The Department of Veterans Affairs’ Office of Inspector General has found that officials have not made necessary changes to the suicide hotline for veterans. From The Wall Street Journal:

The Department of Veterans Affairs’ suicide crisis hotline is understaffed, poorly supervised and sometimes leaves veterans on hold so long that they simply hang up, according to an investigation released Monday.

The IG stated:

“Veterans are at a disproportionately high risk for suicide compared to the rate of U.S. civilian adults,” Michael Missal, Veterans Affairs inspector general, said in a statement. “The VCL is a critical effort to reduce veteran suicide for those who call in crisis. Therefore, it is imperative that VA take further steps to increase the effectiveness of VCL operations.”

The IG found these exact same problems over a year ago:

“Veterans are at a disproportionately high risk for suicide compared to the rate of U.S. civilian adults,” Michael Missal, Veterans Affairs inspector general, said in a statement. “The VCL is a critical effort to reduce veteran suicide for those who call in crisis. Therefore, it is imperative that VA take further steps to increase the effectiveness of VCL operations.”

The Veterans Crisis Line receives over 500,000 calls every single year. If too many calls come in, the calls move “to one of four backup centers run by a VA contractor.” The year old report found many voicemail errors at these centers and that counselors may not have received the proper training “to answer calls from those experiencing a mental health crisis.” From The Wall Street Journal:

“Staff described that queuing a call before a responder answered was not the same process as placing a call on hold after a responder answered,” the report said. “A veteran could be queued for 30 minutes, for example, and that wait time might not be reflected in hold time data; however, the result of the delay is the same, whether the veteran was in a queue or on hold.”

One backup call center saw 30% of callers hang up in what are known as “abandoned calls” over a five-month period, investigators determined.

Investigators found the VA hadn’t established an overarching directive or handbook to guide the administration of the Veterans Crisis Line. And the hotline had no effective way of tracking the outcome of calls.

The VA has nothing to do with these centers, meaning these officials do “not train the backup center employees or monitor the centers’ training requirements.” Therefore, officials have no idea “whether their training is sufficient.” The IG made these recommendations:

  • Resolving all problems related to calls routed to the backup centers.
  • Improved tracking of calls at the backup centers.Establishing a quality assurance process for both the Veterans Crisis Line and the backup centers.Ensuring that contracts with the backup centers set expectations.

Officials promised to implement these recommendations by September 30, 2016. But the IG found that nothing changed by December 15, 2016. In one case, a veteran could not receive help from the hotline, but officials “couldn’t identify the problem because of poor quality control.” From The Hill:

The new report also found that 28 percent of calls from August to September rerouted to the backup centers despite the VA’s goal of no more than 10 percent of calls rolling over.

Monday’s report does not address how many of the backup center calls are still going to voicemail. But it said two of the centers placed callers into a queue, which left some veterans waiting 30 minutes or more to talk to someone.

The report also found a number of issues with the governance structure, operations and quality assurance practices of the hotline. For example, the VA’s Office of Suicide Prevention and the crisis line’s clinical staff “felt marginalized concerning decision-making with clinical implications,” the report says.

Acting Undersecretary of Health Poonam Alaigh insists that the crisis hotline “is the strongest it’s ever been since its inception in 2007.” She noted that the VA opened a center in Atlanta, which “will provide callers with immediate service and achieve zero percent rollover to contracted back-up centers.”

But the report still disgusted some in Congress:

Sen. Johnny Isakson (R-Ga.), chairman of the Senate Veterans Affairs Committee, said he was disappointed with the lack of progress in improving the hotline.

“This crisis line is a lifeline for many veterans, and I am disappointed by the lack of action taken by the Department of Veterans Affairs to consider the recommendations for improving the shortcomings of the Veterans Crisis Line that were previously identified by the inspector general more than a year ago in February 2016,” he said in a statement. “The Veterans Crisis Line should be collaborating with clinical services every step of the way. I urge [VA] Secretary [David] Shulkin to act without further delay to remedy this issue.”

Rep. Tim Walz (D-Minn.), ranking member of the House Veterans Affairs Committee, called the issues with the crisis line “unacceptable.”

“Let me be clear: the ongoing issues with the Veterans Crisis Line identified in today’s VA Office of Inspector General report are completely unacceptable,” Walz said in a statement. “Secretary Shulkin needs to take immediate action to address this situation. When veterans seek mental healthcare, they should have immediate access. They deserve nothing less and upholding our responsibility to them means fixing this problem now.”