Suicide prevention hotline for veterans still falling short, more than a year after troubling report
The Veterans Health Administration (VHA) which manages the nation's suicide prevention hotline for veterans, has been unable to implement seven recommendations from its own inspector general designed to improve the crisis line's performance, more than a year after a February 2016 investigation found significant problems with response times and quality assurance at the call center, headquartered in Canandaigua.
That 2016 report substantiated allegations that "some calls routed to backup crisis centers were answered by voicemail and callers did not always receive immediate assistance from VCL (Veterans Crisis Line) and /or backup staff."
The recommendations included addressing gathering better data when callers were routed to backup centers, silent monitoring of responders and ensuring orientation and training goals for staff are being met.
According to the Department of Veterans Affairs' own assessment, an average of 20 veterans die by suicide every day. The VCL was established in 2007 and operates on its own site at the Canandaigua VA Medical Center with an additional center in Atlanta that opened in October 2016. The VA estimates that the VCL has answered close to 2.8 million calls since it was launched and initiated emergency services over 74,000 times.
The VHA was scheduled to implement the recommendations for the crisis line by September 2016, and then asked for an extension to March 2017; a deadline it also hasn't met. The report by the Veterans Affair's office of the inspector general released on March 20 found that the VHA's "...failure to implement our previous recommendations impairs the VCL's ability to increase the quality of crisis intervention services to veterans seeking help."
Other findings included:
- The VCL did not respond adequately to a veteran's urgent need
- There are continuing deficiencies in the way the VCL managed incoming phone calls
- There are ongoing deficiencies in governance and oversight of VCL operations
The veteran's interaction with the VCL and the backup centers led the office of inspector general to identify problems with the manual writing down of VCL caller numbers, a lack of process to review adverse outcomes, an inability to record calls and an inability to track the quality performance of the backup call centers that take the overflow of calls.
The most recent evaluation from the office of inspector general also said that currently "VCL leaders did not collect data regarding attempted or completed suicides following a veteran's contact with the VCL".
The office of inspector general also observed that there were no debriefings or reviews by VCL leadership if veterans who had been in contact with the VCL attempted or completed suicide.
In a statement accompanying the release of the report, the VA Inspector General Michael Missal acknowledged the professional dedication of VCL staff but said "...it is imperative that VA take further steps to increase effectiveness of VCL operations."
The OIG report also found that the VCL lacks permanent leadership; "as of December 2016, the VCL continued to operate without a permanent director." As reported by The Military Times in June last year, the VCL director appointed after a leadership shakeup following the February 2016 report resigned four months later.
The March 20 report makes an additional 16 recommendations intended to address the ongoing deficiencies including; holding backup call centers to the same standards as the VCL, develop more robust reporting of the clinical outcomes, implementing an automated transcription function for caller's phone numbers and reviewing data on outcomes.
Atlanta call center
The issues have continued in part as the result of the launch of the additional call center in Atlanta in October 2016 that redeployed Canandaigua staff to provide training.
The VA estimate that the crisis line handles half a million calls a year — in addition to texts and emails — and space requirements in upstate New York and recruitment pool limitations underpinned the expansion to a second site.
In a statement delivered to a U.S. Senate hearing on preventing veteran suicide on April 27, Missal said that bringing Atlanta online" contributed to a delay in development of policies, programs and procedures," including "the deferral of annual lethality assessment training for responders."
Lethality assessment is a systematic method for gauging a callers potential for suicide.
"Lack of formal planning and inaccurate forecasting resulted in more than 16,000 hours of Canandaigua FTE (full–time equivalent) employees being temporarily redirected to the Atlanta Call Center for training and operations. This led to an increase in the number of calls that rolled over to backup centers and delays in the development and implementation of VCL processes, policies, and procedures," Missal said.
The report showed that the VCL Rollover Rate, the number of inbound calls that were not answered by the VCL in November 2016 was close to 30%.
"...backup call centers historically have placed VCL rollover calls into a queue without immediately providing service or risk assessment," the OIG found.
In response to the latest recommendations, the acting Under Secretary for Health, Dr. Poonam L. Alaigh, concurred with the report and all 16 of the OIG's recommendations and outlined a list of responses with target dates from May to December 2017 including a "root cause analysis" to the lack of analysis of adverse outcomes.
Help is available
Veterans, their friends and family and military personnel can confidentially call, 1-800-273-8255 and Press 1, text 838255, or chat online with qualified responders by accessing resources at https://www.veteranscrisisline.net/
Laura Stradley, director of the Monroe County Veterans Service Agency, said she was unable to comment on the recent findings from the VA's inspector general, referring requests for comment to county spokesman Brett Walsh, who did not respond by deadline.
A request for comment from the Department of Veterans Affairs on the Veterans Crisis Line was not answered by the deadline for this story.
Other report reviews clinical program
A separate office of inspector general report released March 27 highlighted issues with inpatient and outpatient care at Canandaigua undertaken during the week of October 17, 2016.
Based on the review, the office of inspector general said it was not satisfied that there was effective oversight of the Community Nursing Home Program or that there was effective training for employees on managing "disruptive or violent behavior" and it pointed to a breakdown in the procedure for completing suicide risk assessments for patients.
In the week of the review, the office of inspector general observed that 17 out of 39 patients or 44% of patients who had a positive PTSD screen did not receive a suicide risk assessment.
In an interview Sarah Levis, behavioral health operations manager for the Canandaigua VA, said that there were two factors to consider as context for the finding; veterans are entitled to decline treatment if they choose and while "our goal is to do same-day evaluation," Levis said that time frame is often extended at request of the patient due to family or work obligations.
Since the review last year, the VA now has four primary care mental health professionals available to veterans same day, Monday through Saturday, in Rochester and Canandaigua.
Internal audit shows broader progress
Indicators from Veterans Affairs own internal confidential reporting shows that the Canandaigua VA Medical Center has made steady progress toward meeting quality benchmarks in the first quarter of 2017, compared with the last quarter of 2016.
The VA's Strategic Analytics for Improvement and Learning (SAIL) are internal indicators that VA uses as a basis for the ongoing improvement of services.
A score out of 100 used as a measurement of efficiency at the facility showed a jump from 83.532 in the last three months of 2016 to nearly 92 in the first quarter of 2017.
The VA's benchmark score is 96.153. The same benchmarking system shows that Canandaigua VA consistently rates 4 out of 5 stars for quality-of-care.