In the wake of a troubling trend of veteran suicides and at least one shooting on the premises of Department of Veterans Affairs facilities in recent weeks, VA leaders are preparing for congressional scrutiny and hearings on the matter.
What they're not doing, however, is planning to ramp up security at VA centers through the use of metal detectors. While incidents at individual VA facilities may prompt local reviews, the majority of security decisions are not made at the national level.
It's a delicate balance between providing a safe environment at the VA and keeping facilities safe and accessible to all, said Dr. Keita Franklin, the VA's National Director of Suicide Prevention. And officials, she said, are sensitive about taking steps that might undermine that message of openness.
"We want our VA facilities to be warm and welcoming -- a place where veterans are willing, where they want to go. We don't want them to perceive the facilities as places where they get hassled or that they have any level of barrier when it comes to accessing care," Franklin told Military.com in an interview Thursday.
The message was underlined earlier this week in a statement by VA Secretary Robert Wilkie: "Providing same-day 24/7 access to mental health crisis intervention and support for veterans, service members and their families is our top clinical priority."
That's not to say that nothing is changing in the wake of the recent tragedies.
In a horrific incident on April 9, a veteran pulled a gun in the waiting room of a VA clinic in Austin, Texas, and killed himself in front of staff and other patients. The Austin suicide followed two others at VA facilities in Georgia.
On April 5, a veteran killed himself in the parking lot of the Carl Vinson Veterans Affairs Medical Center in Dublin, Georgia, VA officials said, and on April 6 a 68-year-old veteran died by suicide outside the Atlanta VA Medical Center.
In addition, a double amputee later identified by the FBI as Larry Ray Bon, 59, fired at least six shots on Feb. 27 in the emergency room of the West Palm Beach VA Medical Center in Riviera Beach, Florida. A VA doctor and a hospital staffer were slightly wounded in the melee to wrest the gun away from the patient, the FBI said.
"This unfortunate incident [in Florida] has prompted changes in the facility's security plan, which now has an additional level of security at all of its entrances and in the emergency department," VA spokesman Curt Cashour said.
Adding metal detectors, however, is not under consideration, he said.
"It would create a barrier to entry that might drive patients away," he explained.
It's not the first time the VA has grappled with the competing interests of security and openness.
In a 2018 review, the Government Accountability Office said the VA was not meeting standards for security required at federal buildings following the 1995 Oklahoma City bombing and lacked central oversight of measures taken at individual facilities.
The GAO report also noted that "Ensuring physical security for these medical centers can be complicated because VA has to balance safety and security with providing an open and welcoming healthcare environment." Security was often left to the discretion of individual medical center directors, the report said.
The VA agreed with the findings and pledged to follow recommendations to improve requirements that already include security cameras, silent distress alarms, perimeter fencing and a police force at all of its hospitals.
A reporter's visit Thursday to three VA facilities revealed understated, but consistent, security measures.
As is the case at private and non-profit hospitals, there were no metal detectors at the Washington, D.C. VA Medical Centers. Security staff in yellow vests were at the entrance to assist patients and visitors.
The yellow vests were also in the parking lot and garage to guide arrivals, and also had golf carts to assist those who had difficulty in walking.
Inside the main entrance, security personnel asked for ID before directing visitors to the information desk. They also stand prepared to conduct random searches.
VA officials said security measures seen at the Washington VAMC and two clinics were typical of those throughout the nation's largest health care system of 170 hospitals and more than 1,000 outpatient clinics.
VA Seeks Answers Amid Suicides
The April 9 incident in Austin was the sixth veteran suicide this year at a VA facility. Between October 2017 and November 2018, 19 veterans died by suicide on the grounds of VA medical facilities, according to a Washington Post report. But the deaths at VA facilities only hinted at the scope of the problem.
A VA state-by-state report in 2016 showed that there were 530 veteran suicides in Texas alone, tying with Florida as the states with the most veteran suicides.
The grim statistics haven't changed for years.
"Sadly, we haven't seen a change in the numbers yet," said Franklin, a licensed clinical social worker who formerly headed the Defense Department's Suicide Prevention Office.
Of the average 20 veterans who take their lives daily, about 14 have never been in contact with the VA, she said.
She pointed to an executive order issued in March by President Donald Trump to establish a Veteran Wellness, Empowerment and Suicide Prevention Task Force.
Franklin said the need was for a "whole-of-government -- really a whole-of-nation -- approach because we recognize we can't reach every veteran ourselves and only six of them [out of 20] have touched our hospital system."
The task force will include the Secretaries of Defense, Health and Human Services, Energy, Homeland Security, Labor, Education and Housing and Urban Development, as well as the Director of the Office of Management and Budget, Assistant to the President for National Security Affairs, and Director of the Office of Science and Technology Policy.
It will be charged with developing a "comprehensive national public health roadmap outlining the specific strategies needed to lower effectively the rate of veteran suicide, with a focus on community engagement," VA officials have said.
VA leaders only recently discovered that about three of the 20 daily veteran suicides were among members of the National Guard and Reserve who were never federally activated, Franklin said.
She said that the VA recently signed a memorandum of agreement with the Guard and Reserves to have mobile VA health centers sent to drill weekends.
"We want to start this early intervention" and "make sure we're doing everything we can to get our arms around this," Franklin said.
One concern is that veterans with problems often come to the VA as a last resort, Franklin said.
"Those veterans that do come to us -- they're pretty chronic when they come to the point where they're engaging in our mental health system," she said.
"Usually, a lot of other systems -- I hate to use this word -- have failed them. They, perhaps, tried to get help from family, friends, church, other types of entities along the way.
Thus, some of those who do make it to VA facilities are immediately among the high-risk veteran population, she said.
"And so the subgroup that comes to us comes with an elevated level of risk, if you will, compared to others that are struggling but don't end up in our health care system," Franklin said.
Demands for Action
She acknowledged that she was speaking ahead of demands for investigations and Congressional hearings that will call on her for action plans.
In a letter last week to the Inspectors General of the VA, the Defense Department and the Department of Health and Human Services, AMVETS Executive Director Joe Chennelly said suicides among veterans and service members were a "national crisis."
"We are calling on your offices to launch immediately a joint, coordinated investigation into the veteran and service member suicide epidemic, to include a macro evaluation of mental health treatment programs and personnel assigned to operate them," he said. "Many of these suicides appear to be protests of last resort where healthcare systems, treatment programs, and the underlying cultures of the responsible federal agencies have failed them."
"We can no longer accept that "20 suicides a day" is the norm and approach this crisis with passive resignation," he added.
Of the 19 suicides on VA campuses from October 2017 to November 2018, seven took place in parking lots, Chennelly said.
"These include a Marine Corps veteran who took his life in the Minneapolis VA hospital's parking lot, as well as a Marine colonel who shot himself in December 2018 outside the Bay Pines [Florida] Department of Veterans Affairs while dressed in his service uniform," he said.
Rep. Mark Takano, D-California, chairman of the House Veterans Affairs Committee, announced last week that he will hold a series of hearings beginning later this month on the suicide crisis. He said the hearings were intended to "spark a larger discussion about what actions we can take together as nation."
Focus on Outreach
Franklin said the pressing need was for outreach to make more veterans aware of VA's mental health services and get them into the system prior to any crisis. She pointed to a recent National Academy of Sciences evaluation.
"One of their findings was that when we do get people into care they fare better," she said.
The congressionally mandated NAS report, titled "Evaluation of the Department of Veterans Affairs Mental Health Services," found that there was "a substantial unmet need for mental health services," particularly among post-9/11 veterans.
The report said that about half of post-9/11 veterans "who may have a need for mental health care services do not use VA or non-VA mental health care services."
In addition, many veterans are resistant to seeking help, the NAS report said.
"More than half of veterans who screened positive in the survey for having a mental health care need do not perceive a need for mental health services," the report said.
For those veterans with a need for mental health care who have not sought VA services, lack of knowledge about how to apply for benefits, as well as uncertainty about eligibility and lack of information, were the main barriers to seeking care.
However, when veterans do use the VA system, most are satisfied with the results, the report said. A majority of post-9/11 veterans who use VA services "report positive experiences with its mental health services, including the availability of services, privacy and confidentiality of medical records, the ease of using VA mental health care, and the staff's skill, expertise, and courtesy toward patients," it said.
Franklin said that getting more veterans into the system required an overhaul of the outreach methods that came under scrutiny last year.
In December, the Government Accountability Office study found that of $6.2 million set aside for suicide prevention media outreach in fiscal 2018, only $57,000 -- less than 1 percent -- was actually spent.
VA officials at the time acknowledged that "organizational transitions and realignments" led to the funds going unspent, but said that more outreach was being planned targeting social media.
Last year, the VA joined with the non-profit PsychArmor Institute to develop an online suicide prevention video titled "SAVE" to aid those who interact with veterans who might be at risk.
Cashour, the VA spokesman, said that more than 93 percent of VA personnel have taken the training, and the video has been viewed more than 17,000 times.
In a fact sheet put out in January, the VA said that suicide prevention coordinators were currently managing care for nearly 11,000 veterans judged to be clinically at high-risk for suicide.
In addition, the VA in fiscal 2018 provided more than 2.4 million same-day mental health appointments, the fact sheet said.
In a release Tuesday, the VA said that in the first quarter of fiscal 2019, about 90% of new patients completed an appointment in a mental health clinic within 30 days of scheduling an appointment, and 96.8% of established patients completed a mental health appointment within 30 days of the day they requested.
But the definitive solutions to the epidemic of "parking lot" suicides and veteran suicides overall were still elusive.
Earlier this month, the Senate Veterans Affairs Committee called a hearing on the implementation of the Mission Act to expand private-care options for veterans, but the hearing quickly veered off into a back-and-forth with VA officials on the recent suicides in Georgia and Texas.
Dr. Richard Stone, the executive in charge of the VHA, told the senators that suicides and attempted suicides at VA facilities were more numerous than they may have thought.
He said that more than 260 suicide attempts had been recorded at VA facilities over the years. He did not give a time period for when the attempts were made, but said VA staff had intervened in about 240 of them and were able to save lives.
To curb what he called the "epidemic," Stone said the nation as a whole must ask itself where veterans have been failed.
"Where have we as a community and society failed that veteran is a very complex [question]," he said.
"I wish it was as simple as me saying I could do more patrols in a parking lot that would stop this," Stone said.
Military personnel who need help can call the Veterans Crisis Line at 800-273-8255. Suicidal troops and veterans can call the Military Crisis Line at 800-273-8255, press 1, for assistance, or text 838255.
-- Richard Sisk can be reached at Richard.Sisk@Military.com.
This story was updated April 20 to clarify the administrative level at which security decisions are made.