we missing anything that people can think of?

17 Anything that you want to add to the discussion

18 before we move on to alcohol use disorder?

19 DR. POTOCZNIAK: I think it's just

20 striking in a lot of ways how much of this is

21 offered for and paid for by the VA, but is not

22 founded in anything that was real, except


136

1 veterans' experience saying like, "Wow, I liked

2 this," or whatever it was.

3 But it is just striking me because I

4 have seen your -- I know what's coming next also

5 with the rest of them.

6 DR. MAGUEN: Right, right.

7 (Laughter.)

8 DR. POTOCZNIAK: And it just goes on

9 and on and on about -- I mean, it's noteworthy, I

10 think, that not only are we providing these, but

11 we're also paying community care clinicians to do

12 these things. That is health care money that is

13 being spent -- not necessarily that it's bad, but

14 I think it is just notable that we don't have

15 anything backing it up.

16 COLONEL AMIDON: And to the economics

17 of the cost-benefit analysis.

18 DR. POTOCZNIAK: And there is a

19 tremendous cost to this stuff. It's not cheap.

20 COLONEL AMIDON: And it would be

21 interesting, I guess, as an adjunct, just history

22 matters here, and that certainly matters in this.


137

1 This is a snapshot in time, but what was the

2 growth? How long, I guess from your perspective,

3 did it take to get all of these modalities

4 offered within the VA portfolio to just start?

5 DR. POTOCZNIAK: Right. And it's not

6 just, you know --

7 COLONEL AMIDON: We're not guiding

8 them in any way.

9 DR. POTOCZNIAK: No, but I think the

10 scope of it can be lost on non-mental health

11 people, because it's like we've spent how much

12 time -- like when you think of CBT for depression

13 or PE for post-traumatic stress disorder, we have

14 spent so much time figuring out how many sessions

15 is effective, how do we do the treatment, what

16 style do we do the treatment, and what

17 environment do we do the treatment, who provides

18 it. And we've kind of talked about those things

19 forever and ever over years to make sure that it

20 works, and to make sure that it's cost-effective.

21 And so, then, when you bring in things

22 like equine therapy, which I know is useful to a


138

1 lot of people, but we don't know how often. We

2 don't know what kind of horses, what kind of --

3 like we don't know that stuff. And it's not just

4 research; it's also research -- it's research

5 plus. Like it's a lot of research. Think of how

6 much research goes into CBT alone, and has gone

7 into CBT alone, and we're still researching it.

8 And yet, it's a gold standard.

9 DR. MAGUEN: And I'll add onto that.

10 I think that if you look at, for example, CBT and

11 PE research, what we know is that the trials were

12 done and, then, we've looked at it in the mixed-

13 method way, right? And so, I think to add onto

14 that, I think it's important not only to do the

15 studies that look at what dose is it effective

16 in, how is it best delivered, but, then, to do

17 the companion piece, which is to talk to patients

18 who have done CBT and PE and understand like what

19 was their experience; what was best for them;

20 what were their preferences; what were their

21 barriers, right? And so, these things have to

22 necessarily also go hand-in-hand, so you can get


139

1 at that nitty-gritty detail, not only through the

2 RCTs, but also talking to patients and

3 understanding the qualitative, in addition to the

4 quantitative data.

5 MR. KUNTZ: While we were touring

6 Columbia, they have a leading equine program

7 there, and they said, you know, there's no RCTs

8 on this. It probably costs about 5 to 10 million

9 bucks to run one.

10 MR. SPERO: I think it was if they

11 wanted to do MRIs with it, it was 9 million;

12 without it was 5 million.

13 MR. KUNTZ: Yes.

14 DR. POTOCZNIAK: And that's one.

15 MR. KUNTZ: And that's one. So that's

16 exactly what I'm saying. It makes me wonder,

17 just to plant it in your clinician-researcher

18 heads, are pragmatic trials, since we already

19 have these going in the system, is that the only

20 way to really try to capture what we're spending

21 our money on and if it works? Because I exactly

22 want to point out that 10 million bucks for one


140

1 thing, I've been told by SVAC they couldn't find

2 $3 million for something else. So, is that kind

3 of institute pragmatic studies the only realistic

4 way to go with that?

5 DR. POTOCZNIAK: I think that if

6 you're paying -- certainly, part of it is I think

7 so because the ramifications of not knowing

8 whether it works is billions, you know, and

9 that's at the cost of other forms of treatment to

10 veterans, right? So, I think it is important to

11 do RCTs, if you're going to offer it. If you're

12 not going to offer it, that's -- or if it's going

13 to be offered by volunteer people, or captured

14 under rec therapy, but when it's used -- like,

15 right now, in the VA we can order equine therapy

16 for community care. And there are no boundaries

17 at all on how that's provided because there's

18 nothing to say what works.

19 So, if you don't do RCTs, you have the

20 situation where there are no boundaries on how

21 big it can get. If it's researched, it can be

22 like six or seven sessions of equine therapy


141

1 works under these conditions, on a ranch, in

2 these. But if you don't do that research, you're

3 paying for whatever the person on the outside is

4 going to offer, and that could go on forever.

5 MR. KUNTZ: I guess I was wondering

6 about pragmatic trials or more of a records-based

7 analysis of who is going for equine therapy and

8 does their hospitalization rate decrease, and the

9 things that you may be able to find. Because the

10 VA is actively paying for all these things, we

11 have the records.

12 DR. MAGUEN: So, that is an excellent

13 question. I think, ideally, the answer would be,

14 yes, the hope is that you would be able to track

15 that in the medical record. However,

16 unfortunately, when the patient goes to equine

17 therapy, there's not a pre and post measure done.

18 Because when community care is done, a lot of

19 times there's not necessarily any measurement

20 that they have to bring back to the VA system.

21 And so, I think that there's been a

22 lot of advocacy, and I know that's part of some


142

1 of the work that people are working on for the

2 future, to be able to eventually collect those

3 data from community providers. But, as you know,

4 it's very hard to get community providers

5 reimbursed for work, never mind having them sort

6 of be able to fill out pre and post measures,

7 right?

8 DR. POTOCZNIAK: They don't even turn

9 in the records.

10 MR. KUNTZ: Well, I guess what I was

11 saying is if you know that they went out to do

12 this, and you have their records, and did their

13 medications decrease, did their hospitalization

14 rate change, something in that record that may

15 suggest positive or negative outcome.

16 DR. POTOCZNIAK: What would make that

17 so difficult is that veterans rarely -- you would

18 never, I don't know if you would ever find a

19 veteran that you could cleanly study, like a

20 group of veterans, because usually they're doing

21 -- some are doing equine therapy. Some are also

22 doing chiropractic. Some are doing acupuncture.


143

1 Some are doing none. Some of them did it for a

2 little while and discontinued. Some of it for --

3 that's all they do in the VA is that, you know.

4 DR. MAGUEN: And they change their

5 medication a few times during the course --

6 DR. POTOCZNIAK: And it all happens

7 independently. So, you would always be looking

8 at what change was responsible for what, and you

9 would never be able to say like anything cleanly,

10 that this --

11 COLONEL AMIDON: You can't keep any

12 variable constant.

13 DR. POTOCZNIAK: Because it's a

14 constant -- you can't control the psychiatrist

15 that changed it from sertraline to citalopram to,

16 you know -- who knows what that was? So

17 frequently, veterans are just inundated with a

18 bunch of treatment at the same time. So, it's a

19 hard thing to do for records research on that.

20 DR. KHAN: So, listening to what you

21 are saying, the way I am looking at it is we

22 should improve the VA system to capture the


144

1 results of these things being done. Now sharing

2 with you, in Wisconsin we have farmers who have

3 their own horses. And the BCOCs and the

4 psychiatrists, they have connections with,

5 collaboration with non-VA care. So, too long VA

6 care -- my psychologist, he sends me to equine

7 therapy. As a non-VA, it's in my record.

8 DR. MAGUEN: Yes.

9 DR. KHAN: It goes back to that

10 psychologist to capture it. So, if we emphasize

11 on capturing that information, that will be less

12 expensive than trying to go through -- I mean,

13 I'm talking about dollar-wise, you know.

14 DR. MAGUEN: Yes. Well, I don't know

15 if you had a chance to look, but in the RAND

16 report one of the things that they do bring up

17 specifically as a recommendation is "Improve

18 monitoring and performance measurements via

19 community care program." So, that is an explicit

20 recommendation for research, and I do think that

21 that is important, for the reasons that we are

22 highlighting here. It will help us better


145

1 understand, if people are doing these things in

2 the community, we will have some data to look at.

3 For any experience that they had outside, was

4 that actually effective? And if that's where the

5 CIH treatments are being done in some cases, then

6 that could be monitored.

7 Yes, thank you. I think it's an

8 important point and very related to what we're

9 talking about. But I think there also needs to

10 be -- we're undergoing right now a time of

11 change, a big change in terms of community care.

12 So, there is a lot of refinements that are being

13 made. And I know people are thinking about this,

14 but I think that part of what our work will

15 depend on is those systems being in place. And

16 we don't know how long that's going to take to

17 have that, but we know that we're thinking about

18 it. RAND was clearly thinking about it and

19 advocating for it, too.

20 But there has to be, in the same way

21 that VA is focused on measurement-based care,

22 right -- and so, we are collecting data here.


146

1 And if our veterans are getting care outside the

2 community, it also behooves us to collect

3 measurement-based care outside, so we can compare

4 and see how they're doing overall. So, it's

5 important.

6 DR. JONAS: I think we have, later on,

7 when we get to some general recommendations

8 -- you're going through the modalities now,

9 unless you did that first?

10 DR. MAGUEN: No, I'm saving that for

11 last, yes.

12 DR. JONAS: Yes. So, at the end, I

13 think we have a couple of generic recommendations

14 that I think get at what you all are talking

15 about, which is that there needs to be, I mean,

16 clearly, there needs to be more research done,

17 period. I mean, that's going to be a general

18 recommendation here.

19 DR. MAGUEN: Yes.

20 DR. JONAS: It's just these things are

21 important. People are using them. We don't know

22 how to do it. Okay?


147

1 DR. POTOCZNIAK: The VA is opening

2 departments on it.

3 DR. JONAS: Yes.

4 DR. POTOCZNIAK: And we don't know

5 whether it works.

6 DR. JONAS: Invest in research.

7 Invest in finding out. So, that's going to have

8 to be one.

9 But I think, beyond that, we've also

10 discussed -- and I think Shira will get to those

11 -- you know, there needs to be more thinking

12 about creating an evidence-based informed --

13 strategies for research that allow for more ready

14 applications and decision-making about measure-

15 based and evidence-based practice.

16 DR. MAGUEN: Right.

17 DR. JONAS: And so, that means, okay,

18 well, do you need a randomized control trial on

19 every little component? No. Okay. So, then,

20 what, then, takes it to the threshold of we're

21 saying, that particular thing, well, you need to

22 do a randomized control trial on, and the other


148

1 things, you know, other types of evidence we can

2 collect would be sufficient? What is that

3 strategy?

4 And there is a lot of writing about

5 it. I gave this book to the Chairman here that

6 was an Institute of Medicine's report several

7 years ago on CAM. They called them CAM

8 modalities. It's the same types of things. And

9 they have an extensive discussion of the need to

10 create strategies and example strategies of how

11 to address these very issues. So, we should

12 probably look at that, pull it in. We have some

13 of the same recommendations that are in there.

14 DR. MAGUEN: Yes, yes.

15 DR. JONAS: But that would be

16 background in those areas. They talk about whole

17 systems approaches. They talk about external

18 validity. They talk about qualitative research,

19 all the validity, those kinds of things.

20 And this isn't isolated to CIH,

21 though. I mean, these are the same issues. I

22 mean, we do back pain surgery to the tune of $41


149

1 billion a year in this country, and 80 percent of

2 it isn't evidence-based; it's unnecessary, okay?

3 Because you can't do a blinded, you don't do

4 double-blind surgery studies. So, they do use

5 stuff that would never -- that would have the

6 same poor quality, if you looked at it using the

7 same lens.

8 DR. POTOCZNIAK: But when you have

9 treatments that do work for things like PTSD and

10 substance use and opioid dependence, and you're

11 paying -- because the money has to come from

12 somewhere. So, with the back surgery-type stuff,

13 sometimes it's for lack -- it's out of

14 desperation that we do things --


16 DR. POTOCZNIAK: -- that aren't

17 researched well. But, in these situations, the

18 money has to come from somewhere. So, sometimes

19 it's going to come from things that do work and

20 fund things that maybe work or don't work.

21 DR. JONAS: Yes. We're already doing

22 that. We're doing a lot of back surgery. A lot


150

1 of money is going into it. The evidence in back

2 pain shows that yoga actually is probably just as

3 effective for most functional back pain, half of

4 which, or whatever, are getting surgery. So, we

5 ought to be investing in it.

6 So, it needs to be a consistent,

7 overall strategy, and especially is it addressing

8 questions that are important to veterans and that

9 are expanding sort of lens? And there's

10 different methodologies that allow you to kind of

11 do that. That's about a strategy, and I think we

12 have some suggestions along those lines.

13 DR. MAGUEN: Yes. Yes.

14 DR. JONAS: Then, when you have to

15 actually differentiate the placebo component and

16 you separate it out and do that, then you have to

17 do rigorous types of research on the placebo

18 components and that kind of stuff, if it's

19 possible.


21 COLONEL AMIDON: I guess from a

22 customer perspective, though, the differentiation


151

1 between evidence-based and yoga within VA and

2 back surgery and yoga in the private sector would

3 be somebody who chooses to engage in yoga vis

4 back surgery in the private sector is, thus,

5 going to pay for it themselves, correct?

6 DR. JONAS: It's not because it works.

7 It's because a lot of them have got to pay for

8 it.


10 DR. JONAS: So, it gets to a Michael's

11 question about where are we putting the money.

12 DR. MAGUEN: Yes.

13 DR. JONAS: Which, ultimately, that's

14 what they have to decide, right, where are we

15 going to put the money?


17 DR. JONAS: Because you can't do

18 everything, as Michael says.


20 DR. POTOCZNIAK: And the heart's in

21 the right place, right? I mean, there's all

22 these things. What it shows to me is the


152

1 desperation which the VA is willing to go to to

2 help heal veterans.


4 DR. POTOCZNIAK: It's like we're

5 willing to do anything. I think what we need to

6 look at now is, okay, does any of this work,

7 though?

8 DR. JONAS: Correct.

9 DR. POTOCZNIAK: A lot of whole health

10 was deployed during the height of the Iraq War,

11 is when it started. And so, there's a lot of

12 desperation out there to get something. And I

13 think we do have some things that work, but,

14 then, you have these things that may or may not.

15 DR. JONAS: And you have to

16 distinguish between, you know, answering the

17 question of does it work. Is it because we've

18 tested it and it doesn't work, or it's just never

19 been tested? With what we have we don't know.

20 DR. MAGUEN: Yes.

21 DR. JONAS: Those are two different

22 reasons for saying maybe we shouldn't pay for it,


153

1 right?

2 DR. MAGUEN: Well, and I think just,

3 again, going back to the yoga example, we know

4 that for things like, as you were mentioning, for

5 pain yoga works, right? And so, those trials

6 have been done. So, this goes back to the issue

7 of comorbidity, right?

8 So, the veteran is coming in and they

9 have PTSD and they have pain and they have

10 alcohol use disorder, and you recommend yoga.

11 That's why we're looking at the whole person,

12 right? We're not just looking at the disorders.

13 So, that's a key piece here, that the

14 recommendation to do yoga and the whole health

15 model, in and of itself, is taking all of that

16 into account and saying, okay, what are your

17 preferences? What's important to you? Okay, you

18 have back pain and you have a preference for non-

19 medication modalities. Let's start you out with

20 yoga and see where we go from there. Right? And

21 so, it's looking at everything that's going on

22 with the person.


154

1 DR. JONAS: And the big question is,

2 how do you do that kind of a strategy, that kind

3 of an approach and, also, make decisions in that

4 space?


6 DR. JONAS: I mean, we know the answer

7 to that.

8 DR. MAGUEN: Right. Yes.

9 MR. KUNTZ: Should we get back into --

10 I'm sorry.

11 DR. MAGUEN: Yes, there's a lot going,

12 there's a lot of good discussion to be had. But,

13 yes, let's get back into the alcohol use order

14 search that was done.

15 And so, our Recommendation No. 1 --

16 so, again, I've listed all of the CIH

17 interventions in which there were not any RCTs

18 here. You can see again, overall, more studies

19 do not have any, including yoga here, including

20 service dogs, tai chi, massage therapy, so with

21 AUD, none of these studies exist.

22 And then, there are some studies --


155

1 acupuncture, cannabinoids, exercise, meditation,

2 music therapy, relaxation therapy, and TMS

3 studies -- there were some studies that were done

4 in the AUD area, but they had low strength of

5 evidence, again, due to methodological and study

6 design issues. Again, further study might be

7 required.

8 And there is some limited evidence to

9 suggest that meditation used in the context of

10 mindfulness-based relapse prevention can reduce

11 cravings, post-intervention alcohol or drug

12 consumption, and perceived stress. Okay? So,

13 very specific. As you can tell, there was some

14 limited evidence to suggest --

15 DR. POTOCZNIAK: So, cannabinoids had

16 a low strength of evidence?

17 DR. MAGUEN: Low strength of evidence.

18 Again, there was a study, but there were a lot of

19 problems with the methods.

20 DR. POTOCZNIAK: It's interesting to

21 consider cannabinoids a treatment for AUD.

22 DR. MAGUEN: Right, right. There


156

1 might be ethical --

2 DR. POTOCZNIAK: That's super-

3 controversial.

4 DR. MAGUEN: Yes, yes. Right. And

5 so, that's a whole other can of worms, but I

6 think it looks here like there's -- you know, the

7 study that was done, although it was done, we

8 could talk about the ethical issues, but, again,

9 there's methodological problems despite all of

10 that.


12 DR. MAGUEN: So, yes, there's a lot

13 more to say about that, I believe.

14 DR. JONAS: Well, that's sort of what

15 we do with methadone, isn't it?

16 (Laughter.)

17 DR. POTOCZNIAK: It is, but --

18 DR. JONAS: It's what methadone is.

19 Take that, instead of this; it's not as bad.

20 MR. HARVEY: The lesser of two evils.


22 DR. MAGUEN: So, good. Let me go on


157

1 to say -- unless there's any further comments? I

2 feel like we could talk about that one for quite

3 some time probably.

4 DR. POTOCZNIAK: I could go on, but --

5 DR. MAGUEN: Okay. We can table that

6 and get back to that.

7 So, "To conduct/fund studies that

8 focus on prevention." Again, you will see a

9 common theme here, that we're not only looking at

10 treating it, but we really want to focus on

11 prevention, too. Developing AUD, using CIH

12 modalities, given the public health issue of

13 alcohol use among veterans. So, we want to be

14 thinking preventatively with OUD, with AUD, and,

15 of course, with suicide, but we'll get to that in

16 a second.

17 Yes?

18 DR. JONAS: I would just make one

19 point, and maybe we'll talk about it later. But,

20 you know, there's so much emphasis right now on

21 opioids, and, yes, it's a problem. Alcohol is a

22 much bigger public health problem, I mean, if you


158

1 just look at the damage --

2 DR. MAGUEN: The scope.

3 DR. JONAS: -- and the scope of it.

4 I don't know if we want to somehow point that

5 out, because a lot of times people lose the

6 forest for the tree, you know. And so, do we

7 want to --

8 DR. MAGUEN: Yes, yes, absolutely.

9 And I think, again, the public health issue here

10 is tremendous.

11 DR. POTOCZNIAK: And similarly, you

12 make this later on, but similar to your PTSD

13 recommendation, it would almost seem that it

14 would be important to mix -- or maybe it was the

15 OUD one -- but to mix CIH with naltrexone, like

16 medication-assisted treatment for the --

17 DR. MAGUEN: Yes.

18 DR. POTOCZNIAK: Because that's the

19 current trend, is to engage MAT with AUD. And

20 also, to really look at programs that integrate

21 CIH.



159

1 DR. POTOCZNIAK: Because there's two

2 schools, like in AUD, of treatment, right?

3 There's programs that integrate CIH, and

4 frequently, they're the ones that are open to

5 more harm-reduction-type stuff.

6 And then there is old school 12-step.

7 Kind of they might do a little motivational

8 enhancement, but there's like, you know --

9 DR. JONAS: Six months. Six months

10 first.

11 DR. POTOCZNIAK: Yes, exactly. So,

12 there's two separate schools. That would

13 actually be a very easy controlled kind of easy

14 research because you have such a divide between

15 those programs, what works better, essentially?

16 DR. MAGUEN: Uh-hum.

17 DR. POTOCZNIAK: So, it almost seems

18 like we would want to plug at that a little bit

19 in some way, to look at programs, integrated

20 programs.

21 DR. MAGUEN: Yes. Let's see, because

22 I think that is one of the overall


160

1 recommendations. Let's see if it actually fits

2 what you're saying to some extent.


4 DR. MAGUEN: Are you talking more

5 about like residential --

6 DR. POTOCZNIAK: Residential or

7 intensive outpatient.

8 DR. MAGUEN: Yes. Good.

9 DR. POTOCZNIAK: Because usually those

10 are similar. They all offer, you know, a lot of

11 the IOPs in the VA offer CIH. But, then, you

12 have certain VAs, especially older-school VAs,

13 that don't at all.

14 DR. MAGUEN: Yes.

15 DR. POTOCZNIAK: And so, who's running

16 the program?

17 DR. MAGUEN: Yes.

18 DR. POTOCZNIAK: And there's nothing

19 to force one to move forward or backward. It's

20 like that person, they've owned it for 20 years.

21 This is what works.

22 DR. MAGUEN: Yes.


161

1 DR. POTOCZNIAK: But if we had

2 something that actually said CIH, when

3 integrated, would help, it would make people move

4 forward.

5 DR. MAGUEN: Yes. Good. When we get

6 to the general recommendations, let me know if

7 you think the wording of that is sufficient, or

8 if we need to add to that, we can do that. I

9 think, originally, we had it in several, and

10 then, we moved it to the general because it was

11 capturing different areas. So, we'll stay tuned

12 about that, and we can circle back to that. It's

13 an excellent point.

14 So, suicidal behavior, this is our

15 last formal search that we have results on. Like

16 I said, we're going to talk about depression when

17 we have our Workgroup call next week. So,

18 suicidal behavior is a little bit unusual because

19 really it's important for us to look at

20 separately, but, as we know, that's not a mental

21 health diagnosis. It's a behavior.

22 DR. POTOCZNIAK: It's a V code, right?


162

1 DR. MAGUEN: Yes, I think it's -- in

2 terms of diagnosis, you can diagnose, you know,

3 you can put in a V code for it, but it's not a

4 typical diagnosis per se. So, it's more of the

5 behavior, but very important to look at,

6 nonetheless.

7 Again, speaking about comorbidity, you

8 can have suicidal behavior, as we know, with many

9 different diagnoses. So, I think that, here

10 again, more specifically, we found that there

11 were not any RCTs for all of the following

12 modalities. Again, the majority of these

13 modalities do not have an RCT in those with

14 suicidal behavior.

15 Again, as a reminder, research with

16 individuals with suicidal behavior is very

17 difficult to do. Outcomes are very difficult to

18 track. So, there's a lot of challenges that

19 we've talked about on our calls and over the last

20 few days amongst the Commissioners, just about

21 the challenges of doing behavior with individuals

22 who have suicidal behaviors and tracking that.


163

1 So, the following modalities had low

2 strength of evidence with respect to suicidal

3 ideation outcomes due to methodological and study

4 design issues. So, further studies might be

5 required. Exercise, relaxation training, and

6 TMS, so there was some evidence, but, again, low.

7 Exercise examined in conjunction with CBT versus

8 CBT alone was done in one study and demonstrated

9 a potentially promising result. Yet, further

10 research is needed.

11 Again, I think I spoke to some of you

12 about this particular study where they looked at

13 exercise with CBT versus CBT alone. These are

14 the kinds of studies that we would want to see

15 happening. Again, we don't want to take someone

16 with suicidal behavior and just have them

17 exercise, right? We want something that we know

18 is going to be evidence-based therapy

19 specifically, whether that be CBT or medication,

20 et cetera. Bilateral TMS also seemed most

21 promising for suicidal behavior, but, again,

22 further study is needed.


164

1 And again, the strength of the

2 evidence across the board is not as strong as we

3 would want in some of these studies, but there

4 were some hints at least of which direction to go

5 from some of the preliminary studies that have

6 been done.

7 MR. ROSE: Shira?

8 DR. MAGUEN: Yes?

9 MR. ROSE: On the suicidal behavior --

10 DR. MAGUEN: Yes?

11 MR. ROSE: -- is that just they have

12 thought about suicidal behavior or they have made

13 an attempt? What is that?

14 DR. MAGUEN: Right. Well, I think

15 that, again, it varies in terms of the studies.

16 And so, we would have to kind of break it down.

17 But these are in individuals who either have

18 ideation or behavior, yes. Yes.

19 MR. ROSE: Okay. Thank you.

20 DR. MAGUEN: Yes, you're welcome.

21 Okay. Good. And then, our next

22 recommendation is, "To conduct or fund research


165

1 studying CIH modalities as an adjunct treatment

2 to evidence-based psychotherapies for suicide

3 risk and medication, since these trials would

4 mirror how treatment is generally provided in the

5 clinics." Again, you will find that this is a

6 familiar recommendation, that we're really

7 stressing that we don't want any CIH modality

8 used alone with patients who are suicidal or

9 exhibit suicidal behavior. For example, TMS

10 could be studied as an adjunctive treatment to

11 cognitive behavior therapy, similar to what we

12 saw done with exercise.

13 Okay. So do you have questions about

14 that before we move to applicable to all disorder

15 recommendations?

16 Okay. So now we're starting to get

17 into oversight and implementation

18 recommendations. Again, we recognize that we can

19 make the most beautiful recommendations, but

20 that, unless we have a very tight structure in

21 place to make sure that the recommendations are

22 received and that there is oversight to carrying


166

1 them out, we're not going to do justice to sort

2 of the work that we've done here.

3 So the first recommendation is

4 "Oversight and implementation of these

5 recommendations should be assisted by several VA

6 FACA groups, including the Special Medical

7 Advisory Group, National Research Advisory

8 Council, Advisory Committee on the Readjustment

9 of Veterans, and Advisory Committee Management

10 Office. These groups should address the topic of

11 CIH research and the needs for veterans, the CIH

12 research needs for veterans particularly."

13 So, any questions about that

14 recommendation?

15 CHAIR LEINENKUGEL: Yes. How did you

16 get to those groups, Shira? I'm just curious.

17 DR. MAGUEN: So, we consulted

18 specifically with John Goodrich and were sort of

19 advised. We looked into which ones would be

20 directly related to veterans and which ones could

21 have oversight that would be related to the areas

22 that we were looking into.


167

1 CHAIR LEINENKUGEL: Let me ask another

2 follow-up question to that.

3 DR. MAGUEN: Sure.

4 CHAIR LEINENKUGEL: Do these advisory

5 groups actually either mitigate, implement,

6 extrapolate, get in front of the Secretary, USH,

7 and actually follow up on implementation plans or

8 ideas for implementation? That would be my

9 question.

10 DR. MAGUEN: Yes. So, I think that

11 what we're really thinking of is a multi-pronged

12 approach, right. So, this is one of several

13 things that we're going to recommend. I don't

14 think any one of these is going to work in a

15 nutshell. We've talked about stakeholders, in

16 addition to that.

17 I think that what we have to do -- and

18 we're just starting to think about this -- is

19 really set the stage to how this going to be

20 received and who are going to be the champions

21 that really carry out this work.

22 CHAIR LEINENKUGEL: I think it's


168

1 critical.

2 DR. MAGUEN: Yes, I agree.

3 CHAIR LEINENKUGEL: I love seeing some

4 of those groups up there. I just don't know how

5 actionable they are.


7 CHAIR LEINENKUGEL: And they may be,

8 but I love the oversight and implementation

9 phraseology that you're using there. I think

10 that needs to become a model for the rest of us

11 to consider once we make recommendations.

12 DR. MAGUEN: Yes.

13 CHAIR LEINENKUGEL: That there has got

14 to be some sort of oversight and implementation

15 for our suggestions/recommendations.

16 DR. MAGUEN: Yes, agree. And I would

17 love to get more input about those who have had

18 more experience with these groups, in particular,

19 about some of the questions that you were asking

20 about or some advice about that. What are sort

21 of the limits of these groups? How far can they

22 take us? What are going to be some of their


169

1 strengths; what are going to be some of their

2 weaknesses in helping us kind of achieve the

3 goal? So, I think it's an important point.

4 DR. JONAS: Yes. I mean, a group

5 that's not up there, for example, is the review

6 panels.

7 CHAIR LEINENKUGEL: Is the what,

8 Wayne?

9 DR. JONAS: The review panels.

10 DR. MAGUEN: The research review

11 panels, you mean?

12 DR. JONAS: Yes. The research comes

13 in. Review panels have to do peer review to see

14 how well they're done.

15 DR. MAGUEN: Yes.

16 DR. JONAS: If they have nobody that

17 has any experience with CIH on it, then they go,

18 "I don't know." And those usually get pushed to

19 the side. I've been on a number of those.

20 And that's a problem at NIH. It's why

21 the whole Center was developed, because there was

22 nobody within NIH that had any expertise in it.


170

1 The VA has been pushing things into those areas,

2 but they actually don't have a review panel for

3 this.

4 DR. MAGUEN: Yes.

5 DR. JONAS: So, they have to cede it

6 in and that kind of stuff.

7 DR. MAGUEN: Yes. Well, I think the

8 VA also works a little bit different than NIH.

9 So, the NIH review process, there is a specific

10 panel for this particular issue, but, for the VA,

11 you can submit a grant under HSR&D or clinical or

12 under rehab, right?

13 DR. JONAS: Yes.

14 DR. MAGUEN: And within those, what

15 they will do is, then, try to find the experts

16 that have expertise in that area.

17 DR. JONAS: Yes.

18 DR. MAGUEN: So, you apply under one

19 of the three larger groups.


21 DR. MAGUEN: And then, that is kind of

22 done for you.


171

1 DR. JONAS: Yes, it is. It's designed

2 a little different than NIH.

3 DR. MAGUEN: Exactly.

4 DR. JONAS: The process of reviewing

5 is pretty much the same. They have a go-to set

6 of folks that have time to do it --

7 DR. MAGUEN: Yes, agree.

8 DR. JONAS: -- and people to do it.

9 And then, they try to supplement it --


11 DR. JONAS: -- with people with

12 particular expertise or in some cases -- but the

13 most effective ones at NIH were special emphasis

14 panels, where they put together an emphasis panel

15 specifically to do a topic that was not normally

16 done within the standard processes that they use,

17 to make sure they have the kind of expertise.

18 DR. MAGUEN: Yes.

19 DR. JONAS: But that's all part of the

20 standard review process.

21 DR. MAGUEN: Right. And so, we might

22 want to add a recommendation that's based on --


172

1 DR. JONAS: Yes.

2 DR. MAGUEN: -- gathering a special

3 emphasis panel. You know what I mean? That

4 might be something that we want to --

5 DR. JONAS: Or I think if we feel that

6 these areas deserve more emphasis because there's

7 such a paucity of research, and if the VA is

8 going to start investing in it, that they design

9 a way to put it more permanently into their

10 standard review processes.


12 DR. JONAS: If it was NIH, you would

13 ask them to set up a review group on it, right?

14 VA, there may be a different way to do that.

15 DR. MAGUEN: Yes, absolutely.

16 MR. ROSE: I have a question. Who

17 actually pulled these together to set this panel

18 up? Who does that?

19 DR. JONAS: So, HSR&D has an entire

20 bureaucracy that does it, manages it. A very

21 rigorous, formal, structured process where they

22 bring in reviewers and distribute all the


173

1 applications that come in. They solicit

2 applications. If they want to see an area done,

3 let people know that they're going to set aside

4 some money to do it. So, then, all the

5 researchers are coming out of the woodwork and

6 apply, and that's how you move it forward.

7 MR. ROSE: How long does that take to

8 set up?

9 DR. JONAS: Well, it takes a long

10 time. I mean, at the NIH, which I'm more

11 familiar with the overall process -- I mean, I've

12 been on review panels in the VA, but I've never

13 overseen the overall process, where at NIH I

14 have. If you're a new investigator or even if an

15 established investigator, and you really want to

16 do it, and you know you're a good researcher, you

17 can anticipate applying, minimum, two, probably

18 three or four, times before you actually get your

19 grant funded. And each time it will take, you

20 know, the fastest would be three months.

21 Probably most of the time it's six months each

22 time, because it has to go to the review panel,


174

1 and then, it has to go above that to be approved

2 by the advisory group.

3 And I don't know if any of those

4 advisory groups are the ones that do it, but,

5 then, it has to be actually approved by the

6 advisory group to say, yes, the review is good,

7 but our priorities are this. And then, they

8 might not fund it for other reasons. Okay?

9 You can get a good scientific

10 evaluation and still not get it funded because

11 the advisory group says, "No, we decided we were

12 going to do that this year."

13 DR. MAGUEN: And I'll just add that,

14 by the way, we have talked about NIMH and we have

15 talked about VA, but there is also DoD, right,

16 which we haven't mentioned.


18 DR. MAGUEN: And the DoD grant

19 application process is quite different. And so,

20 DoD will fund things, they'll make calls for

21 things and fund things potentially within the

22 first round that you submit it.


175

1 DR. JONAS: Yes, that's true.

2 DR. MAGUEN: And so, it's a very

3 different system that the DoD has. And so, one

4 of the recommendations that we're going to be

5 getting to is saying that no one system should

6 oversee this, but we really should be working

7 together across this. And so, we're going to get

8 to that.

9 But I think what you're hearing is

10 that it's NIH, VA, and DoD have different

11 processes.

12 DR. POTOCZNIAK: How about SAMHSA?

13 DR. MAGUEN: SAMHSA is also -- I'm not

14 as familiar with SAMHSA.

15 DR. JONAS: PCORI has its own process.

16 DR. MAGUEN: Yes.

17 DR. JONAS: Yes, the reason why DoD is

18 able to do it faster is because they don't even

19 do a call until they already have the money.

20 They already have the money and they're ready,

21 and they have to distribute it within a short

22 period of time; whereas, the NIH can kind of


176

1 float it. They could do something saying, well,

2 if we get good applications, we'll find the money

3 and do it. And then --

4 MR. ROSE: Okay. Thank you.

5 DR. MAGUEN: You're welcome.

6 Let's see. So, we've talked about

7 applicable to all disorders. This slide was

8 Recommendation 1.

9 And Recommendation 2, "Oversight

10 should be delegated under the Executive Branch

11 implementation, ensuring that action takes place

12 by having Congress direct the orders for CIH

13 research." Again, we're trying to think of just

14 working recommendations that are talking about

15 where oversight should be delegated. So, that's

16 not lost in the shuffle.

17 Recommendation No. 3, "Ensure that all

18 studies include adequate representation of women,

19 at least 20 percent." So, we were just talking

20 last night about how the number of women veterans

21 are growing at quite a fast pace, and that we're

22 already at at least, you know, getting up to 20


177

1 percent, and certainly we'll be there in the next

2 few years.

3 And so, I think it's important to make

4 sure that not only are women adequately

5 represented, but that racial and ethnic

6 minorities are also adequately represented in

7 research. In research, there's a way to do that.

8 And so, some of these groups that distribute the

9 funds will monitor and ask you to report out on

10 your representation of women and racial and

11 ethnic minorities. So, we have to make sure that

12 that's reflected in the research that is being

13 done.

14 DR. POTOCZNIAK: And the effect of the

15 requirement could also even be higher if you

16 really consider that CIH is probably most

17 integrated into the women's clinics and stuff

18 like that. So, there's probably, I would say,

19 with CIH, the utilization of CIH is probably more

20 heavy on the female veteran side. They probably

21 use it more often. And so, I wonder, with the

22 people that you use CIH, I would wonder what the


178

1 percentage of women is. I would bet you it's

2 closer to 30 to 40 percent.

3 DR. MAGUEN: Yes.


5 DR. MAGUEN: Well, I think it's an

6 excellent point, right. So, we absolutely have

7 to make sure it's at least 20 percent, and

8 perhaps even more than that, right, depending on

9 what we find in terms of the percentage of people

10 actually using it.

11 Recommendation No. 4, "Given the

12 paucity of studies with individuals with MST and

13 CIH modalities, studies should be funded that

14 include veterans with MST exposure." And so, one

15 of the things that we looked at, in particular,

16 when we were doing some of the searches is we

17 wanted to see if there were any MST studies, in

18 particular. As we discussed as part of our

19 Workgroup, we think that MST is an issue that's

20 critical to examine in the VA system. And so, we

21 want to make sure -- and MST is not only seen in

22 individuals with PTSD, but depression and alcohol


179

1 uses. So, across really all of these disorders

2 we see people who have experienced military

3 sexual trauma, and we want to make sure that that

4 population does not get lost in the shuffle as

5 well, men and women with MST.

6 DR. POTOCZNIAK: And I don't know if

7 anybody saw the study that just came out --

8 DR. MAGUEN: Yes.

9 DR. POTOCZNIAK: -- that they estimate

10 about 10,000 men a year are affected by MST in

11 the military. So, like that's DoD people.

12 DR. MAGUEN: Yes.

13 DR. POTOCZNIAK: So, that's a

14 tremendous -- I think over the past decade, they

15 said, probably close to 100,000 men, which is a

16 ton of people.

17 DR. MAGUEN: Yes.

18 COLONEL AMIDON: Who did that study?

19 DR. POTOCZNIAK: I can forward it to

20 you.


22 DR. POTOCZNIAK: It was all over the


180

1 news, though.


3 DR. MAGUEN: So, The New York Times

4 has an article as well, I think from yesterday,

5 that was covering men and MST.

6 DR. POTOCZNIAK: Basically, it said

7 that -- what was it? -- that they've always seen

8 it as kind of a women's issue, but in the

9 military they actually said, even though the

10 percentage of women affected is much higher, the

11 numbers are either similar or greater on the male

12 side.

13 DR. LaRUE: A surprising number of our

14 focus group male participants have mentioned at

15 least --

16 DR. POTOCZNIAK: Yes, victims of it.

17 DR. MAGUEN: I'm glad to hear that

18 those folks are represented in our focus groups

19 because it really is something that is,

20 unfortunately, so stigmatized, I mean among men

21 and women, that we are just not seeing as many

22 men represented in research.


181

1 DR. LaRUE: It was interesting the way

2 they mentioned it versus women mentioned it

3 because they just start listing letters, PTSD,

4 blah, blah, blah, and MST, where women will say,

5 "MST. I was raped." So, it's very different in

6 how they present it, but I was surprised how

7 often it came up.

8 DR. MAGUEN: Thank you for sharing

9 that.

10 DR. POTOCZNIAK: The other thing they

11 said was only four out of five, or only one out

12 of five men tended to report it, even in the

13 research, not just legal, but even in the

14 research. They wondered. It was obviously much

15 greater.

16 DR. MAGUEN: Yes. There have been

17 studies on that, too, showing that over time

18 people will come out. The rates are different

19 over time, as people potentially get more

20 comfortable or some treatment or out of it.

21 DR. POTOCZNIAK: Just further away

22 from the military.


182

1 DR. MAGUEN: Yes, right. There's all

2 of that, too, as you get further away from the

3 trauma.

4 So, yes, I think we want to call this

5 out to make sure that this is a population that

6 we really want to see represented in the

7 research, men and women with MST.

8 So, Recommendation No. 5, "Prioritize

9 modalities or studies that can positively impact

10 multiple comorbidities simultaneously and have a

11 track record of safety." Again, we are talking a

12 lot about how do we prioritize, and this is one

13 way we can prioritize, is thinking about, for

14 those people who are coming in who have PTSD and

15 depression and pain, and maybe are abusing

16 alcohol as well, what are some of the modalities

17 that we can think of, again, in a sort of

18 transdiagnostic way, are helpful for people? So,

19 we want to deal with that.

20 Recommendation No. 6, okay, "Request

21 and fund a consensus study by the National

22 Academy of Medicine on salutogenesis models of


183

1 research. This study should develop a framework

2 for setting priorities and optimizing

3 methodologies focused on building resilience,

4 enhancing health promotion, improving function,

5 fostering well-being, rather than using a

6 pathogenic; i.e., disease treatment, model."

7 Again, this is going back to the point

8 of resilience and specifically looking at a model

9 of research that really fosters well-being rather

10 than a disease model.

11 "This study should explore the

12 rationale, approaches, priority, processes, and

13 ways to enhance funding of studies on how

14 veterans can better enhance their existing

15 resilience capacity, ability to enhance well-

16 being, and tap inherent healing and recovery

17 processes of veterans."

18 So, this is really speaking to the

19 point of a focus on well-being, resilience. We

20 know that there are inherent strengths in people

21 that we want to foster and to really look at a

22 model of research that enhances those strengths


184

1 in veterans.

2 Any questions about that? I think

3 that this will not be new to anyone. This is

4 something that has been -- we've been talking a

5 lot about resilience in this Commission. And so,

6 this is speaking to that, in particular.

7 Do you want to say anything?

8 DR. JONAS: Well, I was just going to

9 say I'm going to try to reinforce this with the

10 model discussion about --

11 DR. MAGUEN: Good.

12 DR. JONAS: -- resilience, well-being,

13 and whole-person --

14 DR. MAGUEN: Exactly. And so, I

15 think, again, the beauty of this is, this is

16 going to echo throughout many of the Workgroups.

17 This is the crosstalk we've been having.

18 Okay. Good. And No. 7, "Establish a

19 committee made up of veterans with oversight and

20 approval authority for VA-funded research on

21 CIH." So, we want to hear from the veterans,

22 again, if we think about veterans' voices being


185

1 represented not only in the research, but also of

2 the oversight piece. "The purpose of this

3 committee would be to assure that VA research is

4 developed and funded based on veteran preferences

5 and needs. The committee should be made up of a

6 diverse group of veterans representative of

7 current populations and ensuring sufficient

8 representation across gender and race, ethnicity,

9 and age."

10 Any questions about that? I think

11 that's pretty straightforward. We want to see

12 the people who are using these treatments

13 represented in oversight and approval and making

14 their voices be heard.

15 DR. JONAS: May I just point one thing

16 out here?

17 DR. MAGUEN: Please.

18 DR. JONAS: I think this is great.

19 There is a bomb in there. No, no. Let me

20 rephrase that.

21 DR. MAGUEN: Oh, okay.

22 DR. JONAS: There is something in this


186

1 recommendation that is potentially explosive

2 socially.

3 (Laughter.)

4 It's the word approval. Because,

5 right now, there are committees that have, you

6 know, patients and the public, and all that stuff

7 represented. It's standard. Okay? But they

8 don't say that they need to be part of the

9 oversight and approval in there.

10 And so if VA were to do that, that

11 would be revolutionary. It would be

12 revolutionary. Even PCORI, who was told to do

13 that, didn't figure out how to do it.

14 DR. MAGUEN: Right. And so, I think,

15 yes, it's something for us to think about, you

16 know, whether --

17 DR. JONAS: What does it mean?

18 MR. ROSE: Think about it as a team.

19 Right. I mean, also, the approval can also be

20 about what studies get funded, you know, to

21 approve that.

22 DR. JONAS: That's what I mean.


187

1 DR. MAGUEN: Yes.

2 DR. JONAS: Specifically, it's about

3 what gets funded.


5 DR. JONAS: And who has control over

6 the purse. And if the veterans actually had

7 control over it, that would be pretty radical to

8 be changing that.

9 DR. MAGUEN: Right. So, PCORI, that

10 is in their model, right?

11 DR. JONAS: Yes, there are some

12 examples, yes.

13 DR. MAGUEN: Right. I think, too,

14 it's about how we think about how veterans get

15 incorporated into the process, too, right? So,

16 if the whole health model is about the veteran,

17 shouldn't they have a say at the table in the

18 research, too?

19 DR. JONAS: Right, exactly.

20 CHAIR LEINENKUGEL: This is very

21 interesting, and Wayne beat me to the punch for

22 explosiveness.


188

1 DR. MAGUEN: Sorry.

2 (Laughter.)

3 CHAIR LEINENKUGEL: But it's great to

4 see.

5 DR. JONAS: There's an explosive

6 issue.

7 CHAIR LEINENKUGEL: But Recommendation

8 7 is going to need a lot of Commissioner

9 discussion. And I'll give you my two cents from

10 just, again, the 18 months, the amount of groups

11 that bring veterans that have done a CIH modality

12 that has, in their eyes, just about completely --

13 I will not say "cured" --

14 DR. JONAS: Helped them in recovery.

15 CHAIR LEINENKUGEL: -- but put them on

16 the right recovery path, okay, outside of the

17 evidence base. And you are going to run into

18 staunch believers for each one of those out of

19 the veteran covert subset, male and female.

20 I've seen enough of them. I've

21 touched enough of them. I've listened to enough

22 of them. And it's going to be the power and the


189

1 vocality of the group. So, not that they're

2 wrong, but you started out with basically saying

3 we just have not researched this.


5 CHAIR LEINENKUGEL: And we don't know

6 what we don't know.


8 CHAIR LEINENKUGEL: So now, we're

9 going to a phase that, okay, we do believe that

10 some veterans, on top of the evidence base,

11 probably get some sort of other means of support

12 from one or a couple of these other ones. Again,

13 we don't know for sure, right?

14 DR. MAGUEN: Right, right.

15 CHAIR LEINENKUGEL: So, when you get

16 into establishing committees or groups to make

17 approvals or recommendations, this will create

18 who gets a seat at the table out of all of these

19 groups, and how big is this going to be? So, I

20 mean, we can table it. We could spend a lot of

21 time on this. But I think you just need to keep

22 aware of that.


190

1 DR. MAGUEN: Yes, of course.

2 CHAIR LEINENKUGEL: Because I think

3 it's a great thing to do. It's going to be a

4 very difficult thing to implement.

5 DR. MAGUEN: And I think, too, I mean,

6 to also think about, you know, when we say

7 "veteran," there are already veterans that are a

8 part of the oversight and approval authority. I

9 mean, in VA there are a huge number of veterans

10 that are already at the table. And so, I

11 appreciate sort of the --

12 DR. JONAS: Let's develop that even

13 better --

14 (Laughter.)

15 DR. MAGUEN: Yes.

16 DR. JONAS: -- related to research is

17 more relevant and rigorous.

18 DR. MAGUEN: Right. I mean, think

19 about the number. I know like on review panels

20 that I've been on there already are veterans on

21 it, because they're a psychologist, because

22 they're already in the groups that we're looking


191

1 to have oversight and approval anyway.

2 And so, I think, again, we should talk

3 more about the expertise or who we would see at

4 the table, but I think that I guess I see this as

5 already happening to some extent. But just to

6 make sure that there are -- the same ways that we

7 have people who are at the table who make the

8 decisions are the ones that have knowledge in

9 this area, we want to get the people at the table

10 who have knowledge in this area.

11 MR. ROSE: How effective have they

12 been so far, these groups that have the veterans

13 onboard at the table making some decisions that

14 you are aware of?

15 DR. JONAS: Great question. Great

16 question.

17 DR. MAGUEN: Yes. I don't think

18 there's any data on that.

19 DR. JONAS: In my experience, it goes

20 all the way from the range of they're just tokens

21 that are just sticking on and they don't say

22 much, they don't actually feel like they have


192

1 power and authority, all the way to quite a lot

2 of input in those areas. So, how effective that

3 is, I don't know.

4 MR. ROSE: What makes the difference

5 between those two you talked about?

6 DR. JONAS: I think the ones that are

7 very effective, actually some of the best ones

8 are in NCI, so the National Cancer Institute,

9 because they've actually been working on this for

10 a long time. And NIAID, when the whole AIDS

11 stuff came up, and the patients said, "We think

12 you should move this forward and we think you

13 should pay attention to our interests," and all

14 that kind of stuff, they set up whole processes

15 where they trained patients basically and

16 families on how to work in these kinds of panels.

17 Okay. So, that they were empowered. They knew

18 what their role was. They actually knew enough

19 about the science and the methodology that they

20 could have conversations there. They had to

21 train people that could do that. Otherwise, they

22 would get kind of shoved aside, and the interests


193

1 of the patients wouldn't be represented.

2 I mean, you know, you see this when

3 you walk into a hospital. Suddenly, they're

4 saying do this; do that. And if the patient

5 doesn't want to do it, you need a patient

6 advocate with you who's not you who is sick,

7 right? But this is sort of the equivalent of the

8 research done.

9 DR. MAGUEN: I'll just also give

10 another example, since we brought up PCORI. For

11 example, if a PCORI study is funded, veterans are

12 necessarily part of a group of researchers. So,

13 they are veterans who are psychologists, who are

14 psychiatrists, veterans who are just

15 stakeholders. So, it can be the broad range,

16 MSWs, you know, people who have enough knowledge

17 to sort of be part of the team, but also give

18 their input. Whatever their hat is, they give

19 some input on the research process and, then,

20 when the data come out, it's run also by the

21 whole group of researchers, including the veteran

22 stakeholders.


194

1 So, I think there are already

2 processes that are models of this in place. And

3 I just want to make that point because I think

4 it's an important one. This is something that in

5 some systems this is already happening.

6 DR. JONAS: Exactly. And there's

7 actually textbooks written on methodologies for

8 how to incorporate subjects, people who are in

9 research, into the actual methodology. It's

10 called community-based participatory research.

11 And there's an entire methodology for it, and

12 there's textbooks written about how to do it, so

13 that the people are not simply subjects. Okay?

14 But you actually have involvement in executing

15 the research. There it is.


17 DR. MAGUEN: Yes. Okay. So, we can

18 definitely come back to this.

19 So, Recommendation No. 8, "Conduct

20 studies of whole health implementation that

21 specifically exam mental health and functional

22 outcomes." One of the things that we heard from


195

1 Ben Kligler is that they are doing incredible

2 work to look at some outcomes, but there isn't,

3 unfortunately, any information on the mental

4 health outcomes, as we heard about in Atlanta.

5 And so, this is specifically to call out that we

6 want to look at mental health and related

7 functional outcomes in terms of whole health

8 implementation. And I know that that's also an

9 area that their group is hoping to go in the

10 future. So, I think that's aligned with where

11 they're hoping to go as well.

12 Recommendation No. 9. And there's

13 only one more. So, thank you for hanging in

14 with me. I know these are a lot to go through.

15 "Examine mental health and functional outcomes of

16 residential programs that integrate mental health

17 plus a combination of CIH modalities compared to

18 similar mental health programs that do not have

19 CIH components."

20 And, Mike, this was kind of getting at

21 a little bit of what you were bringing up.



196

1 DR. MAGUEN: And please feel free, if

2 you think that there should be tweaks to this, to

3 let me know.

4 But I think this is really getting at

5 the point that Mike was raising, that there are

6 already systems in place, whether it's

7 residential or IOP programs, that integrate

8 mental health plus CIH modalities. So, let's

9 look at those. Let's do those studies, so we can

10 learn about systems that are already in place, if

11 that's beneficial.

12 DR. POTOCZNIAK: You might add, you

13 may, I mean, you might add "residential or

14 intensive outpatient programs" --

15 DR. MAGUEN: Yes. That's right.

16 DR. POTOCZNIAK: -- because a lot of

17 the people that get treated for AUD and OUD are

18 typically part of some sort of intensive

19 outpatient model.

20 DR. MAGUEN: Yes. Right. Okay.

21 Any other thoughts about that?

22 MR. SPERO: Would it be helpful,


197

1 because this was a lot to take in, I think --

2 DR. MAGUEN: Yes.

3 MR. SPERO: We can send this

4 PowerPoint around to the group to think about,

5 now that it's out there.

6 DR. MAGUEN: Yes, please.

7 MR. SPERO: So, we'll do that at the

8 conclusion of the meeting.

9 DR. MAGUEN: Yes, I appreciate that

10 because this is a lot to take in. I'm trying to

11 keep us moving at a reasonable pace, but I also

12 understand, for those of you who have not been on

13 the Workgroup, it's a lot to take in. So, we're

14 kind of incorporating presenting the results of

15 the searches, the result of some of our

16 deliberations, and it's been a multiple-month

17 process. So, yes.

18 CHAIR LEINENKUGEL: Yes, it's a lot of

19 work.

20 DR. MAGUEN: It's a lot of work, yes.

21 MR. KUNTZ: But you guys did great.

22 I mean, that's a lot of work to see you get to


198

1 where you're at.

2 CHAIR LEINENKUGEL: One slide left.

3 DR. MAGUEN: That's right. That's

4 right. We are almost there. So, okay.

5 No. 10, last but not least, and I

6 think that this, hopefully, will look familiar.

7 "Establish a collaborative VA and DoD oversight

8 committee that would lead to" -- and we can add

9 "NIH" there as well -- "that would lead to a

10 joint-funded research" -- example: VA, DoD, NIH

11 -- "such as the Pain Management Collaboratory,"

12 as we were talking about earlier today. Again, a

13 model like this exists and has recently been

14 rolled out. "And ultimately, development of a

15 Center for Integrative Health Research."

16 So, we kind of gave an example of

17 something like being called "The Warrior Care

18 Mental Health Collaborative," right? So, this

19 idea that there's a center where this research

20 can actually be done that's really a

21 collaborative and an across-agency center where

22 these kinds of research studies are happening.


199

1 I know that's a big one, and it's

2 something that we kind of talked about in our

3 Workgroup. We can open it up to discussion and

4 conversation.

5 But I think that, with the direction

6 that health care and mental health care is

7 headed, we just think that the kinds of studies

8 that need to be funded really require weighing-in

9 from the VA side, the DoD side, and the NIH side.

10 Again, we're not doing it just in one agency, but

11 that the agencies are talking to each other and

12 having shared goals, and where the money is going

13 together.

14 CHAIR LEINENKUGEL: Yes, I think that

15 the timing is absolutely critical, and the timing

16 is actually right at this point in time as far as

17 the climate on the Hill that we say yesterday,

18 Shira, if you remember --

19 DR. MAGUEN: Yes, I do.

20 CHAIR LEINENKUGEL: -- to certainly

21 move forward with something like this.

22 DR. MAGUEN: Great. Great. Thank


200

1 you.

2 DR. KHAN: That's a great job.

3 DR. MAGUEN: Thank you. Thank you.

4 It's a huge team. I think I started out with

5 acknowledgment to everyone who is on the team

6 from Commissioner, the VA side, and the Sigma

7 side. It truly has been a really great group

8 effort, and we appreciate everyone's support.

9 This doesn't happen in a vacuum, right? So, I

10 appreciate everyone's support that's both on the

11 Workgroup and all the conversations that we've

12 had, also, outside of the Workgroup as well.

13 CHAIR LEINENKUGEL: And it should be

14 noted that an absolutely fantastic job on the

15 Hill with both HVAC and SVAC yesterday, extremely

16 well-buttoned-up and presented, and they were all

17 amazed at the horsepower I think that you had on

18 your team working on this; and also, where the

19 Commission is under your Workgroup right now.

20 So, just really well done, Shira.

21 DR. MAGUEN: Thank you. Thank you.

22 It's a good village that I have here.


201

1 CHAIR LEINENKUGEL: Thank you, Shira.

2 Any other questions at this time?

3 Because it is a time check, 2:26, and

4 we've got 34 minutes to do basically two things

5 under the open session. Are we ready to move on

6 those, Casin?

7 MR. SPERO: So, we need to do a little

8 Atlanta travel summary, go over our Workgroup

9 site visits in Atlanta just briefly. And then,

10 we'll make sure that the information we gather

11 there is added to the transcript of this meeting.

12 CHAIR LEINENKUGEL: The Atlanta site

13 group thing is something that we just wanted to

14 make sure that we got on the record. All the

15 Workgroups had feedback. So, this would be just

16 be for the general public and for the actual

17 record of why the Commission was at the Atlanta

18 site visit, why we chose Atlanta, some of the big

19 ahas that came out of that particular COVER

20 Commission meeting at that time.

21 So, I think that let's let the

22 Commissioners think about that first case, and


202

1 then, let's go back to Wayne, who's going to give

2 us the Boston site visit overview. And then,

3 we'll conclude with Atlanta. Does that make

4 sense?

5 MR. SPERO: It works for me.

6 DR. JONAS: Yes, so I passed around a

7 little overview of sort of why Boston. It might

8 fill in some gaps for what we're doing here. And

9 I laid out some of the goals.

10 My understanding from talking with a

11 number of people in the VA and some outside the

12 VA is that Boston has two things that would be of

13 value to look at. One is the integration of

14 whole health into actual clinical delivery sites.

15 That's been a challenge. We've seen a lot of

16 examples where groups are running, where

17 individual projects have been incorporated into

18 whole health, if they were already there, because

19 they were so, some of them, well-developed and

20 that stuff, not called that, but they were doing

21 the same thing, were brought in.

22 But the folks up in Boston, I have


203

1 been told, have been trying to sort of

2 systematically embed a process whereby whole

3 health is part of the clinical delivery services.

4 So, the patient health inventory, personalized

5 health plans, et cetera, are part of what the

6 clinicians actually get involved in, because

7 that's usually the big gap. That's usually the

8 challenge, is to get the clinicians to understand

9 what their role is in that. So, the group up

10 there is doing that, working on that. So, it

11 would be good to get an overview of that.

12 Ben listed three people up there who

13 he thought would be good to do that:

14 Michael Charness, who was their Chief

15 of Staff who oversees that. If we got on the

16 phone and talked with him, he could probably

17 flesh out for us what needs to be done.

18 Ed Phillips is focused specifically on

19 lifestyle. There's lifestyle medicine which is

20 lifestyle change and that type of stuff, and he's

21 the lead in the VA for doing that. So, we have

22 to kind of look at that.


204

1 Elizabeth Recupero is, I think, a

2 primary care person that was also mentioned up

3 there.

4 Also up there we talked about the

5 wellness measures and how do we measure wellness,

6 how do you kind of know what it is. And so,

7 Dawne Vogt is the lead in the VA for developing

8 those components. She's also up there. So, we

9 thought it would be great to get a download from

10 her on that. You know, where are they? What are

11 they doing? How are they developing that and

12 what's been validated, whether they plan to bring

13 any news in measurement systems?

14 So, that would be the primary reason

15 for going to Boston VA. And the thought is, if

16 we spent a day there with that, and whatever

17 other things Charness comes out with, that that

18 would be worth a trip.

19 The other two things we wanted to look

20 at was this whole issue of quality assessment

21 models and metrics. What is the current state

22 from the experts that are looking at those? And


205

1 Boston, not everybody is in Boston, but there are

2 two groups that do a lot of that.

3 IHI that developed the Triple Aim is

4 up there. I talked to Don Berwick who he started

5 IHI, and that kind of stuff. We're going to have

6 a call with Maureen Bisognano who is also a

7 former IHI person about these components; and to

8 see if we can get some advice from some of the

9 experts and have a discussion with them about how

10 do you go about assessing the Quadruple Aim. We

11 could show them what we're planning to do, what

12 we're doing, get their feedback from that.

13 And then, some of them are in Boston,

14 some of them are not, and if they are willing to

15 participate, we could maybe just have them come

16 in virtually, if we had a place to do it.

17 There's a number of folks that have

18 been doing VA/non-VA health care quality

19 comparison. I have listed some of the main ones

20 down there. This is based on two things, our

21 literature search and ones we already know about.

22 The Dartmouth Center for Health Care


206

1 Quality is right up there, and a number of these

2 studies have come out with them. And several

3 people are up there. Weeks from Dartmouth is

4 there. We could ask him if he would participate

5 in that. And then, some of the RAND folks are

6 also up there. We could ask them to call in.

7 So, the thought is, if we went up and

8 spent at the VA looking at those first items, and

9 then, maybe spent a half a day where we asked

10 some of these other folks to give us input, sent

11 them the questions, perhaps do it over at IHI,

12 which is a little different place in Boston, but

13 they have centers and stuff like that; that that

14 would be a worthwhile trip.

15 Anyway, that's the idea. And so,

16 feedback welcome. Anybody who wants to come

17 virtually or personally?

18 CHAIR LEINENKUGEL: Well, Wayne, it's

19 a great one-pager.

20 Personally, from the Chairman's

21 position, I look at No. 3 under your first piece

22 of rationale as being right on the mark. It goes


207

1 back to an earlier discussion this morning. It's

2 the direction of wellness outcomes. That would

3 be very interesting, I think, for all of us, as

4 all of these will.

5 At the bottom of your page, though, 3,

6 4, and 5, if we can get something, because I

7 think that's one of the missing links at this

8 point in time. And how in the next few weeks are

9 we going to be able to get some of that feedback

10 or measurement for inclusion in our report, or at

11 least discussion amongst Committee members?

12 DR. JONAS: I don't know what the best

13 process is for doing that. I would leave it open

14 to both VA and the other folks to know what the

15 best process is to do that. Right now, the days

16 that had been set aside are the 8th and the 9th

17 of October. That's fairly soon. So, that would

18 give us information pretty soon. We'll be able

19 to fill these gaps in pretty soon. And if we

20 were able to send out a request that they brief

21 and present us, find a place to do it, or we set

22 up a process to do it, then we could get as many


208

1 of these subject matter experts at the bottom

2 there who might be willing to participate in

3 that; lay out the questions. And then, the VA

4 folks, I don't know, I think you would probably

5 have to contact Michael Charness and help

6 organize. And I'd be happy to talk with him

7 about it with you all.

8 COLONEL AMIDON: It might be worth a

9 flyby to the Home Base folks, too, which is part

10 of that work based in Boston doing their two-week

11 IOP funded by Wounded Warrior Project. And they

12 are to the point of where a veteran can engage in

13 the non-VA care, a lot of them. It's very known

14 in the State of Massachusetts that Home Base is

15 one of the other places to go that's right there

16 by the downtown,

17 DR. JONAS: It's right there in the

18 downtown? Okay. It sounds great.

19 COLONEL AMIDON: It's just like Emory

20 or the Network for Warrior Care. If you're

21 there, it makes sense to go.

22 DR. JONAS: Yes, that makes sense.


209

1 CHAIR LEINENKUGEL: So, from the

2 process piece -- and then, I don't know if most

3 Commissioners feel the way I do -- I think that

4 you address three of them laying right there with

5 3, 4, and 5 that we have not really come to a

6 deeper solution to or comparing the two, whether

7 it's VA versus non-VA. And I think that at some

8 point we've got to get better at that because I

9 think we're going to be questioned that: have

10 you done or gotten at least a comparison between

11 VA versus non-VA on those three items?

12 DR. JONAS: We are doing a literature

13 analysis of what is the current studies that have

14 looked at this.

15 CHAIR LEINENKUGEL: Right.

16 DR. JONAS: Yes, so we will have that.

17 But it would be great to hear from some of these

18 people that actually do, to say, you know, "What

19 do you find," especially in mental health because

20 there's not a lot in mental health. I mean, we

21 can ask them.

22 MR. ROSE: I would think -- their


210

1 impression and what they think of the interaction

2 between VA and Federally-Qualified Health

3 Centers. We've talked about that. We've had

4 questions, go back to --

5 DR. JONAS: Yes. And then, we had

6 folks from the medical, or AHRQ, not AHRQ -- I'm

7 sorry -- but HRSA who came and presented on that.

8 And they're a huge network. They didn't actually

9 have any good data on how many veterans they take

10 care of.

11 MR. ROSE: No, they didn't. They

12 didn't have that at all.

13 DR. JONAS: And that question was re-

14 asked, and I don't know that they answered.

15 Maybe they don't have it.

16 MR. ROSE: I don't think they actually

17 have it. I don't think they actually have it.

18 CHAIR LEINENKUGEL: We haven't heard

19 back. So, it would be interesting --

20 DR. JONAS: I mean, they gave a number

21 which was ridiculously small. I mean, it was

22 they take care of 24 million people and they said


211

1 it was like -- I forget what the number was, but

2 it was like, come on; it's got to be more than

3 that. And then, they said, well, we actually

4 don't have a systematic way of capturing if

5 you're a veteran or not.

6 CHAIR LEINENKUGEL: Wayne, what are

7 your dates that you are doing the trip?

8 DR. JONAS: So, right now, I think we

9 have the 8th and the 9th set aside for that. So,

10 that's pretty quick. So, it would be great if we

11 could --

12 CHAIR LEINENKUGEL: And who at this

13 point in time, besides you, Wayne, would be

14 going?

15 DR. JONAS: I don't know. Anybody who

16 wants to, I guess.

17 MR. SPERO: We can't do more than

18 five. We just don't have the time to get

19 approval to have more than five people travel.

20 MR. GOODRICH: When we initially did

21 the call, I think every Commissioner wanted to

22 go. I think there were eight, eight people who


212

1 indicated an interest.

2 COLONEL AMIDON: I am no longer

3 interested.

4 CHAIR LEINENKUGEL: I will be out.

5 So, all of a sudden, you've got three less.

6 MR. SPERO: The limit is five.

7 CHAIR LEINENKUGEL: Why don't we work

8 this offline? We'll get the Boston trip. You'll

9 have your five, your support.

10 DR. POTOCZNIAK: I think given

11 visiting the Warriors here, and as much as I

12 wouldn't want to add another trip to my schedule,

13 it kind of fits a little bit with what I do. I

14 mean, I could see going to it.

15 CHAIR LEINENKUGEL: It's your call.


17 CHAIR LEINENKUGEL: Two?

18 MR. ROSE: Three maybe.

19 DR. POTOCZNIAK: What's the dates

20 again?

21 DR. JONAS: The 8th and 9th.

22 COLONEL AMIDON: Dawne's at the


213

1 National Center for PTSD in White River Junction.

2 DR. MAGUEN: No, no, she's in Boston.

3 CHAIR LEINENKUGEL: So, we'll move to

4 the last piece on the open agenda today, and that

5 is a synopsis and an overview as to our site

6 visit to Atlanta, which took place two weeks ago.

7 I believe it was back August 25th and 26th.

8 The purpose really was that we have

9 not, as a Commission group, really been to a one-

10 star SAIL facility and, also, at the same time to

11 explore other things that take place within

12 mental health care within a large VISN and

13 veteran-centric area such as Georgia. And so, it

14 was another good opportunity for us to go in as a

15 group.

16 We also saw some other things that I

17 think were enlightening, and I would like each

18 group to have a quick overview, so that we have

19 time to do that.

20 MR. ROSE: I think, all in all, with

21 Group 4, it was quite an enlightening visit. We

22 saw a huge transition in the leadership of what


214

1 they were going through. I think the Wounded

2 Warrior Program at Emory was pretty amazing for

3 what they do with $25,000. Is that right?

4 COLONEL AMIDON: Per.

5 MR. ROSE: Per. Two days. And it's

6 actually outpatient, but they're really living in

7 a hotel right across the street. Their success

8 rate has been extremely high, and talking to the

9 people that are actually making it happen, very

10 positive. So, I think that that part was very

11 key.

12 And I think another point was the

13 Veterans' Call Center, of how they started and

14 where they are right now. The number of people

15 that they have there, I think the morale of the

16 people that are working there is extremely high.

17 And I think that that's key because you look at

18 what they deal with every day and talk to how

19 they can help people and examples of how they

20 have helped people.

21 And I don't know if it's a decision

22 point at this time, something to maybe think


215

1 about, but could there be a role of artificial

2 intelligence in how you do things at a call

3 center? Just for different strides that are

4 currently being made, we talk about the areas of

5 research. Is that one? And it may go well

6 beyond the Call Center.

7 But I think, overall, it was a very

8 successful trip. And as the Chairman says, it

9 was not the type of facility that we have been

10 looking at from the get-go. I think, in all

11 fairness, that that's important. I mean, if you

12 keep looking at the facilities right at the top,

13 you get one impression. And I think one of the

14 things that we talk about, it's comparing the

15 different facilities and the different leadership

16 that makes that particular facility go. So, I

17 think, all in all, it was time well spent.

18 CHAIR LEINENKUGEL: That was a great

19 synopsis, Commissioner Rose.

20 I also want to add that we spent a lot

21 of time in small groups, so we did a lot of

22 dividing and conquering because it is such a


216

1 large campus area, and there were three or four

2 different facets that we wanted to cover in 36

3 hours. So, I think that it was still a very

4 controlled, small-group situation of

5 Commissioners piecing off, being able to work

6 amongst various veteran staff groups internally

7 within Atlanta and at the same time getting Emory

8 and the Call Center in, which were enlightening.

9 MR. ROSE: And I think one other

10 point, if I may make, it's another example that

11 we have seen throughout our travels about the

12 role of a Veteran Peer Support Specialist.

13 DR. POTOCZNIAK: I think the visit to

14 Atlanta, you know, there were some really good

15 highs and some really low lows. To go and see

16 the Call Center was inspiring, all that are

17 coming to work day-in and day-out, listening to

18 people at their kind of most acute -- people that

19 are probably the backbone of the VA mental health

20 system that are GS-7s and -9s, taking some of the

21 most intense work and doing audio phone calls

22 with veterans who are on the edge of suicide. It


217

1 has got to be some of the most stressful work

2 within the system, I would say. Watching them

3 and how they dealt with internally, and seeing

4 the camaraderie amongst them was heartwarming.

5 And the Emory program, I mean, I will

6 totally refer patients to it. It has a really

7 good -- it seems very well-organized and great.

8 I think the concerning parts of the

9 trip were probably the total almost decimated ELT

10 at that facility. Well, they didn't have an ELT,

11 right? I mean, they have one Director of a

12 massive, expanding health care system. I think

13 it was incredibly concerning to see how little

14 experience they had on the executive level and,

15 also, some of the negative attitudes that I heard

16 about mental health from that executive

17 leadership, which was basically everything in the

18 rural areas onto telehealth, which I thought

19 flies in the face of what we would want the VA to

20 be, which is a community that a veteran can

21 engage with. Especially with veterans expanding

22 into the rural areas, increasingly kind of taking


218

1 it and making it something that you're going to

2 always get one kind of care further out and a

3 higher level of care further in. I think that's

4 the opposite direction of where we're supposed to

5 be headed.

6 So, that was what I got from Atlanta.


8 Potoczniak, I congratulate you on being brave and

9 forthright, because I would absolutely agree with

10 you. And I think that most other Commissioners

11 that saw or noticed what you did in regards to

12 what was taking place in Atlanta, as you noted,

13 is right on. And it is concerning. Also, it

14 made me wonder how many other VA leaders or

15 leadership roles are that type of capacity at

16 this point in time.

17 Also, directionally, where they were

18 going, to your rural comments, was contrary to

19 what we saw with some of the discussions in

20 Montana, which seemed to be making a larger

21 effort with a much larger space to do a little

22 bit more.


219

1 And we also saw the tribal, and we

2 also saw, not to conflate the two, but they were

3 different, to say the least.

4 But thank you for that.


6 CHAIR LEINENKUGEL: Any other

7 Commissioner comments?

8 COLONEL AMIDON: I'll just echo what

9 you said. It takes a special person to be a part

10 of any call center. It takes an incredibly

11 special human being to be at the VCL. I was very

12 taken with those folks and the way they managed

13 their own wellness. They deliver to the extreme

14 on a daily basis.

15 DR. MAGUEN: Yes, I want to echo that

16 as well. I think that's one of the things that

17 stood out to me, aside from the camaraderie and

18 the incredibly hard work that they do, and how

19 thoughtful they are in the process, just how they

20 think about burnout, taking care of each other.

21 There was a whole wellness component

22 to how they do self-care of themselves as


220

1 providers. And as we know, that's part of what

2 we're looking at in this Commission, too, not

3 only in order to sort of serve the veterans in

4 crisis, you have to take care of yourself. And I

5 thought that was a really nice model of how they

6 do that. So, I want to echo that.

7 CHAIR LEINENKUGEL: I think we saw the

8 highest of the highs of leadership out at that

9 Veteran Crisis Line Center. If you look at who

10 is in charge and the personality of that person

11 that established that camaraderie and connection

12 to the entire group, of doing something that,

13 quite frankly, he noted -- and I told him later

14 -- he said he could not do what they're doing.

15 And I said to him, "There's no way I could do

16 that, what they're doing."

17 Yet, we all touched and saw the people

18 that are doing it, and they all had smiles on

19 their faces while they were discussing their

20 challenges with us, which absolutely amazed me,

21 that they do this day-in and day-out, and make a

22 difference to saving veterans' lives.


221

1 DR. KHAN: Of all the places I

2 visited, that Call Center was at home to me. I

3 mean, you could see veterans; I mean, it was a

4 home to me, that place.

5 DR. POTOCZNIAK: It's also led by a

6 veteran. That's important. Matt Miller was a

7 psychologist in the Navy, I think, and worked

8 with a lot of pilots, and then, transferred over

9 to the VA afterwards. So, it's really like

10 having veteran leadership up top can be a really

11 good thing.

12 COLONEL AMIDON: The functional

13 interactions, too, were important, as evidenced

14 by the Emory Veteran Center, where Sheila Rauch,

15 she's sort of dual-hatted as it be, a person and

16 a key component to Emory. You can see that just

17 sort of breaks down the functional stovepipes

18 CHAIR LEINENKUGEL: Matt, expand on

19 that because that came up yesterday in the

20 Congressionals, too, about that dual-hatted role.

21 COLONEL AMIDON: I think it just

22 supports your point, easy and seamless referrals


222

1 between the two both ways. It seems like they

2 had a very good relationship between the two

3 enterprises in delivery.

4 DR. JONAS: That's all peer-to-peer,

5 isn't it?

6 MR. ROSE: It works.


8 Commissioners with any other insight?

9 MR. ROSE: I made a comment, and it

10 came up in the discussion the second day at the

11 Care Center, when the question was asked, "Why

12 does it work? Why does it work where something

13 else does not work?" And I think that the

14 general said, "Access, stigma, and impact, when

15 you compare that Care Center with what may occur

16 at a VA."

17 CHAIR LEINENKUGEL: You're talking

18 about Emory, right?

19 MR. ROSE: Yes, Emory.

20 COLONEL AMIDON: But to hear from you

21 guys about the relevance of the two-week IOP, and

22 sort of having that concentrated delivery, it


223

1 would be interesting to hear your observations of

2 measurement outcomes upon intake and exit, and

3 then, three, six, and nine months. It certainly

4 doesn't assume that you're finished. It would,

5 then, assume that you need some frequency of

6 follow-on.

7 MR. ROSE: Recovery, it's part of the

8 recovery, right.

9 COLONEL AMIDON: But, also, there's

10 streamlined process.

11 DR. POTOCZNIAK: It truly is. It

12 brought up a couple of issues. And one was that

13 they were still funding it, even though we have

14 VA community care. It highlighted an emerging

15 problem in the VA, which is you've got an

16 excellent program that really could be getting

17 paid by the VA to get funding, and they can't

18 logistically make it happen, even though they've

19 got great lines there. And that's how we lose so

20 many really great programs with the VA, is just

21 the bureaucratic nature of what happens around

22 community care.


224

1 Then, the other thing about Emory that

2 they highlighted, which I'm glad you brought up,

3 is we've seen other PTSD-related programs through

4 the VA, some of which have had three-, four-,

5 five-, six-month waits to get into them; whereas,

6 Emory does not have that issue. And so, I think

7 that's an important point because access is the

8 key to success in a lot of cases. People will go

9 almost anywhere if they can get in. So, getting

10 in is the big issue.

11 COLONEL AMIDON: I think the rolling

12 cohort model for them is unique in the Warrior

13 Care Network. The other ones are fixed cohort.

14 And I don't know that. I can't remember.

15 DR. JONAS: I was talking to Tom about

16 this, and it's very similar to what the Intrepid

17 Center does here. It's even a bigger program at

18 the Intrepid Center, and it's four weeks and even

19 more resources. This is sort of a mini one.

20 And we saw another model -- I think

21 there's a variety of ways to go about doing this

22 -- in the VA in Atlanta, and that was the EVP


225

1 program that Michael Saenger ran. It was a 10-

2 week, group-based program that, from the data he

3 reported, it looked to be very similar in terms

4 of outcomes from what Emory was doing, but it's

5 very different. They have to come every single

6 week, okay, for 10 weeks, a long time, but

7 probably about the same amount of total time, if

8 you think about it in those areas.

9 And so, there was an example of one

10 leader who put together an excellent program that

11 was having an impact. And to one of the points

12 you just made, Shira, about, hey, we need to

13 evaluate these things, how do you evaluate, the

14 VA needs to think about how do we evaluate that.

15 Because, you know, when I asked folks at Emory,

16 "Are you going to do a randomized control trial,"

17 they said no.

18 (Laughter.)

19 And so, if it comes down to paying

20 dollars and cents, the question will be, well, is

21 there an optimal model that could be done? And

22 one could do an RCT of that kind of an intensive


226

1 two-week program versus a longer-term thing like

2 what Michael Saenger's was. So, there would be a

3 way of doing that, if you wanted to do that.

4 DR. MAGUEN: I mean, there are newly-

5 published studies of massed treatment, so for

6 evidence-based psychotherapy.

7 DR. JONAS: Yes.

8 DR. MAGUEN: So, you do it in kind of

9 a chunked way.


11 DR. MAGUEN: So, rather than having

12 people come back weekly, they come back for

13 massed EVP. And so, those studies are published,

14 are recently published. And there's, I think, a

15 lot of talk in the community about thinking about

16 delivery and models of delivery. Those studies

17 are obviously expensive to do, right, and there

18 is some evidence showing that that is helpful for

19 people.

20 DR. JONAS: Right. And if you wanted

21 to expand the Emory program to make it more

22 generalizable, because it is a very select


227

1 population that they get there, then the question

2 of how would you make this expandable, you have

3 to ask, you have to evaluate that in some way.

4 Is that effective for 5 percent of the

5 population, 10 percent? Which ones, and that

6 type of thing. So, all the questions we were

7 just asking about that.

8 DR. MAGUEN: Yes.

9 DR. JONAS: And they need to be asked

10 around those questions. But what I liked about

11 that is that you could do those without going

12 through every little modality that they have and

13 say, okay, we want RCT on this one and this one

14 and this one. You could actually look at the

15 integrated program for complex, multi-modality,

16 and for lots of comorbidities. I mean, the

17 people they had there had -- nobody had one

18 thing, right? And then, look at, well, does this

19 impact? What is the impact of it? What does it

20 cost?


22 Commissioner at this point in time?


228

1 I think, as a Commission, on behalf of

2 the entire COVER Commission, to the general

3 public, to our constituents on the line, to our

4 support staff in the room, and the general

5 public, thank you for a great day today. I hope

6 you have a sense that this Commission is highly

7 engaged, that we do have a working plan in place,

8 and also an end plan in place, in order to get to

9 all of the actions of each five Workgroups.

10 Today, you heard from Workgroups 1 and

11 3, in particular, Dr. Shira Maguen and, also, Dr.

12 Wayne Jonas, an update of the status where they

13 are, some of the gaps, very few gaps in research,

14 some more data collection still coming in on both

15 parts probably over the next couple of weeks, but

16 also a sense of urgency of changing gears from

17 going from the research analysis stage to the

18 recommendation, and then, deliberation and

19 writing stage. And that's where we will pick up

20 in offline Workgroups the rest of this afternoon.

21 And also, tomorrow we will be hearing

22 in the open session, starting at 9:00 a.m.,


229

1 Workgroups 2, 4, and 5 will present during the

2 morning, a very similar status update on their

3 outputs and recommendations, and any constraints

4 and barriers that they may have before we come to

5 a conclusion of next month's meeting in October

6 with more solid recommendations.

7 Any other further comments or

8 additives from the rest of the Commission at this

9 point?

10 If not, ordered that this session of

11 the COVER Commission be terminated.


13 went off the record at 3:00 p.m.)

14

15

16

17

18

19

20

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6:16 7:1,5art 69:21 106:18article 180:4articles 50:20 51:7artificial 215:1aside 173:3 192:22

207:16 211:9 219:17asked 9:4 12:10 21:11

34:15 59:20 74:190:18 206:9 210:14222:11 225:15 227:9

asking 10:10 47:5 54:354:22 118:12 168:19227:7

aspect 64:9,9 79:980:21

aspects 65:4assess 76:20assessing 205:10assessment 20:18 75:5

81:5 204:20assistance 15:3Assistant 6:1assisted 166:5assume 223:4,5assumption 98:12assure 185:3Atlanta 3:16 195:4

201:8,9,12,17,18202:3 213:6 216:7,14218:6,12 224:22

attack 24:12attempt 131:7 164:13attend 12:7attendees 4:14attending 11:18attention 192:13attitudes 217:15AUD 154:21 155:4,21

157:11,14 158:19159:2 196:17

audio 32:19 41:4,8 42:758:9 216:21

August 104:13 213:7authority 184:20 190:8

192:1automatically 43:17available 18:18 19:11

35:7,15,19 74:2,976:17,19 77:1,4

102:21 119:5average 76:17avoid 47:19 51:13aware 7:20 10:11 12:16

16:8,20 50:21 56:790:11 100:11 102:18123:1,14 189:22191:14

awareness 8:9

Bback 13:4 14:2 20:12

41:12 42:4,7 44:1547:20 55:15 57:859:10 72:1 74:1377:19 83:6 86:1,1891:11 99:5 100:15,20108:21 134:8,16141:20 144:9 148:22149:12,22 150:1,3151:2,4 153:3,6,18154:9,13 157:6161:12 183:7 194:18202:1 207:1 210:4,19213:7 226:12,12

backbone 216:19backfill 44:10background 49:1 63:21

148:16backing 136:15backup 85:4backward 160:19bad 136:13 156:19bag 99:4,9balancing 64:18barrier 123:10barriers 51:21 118:14

120:19 122:14,17123:2,6,7,8,14 125:5138:21 229:4

base 89:14 188:17189:10 208:9,14

based 22:1 44:21 75:17108:5 112:15 114:3115:2 121:13 147:15171:22 185:4 205:20208:10

basic 65:8 96:12 125:18basically 62:7 88:12

108:11 114:8 133:14180:6 189:2 192:15201:4 217:17

basis 219:14BCOCs 144:3beat 187:21Beattie 2:6 103:19beautiful 165:19beauty 184:15

Beeman 7:16 61:2092:22 103:12

began 33:7beginning 22:10 40:16behalf 41:7 96:6 228:1behavior 25:22 63:10

103:9 161:14,18,21162:5,8,14,16,21163:16,21 164:9,12164:18 165:9,11

behaviors 105:17162:22

behoove 12:1 42:17behooves 146:2believe 15:18 23:7,10

109:11 110:1 156:13189:9 213:7

believed 126:16,18believers 188:18Ben 121:6 195:1 203:12beneficial 11:19 36:10

196:11beneficiaries 35:20benefit 116:5benefits 103:1Berwick 205:4best 43:8 48:21 75:10

84:12 85:17 86:1491:20 92:1 97:18109:15,17 119:17138:16,19 192:7207:12,15

bet 178:1better 15:1,3 21:8 25:17

26:14 30:19,19 42:650:9 56:22 58:10,1484:2 87:14 100:16121:10,14 144:22159:15 183:14 190:13209:8

beyond 63:16 147:9215:6

Bias 108:6big 37:10 46:18 52:8

69:3 77:14 87:8,990:8 111:7 114:12140:21 145:11 154:1189:19 199:1 201:18203:7 224:10

bigger 157:22 224:17biking 115:4Bilateral 163:20billion 149:1billions 140:8biopsy 77:4 81:20bipolar 103:9Bisognano 205:6bit 32:22 33:6 60:2

61:15 72:6 73:10 77:683:10 100:4 121:11124:3 132:20 159:18161:18 170:8 195:21212:13 218:22

blah 181:4,4,4blamed 35:1blinded 149:3block 36:7 62:20blocks 129:22board 1:15 2:1 45:6

79:4 98:6 164:2body 66:5Bold 38:8bomb 185:19bone 59:1book 73:17 148:5Boston 3:12 22:11,12

83:10 101:4,10 202:2202:7,12,22 204:15205:1,1,13 206:12208:10 212:8 213:2

bottom 207:5 208:1boundaries 140:16,20boy 14:21brainstorm 94:5Branch 176:10brave 218:8break 24:11 41:3,11,21

80:17 99:22 100:20102:9 164:16

breaking 59:9breaks 221:17brief 8:19 26:18 207:20briefly 201:9bring 31:7 83:6 84:13

121:11 137:21 141:20144:16 172:22 188:11204:12

bringing 55:20 63:6124:18 195:21

brings 115:13broad 46:8 121:21

193:15broad-scale 32:14broader 36:2 127:5brochure-type 53:13brought 11:13 42:19

193:10 202:21 223:12224:2

bubble 123:13 124:10124:15 128:4

bucks 139:9,22budget 14:12 129:12budgetary 131:15builders 129:17building 129:22 135:9

183:3


232

built 60:10bunch 143:18buprenorphine 133:13bureaucracy 172:20bureaucratic 51:21

223:21burnout 219:20Bush 1:15 6:9business 35:16 44:18

87:20 88:11 89:1399:20

busy 56:5 118:13button 98:16

Ccake 20:15calendar 13:17California 1:22 94:14call 3:2 13:22 32:20

42:4,22 78:17 88:689:12 92:5 94:8102:18 104:4,19112:20 161:17 175:19182:4 195:5 205:6206:6 211:21 212:15214:13 215:2,6 216:8216:16 219:10 221:2

called 24:9 148:7194:10 198:17 202:20

calls 40:7 44:22 88:989:2,3 90:19 162:19174:20 216:21

CAM 148:7,7camaraderie 217:4

219:17 220:11campus 216:1Cancer 192:8cannabinoids 106:19

106:20 155:1,15,21capacity 6:8 19:11

183:15 218:15Captain 1:21 2:1capture 139:20 143:22

144:10captured 98:13 140:13capturing 144:11

161:11 211:4CARA 8:11care 1:20 6:18 13:9,12

15:4 18:3 19:9 21:1923:19 25:6,9,10 26:726:13 27:8 30:1 31:833:21 37:7,8 39:1342:16 48:20 49:752:18 53:7 60:18 62:962:9,14,15 63:5,7,964:5 65:3,4 66:470:14 74:21 76:21

78:5 79:6 81:4,12,22107:9 109:21 110:4114:22 119:19 136:11136:12 140:16 141:18144:5,6,19 145:11,21146:1,3 198:17 199:6199:6 204:2 205:18205:22 208:13,20210:10,22 213:12217:12 218:2,3219:20 220:4 222:11222:15 223:14,22224:13

Care-Mental 62:17career 5:20 23:8cares 98:8CARRION 2:7carry 167:21carrying 165:22cascading 52:1case 39:1 80:12 201:22cases 14:13 145:5

171:12 224:8Casin 2:5 11:3 12:4

28:2 36:8 45:5 47:1654:14 99:13 100:21201:6

CASTILLO 2:8catch 100:22categories 20:19 52:8

52:11 75:19 76:2categorize 54:5category 82:6CBT 137:12 138:6,7,10

138:18 163:7,8,13,13163:19

cede 170:5center 1:10,20 7:10

23:21 25:18 39:8 65:3169:21 198:15,19,21205:22 213:1 214:13215:3,6 216:8,16219:10 220:9 221:2221:14 222:11,15224:17,18

centers 206:13 210:3cents 188:9 225:20certain 160:12certainly 8:12 12:3,13

35:21 36:6,7 88:1993:1 124:22 136:22140:6 177:1 199:20223:3

cetera 24:21 75:21114:2 163:20 203:5

Chairman 4:17 12:1213:5 17:20 61:1673:17 102:16 148:5

215:8Chairman's 206:20challenge 24:10 34:22

64:6 202:15 203:8challenges 21:15 32:6

32:14 34:21 49:1474:22 162:18,21220:20

challenging 33:11champions 167:20chance 89:14 98:7

144:15change 142:14 143:4,8

145:11,11 203:20changed 143:15changing 42:13 187:8

228:16charge 18:5 220:10Charness 203:14

204:17 208:5chasing 35:10Chasm 23:19chat 100:22 127:10cheap 136:19check 31:20 201:3cherry 20:14cherry-pick 52:18chi 35:7,15 37:16 107:9

154:20Chief 203:14children 5:3chiropractic 107:9

142:22choice 79:5chooses 151:3chose 201:18chronic 24:17 65:5chunked 226:9chunks 51:6CIH 27:15 108:18 109:3

109:15 114:21 115:7115:11 119:17 121:4121:10,12 122:15,20123:20 124:20 126:11130:13 133:1,8 135:4145:5 148:20 154:16157:11 158:15,21159:3 160:11 161:2165:1,7 166:11,11169:17 176:12 177:16177:19,19,22 178:13184:21 188:11 195:17195:19 196:8

circle 161:12citalopram 143:15City 1:11civilian 6:7 19:21 56:10clarify 47:5 62:5

clarifying 40:15 56:12clarity 100:8class 123:11classify 75:8cleanly 142:19 143:9clear 9:8 41:14 56:17

57:13 61:1 112:13132:19

clearer 99:13 100:13clearly 19:19 67:1

145:18 146:16climate 199:17clinic 1:20 5:9 6:17

78:22 79:5clinical 5:13 21:22

22:12 23:6,10 61:1767:17,18 109:20110:2,4 170:11202:14 203:3

clinician-researcher139:17

clinicians 79:14 136:11203:6,8

clinics 109:1,13 119:10119:13 120:8 165:5177:17

close 13:19 44:18 87:2089:13 179:15

closed 88:20 95:15100:12 102:1

closely 33:1closer 178:2CMS 75:17Cochrane 108:5code 161:22 162:3coding 97:2cognitive 165:11coherent 61:1 83:6cohort 224:12,13collaboration 128:2

144:5collaborative 40:18

127:12 198:7,18,21Collaboratory 128:9

198:11collect 54:3 73:12 77:2

82:21 142:2 146:2148:2

collected 18:10 81:16collecting 28:2 44:10

48:20 50:19 65:1468:8 69:5 71:22 73:678:4 96:12 145:22

collection 13:15 16:1516:19 42:12 73:8 76:476:6 228:14

COLONEL 1:14 6:510:5 36:12,21 37:14


233

37:20 38:7,17 51:1352:5,9,13,16,19 53:292:3,16 97:17 98:12107:2,6 112:12,20113:4,8,11,16,19114:6 127:4,15 128:5128:10,15 131:6136:16,20 137:7143:11 150:21 151:9179:18,21 180:2208:8,19 212:2,22214:4 219:8 221:12221:21 222:20 223:9224:11

Columbia 139:6combination 135:11

195:17combined 112:16come 17:2 24:14 25:11

29:12 30:9 33:2,834:10,13 39:5,1141:12 48:8 70:1586:18 91:8 96:20 98:2100:15 104:1 118:3118:12 120:4,10125:19 126:7 149:11149:18,19 173:1181:18 193:20 194:18205:15 206:2,16209:5 211:2 225:5226:12,12 229:4

comes 61:1 66:7109:13 128:22 169:12204:17 225:19

comfortable 95:2196:15 181:20

coming 8:1 15:17 59:1084:9 97:6 102:8118:14 136:4 153:8173:5 182:14 216:17228:14

commandments 46:8comment 57:5 222:9comments 10:9 56:13

58:3 70:17 83:18157:1 218:18 219:7229:7

comments/questions65:16

Commission 1:3,10 3:33:5 4:4,18,20 5:5,116:3,14 7:17 8:1810:19 11:22 13:2230:3 40:6 41:7 42:442:20 45:10 48:452:22 53:4 69:3,778:21 79:18 100:3102:6 184:5 200:19

201:17,20 213:9220:2 228:1,2,6 229:8229:11

Commission's 31:20Commission-type 43:1Commissioner 4:7 7:16

9:12 10:3,8,22 17:1823:4 26:16,18 29:1829:19 31:14,15 36:538:15 40:2,14 47:1884:21 88:8 91:18 92:892:13 98:1,5,8 99:1,3101:2 102:12 188:8200:6 211:21 215:19218:7 219:7 227:22

Commissioners 3:174:14 7:14 8:4,13,1911:17 12:5 13:3 14:1114:15 31:18 33:536:10 40:17,21 41:1542:21 47:9 53:2056:14 57:3 58:2 91:991:12 93:2 97:2198:10 100:10,18102:18 103:15 105:1108:3 122:1 126:22131:18 162:20 201:22209:3 216:5 218:10222:8

Commissioners' 55:1258:15 81:9 100:14104:2

committee 5:22 9:16,1714:8,9 166:8,9 184:19185:3,5 198:8 207:11

committees 186:5189:16

common 31:10 157:9commonality 55:17communicate 48:22communication 51:15communications 51:19community 74:21,21

76:21 136:11 140:16141:18 142:3,4144:19 145:2,11146:2 217:20 223:14223:22 226:15

community-based62:21 194:10

comorbidities 182:10227:16

comorbidity 132:12153:7 162:7

companion 138:17comparative 81:21compare 35:5,8 37:11

146:3 222:15

compared 195:17comparing 209:6

215:14comparison 205:19

209:10compile 116:3compiling 16:10complementary 19:4

28:17 33:13,17 39:862:21 73:19 102:21106:5

complete 14:3 15:1034:6

completed 13:16 16:629:4 77:9,11 82:11103:21 104:8,10,11104:12,16

completely 20:4 188:12completion 13:2 15:13

42:10complex 24:17 77:14

118:15 227:15compliance 24:9complicated 118:10component 21:3 23:11

63:6 68:19 69:15147:19 150:15 219:21221:16

components 18:9 19:625:8 61:13 84:10150:18 195:19 204:8205:7

comprehensive 20:862:9 77:12

comprehensively 75:1concentrated 222:22concept 37:4concern 93:5,6,11concerning 84:21

217:8,13 218:13concerns 56:15 98:10

125:13concise 57:13conclude 202:3conclusion 197:8 229:5concur 92:15concurred 88:13concurrence 92:19

100:4condensed 88:11condition 105:11 111:9

113:15 118:11conditions 67:18 103:7

105:10 107:16,18111:1,5 112:16113:10 131:4 141:1

conduct 106:4,8 118:1119:15 129:10 133:6

134:11 135:3 164:22194:19

conduct/fund 108:17130:12 157:7

conducted 106:20,22107:3

conducting 27:20111:7 122:15 123:15

conference 1:10 40:7conflate 219:2conflicting 50:13confuse 63:3congratulate 218:8Congress 8:9 34:14

46:16 129:6 176:12Congressional 3:4 6:2Congressionals 12:11

221:20conjunction 109:16

163:7connection 220:11connections 144:4conquering 215:22consensus 94:19

182:21Conservation 38:7consider 36:2 46:14

96:10 155:21 168:11177:16

consistency 83:1consistent 70:9,16 72:4

72:22 150:6consolidate 46:4

111:18constant 143:12,14consternation 56:15constituents 14:9,20

15:11 228:3constraints 10:18

19:18 229:3Consultant 2:8,12consulted 166:17Consulting 2:6,7,8,13

2:17,21consumption 132:11

155:12contact 80:14 208:5contacts 49:5containing 107:10content 43:21 53:5CONTENTS 3:1context 16:9 52:2 60:4

88:14 126:8 127:6155:9

continue 41:9 55:2280:19

continued 120:16contract 16:18 76:21


234

Contracting 2:14contractors 34:2contrary 218:18control 67:17,20 106:3

130:17 143:14 147:18147:22 187:5,7225:16

controlled 159:13216:4

controversial 156:3conversation 71:5

114:19 124:16,19,22199:4

conversations 192:20200:11

core 18:1Corps 1:17 4:18 6:6correct 47:10,13 48:12

101:19 129:7 151:5152:8

corrected 41:5correctly 49:7correlates 37:21cost 21:21 136:19

140:9 227:20cost-benefit 136:17cost-effective 137:20costs 24:20,20 37:8

64:14,16 139:8Council 166:8country 7:19 19:22

20:20 21:5 24:20 75:275:6 106:12,15 149:1

couple 12:10,17 59:393:15 146:13 189:12223:12 228:15

course 143:5 157:15190:1

cover 1:3 3:5 4:4,178:10,18 13:22 18:1731:20 42:4 102:6201:19 216:2 228:2229:11

coverage 101:11covering 180:5covert 188:19CPT 120:2cravings 132:10 155:11create 52:19 120:11

148:10 189:17creating 1:3 124:10

147:12crisis 220:4,9critical 23:11 69:15

168:1 178:20 199:15cross-system 128:2cross-tabulation 93:17Crossing 23:19

crosstalk 184:17crunch 41:19 43:3 50:8Crystal 1:10,11cultures 106:15cure 117:2cured 188:13curious 166:16current 11:10 12:19

24:17 44:17 81:2082:9 89:7 119:17158:19 185:7 204:21209:13

currently 4:15 5:8,148:14 13:11 27:19 31:741:19 45:7 62:11104:14 120:5 215:4

customer 150:22cut 43:17

DD.C 102:8daily 219:14Dallas 6:10damage 158:1Dan 11:4 12:4Dartmouth 205:22

206:3data 13:15 14:17 16:10

16:15,19 18:11 27:1128:3 32:9 33:1 42:1144:10,11 48:14,2065:14 66:3 69:5 73:773:8,12 74:13 77:798:15 112:6,7,14,15116:3 139:4 142:3145:2,22 191:18193:20 210:9 225:2228:14

dataset 81:2date 55:20 56:12,14

81:20 90:22 91:892:22 93:4,4 95:9,1095:18 103:21 107:1121:14

dates 13:15 16:1 57:7211:7 212:19

David 34:11Dawne 204:7Dawne's 212:22day 8:20 10:7 12:18

56:4 58:20 89:1594:10 204:16 206:9214:18 222:10 228:5

day-in 216:17 220:21day-out 216:17 220:21days 15:13 29:6 41:16

45:20 88:12 93:16100:8 127:8 162:20

207:15 214:5deadline 11:21 12:12

89:9 91:20deal 30:18,22 182:19

214:18deals 16:13dealt 217:3debate 91:7 99:6decade 179:14decades 25:4December 15:9 16:3

43:15,20 44:13 57:3decide 151:14decided 112:14 174:11decimated 217:9decision 91:13 214:21decision-making 23:21

124:1 147:14decisions 67:16 70:13

154:3 191:8,13deck 59:15declare 10:18declining 24:21decompress 100:22decrease 141:8 142:13deep 10:11 32:22 84:4deeper 17:10 33:6

106:13 209:6define 19:18defined 98:14definitely 96:14 128:13

194:18definitive 56:17delegated 176:10,15delete 98:16deliberation 17:16 54:2

86:17 91:8 95:4 96:899:6 228:18

deliberation/discussi...131:17

deliberations 47:20105:4 121:19 197:16

delighted 8:15delineations 51:18deliver 11:11 84:2

127:6 219:13deliverables 9:10delivered 29:5,7 127:8

138:16delivering 36:14 135:10delivery 19:12 29:22

37:21 61:8 62:1567:17 68:7 70:9202:14 203:3 222:3222:22 226:16,16

demonstrated 163:8Department 1:1 29:22

33:13

departments 147:2depend 145:15dependence 149:10depending 178:8deployed 152:10depression 103:9 132:7

132:13,17 137:12161:16 178:22 182:15

depressive 104:14Deputy 5:22describe 63:20describing 61:19descriptions 63:19Desert 6:12deserve 172:6design 108:1,8 118:9

132:1 155:6 163:4172:8

Designated 2:5designed 171:1designer 50:6desperation 149:14

152:1,12despite 156:9detail 86:16 139:1determinants 25:20determining 64:5develop 55:6 77:12

80:5 183:1 190:12developed 22:17 33:4

75:4 83:21 169:21185:4 205:3

developing 157:11204:7,11

development 57:1292:5 198:14

developmental 82:13DFO 2:5,10,11,15,19

15:19 47:4diagnose 162:2diagnoses 65:19 162:9diagnosis 24:3 63:8,12

63:15 161:21 162:2,4diagnostics 34:21dialed 35:14difference 14:19 23:6,9

61:17 94:11 192:4220:22

differences 82:4different 20:19 27:2,7

27:16,21 29:1 30:831:22 32:10 38:3 40:852:15 53:8,9 62:1065:22 70:12 75:9103:5,6 105:16106:14,15 109:21132:15 150:10 152:21161:11 162:9 170:8


235

171:2 172:14 174:19175:3,10 181:5,18206:12 215:3,15,15216:2 219:3 225:5

differentiate 150:15differentiation 150:22differently 71:6difficult 66:9,9,10 74:7

77:2 134:3 142:17162:17,17 190:4

difficulties 32:19difficulty 16:10 20:7digestible 124:5 130:5dilatory 80:21diligence 8:5direct 129:6 176:12direction 26:6 70:10

86:4 127:20 164:4199:5 207:2 218:4

directionally 218:17directions 50:20 121:22directly 8:7 34:19 47:7

74:13 166:20Director 1:14,16,18,19

2:5 5:9,21 6:8 7:8,108:6 12:3 34:11,1939:8 217:11

disclose 79:3discontinued 143:2discoveries 7:21discuss 11:21 12:14

41:13 45:10 47:1255:15 59:2 93:6,7105:1 130:1

discussed 29:4 56:20125:7 147:10 178:18

discusses 27:12discussing 29:11 61:19

104:3,18 220:19discussion 3:17 16:7

41:12 56:1 60:1 84:484:14 89:1,5,9 93:1495:2,3 97:13 99:6118:16 124:10 135:17148:9 154:12 184:10188:9 199:3 205:9207:1,11 222:10

discussions 39:1661:21 68:18 129:1218:19

disease 24:3 183:6,10disease- 21:22disorder 65:21 103:8,8

103:9,10 104:6,9,11104:15 105:13 106:1111:12,16 112:5130:9 133:6 135:18137:13 153:10 165:14

disorders 105:17,20127:19 153:12 176:7179:1

disseminated 123:22distinguish 152:16distribute 47:17 172:22

175:21 177:8dive 17:10 33:6 84:4

106:13diverse 185:6dives 32:22divide 159:14dividing 215:22doable 92:10doctor 23:8DoD 39:13 174:15,18

174:20 175:3,10,17179:11 198:7,10199:9

DoDs 127:11dogs 107:9 154:20doing 9:19 10:1,12 20:1

20:16 21:5 22:13 25:326:8 28:3,22 29:2,1230:5 32:14 34:16 36:145:7 50:15,16 56:560:4,9 65:13 68:1469:3,10,17 70:5 73:673:11 74:5,8,14 75:1776:3,11,12,13 78:480:10 81:5,18,21 82:783:1,2,4 84:16 85:1886:9,10,12,14 89:395:4 101:11 106:12115:6 117:11,15120:20 124:4 135:12142:20,21,22,22143:1 145:1 146:4149:21,22 162:21178:16 195:1 199:10202:8,20 203:10,21204:11 205:12,18207:13 208:10 209:12211:7 216:21 220:12220:14,16,18 224:21225:4 226:3

dollar-wise 144:13dollars 225:20Don 205:4door 115:17dose 138:15double-blind 149:4dovetail 72:22dovetails 68:16download 204:9downrange 94:1downtown 208:16,18draft 14:5 15:10 56:19

71:21drafts 43:22 72:16drawback 117:11drive 1:11 98:15drug 155:11dual-hatted 221:15,20due 108:1 131:22 155:5

163:3duties 30:3 56:9 103:13duty 17:22 18:2 31:15

31:18 33:8 35:22 60:760:9,12,19 61:3 71:2187:16 89:8 92:1293:21 98:1 101:2102:19,20

Eearlier 15:7 50:3 53:10

54:1 56:22 58:1271:12 78:15 86:1 91:598:19 99:13 198:12207:1

early 99:22easily 72:10 123:22eastern 79:10easy 24:18 43:16 53:15

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19:2 20:12,17,21


239

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213:12 216:1large-scale 116:2largely 64:3 85:10larger 80:2 111:14

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Meaning 133:12means 109:6 117:7

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204:13 207:10 223:2measurement-based


241

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Medicine's 148:6meditation 119:1,5,8

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Nnaloxone 133:8naltrexone 133:12

135:8 158:15name 5:17


242

names 62:10NAMI 1:19 2:2 7:8national 1:10,18 2:1 5:1

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offered 135:21 137:4140:13

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overall 12:6 110:13146:4 150:7 154:18159:22 173:11,13215:7

overarching 46:6,1860:13

overdose 133:8,18134:2

overlap 44:20 45:21


243

46:4 54:5 87:12 93:22overlaps 51:16 60:17oversee 175:6overseen 173:13oversees 203:15oversight 165:17,22

166:4,21 168:8,14176:9,15 184:19185:2,13 186:9 190:8191:1 198:7

overview 17:22 18:2071:2 73:19 78:3101:10 121:21 202:2202:7 203:11 213:5213:18

overwhelm 86:20owned 160:20oxygen 107:10

PP-R-O-C-E-E-D-I-N-G-S

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244

84:13 90:13 91:1696:5,9,11 98:15 99:199:20 100:19 102:8112:11 115:14 116:1116:11 117:12,14129:15 130:22 134:8139:22 145:8 157:19158:4 161:13 169:3178:6 183:7,19185:15 194:3 196:5199:16 207:8 208:12209:8 211:13 214:12214:22 216:10 218:16221:22 224:7 227:22229:9

pointed 19:7 48:5points 33:2 225:11Pollack 2:18 103:18poor 149:6popped 71:3population 36:15

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104:6 105:13,22137:13

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potentially 163:9174:21 181:19 186:1

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134:17,19 182:8,12182:13

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43:8 48:15 55:3 77:1677:21 86:2 88:1989:19 94:13 97:5,8112:18 139:8 148:12150:2 157:3 173:17173:21 177:16,18,19177:20 179:15 189:11203:16 208:4 216:19217:9 225:7 228:15

problem 28:12 50:255:6 127:13,16 134:1157:21,22 169:20223:15

problems 24:19 41:5108:8 134:3 155:19156:9

procedurally 97:20process 20:11 23:1,22

26:2 27:10,14 28:2233:7 40:8 42:13 56:877:10 85:18 86:11,14170:9 171:4,20172:21 173:11,13174:19 175:15 187:15193:19 197:17 203:2207:13,15,22 209:2219:19 223:10

processes 171:16172:10 175:11 183:12183:17 192:14 194:2

processing 50:22produce 53:13producing 24:19 50:11product 11:12 40:11productive 9:1professional 63:14program 2:20 30:7,18

139:6 144:19 160:16214:2 217:5 223:16224:17 225:1,2,10226:1,21 227:15

programmatic 37:2programs 1:17 158:20

159:3,15,19,20195:16,18 196:7,14223:20 224:3

progress 100:2project 2:6,16 112:18

208:11projects 202:17promising 163:9,21promotion 183:4proposals 17:10proposed 71:20 80:1proud 4:20 5:4provide 30:11 45:18

64:16 77:4 78:4 82:8105:15

provided 33:21 109:1140:17 165:4

provider 76:18providers 66:17 79:14

123:21 124:6 125:10142:3,4 220:1

provides 137:17providing 20:11 136:10psychiatrist 143:14psychiatrists 144:4

193:14psychologist 5:13

144:6,10 190:21221:7

psychologists 193:13psychotherapies

108:19 165:2psychotherapy 109:8

110:5 226:6PTSD 103:7 106:6,17

107:11,11,13,22108:19 109:5,8,9,14110:4,5,9,22 114:14114:22 115:2 116:18117:10 119:6 125:12130:9 149:9 153:9158:12 178:22 181:3182:14 213:1

PTSD-related 224:3public 4:13 12:16 13:21

16:4,8 23:5 28:1640:5,22 42:8,18,2247:20 54:2 56:3 58:1276:8 79:4 80:22157:12,22 158:9186:6 201:16 228:3,5

public's 15:16publicly 56:20publicly- 76:22publicly-available 76:9published 53:5 73:18

106:21 226:5,13,14pull 46:21 148:12pulled 172:17punch 187:21purpose 26:5 185:2


245

213:8purse 187:6pushback 100:5pushed 49:16 169:18pushing 92:11 170:1put 14:4 23:20 25:17,18

46:22 50:9 60:3 64:1068:18 70:3 73:5 75:1980:13 81:8 93:13 96:6105:4 151:15 162:3171:14 172:9 188:15225:10

puts 67:20putting 65:2 151:11

QQuadruple 21:20 22:18

30:6 37:4 64:1 205:10qualitative 67:15,22

68:12 69:6 112:22139:3 148:18

quality 11:12 20:1921:18,19 23:19 26:364:5,8 75:18 81:3,581:11 82:10 108:7114:11 132:14 149:6204:20 205:18 206:1

quantitative 69:6 139:4query 84:21question 54:9 61:16

83:19 86:13 90:4 95:7112:10 128:18,22134:17 135:5 141:13151:11 152:17 154:1167:2,9 172:16191:15,16 210:13222:11 225:20 227:1

questioned 209:9questions 9:4 10:9 18:1

18:15 19:10,20 21:1039:10 56:1 58:2 65:1288:21 110:6,10112:11 122:10 123:19130:8 134:6 150:8165:13 166:13 168:19184:2 185:10 201:2206:11 208:3 210:4227:6,10

quick 41:2 211:10213:18

quickly 57:20quite 11:5 69:2 77:6

90:1 124:3 157:2174:19 176:21 192:1213:21 220:13

quote 115:14

R

race 185:8racial 177:5,10radical 187:7raise 43:14raising 196:5ramifications 140:7ran 225:1ranch 141:1RAND 81:10,10 144:15

145:18 206:5randomized 67:17,20

106:2 130:17 147:18147:22 225:16

randomly 79:22 80:1range 191:20 193:15rank 75:18raped 181:5rarely 64:10 142:17rate 141:8 142:14 214:8rates 36:15,16,20

181:18rationale 183:12 206:22Rauch 221:14RCT 106:20,21 112:15

162:13 225:22 227:13RCTs 106:17 107:10,17

110:14 113:21 116:2127:2 139:2,7 140:11140:19 154:17 162:11

re- 210:13reaches 49:5read 53:6,7 57:4 102:19

105:14 108:16Readjustment 166:8ready 9:9 59:6,8 90:1

92:12 147:13 175:20201:5

real 36:5 135:22realistic 140:3reality 32:3realize 44:9realizing 50:12reason 30:19 37:7

131:2 175:17 204:14reasonable 45:11

197:11reasons 131:15 144:21

152:22 174:8rec 140:14receive 109:7,14received 74:19 104:16

165:22 167:20receptive 79:17receptivity 8:16recognize 165:18recommend 49:4 51:12

91:17 109:10 127:21127:22 153:10 167:13

recommendation 17:1621:8 36:5 46:17 48:1748:18 49:1,5 50:1454:15 78:14 92:4 98:598:16 106:3 107:20108:17 110:21 118:18118:20 119:3,15,21122:14,19 123:20127:5,10 130:2,11133:2 134:7 135:3144:17,20 146:18153:14 154:15 158:13164:22 165:6 166:3166:14 171:22 176:8176:9,17 178:11182:8,20 186:1 188:7194:19 195:12 228:18

recommended 25:1recommending 128:20

130:12record 42:1 102:3

141:15 142:14 144:7182:11 201:14,17229:13

records 141:11 142:9142:12 143:19

records-based 141:6recovery 1:3,21 7:11

30:18 31:4 33:1567:12 183:16 188:14188:16 223:7,8

Recupero 204:1reduce 37:8 132:13

155:10reducing 132:7,17reduction 118:22 119:7redundancy 51:14

55:11redundant 55:14refer 217:6referrals 221:22refine 78:11 97:1refined 78:8 80:3refinements 145:12reflected 177:12reflecting 109:20Regarding 3:4regards 218:11Register 15:20 56:21regular 63:7 87:21regulations 48:3rehab 170:12reimbursed 142:5reinforce 184:9relapse 155:10relate 34:15 73:22related 105:17 106:4

109:8,9 122:18,20

130:13 145:8 166:20166:21 190:16 195:6

relating 5:21relation 7:22Relations 6:2relationship 56:6

132:20 222:2relaxation 108:14 155:2

163:5released 74:3relevance 222:21relevant 190:17remain 18:13remaining 29:7Remarks 3:4remember 199:18

224:14remind 103:11 104:5reminder 18:2 28:16

102:17 108:3 132:9162:15

repackaging 53:8repeatedly 31:20rephrase 185:20replied 91:4report 3:6 14:4 17:6

41:14 42:10 43:1,1243:13,19 52:18 53:1157:4,16 60:22 75:1480:6 85:2,8 126:4127:6,8 144:16 148:6177:9 181:12 207:10

reported 225:3reports 73:13 104:21

113:14representation 176:18

177:10 185:8representative 2:15 8:6

12:4 185:6represented 177:5,6

180:18,22 182:6185:1,13 186:7 193:1

request 44:14 97:19100:5,14 182:20207:20

requested 93:21requesting 98:11requests 38:20 59:8require 131:16 199:8required 8:1 14:17

108:2 132:2 155:7163:5

requirement 177:15researched 140:21

149:17 189:3researcher 173:16researchers 173:5

193:12,21


246

researching 138:7reservation 27:6Reserve 1:21Reservist 6:7residential 160:5,6

195:16 196:7,13resilience 183:3,8,15

183:19 184:5,12resolution 108:12resolve 108:10resources 19:17 29:21

224:19respect 107:22 131:22

163:2responding 84:20responsible 143:8responsive 79:8rest 53:20 91:15 98:1,2

98:7 136:5 168:10228:20 229:8

result 115:6 163:9197:15

results 106:22 123:20144:1 161:15 197:14

resumed 42:1 102:3Ret 1:15,17,18 2:1review 21:1,2 59:15

104:7,9,12,15 105:2112:5 169:5,9,10,13169:13 170:2,9171:20 172:10,13173:12,22 174:6190:19

reviewers 172:22reviewing 57:10 104:18

171:4reviews 29:1,3,3,7 57:2

110:13revolutionary 186:11

186:12rewarding 10:6rewriting 53:21RFA 39:12ridiculously 210:21rigorous 81:13 150:17

172:21 190:17risk 104:12 165:3River 213:1roadmap 44:12robust 26:10role 192:18 203:9 215:1

216:12 221:20roles 218:15roll 45:4rolled 33:20 120:3

121:2 198:14rolling 33:16 224:11rollout 120:9

room 16:16 17:13 228:4Rosa 5:9rose 2:1 4:21,21 29:19

29:20 31:14 40:3,4,1458:7 65:17 67:5 91:491:18,19,22 103:15115:13,20 116:7121:9,16 122:8 164:7164:9,11,19 172:16173:7 176:4 186:18191:11 192:4 194:16209:22 210:11,16212:18 213:20 214:5215:19 216:9 222:6,9222:19 223:7

rough 33:2round 91:7 174:22routine 63:7routinely 119:5rules 48:3 108:6run 139:9 188:17

193:20running 33:4 94:9,16

160:15 202:16rural 27:3 75:20 79:9

217:18,22 218:18

SS 1:17Saenger 225:1Saenger's 226:2safety 182:11SAIL 213:10sake 15:16SALMAN 2:20salutogenesis 182:22SAMHSA 175:12,13,14Samueli 1:16San 1:20 5:9,14Santa 5:9satisfaction 21:21 82:5save 24:15saving 146:10 220:22saw 63:13,14 78:15

106:21 165:12 179:7213:16,22 218:11,19219:1,2 220:7,17224:20

saying 13:15 72:1,787:1 94:22 129:5136:1 139:16 142:11143:21 147:21 152:22153:16 160:2 175:5176:1 189:2 193:4

says 151:18 174:11215:8

scale 10:16 36:13 113:2schedule 17:4 58:9

89:8 90:19 100:1212:12

scheduled 15:9,18scheduling 118:13school 159:6schools 159:2,12science 35:2 68:13

119:16 125:17 192:19scientific 32:14 174:9scientists 120:4,10scope 10:16 34:7 36:13

102:19 113:2,18116:9 122:7 126:6137:10 158:2,3

scratch 51:9se 162:4seamless 221:22search 81:15 117:15

154:14 161:15 205:21searches 109:2 119:1

178:16 197:15seat 189:18second 74:15 82:2,6

85:10 108:21 157:16222:10

secondary 66:20Secretary 6:1 14:6 71:7

167:6section 85:3,7sections 85:3sector 151:2,4seeing 34:7 46:19

96:21 99:22 114:9116:9 168:3 180:21217:3

seeking 27:7 38:21seen 20:4 31:1 32:3

60:17 62:4,10 87:1793:19 136:4 178:21180:7 188:20 202:15216:11 224:3

sees 54:20select 226:22selected 76:1selective 75:5self-care 219:22Senate 5:22 14:7send 20:9,12 44:16

45:19 46:20 47:15,1854:16 86:17 87:1889:15 197:3 207:20

sending 79:21sends 144:6Senior 1:13 2:6,8,12sense 12:9 39:22 43:3

58:20 70:22 93:1100:7 110:12 126:1202:4 208:21,22

228:6,16sensitive 96:5sent 20:10 47:1 88:6

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161:20September 1:8 15:8

44:2 55:13,19 87:1,888:2 90:11,21 91:6,2092:9,15,19 102:7

serious 50:8sertraline 143:15serve 6:3 124:8 220:3served 13:11,13service 1:14 6:9 61:8

107:9 154:20servicemember 7:7services 1:22 18:17

19:10 63:10 64:16135:9 203:3

serving 6:6session 1:5 4:5 11:22

16:14 17:5,12 36:740:1 42:4 55:15 88:20100:12 101:1 102:7102:10 123:12 201:5228:22 229:10

sessions 16:4 55:295:14 137:14 140:22

set 12:4 13:14 41:889:22 127:13,16,22167:19 171:5 172:13172:17 173:3,8192:14 207:16,21211:9

sets 11:7setting 11:4 183:2seven 140:22sexual 179:3SHAMSI 2:20Shannon 2:6 103:19share 40:5,9 130:9shared 47:8 55:2,4

124:1 199:12sharing 54:19 72:16

103:22 144:1 181:8Sheila 221:14SHEWMAKE 2:22Shield/Desert 6:13shift 48:14Shira 1:19 3:10 5:12

8:21 59:10 61:20 73:3102:12,13 110:18121:9 129:17 147:10164:7 166:16 199:18200:20 201:1 225:12228:11


247

short 100:3 117:18175:21

shoved 192:22show 60:11 66:3 205:11showing 34:4 181:17

226:18shown 134:14shows 150:2 151:22shuffle 176:16 179:4sick 193:6side 169:19 177:20

180:12 199:9,9,9200:6,7

Sigma 2:6,7,8,12,16,2016:18 28:3 74:1 76:3103:18 200:6

Sigma's 81:17Silver 35:16 36:19similar 26:21 110:21

130:11 158:12 160:10165:11 180:11 195:18224:16 225:3 229:2

similarly 158:11simplified 78:1simplistic 88:13simply 194:13Simultaneous 131:12simultaneously 182:10single 60:9,12 225:5sir 29:20 31:12sit 111:6 124:12site 3:12,16 201:9,12,18

202:2 213:5sites 202:14sitting 44:21 70:22situation 65:20 140:20

216:4situational 8:10situations 149:17six 7:18 44:3 88:11

94:14 125:12 140:22159:9,9 173:21 223:3

six-month 224:5size 122:11slide 176:7 198:2small 71:16 75:20 83:22

107:11 210:21 215:21small-group 216:4smart 95:13smiles 220:18snapshot 137:1Sneakers 35:17 36:19snippets 83:22social 25:21 26:1 66:12socialize 53:16socially 186:2solicit 173:1solid 14:18 16:11 43:22

56:18 57:15,20 72:13110:19 114:10 229:6

solidified 78:8solution 21:4,13 209:6somebody 53:10 77:15

78:12 151:3somewhat 122:18soon 9:10 22:9 207:17

207:18,19sorry 108:21 154:10

188:1 210:7sort 13:20 17:21 18:1

20:21 22:2 50:5 52:260:1,4,13 62:1,1964:18 65:8 66:12,2069:5 74:5 79:22 82:882:15 85:10 121:22123:2 127:5 131:8142:5 150:9 156:14166:1,18 168:14,20182:17 189:11 190:11193:7,17 196:18202:7 203:1 220:3221:15,17 222:22224:19

sounds 84:1 85:9208:18

sources 76:9 77:1space 38:8 154:4

218:21speak 31:4speaking 58:13 131:12

162:7 183:18 184:6special 166:6 171:13

172:2 219:9,11Specialist 216:12specific 10:10 17:9

48:17 70:12 85:5105:16 106:12 118:21119:3 121:12 122:4,6129:3,15 155:13170:9

specifically 18:4 27:1428:19,21 29:14 33:1949:3 82:3 106:1,9,16117:10 119:22 127:3130:16,22 135:13144:17 162:10 163:19166:18 171:15 183:8187:2 194:21 195:5203:18

specificity 130:1specifics 11:20specified 111:9specify 113:21speed 42:12spend 51:15 80:4 84:8

189:20

spending 139:20spent 4:22 5:18,20 34:1

57:12 136:13 137:11137:14 204:16 206:8206:9 215:17,20

Spero 2:5 11:3 28:249:11,16 54:17 55:1,890:10,18 95:9,19 96:397:10 101:3,7,17,20129:6,9 139:10196:22 197:3,7 201:7202:5 211:17 212:6

spiritual 66:14split 62:2spoke 163:11Stacey 2:18 103:18staff 2:4,9,22 5:21 8:5,5

8:8 9:3,18,20 11:712:3 31:17 34:2 40:2242:21,22 43:5 47:1750:4 96:4 203:15216:6 228:4

staff's 95:19stage 17:16 167:19

228:17,19stakeholder 127:9stakeholders 167:15

193:15,22standard 110:4 119:18

138:8 171:16,20172:10 186:7

standards 45:11standpoint 48:7 58:15star 213:10start 4:15 8:2,21 11:3

17:3,7,17 29:10 43:944:19 45:6 46:9 51:958:17 73:5 82:19101:7 121:14 131:2137:4 153:19 172:8181:3

started 14:2 28:1 30:1168:18 105:12 152:11189:2 200:4 205:4214:13

starting 33:2 44:7 51:11165:16 167:18 228:22

startup 101:1state 5:2 7:11 9:17

12:19 77:7 204:21208:14

stated 99:14statement 125:20

126:12states 1:1 6:12 35:2statistic 32:13statistical 32:6status 12:19 26:19

228:12 229:2statuses 12:21staunch 188:18stay 161:11step 25:13step- 129:16stepped 62:8stepping 72:1steps 3:5 9:6 18:8

41:13 129:12stick 72:21sticking 191:21stigma 122:18 222:14stigmatized 180:20stood 219:17stop 16:22 64:15 65:15

83:16stopped 71:12Storm 6:13stovepipes 221:17straightforward 185:11strategies 147:13

148:10,10strategy 51:19 148:3

150:7,11 154:2streamlined 55:14

223:10street 214:7strength 105:9 107:22

108:12 110:15 112:7124:13 125:4 131:21155:4,16,17 163:2164:1

strengths 169:1 183:20183:22

stress 7:7 104:6 105:13105:22 118:22 119:7137:13 155:12

stressful 217:1stressing 165:7strides 215:3striking 135:20 136:3strong 108:7 164:2strongly 67:1 110:1structure 54:7 85:2

111:17 165:20structured 74:5,8 111:4

119:4 130:11 172:21struggling 78:16studied 110:3 165:10studies 31:1 50:20 81:5

81:16,19,20 82:3108:2,4,10,15 109:12109:18 110:14 111:12114:20 115:9 116:18116:20 119:16 121:2121:6,7 122:16123:17,21 127:21


248

128:12 131:1,21132:2,3,4,6 133:1134:9,12,15,19,21135:3,13 138:15140:3 149:4 154:18154:21,22 155:3,3157:7 163:4,14 164:3164:5,15 176:18178:12,13,17 181:17182:9 183:13 186:20194:20 196:9 198:22199:7 206:2 209:13226:5,13,16

studios 38:4study 23:20 108:1,5,7,8

114:12 118:1 132:1142:19 155:5,6,18156:7 163:3,8,12,22179:7,18 182:21183:1,11 193:11

studying 108:18 165:1stuff 23:2 64:15 74:19

76:11,12 92:16 97:2117:20 136:19 138:3149:5,12 150:18159:5 170:6 177:17186:6 192:11,14202:20 203:20 205:5206:13

style 137:16sub-recommendations

46:14 47:2 86:16,19subcommittee 103:13subcommittees 47:7subcomponent 51:19subcomponents 84:12subgroup 95:5subgroups 107:12subject 2:9,18 13:8

16:17 53:21 103:17208:1

subjects 194:8,13submit 93:22 170:11

174:22submitted 54:11suboxone 135:9subscribe 38:4subsections 60:8,10subsequent 127:8subset 188:19substance 149:10succeed 11:7success 214:7 224:8successful 26:3 215:8sudden 212:5Suddenly 193:3sufficiency 29:21sufficient 49:7 148:2

161:7 185:7suggest 78:10 94:3

97:10 142:15 155:9155:14

suggestion 14:21suggestions 16:12

150:12suggestions/recom...

168:15suggestions/strong

42:15suicidal 103:9 161:14

161:18 162:8,14,16162:22 163:2,16,21164:9,12 165:8,9

suicide 32:2,4,7,11,1563:13 104:12 157:15165:2 216:22

Suite 1:10summaries 104:21summarize 105:7summarized 86:8summary 38:11 53:12

53:14 57:14,16 60:173:10 74:6,8 81:3,1081:18 82:7 85:15104:7,9,15 201:8

summer 13:16,18 15:7super- 156:2supplement 171:9support 2:9,22 8:5 31:3

42:21 43:5,15 50:2063:11 103:19 114:10120:15 189:11 200:8200:10 212:9 216:12228:4

supported 31:17supporting 83:1supportive 40:19 65:4

73:1supports 221:22supposed 218:4surgery 148:22 149:4

149:22 150:4 151:2,4surgery-type 149:12surprised 181:6surprising 116:16,21

180:13surrounding 65:4survey 19:15 20:2 21:4

77:13 78:17 82:12sustained 117:20SVAC 9:3 12:10 140:1

200:15SVAC-HVAC 8:8switch 83:17synergistic 60:20synopsis 8:19 213:5

215:19system 5:15 19:15

24:16 31:8 35:8 42:758:9 66:4 76:10 120:2120:5,7,11,15,17,22121:3,5 127:16 128:3139:19 141:20 143:22175:3,5 178:20216:20 217:2,12

system-level 123:6systematic 20:18 21:1

21:1 32:9 81:14 104:7104:9,12,15 110:13122:17 211:4

systematically 203:2systemic 123:9systems 19:21,21 20:9

20:19 64:2,6,10 75:575:9,10,12,13 76:2077:22 78:4 80:2,4128:7 145:15 148:17194:5 196:6,10204:13

Ttable 4:16 82:7 95:9

157:5 187:17 189:18189:20 190:10 191:4191:7,9,13

tables 113:6,20 132:9tackle 13:8 34:9tai 35:6,14 37:16 107:8

154:20tailored 125:1take-home 132:22taken 10:7 19:8 53:3

219:12takes 147:20 173:9

176:11 219:9,10talk 13:1 14:13 15:7

17:4 22:13 34:10 39:540:6 41:13 49:2,875:10 83:10 121:9133:5 138:17 148:16148:17,18 156:8157:2,19 161:16191:2 208:6 214:18215:4,14 226:15

talked 13:4 42:9 46:146:10 50:3,6 60:2,1661:14 64:20 67:1268:10 73:9 74:1579:22 137:18 162:19167:15 174:14,15176:6 192:5 199:2203:16 204:4 205:4210:3

talking 12:18 14:16

43:9 44:2 51:20 67:1185:9,12,17 88:1593:17 124:3 139:2144:13 145:9 146:14160:4 176:14,19182:11 184:4 198:12199:11 202:10 214:8222:17 224:15

tap 74:11 183:16target 31:11,11task 19:16 31:19 71:16

72:19,20tasks 32:21 62:1team 1:21 11:13 25:6

186:18 193:17 200:4200:5,18

telehealth 217:18tell 11:6 24:13 70:18

76:10,12 116:10117:1 155:13

tells 77:20tended 181:12tends 67:21tentative 45:18term 25:17 69:20,20terminated 229:11terminology 63:3terms 18:11 24:20 35:9

37:15 66:21 68:6 73:573:8 76:16 81:18 83:186:8 126:5 132:20145:11 162:2 164:15178:9 195:7 225:3

test 80:12 93:4tested 20:4 152:18,19Texas 6:10textbooks 194:7,12thank 4:11 5:6 6:10,14

7:13 8:21,22 11:1717:19 26:15 28:1,1029:17 31:12,13 40:1340:15 42:5 43:7 47:2248:1 55:20 58:1,4,659:18 61:16 67:599:17,18 102:15112:1,9 114:6 122:8,9128:13 145:7 164:19176:4 181:8 194:16195:13 199:22 200:3200:3,21,21 201:1219:4 228:5

thanking 11:3thanks 5:11 40:15

56:11 58:7 101:22107:6 112:2

thematic 51:17theme 130:15 157:9themes 27:6,7 28:1,5


249

51:22 96:21 97:14theoretically 76:8therapies 102:22therapy 61:5 106:18

107:8,10,15 108:13108:13,14 109:6118:3,4 137:22140:14,15,22 141:7141:17 142:21 144:7154:20 155:2,2163:18 165:11

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11:18 36:22 41:742:17 69:12 77:399:21 164:12 203:13204:9,15 206:7217:18 220:5

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70:17 83:18 118:17125:13 135:15 196:21

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TMS 108:14 155:2163:6,20 165:9

today 12:15 17:2129:10 59:2 88:2090:14 97:9 105:21198:12 213:4 228:5228:10

today's 55:3tokens 191:20told 12:12 54:16 140:1

186:12 203:1 220:13Tom 1:15 5:17 7:16

58:14 61:19 73:3224:15

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67:20 75:5,18 189:10215:12 221:10

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treatments 27:17 28:1833:14,17,20 103:2106:13 109:7,16115:4,6,11 118:21120:12 123:3 145:5149:9 185:12

tree 158:6tremendous 31:5

113:17 136:19 158:10179:14

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147:22 225:16trials 67:17 106:3,7,10

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180:20 195:3


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252

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212:21

__________________________John GoodrichDesignated Federal Officer

________________________________________Jake LeinenkugelChariman


1

UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

+ + + + +

CREATING OPTIONS FOR VETERANS' EXPEDITED RECOVERY (COVER) COMMISSION

+ + + + +

OPEN SESSION

+ + + + +

FRIDAY SEPTEMBER 13, 2019

+ + + + +

The Commission met in Suite 150A atthe VHA National Conference Center, 2011 CrystalDrive, Crystal City, Virginia, at 9:00 a.m., JakeLeinenkugel, Chair, presiding.

PRESENT

JAKE LEINENKUGEL, Chair; Senior White House Advisor, Veterans AdministrationCOLONEL MATTHEW F. AMIDON, USMCR, Director, Military Service Initiative, George W. Bush InstituteWAYNE JONAS, M.D., Executive Director, Samueli Integrative Health ProgramsJAMIL S. KHAN, U.S. Marine Corps (Ret.)MATTHEW KUNTZ, U.S. Army (Ret.), Executive Director for the Montana National Alliance on Mental Illness (NAMI)SHIRA MAGUEN, Ph.D., Mental Health Director of the OEF/OIF Integrated Care Clinic, San Francisco VA Medical CenterMICHAEL POTOCZNIAK, Ph.D., Captain, U.S. Army Reserve, Team Lead for Addiction Recovery

Treatment Services, Martinez, California


2

JOHN M. ROSE, Captain, U.S. Navy (Ret.), Board Member, National Alliance on Mental Illness (NAMI)

STAFF PRESENT

JOHN GOODRICH, Designated Federal Official (DFO)CASIN SPERO, Executive DirectorYESSENIA CASTILLO, Senior Consultant, Sigma

Health Consulting, LLC

KATHRYN FAUSTMANN, Support Staff

JOHN KLOCEK, Subject Matter Expert; Alternate

DFO

WENDY LARUE, Alternate DFO; Writer

NICK MAJIE, Senior Consultant, Sigma Health

Consulting, LLC

LAURA McMAHON, Contracting Officer

Representative; Alternate DFO

HANIFAH MOHAMED, Project Analyst, Sigma Health

Consulting, LLC

STACEY POLLACK, Ph.D., Subject Matter Expert;

Alternate DFO

SALMAN SHAMSI, Program Manager, Sigma Health

Consulting, LLC

TRACY SHEWMAKE, Support Staff


3

CONTENTS

Welcome and Introductions. . . . . . . . . . . . . 4

Workgroup 2 Update

Mike Potoczniak. . . . . . . . . . . . . . .10

Workgroup 4 Update

John Rose. . . . . . . . . . . . . . . . . .91

Workgroup 5 Update

Matt Kuntz . . . . . . . . . . . . . . . . 151

Adjourn. . . . . . . . . . . . . . . . . . . . . 204


4

1 P-R-O-C-E-E-D-I-N-G-S

2 9:03 a.m.

3 MR. GOODRICH: Good morning, ladies

4 and gentlemen and welcome to the September 13th

5 meeting of the COVER Commission. My name is John

6 Goodrich. I am the designated federal officer

7 for the Commission.

8 If you are attending our meeting

9 remotely via phone, we would ask that you notify

10 us of your attendance by emailing us at

11 [email protected]. Again,

12 [email protected].

13 And I will now turn it over to our

14 chairman, Mr. Jake Leinenkugel.

15 CHAIR LEINENKUGEL: Thank you, John.

16 And good morning everybody and welcome

17 participants and all the commissioners on this

18 Friday, September 13th. At this time, I would

19 like to have Commissioner Jamil Khan lead us in

20 the Pledge of Allegiance.

21 DR. KHAN: Please join me.

22 (Pledge of Allegiance.)


5

1 DR. KHAN: Thank you.

2 CHAIR LEINENKUGEL: I would also like

3 to take a minute for everybody to briefly have a

4 statement from each commissioner that is in

5 attendance today, with a brief background note as

6 well, so that if there's any questions about

7 anything during this time you can email those to

8 what the DFO, John Goodrich, said under the COVER

9 Commission.

10 I'm Jake Leinenkugel. I'm the

11 chairman of the COVER Commission. I'm a Marine

12 Corps vet and also a veteran advocate.

13 MR. ROSE: Jack Rose, a 26-year Navy

14 veteran. I also spent the last 19 years

15 affiliated with the National Alliance on Mental

16 Illness, both at the local and State level, and

17 we have two adult children who live with mental

18 illness. And it is truly an honor to be on this

19 Commission.

20 DR. POTOCZNIAK: I'm Mike Potoczniak.

21 I'm a psychologist and the Mental Health Director

22 at the Santa Rose Clinic in the San Francisco VA.


6

1 I am also an Army Reservist major.

2 DR. MAGUEN: Shira Maguen. I am a

3 clinical psychologist at the San Francisco VA,

4 Mental Health Director of our Post-9/11

5 Integrated Care Clinic and PTSD researcher and

6 clinician as well.

7 COLONEL AMIDON: Matt Amidon, Marine

8 Corps Reservist and Director of the Military

9 Service Initiative at the George W. Bush

10 Institute in Dallas, Texas. Thank you, Mr.

11 Chair.

12 DR. KHAN: Good morning. Jamil Khan,

13 United States Marine. It's an honor to be part

14 of this Commission. Thank you.

15 DR. JONAS: Wayne Jonas, Army veteran,

16 24 years, family physician. I still see patients

17 in the military.

18 MR. KUNTZ: Matt Kuntz. I'm an Army

19 veteran. I also come from a family that lost a

20 servicemember to post-traumatic stress. And I am

21 Executive Director for NAMI Montana and the

22 Director of the Center for Mental Health Research


7

1 and Recovery at Montana State.

2 CHAIR LEINENKUGEL: And this is

3 Commissioner Leinenkugel again noting that two

4 commissioners have excused absence from this

5 session today, Tom Harvey and Admiral Thomas

6 Beeman. And they both have been involved on

7 weekly calls, and were project leads, and are

8 very up to speed as far as all the content and

9 subject matter as to what the Commission is

10 working on.

11 And on that note, I think it would be

12 a good idea to give a brief recap for some of

13 those that may have not been on the call

14 yesterday as to actually what a select group of

15 commissioners did 48 hours ago, our first dynamic

16 Hill visit to both SVAC, HVAC staff members, and

17 also to select Congressionals. And it was a very

18 productive day, so productive that we think this

19 will be an ongoing practice.

20 So for meetings, certainly for next

21 month in October, we will select another group of

22 five commissioners to do about the same thing


8

1 that we did to keep the key constituents, such as

2 SVAC, HVAC, White House, and the Secretary of the

3 VA up to date with the progress of the Commission

4 and our work agendas.

5 We also spoke yesterday at length

6 about milestones for completing the Commission.

7 The completion date has been set for December of

8 this year, with the writing of the report due in

9 late January of 2020. And so we had discussion,

10 debate, and analysis of how to go about reaching

11 the milestone and addressing gaps in research and

12 data collection from each of the workgroups. And

13 we also realized a sense of urgency that it was

14 time to change gears and get to the

15 recommendation stage, which we are currently

16 vigorously working on at this point in time.

17 All the Commissioners onboard believe

18 that we can make the date. We're putting a lot

19 of stress on the writing end, with final

20 recommendations and then deliberations, debate,

21 and discussion by the full Commission. And that

22 will be upcoming October-November with the final


9

1 write-up in December.

2 So that being said, and this being Day

3 2 of the COVER Commission's September meeting, we

4 have been going through the workgroups one by

5 one. And yesterday, we heard from Dr. Wayne

6 Jonas on his Workgroup 1 update, and also other

7 needs and requested site visits that he wanted to

8 do. The commissioners thought it was viable and

9 necessary and so he will be doing those within

10 the next 30 days.

11 Also, Dr. Shira Maguen on a Workgroup

12 3 update, which was very complete and had

13 numerous recommendations for the commissioners to

14 consider at that point in time as well.

15 So today, we are looking at, in the

16 morning session, of going through Workgroups 2,

17 4, and 5 in similar format and style as we did

18 yesterday.

19 So at this time, I would like to turn

20 to Commissioner Mike Potoczniak, who is the lead

21 for Workgroup 2 and his current update.

22 Commissioner Potoczniak.


10

1 DR. POTOCZNIAK: Thank you, Jake. So

2 first let me start, for the benefit of the people

3 that are on the phone, what are the duties of

4 Workgroup 2. Workgroup -- so next slide, please.

5 Workgroup 2 is patient-centered -- is

6 to conduct a patient-centered survey within each

7 of the VISNs, which is kind of like regions of

8 the VA, to examine the experience of veterans

9 with the Department of Veterans Affairs when

10 seeking medical assistance for mental health

11 issues through the healthcare system of the

12 department.

13 B is to look at the experience of

14 veterans with non-department facilities and

15 health professionals for treating mental health

16 issues.

17 C is the preference of veterans

18 regarding available treatment for mental health

19 issues and which issues the veterans believe to

20 be most effective.

21 D is the experience, if any, of

22 veterans with respect to the complementary and


11

1 integrative health treatment therapies.

2 And E is the prevalence of prescribing

3 medication -- prescription medication among

4 veterans seeking treatment through the healthcare

5 system.

6 F is to look at the outreach efforts

7 of the Secretary. And I can go further into that

8 but we're going to focus mostly on A through D

9 today because that's where most of the activity

10 is happening.

11 And so I want to go into kind of an

12 update -- next slide -- an update on the current

13 activities. So the focus groups that are

14 underway: We have done Cleveland; Baltimore;

15 Chicago; Atlanta; New Orleans we did but nobody

16 showed for that; Nashville; Miami; Philadelphia;

17 White River Junction, Vermont; Denver, Colorado;

18 Canandaigua was canceled -- or are we still going

19 there?

20 PARTICIPANT: We're going to try to

21 reschedule Canandaigua and Richmond.

22 DR. POTOCZNIAK: And Richmond also,


12

1 which was also canceled. The Northern California

2 VA, which is in Sacramento, is scheduled for this

3 upcoming week, as well as the Puget Sound VA in

4 Seattle.

5 We've had three virtual focus groups

6 to cover a wider area of more rural veterans that

7 are kind of scattered throughout the VISNs. So

8 we've kind of done some outreach in that

9 direction. We had good participation in that

10 with some good results.

11 Go to the next -- okay. Emerging

12 themes of Part A. So what I wanted to do is just

13 talk a little bit about what's coming out of the

14 focus groups. These are not so -- these are just

15 emerging themes. We haven't done the coding for

16 it yet but these are kind of what's coming out,

17 what we're hearing from the focus groups thus

18 far, noting that we have at least two or three

19 more focus groups to do. But we are, as Wendy

20 LaRue had said, we're reaching data saturation so

21 some of the same themes are coming up with the

22 veterans.


13

1 And so Part A, just to remind you, is

2 to look at the experience of veterans within the

3 Department of VA when seeking medical assistance

4 for mental health issues.

5 So some of the themes that have come

6 out, veterans have reported generally favorable

7 experiences with VA providers and that they

8 really enjoy that they are specially-trained to

9 understand their military experience. So

10 veterans tend to enjoy the fact that they don't

11 have to explain themselves and what military

12 culture is to their providers.

13 We've heard some themes of Vietnam-era

14 veterans tending to report feeling stigma from VA

15 employees when seeking mental health treatment.

16 So that was something that we did hear.

17 Veterans also reported experiencing

18 difficulties with frequent changes in providers

19 due to recruitment and retention. So they didn't

20 like having to tell their story over and over

21 again. There were people that had multiple

22 providers over a short period of time, whether


14

1 that's because they were students or whatnot,

2 these were themes that came out.

3 Veterans appreciated the coordination

4 of care between providers at VA. They liked you

5 know knowing that other providers had read the

6 notes of the other providers and they didn't have

7 to explain some of the things that were going on.

8 So that was a benefit that they had.

9 Veterans reported the importance of

10 being your own advocate in seeking VA care. So

11 in needing to kind of advocate for yourself

12 within the system is something that they felt was

13 very important.

14 So family involvement was also

15 important to veterans. A lot of -- there were

16 some themes of veterans saying that they wouldn't

17 have sought treatment if their spouse or family

18 member did not initiate the care.

19 So this is all within seeking

20 treatment in the VA. These are some of the

21 themes that came out.

22 And then also, veterans reported


15

1 difficulty in initiating care as a new patient in

2 VA mental health but, once they began, they

3 believed it was good quality. So it depends on

4 the facility. There's different experiences that

5 people have you know when initiating care. Some

6 people it was, obviously you know okay, and then

7 other people reported that they had difficulty

8 getting in for that first appointment.

9 So and then they also reported

10 variability based on their VA, which VA they were

11 in, with getting appointments that complemented

12 their work schedule. So some veterans that you

13 know work, had trouble getting weekend, night

14 appointments, or just an appointment that would

15 match whatever work schedule they have.

16 So in seeking care, these were some of

17 the things that came out for veterans.

18 I just want to pause for a second if

19 anybody has any questions about some of the

20 emergent themes from seeking care in the VA for

21 mental health issues.

22 MR. KUNTZ: Dr. Potoczniak, was there


16

1 anything that surprised you?

2 DR. POTOCZNIAK: No. I think all of

3 this was stuff that I have heard before and

4 experienced either as a veteran or working with

5 veterans in the VA. So I've seen people -- there

6 are definitely people that you know always bring

7 their family members in. I think that family

8 involvement is a little bit unique to the VA. I

9 know that other people in other settings bring

10 family members but I think -- and I'll get to

11 that a little bit later but I think the family

12 involvement can't be underscored enough as being

13 important because of the importance I think of

14 family in Military culture. So that was a good

15 thing.


17 Potoczniak, could you elaborate a little more on

18 the veterans -- it's in the middle there -- the

19 veterans reported the importance of being your

20 own advocate in seeking VA care --


22 CHAIR LEINENKUGEL: -- any explanation


17

1 as to what that means?

2 DR. POTOCZNIAK: So knowing how to --

3 whether it's knowing how to navigate the system

4 or when things aren't going well, who do you talk

5 to, how do you elevate a problem. So if there's

6 an issue that you're experiencing, you want to

7 change a provider, you want better appointment

8 times, or whatever it is, how do you go about

9 doing that?

10 And so some of it is a skill that I

11 think a lot of people in private healthcare learn

12 that you know you have to talk to the person in

13 charge in order to get what you want but veterans

14 aren't necessarily always skilled in knowing --

15 they kind of take what they get a lot of times

16 and don't advocate on their own behalf.

17 So whether it's from their experience

18 in the Military health care, or whatever, that

19 you just kind of take what you get and you don't

20 complain, I don't know whether it's because of

21 that kind of background but learning how to

22 actually be, as one commissioner said, a


18

1 healthcare consumer, is very important and

2 learning how to navigate, how do you deal with

3 complaints, and that kind of stuff.

4 Does that make sense?

5 CHAIR LEINENKUGEL: It does. And I'd

6 like one more follow-up to your second to the

7 last bullet point. If you could put a little

8 more clarity under the aspect of those veterans

9 that report difficulty, and you just mentioned it

10 as well, in initiating care as a new patient for

11 VA mental health.

12 DR. POTOCZNIAK: Right.

13 CHAIR LEINENKUGEL: Why is that?

14 DR. POTOCZNIAK: I think there's a

15 lack of uniformity throughout the system and how

16 you begin that. There's you know different

17 clinics have walk-in hours. Some of them really

18 don't have the capacity to do walk-in hours.

19 Some of them don't know how. Who do you ask to

20 get a mental health appointment? Do I feel

21 comfortable asking the front desk to connect me

22 to mental health, especially if it's a smaller


19

1 VA, a small town, et cetera? But just knowing

2 the process by which you do it, you know a lot of

3 mental health clinics are locked behind different

4 doors and it's not easy enough just to walk up

5 and say hey, I need an appointment.

6 So I don't think they know how to ask

7 for it. Sometimes its embarrassment in doing it

8 or stigma but then also, just how do you get the

9 referral. Where is it? I know you know it's

10 like for example -- I always use this as an

11 example. Palo Alto, one of my favorite

12 healthcare systems in the VA has a big building

13 on campus with a big sign in front of it that

14 says Mental Health Building. There's not

15 outpatient mental health care in that building.

16 (Laughter.)

17 DR. POTOCZNIAK: So, in fact it's on

18 another campus about 20 minutes away.

19 So that's an example of kind of what

20 -- so I'd always have veterans walking up to that

21 building saying can I get an appointment. And

22 I'd say well, you have to get on the shuttle and


20

1 go to Menlo Park and they're just, by the time

2 you say that, they're just like oh, I'm good.

3 Thanks. I'll figure it out.

4 So that's the kind of example of kind

5 of, whether it's signage or it's such a big

6 system, it's hard to know who to go to first and

7 how to get there.

8 CHAIR LEINENKUGEL: Thanks for that.


10 MR. ROSE: Just a question, if I may.

11 Just with respect to mental health in general and

12 the stigma associated with it, I think anywhere

13 you go, inside or outside, many times the mental

14 health system is very difficult to navigate. And

15 whether you have what I'll talk about later, a

16 veteran peer support specialist, somebody that

17 can help bring you. You need some kind of

18 connection, especially if there's difficulty in

19 where am I really supposed to go. And that's an

20 issue.


22 CHAIR LEINENKUGEL: But isn't there


21

1 one thing that we did learn on many of our site

2 visits is the PAC Team makeup? Actually, we

3 heard consistently that it's up to that primary

4 care doc and the list of questions in that first

5 examination or scheduled appointment to make

6 that, they use the term, warm handoff

7 consistently. Whether it's done consistently is

8 something for us to decide but isn't that part of

9 it, though, Mike? Shouldn't it start there?

10 DR. POTOCZNIAK: So where it can start

11 is in primary care but it also can start when

12 veterans first come out of DoD and they go into

13 the VA for their healthcare you know they're

14 usually assigned or directed to a transition care

15 manager. And that's another place where it

16 frequently gets brought up. That program is

17 unevenly kind of distributed, depending upon

18 which VA you walk in to.

19 So if you're walking into a small

20 clinic in Montana versus a large VA in Palo Alto,

21 you're going to have a very different experience

22 whether you get in touch with one of those


22

1 people. Clearly, it doesn't happen. As we

2 talked to people on the reservation, they've

3 never talked to a transition care manager and so

4 they don't know all the different things that are

5 available to them.

6 It does get explained to a lot of

7 people when they get out of the Military but they

8 don't absorb that.

9 CHAIR LEINENKUGEL: You used the term

10 lack of uniformity --


12 CHAIR LEINENKUGEL: -- also, lack of

13 consistency.

14 DR. POTOCZNIAK: Right. Good

15 resources that work but they are unevenly

16 applied.


18 DR. POTOCZNIAK: Any other questions

19 on Part A, seeking out treatment?

20 So emergent themes of B, which is the

21 experience of veterans in non-VA facilities, and

22 so there's not -- there was difficulty in


23

1 recruiting veterans that sought treatment outside

2 VA. There was some representation of that.

3 Non-VA veterans reported, in the focus

4 groups, some difficulty with lack of knowledge

5 related to -- or difficulty or lack of knowledge

6 related to VA eligibility. So that's definitely

7 a theme that you hear a lot of in VAs is

8 difficulty in knowing what you're eligible for,

9 whether you're eligible at all, and how many

10 veterans believe that they're not eligible when

11 really, they get five free years of care post-

12 combat. You know it's like but they're not

13 eligible for it.

14 So recently this year, I saw a guy

15 from my unit that was on his fourth year post-

16 combat that we finally got enrolled. I said you

17 know you are eligible for this and he had

18 absolutely no idea. And the amount of people

19 that I've run into over my career that have that

20 issue -- I'm sure Shira probably knows a lot of

21 stories like that -- you know that there's a lot

22 of people that don't know the eligibility and it


24

1 is so complex. And that's part of the confusion

2 of the VA is knowing what you're eligible for and

3 what you have to do to get it. So that came out

4 in this theme here.

5 Vietnam-era veterans had reported some

6 trust issues with VA, so they had sought care

7 outside.

8 And veterans who split their care

9 between VA and community had some difficulty

10 coordinating their care between community and VA.

11 So people that were getting care in non-VA and VA

12 felt it was disjointed, which makes sense because

13 it's a closed system and a lot of their records

14 don't get put into the VA system. Whether the VA

15 is paying for it or not, it doesn't matter. A

16 lot of times it doesn't get in.

17 Any questions on Part B?

18 COLONEL AMIDON: Just one -- two.

19 Just for the record, that five-year eligibility

20 is for the full expanse of VHA healthcare

21 delivery or is it just for mental health?

22 DR. POTOCZNIAK: So there's a weird --


25

1 and this is what makes it even more complicated.

2 There's a weird thing that says that service-

3 related issues but that is never true in my

4 experience.


6 DR. POTOCZNIAK: Like, I've never seen

7 anybody come in in the five-year span that

8 doesn't get -- you have to start with a primary

9 care appointment. And so there's no way to know

10 what is service-connected, at that point, or not.

11 So pretty much everything that then

12 results from that primary care appointment is

13 covered, so regardless of whether it really

14 happened during your service or not. And a lot

15 of people don't know that. They see that for

16 service-related injuries and they think well, if

17 I have to go for my ankle, I'll go the VA but

18 they really need to go a primary care appointment

19 to start off with --

20 COLONEL AMIDON: To get in the system.

21 DR. POTOCZNIAK: -- and then they get

22 treated for everything else. So --


26

1 COLONEL AMIDON: Can you share some of

2 -- I mean when you read the legislative mandate

3 for what you're tasked to do, we should

4 appreciate the scope and scale in difficulty in

5 finding those who are not partaking of VA health

6 care.

7 CHAIR LEINENKUGEL: Matt, can you do

8 us a favor? Speak up a little bit because I

9 think --


11 CHAIR LEINENKUGEL: -- this is

12 critically important.

13 COLONEL AMIDON: No, I just I applaud

14 your efforts and I know that, even at the

15 national level, it's very difficult. You know

16 Pew Research has difficulty finding vets. That's

17 an over-simplification but I just -- if you could

18 take a minute to talk about the difficulty of

19 scope and scale of finding those people. I

20 certainly applaud your efforts in getting them

21 into focus groups.

22 DR. POTOCZNIAK: Well actually, I


27

1 think I'd like Casin to talk a little bit about

2 that because we advertised on social media to

3 kind of pull people in. And that's where I think

4 a lot of those people came from.


6 MR. SPERO: Yes --

7 CHAIR LEINENKUGEL: Casin, do us a

8 favor and introduce yourself and your role, as

9 well.

10 MR. SPERO: I'm Casin Spero. I'm the

11 Staff Director for the Commission. And I'll ask

12 if Wendy LaRue, our Chief Content Development

13 person wants to jump in. She assisted a lot in

14 the recruitment as well.

15 I would say that you know we did a few

16 different things. There were some emails that

17 went out from the VA. Social media went out from

18 the COVER Commission social media post that went

19 out from the department. We asked facilities to

20 share posts. There was fliers. There was

21 handouts. There was -- at all the facilities

22 where these were conducted.


28

1 DR. POTOCZNIAK: And outreach to the

2 VSOs, too, I think.

3 MR. SPERO: We did outreach to the

4 VSOs but most of them were -- I had some success

5 at the local level contacting the Baltimore

6 American Legion Office and they shared some

7 posts, sent some stuff out on their listservs.

8 But the national VSOs, it didn't seem to be a

9 priority for them to really participate in

10 sharing that. It went out to the Secretary of

11 the VSO Communicators Group. So that's the

12 communications lead for the national VSOs.

13 Pretty minimal participation in that.

14 But even with that you know all those

15 groups also had trouble touching those 14

16 veterans you know who don't engage through VA.

17 And if you think about coming to a VA facility or

18 a focus group in the middle of the day on a

19 weekday, or even if it was a night or a weekend,

20 coming to a VA facility when you've never been to

21 one you know it's just a lot to ask.

22 And I think if we had five years, we


29

1 would still see you know pretty low numbers in

2 this, based on what we've had.

3 Where we did have some success is we

4 did have some veterans who had started in the VA

5 system left because they had an issue and sought

6 care elsewhere and then, as their issues have

7 gotten better, they had come back to the VA and

8 were learning to trust again, or using it for

9 other things, or --

10 DR. LaRUE: And so people who started

11 in private sector care and then realized that

12 they were eligible for VA care and then moved

13 over.

14 MR. SPERO: And also some people who

15 used a mix of service, you know wanted to do this

16 in the private sector and do this in the VA.

17 But yes, the recruiting thing was

18 definitely a challenge. And given the amount of

19 time between the time we received -- you know

20 going back a year, the time we had, you know 18

21 months to develop the survey, test everything

22 through the pilot, get approval from OMB with the


30

1 Government shutdown mixed in, develop a plan for

2 execution once we had approval, and execute it,

3 it's a very tight window.

4 DR. LaRUE: And frankly, an impediment

5 to recruiting people, it's two hours for a focus

6 group, is our inability to compensate them you

7 know, when you can't even give them cookies.

8 You know we had a number of veterans

9 who contacted us, asked about compensation, and

10 then didn't participate because there wasn't any.

11 And just as a point of reference, somebody that I

12 knew personally who was participating in a non-

13 government focus group this week was paid $125

14 for an hour of time.

15 So people kind of know that and it

16 does inhibit the quality of research that we can

17 do just by virtue of that.

18 COLONEL AMIDON: Yes, all that to

19 commend you, and the support staff, and the team

20 for, in a short amount of time, extracting the

21 themes that you're talking about today.

22 DR. LaRUE: We did have one


31

1 participant, that was in one of the focus groups

2 I had run, who had not received any care at all

3 in VA and he found out about the focus group

4 through social media. And interestingly, he was

5 getting ready to move. And after sitting,

6 hearing about the care that the others in the

7 room received, said when he moved he was going to

8 check out the VA in the new city where he was

9 going. He had to start from scratch on providers

10 anyhow. So he was going to go to the VA.

11 DR. POTOCZNIAK: Thank you.

12 MR. ROSE: Mike, if I may, just

13 another possible source of veterans who are not

14 in the VA can possibly come from Federally

15 Qualified Health Centers. And we've had some

16 contact with those folks. We've had some numbers

17 and we probably need to maybe look a little bit

18 closer at those numbers but that may be another

19 source.

20 DR. POTOCZNIAK: That's a really --

21 we've got to learn that in Montana where they've

22 had veterans in their catchment. So, yes, thank


32

1 you.

2 MR. ROSE: Yes.

3 DR. POTOCZNIAK: Go to the next slide,

4 please.

5 So emerging themes of Part C, which is

6 the preference of veterans regarding available

7 treatment for mental health issues and which

8 methods veterans believe to be most effective.

9 So one of the big themes that came

10 about was veterans reported that walk-in

11 appointments, walk-in appointment availability

12 was important to them. It's something that the A

13 has rolled out under -- it's under the title Same

14 Day Appointments, but being able to walk in and

15 be seen that day was something that was -- that

16 they talked about as being key for them.

17 And veterans also reported

18 satisfaction with being able to contact their

19 providers with secure messaging in-between

20 sessions. So that was something that's part of

21 what we used to call My HealtheVet. I think it's

22 called something else now but there's still


33

1 secure messaging on it. And so veterans being

2 able to contact providers is a big thing.

3 A majority of veterans in the focus

4 groups reported satisfaction with the care they

5 received in mental health. So that was good to

6 hear. Veterans reported satisfaction with

7 cognitive behavioral therapy and some

8 dissatisfaction with prolonged exposure. I think

9 Yessie had that. And that makes sense because

10 prolonged exposure is -- it's not -- I mean it's

11 not a feel good therapy in a lot of ways. It's

12 kind of a rougher experience but it does -- it is

13 very effective. So I would be surprised if

14 people said that they enjoyed the prolonged

15 exposure experience. It's kind of really not

16 enjoyable but it does work.

17 So there was a mixed response from

18 veterans regarding their preference for group

19 versus individual therapy. So that, to me, just

20 talks about probably personalities. Some people

21 are introverts, people are extraverted.

22 Veterans who did enjoy groups


34

1 commented about the importance of comradery with

2 other veterans. And from what I recall, that was

3 typically a lot of Vietnam-era and older

4 veterans. There wasn't as many 9/11 veterans

5 saying that.

6 DR. LaRUE: We actually did have some

7 younger veterans in smaller groups.

8 DR. POTOCZNIAK: You did? Okay.

9 So the comradery was important. There

10 was significant variability between VA focus

11 groups in the types of treatments available and

12 their overall satisfactions. So some people did

13 have bad experiences. Some people had different

14 kinds of treatments. So there's some variability

15 there.

16 Peer support specialists were

17 considered helpful, although many veterans did

18 not always understand their role or be able to

19 really identify them. So they didn't understand

20 what their purpose was but wow, that person was

21 helpful.

22 I don't know if any of you guys want


35

1 to say any more about that but, Yessie, I think

2 you had that also.

3 MR. SPERO: I think that like they

4 would identify someone who helped them get

5 enrolled in care but it was unclear whether that

6 was just another veteran sometimes or if that was

7 -- I don't think they knew to call maybe their

8 peer support specialist, a peer support

9 specialist, the formal title that the VA gives

10 them.


12 MR. SPERO: So it was tough to I think

13 identify when there was a formal I'm a peer

14 support specialist helping Shira get enrolled in

15 care or you know get this researched. You know

16 what is my battle buddy, you know just saying

17 hey, in case you needed to go in and see what

18 they can do.

19 DR. LaRUE: In some cases, veterans

20 within the facility had, like in one situation,

21 created their own sort of local DSO. And they

22 had a network that does many of those roles.


36

1 At one facility --

2 DR. POTOCZNIAK: We saw that in

3 Montana.

4 DR. LaRUE: -- participants created a

5 program called Vet to Vet, which he maintains was

6 the basis of starting the peer support specialist

7 program. So they still do some things through

8 that nonprofit in that area.

9 So there's some gray area but when

10 they knew that they had peer support specialists,

11 they seemed to really like that person who gets

12 them, helping them navigate things.

13 MS. CASTILLO: And I would just add

14 that even for those veterans that have a lack of

15 awareness of the peer support program that was

16 available, there was still agreement across the

17 board that something like that would be very

18 valuable and wanted. And they definitely you

19 know saw the value in a program like that.

20 DR. KHAN: If I may ask, we are using

21 the term VSO. Is that a Veterans Service

22 Organization or is it a Veterans Service Officer?


37

1 MR. SPERO: I was using it as

2 organization.

3 DR. POTOCZNIAK: Yes, I think we're

4 almost always saying organization but I know the

5 counties have Veterans Service Officers, which

6 makes it even more complicated. I always got

7 confused with that.

8 So the veterans did report a lack of

9 mental health providers available. So they

10 didn't -- the lack of staffing was present I

11 guess to some veterans.

12 And then Telehealth was an important

13 intervention for veterans, especially in rural

14 locations. However, they reported in some cases

15 that it was not as maybe satisfying as an in-

16 person treatment. So being able to come in in

17 person was still important to some veterans.

18 Would you want to say anything more

19 about that? No, okay.

20 And so I think a current theme in

21 mental health treatment I think is important to

22 mention is that Telehealth is being really pushed


38

1 as kind of the answer to rural -- to address the

2 needs of rural people who are veterans. However,

3 I think it's still important to mention that it's

4 still good to staff some of those locations with

5 actual providers because they are part of a

6 community. And so I know the larger, a lot in

7 the VA they are kind of saying yes, this is just

8 as effective and whatever but, kind of time and

9 time again, what we're hearing is yes, but it is

10 good to still have a person there sometimes.

11 MS. CASTILLO: Commissioner

12 Potoczniak, if I may add, in addition to the lack

13 of mental health providers available, it was also

14 staff, as well, where the veterans felt that they

15 could always use more nurses or social workers

16 because they were sometimes their liaison in

17 navigating through the process, and how to get

18 the care, and also the ones that kept more in

19 contact with them as far as their appointments

20 and answering their questions. So it was across

21 the board needing more staff, as well.

22 DR. POTOCZNIAK: So you have mental


39

1 health --

2 CHAIR LEINENKUGEL: Excuse me,

3 Commissioner, if I could. Yessie, would you

4 please introduce yourself --

5 MS. CASTILLO: I'm sorry.

6 CHAIR LEINENKUGEL: -- to the folks on

7 the phone, and also Wendy, and also your roles,

8 please.

9 MS. CASTILLO: So my name is Yessenia

10 Castillo. I go by Yessie. I am an

11 epidemiologist by training and part of the

12 contracting staff, helping with the analytic task

13 for Workgroups 2, 4, and 5.

14 DR. LaRUE: Wendy LaRue. I'm the

15 Chief Content Development Officer for the

16 Commission. My main role is getting the report

17 completed by January and then, also, I have been

18 conducting many of the focus groups for the

19 Commission.

20 DR. POTOCZNIAK: Yes and I want to

21 just take a moment real quick to thank everybody

22 who has been out. Wendy has been out, I think,


40

1 probably on the road -- I don't even want to know

2 how many places you've been to. And Casin Spero

3 has been out. And I know, Yessie, you did some

4 of the virtual focus groups, right? And Salman

5 also did virtual or in-person?

6 MS. CASTILLO: Assisted.

7 DR. POTOCZNIAK: Yes, okay.

8 DR. LaRUE: He's been making sure we

9 have transcriptions of them all as well.

10 DR. POTOCZNIAK: Was there anybody

11 else that was helping out?

12 MS. CASTILLO: Doctor --

13 MR. SPERO: Jennifer, Katie, and Tracy

14 have been out supporting as well.

15 DR. POTOCZNIAK: That's a crew.

16 MR. SPERO: Yes, it's --

17 MS. CASTILLO: Truly a team effort.

18 DR. POTOCZNIAK: It's been a herculean

19 task and I just want to say how appreciative I am

20 that everybody's been out there you know talking

21 to veterans and listening to them, and getting

22 all the data that we really need to move forward.


41

1 MS. CASTILLO: Well, sorry, with that

2 point -- sorry. One thing that was unanimous in

3 at least all the virtual ones that I assisted

4 with, all the veterans were really grateful in

5 having the opportunity to express their opinions,

6 and coming together not only hearing each other's

7 experience but having the opportunity to express

8 and provide their opinions. So they really liked

9 the platform and being heard.

10 DR. POTOCZNIAK: Yes and you know I

11 think that goes to Jake's point you know that

12 this should be more of an ongoing process.

13 So you know but I think the thing that

14 -- part of the reason I think in the very

15 beginning I think a lot of people didn't

16 understand why I did want to do this in a

17 qualitative fashion, which was because I did want

18 to have that interaction between veterans, which

19 is what Yessie is talking about, because veterans

20 hear things.

21 And also, it has an additional benefit

22 for the veteran to participate. So they're not


42

1 getting paid but they do learn about things that

2 maybe save them thousands of dollars in the

3 future because you know veterans trade

4 information at these things.

5 So I think there's some benefit to

6 that, even if it's not immediately monetary.

7 DR. MAGUEN: I have a quick question

8 about the Telehealth not being -- saying it's not

9 as satisfying as in-person treatment. I'm

10 curious because, obviously, we're thinking a lot

11 about preferences and I'm wondering if specific

12 reasons were given for the satisfaction versus

13 nonsatisfaction.

14 MS. CASTILLO: So I can tell you, at

15 least first for the vets that some veterans have

16 reported that. They were specific. It depended

17 on the mental health condition and the reason for

18 the Telehealth service being provided. That for

19 some of them, for example, those that suffer with

20 PTSD, they didn't always like the impersonal

21 nature of speaking through technology and they

22 missed the eye contact being there in person, and


43

1 just feeling they just missed that.

2 So it wasn't the same experience for

3 them. They didn't feel as comfortable sharing

4 something so personal to a TV screen versus an

5 actual person. And along with that, they also

6 were really clear that even when they are in

7 person, then now with the use of technology and

8 having the electronic records, there's a

9 difference in providers looking at their computer

10 typing all their notes and they miss the old --

11 the old method of just pen and paper and having

12 more of a discussion. So they also want that eye

13 contact. Even when they are in person, they

14 don't always get that experience as well now.


16 CHAIR LEINENKUGEL: I have an

17 interesting anecdote that might be timely and

18 worth to be put on the record as well, just from

19 the Chippewa Falls CBOC, which is relatively

20 small but growing nicely, located 100 miles away

21 from the Minneapolis VAMC, which is an excellent

22 facility.


44

1 I talked to, over the last four

2 months, really since May of this year, to three

3 different veterans -- young, 30s and 40s -- that

4 have gotten into the Telehealth with mental

5 health. And their comments to me were similar I

6 think to what Yessie was saying but it changed.

7 Once they got comfortable with the

8 face-to-face with the mental health provider that

9 they were working with, they had no issues

10 because it saved them approximately six hours a

11 day to do that Telehealth out of the CBOC in a

12 very private, comfortable, wonderful setting,

13 which I was able to witness but not see during

14 one of their sessions, of course, but they felt

15 very comfortable after about a six-month period.

16 So I mean that's just anecdotal but it

17 was from three veterans that I thought would be

18 relevant to this discussion.

19 MS. CASTILLO: I'm sorry. To add to

20 your point, Chairman, they were also still really

21 clear they still preferred Telehealth than not

22 getting the services, that it was still a really


45

1 great way to provide those type of services,

2 especially in the resource-lacking areas like

3 rural areas.


5 MR. ROSE: If I may just also follow

6 on to that. I mean as far as Telehealth, in

7 light of the lack of psychiatrists that we are

8 faced with throughout the United States, whether

9 it's in the VA or out of the VA, it's an

10 opportunity to get access to treatment. And I

11 think a lot of it has to do, if it's in a

12 facility like a CBOC, we're talking some where it

13 may be in the individual's home, with respect, if

14 they have the right kind of technology.

15 But it's still, I think even in CBOC,

16 I think it's the handle that gets that person

17 into the setting where, all of a sudden, the

18 provider is on the other side of the screen. And

19 I think there are some people, both inside and

20 outside, that really it helps them.

21 And I would be interested how many

22 folks in the focus group said well, it was --


46

1 they weren't appreciative or they didn't like the

2 Telehealth. Do we know?

3 DR. LaRUE: I don't know that we have

4 a set number or anything.

5 MR. ROSE: Yes, okay.

6 DR. LaRUE: I will say a factor in why

7 we're hearing that may be the -- I think that the

8 average age probably skews older and just by

9 virtue of doing focus groups during the day. And

10 if we had more younger vets talking to us, we may

11 not hear that as much because they're accustom to

12 FaceTime and other sorts of video chats.

13 So I think younger vets would probably

14 give us a little bit different answer.

15 DR. KHAN: If I may add, Telehealth is

16 a very good concept administered by and in a

17 simplicity form. But in actually, from technical

18 side of the house, it's a big giant.

19 The contract is given to Apple. Apple

20 has created applications, the majority of them

21 you only use on Apple machines. Within the VA,

22 there is an ongoing effort to provide those iPads


47

1 to veterans who are in remote conditions on one

2 of them. And since last January, the system is

3 still working on writing that machine. So there

4 is another difficulty is to -- but it's a very

5 good concept you know to help.

6 DR. POTOCZNIAK: Yes, I think that's

7 a huge effort by the VA is to provide a lot of

8 veterans with iPads. I know San Francisco does

9 that quite a bit.

10 And another thin that San Francisco

11 does which I think is an interesting add-on to

12 people that have difficulty, especially the older

13 kind of Vietnam-era and older kind of group of

14 people, is that we have a Telehealth -- he's not

15 a coordinator but he's like a tech support person

16 and he's their age. Like he's around -- he's

17 probably 70 or -- I don't know if I want to say

18 but he's an older guy.

19 And so he's able to break it down

20 really simply and kind of say do this. And he's

21 patient you know and conducts all the test phone

22 calls and events so that veterans feel


48

1 comfortable.

2 And honestly, we've gotten more

3 veterans on Telehealth for that reason because

4 they're able to sit with him and explain it. And

5 it's kind of peer-to-peer. So that's been a very

6 effective method of getting people on.

7 Go to the next slide, please.

8 So emerging themes of Part D, which is

9 the last part. It's experience, if any, of

10 veterans with respect to complementary and

11 integrative health treatments. So we have a few

12 points on this.

13 Veterans had some lack of knowledge of

14 the types of CIH treatments that were available.

15 So they were learning in the group about all the

16 different kinds that were available but they

17 didn't know the full array of what was available.

18 They reported variability about

19 whether CIH was discussed as an option by their

20 mental health provider. So it depended. A lot

21 of them, I guess, had said that their mental

22 health providers had never brought it up --


49

1 you're shaking your head -- and some people were

2 using it. So there's variability with that.

3 There's some variability between VAs

4 of the treatments available to them and how they

5 were discussed.

6 Veterans that used CIH treatments

7 reported they learned of the availability through

8 word of mouth or within a network of veterans.

9 And so that was a theme that came out. So maybe

10 they didn't hear about it from their provider but

11 they heard about it from another veteran that

12 maybe was doing the treatment or something like

13 that. So it spread kind of informally a lot of

14 times.

15 MS. CASTILLO: That's a great example

16 in a group therapy session, if a veteran said

17 they were doing yoga and they were doing it at

18 their facility, then that's how the other

19 veterans participating would find out.

20 And so just to add one more point I

21 forgot to tell yesterday, actually I should have

22 told you then, that for some of the veterans that


50

1 did report utilizing CIH treatments, it wasn't

2 always through the VA. They sometimes did it on

3 their own in the community but not with the VA

4 referral because they were not aware that VA also

5 provided it.

6 COLONEL AMIDON: Was that under the --

7 I mean I know that the sample size was low but

8 was it under the context of the CIH being a

9 monotherapy or additive to evidence-based care?

10 Did you hear them say I'm only doing yoga?

11 MS. CASTILLO: No.


13 DR. LaRUE: Everybody that I saw was

14 getting other treatment.

15 MR. SPERO: Or had been.

16 DR. LaRUE: At some point.

17 MR. SPERO: There was traditional

18 treatment sprinkled in.


20 DR. MAGUEN: And if I can ask you

21 something.

22 DR. LaRUE: I can think of one case


51

1 where the person did not want medication and so

2 forth, just wanted to other things.

3 DR. MAGUEN: Can I ask a follow-up

4 about -- up here it says it was not always

5 discussed with their mental health provider.

6 What about a primary care provider, or peer

7 support specialist, or other providers?

8 DR. LaRUE: I would say primarily

9 people talked about receiving newsletters that

10 had information about art therapy, recreation

11 therapy, and so forth. So that was the source of

12 going to something and then talking to -- you

13 know like I go on a hiking trip and then somebody

14 says oh, I go to art therapy; you should come

15 too.

16 The networking was huge. I didn't

17 hear very much about providers, although you know

18 I think more with acupuncture, chiropractic.

19 MR. SPERO: They asked a provider for

20 a referral --


22 MR. SPERO: -- after hearing a


52

1 positive experience from a friend veteran, family

2 member, something like that.

3 DR. LaRUE: And a number of

4 participants talked about literally going to the

5 -- they're having a bad day. They go hang out at

6 the VAMC and they know there are other vets there

7 that get those kind of bad days. And then you

8 know those become networking opportunities, where

9 they find out about oh, I can go learn how to

10 meditate to do on my bad day.

11 MS. CASTILLO: A two-part answer to

12 your question. For some veterans, they did go

13 back to their provider and the provider was

14 unaware, whether it's primary care or a mental

15 health provider.

16 But then the second answer to that:

17 It depends on the facility as well because we

18 know from, at least for the virtual sessions,

19 some of the veterans were attending care at a

20 Whole Health Flagship Site. So those providers

21 were more well-informed of the treatments that

22 were available related to CIH.


53

1 So it goes back to the variable

2 experience among facilities and providers.

3 DR. POTOCZNIAK: Yes, it's very

4 different, I think, between the CBOCs and the

5 Medical Centers. It's like you're going to hear

6 a lot more in the Medical Centers versus even 30

7 miles away in a CBOC. So I think that's --

8 that's I think an experience I've seen throughout

9 the VA is just that there's two different levels

10 of knowledge. And if you're further away from a

11 flagpole, you're just going to miss some of that

12 stuff.

13 DR. LaRUE: I think that an important

14 side note is that, beyond what's happening in the

15 CBOCs and VAMCs, veterans talked about care that

16 they got at the Vet Centers. And at least in one

17 case in a rural area, that was how a participant

18 was able to get flexibility in therapy times, for

19 example. The Medical Center standard business

20 hours, 8:30 to 4:00 or something and because he

21 needed to work, that was not a good schedule.

22 But the Vet Center provided extra opportunities


54

1 and lots of CIH opportunities.

2 MS. CASTILLO: And to piggyback off of

3 Wendy, on her comment, for some of the veterans I

4 met or spoke to, they also said the Vet Center

5 was their entry point to getting care at a major

6 medical center for VA, where they had more trust

7 with the Vet Center. They also sometimes felt

8 more welcomed at a Vet Center than a Medical

9 Center but that was one of their entry points to

10 building that trust back with VA, especially if

11 they were older.

12 And then, sorry, going back to CIH,

13 the veterans also said, even with the lack of

14 awareness related to treatments, I think it was

15 pretty unanimous or at least the majority still

16 wanted to know more about it. So there was a

17 strong interest in using CIH treatments and

18 learning more about it.

19 And then they also stated some

20 recommendations of just better communication

21 related to all of the available services, not

22 just CIH, but in general, like a missed


55

1 opportunity of bulletin boards within the Medical

2 Centers not being updated. They don't always

3 read the newsletters but they do log into the My

4 HealtheVet -- sorry if I'm getting that wrong.

5 But even advertisements through that portal is

6 you know something that they would recommend as

7 well.

8 And then also related to more positive

9 media coverage or advertisement with the VA, they

10 can be advertising all these services that are

11 available to their veterans. So they will -- you

12 know the majority agree just these things could

13 be done better, too.

14 So VA in better light, as well, the

15 positive things they are doing for their veterans

16 that are already available and just the better

17 communication related to it.

18 DR. POTOCZNIAK: So I'm going to go

19 into the next slide but I want to be really clear

20 that we haven't even coded the data yet. So I'm

21 going to talk about what potential, kind of spit

22 balling some recommendations for Part A through


56

1 D. I'm just going to talk briefly about them

2 because I don't want to spend too much time on

3 them because it's premature but I want to give an

4 idea of what we're thinking about.

5 So why don't we go to the next --

6 there we go.

7 Okay, so additional focus groups are

8 going to be conducted in the next week. Kind of

9 a coding of the data is going to go into the

10 themes -- or the coding of the data into themes

11 will follow.

12 But potential recommendations for Part

13 A could include addressing the frequent changing

14 of providers related to retention. So that does

15 seem to be a theme throughout the VA and there's

16 reasons for that, some of which are kind of

17 outside of our scope but there are things that

18 can be addressed related to that.

19 Training veterans in skills to assist

20 them with advocating for their own healthcare.

21 So I think that there's definitely a lack of

22 skill in that way that veterans are -- they think


57

1 they have to kind of take whatever is given to

2 them and they don't really know how to ask the

3 questions. They don't really know how to

4 advocate without getting angry sometimes.

5 So I think if veterans were trained in

6 some skills to assist them with that, it might be

7 helpful. So that's an idea.

8 Examining the process of initiating

9 mental health care and identifying issues. So

10 different VAs have different issues. And I think

11 the lack of uniformity around how you seek care

12 throughout the different VAs is part of the

13 problem.

14 And that does kind of dovetail into

15 eligibility issues, which I won't get into, but

16 there could be a potential recommendation around

17 that because it does stand in the way of

18 accessing mental health.

19 Examining compliance of night and

20 weekend appointment availability. So there is a

21 mandate that's out there around night and

22 weekends but very typical of Government agencies,


58

1 sometimes, there's been a lot of solutions to

2 that that basically make the -- that kind of

3 touch on the mandate or gently meet the mandate

4 but don't actually -- but I personally don't

5 consider a 5:00 p.m. appointment to be a night

6 appointment. I kind of still consider that to be

7 a day appointment, even though it is outside the

8 Government workday.

9 So a lot of VAs don't go past 6:00.

10 Vet Centers do and some VAs do. Some VAs do a

11 great job of that, a lot of VAs don't.

12 So what is kind of slightly meeting

13 the mandate? Who is robustly meeting the

14 mandate? How can we get those things closer

15 together?

16 Because that is an issue. Our weekend

17 -- our night and weekend appointments, especially

18 in the plight that I'm in, are gobbled up really

19 quickly. So there's clearly demand around that.

20 It's just how do we get it to be uniform.

21 MR. ROSE: Mike, if I may, is that a

22 staffing issue did you say or not necessarily?


59

1 DR. POTOCZNIAK: It's not -- it can be

2 a staffing issue. It can be that it's hard to

3 get people who are already feeling underpaid to

4 stay late.

5 MR. ROSE: Okay. Well, it's like a

6 staffing issue.

7 DR. POTOCZNIAK: You know so I take a

8 job in the Government because I want a certain

9 quality of life and you're telling me now I'm

10 going to work late. Maybe I'll go work for

11 Stanford, or Kaiser, or whatever.

12 MR. ROSE: Yes.

13 DR. KHAN: But I think the complement

14 there, you have a triage system within the --

15 throughout all the -- even otherwise, your

16 quality, it's a matter of information. How does

17 a veteran know what to do for his or her own

18 health?

19 DR. POTOCZNIAK: Are you talking about

20 the nurse -- the advisors?

21 DR. KHAN: You call in your -- you

22 call in your 911 and you say I'm a veteran.


60


2 DR. KHAN: And you say I'm a veteran.

3 They'll transfer you to a triage. In the triage,

4 you have a mental health psychologist on station.

5 They will take those calls.

6 So the system is available but the

7 difficulty for the veteran is not knowing it, how

8 to navigate through this. We always have a

9 shortfall of expert people you know and they will

10 not be available on duty 24 hours a day the same

11 person but within the system there are resources

12 available. The lack of information, how to get

13 to those resources is the biggest hurdle.

14 DR. POTOCZNIAK: So thank you.

15 So conducting training on the

16 importance of family involvement in veteran care

17 for VA providers and review clinically

18 appropriate ways of involving family. So I think

19 there is some variability around how VA providers

20 feel about involving family. It's a difficult

21 issue in mental health around involvement of

22 family because there's a lot of times in the


61

1 private industry family is seen as -- you know if

2 family were to show up at a session at a private

3 practice, it would be considered intrusive and

4 that's the culture with which a lot of

5 psychologists are raised in. Some are raised

6 differently but a lot of times you wouldn't just

7 automatically involve a family member. But in

8 the VA, you are expected or at least informally

9 expected I think, if somebody brings their spouse

10 in and they're sitting in the waiting room and

11 they want to come in you're probably not going to

12 turn them away. But a lot of veteran -- a lot of

13 providers feel very differently about it and

14 there's an unevenness into how families are

15 involved in talking and training providers more

16 kind of uniformly on how do you involve family,

17 how do you deal with the privacy issues that are

18 involved effectively so that it's not a surprise,

19 especially for trainees and young providers that

20 are coming out of a training program that may not

21 have any background involving family in

22 individual therapy, or group therapy, or


62

1 whatever. So I don't know.

2 MR. ROSE: Just, if I may, say

3 something on that Mike. I mean with respect to

4 family, and it may not be right in session with

5 the provider, but you know putting on the NAMI

6 hat, I mean we have been very successful in

7 family-to-family training, something that is

8 maybe outside the office hours, if you may,

9 because the families need that. They really do.

10 They probably need as much help as the veteran,

11 in many instances.

12 DR. POTOCZNIAK: At a lot of the

13 veteran town halls that I've been to, you hear

14 more from the family of the veteran, frequently,

15 than you hear from the veteran themselves. You

16 know and so you hear about what they're happy

17 about or what they're not happy about.

18 And so the thing is is that you'll get

19 a lot of new providers, as well as even some

20 established providers, when a family member calls

21 to say I don't release information to talk to you

22 so I'm not blah, blah, blah. But the reality is


63

1 is what they don't know. You know you can listen

2 to anybody talk about anything and you just can't

3 promise to keep it a secret. You know it's like

4 so you know but there are ways to effectively

5 work with family that can help the care of the

6 veteran and the care of the family, which is

7 sometimes the whole -- the patient is the family

8 sometimes.

9 So that's an important point, I think.

10 And doing work, concentrated training on that

11 across the system might be very beneficial. So

12 that's just some potential recommendations for

13 Part A.

14 Any questions? Any more questions on

15 that?

16 Okay, then Part B, I don't have a lot

17 for Part B because there wasn't a ton of

18 participants with this but potential

19 recommendations for Part B could include

20 addressing barriers that contribute to a lack of

21 knowledge related to eligibility.

22 So I think the complexity -- the


64

1 complexity of the eligibility system does not

2 allow for the veteran to advocate for themselves

3 in a lot of situations because there's so many

4 different rules and subparts to those rules and

5 you can't effectively advocate for yourself with

6 it -- usually the help of a VSO or something like

7 that. So and that's where a lot of veterans kind

8 of boil over is in the eligibility process.

9 So dealing with eligibility issues and

10 making it streamlined, less complex, so they

11 better know what they're entitled to when they

12 walk in, would be a lot -- a lot better.

13 And then improvement of coordination

14 of care between community care contracted

15 providers and VA treatment teams. I think it's

16 harder to coordinate the care. So I don't know

17 if there's a recommendation coming on care that

18 veterans privately paid for. It's easier if --

19 but we could improve -- I mean we could improve

20 that but I think that's a bigger leap but we can

21 improve at least the community care that we pay

22 for and improve how we coordinate that.


65

1 And I think with the rollout of the

2 MISSION Act, the problems only become a little

3 bit more acute. It hasn't really gotten better

4 because now we have a lot more records coming in

5 and that's being unevenly kind of dealt with,

6 depending upon the system that you're in.

7 So I think there could be a good

8 recommendation around how to coordinate the care

9 between community providers. And right now you

10 know if a veteran has a suicide flag, or if they

11 have a behavioral flag, or if they have any of

12 these things, the community providers are in the

13 dark with that stuff. So they don't know really

14 what's walking into their office and that can be

15 a big issue in the coordination of care, as well

16 as if they discover something.

17 Like we have veterans that get

18 hospitalized but we're get notified but the

19 provider won't get notified. So how do they know

20 in their next session?

21 These are all important gaps that

22 exist under the current MISSION Act rollout and I


66

1 think it's important to kind of address some of

2 that. Potentially you know there could be a

3 recommendation on that.

4 Any questions around that?

5 Part C is to address lack of

6 uniformity between VAs related to the same day

7 access and walk-in processes. So I know that the

8 VA I think has done a great job with rolling out

9 same day access and providing models that VAs can

10 implement. That doesn't mean that they always

11 implement it in the same way. And so addressing

12 lack of uniformity between the VAs because that

13 lack of uniformity, in some ways -- you know I

14 don't mean to make it overly simplistic but I

15 know that when I go to McDonald's in Washington,

16 D.C. or if I go to McDonald's in San Francisco,

17 I'm getting the same chicken sandwich. You know

18 it's like and I go about ordering that chicken

19 sandwich in about the same.

20 So VA is a chain, like any other, you

21 know in some senses but it doesn't behave that

22 way. You order a chicken sandwich in Sacramento,


67

1 it's going to be different than that chicken

2 sandwich in Dallas. So changing that and trying

3 to come up with better uniformity around a lot of

4 processes, especially same day access and walk-

5 in, that's important to veterans.

6 COLONEL AMIDON: Can you describe,

7 just for those of us -- is the variability in the

8 delivery of that contingent upon staffing

9 variance you know per VISN?

10 So I understand the chicken sandwich

11 example but McDonald's doesn't have staffing

12 shortages the same way VA you know in that way.

13 And I get the complexity differences but there's

14 a universal policy that was in some over-

15 simplistically mandated to say same day access

16 but in some ways it cannot be delivered. So in

17 order to address the lack of uniformity, is it

18 accepting that there will be some variance in

19 that uniformity?

20 DR. POTOCZNIAK: There has to be some

21 variance but I think that different VAs have

22 their ELTs, their Executive Leadership Teams,


68

1 have different priorities. And so VAs are

2 staffed -- so mental health is staffed in a

3 certain way, based on staffing ratio. But

4 whether VA meets that staffing ratio or not and

5 whether the ELT wants to save some money that

6 year for other things, that's up to the ELT,

7 right?

8 And so staffing-wise, that ratio, if

9 applied, would allow you to meet the same day

10 access.


12 DR. POTOCZNIAK: But if ELT, like in

13 Atlanta or whatever, decides we're just not doing

14 that, we don't -- we have bigger priorities right

15 now. And there are sometimes bigger priorities

16 if you have dermatology, and ortho, and all those

17 different services, probably think they're very

18 important also to the care of veterans. And they

19 are. So who do we meet? How do we meet all

20 these different needs? And I think ELT picks and

21 chooses how it deals with that.

22 So you know if it was staffed


69

1 correctly, same day access shouldn't be as much

2 of an issue.

3 The smaller CBOCs are always going to

4 struggle, I think, with this because their ratio,

5 they may only be staffed with one or two people.

6 That's a problem, right? But how do you meet

7 that problem?

8 And I think the Mental Health Uniform

9 Handbook, which was rolled out, you know it was

10 rolled out so long ago it doesn't address any of

11 these things because it's like 2013 or so.

12 PARTICIPANT: That's optimistic.

13 DR. POTOCZNIAK: Yes. So it doesn't

14 address, I think, a lot of the -- a lot of these

15 different things. And so I think that there's

16 ways of dealing with it in different environments

17 and I think the VA should address in smaller

18 environments, this is how we handle this, as

19 opposed to one policy that covers the whole

20 Medical Center that can't possibly be applied on

21 lower levels. If they just spelled it out, it

22 would be a little bit better.


70

1 DR. MAGUEN: And one point that I'll

2 just add to that, if you have a set number of

3 providers and you allocate their time to the

4 front door, now they're not able to do as much of

5 the ongoing therapy, right? And so I think it's

6 a constant balance in terms of how many people

7 you allocate to the front door versus ongoing

8 care.

9 And no matter -- right, there's only

10 so much of the pie you can slice to one direction

11 and have the other be left for the other piece of

12 it.

13 COLONEL AMIDON: And I agree. It

14 reveals sort of the tension of the unfunded

15 mandate, where you set a universal policy that

16 you know they are just now getting behind it. I

17 guess in some simple way where you then now have

18 to try to abide by the mandate without the

19 resources to do so or you have to manage your

20 resources in such a way.


22 MR. SPERO: To clarify something on


71

1 the same day access, is that -- so if I get an

2 appointment but I'm not going to be seen for two

3 and a half weeks because that's when the next

4 appointment is, if I don't like that, I just show

5 up because I have same day access and the mandate

6 is to care for me then.

7 DR. POTOCZNIAK: That's exactly it.

8 MR. SPERO: So to the point of the

9 front door.

10 DR. POTOCZNIAK: But so there's

11 different ways of applying same day access. John

12 could probably talk our ears off about it but I

13 won't put him in that position.

14 So but same day access can be applied

15 in the sense that okay, instead of having like in

16 my size CBOC, which is like a large CBOC, the way

17 that we apply it is we just allow for certain --

18 like, Matt, today you have an 11:00 same day

19 appointment and a 1:00. So you're not sitting

20 around all day just waiting for someone to come

21 in. And Wendy, you're going to do 9:00 and 1:00.

22 You can see patients the rest of the day but


72

1 between 9:00 and 1:00, you've got to leave those

2 open in case someone comes in.

3 So that's generally how we deal with

4 it on a lower -- on a smaller level but then you

5 still have crises that walk in. So it is hard to

6 balance.

7 The larger VAMCs sometimes have like

8 an Access Center, where someone just comes in and

9 here I am. And that's the benefit of the larger

10 center.

11 DR. MAGUEN: And oftentimes the people

12 who will go into the same day clinic, they need

13 their medications refilled urgently or you know

14 they're having suicidal ideation or homicidal

15 ideation. So I think it also varies tremendously

16 who you get walking into the same day clinic, who

17 can't wait for two weeks.

18 MR. ROSE: How -- can you talk a

19 little bit about the no-shows? Is that an issue,

20 no-shows for the appointment, or not so?

21 DR. POTOCZNIAK: Well, for same day,

22 no.


73

1 MR. ROSE: No, no, no but I'm talking

2 just appointments, for mental health

3 appointments.

4 DR. POTOCZNIAK: I think that is

5 highly variable also. I don't see as many no-

6 shows. I know that, John, there's a certain

7 percentage, right? Is it a 15 percent?

8 DR. KLOCEK: Nationally, that's about

9 where it stands, yes.

10 DR. POTOCZNIAK: Yes, so I think that

11 when they look at like labor mapping, and RVUs,

12 and all that stuff, there's a given like 15

13 percent no-show rate.

14 Now, depending on your VA -- would you

15 say that some VAs are a lot higher than others,

16 John?

17 DR. KLOCEK: It's variable. I'm not

18 sure of the range overall.

19 DR. POTOCZNIAK: Okay. So there is --

20 I mean personally, anecdotally, I've experienced

21 a range. I just -- I've seen it low in the

22 clinic but I mean I think we're smaller. But the


74

1 larger Medical Centers --

2 MR. ROSE: Okay, thank you.

3 DR. POTOCZNIAK: Yes, but 15 percent

4 is the -- is what we're allotted for no-show

5 rates.


7 DR. KHAN: If I may add to the same

8 day, for example, I have a primary care

9 appointment and I go to my primary care team and

10 they observe something in me. They refer me to

11 the mental health. In that concept, it's quite a

12 bit practiced because it's a primary care and

13 that team sees me and they said oh, he's

14 dangerous, he shouldn't walk out of the hospital.

15 He needs to see someone. So with that, the PAC

16 Team comes into contact. So that is very much

17 being practiced.

18 DR. MAGUEN: Right and that is a

19 little bit separate than the same day clinic. So

20 within the PAC Team, there is that integrated

21 care where you might see your primary care doctor

22 and they can do a warm handoff to a mental health


75

1 provider that's within the Mental Health Team.

2 But the same day clinic is also for people who

3 can just walk in without even having touched

4 their primary care provider, too.

5 But you're absolutely right. That's

6 another way in which people can be seen same day

7 for mental health with a warm handoff in a

8 different context. So I'm glad you brought that

9 up.

10 DR. POTOCZNIAK: Yes. So, gosh, where

11 am I on this now? We've been talking about --

12 MR. KUNTZ: Probably the peer

13 supports.

14 DR. POTOCZNIAK: Yes, yes.

15 Yes, so the other piece is to I think

16 there are peer support specialists that are

17 everywhere. And that's also -- I guess I

18 wouldn't say everywhere, because they are

19 unevenly rolled out. But peer support

20 specialists is a growing thing in the VA system

21 and it's been highly effective.

22 But enhancing the identification of


76

1 the peer support specialist so that veterans

2 actually can point out and see this is the peer

3 support specialist. You know right now, they're

4 kind of within mental health staff. Sometimes

5 they are in primary care. Sometimes it depends

6 on where they are. But in some ways, you should

7 be always able to pick out that's the peer --

8 like if that person walked down the hall, that's

9 the peer support specialist, whether it's

10 something they're wearing, or a tag, or something

11 like that so that veterans can easily identify

12 that person and know the person that helped them

13 was the peer support specialist, rather than

14 guess.

15 And I don't want them wearing big name

16 tags but something that easily identifies them as

17 the person, the peer veteran that you can talk to

18 about what's going on.

19 MR. ROSE: About how many times,

20 though, is the exchange where the veteran peer

21 support specialist will make that initial

22 contact? Not so? I don't know. I'm just


77

1 asking.

2 DR. POTOCZNIAK: How many times --

3 what was this?

4 MR. ROSE: You know if the veteran

5 peer support with no name tag approaches Mike and

6 whether it's in the waiting room or whether it's

7 out --

8 DR. POTOCZNIAK: Yes, that happens a

9 lot.

10 MR. ROSE: -- anywhere, I mean that is

11 a link right there, to kind of bring somebody in.

12 DR. POTOCZNIAK: Yes, it's what they

13 do.

14 MR. ROSE: Yes.

15 DR. POTOCZNIAK: But the person that

16 walks up to them, they may not know what to call

17 that person.

18 MR. ROSE: Well --

19 DR. POTOCZNIAK: Or I mean but they

20 might not know whether that is a person that can

21 be -- like they don't know the -- like if I go up

22 to a psychologist, I know what a psychologist is


78

1 going to do.

2 MR. ROSE: Yes.

3 DR. POTOCZNIAK: A social worker, I

4 know what a social worker is going to do,

5 psychiatrist. That person that walks up to me is

6 just a helpful vet.

7 MR. ROSE: Okay.

8 DR. POTOCZNIAK: That's great but

9 there's a lot more that they can do for. And

10 it's helpful to know that I can go back to that

11 person when I have another question.

12 MR. ROSE: True, true. Okay.

13 DR. POTOCZNIAK: So right now, they're

14 there but are they just a helpful person? Are

15 they an MSA? Are they -- what are they?

16 CHAIR LEINENKUGEL: That's a great

17 point, Mike. I think what you're really getting

18 to here is better branding of the role.

19 DR. POTOCZNIAK: Yes but it's

20 something the VA is very proud of. So they

21 should be happy to brand it.



79

1 DR. POTOCZNIAK: Is there any efforts

2 around that, John?

3 DR. KLOCEK: Not that I'm aware of.


5 And so also it's to utilize peer

6 support specialists to increase knowledge within

7 the network of veterans about various treatment

8 options available.

9 So I think you know if what veterans

10 are saying is they're finding out about CIH

11 treatments -- I didn't say CIH in this because

12 they can be used for any kind of treatment but a

13 lot of times peer support specialists will show

14 you how to navigate certain things. But I think

15 if they could broadly increase knowledge using

16 the network of veterans because Vet to Vet is a

17 very strong thing within the VA.

18 If I am sitting in the waiting room

19 talking to Jake, you know I'll tell Jake oh, yes,

20 that was a really good doctor, blah, blah, blah.

21 And peer support specialists do that but they

22 also can enhance like did you know we've got


80

1 these things. And you've got that problem about

2 all these things. You know are you using those?

3 And just making that a little bit more uniformly

4 part of the peer support role.

5 And so I think the last piece of this

6 presentation is Yessenia is going to talk a

7 little bit about, just if you could for a little

8 bit, about the -- go to the slide -- there you

9 go, 13.

10 MS. CASTILLO: Sure. So thank you,

11 Commissioner Potoczniak.

12 DR. KHAN: Would you speak a little

13 louder?

14 MS. CASTILLO: Oh, sure. Sorry.

15 And just to go back to one of the

16 recommendations related to A, as you know, I

17 can't help myself --

18 DR. POTOCZNIAK: Go ahead.

19 MS. CASTILLO: -- but related to the

20 family aspect and this pertains more to Duty 5

21 but also speaks to the synergy across the

22 workgroups.


81

1 The families are usually also the

2 first people to recognize signs of suicidal

3 behavior or ideation. So it's more reason and

4 importance that it should be provided to the

5 family and caregivers of these veterans as well.

6 So I just wanted to make that point known.

7 DR. MAGUEN: Well, can I just add to

8 that? I think that one of the things that we

9 should really be thinking about and talking

10 about, too, is those -- the veterans we're not

11 reaching. And I think not only the suicidal

12 veterans but the veterans we don't even have

13 hands on and how to involve the family more and

14 just getting them into care.

15 We saw from the slides that veterans

16 are saying most of the reason that they come in

17 is because family members say to them you know

18 you have a problem or please go get help. And

19 sometimes it's sort of the last resort for the

20 veterans.

21 So I think if the family is so

22 involved and we're hearing that, then it has to


82

1 be at the front end, too, where that's how we're

2 getting to those veterans we can't touch is

3 through the families.

4 MS. CASTILLO: Absolutely. And just

5 one more thing to add, there's also caregiver

6 burnout. You know we talk about provider burnout

7 but there is also the other side of it for those

8 dealing with helping these veterans at home.

9 There is such a thing as caregiver burnout as

10 well, so providing you know greater assistance to

11 those helping veterans at home is just also

12 another reason why I strongly agree with the

13 recommendation put forth by Commissioner

14 Potoczniak.

15 DR. JONAS: Just before we get off

16 here, sort of recommendation draft here --

17 DR. POTOCZNIAK: Very rough draft.

18 DR. JONAS: A very rough draft, yes.

19 I think it would be great for the group, your

20 group to think about sort of the more meta

21 recommendation or a general recommendation that

22 might help with this, sort of like what Shira and


83

1 the evidence-based group.

2 You know we've gone through specific,

3 okay, more of this research for that. And then

4 we said you know what, there's some research

5 system issues that need to be addressed here.

6 And that goes to the point under our general

7 recommendation. It would be really helpful in

8 this scenario.

9 You know we hear over, and over, and

10 over again that there are coordination problems,

11 that we have a system with multiple factors, lots

12 of different service members based on episodic

13 models of I see you, I see you, then I go there,

14 et cetera, and it's chaotic for people.

15 And so a company that would normally

16 want to solve those problems that they do

17 routinely every single day would sit down and

18 they would design you know a coordination matrix

19 and actually address those issues. They would go

20 through the flow to see what are the routine

21 needs that occur and how can I design the team to

22 deliver that. And would probably improve the


84

1 resource -- I mean would actually access more

2 resources. It would be better spent. You'd

3 actually probably save money on those types of

4 things because it would be more efficient.

5 And so I mean we have peer support

6 people coordinating. We have navigators. We

7 have health coaches. We have, in the stepped

8 care model, you know they keep talking about

9 okay, all these different levels of care and

10 self-care being down there, and then across then

11 we are trying to get people to flow this way, and

12 all that, that's all a coordination challenge.

13 And so one of the meta recommendations

14 could be, very draft, is that you know the VA

15 really needs to do some systematic -- and also

16 then because they're standards --because we don't

17 have that, there's lack of standards, or there's

18 in applicability or there's poor applicability of

19 things that are standards.

20 So some design issues around

21 simplifying connectivity and coordination or

22 integration around mental health care I think


85

1 would be something to consider as a meta.

2 We saw several examples of how this

3 was done --

4 MR. ROSE: Iora.

5 DR. JONAS: Iora was an example

6 outside the VA but we saw several examples inside

7 the VA where they did a really good job of it.

8 You know when I walk into my hospital

9 where I see patients every day, there is a

10 greeter at the front door. And they're friendly.

11 They're knowledgeable. And you know if I ever --

12 I use them. I work in the hospital and I'll say

13 you know where do I get this and that. And they

14 will know exactly, and they will show you, and

15 they'll take you there. And that was set in

16 because there was a design problem, in terms of

17 navigation, when you walked into the hospital.

18 That's just one of the design issues.

19 So anyway, that general design

20 coordination around that to increase the

21 efficiency of the integration across the services

22 I think might be something to think about.


86

1 MS. CASTILLO: I would just add to

2 that if you also include then the whole health

3 model with that and looking at the social

4 relationship, it goes back to the family. They

5 should be considered part of that coordination.

6 DR. JONAS: Well, there's whole

7 community services that are huge, okay, and yet

8 those don't get coordinated very well either,

9 except in certain places.

10 I mean we saw down in Phoenix you know

11 around the community around the homelessness, and

12 the food, and everything. They had a tremendous

13 coordination system and community support. I'm

14 talking the community was embedded in it and they

15 were providing it. So there are some great

16 examples even within the VA.

17 MR. ROSE: And you even had -- we had

18 examples of law enforcement that were included in

19 that.

20 DR. JONAS: Exactly.

21 MR. ROSE: And they have access and

22 they can really be a contact for maybe some


87

1 people that aren't even in the VA. They are a

2 veteran but they get to know them and they may be

3 another source.

4 MS. CASTILLO: Well and we know that

5 the veterans that have a strong social support

6 network also adhere to the treatment better.

7 They have better health outcomes, better

8 adherence rates. So it's just -- I'll get off my

9 soapbox now.

10 But related to the data source for

11 Duty 2, the spreadsheet in front of you lists the

12 different data sources on the left-hand side,

13 they type of analyses associated with it --

14 CHAIR LEINENKUGEL: Just -- I

15 apologize but just because of time, we're 25

16 minutes over and this was extremely important.

17 It's very valuable. Mike, just a terrific job.

18 But rather than go through the whole

19 list, as chairman, I'm going to note that there

20 are some items on every one of these that the VA

21 or other folks owe us.

22 MS. CASTILLO: Yes.


88

1 CHAIR LEINENKUGEL: Okay. What I am

2 recommending is that the support staff that owns

3 this and the VA person, if there's not an

4 assigned person to each one of these asks, I want

5 an assigned person by Monday. Okay, today is

6 Friday. So by close of business -- and I'll

7 throw that to John and to Casin to work with our

8 partners in here to assign who is going to be

9 held accountable for getting this information and

10 when are they going to get to Mike, and his team,

11 and to you to complete this.

12 MS. CASTILLO: Thank you. That is a

13 great summary of --

14 CHAIR LEINENKUGEL: So I just rather

15 want to speed things up because there's a lot of

16 things on this eye chart that --

17 MS. CASTILLO: Yes, that's the perfect

18 summary, Chairman. Thank you.

19 CHAIR LEINENKUGEL: -- would be --

20 they're all nice to have. There's a couple of

21 things in here that I think that Mike and his

22 team feel are essential at this point in time.


89

1 And so let's do it that way.

2 Casin, while you are walking back, I

3 just assigned you and John a major task in the

4 next 72 hours.

5 Everybody good with that, as far as

6 the commissioners, with that direction?

7 DR. POTOCZNIAK: Thank you, everybody.

8 CHAIR LEINENKUGEL: And, Mike, that

9 was -- compared to 30 days ago, where you were at

10 --

11 DR. POTOCZNIAK: Compared to last

12 night.

13 (Laughter.)

14 CHAIR LEINENKUGEL: It's an

15 unbelievable amount of really good synopsis,

16 condensation of some of the hot topics with what

17 we thought was going to be something that was

18 going to be very difficult to do, if not

19 impossible.

20 And you came up with an alternative

21 method. I think that the methodology used, and

22 the support team, and the people that you


90

1 recognized, just did a terrific job in a very

2 short amount of time to get to what I think are

3 going to be some great recommendations coming

4 forward. So thank you.

5 DR. POTOCZNIAK: Thank you. Thank you

6 to everybody that's doing -- that's out there in

7 the field doing it. They're doing all the work.



10 CHAIR LEINENKUGEL: With that, we will

11 take a 15-minute break. It is 10:25. So let's

12 restart at 10:40. So those on the phone, we'll

13 go to mute and just stand by. We'll be back on

14 live at 10:40. Thank you.

15 (Whereupon the above-entitled matter


17 10:40 a.m.)

18 CHAIR LEINENKUGEL: Okay, 10:40 a.m.

19 Eastern Time and we are back on the COVER

20 Commission open session. We just finished with

21 Mike Potoczniak and his workgroup to update.

22 And at this time, we're going to


91

1 transition to Commissioner John Rose with

2 Workgroup 4. Commissioner Rose.

3 MR. ROSE: Thank you very much, Mr.

4 Chairman. Welcome all those that are onboard

5 today and thank you for the team that makes up

6 Group 4 here for our Commission.

7 The Duty 4 is to study the sufficiency

8 of the resources of the VA Department to ensure

9 that delivery of quality health care, health

10 issues among veterans seeking treatment within

11 the department. And our workgroup membership

12 includes Matt Amidon, Jake Leinenkugel, Jamil

13 Khan, Thomas Harvey. And I serve in the capacity

14 of leader.

15 At this time, before I get started, I

16 will ask Matt if he would like to say anything,

17 since he is in charge of both 4 and 5. Let's go

18 to you.

19 COLONEL AMIDON: Thank you, Jack. No,

20 I appreciate that. I think what's interesting

21 about Workgroup 4 is how the

22 definition/identification capture of data


92

1 supporting our sufficiency is sort of universal

2 to a lot of the other workgroup objectives as

3 well. I know we've had some good intellectual

4 conversations on how to define sufficiency and

5 interested also to hear on the data capture and

6 support of that definition, sort of how each VISN

7 is organizing and managing the demand signal and

8 supply of resources relevant to the demand signal

9 but I appreciate the hard work.

10 MR. ROSE: Okay. Well, we've got a

11 great crew that's doing it, getting it done, and

12 I appreciate the support staff.

13 So for the public out there, we're

14 using the Quadruple Aim model. And so what does

15 that mean? And so there are basically four parts

16 of that and the first one being the experience of

17 the veteran.

18 And so I think we've heard different

19 members of the Commission talk to that, that as

20 we go forth with respect to mental health and any

21 related issues, we should be focusing on the

22 effect on the veteran. And Dr. Jonas talked


93

1 about that, as far as the style of treatment, in

2 his presentation but we really need to focus on

3 the veteran and we need to listen to the veteran.

4 And I think, as we go through dealing

5 with mental health, we are all individuals and I

6 think we are getting to a point in our mental

7 health care that, instead of a medical mandate,

8 we are listening to how the prescribed treatment

9 is working out.

10 So if you look at treatment in laymen

11 terms, I think of it as a three-part process.

12 You have a medication part and that is in

13 different levels, depending upon the individual.

14 I think you also have a therapy part that can be

15 key, depending upon what that mental illness is.

16 And then the third part, which we've talked about

17 quite a bit is the whole person, the CIH model.

18 And as we go forward, we are going to see a role

19 for CIH in the treatment of our veterans and it's

20 key. And I think as Dr. Maguen pointed out, it's

21 maybe not so much as a CIH, complementary and

22 integrative health, the models that you have gone


94

1 through, the modularity, and with respect to how

2 it may be coordinated with another type of

3 treatment. And it may not always go into each's

4 but a combination. And I think the effort that

5 has been taken with looking at the research and

6 just seeing what's available out there and is it

7 an evidence-based practice or not. But that's

8 just -- it's been key to the task that we've had

9 here.

10 I think the health of the defined

11 population, that's the second part of the

12 Quadruple Aim, we have a cohort that is not so

13 well, maybe, for various reasons. They are

14 veterans. They have given the ultimate sacrifice

15 in going on deployments as different members of

16 our military services. And we actually owe it to

17 these people for the rest of their lives for the

18 duty that they've paid for our country.

19 The third part of the Quadruple Aim is

20 the per capita cost of the population and again,

21 looking at the veterans. And we've talked to Dr.

22 Klocek and there are some opportunities to check


95

1 and see what these numbers are.

2 And I think with respect to cost, Team

3 4, the whole Commission is really looking forward

4 to getting results from our ask to the VA as far

5 as how is the $9 billion that they have in the

6 budget for this year for mental health, how is

7 that going to be utilized. And I think that is

8 extremely important. I think it can help us get

9 a benchmark for what we're doing now with respect

10 to the budget and mental health. And also part

11 of that ask, but let's take it one step at a

12 time, it would be good to look back five years

13 and just see what has happened with that budget

14 and what are the results that we're getting. How

15 is this helping out our veteran? I think that's

16 a very important part.

17 The fourth part is the impact on

18 providers. And I think we've had different

19 mention. Mike has talked about it and it's the

20 potential burnout rate for our providers. And

21 it's a very serious business. It's a very

22 demanding business. And I think anytime that


96

1 you're dealing with mental health, you're dealing

2 with people that are potential suicide folks,

3 it's very, very demanding.

4 I think the way that the different

5 facilities approach this and recognizing the

6 potential burnout rate, I think this is important

7 because in the visits that we've made, a lot of

8 times you'll go in the VA, the people seem to be

9 very passionate in what they do. This is

10 important and we just need to take care of the

11 people that are providing the care to our

12 veterans.

13 Some of the things that we've done so

14 far, we have had different speakers that have

15 come and talked to us. We've had a

16 representative from the National Director of the

17 VA Office on Rural Health. We've heard a lot

18 about rural health. We've heard a lot about

19 Telehealth and how it becomes very difficult to

20 deal with our veterans that are seeking care in a

21 rural setting.

22 We also had Dr. Mike Schoenbaum, who


97

1 is the Senior Advisor for Mental Health Services

2 come in and talk about some of the research that

3 is being done by the National Institute of

4 Health. Very, very informative. And I think one

5 of the good things, and it's been I think a cost-

6 effective effort, that as we bring in speakers,

7 we, as a group, will go back, initially start off

8 with questions that we're looking for. Depending

9 on how the call goes, we will go ahead and even

10 ask more questions to that same individual and

11 it's really kind of built our body of knowledge.

12 We've had Ms. Ellen Bradley, Director

13 of Information Reporting for the Allocation

14 Resource Center. We've had this on a couple of

15 occasions. And we've also had Ms. Tonya Bowers,

16 who is the Acting Administrator for Primary

17 Health Care and Health Resources Service

18 Administration.

19 And we've talked about this and we've

20 talked about community resources, outside

21 resources that can help the VA. And one of

22 those, we've found out, is the Federally


98

1 Qualified Health Centers. And you'll see, as we

2 get to the recommendations, this is something

3 that really should be investigated because we're

4 seeing evidence that the VA may not be able to do

5 everything for that veteran. And I know it's a

6 huge organization but there are members in the

7 community out there that can help the veteran.

8 And we've got the MISSION Act that's coming out

9 and we're trying to I think do a better job with

10 our community partners out there. And we've seen

11 things in our travels that we have an outside

12 resource, maybe it deals with CIH, and we have a

13 contract with them but sometimes payment of the

14 invoice to that person that's providing the care

15 out in the community is not there. We need to do

16 a better job of it. And it can be a valuable

17 resource but we need to really recognize that

18 resource and pay for that resource.

19 Aside from the calls that we've done,

20 we've also made some trips. We've gone out

21 either the entire Group 4 or parts of it. And we

22 had an opportunity in June to go to the Captain


99

1 James Lovell Federal Health Center. Now this is

2 the first Federal Health Center VA and DoD. And

3 so it's been an opportunity to see how the DoD

4 and the VA can work together.

5 I think that's one of the issues we

6 have seen in our time on the Commission, and that

7 is the ability of somebody coming out of the DoD,

8 coming out of the Service and going into the VA.

9 I think we need to do a better job of that and

10 you can see how this large facility at -- in

11 Chicago at Lovell, how they deal with some of

12 this stuff. And so there'll be more to follow on

13 that.

14 DR. POTOCZNIAK: Is that a DoD-VA

15 facility?

16 MR. ROSE: Yes.


18 MR. ROSE: Yes, that's the first one

19 and for everybody's benefit.

20 DR. POTOCZNIAK: There's a couple more

21 now I think out there.

22 MR. ROSE: That was the first ever.


100

1 DR. POTOCZNIAK: That was the first

2 ever?

3 MR. ROSE: Yes.

4 DR. POTOCZNIAK: So they're in Hawaii.

5 MR. SPERO: So Lovell is the first

6 actually integrated system where they actually

7 have the Director is a VA employee, the Deputy

8 Director is a Naval Officer.

9 MR. ROSE: Right.

10 MR. SPERO: There's ones that are very

11 close together and linked but they have a

12 completely separate funding stream. They have a

13 completely -- they are one of a kind. I think

14 it's a ten-year implementation --

15 MR. ROSE: Yes.

16 MR. SPERO: -- and that they're not

17 all the way through yet.

18 MR. ROSE: Right.

19 MR. SPERO: So Hawaii is --

20 DR. JONAS: Same building but separate

21 operational.

22 MR. SPERO: Right, so they have


101

1 separate budgets, separate everything. So they

2 actually you know for example, they converted

3 positions from DoD civilians to VA civilians and

4 things like that. So it is still unique in that

5 way.

6 DR. POTOCZNIAK: And Monterey is --

7 it's DoD-VA also.

8 MR. SPERO: But they have separate

9 operational structures.

10 MR. ROSE: Yes. It's the first one

11 ever. And as you mentioned, or as John had, it's

12 like a ten-year deployment plan.

13 DR. JONAS: There's a VA Clinic at

14 Fort Belvoir, it's a VA operated by the VA. It's

15 again, operated by the VA, it sounds like.

16 MR. ROSE: A little bit different.

17 Okay. We also, part of the group went

18 to Great Falls, Montana and you had an

19 opportunity. And one of our commissioners here

20 was the host and went out there to see Great

21 Falls. And that's a huge area and it's just how

22 they have to conduct business in Great Falls.


102

1 I don't know. Matt, do you want to

2 add anything on that? I mean it was a pretty

3 unique visit.

4 MR. KUNTZ: Yes, I was really grateful

5 to the commissioners for coming. Part of what I

6 -- I know when I was appointed to this, this was

7 part of the goal was to help the Commission

8 really think about those rural veterans. And

9 then some of that means really, really, really

10 rural and just what that geographic scope means,

11 what that means for the clinicians and the care

12 system. So I was very grateful to everyone that

13 came out and also for the communities that hosted

14 us and Fort Harrison VA, as a Montanan, I was

15 very proud of how our people hosted us.

16 COLONEL AMIDON: I wanted to say thank

17 you for that. That was a wonderful learning

18 experience. And you know rural is rural and then

19 there's the frontier aspect of rural, certainly.

20 And it certainly reveals the tension of the word

21 access and realistic expectations of access,

22 depending on where you live.


103

1 But I think what was also very

2 educational was how, in terms of like your

3 previous comment on healthcare consumers, how you

4 can be a consumer of two different healthcare

5 systems in the same location that don't talk to

6 one another, sort of you know the IHS and the VHA

7 interactions. Some of the folks living up on the

8 reservation who can partake of IHS in some ways

9 but not VHA.

10 Maybe you can allude to some of that

11 but it was very --

12 MR. KUNTZ: And that hospital was

13 funded as a Critical Access Hospital, which is an

14 entirely different pot of federal money. So I

15 mean it is difficult for a lot of different

16 folks.

17 And I think it was nice to see from

18 the VA staff that they were very clear that,

19 what, 25 percent of our care is in the community

20 and it's not realistic to ever try to bring that

21 in. It's just something that we have to work

22 with the community partners to make sure that


104

1 it's done in the best way possible and to make

2 sure that the interface is as easy as possible

3 for the veterans to navigate.

4 DR. POTOCZNIAK: But at the same time,

5 what -- I think what we learned is that there's a

6 lot of times when people say well, we can't.

7 It's so remote or it's so whatever, we can't

8 possibly provide X or Y. And what we learned, I

9 think, by going to the reservation, which was the

10 remotest place I've been in a long time, is that

11 really what was lacking was not the desire by the

12 veterans to receive care at the VA but the

13 information and relationships necessary to

14 connect them.

15 There were simple things like $2

16 solutions, you know what I mean, that would have

17 changed their lives and that was lacking. And

18 despite, I mean Montana is -- Montana has -- I

19 think it was an amazing VA. There were some

20 simple solutions that would have made a world of

21 difference, like if they had rolled out -- this

22 speaks to the lack of uniformity, which I don't


105

1 want to highjack with, but the lack of

2 uniformity.

3 Had they employed the Peer Support

4 Program effectively in that VISN, because they

5 don't. It's funny that was the birthplace, I

6 think, of the Peer Support Program and yet, in

7 Montana, like if you have two peer support

8 specialists sitting up in Havre, like that would

9 have made all the difference in the world to

10 those veterans. They would have had probably

11 adequate care from the VA.

12 But it's those little solutions that

13 we're lacking and that's not Montana's fault.

14 You know that's --

15 MR. KUNTZ: Well, and I think it shows

16 that you know if you're in a resource-poor

17 environment, the ability for management to take

18 on -- you know it's just they end up dealing with

19 today's problems instead of taking care of things

20 that may be a long-term fix.

21 MR. ROSE: Right. It's just you have

22 limited -- you have to put the fires out before


106

1 you can really do this other stuff.

2 MR. KUNTZ: Instead of taking care of

3 the forest.

4 MR. ROSE: Right, the forest and the

5 trees.

6 That brings up an interesting point,

7 though, about the peer support or it sounds like

8 kind of a lack in Montana. But I think we, as a

9 Commission, have seen the importance of peer

10 support specialists throughout all our calls,

11 throughout all our visits. And I think, as we

12 get into the recommendations, I think it really

13 needs to be a point that, as Wendy says, we need

14 a verb at the beginning of that recommendation

15 but we need an implementation, a continued

16 implementation of the veteran peer support

17 specialist.

18 And I think if you look back

19 historically, there was a huge movement towards

20 veteran peers support specialists a while back.

21 And when that occurred, the road block, and I

22 think the guides might have been well, we need a


107

1 thousand peer support specialists. And to this

2 day I think, I don't know, we have 800. John,

3 you may know a better number than that, ballpark.

4 DR. KLOCEK: I don't know the number

5 offhand but the original hire was 800 --

6 MR. ROSE: Eight hundred.

7 DR. KLOCEK: -- and it's gone up since

8 then.

9 MR. ROSE: Yes, but the initial

10 problems with that is they didn't have the proper

11 certifications for the veteran peer support

12 specialists. And this was not unlike what was in

13 the civilian side, too.

14 Peer support specialists are really a

15 tremendous link to the glue that can hold us

16 together but there was a problem outside and

17 inside with respect to the certification. And I

18 think that that has been corrected.

19 So I think, once again, we need that

20 veteran peer support specialist in many, many

21 different roles. We really do.

22 CHAIR LEINENKUGEL: Jack, if I may.


108

1 It's a great opportunity to go on the record.

2 And some people that know me from a couple of

3 years ago know that I became very excited about

4 learning that we are discharging 10,500 Medic

5 Corpsman docs every year and we're capturing less

6 than one percent of them into a VA healthcare

7 network.

8 So there has been a joint VA-DoD

9 partnership to try to correct that. I don't know

10 where it sits right now but again, John, you may.

11 But I think it's a huge opportunity to

12 utilize that stream on an ongoing basis, not just

13 for ICT, intermediate care technicians in a

14 clinical sense, but also peer support. You know

15 whether or not they've had issues dealing with

16 their time in service, to me, is something you

17 know a clinician could answer with a peer support

18 role.

19 I think having a Navy Corpsman doctor,

20 Army doc, somebody like that come into the

21 system, be trained up, certified, and have the

22 opportunity to continue their education and


109

1 training to further develop their career using

2 the GI bill at the same time because the majority

3 of them are still young and they're looking for

4 something. And if we want to really aggressively

5 make a new recommendation, I think that this

6 Commission has the opportunity to explore that

7 avenue as well.

8 DR. POTOCZNIAK: Well, let me go one

9 step further on that because we do have, I would

10 say, like probably in the thousands range of

11 behavioral health -- behavioral health -- they're

12 kind of like behavioral health medics,

13 essentially, that are Army, Navy -- I don't think

14 the Coast Guard has one but there's tons of them

15 and they're all enlisted techs. They are the

16 behavioral health side of the medic kind of role.

17 And so they're all trained and

18 certified through the Army or the AIT but the

19 problem you know similar to bringing medics in

20 from the DoD side to the VA, where there is a

21 certification problem and a licensure problem,

22 you have a problem where they -- and it's self-


110

1 imposed. The peer support specialist has to have

2 had a mental health experience and have recovered

3 to be in that role.

4 And so I just go on the record to say

5 you know that seems to be -- I'm not sure if

6 having that experience is as important as the

7 training that some of these veterans have had,

8 which is deploying as a behavioral health

9 specialist to Afghanistan, Iraq, and be trained

10 in AIT for six months, which is bigger and much

11 longer than the VA certification.

12 CHAIR LEINENKUGEL: Thanks for

13 responding to my concern.


15 CHAIR LEINENKUGEL: I asked for a

16 clinician's take on it. So, thank you.

17 And Shira, would you agree with that

18 as well, in that context?

19 DR. MAGUEN: Yes.

20 CHAIR LEINENKUGEL: I mean would that

21 type of person be able to get into that peer

22 support role without the way we currently


111

1 classify the requirements?

2 DR. MAGUEN: Yes, I think that there's

3 no question that those folks are being

4 underutilized and can be a very effective part of

5 the system.

6 And not only -- you know not all of

7 them want to necessarily serve in that role but

8 there are other roles that they could potentially

9 serve in. They have you know a larger view of

10 the system.

11 So in addition to this role, I think

12 we need to think creatively about what are the

13 other roles we can utilize them in as well.

14 MR. KUNTZ: And I guess, from my

15 perspective, would NAMI have been, you know part

16 of helping build peer support in Montana as a

17 type of care?

18 And I also served as a mental health

19 tech. That was one of my first jobs out of the

20 Army at a residential treatment center. And I do

21 think both of you are spot on that those are

22 needed and they may be different roles. One may


112

1 be a care, you know just be able to serve.

2 Anything to make that clinician's life easier and

3 make them want to stay in the VA and have those

4 patients get the access.

5 I mean critically essential and peer

6 support is critically essential. We're not

7 talking about the highest paid employees. You

8 know I mean I do think we have room for both

9 tracks.

10 MR. ROSE: I think one thing to go

11 with Matt, I mean if you look at a veteran peer

12 support who is in recovery, I think that goes a

13 long way with somebody that you're trying to get

14 into recovery because I think they bring their

15 experience to the table. And I think it can be

16 very effective because -- for many reasons.

17 You can show that individual how to

18 navigate the system. We've talked about that

19 this morning. It can be an issue. We can

20 improve that. But I think it also shows the

21 person that -- the veteran that they're bringing

22 through, what a recovery can do. And it can


113

1 happen.

2 And I don't care if it's a mental

3 health. Many times now you see a dual diagnosis,

4 a co-occurring. You've got some type of

5 addiction plus you have the mental illness.

6 Chicken or egg, what came first, whether it's

7 self-medication. But I think you can show that

8 veteran that recovery is possible.

9 And I think the recovery piece of

10 this, I think it's very important. And you talk

11 about the CIH and you talk about helping the

12 individual get a better quality of life, that

13 veteran get a better quality of life. And it's

14 extremely important to do that because he or she

15 may be on a recovery that may be the rest of

16 their life. But if you can show them and give

17 them some hope that they will be able to have a

18 full life, I think that it just really goes

19 extremely far.

20 CHAIR LEINENKUGEL: Any other comments

21 on that?

22 DR. JONAS: I just had a question.


114

1 You said, Jack, that we need and your draft

2 recommendation here is increase the number of

3 veteran peer support. And that's sort of

4 assuming that the current roles are adequate. We

5 just need more of them, increase the number.

6 But you said -- you made a comment

7 saying in many roles. And we've talked about

8 many roles. And so I'm wondering if there needs

9 to be -- the VA needs to reexamine what is the

10 role of peer support specialists, especially if

11 we're trying to transition to a different model,

12 which is not the current model where we've got

13 all these different roles. We have that one, now

14 you need to hire somebody else, and a mental

15 health person has to have these qualifications.

16 MR. ROSE: Right.

17 DR. JONAS: And so I mean redefining

18 what is the role. What actually does the peer

19 support person do and what kind of

20 qualifications, page, training, experience that

21 they need may be something that should be a

22 component in there. It's more than just say


115

1 increase the number.

2 MR. ROSE: Right.

3 DR. JONAS: It's saying define it in

4 a way that can provide a better access, better

5 integration, you know more maximum components.

6 I mean a lot of the medics that I have

7 worked with are highly trained in the DoD. And

8 when they're deployed, they're doing tons of

9 stuff. They come back and they go in the clinic

10 over here and they're taking blood pressures and

11 they're going what the hell is this. Okay? They

12 don't want to do that anymore.

13 MR. ROSE: Yes.

14 DR. JONAS: And I think if they were

15 in the -- if they were then asked by the VA well,

16 why don't you come be a peer support person, they

17 would look at the current role that we see and

18 many of them would say no, I can help do

19 navigation. I can be a coach. I can actually

20 you know do some treatments.

21 So I guess the question is what is

22 sort of the role, given that we're trying to


116

1 increase the integration components across the

2 system.

3 MR. ROSE: Matt.

4 MR. KUNTZ: One challenge is trying to

5 make sure that we line up with what the licensing

6 is at the state level and what the certification

7 because if you create a weird niche that doesn't

8 fit in, that person doesn't have a track for

9 promotion. That person can't switch systems.

10 The nice thing about peer support, as

11 it is now in the VA, is they can walk across the

12 street and work somewhere else. And I think

13 there's room for doing that with the medics and

14 there's room for doing that with the behavioral

15 health folks.

16 But if we walk too far away from state

17 licensing, we're creating a dead end position

18 that only works in the VA.

19 DR. JONAS: Yes, and if we're also

20 going to provide care in community centers and we

21 want them to have the same quality of care, then

22 maybe the state thinks they can figure out how to


117

1 provide a better quality of care, if they want to

2 take care of veterans. I mean so you know --

3 DR. POTOCZNIAK: I think the thing

4 that --

5 DR. JONAS: I hear you. For the

6 individual, that may be a problem.

7 DR. POTOCZNIAK: Right. I think the

8 thing that I would just caution you guys about

9 with the recommendation is increasing the number

10 of veterans' peer support specialists without

11 uniformity and clear identification is kind of a

12 -- it's a road to failure at the VA because VA

13 knows how to throw resources at something but not

14 uniformly.

15 And so if you go to different VAs --

16 well I mean we've been to different VAs. But if

17 you go to a variety of them, I mean Wendy's

18 probably been to the most, you're going to see

19 peer support specialists doing admin work because

20 they're understaffed. And so you know so

21 frequently, and this happens in DoD all the time,

22 is they take the behavioral health person, you


118

1 know the tech or the peer support person, and

2 because they have a lack of resources, they say

3 well, you do this. And then more tasks get added

4 on to them that they're actually now not doing

5 peer support anymore. They're just an admin

6 person.

7 And so you grow more resources. For

8 the VAs that are using it in an inefficient way,

9 you're just adding more --

10 MR. ROSE: Inefficiency.

11 DR. POTOCZNIAK: -- inefficiency but

12 you have to get them uniform on how they're using

13 them and make sure that that's actually

14 happening. Otherwise, you're just going to

15 contribute to a broken system and you'll have VAs

16 with a flourishing peer support program next to a

17 VA that has front desk people.

18 MR. ROSE: Good point.

19 CHAIR LEINENKUGEL: You know to that

20 point, I think that we've seen at least two very

21 effective VA systems in our travels in site

22 visits, where peer support, I don't know if it's


119

1 properly defined as far as their role but it

2 appeared to be but we never saw the job

3 description and the actual day-to-day duties. So

4 maybe that's a pull out going back to Palo Alto

5 area, Tampa area for you to do, Jack, and your

6 team.

7 MR. KUNTZ: Tampa didn't use a lot of

8 internal peer support. The interesting part of

9 them was they relied on the community to provide

10 the peer support. So it was a slightly different

11 model.

12 DR. POTOCZNIAK: Whereas, like San

13 Francisco has like one of the most robust, I

14 would say, peer support programs that I've ever

15 seen. Even I think their goal is to have two in

16 each CBOC by the end of whatever period, which is

17 pretty intense. That's much more than most

18 places.

19 Palo Alto has got them and there's a

20 lot of places that do. Denver had a ton and then

21 all of a sudden now they don't.

22 So it's interesting to see like why is


120

1 there a change. Why does Montana only have two?

2 We didn't even meet them. So and yet, they could

3 be doing such great things. So how are they

4 being utilized that we didn't even meet them?

5 DR. MAGUEN: And I just want to add

6 one more thing to add on to Mike's point about

7 caution, I think, in adding more peer support

8 specialists. So these are individuals who are,

9 in many cases, doing very intensive work. So the

10 support structure has to be there. So if you add

11 more peer support specialists to make sure that

12 they're getting you know adequate supervision,

13 that their needs are being met, too. They have

14 their own lived experience and can get triggered

15 and there are other issues, too.

16 So I think we have to be aware of the

17 net that is there to support them and if you know

18 the supervisors are already being stretched thin

19 and you add more and more peer support

20 specialists, now they're not able to take care of

21 the people who are taking care of the veteran.

22 So I think that that's a critical


121

1 piece that we can't lose sight of. If you create

2 more peer supports, you have to --

3 MR. ROSE: Create the whole system.

4 DR. MAGUEN: Absolutely. You have to

5 fill in the whole system behind them as well.

6 DR. KHAN: If I may add to it.

7 MR. ROSE: Hang on just a second.

8 Are you through?

9 DR. MAGUEN: Yes.

10 MR. ROSE: That's it?

11 DR. KHAN: The target is mental

12 health. So our target is within mental health.

13 We want to improve the veteran who is coming into

14 that building. And at present, the peer support

15 specialist is a bridge between that veteran and

16 the higher staff. That's why wherever we used

17 it, those peer support specialists were in mental

18 health clinics. They had like two peer support

19 specialists taking care of some 1800 veterans.

20 So given that side, that peer support

21 specialist is very much defined. Their job is

22 defined. Their role is defined. And within


122

1 mental health, that peer support specialist is

2 not doing admin job. They work with the veteran.

3 They work with the family. They even work with

4 Vet Centers. They go across the board.

5 So what I'm sharing with you is I'm

6 the one who wrote the recommendation and their

7 role should be -- at present I think they go as a

8 V and G7 or something like that.

9 DR. POTOCZNIAK: GS-9 is the highest.

10 DR. KHAN: The highest. My

11 recommendation was that they should be given

12 management within the mental health higher than

13 nine, so there is more motivation for them to

14 stay in.

15 DR. POTOCZNIAK: I think they're

16 working on that, actually, Jamil. I think that's

17 actually already a thing that's happening is

18 they're trying to get a GS-11 supervisor for peer

19 support. So I think that's already happening.

20 One other piece -- I don't mean to

21 pull wrenches for you.

22 MR. ROSE: No, go ahead.


123

1 DR. POTOCZNIAK: Another -- because I

2 really strongly believe in peer support and I

3 think we should increase the numbers. I want to

4 be really clear about that.

5 MR. ROSE: Yes.

6 DR. POTOCZNIAK: But I can't echo what

7 you're saying enough about having infrastructure

8 in place. But also, the peer support specialists

9 serve in an outreach role.

10 Now in a clinic, where you have a two-

11 or three-month wait for therapy, if you throw

12 more outreach into the community, guess what

13 you're going to have?

14 MR. ROSE: You're going to have --

15 DR. POTOCZNIAK: You're going to have

16 a system that's going to fail you know in the

17 sense that you're going to be pulling people in,

18 only to find out that we can't actually

19 accommodate you.

20 So while peer support can serve as a

21 bridge and they actually can provide a holding

22 place while patients are waiting, they can


124

1 provide peer-to-peer support, which is what they

2 do best but there has to be something on the

3 other end.

4 And so in thinking about that

5 recommendation, you might think about these

6 aspects of it. And those other aspects may be

7 covered in other slides.

8 MR. ROSE: Well I think you know in

9 the discussion and some of the recommendations

10 we're seeing, I think that's the process we're

11 going through right now.


13 MR. ROSE: And you're getting a pot of

14 recommendations and we need to go ahead and sort

15 through these and see what fits and what doesn't

16 fit. But I think that -- I truly believe that

17 the veteran peer support specialist has a role

18 and maybe we really need a better definition of

19 what that person is doing but -- I don't know.

20 More to follow on that, really, and I appreciate

21 your input.

22 Wendy, yes.


125

1 DR. LaRUE: The sorts of things that

2 you were talking about would potentially be the

3 implementation for a broadly stated

4 recommendation like that. The implementation

5 could say and they must have adequate supervision

6 and so forth.

7 MR. ROSE: Right.

8 DR. LaRUE: So just keep that in mind

9 as you're thinking -- moving forward to that

10 deadline next week.

11 MR. ROSE: Okay. We will not forget.

12 We will not forget, Wendy.

13 CHAIR LEINENKUGEL: Also, it would be

14 very helpful to remember what Wayne said as well.

15 I think that there has to be uniformity. It goes

16 back to, Mike, your issue that you brought up

17 earlier this morning is uniformity, so that that

18 role actually has a standard uniform model and is

19 guided that way throughout the system.

20 MR. SPERO: And I was just looking at

21 my site visits for Chicago the other day and I

22 think that the mental health leadership there


126

1 echoes Mike's point, where he said I love my peer

2 support specialists but if you give me any salary

3 for one employee and tell me I can hire a mental

4 health care provider or peer support specialist,

5 because of the staffing reality of his facility,

6 right now, he's always going to go with that

7 mental health care provider.

8 So that I mean says something there,

9 where he said I love the program but, at the end

10 of the day, I have to get appointments done.

11 MR. ROSE: Right, the bureau dollars

12 come from the appointments and peer support

13 specialist provide counters but they don't

14 provide our views.

15 DR. JONAS: And that's the problem

16 with the way the system is designed.

17 MR. ROSE: Okay.

18 CHAIR LEINENKUGEL: I think that adds

19 to your recommendation. Wendy, if there's a

20 chance to flag that as an implementation part for

21 -- I know that that had come up before for VERA

22 dollars for peer support specialist.


127

1 MR. ROSE: So be it, right?

2 Okay, anybody else on peer support

3 specialist?

4 COLONEL AMIDON: Well and I think it's

5 important that as we describe these

6 recommendations, we tie back to our observation

7 of how this recommendation can impact our

8 definition of sufficiency.

9 MR. ROSE: Right. Okay.

10 One other thing, as we go through this

11 and I think it sure has been a big help to our

12 analytical plan and shortly, we'll get --

13 Yessie's going to go through that. We'll go

14 through the bullets and it's quite detailed. But

15 I mean you helped with getting us the questions.

16 But before we get to that, we'll go

17 through the working list of recommendations that

18 we will be improving as we go forth.

19 But we've talked at length about

20 increasing the number of veteran peer support

21 specialists employed in the VA. We're trying to

22 mandate a VA suicide prevention protocol and I


128

1 just have a comment there.

2 As we made our different visits and

3 had our different calls, that this particular

4 thing about VA suicide prevention, there was one

5 point that was brought out that the VA developed

6 a safety plan and it was based on a Barbara Brown

7 from Columbia University. And it should be a

8 requirement. We have the plan right now and it's

9 been set up as a recommendation only.

10 And so as Matt gets into more on the

11 suicide piece, I mean you have a prevention plan

12 that's based on science, that works and it just

13 needs to be made a requirement within the VA.

14 DR. MAGUEN: Can I ask just a quick

15 follow-up?

16 MR. ROSE: Yes.

17 DR. MAGUEN: So we do have a suicide

18 prevention protocol. And so that exactly is

19 based on the Columbia screener that is done with

20 every patient that comes in.

21 MR. ROSE: Right.

22 DR. MAGUEN: And then a number of the


129

1 safety plans. So there's a number of documents

2 that every clinician -- it's a cascade.

3 DR. POTOCZNIAK: And a certain amount

4 of visits.

5 MR. ROSE: And so a follow-on?

6 DR. POTOCZNIAK: Yes, so there's like

7 four visits in a week, six visits, I don't know.

8 DR. KLOCEK: When the client is

9 activated, it's four visits within 30 days but

10 the flag is sustained. It's one visit every 30

11 days.


13 DR. KLOCEK: A safety plan has to be

14 in place after seven days, either before or after

15 the activation.

16 DR. MAGUEN: And usually, I mean if a

17 clinician can do the safety plan in that moment

18 with a Columbia's positive, generally they will

19 do that. They don't want to let a patient leave,

20 oftentimes, without a plan in place.

21 So I think -- I don't know if you're

22 thinking about specific things that might be


130

1 missing from the protocol that already exists.

2 MR. ROSE: Is it being utilized

3 throughout the VA?

4 DR. POTOCZNIAK: It is.

5 DR. MAGUEN: So yes, we had to do --

6 it was mandated every provider had to do a

7 training, actually quite recently, because they

8 shifted to doing the Columbia and it had a bit of

9 a different protocol. There was a prior protocol

10 before but it was shifted more recently. Every

11 provider had to do a mandated training and knows

12 -- prove that they have to know how to do the

13 protocol if they are seeing patients.

14 DR. POTOCZNIAK: So in every VA, if

15 there is one thing that the VA is, I would say

16 one of the most uniform things about the VA is

17 the suicide prevention protocol --

18 DR. MAGUEN: I agree.

19 DR. POTOCZNIAK: -- because there are

20 social workers and psychologists who their job is

21 -- in most cases their job is not clinical but

22 their job is to literally review charts and flags


131

1 every day and then people that are having issues,

2 as they emerge, they are in the clinic, even some

3 of the smaller clinics, and they will highlight

4 that person and say now you need to -- they will

5 literally come into your office. It's always a

6 bad morning when Anne's in my office but you know

7 she's like you have to do the suicide plan.

8 And I've seen this very uniformly.

9 Like I haven't seen a VA where this is not done.

10 And that specialist will come into your office

11 and just hey, you have got to do the safety plan;

12 make sure you get that in today.

13 DR. MAGUEN: And I would add, in

14 addition to that, we've talked a little bit about

15 this here, but there is a whole protocol that is

16 done on the other end of things called a REACH

17 VET, which is the analytics. And if your vet is

18 identified as a high-risk vet, you have to inform

19 that vet about that and have a conversation as

20 well.

21 So there's multiple things in place

22 that are both at the clinician end and the back


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1 end that kind of speak to this point here. So I

2 would say if you think that there are things that

3 need to be modified or changed, I would call them

4 out specifically and you know I think that would

5 be the way to go if you're going to go with that

6 kind of recommendation.

7 MR. ROSE: And the follow-on, is that

8 a problem with that?

9 DR. MAGUEN: It's a very clear

10 mandate.

11 MR. ROSE: Okay.

12 DR. MAGUEN: And they're flagged. So

13 their charts are flagged, as John was mentioning.

14 So until that flag is taken off -- once that flag

15 is taken off, then it goes back to a different

16 protocol. But the minute that the person is

17 flagged for high risk --

18 DR. POTOCZNIAK: They are being

19 monitored.

20 DR. MAGUEN: -- monitored --

21 DR. POTOCZNIAK: Okay, like heavily.

22 DR. MAGUEN: -- by the suicide


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1 prevention coordinators as well. So there are

2 eyes on that chart. There are eyes on that

3 treatment from multiple levels, both at the

4 clinician and as well as the suicide prevention

5 coordinators.

6 DR. POTOCZNIAK: Yes, and there's, you

7 know as far as there's a protocol that if a

8 veteran doesn't show up for a scheduled

9 appointment, for one of the four scheduled

10 appointments, there is a welfare check done at --

11 basically within a certain amount of hours. It's

12 very prescribed --

13 DR. MAGUEN: Yes.

14 DR. POTOCZNIAK: -- and pretty rigid

15 but it is one of the things the VA, I would say,

16 is most uniform on, of all of the things that

17 they roll out.

18 DR. MAGUEN: Agree.

19 MR. ROSE: Thank you. Any other --

20 yes, Wayne.

21 DR. JONAS: Does it work? Is it

22 reducing suicides?


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1 DR. POTOCZNIAK: That I would leave to

2 John Klocek.

3 DR. KLOCEK: In terms of?

4 DR. JONAS: So is the suicide

5 prevention program, which sounds like is

6 standard, and uniform, and mandated, is it

7 reducing suicides? Is it preventing suicides?

8 MR. KUNTZ: So that is Duty 5A.

9 DR. KLOCEK: We won't know that for a

10 couple of years because of how -- essentially how

11 that data is collected and then produced. We'll

12 be able to look for those kinds of numbers.

13 You had John McCarthy on at one point

14 from SMITREC. He may have some early indicators

15 with regard to that. That may be in our previous

16 testimony in some of those areas.

17 MR. KUNTZ: Well, we were briefing

18 that in Duty 5A. That's exactly what Duty 5A.

19 DR. KLOCEK: And that's also something

20 that is monitored in a performance metric on an

21 ongoing basis.

22 COLONEL AMIDON: And to highlight some


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1 of sort of lead over from generalities of

2 Workgroup 4 on sort of the context of

3 sufficiencies that relates to some of the other

4 precise.

5 DR. JONAS: And this protocol is in

6 the mental -- it's primarily a mental health

7 function.

8 DR. KLOCEK: It's considered to be

9 across the board. Regardless of where this is

10 indicated, there are mandated questions

11 throughout the healthcare system, not just mental

12 health providers. And if those questions are

13 answered positively, there is a mandated protocol

14 that is followed in terms of screening an

15 individual for risk of suicide at that point and

16 active engagement of mental health professionals

17 as a result.

18 DR. POTOCZNIAK: Where it can fall

19 down is in primary care. I think mental health

20 has a lot of focus on it but does the LVN, or

21 LPN, or the RN actually do the screener that

22 triggers the response? That part I think can


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1 fall down because if they don't do the screener

2 --

3 DR. JONAS: So the screener is

4 required for everybody that walks into a clinic?


6 DR. JONAS: Any clinic, primary care,

7 specialist, pain clinic?

8 DR. POTOCZNIAK: Primary care, a

9 specialist. There is a primary care reminder and

10 there is a mental health reminder. So it gets

11 done.

12 DR. MAGUEN: Right, so there's several

13 layers of where --

14 DR. JONAS: And it's not just are you

15 -- have you ever thought of suicide?

16 DR. POTOCZNIAK: No.

17 DR. MAGUEN: No, no. So if the LVN

18 misses it, the primary care doc. The primary

19 care doc does a warm handoff to the mental health

20 specialist. The mental health specialist can

21 take care of it. So there's layers of protection

22 built in.


137

1 But when a person comes into the

2 system, they are screened for depression. If

3 they screen positive for depression, you have to

4 follow that up with a suicide screen or the

5 Columbia. And then there's a whole chain that

6 comes from there.

7 DR. JONAS: Right but we know that a

8 good chunk of them won't screen positive for

9 depression and then another big chunk of them

10 never see mental health or --

11 DR. POTOCZNIAK: Or they decline,

12 which they are allowed to do. And I would say

13 that if there is one issue with it is that you

14 know a lot of veterans will screen positive and

15 decline any further contact.

16 DR. JONAS: Yes.

17 DR. MAGUEN: I will say, though,

18 that's precisely why, for example, in the post-

19 9/11 clinic what we do is that three-part visit.

20 So they -- we just tell them that mental health

21 is a routine part of their care. They get that

22 three-part visit. It's normalized. And so they


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1 have to say I absolutely don't want that and very

2 few people do, once you set it up that way as a

3 one-stop shop that everyone gets. So there's

4 ways in the system to make sure that that doesn't

5 happen.

6 DR. JONAS: I know on their active

7 duty side, getting flagged is a no-go. You know,

8 if there's a possibility of getting flagged, then

9 you just don't even touch that place. You don't

10 go there.

11 On the veteran side, it's different.

12 MR. ROSE: Okay, good. Let's move on

13 here. Thank you. Good discussion.

14 The third one there is adopt a

15 recovery-oriented approach to all mental health

16 treatment in the VA and this is something we've

17 talked about. And if you look at mental health,

18 it is a recovery process. As it stands right

19 now, there is not a cure.

20 So you help an individual get so far

21 along. The follow-on treatment is important. I

22 think you're bringing out CIH modalities that can


139

1 help that individual go through the mental health

2 treatment.

3 Anybody have any comments on this? I

4 know you've talked about it a little bit.

5 DR. JONAS: Yes, I mean a recovery

6 model is very different than a treatment model,

7 although they overlap quite a bit. And so we've

8 had discussions in the models thing, even in the

9 evidence case thing about what's the difference

10 between a pathogenic disease-oriented model and a

11 healing-oriented model or a recovery-oriented

12 model.

13 It links back to the processes that

14 build resilience, that enhance wellness, the same

15 kind of thing. So I think that recommendation, I

16 think, has touched across a lot of areas.

17 MR. ROSE: Okay. Any other comments

18 on that?

19 Okay, create a robust Telehealth

20 system that takes mental health care to veterans.

21 We've talked about this, too. We can increase

22 it, utilize the technology that's out there, make


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1 it as user-friendly as possible. And I think as

2 long as we have the shortage of the prescriber,

3 which is an important part, a piece of the

4 treatment process, we need to do it. We have

5 rural communities. We have rural settings and it

6 has been effective.

7 We talked about it today as far as who

8 may get the most benefits out of it. I think

9 it's how it's presented to the veteran and the

10 utility of the technology that is being utilized.

11 Anything on --

12 COLONEL AMIDON: Just to be clear.

13 MR. ROSE: Yes.

14 COLONEL AMIDON: As it relates to

15 sufficiency, I think the thesis is we know that

16 Telehealth and Telemedicine impacts and enhances

17 sufficiency by our definition. So, therefore,

18 clearly VA has invested in this as an

19 opportunity.

20 MR. ROSE: Right.

21 COLONEL AMIDON: It's how do we

22 enhance it. What are the barriers to enhancement


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1 of that as it relates to sufficiency?


3 All right, and the last one there is

4 to ensure rural veterans have painless interface

5 to receive care through entities such as

6 Federally Qualified Health Centers -- we've

7 talked about that -- Critical Access Hospitals,

8 Rural Health Centers, Tribal Health Centers,

9 Indian Health Centers for Mental Health,

10 mitigation management, lab testing, dental care,

11 and other services.

12 And I think this is kind of a broad

13 brush but I think what we're saying, and it needs

14 to be refined, but there are other entities out

15 there that can help the VA do their job. And

16 we've talked about community outreach. These are

17 some of the agencies that are out there that can

18 be brought into the fold, utilized better, and

19 just further investigated as far as their

20 potential help in taking care of the sufficiency

21 of the mental health care provided to our

22 veterans.


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1 DR. MAGUEN: I would add, in addition

2 to -- sorry.

3 MR. ROSE: Yes.

4 DR. MAGUEN: About the painless

5 interface, I would add ongoing communication

6 between the systems because it was part of what

7 we brought up that there can be an interface but

8 not a feedback loop.

9 MR. ROSE: Right.

10 DR. MAGUEN: And that's not going to

11 be the best thing for the veteran.

12 MR. ROSE: Okay.

13 DR. JONAS: Just one thing that might

14 help facilitate this, and I'm just thinking

15 specifically about the Federally Qualified Health

16 Centers, we had a really nice presentation on

17 that from HRSA Bureau of Health Director. And I

18 had a follow-up call with her to get -- since

19 they actually have a VA-HRSA Committee that meets

20 -- I don't know how often it meets but they meet

21 regularly to discuss these areas. And they were

22 interested in figuring out how they could make


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1 that more robust, how they could make it operate

2 better in mental health areas, and whole health

3 areas, et cetera.

4 So I put her in touch with the VAN, at

5 the time, and you know thought there may be --

6 with that there may be a need. You know we've

7 talked about you know enhancing development of

8 oversight boards that increase interagency work

9 across these areas and this may be one that we'd

10 want to recommend robustly because --

11 CHAIR LEINENKUGEL: Thanks for

12 bringing that up because it's a reminder also,

13 Jack, that we were owed on one of our calls the

14 number, first of all, of Federally Qualified

15 Health Centers and where they are located. I

16 remember I asked where could I go in Wisconsin to

17 view one of these. Oh, we have many of them in

18 Northern Wisconsin. I'm still waiting for that

19 data. So it would be a good opportunity to get

20 that to plug in.

21 DR. JONAS: Yes, follow-up. I mean

22 it's a huge system and HRSA has had, I don't know


144

1 about in mental health areas, but in other areas

2 they have had some very effective ways of looking

3 at developing innovations and then rolling that

4 out across their system. Diabetes is the one

5 that they're the most famous for.

6 They created a diabetes management

7 program. It was very effective in a couple of

8 these systems. And then they set up an education

9 training and implementation process that spread

10 it quite uniformly across the Federally Qualified

11 Community Health Centers. And so that's -- those

12 are the kind of things that the VA would need in

13 general. It has an infrastructure and is doing

14 it but I think you know, again, something that a

15 joint effort could combine.

16 I don't know if the community care

17 groups, when they're going out and looking for

18 folks to get certified in providing community

19 care are specifically going out to Federally

20 Qualified Health Centers or HRSA and saying, hey,

21 let's set up a process to get them certified so

22 that they can provide appropriate care in those


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1 areas.

2 MR. ROSE: Yes.

3 DR. JONAS: That would rapidly widen

4 the access points that were available.

5 MR. ROSE: Yes, one of the questions

6 we had, too, and we really haven't got an answer

7 yet, was just how many veterans were seen by the

8 Federally Qualified Health Centers. And so

9 that's another thing we need to follow up on.

10 CHAIR LEINENKUGEL: I love your word

11 painless because there's nothing painless in

12 dealing with access to any health care or any

13 system.

14 DR. MAGUEN: It's an aspirational

15 goal.

16 CHAIR LEINENKUGEL: Yes, that's why I

17 loved it.

18 DR. JONAS: I'm glad that you asked

19 that, actually. There's a new metric that's been

20 evolving, mostly in primary care but they're

21 starting to look at it in other areas, that is a

22 patient assessment of quality. And it's called


146

1 the Person-Centered Primary Care Metric. It was

2 developed by an anthropologist out of the

3 University of Virginia and it's now being tested.

4 It's being tested internationally. It's looked

5 at some large and small systems and they've

6 started to correlate it with other quality

7 assessment majors.

8 And what happens so much in the way we

9 currently do, as John and others know quite

10 extensively, is that the burden of the quality

11 assessment then becomes part of a system and

12 everybody's got what they want to have. Right?

13 They want to have their disease condition. And

14 then they want to have their delivery metrics and

15 they want to have their cost metrics. And it's a

16 huge complicated thing.

17 Very little is actually -- other than

18 patient satisfaction, which is very easy to game,

19 you know there's very little actual input from

20 the actual person or the patient. And if we're

21 interested in a model in which the veteran is in

22 the center, then we should probably look at


147

1 metrics that examine things like painless and

2 other kinds of things from the veterans'

3 perspective. Easy, they help me, they move it

4 along.

5 MR. ROSE: Yes.

6 DR. JONAS: And that metric has those

7 questions and has been correlated with all the

8 other major quality aspects within the Quadruple

9 Aim, actually. But it's simply, the patients

10 just answer it. It's an 11-point thing.

11 So those kinds of things get at this

12 and they flip the quality assessment from a

13 system, a medical-centric approach with all these

14 things that everybody wants to know, to okay, is

15 this something that the patient does. You read

16 the questions and they're just intuitively right.

17 They're just like yes, does my -- and it asks

18 things like painless. You know does my provider

19 or does my system help me get the care I need?

20 Have I been through a lot with them together?

21 Can I trust them? And I know that you know I

22 would go there in a heartbeat to take care of me.


148

1 Those kinds of questions, which I think, again,

2 gets at the patient-centric sort of assessment

3 tool in those areas.

4 DR. MAGUEN: Can I ask has that -- was

5 that developed for primary care, for mental

6 health, or just system-wide?

7 DR. JONAS: So it was developed

8 originally for primary care to try to measure

9 what is high quality. How do you determine from

10 a patient perspective if you're delivering high

11 quality primary care?

12 But they've now started to look at it

13 in a variety of models of care delivery.

14 DR. MAGUEN: Including mental health?

15 DR. JONAS: I don't know. That's a

16 good question. I can ask Rebecca Etz, who is the

17 developer of it has it been looked at

18 specifically in a mental health population around

19 that.

20 DR. MAGUEN: Right because those

21 questions seem like they would also apply to

22 mental health but, until it's been tested in


149

1 mental health, we would want that information

2 before we recommend that.

3 DR. JONAS: Correct. Yes, I'll ask

4 her if it's been tested in mental health. I

5 don't know.

6 DR. MAGUEN: Perfect.

7 MR. ROSE: Yes, thank you.

8 DR. MAGUEN: Yes, that would be very

9 helpful.

10 MR. ROSE: Any other comments or

11 questions? Anything, anybody?

12 Thank you all very much.

13 CHAIR LEINENKUGEL: Jack, thank you.

14 Well, it is a good start. I want to

15 make sure that everybody in the room, including

16 those on the phone know these are all just first

17 stage, very preliminary overviews of working.

18 The key item and the key word on all the slides

19 that you saw yesterday and today, these are

20 working lists of recommendation.

21 There's a lot of meat that needs to be

22 put on these bones and also definitive


150

1 delineations need to be made that all of us, as

2 commissioners, will be deliberating, discussing,

3 and then voting on beginning in five weeks. And

4 then at that same time -- I know that Wendy is

5 smiling back there because the writing piece, we

6 still owe you that by the close of this business

7 as well, a definitive time for each workgroup.

8 And we will get there, as well.

9 So that being said, it is now 11:42.

10 I think that because of the time of where we're

11 at, which don't we take a quick seven to ten-

12 minute -- seven-minute break? Be back in the

13 room at 11:50 so that we can get on with

14 Commissioner Kuntz and Workgroup 5.

15 Is that agreeable for the

16 commissioners?

17 So we'll break for about eight

18 minutes. Stay on the line. We'll mute you.

19 (Whereupon the above-entitled matter


21 11:53 a.m.)

22 CHAIR LEINENKUGEL: Welcome back.


151

1 This is Chairman Leinenkugel, and, at this time,

2 thanks for holding on. We are going on to Duty 5

3 with Commissioner Matt Kuntz at this time.

4 Commissioner Kuntz.

5 MR. KUNTZ: All right. Thank you,

6 Chairman Leinenkugel. I really appreciate this

7 opportunity to brief on this duty, very thankful

8 for the commissioners on the team and the staff.

9 We've been hitting it hard, and I'm really

10 excited about some of the things that we've dug

11 into.

12 Duty 5 is a little bit more kind of

13 broken into categories, and they're very

14 different categories, so I will go through them.

15 One is to study the current treatments and

16 resources available and see the effectiveness of

17 such treatment and resources in decreasing the

18 number of suicides per day by veterans, to

19 analyze the number of veterans who have been

20 diagnosed with mental health issues, the

21 percentage of veterans using the resources of the

22 Department who have been diagnosed with mental


152

1 health issues, and then the percentage of

2 veterans who have completed counseling sessions

3 offered by the VA, and then, finally, the efforts

4 of the Department to expand complementary and

5 integrative health treatments viable to the

6 recovery of veterans with mental health issues as

7 determined by the Secretary to improve the

8 effectiveness of treatments operated by the

9 Department.

10 So I know it's my legal background,

11 but trying to really answer what we've been asked

12 is the goal. And it's hard because it's really

13 broad. It goes from suicide prevention all the

14 way in to how is the VA implementing CAM and then

15 a bunch of data pools in the middle, which Dr.

16 John Klocek has been remarkable on.

17 It's important to start out, I think,

18 with who we met with. Sigma is working on a

19 broad analytical plan that we've improved or have

20 approved, but the other piece is who are we

21 meeting with? Outside of just the

22 regularly-scheduled meetings, we have our weekly


153

1 group and we try to bring in some of the nation's

2 leading experts. And the list only goes to March

3 12th, but I want to highlight one from February

4 26th because it's going to come up, and that's

5 Dr. Alan Teo of the Oregon VA, and he wrote the

6 systematic review that we'll be talking about

7 later.

8 After that, we had Dr. Shana Bakken,

9 the National Director of the VA Compensated Work

10 Therapy and Supportive Employment Program. It

11 was very interesting to hear her describe the

12 importance of work for suicide prevention. It's

13 a critical part of recovery, and it tied directly

14 into suicide prevention in her eyes and just

15 overall mental health wellness. She also

16 described how the fear of losing veterans or

17 losing benefits is a barrier to employment for

18 her population. So it was interesting to pull

19 that out of there.

20 We talked to Dr. John McCarthy and he

21 presented to us on REACH VET, the predictive

22 modeling program to enhance suicide risk


154

1 assessment. We talked to Dr. Stephanie Gamble.

2 She presented on the VA's behavioral autopsy

3 program to understand kind of that

4 after-evaluation of completed suicides.

5 We talked to Command Sergeant Major

6 Tom and Jen Satterly, the founders of the All

7 Secure Foundation. It was a command sergeant

8 major of Delta Force, and they've really worked

9 very hard to bring in veterans from across the

10 country. And one of the things that we heard

11 loud and clear from Command Sergeant Major

12 Satterly is we need to continue to improve our

13 system. We need to continue to get better and

14 better and better. That's what they do in Delta

15 Force, and that's what they expect from their

16 veterans' mental health system.

17 We visited Columbia Psychiatry, which

18 is one of the leading suicide prevention centers

19 in the world. It was very nice to get their

20 take, as well. We weren't able to meet with Dr.

21 John Mann while we were there. He did present to

22 us, and he is one of the nation's leading suicide


155

1 prevention experts. He leads the Conte Center on

2 Suicide Prevention that's well funded by the

3 National Institute of Mental Health.

4 We talked to Dr. Helen Lavretsky, kind

5 of moving towards complementary integrative care,

6 and she works on researching those types of care

7 for the UCLA and did a really cool analysis of

8 mental health and complementary integrative care.

9 We talked to Dr. Madhukar Trivedi from

10 the University of Texas Southwestern. He is one

11 of the nation's leading depression experts and

12 probably the preeminent researcher on exercise

13 and depression. Incredibly well funded out of

14 the National Institute of Mental Health to figure

15 out how exercise is involved with helping certain

16 types of depression.

17 We talked to Dr. Donna Ames, and I

18 think she was a real highlight for a number of

19 the commissioners. She is a researcher at UCLA

20 and also a staff psychiatrist at VA and the

21 Greater Los Angeles Healthcare System. And she

22 had complementary integrative care as the


156

1 recovery model, really how to implement these

2 things in the VA while still having a strong

3 research background, so she could speak to both

4 sides.

5 One of the things that I think really

6 came out loud and clear from everyone that we

7 talked to was these complementary integrative

8 care treatments can be measured through science.

9 You know, like the standard methodology that Dr.

10 Maguen and her team are working on to analyze

11 these things, that is how they said that they

12 should be described. And they said that

13 international groups are moving in that

14 direction. It was a nice way to check our

15 methods and have all of these researchers say

16 we're going about this in the right path.

17 So we had a number of different other

18 visits, but I will move in to our recommendations

19 and what we found. And I'll stand up for that

20 because at West Point and then in the Army and

21 they yelled at me for briefing while sitting

22 down, and I still hear that in my ear. So I


157

1 apologize to anybody on the phone if you can hear

2 me worse.

3 But the main thing that jumps out to

4 me in Duty 5 is very similar to Dr. Maguen. I

5 think it's going to be one of the more

6 potentially controversial elements of our

7 commission is what we do we have high data on and

8 what do we have low data on? There are practices

9 that we are working in a low-data environment.

10 There are practices, such as cognitive behavioral

11 therapy, that have been studied in-depth and

12 detail where we have a high-data environment.

13 We're trying to compare these two systems where

14 we have very different levels of data, and we

15 have to bring that forward in a very honest way

16 but it doesn't mean that things are ineffective

17 because they haven't been studied. You could not

18 do research on whether or not it's good to drop

19 refrigerators on people, but that doesn't mean we

20 don't know what happens and that it's a negative

21 health consequence.

22 You know, there are some of these


158

1 things that we haven't proven. There's some of

2 these things that are going to be, like, veteran

3 suicide prevention, addressed on a national level

4 regardless of the level of data that's out there.

5 So we need to realize that part of what Duty 5 is

6 trying to do was to say, you know, we are in a

7 low-data environment. That does not mean that

8 anybody's time is wasted. That does not mean

9 that we should stop trying to save veterans'

10 lives from suicide or stop CAM. But whether or

11 not we're in a high-data environment or a

12 low-data environment is important in every field,

13 just as it is in the military. The amount of

14 intelligence that you have affects what you do

15 and how you operate. It doesn't stop your

16 mission, but it affects how you go after it.

17 So starting out with the first part of

18 our duty, there was a big systematic review done

19 by Dr. Alan Teo and his associates within the

20 Portland VA about suicide prevention and risk

21 assessment. This was a very important systematic

22 review for us. We got an in-depth presentation,


159

1 and the results were effectively, for these

2 interventions, we're dealing in a low-data

3 environment.

4 And I can say, as the PI of a suicide

5 prevention project myself, it's hard to do these

6 studies. It's expensive to do these studies

7 right. We brought over an intervention from

8 Europe, and the amount of money that they had to

9 spend just to get a base level of research is

10 hard. This is not the VA's fault; this is not

11 NIMH's fault. It's hard.

12 So next slide, please. This is what

13 they basically said. Their conclusions were

14 these assessment methods have been shown to be

15 sensitive predictors of suicide and suicide

16 attempts, but the frequency of false positives

17 limits our clinical utility. Research to refine

18 these methods and examine clinical applications

19 is necessary.

20 The second finding was studies of

21 suicide prevention interventions are

22 inconclusive. Trials of population-level health


160

1 interventions and promising therapies are

2 required to support their clinical use. And this

3 was the same thing that we heard at Columbia.

4 Not the VA's fault, not anyone's fault, but we

5 are dealing in a low-data environment. Being a

6 veteran that lives with suicidality myself,

7 having lost a family member to suicidality, we

8 will continue to fight for these levels of care,

9 but we have to honestly acknowledge we're in a

10 low-data environment on how well they work.

11 Next slide, please. Okay. One of the

12 things that did come out when we were briefed by

13 Dr. Keita Franklin, the prior head of suicide

14 prevention from the VA, is there were so many

15 different ways that the VA was looking at suicide

16 prevention that there seemed to even be some

17 confusion about environmental stressors and

18 mental health and a lot of different angles to

19 look at it. And from the outside, that can be

20 very confusing. From the inside, that can be

21 very confusing.

22 And when we talked to Dr. Mann of


161

1 Columbia, he has been a multi-decade proponent of

2 the stress-diathesis model, which is really

3 simple and it says that, you know, suicide is the

4 result of an interaction between environmental

5 stressors and susceptibility to suicidal

6 behavior, which fits in to how the VA deals with

7 suicide. The nice part about this is we do send

8 people to psychologists to get better. You know,

9 if you call the veterans' care line, this is what

10 we're trying to deal with. We are trying to get

11 people employment. We are trying to build

12 community connections which can limit their

13 environmental stressors or reduce their

14 susceptibility.

15 So what we liked about this model or

16 what I really liked about this model is it fits

17 into what we're doing. And as a family member

18 and as an individual who struggles with this

19 stuff, it makes sense and it makes sense to what

20 we're doing. Find a model and run with it.

21 There's an argument that Dr. Thomas Joyner's

22 model may tweak this a little bit. But at that


162

1 level of complexity, it's pretty hard to

2 understand for the person on the ground being

3 briefed by the VA about why suicide happens.

4 So next slide, please. So we've got

5 into veterans' suicide. We'll spin out a couple

6 of recommendations at the end. Again, there's a

7 giant analytical plan under works to add more

8 data, but that was kind of the big pieces was

9 that effectiveness, we have a massive systematic

10 review that helped guide us and then from leading

11 researchers in the field.

12 The next few were more data pools.

13 Duty 5B, find out the number of veterans who have

14 been diagnosed with mental health issues. And

15 this was from 2017 pooled by Dr. John Klocek and

16 his team.

17 Percentage of service users in the VA

18 system in fiscal year 2017 roughly the same

19 number that we've seen throughout. So no

20 surprises to this commission.

21 All right. Duty 5C, the percentage of

22 veterans using the resources of the Department


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1 who have been diagnosed with mental health

2 issues. Again, very similar to what we've looked

3 at before. The Commission has been briefed by

4 this. John is digging deeper to provide some

5 nuance to those numbers. From a legal

6 standpoint, relatively clear, asked and answered

7 based upon existing data.

8 And this was where he got the

9 confirmed mental illness diagnosis or definition

10 from the last slide. Same definition that we've

11 looked at before when we first started working.

12 Next slide, please. Okay. So Duty 5B

13 was a little bit more complicated. That's the

14 percentage of veterans who have completed

15 counseling sessions offered by the Department.

16 And as commissioners may remember, this was up

17 for debate. You know, what this means and what

18 this looks like is up for debate, and what we

19 decided to do was not to settle the debate, but

20 just give the data on all of the different

21 interpretations that this could be, you know.

22 Does this mean crisis or same day? Let's get the


164

1 numbers on that. Does this mean completed

2 counseling one session? Get the numbers on that.

3 Completed counseling multiple sessions, get the

4 number on that.

5 And Dr. Maguen made a great

6 recommendation to us, I think it was in our March

7 report-out, that the data that the VA pooled or

8 normally pools doesn't go out far enough to

9 suggest whether or not they completed enough

10 sessions to fit in to the standard of

11 evidence-based practice.

12 So we had our basic data pool. We got

13 that guidance from Dr. Maguen, and I will refer

14 to our subject matter expert, Dr. John Klocek to

15 explain the results in a little bit more detail.

16 DR. KLOCEK: I'll come over and stand

17 a little closer so you can hear me more clearly.

18 So Dr. Maguen had suggested that we look for what

19 would be sort of a minimal dose of an

20 evidence-based protocol or evidence-based

21 treatment, which is eight sessions as usually

22 understood. We looked at it as eight sessions


165

1 within 16 weeks of initiation of psychotherapy,

2 so that was the request that we made for the data

3 pool.

4 We also specified it to be eight

5 sessions for the same diagnosis over the course

6 of those 16 weeks, rather than multiple diagnoses

7 being indicated over those eight sessions. So

8 those were the numbers that we pooled for the

9 completed counseling sessions at that point.

10 MR. KUNTZ: And we do have an in-depth

11 handout that Dr. Klocek developed for everyone

12 that goes into this in more detail. If there's a

13 request for another data pool, let us know at the

14 end of the day if there's a reason. We are

15 running up against the shot clock, so right now

16 is very happy about how we handled this because

17 we didn't want to tell Congress what they meant

18 but just give them all of their relevant data and

19 we'll let the policymakers work from that.

20 Next slide, please. So we missed Duty

21 5E, and we do have white papers or a white paper

22 on Duty 5E that we're waiting for. And this was


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1 an in-depth two-page white paper, and it was

2 assigned back in December or January. We had our

3 first take on it in June, and now we're waiting

4 for a second take. Wendy LaRue has been working

5 on it. She was overwhelmed by the focus group,

6 so we had a delay in completing it. We don't

7 have to all blame Dr. Potoczniak for that, but --

8 DR POTOCZNIAK: You can.

9 MR. KUNTZ: -- but we can.

10 But the way that we did it was to try

11 to wrap our heads around, you know, how is the VA

12 implementing these complementary and alternative

13 treatments? Like, how is it going out there?

14 And such a giant question. A lot of that will be

15 answered in the analytical plan, but we wanted to

16 start out with what could we capture beforehand

17 and thought that the ways to limit that search

18 would be in to outpatient treatment. The

19 majority of the VA's care is provided through

20 outpatient treatment, so let's focus on the

21 interventions that are provided on an outpatient

22 basis. And then let's focus on the interventions


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1 that are paid for, that either in VA staff time

2 or in dollars to outside community providers.

3 I love the folks that are doing

4 different things on a voluntary basis, but we

5 were working off the premise that if you value

6 something you're willing to pay for it. And if

7 you are not willing to pay for it, that is a

8 statement that you don't value it.

9 A little bit controversial there, but

10 I do think that there's also a point where some

11 of these things prove themselves on a voluntary

12 basis on the community level and then work

13 themselves into the VA for the long term.

14 We're still working out those white

15 papers. We started out with exercise and thought

16 that, you know, that was one of the most

17 standardized, complementary, and integrated

18 interventions. Let's look at that first, and

19 then we'll go towards some of the more niche

20 ones. And what we found out with exercise was

21 the VA has a rule against providing gym

22 memberships. There's an administrative rule


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1 against providing gym memberships. What's

2 interesting about that is Medicare Advantage

3 plans, gym memberships is exactly how they solved

4 this problem. So we will be talking to

5 UnitedHealth later to figure out how they worked

6 through that problem and, as that doctor in Palo

7 Alto said, I like the idea of incentivizing

8 veterans' exercise, I don't want to pay for

9 people that don't go to the gym. You know, a

10 very real point for all of those of us who have

11 been in busy gyms in January and February and

12 entirely empty in December. We'll work the

13 issue. UnitedHealth serves millions of people.

14 How did they solve it? How do they look at it?

15 And from a cost standpoint, does it make sense to

16 them? Is this actually making their population

17 healthier?

18 And one of the reasons why this is

19 important regardless of the data and how it comes

20 back is, again, with these alternative

21 treatments, we're working in a low-data

22 environment and we have more desire and need than


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1 data to back these things up. Why did

2 UnitedHealthcare think it was worth it? Why did

3 they feel like they had enough data for their

4 Medicare Advantage plans when the VA chose the

5 alternative?

6 DR. POTOCZNIAK: How did they deal

7 with people who don't use it?

8 MR. KUNTZ: That's exactly what we, as

9 a group, will grill them on when they present

10 with us because that's a big issue.

11 DR. POTOCZNIAK: Some of the VA

12 programs that do provide subsidized gym

13 memberships is under contract with the YMCA. But

14 the veterans have to go to a variety of, like,

15 recreation therapy appointments or classes would

16 have to take place within the YMCA to qualify to

17 do that.

18 DR. MAGUEN: Yes, I think there's, you

19 know, for some kinds, there's a six-month trial

20 period, you know, where they can get a free

21 membership for a period of time and then, you

22 know, they have to pay for it --


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1 MR. KUNTZ: And that was, there is a

2 rule that says the VA can't pay for it. They can

3 go and ask for free gym memberships. The YMCA in

4 my town spoke to or the VA said that they send

5 folks from inpatient to the YMCA but they don't

6 pay for it. We have an administrative rule that

7 prevents that.

8 So we'll suss that out a little bit

9 more, but I think it's an example of why we did

10 the white paper process. We're excited to find

11 out more in the analytical plan, but it will be a

12 nice way for us to compare what does a

13 million-plus person system do for this?

14 MR. ROSE: Is there still an MOU

15 between the VA and the YMCA?

16 DR. MAGUEN: I believe so, yes. I

17 believe so, I mean, on the national level.

18 DR. POTOCZNIAK: There is because I

19 had to, you know, we have YMCA stuff that goes on

20 in our VISN. So, yes, for sure.

21 MR. KUNTZ: And, again, I think that

22 with this white paper, it's what are you willing


171

1 to pay for? And if you're not willing to pay for

2 the veterans to get gym memberships, if you have

3 an administrative rule that says you can't, you

4 are treating this different than Prozac, you are

5 treating this different than a back stint. I

6 mean, like, at some level, if you've chosen not

7 to pay for it, that's a decision. Maybe you

8 might have some small programs here or there, but

9 you do have an administrative rule. And I think

10 that we'll see in the white papers what the

11 numbers look like, and they reflect that there's

12 a rule saying that they can't do it.

13 So we are still waiting on the next

14 phase of the white paper, but I do think that it

15 will give us a little bit more nuance in how

16 these play out.

17 I'll move on to the working list of

18 recommendations. For the folks on the phone or

19 in the room, again, these are rough drafts of

20 rough drafts, just something to bring up from the

21 commissioners in our group.

22 Based upon that systematic review, it


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1 does seem that there needs to be more funding to

2 the VA and the National Mental Health to develop

3 research-proven suicide prevention initiatives.

4 We have a lot of great research on other things.

5 Suicide prevention in particular is a low-data

6 environment.

7 Eliminate the possibility of benefit

8 reduction for disabled veterans who pursue

9 careers. This is especially important for mental

10 health, as was mentioned by the VA workforce.

11 Vocations are a critical part of your wellness,

12 and we did talk to one veteran at Fort Belknap

13 that described exactly this issue and he did get

14 employment, only to have his benefits take away.

15 And it was solved through working with Buck

16 Richardson, a VA employee. But it was testified

17 exactly that this happened. This was something

18 that came up very loud and clear in the workforce

19 presentation.

20 Develop a telehealth resource to

21 deliver suicide assessment and follow-up

22 engagement, veteran emergency treatment, which is


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1 labeled as SAFE VET, to veterans in emergency

2 rooms throughout the country. When I went to

3 Columbia and talked to Dr. Barbara Stanley, she

4 was the developer of this, one of the nation's

5 leading suicide prevention experts. The VA

6 helped develop this model. The VA tested it out

7 in emergency rooms. The results were very

8 positive on delivering a safety contract in those

9 emergency rooms and basically having four

10 follow-up phone calls to help prod the veteran

11 into care. You know, it was very well proven.

12 There was the challenge of the emergency rooms

13 not being willing to have someone in there

14 delivering safety plans, scheduling follow-ups.

15 That was the infrastructure stick that they had,

16 so this came out of that, that there's a lot of

17 data and research on safety plans through SAFE

18 VET that I provided to Dr. LaRue.

19 Develop a grant program to help

20 incentivize community partners to develop firearm

21 safe storage capacity that can be used by

22 veterans as part of their mental healthcare plan.


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1 Not all communities have safe storage plans. The

2 VA has adopted safe storage and has adopted those

3 conversations, but not all communities have a

4 place to actually keep those guns. And how do

5 you interface with that?

6 Incentivize exercise among disabled

7 veterans at least to the same level as Medicare

8 Advantage plans, such as the Silver Sneakers

9 program.

10 Ensure that all veterans in the VHA

11 system have access to effective care for

12 treatment-resistant depression. In one of our

13 data pools that we did, Dr. Klocek looked into

14 the number of veterans that have received care

15 through TMS or ECT. Both of these are on the

16 clinical practice guidelines that the VA has

17 endorsed. The numbers of veterans in 2018 that

18 actually received them were low enough to justify

19 a recommendation on that. If we believe in those

20 clinical practice guidelines, the VA believes in

21 those clinical practice guidelines, it should be

22 available to veterans everywhere. For example,


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1 in Montana, an entire state, we have no access to

2 TMS or ECT for our veterans, as discussed at Fort

3 Harrison.

4 Next slide, please. All right.

5 DR. KLOCEK: So there's no community

6 providers that do ECT?

7 MR. KUNTZ: The VA in Montana has

8 chosen not to offer or not to work with community

9 providers for ECT or TMS. They just don't offer

10 it.

11 DR. POTOCZNIAK: Can they do that,

12 John?

13 MR. KUNTZ: That's what this

14 recommendation -- when you see the numbers of how

15 many veterans got these services nationwide, the

16 question of whether or not they can do it --

17 DR. POTOCZNIAK: I mean, but that

18 almost seems like, I mean, like withholding care

19 --

20 MR. KUNTZ: The data will speak to it.

21 DR. POTOCZNIAK: So is it the providers

22 saying that they won't do it or is it the system


176

1 saying they won't do it?

2 MR. KUNTZ: The system does not send

3 people for ECT or TMS. But what we saw at a

4 national level will show you, and I don't know if

5 that's been cleared.

6 DR. KLOCEK: It has.

7 MR. KUNTZ: Okay. So we can send

8 those numbers out, but it was not what it should

9 be, in my opinion as a single commissioner.

10 DR. MAGUEN: Can I ask a question?

11 Are some of those numbers also, it's the number

12 of veterans that are utilized, but does it also

13 reflect the percentage of places it's available

14 at all? I don't know if there's information on

15 that. You know, it's one thing to say X number

16 of veterans received it, but I think, along with

17 that, if we don't know where it's actually

18 offered, it's hard to make sense of that, right?

19 MR. KUNTZ: We did ask for both, and

20 I believe that that Excel spreadsheet shows both.

21 DR. POTOCZNIAK: I believe the survey

22 is to assess what they call somatic treatments at


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1 any facility. So the facilities that responded

2 extensively have those treatments available.

3 That's my best understanding of it.

4 DR. MAGUEN: Got it.

5 DR. POTOCZNIAK: And I get

6 clarification.

7 DR. MAGUEN: So TMS falls under

8 somatic?

9 DR. POTOCZNIAK: Yes, as does ECT.

10 DR. MAGUEN: Got it. Thanks.

11 DR. POTOCZNIAK: So how does that work

12 when veterans request, these four providers

13 thinks ECT is good for a veteran, under the

14 MISSION Act, if the facility decides it doesn't

15 provide it, that doesn't, they can't stand in the

16 way of the community care referral. I'm just

17 trying to think this through because it's one

18 thing for the facility to say I'm not providing

19 this, for whatever reason they're saying that

20 they're not providing it. Their psychiatrists or

21 whatever get an idea, and they don't want to do

22 something and --


178

1 DR. MAGUEN: Or they're not trained to

2 do it.

3 DR. POTOCZNIAK: Or they're not

4 trained to do it. But it's another -- but if

5 they're not willing to work with community

6 providers, it goes a little further than that,

7 right? Because then it's like I'm not trained to

8 do it and I don't want you to have it. But

9 under, like, the MISSION Act, they really can't

10 say we're not doing this because they're not

11 national VA.

12 MR. KUNTZ: And I guess that, having

13 been someone who's lost a veteran to

14 treatment-resistant depression that couldn't

15 access that level of care, you know, I'm probably

16 a little bit, a little bit too tied to it to dig

17 into it. I do want to let the data speak to, you

18 know, this is not one commissioner's

19 interpretation. We asked the VA, are you

20 providing this, and this is the data that we got

21 back. From an individual advocacy level in

22 Montana, the idea that our VA refuses to provide


179

1 those two services in our state, despite them

2 being on a clinical practice guideline, despite

3 having practitioners in town that they could do

4 it with or in a number of other communities

5 across these state, BlueCross BlueShield pays for

6 it, you know. It is an issue in states, but I do

7 think that we have the data to support that

8 recommendation that the VA follows its clinical

9 practice guidelines in regards to

10 treatment-resistant depression. If you have a

11 veteran that needs it, if you can't do it

12 internally, go get help externally.

13 DR. POTOCZNIAK: And this is an

14 example -- sorry to go further. But this is an

15 example of the lack of uniformity because in

16 other places, you know, a similar kind of

17 hot-button issue is suboxone treatments and

18 referrals for methadone and that kind of stuff,

19 that there are psychiatrists that kind of make it

20 their personal mission that I'm not doing this,

21 yet it's something that's in the practice

22 guidelines.


180

1 So, you know, they kind of, in one

2 clinic that I saw, you know, all psychiatrists

3 got together and agreed we're not doing this.

4 But how can -- so that it's a hot-button topic

5 for me also because it's just like really? You

6 can't hold the system hostage essentially, but

7 they do. And so I don't know, just putting it

8 out there that it's not exclusive to this. There

9 are places where people deviate. I just don't

10 understand why they can't be held accountable for

11 doing that.

12 MR. KUNTZ: So that's kind of what

13 that recommendation is about. And we saw the

14 same thing, very interestingly, with EMDR between

15 Lovell and Jesse Brown. At Lovell, I believe it

16 was EMDR was hailed as being an evidence-based

17 practice that was critical to veterans'

18 healthcare. At Jesse Brown, they chose not to

19 offer it. You know, and this was 30 minutes away

20 from each other. So that lack of uniformity

21 again, but I think the root of that one is if

22 it's on the clinical practice guidelines, you


181

1 know, if we believe in evidence-based medicine,

2 if we're following evidence-based medicine --

3 DR. POTOCZNIAK: Well, it's like a

4 pharmacy that has a formulary and an individual

5 pharmacist saying we're just not going to carry

6 that because I don't like it, you know. It just

7 irks me. But anyway --

8 MR. KUNTZ: Exactly. Let me keep

9 going because I know that we got to keep digging.

10 Exclude the Veterans Healthcare Administration

11 from compliance with the Paperwork Reduction Act

12 to facilitate data collection to improve the

13 quality of care provided by veterans. We had a

14 lot of pain with the Paperwork Reduction Act in

15 my meetings with veterans' healthcare providers

16 on the national level. It does not sound like

17 it's only an issue for the COVER Commission.

18 This one was briefed in Duty 4,

19 increased pay and the number of veterans peer

20 support specialists for all the healthcare

21 facilities. Increased pay and the number of VA

22 police force members present at all VA healthcare


182

1 facilities. And that has become very big in the

2 news with the suicides on campus, and in the

3 community it is police officers that deal with

4 people suicidal on campus. I will say that

5 during one of our site visits, we were there

6 while there was an assault committed at a

7 facility and the person, I mean, I watched

8 someone trying to go find a police officer to

9 report it. So it was something that we saw but

10 also in Georgia and a number of other areas,

11 completed suicides on VA campuses.

12 DR. POTOCZNIAK: Well, it's, when you

13 think about it, it's really a good

14 recommendation, the VA police part, because they

15 were just demoted down to a level lower. I

16 didn't know this, but they were demoted below

17 scheduling assistants. So the people that

18 schedule your appointments are paid more than the

19 people that protect the clinic. They're GS-5s, I

20 think, or something like that. So at least in

21 San Francisco, it means that we're always

22 operating at half-staff police-wise because you


183

1 can't pay $40,000 to somebody to live in San

2 Francisco. It just doesn't work. And they can

3 be pulled, and I think this is via police wire,

4 they can be pulled from facilities that are in

5 outlying areas to come in to VAMCs, but they

6 don't get the extra pay for being in a

7 metropolitan area. So they can be like in a

8 rural system and expected to come down on a

9 regular basis to the main system if they're

10 understaffed and not get paid for it.

11 So there's all these different

12 negatives to the VA police that go on and on and

13 on. But GS-5s for police officers but GS-6s for

14 MSAs.

15 DR. KHAN: Additionally it takes 18

16 months to train their police officer in the

17 pipeline. And after two years, their contract

18 finishes with VA, so the outside company hires

19 them with three times more salary.

20 DR. POTOCZNIAK: And other federal

21 agencies, the biggest problem that we have is we

22 do train them for 18 months to be a federal


184

1 police officer, and then they get sucked up by

2 another federal agency that's willing to pay them

3 what they're worth, you know. So I don't know

4 why they demoted them recently, but they recently

5 changed them from 6s or 7s to 5s.

6 MR. KUNTZ: Thank you for that

7 in-depth analysis. It had come from one of the

8 commissioners. I mean, it makes sense to have

9 that insight from the ground on why that's

10 needed.

11 So the next one that we have is hire

12 professional drivers to drive DA vans used to

13 transport veterans to VA healthcare facilities.

14 DR. KHAN: At present, those van

15 drivers are all volunteers like Jamil. And

16 they're getting old, so the vans are given by the

17 DAV to the VA as a gift. VA manages those vans,

18 but the VA does not provide the drivers. So

19 given a driver every day is 18 hours of driving

20 because wherever they live, they go to pick up

21 the van, they pick up the veterans from different

22 places, they take them from the facility. They


185

1 stay there all day until the last appointment is

2 done. Then they drive back home. So there's a

3 burnout there.

4 On the other side, there is a VA

5 transportation system in place. But the effort

6 is to use, let the VA have its own drivers to

7 drive these other vans also.

8 DR. POTOCZNIAK: What would stop, you

9 know, what would stop us from just doing what

10 BlueCross BlueShield does with its rural patients

11 and just using Uber or Lyft? It's going to be a

12 lot cheaper, I guarantee you, than hiring drivers

13 with the federal government system.

14 MR. SPERO: So Uber actually tried to

15 create a partnership with the VA, and they're

16 trying to do this with Medicare and Medicaid, as

17 well, and they have been for a couple of years

18 now, where a facility will actually be able to

19 task an Uber to a patient's home, and the patient

20 will get just a text, you know, so you can even

21 get it on a flip phone, saying the driver for

22 your healthcare appointment is Casin and he's


186

1 going to be in a blue Toyota, here's his license

2 number, he'll pick you up. And then the Ubers

3 would bill. It would become part of their, you

4 know, what the insurance or Medicare, Medicaid

5 pay for, the appointment.

6 So there's some cool pilots out there

7 but a lot of red tape.

8 MR. KUNTZ: And I think that that's

9 exactly the kind of debate that we can have with

10 that one, you know. Is it just pay for, you

11 know, find better ways to pay for transportation

12 for veterans or, you know. So we'll dig into

13 that in October and in between.

14 The last one that we had was just as

15 part of my team duty lead, trying to navigate how

16 you manage your team. And as part of that, I

17 realize that federal commissions are currently

18 not covered by Title V of the Rehabilitation Act

19 of 1973, which, in comparison to the community,

20 it is considered best practices to have disabled

21 people on the committees that are there to

22 represent them. And the way that you do that is


187

1 through the ADA or through the Federal Compliance

2 Act. I mean, that group of case law and it

3 allows you to have standardized practices that

4 work between the private sector and the federal

5 sector. So if we want veterans long-term wise

6 that live with suicidality, depression, anxiety,

7 some of these disabilities to be able to be

8 active in guiding the VA on how to provide their

9 care, that recommendation would help us.

10 MR. SPERO: Just a couple of other

11 things. The VA police officer training is only

12 ten weeks. It's not 18 months. And I think

13 that's a specific problem because they're

14 advertising for that GS-6 and GS-7.

15 DR. POTOCZNIAK: I know our whole

16 force was just demoted.

17 DR. KHAN: But before they're going

18 through ten-weeks training, they go through other

19 law enforcement training.

20 MR. SPERO: That's not required by the

21 VA, though.

22 DR. KHAN: I was given that figure by


188

1 the police chief of VA Medicine Hospital. He

2 told me, he said, if today one of my police

3 officer leaves for whatever reason, to fill that

4 vacancy, I have 18 months to wait until the

5 qualified person can come in and replace him. In

6 addition to 18 months, the system creates a

7 vacancy after 18 months, then they would delay in

8 filling up the vacancy.

9 MR. KUNTZ: I guess what I would ask

10 is kind of the Duty 5 is, Casin, if you can

11 assign a subject matter expert to run down kind

12 of the brass tacks of what it takes. And I agree

13 with Jamil that it may take state-level training

14 first just to be able to do it in that state and

15 then a second -- I mean, there would be nothing

16 surprising about that. But if you can add a

17 subject matter expert to expand on that a little

18 bit for us.

19 Next slide. Awesome. That was what

20 I hoped. Thank you.

21 CHAIR LEINENKUGEL: Casin, can you

22 keep that up and go back to the previous slide?


189

1 I just have a couple of comments. The second to

2 the last one. Let's see. It's the one with

3 research. There it is.

4 We've heard that a couple of times,

5 certainly from Commissioner Maguen and now from

6 Commissioner Kuntz, and I think that everybody

7 has a little bit of play with a little more

8 research. I wonder if it's appropriate for us to

9 talk amongst commissioners over the next couple

10 of weeks about really going after who we should

11 find the money from or where we're going to

12 access and be consistent because we're looking at

13 this holistically across the United States for

14 veterans' healthcare, mental health care.

15 So if we're going to provide more

16 funding to VA and NIMH, develop research-proven

17 suicide prevention initiatives, I think there's

18 an ongoing initiative at least being talked about

19 right now that is going on concurrently with this

20 commission that we need to have some linkage with

21 and what they're trying to do cross-agency so

22 that at least we should be taking the lead but,


190

1 at the same time, being bold enough to bring in

2 everybody and make it much more inclusive.

3 And when we talk about more funding,

4 I don't necessarily, from my position, that's my

5 position only, think that it has to be additional

6 funding. And I would like to go on record to

7 state that I think that the budget that we've

8 requested after the Secretary told us he was

9 getting $9 billion additional for 2020 mental

10 health and we're still waiting to see how that is

11 going to be appropriated within the structure of

12 the VA, it's timely for us to maybe be much more

13 poignant as to what will it take? And I expect

14 you, from your affiliation, with NAMI, you're

15 doing a lot of research work and certainly Dr.

16 Jonas, as well. What is the amount that we

17 should be requesting or asking for? I'd like to

18 be specific or bold in this case.

19 And also I would like to challenge the

20 VA itself, as a department, to look again

21 holistically at its entire budget of VHA. And

22 I'm pretty sure this has never been done, to look


191

1 and systematically review ongoing programs to see

2 what is actually pointing in the direction of

3 veterans healthcare/mental healthcare and

4 programs that may not or might just be nice to

5 have and get much more pragmatic and definitive

6 about using taxpayer money to really go after

7 mental health in this case and then certainly

8 primary care.

9 So I think there's an opportunity

10 here, Commissioner Kuntz, for all of us to

11 consider tightening this up in a way that might

12 be bolder. And you may disagree with me, and

13 that's fine. Maybe I just take that out. But I

14 think it's an opportunity that gets a further

15 discussion going within the entire, I call it the

16 corporate entity of the Veteran Affairs

17 Department.

18 MR. KUNTZ: I love the concept,

19 Chairman. I guess what I would ask is I found

20 through my dealings with the Senate Veterans

21 Affairs Committee in comparison to what we do in

22 the outside world is the VA does say that the


192

1 numbers are different when they do research than

2 when NIMH. So we are having Dr. Gordon present

3 to us hopefully, and I would love to hear him

4 weigh in on that. But I think it would be

5 valuable to have Dr. Ramoni and her staff look, I

6 mean, it feels to me like that might be best,

7 that number, if we can make a very specific

8 request for both alternative care or, I'm sorry,

9 complementary and suicide prevention, what that

10 would look like, because I do think that would be

11 very hard for me or Dr. Maguen to be able to say

12 that, not knowing exactly what the VA's research

13 costs are and how they compare.

14 CHAIR LEINENKUGEL: Well, it's

15 interesting. I also want to add for the record

16 that we get numerous requests from commissioners

17 that our group leads here for the total amount of

18 research dollars that the VA currently has.

19 DR. JONAS: If we knew that, then we

20 could have --

21 CHAIR LEINENKUGEL: And we could have

22 that for months, right, Wayne? So that still is


193

1 undefined and unpresented to this commission, as

2 well as the usage of the $9 billion. So,

3 hopefully, by next week, and I know that Casin

4 has been diligently partnering with someone

5 within the VA structure, that we'll get a report

6 back on that.

7 I had one last thought, but I want

8 somebody else to go first before I bring that up.

9 Did anybody else have additionals for Matt?

10 DR. JONAS: I just want to support

11 this effort. I think that if we got a good

12 baseline as to what's currently going on and

13 we're saying here's resources that need to go in

14 there, it would be really good if we could have

15 an estimate where we could make specific

16 recommendations that it should be, you know, just

17 like Shira said, hey, 20 percent of the research

18 on MST or on mental health should include women.

19 I mean, we've got a number there. That's a

20 target. They can think about it. You know, it

21 may be off by a few percentages here to there, it

22 doesn't matter. But if we could do something


194

1 like that in this area and say X percent of these

2 dollars need to go into, you know, suicide, whole

3 health, mental health things, you know, it would

4 be a lot more than is going in there now

5 probably. And then with the guidance, you know,

6 in terms of what kind of impact and cost offset

7 do we think this would have if the models shift

8 over, you know, to actually produce health and

9 induce recovery. Then that should be an

10 extremely well placed investment. It should

11 lower costs.

12 MR. KUNTZ: And Yessie had brought up

13 to my attention we have one more handout for Duty

14 5, and that was we had talked earlier about the

15 Commander John Scott Hannon Act, which has both

16 suicide prevention and alternative care and some

17 sufficiency stuff. So there's a small handout

18 there to give you an idea and the full bill is

19 online. It's a bipartisan bill from Senator

20 Moran and Senator Tester, and it's really easy to

21 Google.

22 CHAIR LEINENKUGEL: Another thought,


195

1 Commissioner Kuntz, and this is really well done

2 and, you know, well developed at the bare bones

3 level at this point with a lot of additives over

4 the next five weeks or some shifts and very well

5 let Matt, as well, from your end. But a thought

6 came to me when I was talking to Commissioner

7 Amidon a couple of days ago, that it popped

8 because you're incentivizing, and we talked about

9 an incentive I'm going to get to in a minute, but

10 you're incentivizing exercise amongst disabled

11 veterans at least to the same level as Medicare

12 Advantage plans. I think that's great. But why

13 don't we think bigger? Why don't we think, and

14 I'm going to use very simple terms here, how do

15 we incentivize veterans to get well?

16 So it goes back to your number two:

17 eliminate the possibility of benefit reduction

18 for disabled veterans who pursue careers.

19 Personally, I would never want that veteran who

20 got a specific benefit who actually did get

21 better lose that benefit because, in my opinion,

22 he or she deserved that benefit. And if they got


196

1 better, good for them. Keep getting paid, okay?

2 That's my position only. But at the same time, I

3 think we do a horrible job and I bet you there's

4 another country that maybe some of our subject

5 matter experts, and nobody has the amount of

6 veterans we do, but somebody, maybe it's Israel,

7 does things differently with their veterans. I

8 don't know. Maybe Canada. But why aren't we

9 looking at the wellness factor and the outcome of

10 giving something back to that veteran? And it

11 could be monetary. To me, I think incentivizing

12 them to get better is so much stronger than,

13 jeez, we're going to take your money away from

14 you.

15 So can we at least throw that out

16 there for consideration?

17 MR. KUNTZ: Absolutely. Wendy, will

18 you work with the Chairman on that one to make

19 sure that you get the wording right? All my

20 words are --

21 CHAIR LEINENKUGEL: I think Matt would

22 help me out, as well. I mean, we talked about


197

1 this. You know, it's one thing that we don't do

2 and we never thought of doing and maybe we should

3 start. And the more I thought about it the last

4 48 hours, it makes perfect sense to me

5 personally, but everybody is going to say find me

6 the money. Well, I can tell you we're good CFOs,

7 we can find the money within this current system.

8 DR. POTOCZNIAK: Well, it's not really

9 a lot of money in the sense that they don't

10 adjust people's benefits anyway. I mean, like it

11 happens in one, two, three percent of the cases,

12 but it doesn't happen that often. But the fear

13 of it happening spreads mythical --

14 CHAIR LEINENKUGEL: And that's why the

15 strong word eliminate the possibility is so

16 critical.

17 MR. KUNTZ: Well, thanks to everybody.

18 I'm going to sit down.


20 questions or comments back to Commissioner Kuntz?

21 Really well presented, Matt, and really well laid

22 out and a lot of good information on there. So


198

1 congratulations to you and your group.

2 At this point in time, is there

3 anything else for the good of the order from the

4 commissioners? I know, Casin, you're pointing.

5 We will close with that. Any other pending

6 concerns or business items, except for the

7 whiteboard?

8 And we'll go to the whiteboard right

9 behind Jamil and Dr. Jonas. It's the time line

10 consideration for what we discussed yesterday in

11 open session, which was really getting to the

12 work screen and finalization of what's next.

13 So Wendy laid out a September 20th

14 date, which is a week from today, which is a week

15 from today, about getting some more refined

16 recommendations. And what you saw today, Wendy,

17 was that within the ballpark of what your

18 expectations were or --

19 DR. LaRUE: Absolutely. Based on all

20 the recommendations that have been presented over

21 the last two days, we have a good starting point.

22 I would say if any of the workgroups have


199

1 additional recommendations beyond what they

2 presented today that they should send them.

3 And I have a suggestion for addressing

4 the concern that Commissioner Jonas raised

5 yesterday with the workgroup not having the

6 opportunity to meet. And that would be if you

7 were able to send me what you have in mind and

8 I'll just kind of label those as tentative right

9 now but can start that process of seeing how

10 things group up and so forth. And then after the

11 workgroup meets, you can just let me know remove

12 these or, oh, we have these to add. That would

13 allow me to move forward with my process and

14 accommodate your need to have a meeting if that's

15 agreeable.

16 DR. JONAS: I mean, it's okay with me,

17 but it's up to everybody else.

18 DR. MAGUEN: I was going to say, too,

19 we're going to meet today before we go to the

20 airport, as well. So that --

21 DR. JONAS: Yes, and I sent around

22 some high-level ones last night for people to


200

1 look at them today, and I think Nick has printed

2 them out, right? So we can sit down and look at

3 them and if I can get feedback from that, given

4 the time line, I can incorporate that feedback

5 and send you one that has had some feedback in

6 it.

7 CHAIR LEINENKUGEL: Well, I think

8 you're a lot further along --

9 DR. LaRUE: It sounds like we're going

10 to be way ahead of the party deadline, but if

11 things occur to anyone between now and then that

12 isn't already in my hands or a part of what Mr.

13 Jonas just mentioned, just feel free to send

14 them. They'll go to me, John, Casin.

15 CHAIR LEINENKUGEL: And as chair, I'm

16 going to give Dr. Jonas and his group a little

17 bit of leeway here just because, as we noted,

18 they all have day jobs and night jobs. There's

19 going to be a lot of travel involved even after

20 we disperse, especially with Wayne as the lead.

21 So I would go much more meat on the bone type of

22 thing, Wayne. Maybe it's October 4th, tentative


201

1 day, I'm trying to give them two additional

2 weeks.

3 DR. JONAS: The Commission members and

4 especially my duty group will give me, after we

5 have our discussion this afternoon for the ones

6 that are here because there are some that are not

7 here, you know, if they'll give me and I'll ask

8 if they'll give me forgiveness rather than

9 permission. Then I'll go ahead and write out,

10 you know, as much detail as I think, more detail

11 than you probably even want. But realizing that

12 it's not all been vetted with folks --

13 CHAIR LEINENKUGEL: Fine.

14 MR. KUNTZ: Can I make a request that

15 Admiral Beeman be given the same time line?


17 MR. SPERO: What if we just said that

18 if your workgroup wouldn't have a recommendation

19 related to workgroup one that you've come up with

20 to do that work, if you don't have time to vet it

21 through Wayne before next Friday, can we just

22 send them all to Wendy then? Can we just say


202

1 that --

2 DR. JONAS: Yes, we sent five out at

3 a very high level, and we just need to talk a

4 little bit more concrete. I'll send them to you

5 by next Tuesday because I'm going to be gone, so

6 I don't want to have to be worried about it, and

7 I got other stuff going on after that.

8 DR. POTOCZNIAK: I don't really have

9 all my data yet. We were conducting the last

10 focus group on Friday, so I don't know that I can

11 get you guys, like I can neaten up the

12 recommendations I got, but I can't get you --

13 DR. JONAS: Like pretend it's

14 supported by data?

15 DR. LaRUE: I think what you presented

16 today is a good starting point for looking for

17 where there were overlaps and so forth. And it

18 is going to be an iterative process. In October,

19 all of that will get discussed anyhow, so I think

20 that will be perfectly fine.

21 CHAIR LEINENKUGEL: On behalf of the

22 COVER Commission, I want to thank all the


203

1 commissioners. This was a terrific, in my case

2 and a couple of us, three days, but exceptional

3 two days as far as the COVER Commission on open

4 session and also the amount of work that has

5 taken place. And as the people on the phone and

6 the people in the room know, it's been well

7 supported by the subject matter experts at the VA

8 and also by Sigma and I want to thank them for

9 their continued work, and there's still a lot of

10 work to go. And you just heard from Wendy as far

11 as some diligent writing and drafting that will

12 begin.

13 So I really look forward to five weeks

14 from now when we're all back together again and

15 getting to the points of debate, deliberations,

16 and then final recommendations in that October

17 session.

18 There will also, as a reminder, be

19 some of you commissioners will be pinged by John

20 and Casin and Dan who will put another day on the

21 Hill. And also I requested that there be a VSO

22 type of summit request go out to the VSOs so that


204

1 we can download and interact with them over that

2 October period, as well, which gives them a good

3 90 days out prior to the final submission.

4 Are all commissioners good with that?

5 Any other concerns or items for the good of the

6 order from the COVER Commission? If not, thank

7 you so much and this is not terminated. This

8 session is closed. Thanks, all.


10 went off the record at 1:00 p.m.)

11

12

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14

15

16

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18

19

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24:11 26:20 31:539:16 40:21 42:144:22 48:6 50:14 54:555:4 57:4 66:17 70:1678:17 81:14 82:2 88:992:11 93:6 95:4,14120:12 124:13 127:15138:7,8 184:16 190:9196:1 198:11,15203:15

GI 109:2giant 46:18 162:7

166:14gift 184:17give 7:12 30:7 46:14

56:3 113:16 126:2163:20 165:18 171:15194:18 200:16 201:1201:4,7,8

given 29:18 42:1246:19 57:1 73:1294:14 115:22 121:20122:11 184:16,19187:22 200:3 201:15

gives 35:9 204:2giving 196:10glad 75:8 145:18glue 107:15goal 102:7 119:15

145:15 152:12gobbled 58:18Goodrich 2:4 4:3,6 5:8Google 194:21Gordon 192:2gosh 75:10gotten 29:7 44:4 48:2

65:3government 30:1,13

57:22 58:8 59:8185:13

grant 173:19grateful 41:4 102:4,12gray 36:9greater 82:10 155:21greeter 85:10grill 169:9

ground 162:2 184:9group 7:14,21 28:11,18

30:6,13 31:3 33:1845:22 47:13 48:1549:16 61:22 82:19,2083:1 91:6 97:7 98:21101:17 153:1 166:5169:9 171:21 187:2192:17 198:1 199:10200:16 201:4 202:10

groups 11:13 12:5,1412:17,19 23:4 26:2128:15 31:1 33:4,2234:7,11 39:18 40:446:9 56:7 144:17156:13

grow 118:7growing 43:20 75:20GS-11 122:18GS-5s 182:19 183:13GS-6 187:14GS-6s 183:13GS-7 187:14GS-9 122:9guarantee 185:12Guard 109:14guess 37:11 48:21

70:17 75:17 76:14111:14 115:21 123:12178:12 188:9 191:19

guidance 164:13 194:5guide 162:10guided 125:19guideline 179:2guidelines 174:16,20

174:21 179:9,22180:22

guides 106:22guiding 187:8guns 174:4gym 167:21 168:1,3,9

169:12 170:3 171:2gyms 168:11

Hhailed 180:16half 71:3half-staff 182:22hall 76:8halls 62:13Handbook 69:9handle 45:16 69:18handled 165:16handoff 21:6 74:22 75:7

136:19handout 165:11 194:13

194:17handouts 27:21

hands 81:13 200:12hang 52:5 121:7HANIFAH 2:15Hannon 194:15happen 22:1 113:1

138:5 197:12happened 25:14 95:13

172:17happening 11:10 53:14

118:14 122:17,19197:13

happens 77:8 117:21146:8 157:20 162:3197:11

happy 62:16,17 78:21165:16

hard 20:6 59:2 72:592:9 151:9 152:12154:9 159:5,10,11162:1 176:18 192:11

harder 64:16Harrison 102:14 175:3Harvey 7:5 91:13hat 62:6Havre 105:8Hawaii 100:4,19he'll 186:2head 49:1 160:13heads 166:11healing-oriented

139:11healthcare 10:11 11:4

17:11 18:1 19:1221:13 24:20 56:20103:3,4 108:6 135:11155:21 173:22 180:18181:10,15,20,22184:13 185:22 189:14191:3

healthcare/mental191:3

HealtheVet 32:21 55:4healthier 168:17hear 13:16 23:7 33:6

41:20 46:11 49:1050:10 51:17 53:562:13,15,16 83:9 92:5117:5 153:11 156:22157:1 164:17 192:3

heard 9:5 13:13 16:321:3 41:9 49:11 92:1896:17,18 154:10160:3 189:4 203:10

hearing 12:17 31:6 38:941:6 46:7 51:22 81:22

heartbeat 147:22heavily 132:21held 88:9 180:10

Helen 155:4hell 115:11help 20:17 47:5 62:10

63:5 64:6 80:17 81:1882:22 95:8 97:21 98:7102:7 115:18 127:11138:20 139:1 141:15141:20 142:14 147:3147:19 173:10,19179:12 187:9 196:22

helped 35:4 76:12127:15 162:10 173:6

helpful 34:17,21 57:778:6,10,14 83:7125:14 149:9

helping 35:14 36:1239:12 40:11 82:8,1195:15 111:16 113:11155:15

helps 45:20herculean 40:18hey 19:5 35:17 131:11

144:20 193:17high 132:17 148:9,10

157:7 202:3high-data 157:12

158:11high-level 199:22high-risk 131:18higher 73:15 121:16

122:12highest 112:7 122:9,10highjack 105:1highlight 131:3 134:22

153:3 155:18highly 73:5 75:21 115:7hiking 51:13Hill 7:16 203:21hire 107:5 114:14 126:3

184:11hires 183:18hiring 185:12historically 106:19hitting 151:9hold 107:15 180:6holding 123:21 151:2holistically 189:13

190:21home 45:13 82:8,11

185:2,19homelessness 86:11homicidal 72:14honest 157:15honestly 48:2 160:9honor 5:18 6:13hope 113:17hoped 188:20hopefully 192:3 193:3


213

horrible 196:3hospital 74:14 85:8,12

85:17 103:12,13188:1

hospitalized 65:18Hospitals 141:7host 101:20hostage 180:6hosted 102:13,15hot 89:16hot-button 179:17

180:4hour 30:14hours 7:15 18:17,18

30:5 44:10 53:2060:10 62:8 89:4133:11 184:19 197:4

house 1:13 8:2 46:18HRSA 142:17 143:22

144:20huge 47:7 51:16 86:7

98:6 101:21 106:19108:11 143:22 146:16

hundred 107:6hurdle 60:13HVAC 7:16 8:2

IICT 108:13idea 7:12 23:18 56:4

57:7 168:7 177:21178:22 194:18

ideation 72:14,15 81:3identification 75:22

117:11identified 131:18identifies 76:16identify 34:19 35:4,13

76:11identifying 57:9IHS 103:6,8illness 1:18 2:2 5:16,18

93:15 113:5 163:9immediately 42:6impact 95:17 127:7

194:6impacts 140:16impediment 30:4impersonal 42:20implement 66:10,11

156:1implementation 100:14

106:15,16 125:3,4126:20 144:9

implementing 152:14166:12

importance 14:9 16:1316:19 34:1 60:16 81:4

106:9 153:12important 14:13,15

16:13 18:1 26:1232:12 34:9 37:12,1737:21 38:3 53:13 63:965:21 66:1 67:5 68:1887:16 95:8,16 96:6,10110:6 113:10,14127:5 138:21 140:3152:17 158:12,21168:19 172:9

imposed 110:1impossible 89:19improve 64:19,19,21,22

83:22 112:20 121:13152:7 154:12 181:12

improved 152:19improvement 64:13improving 127:18in- 37:15in-between 32:19in-depth 157:11 158:22

165:10 166:1 184:7in-person 40:5 42:9inability 30:6incentive 195:9incentivize 173:20

174:6 195:15incentivizing 168:7

195:8,10 196:11include 56:13 63:19

86:2 193:18included 86:18includes 91:12including 148:14

149:15inclusive 190:2inconclusive 159:22incorporate 200:4increase 79:6,15 85:20

114:2,5 115:1 116:1123:3 139:21 143:8

increased 181:19,21increasing 117:9

127:20Incredibly 155:13Indian 141:9indicated 135:10 165:7indicators 134:14individual 33:19 61:22

93:13 97:10 112:17113:12 117:6 135:15138:20 139:1 161:18178:21 181:4

individual's 45:13individuals 93:5 120:8induce 194:9industry 61:1

ineffective 157:16inefficiency 118:10,11inefficient 118:8inform 131:18informally 49:13 61:8information 42:4 51:10

59:16 60:12 62:2188:9 97:13 104:13149:1 176:14 197:22

informative 97:4infrastructure 123:7

144:13 173:15inhibit 30:16initial 76:21 107:9initially 97:7initiate 14:18initiating 15:1,5 18:10

57:8initiation 165:1initiative 1:15 6:9

189:18initiatives 172:3 189:17injuries 25:16innovations 144:3inpatient 170:5input 124:21 146:19inside 20:13 45:19 85:6

107:17 160:20insight 184:9instances 62:11Institute 1:15 6:10 97:3

155:3,14insurance 186:4integrated 1:19 6:5

74:20 100:6 167:17integration 84:22 85:21

115:5 116:1integrative 1:16 11:1

48:11 93:22 152:5155:5,8,22 156:7

intellectual 92:3intelligence 158:14intense 119:17intensive 120:9interact 204:1interaction 41:18 161:4interactions 103:7interagency 143:8interest 54:17interested 45:21 92:5

142:22 146:21interesting 43:17 47:11

91:20 106:6 119:8,22153:11,18 168:2192:15

interestingly 31:4180:14

interface 104:2 141:4

142:5,7 174:5intermediate 108:13internal 119:8internally 179:12international 156:13internationally 146:4interpretation 178:19interpretations 163:21intervention 37:13

159:7interventions 159:2,21

160:1 166:21,22167:18

introduce 27:8 39:4Introductions 3:11introverts 33:21intrusive 61:3intuitively 147:16invested 140:18investigated 98:3

141:19investment 194:10invoice 98:14involve 61:7,16 81:13involved 7:6 61:15,18

81:22 155:15 200:19involvement 14:14 16:8

16:12 60:16,21involving 60:18,20

61:21Iora 85:4,5iPads 46:22 47:8Iraq 110:9irks 181:7Israel 196:6issue 17:6 20:20 23:20

29:5 58:16,22 59:2,660:21 65:15 69:272:19 112:19 125:16137:13 168:13 169:10172:13 179:6,17181:17

issues 10:11,16,19,1913:4 15:21 24:6 25:329:6 32:7 44:9 57:957:10,15 61:17 64:983:5,19 84:20 85:1891:10 92:21 99:5108:15 120:15 131:1151:20 152:1,6162:14 163:2

item 149:18items 87:20 198:6

204:5iterative 202:18

JJack 5:13 91:19 107:22


214

114:1 119:5 143:13149:13

Jake 1:11,13 4:14 5:1010:1 79:19,19 91:12

Jake's 41:11James 99:1Jamil 1:17 4:19 6:12

91:12 122:16 184:15188:13 198:9

January 8:9 39:17 47:2166:2 168:11

jeez 196:13Jen 154:6Jennifer 40:13Jesse 180:15,18job 58:11 59:8 66:8

85:7 87:17 90:1 98:998:16 99:9 119:2121:21 122:2 130:20130:21,22 141:15196:3

jobs 111:19 200:18,18John 2:1,4,8 3:17 4:5

4:15 5:8 71:11 73:673:16 79:2 88:7 89:391:1 101:11 107:2108:10 132:13 134:2134:13 146:9 152:16153:20 154:21 162:15163:4 164:14 175:12194:15 200:14 203:19

join 4:21joint 108:8 144:15Jonas 1:16 6:15,15 9:6

82:15,18 85:5 86:6,2092:22 100:20 101:13113:22 114:17 115:3115:14 116:19 117:5126:15 133:21 134:4135:5 136:3,6,14137:7,16 138:6 139:5142:13 143:21 145:3145:18 147:6 148:7148:15 149:3 190:16192:19 193:10 198:9199:4,16,21 200:13200:16 201:3 202:2202:13

Joyner's 161:21jump 27:13jumps 157:3Junction 11:17June 98:22 166:3justify 174:18

KKaiser 59:11KATHRYN 2:7

Katie 40:13keep 8:1 63:3 84:8

125:8 174:4 181:8,9188:22 196:1

Keita 160:13kept 38:18key 8:1 32:16 93:15,20

94:8 149:18,18Khan 1:17 4:19,21 5:1

6:12,12 36:20 46:1559:13,21 60:2 74:780:12 91:13 121:6,11122:10 183:15 184:14187:17,22

kinds 34:14 48:16134:12 147:2,11148:1 169:19

Klocek 2:8 73:8,17 79:394:22 107:4,7 129:8129:13 134:2,3,9,19135:8 152:16 162:15164:14,16 165:11174:13 175:5 176:6

knew 30:12 35:7 36:10192:19

knowing 14:5 17:2,3,1419:1 23:8 24:2 60:7192:12

knowledge 23:4,548:13 53:10 63:2179:6,15 97:11

knowledgeable 85:11known 81:6knows 23:20 117:13

130:11Kuntz 1:17 3:20 6:18,18

15:22 75:12 102:4103:12 105:15 106:2111:14 116:4 119:7134:8,17 150:14151:3,4,5 165:10166:9 169:8 170:1,21175:7,13,20 176:2,7176:19 178:12 180:12181:8 184:6 186:8188:9 189:6 191:10191:18 194:12 195:1196:17 197:17,20201:14

Llab 141:10label 199:8labeled 173:1labor 73:11lack 18:15 22:10,12

23:4,5 36:14 37:8,1038:12 45:7 48:13

54:13 56:21 57:1160:12 63:20 66:5,1266:13 67:17 84:17104:22 105:1 106:8118:2 179:15 180:20

lacking 104:11,17105:13

ladies 4:3laid 197:21 198:13large 21:20 71:16 99:10

146:5larger 38:6 72:7,9 74:1

111:9LaRue 2:10 12:20 27:12

29:10 30:4,22 34:635:19 36:4 39:14,1440:8 46:3,6 50:13,1650:19,22 51:8,21 52:353:13 125:1,8 166:4173:18 198:19 200:9202:15

late 8:9 59:4,10Laughter 19:16 89:13LAURA 2:13Lavretsky 155:4law 86:18 187:2,19layers 136:13,21laymen 93:10lead 1:21 4:19 9:20

28:12 135:1 186:15189:22 200:20

leader 91:14leadership 67:22

125:22leading 153:2 154:18

154:22 155:11 162:10173:5

leads 7:7 155:1 192:17leap 64:20learn 17:11 21:1 31:21

42:1 52:9learned 49:7 104:5,8learning 17:21 18:2

29:8 48:15 54:18102:17 108:4

leave 72:1 129:19 134:1leaves 188:3leeway 200:17left 29:5 70:11left-hand 87:12legal 152:10 163:5Legion 28:6legislative 26:2Leinenkugel 1:11,13

4:14,15 5:2,10 7:2,316:16,22 18:5,13 20:820:22 22:9,12,17 26:726:11 27:7 39:2,6

43:16 45:4 78:16,2287:14 88:1,14,19 89:889:14 90:8,10,1891:12 107:22 110:12110:15,20 113:20118:19 125:13 126:18143:11 145:10,16149:13 150:22 151:1151:6 188:21 192:14192:21 194:22 196:21197:14,19 200:7,15201:13,16 202:21

length 8:5 127:19let's 89:1 90:11 91:17

95:11 138:12 144:21163:22 166:20,22167:18 189:2

level 5:16 26:15 28:572:4 116:6 158:3,4159:9 162:1 167:12170:17 171:6 174:7176:4 178:15,21181:16 182:15 195:3195:11 202:3

levels 53:9 69:21 84:993:13 133:3 157:14160:8

liaison 38:16license 186:1licensing 116:5,17licensure 109:21life 59:9 112:2 113:12

113:13,16,18light 45:7 55:14liked 14:4 41:8 161:15

161:16limit 161:12 166:17limited 105:22limits 159:17line 116:5 150:18 161:9

198:9 200:4 201:15link 77:11 107:15linkage 189:20linked 100:11links 139:13list 21:4 87:19 127:17

153:2 171:17listen 63:1 93:3listening 40:21 93:8lists 87:11 149:20listservs 28:7literally 52:4 130:22

131:5little 12:13 16:8,11,17

18:7 26:8 27:1 31:1746:14 65:2 69:2272:19 74:19 80:3,7,780:12 101:16 105:12


215

131:14 139:4 146:17146:19 151:12 161:22163:13 164:15,17167:9 170:8 171:15178:6,16,16 188:17189:7,7 200:16 202:4

live 5:17 90:14 102:22183:1 184:20 187:6

lived 120:14lives 94:17 104:17

158:10 160:6living 103:7LLC 2:6,12,16,20local 5:16 28:5 35:21located 43:20 143:15location 103:5locations 37:14 38:4locked 19:3log 55:3long 69:10 104:10

112:13 140:2 167:13long-term 105:20 187:5longer 110:11look 10:13 11:6 13:2

31:17 73:11 93:1095:12 106:18 112:11115:17 134:12 138:17145:21 146:22 148:12160:19 164:18 167:18168:14 171:11 190:20190:22 192:5,10200:1,2 203:13

looked 146:4 148:17163:2,11 164:22174:13

looking 9:15 43:9 86:394:5,21 95:3 97:8109:3 125:20 144:2144:17 160:15 189:12196:9 202:16

looks 163:18loop 142:8Los 155:21lose 121:1 195:21losing 153:16,17lost 6:19 160:7 178:13lot 8:18 14:15 17:11,15

19:2 22:6 23:7,20,2124:13,16 25:14 27:427:13 28:21 33:1134:3 38:6 41:15 42:1045:11 47:7 48:2049:13 53:6 58:1,9,1160:22 61:4,6,12,1262:12,19 63:16 64:3,764:12,12 65:4 67:369:14,14 73:15 77:978:9 79:13 88:15 92:2

96:7,17,18 103:15104:6 115:6 119:7,20135:20 137:14 139:16147:20 149:21 160:18166:14 172:4 173:16181:14 185:12 186:7190:15 194:4 195:3197:9,22 200:8,19203:9

lots 54:1 83:11loud 154:11 156:6

172:18louder 80:13love 126:1,9 145:10

167:3 191:18 192:3loved 145:17Lovell 99:1,11 100:5

180:15,15low 29:1 50:7 73:21

157:8 174:18low-data 157:9 158:7

158:12 159:2 160:5160:10 168:21 172:5

lower 69:21 72:4182:15 194:11

LPN 135:21LVN 135:20 136:17Lyft 185:11

MM 2:1M.D 1:16machine 47:3machines 46:21Madhukar 155:9Maguen 1:19 6:2,2 9:11

42:7 43:15 50:20 51:370:1,21 72:11 74:1881:7 93:20 110:19111:2 120:5 121:4,9128:14,17,22 129:16130:5,18 131:13132:9,12,20,22133:13,18 136:12,17137:17 142:1,4,10145:14 148:4,14,20149:6,8 156:10 157:4164:5,13,18 169:18170:16 176:10 177:4177:7,10 178:1 189:5192:11 199:18

main 39:16 157:3 183:9maintains 36:5MAJIE 2:11major 6:1 54:5 89:3

147:8 154:5,8,11majority 33:3 46:20

54:15 55:12 109:2

166:19majors 146:7makeup 21:2making 40:8 64:10 80:3

168:16manage 70:19 186:16management 105:17

122:12 141:10 144:6manager 2:19 21:15

22:3manages 184:17managing 92:7mandate 26:2 57:21

58:3,3,13,14 70:15,1871:5 93:7 127:22132:10

mandated 67:15 130:6130:11 134:6 135:10135:13

Mann 154:21 160:22mapping 73:11March 153:2 164:6Marine 1:17 5:11 6:7,13Martinez 1:22massive 162:9match 15:15matrix 83:18Matt 3:20 6:7,18 26:7

71:18 91:12,16 102:1112:11 116:3 128:10151:3 193:9 195:5196:21 197:21

matter 2:8,17 7:9 24:1559:16 70:9 90:15150:19 164:14 188:11188:17 193:22 196:5203:7 204:9

MATTHEW 1:14,17maximum 115:5McCarthy 134:13

153:20McDonald's 66:15,16

67:11McMAHON 2:13mean 26:2 33:10 44:16

45:6 50:7 62:3,664:19 66:10,14 73:2073:22 77:10,19 84:1,586:10 92:15 102:2103:15 104:16,18110:20 112:5,8,11114:17 115:6 117:2117:16,17 122:20126:8 127:15 128:11129:16 139:5 143:21157:16,19 158:7,8163:22 164:1 170:17171:6 175:17,18

182:7 184:8 187:2188:15 192:6 193:19196:22 197:10 199:16

means 17:1 102:9,10102:11 163:17 182:21

meant 165:17measure 148:8measured 156:8meat 149:21 200:21media 27:2,17,18 31:4

55:9medic 108:4 109:16Medicaid 185:16 186:4medical 1:20 10:10

13:3 53:5,6,19 54:6,855:1 69:20 74:1 93:7

medical-centric 147:13Medicare 168:2 169:4

174:7 185:16 186:4195:11

medication 11:3,3 51:193:12

medications 72:13medicine 181:1,2 188:1medics 109:12,19

115:6 116:13meditate 52:10meet 58:3 68:9,19,19

69:6 120:2,4 142:20154:20 199:6,19

meeting 4:5,8 9:3 58:1258:13 152:21 199:14

meetings 7:20 152:22181:15

meets 68:4 142:19,20199:11

member 2:1 14:18 52:261:7 62:20 160:7161:17

members 7:16 16:7,1081:17 83:12 92:1994:15 98:6 181:22201:3

membership 91:11169:21

memberships 167:22168:1,3 169:13 170:3171:2

Menlo 20:1mention 37:22 38:3

95:19mentioned 18:9 101:11

172:10 200:13mentioning 132:13messaging 32:19 33:1met 1:10 54:4 120:13

152:18meta 82:20 84:13 85:1


216

methadone 179:18method 43:11 48:6

89:21methodology 89:21

156:9methods 32:8 156:15

159:14,18metric 134:20 145:19

146:1 147:6metrics 146:14,15

147:1metropolitan 183:7Miami 11:16MICHAEL 1:20middle 16:18 28:18

152:15Mike 3:14 5:20 9:20

21:9 31:12 58:21 62:377:5 78:17 87:1788:10,21 89:8 90:2195:19 96:22 125:16

Mike's 120:6 126:1miles 43:20 53:7milestone 8:11milestones 8:6military 1:15 6:8,17

13:9,11 16:14 17:1822:7 94:16 158:13

million-plus 170:13millions 168:13mind 125:8 199:7minimal 28:13 164:19Minneapolis 43:21minute 5:3 26:18

132:16 150:12 195:9minutes 19:18 87:16

150:18 180:19missed 42:22 43:1

54:22 165:20misses 136:18missing 130:1mission 65:2,22 98:8

158:16 177:14 178:9179:20

mitigation 141:10mix 29:15mixed 30:1 33:17modalities 138:22model 84:8 86:3 92:14

93:17 114:11,12119:11 125:18 139:6139:6,10,11,12146:21 156:1 161:2161:15,16,20,22173:6

modeling 153:22models 66:9 83:13

93:22 139:8 148:13

194:7modified 132:3modularity 94:1MOHAMED 2:15moment 39:21 129:17Monday 88:5monetary 42:6 196:11money 68:5 84:3

103:14 159:8 189:11191:6 196:13 197:6,7197:9

monitored 132:19,20134:20

monotherapy 50:9Montana 1:18 6:21 7:1

21:20 31:21 36:3101:18 104:18,18105:7 106:8 111:16120:1 175:1,7 178:22

Montana's 105:13Montanan 102:14Monterey 101:6month 7:21months 29:21 44:2

110:10 183:16,22187:12 188:4,6,7192:22

Moran 194:20morning 4:3,16 6:12

9:16 112:19 125:17131:6

motivation 122:13MOU 170:14mouth 49:8move 31:5 40:22

138:12 147:3 156:18171:17 199:13

moved 29:12 31:7movement 106:19moving 125:9 155:5

156:13MSA 78:15MSAs 183:14MST 193:18multi-decade 161:1multiple 13:21 83:11

131:21 133:3 164:3165:6

mute 90:13 150:18mythical 197:13

Nname 4:5 39:9 76:15

77:5NAMI 1:18 2:2 6:21 62:5

111:15 190:14Nashville 11:16nation's 153:1 154:22

155:11 173:4national 1:10,18 2:1

5:15 26:15 28:8,1296:16 97:3 153:9155:3,14 158:3170:17 172:2 176:4178:11 181:16

Nationally 73:8nationwide 175:15nature 42:21Naval 100:8navigate 17:3 18:2

20:14 36:12 60:879:14 104:3 112:18186:15

navigating 38:17navigation 85:17

115:19navigators 84:6Navy 2:1 5:13 108:19

109:13neaten 202:11necessarily 17:14

58:22 111:7 190:4necessary 9:9 104:13

159:19need 19:5 20:17 25:18

31:17 40:22 62:9,1072:12 83:5 93:2,396:10 98:15,17 99:9106:13,15,22 107:19111:12 114:1,5,14,21124:14,18 131:4132:3 140:4 143:6144:12 145:9 147:19150:1 154:12,13158:5 168:22 189:20193:13 194:2 199:14202:3

needed 35:17 53:21111:22 184:10

needing 14:11 38:21needs 9:7 38:2 68:20

74:15 83:21 84:15106:13 114:8,9120:13 128:13 141:13149:21 172:1 179:11

negative 157:20negatives 183:12net 120:17network 35:22 49:8

79:7,16 87:6 108:7networking 51:16 52:8never 22:3 25:3,6 28:20

48:22 119:2 137:10190:22 195:19 197:2

new 11:15 15:1 18:1031:8 62:19 109:5

145:19news 182:2newsletters 51:9 55:3nice 88:20 103:17

116:10 142:16 154:19156:14 161:7 170:12191:4

nicely 43:20niche 116:7 167:19Nick 2:11 200:1night 15:13 28:19 57:19

57:21 58:5,17 89:12199:22 200:18

NIMH 189:16 192:2NIMH's 159:11nine 122:13no- 73:5no-go 138:7no-show 73:13 74:4no-shows 72:19,20non- 30:12non-department 10:14non-VA 22:21 23:3

24:11nonprofit 36:8nonsatisfaction 42:13normalized 137:22normally 83:15 164:8Northern 12:1 143:18note 5:5 7:11 53:14

87:19noted 200:17notes 14:6 43:10notified 65:18,19notify 4:9noting 7:3 12:18nuance 163:5 171:15number 30:8 46:4 52:3

70:2 107:3,4 114:2,5115:1 117:9 127:20128:22 129:1 143:14151:18,19 155:18156:17 162:13,19164:4 174:14 176:11176:15 179:4 181:19181:21 182:10 186:2192:7 193:19 195:16

numbers 29:1 31:16,1895:1 123:3 134:12163:5 164:1,2 165:8171:11 174:17 175:14176:8,11 192:1

numerous 9:13 192:16nurse 59:20nurses 38:15

Oobjectives 92:2


217

observation 127:6observe 74:10obviously 15:6 42:10occasions 97:15occur 83:21 200:11occurred 106:21October 7:21 186:13

200:22 202:18 203:16204:2

October-November8:22

OEF/OIF 1:19offer 175:8,9 180:19offered 152:3 163:15

176:18offhand 107:5office 28:6 62:8 65:14

96:17 131:5,6,10officer 2:13 4:6 36:22

39:15 100:8 182:8183:16 184:1 187:11188:3

officers 37:5 182:3183:13

Official 2:4offset 194:6oftentimes 72:11

129:20old 43:10,11 184:16older 34:3 46:8 47:12

47:13,18 54:11OMB 29:22onboard 8:17 91:4once 15:2 30:2 44:7

107:19 132:14 138:2one-stop 138:3ones 38:18 41:3 100:10

167:20 199:22 201:5ongoing 7:19 41:12

46:22 70:5,7 108:12134:21 142:5 189:18191:1

online 194:19open 1:5 72:2 90:20

198:11 203:3operate 143:1 158:15operated 101:14,15

152:8operating 182:22operational 100:21

101:9opinion 176:9 195:21opinions 41:5,8opportunities 52:8

53:22 54:1 94:22opportunity 41:5,7

45:10 55:1 98:22 99:3101:19 108:1,11,22

109:6 140:19 143:19151:7 191:9,14 199:6

opposed 69:19optimistic 69:12option 48:19options 1:3 79:8order 17:13 66:22 67:17

198:3 204:6ordering 66:18Oregon 153:5organization 36:22

37:2,4 98:6organizing 92:7original 107:5originally 148:8Orleans 11:15ortho 68:16other's 41:6outcome 196:9outcomes 87:7outlying 183:5outpatient 19:15

166:18,20,21outreach 11:6 12:8 28:1

28:3 123:9,12 141:16outside 20:13 23:1 24:7

45:20 56:17 58:7 62:885:6 97:20 98:11107:16 152:21 160:19167:2 183:18 191:22

over- 67:14over-simplification

26:17overall 34:12 73:18

153:15overlap 139:7overlaps 202:17overly 66:14oversight 143:8overviews 149:17overwhelmed 166:5owe 87:21 94:16 150:6owed 143:13owns 88:2

PP-R-O-C-E-E-D-I-N-G-S

4:1p.m 58:5 204:10PAC 21:2 74:15,20page 114:20paid 30:13 42:1 64:18

94:18 112:7 167:1182:18 183:10 196:1

pain 136:7 181:14painless 141:4 142:4

145:11,11 147:1,18Palo 19:11 21:20 119:4

119:19 168:6paper 43:11 165:21

166:1 170:10,22171:14

papers 165:21 167:15171:10

Paperwork 181:11,14Park 20:1part 6:13 12:12 13:1

21:8 22:19 24:1,1732:5,20 38:5 39:1141:14 48:8,9 55:2256:12 57:12 63:13,1663:17,19 66:5 80:486:5 93:12,14,1694:11,19 95:10,16,17101:17 102:5,7 111:4111:15 119:8 126:20135:22 137:21 140:3142:6 146:11 153:13158:5,17 161:7172:11 173:22 182:14186:3,15,16 200:12

partake 103:8partaking 26:5participant 11:20 31:1

53:17 69:12participants 4:17 36:4

52:4 63:18participate 28:9 30:10

41:22participating 30:12

49:19participation 12:9

28:13particular 128:3 172:5partnering 193:4partners 88:8 98:10

103:22 173:20partnership 108:9

185:15parts 92:15 98:21party 200:10passionate 96:9path 156:16pathogenic 139:10patient 15:1 18:10

47:21 63:7 128:20129:19 145:22 146:18146:20 147:15 148:10185:19

patient's 185:19patient-centered 10:5,6patient-centric 148:2patients 6:16 71:22

85:9 112:4 123:22130:13 147:9 185:10

pause 15:18

pay 64:21 98:18 167:6,7168:8 169:22 170:2,6171:1,1,7 181:19,21183:1,6 184:2 186:5186:10,11

paying 24:15payment 98:13pays 179:5peer 20:16 34:16 35:8,8

35:13 36:6,10,15 51:675:12,16,19 76:1,2,776:9,13,17,20 77:579:5,13,21 80:4 84:5105:3,6,7 106:7,9,16107:1,11,14,20108:14,17 110:1,21111:16 112:5,11114:3,10,18 115:16116:10 117:10,19118:1,5,16,22 119:8119:10,14 120:7,11120:19 121:2,14,17121:18,20 122:1,18123:2,8,20 124:17126:1,4,12,22 127:2127:20 181:19

peer-to-peer 48:5 124:1peers 106:20pen 43:11pending 198:5people 10:2 13:21 15:5

15:6,7 16:5,6,9 17:1122:1,2,7 23:18,2224:11 25:15 26:1927:3,4 29:10,14 30:530:15 33:14,20,2134:12,13 38:2 41:1545:19 47:12,14 48:649:1 51:9 59:3 60:969:5 70:6 72:11 75:275:6 81:2 83:14 84:684:11 87:1 89:2294:17 96:2,8,11102:15 104:6 108:2118:17 120:21 123:17131:1 138:2 157:19161:8,11 168:9,13169:7 176:3 180:9182:4,17,19 186:21199:22 203:5,6

people's 197:10percent 73:7,13 74:3

103:19 108:6 193:17194:1 197:11

percentage 73:7 151:21152:1 162:17,21163:14 176:13

percentages 193:21


218

perfect 88:17 149:6197:4

perfectly 202:20performance 134:20period 13:22 44:15

119:16 169:20,21204:2

permission 201:9person 17:12 27:13

34:20 36:11 37:16,1738:10 42:22 43:5,7,1345:16 47:15 51:160:11 76:8,12,12,1777:15,17,20 78:5,1178:14 88:3,4,5 93:1798:14 110:21 112:21114:15,19 115:16116:8,9 117:22 118:1118:6 124:19 131:4132:16 137:1 146:20162:2 170:13 182:7188:5

Person-Centered 146:1personal 43:4 179:20personalities 33:20personally 30:12 58:4

73:20 195:19 197:5perspective 111:15

147:3 148:10pertains 80:20Pew 26:16Ph.D 1:19,20 2:17pharmacist 181:5pharmacy 181:4phase 171:14Philadelphia 11:16Phoenix 86:10phone 4:9 10:3 39:7

47:21 90:12 149:16157:1 171:18 173:10185:21 203:5

physician 6:16PI 159:4pick 76:7 184:20,21

186:2picks 68:20pie 70:10piece 70:11 75:15 80:5

113:9 121:1 122:20128:11 140:3 150:5152:20

pieces 162:8piggyback 54:2pilot 29:22pilots 186:6pinged 203:19pipeline 183:17place 21:15 104:10

123:8,22 129:14,20131:21 138:9 169:16174:4 185:5 203:5

placed 194:10places 40:2 86:9 119:18

119:20 176:13 179:16180:9 184:22

plan 30:1 101:12127:12 128:6,8,11129:13,17,20 131:7131:11 152:19 162:7166:15 170:11 173:22

plans 129:1 168:3169:4 173:14,17174:1,8 195:12

platform 41:9play 171:16 189:7please 4:21 10:4 32:4

39:4,8 48:7 81:18159:12 160:11 162:4163:12 165:20 175:4

Pledge 4:20,22plight 58:18plug 143:20plus 113:5poignant 190:13point 8:16 9:14 18:7

25:10 30:11 41:2,1144:20 49:20 50:1654:5 63:9 70:1 71:876:2 78:17 81:6 83:688:22 93:6 106:6,13118:18,20 120:6126:1 128:5 132:1134:13 135:15 156:20165:9 167:10 168:10195:3 198:2,21202:16

pointed 93:20pointing 191:2 198:4points 48:12 54:9 145:4

203:15police 181:22 182:3,8

182:14 183:3,12,13183:16 184:1 187:11188:1,2

police-wise 182:22policy 67:14 69:19

70:15policymakers 165:19POLLACK 2:17pool 164:12 165:3,13pooled 162:15 164:7

165:8pools 152:15 162:12

164:8 174:13poor 84:18popped 195:7

population 94:11,20148:18 153:18 168:16

population-level159:22

portal 55:5Portland 158:20position 71:13 116:17

190:4,5 196:2positions 101:3positive 52:1 55:8,15

129:18 137:3,8,14173:8

positively 135:13positives 159:16possibility 138:8 172:7

195:17 197:15possible 31:13 104:1,2

113:8 140:1possibly 31:14 69:20

104:8post 27:18post- 23:11,15 137:18Post-9/11 6:4post-traumatic 6:20posts 27:20 28:7pot 103:14 124:13potential 55:21 56:12

57:16 63:12,18 95:2096:2,6 141:20

potentially 66:2 111:8125:2 157:6

practice 7:19 61:3 94:7164:11 174:16,20,21179:2,9,21 180:17,22

practiced 74:12,17practices 157:8,10

186:20 187:3practitioners 179:3pragmatic 191:5precise 135:4precisely 137:18predictive 153:21predictors 159:15preeminent 155:12preference 10:17 32:6

33:18preferences 42:11preferred 44:21preliminary 149:17premature 56:3premise 167:5prescribed 93:8 133:12prescriber 140:2prescribing 11:2prescription 11:3present 1:12 2:3 37:10

121:14 122:7 154:21169:9 181:22 184:14

192:2presentation 80:6 93:2

142:16 158:22 172:19presented 140:9 153:21

154:2 197:21 198:20199:2 202:15

presiding 1:11pressures 115:10pretend 202:13pretty 25:11 28:13 29:1

54:15 102:2 119:17133:14 162:1 190:22

prevalence 11:2preventing 134:7prevention 127:22

128:4,11,18 130:17133:1,4 134:5 152:13153:12,14 154:18155:1,2 158:3,20159:5,21 160:14,16172:3,5 173:5 189:17192:9 194:16

prevents 170:7previous 103:3 134:15

188:22primarily 51:8 135:6primary 21:3,11 25:8,12

25:18 51:6 52:14 74:874:9,12,21 75:4 76:597:16 135:19 136:6,8136:9,18,18 145:20146:1 148:5,8,11191:8

printed 200:1prior 130:9 160:13

204:3priorities 68:1,14,15priority 28:9privacy 61:17private 17:11 29:11,16

44:12 61:1,2 187:4privately 64:18probably 23:20 31:17

33:20 40:1 46:8,1347:17 61:11 62:1068:17 71:12 75:1283:22 84:3 105:10109:10 117:18 146:22155:12 178:15 194:5201:11

problem 17:5 57:1369:6,7 80:1 81:1885:16 107:16 109:19109:21,21,22 117:6126:15 132:8 168:4,6183:21 187:13

problems 65:2 83:10,16105:19 107:10


219

process 19:2 38:1741:12 57:8 64:8 93:11124:10 138:18 140:4144:9,21 170:10199:9,13 202:18

processes 66:7 67:4139:13

prod 173:10produce 194:8produced 134:11productive 7:18,18professional 184:12professionals 10:15

135:16program 2:19 21:16

36:5,7,15,19 61:20105:4,6 118:16 126:9134:5 144:7 153:10153:22 154:3 173:19174:9

programs 1:16 119:14169:12 171:8 191:1,4

progress 8:3project 2:15 7:7 159:5prolonged 33:8,10,14promise 63:3promising 160:1promotion 116:9proper 107:10properly 119:1proponent 161:1protect 182:19protection 136:21protocol 127:22 128:18

130:1,9,9,13,17131:15 132:16 133:7135:5,13 164:20

proud 78:20 102:15prove 130:12 167:11proven 158:1 173:11provide 41:8 45:1 46:22

47:7 104:8 115:4116:20 117:1 119:9123:21 124:1 126:13126:14 144:22 163:4169:12 177:15 178:22184:18 187:8 189:15

provided 42:18 50:553:22 81:4 141:21166:19,21 173:18181:13

provider 17:7 44:845:18 48:20 49:1051:5,6,19 52:13,13,1562:5 65:19 75:1,482:6 126:4,7 130:6,11147:18

providers 13:7,12,18

13:22 14:4,5,6 31:932:19 33:2 37:9 38:538:13 43:9 48:22 51:751:17 52:20 53:256:14 60:17,19 61:1361:15,19 62:19,2064:15 65:9,12 70:395:18,20 135:12167:2 175:6,9,21177:12 178:6 181:15

providing 66:9 82:1086:15 96:11 98:14144:18 167:21 168:1177:18,20 178:20

Prozac 171:4psychiatrist 78:5

155:20psychiatrists 45:7

177:20 179:19 180:2Psychiatry 154:17psychologist 5:21 6:3

60:4 77:22,22psychologists 61:5

130:20 161:8psychotherapy 165:1PTSD 6:5 42:20public 92:13Puget 12:3pull 27:3 119:4 122:21

153:18pulled 183:3,4pulling 123:17purpose 34:20pursue 172:8 195:18pushed 37:22put 18:7 24:14 43:18

71:13 82:13 105:22143:4 149:22 203:20

putting 8:18 62:5 180:7

QQuadruple 92:14 94:12

94:19 147:8qualifications 114:15

114:20qualified 31:15 98:1

141:6 142:15 143:14144:10,20 145:8188:5

qualify 169:16qualitative 41:17quality 15:3 30:16 59:9

59:16 91:9 113:12,13116:21 117:1 145:22146:6,10 147:8,12148:9,11 181:13

question 20:10 42:752:12 78:11 111:3

113:22 115:21 148:16166:14 175:16 176:10

questions 5:6 15:1921:4 22:18 24:1738:20 57:3 63:14,1466:4 97:8,10 127:15135:10,12 145:5147:7,16 148:1,21149:11 197:20

quick 39:21 42:7128:14 150:11

quickly 58:19quite 47:9 74:11 93:17

127:14 130:7 139:7144:10 146:9

Rraised 61:5,5 199:4Ramoni 192:5range 73:18,21 109:10rapidly 145:3rate 73:13 95:20 96:6rates 74:5 87:8ratio 68:3,4,8 69:4REACH 131:16 153:21reaching 8:10 12:20

81:11read 14:5 26:2 55:3

147:15ready 31:5real 39:21 155:18

168:10realistic 102:21 103:20reality 62:22 126:5realize 158:5 186:17realized 8:13 29:11realizing 201:11reason 41:14 42:17

48:3 81:3,16 82:12165:14 177:19 188:3

reasons 42:12 56:1694:13 112:16 168:18

Rebecca 148:16recall 34:2recap 7:12receive 104:12 141:5received 29:19 31:2,7

33:5 174:14,18176:16

receiving 51:9recognize 81:2 98:17recognized 90:1recognizing 96:5recommend 55:6

143:10 149:2recommendation 8:15

57:16 64:17 65:8 66:382:13,16,21,21 83:7

106:14 109:5 114:2117:9 122:6,11 124:5125:4 126:19 127:7128:9 132:6 139:15149:20 164:6 174:19175:14 179:8 180:13182:14 187:9 201:18

recommendations 8:209:13 54:20 55:2256:12 63:12,19 80:1684:13 90:3 98:2106:12 124:9,14127:6,17 156:18162:6 171:18 193:16198:16,20 199:1202:12 203:16

recommending 88:2record 24:19 43:18

90:16 108:1 110:4150:20 190:6 192:15204:10

records 24:13 43:8 65:4recovered 110:2recovery 1:3,21 7:1

112:12,14,22 113:8,9113:15 138:18 139:5152:6 153:13 156:1194:9

recovery-oriented138:15 139:11

recreation 51:10169:15

recruiting 23:1 29:1730:5

recruitment 13:1927:14

red 186:7redefining 114:17reduce 161:13reducing 133:22 134:7reduction 172:8 181:11

181:14 195:17reexamine 114:9refer 74:10 164:13reference 30:11referral 19:9 50:4 51:20

177:16referrals 179:18refilled 72:13refine 159:17refined 141:14 198:15reflect 171:11 176:13refrigerators 157:19refuses 178:22regard 134:15regarding 10:18 32:6

33:18regardless 25:13 135:9


220

158:4 168:19regards 179:9regions 10:7regular 183:9regularly 142:21regularly-scheduled

152:22Rehabilitation 186:18related 23:5,6 25:3

52:22 54:14,21 55:855:17 56:14,18 63:2166:6 80:16,19 87:1092:21 201:19

relates 135:3 140:14141:1

relationship 86:4relationships 104:13relatively 43:19 163:6release 62:21relevant 44:18 92:8

165:18relied 119:9remarkable 152:16remember 125:14

143:16 163:16remind 13:1reminder 136:9,10

143:12 203:18remote 47:1 104:7remotely 4:9remotest 104:10remove 199:11replace 188:5report 8:8 13:14 18:9

37:8 39:16 50:1 182:9193:5

report-out 164:7reported 13:6,17 14:9

14:22 15:7,9 16:1923:3 24:5 32:10,1733:4,6 37:14 42:1648:18 49:7

Reporting 97:13represent 186:22representation 23:2representative 2:14

96:16request 165:2,13

177:12 192:8 201:14203:22

requested 9:7 190:8203:21

requesting 190:17requests 192:16required 136:4 160:2

187:20requirement 128:8,13requirements 111:1

reschedule 11:21research 6:22 8:11

26:16 30:16 83:3,494:5 97:2 156:3157:18 159:9,17172:4 173:17 189:3,8190:15 192:1,12,18193:17

research-proven 172:3189:16

researched 35:15researcher 6:5 155:12

155:19researchers 156:15

162:11researching 155:6reservation 22:2 103:8

104:9Reserve 1:21Reservist 6:1,8residential 111:20resilience 139:14resort 81:19resource 84:1 97:14

98:12,17,18,18172:20

resource-lacking 45:2resource-poor 105:16resources 22:15 60:11

60:13 70:19,20 84:291:8 92:8 97:17,20,21117:13 118:2,7151:16,17,21 162:22193:13

respect 10:22 20:1145:13 48:10 62:392:20 94:1 95:2,9107:17

responded 177:1responding 110:13response 33:17 135:22rest 71:22 94:17 113:15restart 90:12result 135:17 161:4results 12:10 25:12

95:4,14 159:1 164:15173:7

resumed 90:16 150:20Ret 1:17,17 2:1retention 13:19 56:14reveals 70:14 102:20review 60:17 130:22

153:6 158:18,22162:10 171:22 191:1

Richardson 172:16Richmond 11:21,22rigid 133:14risk 132:17 135:15

153:22 158:20River 11:17RN 135:21road 40:1 106:21

117:12robust 119:13 139:19

143:1robustly 58:13 143:10role 27:8 34:18 39:16

78:18 80:4 93:18108:18 109:16 110:3110:22 111:7,11114:10,18 115:17,22119:1 121:22 122:7123:9 124:17 125:18

roles 35:22 39:7 107:21111:8,13,22 114:4,7,8114:13

roll 133:17rolled 32:13 69:9,10

75:19 104:21rolling 66:8 144:3rollout 65:1,22room 31:7 61:10 77:6

79:18 112:8 116:13116:14 149:15 150:13171:19 203:6

rooms 173:2,7,9,12root 180:21Rose 2:1 3:17 5:13,13

5:22 20:10 31:12 32:245:5 46:5 58:21 59:559:12 62:2 72:18 73:174:2,6 76:19 77:4,1077:14,18 78:2,7,1285:4 86:17,21 91:1,291:3 92:10 99:16,1899:22 100:3,9,15,18101:10,16 105:21106:4 107:6,9 112:10114:16 115:2,13116:3 118:10,18121:3,7,10 122:22123:5,14 124:8,13125:7,11 126:11,17127:1,9 128:16,21129:5 130:2 132:7,11133:19 138:12 139:17140:13,20 141:2142:3,9,12 145:2,5147:5 149:7,10170:14

rough 82:17,18 171:19171:20

rougher 33:12roughly 162:18routine 83:20 137:21routinely 83:17

rule 167:21,22 170:2,6171:3,9,12

rules 64:4,4run 23:19 31:2 161:20

188:11running 165:15rural 12:6 37:13 38:1,2

45:3 53:17 96:17,1896:21 102:8,10,18,18102:19 140:5,5 141:4141:8 183:8 185:10

RVUs 73:11

SS 1:17Sacramento 12:2 66:22sacrifice 94:14safe 173:1,17,21 174:1

174:2safety 128:6 129:1,13

129:17 131:11 173:8173:14,17

salary 126:2 183:19Salman 2:19 40:4sample 50:7Samueli 1:16San 1:19 5:22 6:3 47:8

47:10 66:16 119:12182:21 183:1

sandwich 66:17,19,2267:2,10

Santa 5:22satisfaction 32:18 33:4

33:6 42:12 146:18satisfactions 34:12satisfying 37:15 42:9Satterly 154:6,12saturation 12:20save 42:2 68:5 84:3

158:9saved 44:10saw 23:14 36:2,19

50:13 81:15 85:2,686:10 119:2 149:19176:3 180:2,13 182:9198:16

saying 14:16 19:2134:5 35:16 37:4 38:742:8 44:6 79:10 81:16114:7 115:3 123:7141:13 144:20 171:12175:22 176:1 177:19181:5 185:21 193:13

says 19:14 25:2 51:4,14106:13 126:8 161:3170:2 171:3

scale 26:4,19scattered 12:7


221

scenario 83:8schedule 15:12,15

53:21 182:18scheduled 12:2 21:5

133:8,9scheduling 173:14

182:17Schoenbaum 96:22science 128:12 156:8scope 26:4,19 56:17

102:10Scott 194:15scratch 31:9screen 43:4 45:18

137:3,4,8,14 198:12screened 137:2screener 128:19 135:21

136:1,3screening 135:14search 166:17Seattle 12:4second 15:18 18:6

52:16 94:11 121:7159:20 166:4 188:15189:1

secret 63:3Secretary 8:2 11:7

28:10 152:7 190:8sector 29:11,16 187:4,5secure 32:19 33:1

154:7seeing 94:6 98:4

124:10 130:13 199:9seek 57:11seeking 10:10 11:4

13:3,15 14:10,1915:16,20 16:20 22:1991:10 96:20

seen 16:5 25:6 32:1553:8 61:1 71:2 73:2175:6 98:10 99:6 106:9118:20 119:15 131:8131:9 145:7 162:19

sees 74:13select 7:14,17,21self- 109:22self-care 84:10self-medication 113:7Senate 191:20Senator 194:19,20send 161:7 170:4 176:2

176:7 199:2,7 200:5200:13 201:22 202:4

Senior 1:13 2:5,11 97:1sense 8:13 18:4 24:12

33:9 71:15 108:14123:17 161:19,19168:15 176:18 184:8

197:4,9senses 66:21sensitive 159:15sent 28:7 199:21 202:2separate 74:19 100:12

100:20 101:1,1,8September 1:8 4:4,18

9:3 198:13sergeant 154:5,7,11serious 95:21serve 91:13 111:7,9

112:1 123:9,20served 111:18serves 168:13service 1:15 6:9 25:14

29:15 36:21,22 37:542:18 83:12 97:1799:8 108:16 162:17

service- 25:2service-connected

25:10service-related 25:16servicemember 6:20services 1:22 44:22

45:1 54:21 55:1068:17 85:21 86:794:16 97:1 141:11175:15 179:1

session 1:5 7:5 9:1649:16 61:2 62:4 65:2090:20 164:2 198:11203:4,17 204:8

sessions 32:20 44:1452:18 152:2 163:15164:3,10,21,22 165:5165:7,9

set 8:7 46:4 70:2,1585:15 128:9 138:2144:8,21

setting 44:12 45:1796:21

settings 16:9 140:5settle 163:19seven 129:14 150:11seven-minute 150:12shaking 49:1SHAMSI 2:19Shana 153:8share 26:1 27:20shared 28:6sharing 28:10 43:3

122:5SHEWMAKE 2:21shift 194:7shifted 130:8,10shifts 195:4Shira 1:19 6:2 9:11

23:20 35:14 82:22

110:17 193:17shop 138:3short 13:22 30:20 90:2shortage 140:2shortages 67:12shortfall 60:9shortly 127:12shot 165:15show 61:2 71:4 79:13

85:14 112:17 113:7113:16 133:8 176:4

showed 11:16shown 159:14shows 73:6 105:15

112:20 176:20shutdown 30:1shuttle 19:22side 45:18 46:18 53:14

82:7 87:12 107:13109:16,20 121:20138:7,11 185:4

sides 156:4sight 121:1Sigma 2:5,11,15,19

152:18 203:8sign 19:13signage 20:5signal 92:7,8significant 34:10signs 81:2Silver 174:8similar 9:17 44:5

109:19 157:4 163:2179:16

simple 70:17 104:15,20161:3 195:14

simplicity 46:17simplifying 84:21simplistic 66:14simplistically 67:15simply 47:20 147:9single 83:17 176:9sit 48:4 83:17 197:18

200:2site 9:7 21:1 52:20

118:21 125:21 182:5sits 108:10sitting 31:5 61:10 71:19

79:18 105:8 156:21situation 35:20situations 64:3six 44:10 110:10 129:7six-month 44:15 169:19size 50:7 71:16skews 46:8skill 17:10 56:22skilled 17:14skills 56:19 57:6

slice 70:10slide 10:4 11:12 32:3

48:7 55:19 80:8159:12 160:11 162:4163:10,12 165:20175:4 188:19,22

slides 81:15 124:7149:18

slightly 58:12 119:10small 19:1 21:19 43:20

146:5 171:8 194:17smaller 18:22 34:7 69:3

69:17 72:4 73:22131:3

smiling 150:5SMITREC 134:14Sneakers 174:8soapbox 87:9social 27:2,17,18 31:4

38:15 78:3,4 86:387:5 130:20

solutions 58:1 104:16104:20 105:12

solve 83:16 168:14solved 168:3 172:15somatic 176:22 177:8somebody 20:16 30:11

51:13 61:9 77:11 99:7108:20 112:13 114:14183:1 193:8 196:6

sorry 39:5 41:1,2 44:1954:12 55:4 80:14142:2 179:14 192:8

sort 35:21 70:14 81:1982:16,20,22 92:1,6103:6 114:3 115:22124:14 135:1,2 148:2164:19

sorts 46:12 125:1sought 14:17 23:1 24:6

29:5sound 12:3 181:16sounds 101:15 106:7

134:5 200:9source 31:13,19 51:11

87:3,10sources 87:12Southwestern 155:10span 25:7speak 26:8 80:12 132:1

156:3 175:20 178:17speakers 96:14 97:6speaking 42:21speaks 80:21 104:22specialist 20:16 35:8,9

35:14 36:6 51:7 76:176:3,9,13,21 106:17107:20 110:1,9


222

121:15,21 122:1124:17 126:4,13,22127:3 131:10 136:7,9136:20,20

specialists 34:16 36:1075:16,20 79:6,13,21105:8 106:10,20107:1,12,14 114:10117:10,19 120:8,11120:20 121:17,19123:8 126:2 127:21181:20

specially-trained 13:8specific 42:11,16 83:2

129:22 187:13 190:18192:7 193:15 195:20

specifically 132:4142:15 144:19 148:18

specified 165:4speed 7:8 88:15spelled 69:21spend 56:2 159:9spent 5:14 84:2Spero 2:4 27:6,10,10

28:3 29:14 35:3,1237:1 40:2,13,16 50:1550:17 51:19,22 70:2271:8 100:5,10,16,19100:22 101:8 125:20185:14 187:10,20201:17

spin 162:5spit 55:21split 24:8spoke 8:5 54:4 170:4spot 111:21spouse 14:17 61:9spread 49:13 144:9spreads 197:13spreadsheet 87:11

176:20sprinkled 50:18STACEY 2:17staff 2:3,7,21 7:16

27:11 30:19 38:4,1438:21 39:12 76:4 88:292:12 103:18 121:16151:8 155:20 167:1192:5

staffed 68:2,2,22 69:5staffing 37:10 58:22

59:2,6 67:8,11 68:3,4126:5

staffing-wise 68:8stage 8:15 149:17stand 57:17 90:13

156:19 164:16 177:15standard 53:19 125:18

134:6 156:9 164:10standardized 167:17

187:3standards 84:16,17,19standpoint 163:6

168:15stands 73:9 138:18Stanford 59:11Stanley 173:3start 10:2 21:9,10,11

25:8,19 31:9 97:7149:14 152:17 166:16197:3 199:9

started 29:4,10 91:15146:6 148:12 163:11167:15

starting 36:6 145:21158:17 198:21 202:16

state 5:16 7:1 116:6,16116:22 175:1 179:1,5188:14 190:7

state-level 188:13stated 54:19 125:3statement 5:4 167:8states 1:1 6:13 45:8

179:6 189:13station 60:4stay 59:4 112:3 122:14

150:18 185:1step 95:11 109:9Stephanie 154:1stepped 84:7stick 173:15stigma 13:14 19:8

20:12stint 171:5stop 158:9,10,15 185:8

185:9storage 173:21 174:1,2stories 23:21story 13:20stream 100:12 108:12streamlined 64:10street 116:12stress 6:20 8:19stress-diathesis 161:2stressors 160:17 161:5

161:13stretched 120:18strong 54:17 79:17 87:5

156:2 197:15stronger 196:12strongly 82:12 123:2structure 120:10

190:11 193:5structures 101:9struggle 69:4struggles 161:18

students 14:1studied 157:11,17studies 159:6,6,20study 91:7 151:15stuff 16:3 18:3 28:7

53:12 65:13 73:1299:12 106:1 115:9161:19 170:19 179:18194:17 202:7

style 9:17 93:1subject 2:8,17 7:9

164:14 188:11,17196:4 203:7

submission 204:3suboxone 179:17subparts 64:4subsidized 169:12success 28:4 29:3successful 62:6sucked 184:1sudden 45:17 119:21suffer 42:19sufficiencies 135:3sufficiency 91:7 92:1,4

127:8 140:15,17141:1,20 194:17

suggest 164:9suggested 164:18suggestion 199:3suicidal 72:14 81:2,11

161:5 182:4suicidality 160:6,7

187:6suicide 65:10 96:2

127:22 128:4,11,17130:17 131:7 132:22133:4 134:4 135:15136:15 137:4 152:13153:12,14,22 154:18154:22 155:2 158:3158:10,20 159:4,15159:15,21 160:13,15161:3,7 162:3,5 172:3172:5,21 173:5189:17 192:9 194:2194:16

suicides 133:22 134:7134:7 151:18 154:4182:2,11

Suite 1:10summary 88:13,18summit 203:22supervision 120:12

125:5supervisor 122:18supervisors 120:18supply 92:8support 2:7,21 20:16

30:19 34:16 35:8,8,1436:6,10,15 47:15 51:775:16,19 76:1,3,9,1376:21 77:5 79:6,13,2180:4 84:5 86:13 87:588:2 89:22 92:6,12105:3,6,7 106:7,10,16106:20 107:1,11,14107:20 108:14,17110:1,22 111:16112:6,12 114:3,10,19115:16 116:10 117:10117:19 118:1,5,16,22119:8,10,14 120:7,10120:11,17,19 121:14121:17,18,20 122:1122:19 123:2,8,20124:1,17 126:2,4,12126:22 127:2,20160:2 179:7 181:20193:10

supported 202:14203:7

supporting 40:14 92:1Supportive 153:10supports 75:13 121:2supposed 20:19surprise 61:18surprised 16:1 33:13surprises 162:20surprising 188:16survey 10:6 29:21

176:21susceptibility 161:5,14suss 170:8sustained 129:10SVAC 7:16 8:2switch 116:9synergy 80:21synopsis 89:15system 10:11 11:5

14:12 17:3 18:15 20:620:14 24:13,14 25:2029:5 47:2 59:14 60:660:11 63:11 64:1 65:675:20 83:5,11 86:13100:6 102:12 108:21111:5,10 112:18116:2 118:15 121:3,5123:16 125:19 126:16135:11 137:2 138:4139:20 143:22 144:4145:13 146:11 147:13147:19 154:13,16155:21 162:18 170:13174:11 175:22 176:2180:6 183:8,9 185:5185:13 188:6 197:7


223

system-wide 148:6systematic 84:15 153:6

158:18,21 162:9171:22

systematically 191:1systems 19:12 103:5

116:9 118:21 142:6144:8 146:5 157:13

Ttable 112:15tacks 188:12tag 76:10 77:5tags 76:16taken 94:5 132:14,15

203:5takes 139:20 183:15

188:12talk 12:13 17:4,12 20:15

26:18 27:1 55:21 56:162:21 63:2 71:1272:18 76:17 80:6 82:692:19 97:2 103:5113:10,11 172:12189:9 190:3 202:3

talked 22:2,3 32:1644:1 51:9 52:4 53:1592:22 93:16 94:2195:19 96:15 97:19,20112:18 114:7 127:19131:14 138:17 139:4139:21 140:7 141:7141:16 143:7 153:20154:1,5 155:4,9,17156:7 160:22 173:3189:18 194:14 195:8196:22

talking 30:21 40:2041:19 45:12 46:1051:12 59:19 61:1573:1 75:11 79:19 81:984:8 86:14 112:7125:2 153:6 168:4195:6

talks 33:20Tampa 119:5,7tape 186:7target 121:11,12 193:20task 39:12 40:19 89:3

94:8 185:19tasked 26:3tasks 118:3taxpayer 191:6team 1:21 21:2 30:19

40:17 74:9,13,16,2075:1 83:21 88:10,2289:22 91:5 95:2 119:6151:8 156:10 162:16

186:15,16teams 64:15 67:22tech 47:15 111:19

118:1technical 46:17technicians 108:13technology 42:21 43:7

45:14 139:22 140:10techs 109:15telehealth 37:12,22

42:8,18 44:4,11,2145:6 46:2,15 47:1448:3 96:19 139:19140:16 172:20

Telemedicine 140:16tell 13:20 42:14 49:21

79:19 126:3 137:20165:17 197:6

telling 59:9ten 187:12ten- 150:11ten-weeks 187:18ten-year 100:14 101:12tend 13:10tending 13:14tension 70:14 102:20tentative 199:8 200:22Teo 153:5 158:19term 21:6 22:9 36:21

167:13terminated 204:7terms 70:6 85:16 93:11

103:2 134:3 135:14194:6 195:14

terrific 87:17 90:1 203:1test 29:21 47:21tested 146:3,4 148:22

149:4 173:6Tester 194:20testified 172:16testimony 134:16testing 141:10Texas 6:10 155:10text 185:20thank 4:15 5:1 6:10,14

10:1 22:17 31:11,2239:21 43:15 45:460:14 74:2,6 80:1088:12,18 89:7 90:4,590:5,8,14 91:3,5,19102:16 110:16 133:19138:13 141:2 149:7149:12,13 151:5184:6 188:20 202:22203:8 204:6

thankful 151:7thanks 20:3,8 110:12

143:11 151:2 177:10

197:17 204:8theme 23:7 24:4 37:20

49:9 56:15themes 12:12,15,21

13:5,13 14:2,16,2115:20 22:20 30:2132:5,9 48:8 56:10,10

therapies 11:1 160:1therapy 33:7,11,19

49:16 51:10,11,1453:18 61:22,22 70:593:14 123:11 153:10157:11 169:15

thesis 140:15thin 47:10 120:18things 14:7 15:17 17:4

22:4 27:16 29:9 36:736:12 41:20 42:1,451:2 55:12,15 56:1758:14 65:12 68:669:11,15 79:14 80:1,281:8 84:4,19 88:15,1688:21 96:13 97:598:11 101:4 104:15105:19 120:3 125:1129:22 130:16 131:16131:21 132:2 133:15133:16 144:12 147:1147:2,11,14,18151:10 154:10 156:2156:5,11 157:16158:1,2 160:12 167:4167:11 169:1 172:4187:11 194:3 196:7199:10 200:11

thinks 116:22 177:13third 93:16 94:19

138:14Thomas 7:5 91:13

161:21thought 9:8 44:17

89:17 136:15 143:5166:17 167:15 193:7194:22 195:5 197:2,3

thousand 107:1thousands 42:2 109:10three 12:5,18 44:2,17

183:19 197:11 203:2three-month 123:11three-part 93:11 137:19

137:22throw 88:7 117:13

123:11 196:15tie 127:6tied 153:13 178:16tight 30:3tightening 191:11timely 43:17 190:12

times 17:8,15 20:1324:16 49:14 53:1860:22 61:6 76:19 77:279:13 96:8 104:6113:3 183:19 189:4

title 32:13 35:9 186:18TMS 174:15 175:2,9

176:3 177:7today 5:5 7:5 9:15 11:9

30:21 71:18 88:5 91:5131:12 140:7 149:19188:2 198:14,15,16199:2,19 200:1202:16

today's 105:19told 49:22 188:2 190:8Tom 7:5 154:6ton 63:17 119:20tons 109:14 115:8Tonya 97:15tool 148:3topic 180:4topics 89:16total 192:17touch 21:22 58:3 82:2

138:9 143:4touched 75:3 139:16touching 28:15tough 35:12town 19:1 62:13 170:4

179:3Toyota 186:1track 116:8tracks 112:9Tracy 2:21 40:13trade 42:3traditional 50:17train 183:16,22trained 57:5 108:21

109:17 110:9 115:7178:1,4,7

trainees 61:19training 39:11 56:19

60:15 61:15,20 62:763:10 109:1 110:7114:20 130:7,11144:9 187:11,18,19188:13

transcriptions 40:9transfer 60:3transition 21:14 22:3

91:1 114:11transport 184:13transportation 185:5

186:11travel 200:19travels 98:11 118:21treated 25:22


224

treating 10:15 171:4,5treatment 1:22 10:18

11:1,4 13:15 14:17,2022:19 23:1 32:7 37:1637:21 42:9 45:1049:12 50:14,18 64:1579:7,12 87:6 91:1093:1,8,10,19 94:3111:20 133:3 138:16138:21 139:2,6 140:4151:17 164:21 166:18166:20 172:22

treatment-resistant174:12 178:14 179:10

treatments 34:11,1448:11,14 49:4,6 50:152:21 54:14,17 79:11115:20 151:15 152:5152:8 156:8 166:13168:21 176:22 177:2179:17

trees 106:5tremendous 86:12

107:15tremendously 72:15triage 59:14 60:3,3trial 169:19Trials 159:22Tribal 141:8tried 185:14triggered 120:14triggers 135:22trip 51:13trips 98:20Trivedi 155:9trouble 15:13 28:15true 25:3 78:12,12truly 5:18 40:17 124:16trust 24:6 29:8 54:6,10

147:21try 11:20 70:18 103:20

108:9 148:8 153:1166:10

trying 67:2 84:11 98:9112:13 114:11 115:22116:4 122:18 127:21152:11 157:13 158:6158:9 161:10,10,11177:17 182:8 185:16186:15 189:21 201:1

Tuesday 202:5turn 4:13 9:19 61:12TV 43:4tweak 161:22two 5:17 7:3 12:18

24:18 30:5 53:9 69:571:2 72:17 103:4105:7 118:20 119:15

120:1 121:18 157:13179:1 183:17 195:16197:11 198:21 201:1203:3

two- 123:10two-page 166:1two-part 52:11type 45:1 87:13 94:2

110:21 111:17 113:4200:21 203:22

types 34:11 48:14 84:3155:6,16

typical 57:22typically 34:3typing 43:10

UU.S 1:17,17,20 2:1Uber 185:11,14,19Ubers 186:2UCLA 155:7,19ultimate 94:14unanimous 41:2 54:15unaware 52:14unbelievable 89:15unclear 35:5undefined 193:1underpaid 59:3underscored 16:12understaffed 117:20

183:10understand 13:9 34:18

34:19 41:16 67:10154:3 162:2 180:10

understanding 177:3understood 164:22underutilized 111:4underway 11:14unevenly 21:17 22:15

65:5 75:19unevenness 61:14unfunded 70:14uniform 58:20 69:8

118:12 125:18 130:16133:16 134:6

uniformity 18:15 22:1057:11 66:6,12,13 67:367:17,19 104:22105:2 117:11 125:15125:17 179:15 180:20

uniformly 61:16 80:3117:14 131:8 144:10

unique 16:8 101:4102:3

unit 23:15United 1:1 6:13 45:8

189:13UnitedHealth 168:5,13

UnitedHealthcare169:2

universal 67:14 70:1592:1

University 128:7 146:3155:10

unpresented 193:1upcoming 8:22 12:3update 3:13,16,19 9:6

9:12,21 11:12,1290:21

updated 55:2urgency 8:13urgently 72:13usage 193:2use 19:10 21:6 38:15

43:7 46:21 85:12119:7 160:2 169:7185:6 195:14

user-friendly 140:1users 162:17USMCR 1:14usually 21:14 64:6 81:1

129:16 164:21utility 140:10 159:17utilize 79:5 108:12

111:13 139:22utilized 95:7 120:4

130:2 140:10 141:18176:12

utilizing 50:1

VV 122:8 186:18VA's 154:2 159:10

160:4 166:19 192:12VA-DoD 108:8VA-HRSA 142:19vacancy 188:4,7,8valuable 36:18 87:17

98:16 192:5value 36:19 167:5,8VAMC 43:21 52:6VAMCs 53:15 72:7

183:5van 143:4 184:14,21vans 184:12,16,17

185:7variability 15:10 34:10

34:14 48:18 49:2,360:19 67:7

variable 53:1 73:5,17variance 67:9,18,21varies 72:15variety 117:17 148:13

169:14various 79:7 94:13VAs 23:7 49:3 57:10,12

58:9,10,10,11 66:6,966:12 67:21 68:173:15 117:15,16118:8,15

VERA 126:21verb 106:14Vermont 11:17versus 21:20 33:19

42:12 43:4 53:6 70:7vet 5:12 36:5,5 53:16,22

54:4,7,8 58:10 78:679:16,16 122:4131:17,17,18,19153:21 173:1,18201:20

veteran 5:12,14 6:15,1916:4 20:16 35:6 41:2249:11,16 52:1 59:1759:22 60:2,7,16 61:1262:10,13,14,15 63:664:2 65:10 76:17,2077:4 87:2 92:17,2293:3,3 95:15 98:5,7106:16,20 107:11,20112:11,21 113:8,13114:3 120:21 121:13121:15 122:2 124:17127:20 133:8 138:11140:9 142:11 146:21158:2 160:6 172:12172:22 173:10 177:13178:13 179:11 191:16195:19 196:10

veterans' 1:3 117:10147:2 154:16 158:9161:9 162:5 168:8180:17 181:15 189:14

vets 26:16 42:15 46:1046:13 52:6

vetted 201:12VHA 1:10 24:20 103:6,9

174:10 190:21viable 9:8 152:5video 46:12Vietnam-era 13:13 24:5

34:3 47:13view 111:9 143:17views 126:14vigorously 8:16Virginia 1:11 146:3virtual 12:5 40:4,5 41:3

52:18virtue 30:17 46:9visit 7:16 102:3 129:10

137:19,22visited 154:17visits 9:7 21:2 96:7

106:11 118:22 125:21


225

128:2 129:4,7,7,9156:18 182:5

VISN 67:9 92:6 105:4170:20

VISNs 10:7 12:7Vocations 172:11voluntary 167:4,11volunteers 184:15voting 150:3VSO 28:11 36:21 64:6

203:21VSOs 28:2,4,8,12

203:22

WW 1:15 6:9wait 72:17 123:11 188:4waiting 61:10 71:20

77:6 79:18 123:22143:18 165:22 166:3171:13 190:10

walk 19:4 21:18 32:1464:12 72:5 74:14 75:385:8 116:11,16

walk- 67:4walk-in 18:17,18 32:10

32:11 66:7walked 76:8 85:17walking 19:20 21:19

65:14 72:16 89:2walks 77:16 78:5 136:4wanted 9:7 12:12 29:15

36:18 51:2 54:16 81:6102:16 166:15

wants 27:13 68:5147:14

warm 21:6 74:22 75:7136:19

Washington 66:15wasn't 30:10 34:4 43:2

50:1 63:17wasted 158:8watched 182:7way 25:9 45:1 56:22

57:17 66:11,22 67:1267:12 68:3 70:17,2071:16 75:6 84:11 89:196:4 100:17 101:5104:1 110:22 112:13115:4 118:8 125:19126:16 132:5 138:2146:8 152:14 156:14157:15 166:10 170:12177:16 186:22 191:11200:10

Wayne 1:16 6:15 9:5125:14 133:20 192:22200:20,22 201:21

ways 33:11 60:18 63:466:13 67:16 69:1671:11 76:6 103:8138:4 144:2 160:15166:17 186:11

wearing 76:10,15week 12:3 30:13 56:8

125:10 129:7 193:3198:14,14

weekday 28:19weekend 15:13 28:19

57:20 58:16,17weekends 57:22weekly 7:7 152:22weeks 71:3 72:17 150:3

165:1,6 187:12189:10 195:4 201:2203:13

weigh 192:4weird 24:22 25:2 116:7welcome 3:11 4:4,16

91:4 150:22welcomed 54:8welfare 133:10well-informed 52:21wellness 139:14 153:15

172:11 196:9Wendy 2:10 12:19

27:12 39:7,14,22 54:371:21 106:13 124:22125:12 126:19 150:4166:4 196:17 198:13198:16 201:22 203:10

Wendy's 117:17went 27:17,17,18 28:10

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__________________________John GoodrichDesignated Federal Officer

_____________________________________Jake LeinenkugelChariman

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UNITED STATES DEPARTMENT OF VETERANS AFFAIRS ...YESSENIA CASTILLO, Senior Consultant, Sigma Health Consulting, LLC KATHRYN FAUSTMANN, Support Staff JOHN KLOCEK, Subject Matter Expert;