VA Inspector General Report Finds Veterans’ Calls to 24-Hour Crisis Hotline Went Unanswered, Unreturned
CHICAGO, IL – U.S. Senator Mark Kirk (R-Ill.), Chairman of the Senate Appropriations Subcommittee that oversees funding for the Department of Veterans Affairs (VA), called for the immediate firing of Dr. Mary Schohn, the Director of Mental Health Operations for the Veterans Health Administration (VHA), who is responsible for overseeing the crisis hotline that reportedly allowed veterans’ calls to go unanswered and unreturned.
In a letter to VA Secretary Robert McDonald, Senator Kirk demanded Dr. Schohn be terminated effective immediately and suggested she be replaced with an official from the Substance Abuse and Mental Health Services Administration (SAMHSA), a federal agency that administers a suicide hotline effectively.
The letter is available here. The text is below.
February 22, 2016
Hon. Robert McDonald
U.S. Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420
Dear Secretary McDonald,
As Chairman of the Appropriations Subcommittee that oversees funding for the U.S. Department of Veterans Affairs (VA), I am writing to call for the firing of Dr. Mary Schohn, Director of Mental Health Operations for the VA’s Veterans Health Administration (VHA). The VA Office of Inspector General (VA OIG) and the Government Accountability Office (GAO) have identified patterns of failure and consistent disregard for improvements within VA call centers, and the suicide hotline specifically. As head of the office that oversees the VA’s crisis hotline, Dr. Schohn has failed veterans in their darkest hour.
The horrific revelations contained in the recently released VA OIG investigative report, “Veterans Crisis Line Caller Response and Quality Assurance Concerns” (Report No. 14-03540-123), include repeated instances of the VA ignoring veterans’ needs for suicide assistance. Specifically, the report, which was based on a review of Veterans Crisis Line (VCL) records from FY 2014 through the first quarter of FY 2015, found that calls to the VCL, which is a component of VA’s Suicide Prevention Program, may have been put on hold for 20 minutes or more and often went to a voicemail system no one on the call center staff even knew existed.
The VA’s Office of Mental Health Services and Operations, which oversees the VCL program, has been aware of these unacceptable examples of disregard for veterans dating back to at least April 28, 2014. At that time, the Coalition of Veterans Organizations wrote a letter to then-Secretary Eric Shinseki expressing concern over documented occurrences in which the VCL was “seriously deficient,” citing the familiar examples of extended wait times and poorly trained staff.
For several years, media reports have also highlighted problems in the program, all under the direction of Dr. Mary Schohn. A video posted online in 2014 shows a veteran who called the hotline on hold for more than 35 minutes.
And again last year, after you had assumed your current role as Secretary, my colleague Senator Bill Nelson (D-Fla.) wrote to you with concerns that his constituents were being placed on hold repeatedly when they sought help through the VCL.
Moreover, a November 2014 GAO report, “VA Health Care: Improvements Needed in Monitoring Antidepressant Use for Major Depressive Disorder and in Increasing Accuracy of Suicide Data” (GAO-15-55), found “that VA policies lacked clear direction for how staff at VA facilities should document information about veteran suicides as part of VA’s behavioral health autopsy program (BHAP). The BHAP is a national initiative to collect demographic, clinical, and other information about veterans who have died by suicide and use it to improve the department’s suicide prevention efforts. In a review of a sample of BHAP records from five VA facilities, we found that more than half of the records had incomplete or inaccurate information. The lack of reliable data limits the department’s opportunities to learn from past veteran suicides and ultimately diminishes VA’s efforts to improve its suicide prevention activities.”
Even since May 2010, the VA OIG identified clear problems with VA call centers. The report, “Veterans Benefits Administration: Audit of National Call Centers and the Inquiry Routing and Information System” (Report No. 09-01968-150), identified the Veterans Benefits Administration’s (VBA) eight national call centers and pension call center did not have an adequate process to ensure callers reached a call agent. From the 2010 report:
- During FY 2009, 76 percent of the call attempts reached a public contact representative (call agent). Of the 24 percent who did not reach a call agent, the callers either received a busy signal (blocked call) or hung up while on hold (abandoned call).
- This occurred because: VBA’s telephone system did not route calls to ensure the efficient use of the call agents. VBA did not implement performance standards to hold personnel at call centers accountable for timeliness of responses. Call agents did not have easy access to the information needed to answer callers’ inquiries in a timely manner.
- Timely Access During FY 2009, callers made 7.41 million attempts to contact the eight call centers. Of these attempts, 1.77 million (24 percent) were not completed because the call was either blocked or abandoned. Blocked call rates measure the percentage of attempted calls that received a busy signal.
- In FY 2009, 1.26 million (17 percent) of the 7.41 million call attempts were blocked. Abandoned call rates measure the percentage of calls (calls not blocked) that the caller abandoned before reaching a call agent. In FY 2009, 6.15 million (7.41 million – 1.26 million) calls were connected, but .51 million (8 percent) were abandoned.
You’ve often stated that you are changing the culture at the VA. There can be no higher order within the VA than taking seriously the suicide rates of our service men and women when they return from the battlefield. Use the authority you have to demonstrate that repeated failure at the VA is unacceptable by firing Dr. Schohn, and consider replacing her with someone from the Substance Abuse and Mental Health Services Administration (SAMHSA), a government agency that is using a suicide hotline effectively.
United States Senator
A recent report by the VA Office of the Inspector General found that veterans who called the VA Crisis Hotline, which is supposed to be monitored 24 hours a day, 7 days a week, were transferred to a voicemail box and never had their calls returned. The report also found that those who are contracted with the VA to provide backup for the crisis hotline may not be properly trained on how to help a veteran seeking help.
Since the VA scandal broke last year, Senator Kirk has been working with local whistleblowers to expose the misconduct at our nation’s VA centers and hospitals that are hurting veterans and costing lives. A timeline of the Senator’s work can be seen here.
Senator Kirk has been working with whistleblowers like Germaine Clarno, a social worker at Hines and president of the AFGE Local 781, and Dr. Lisa Nee, a former Hines cardiologist who experienced retaliation from VA officials after reporting a backlog of hundreds of unread echocardiogram tests and unnecessary surgeries – both of whom have faced retaliation and intimidation from VA officials, and whose calls to improve care for veterans have been ignored.
Earlier this month, Senator Kirk wrote to Secretary Robert McDonald about complaints in Illinois and nationwide over the “Choice Act,” a new program allowing vets to access private care. A VA Office of the Inspector General report confirmed veterans in Colorado are denied access to basic diagnostic testing and delaying veterans’ requests to use the Choice Act. Senator Kirk called on the VA Secretary to acknowledge the problems using the Choice Act and identify solutions for veterans immediately.
Senator Kirk has introduced S. 2291, the Veterans Patient Protection Act, which forces the VA to address reports of abuse and punishes the managers who retaliate, ignore and intimidate VA whistleblowers.