Forward Observer — Adalberto Morales Introduces Us to Suicide Prevention Services

LVMAC Poster Art 2005Adalberto Morales, one of two Suicide Prevention Coordinators at Wilkes-Barre VA Medical Center (VAMC), gave an outstanding talk to the Council at its 15 May business meeting.  His sole purpose is to help those contemplating suicide to get to needed help, no matter where – within the VA system or within the community. Together with Denise Carey, they operate 24/7 and are busy.

Morales affirmed suicide has become a serious problem for veterans and it is a problem for more than those who have more recently served, the focus of most media articles.  He has witnessed an increase among Vietnam era veterans as they retire also. As a result, the Center for Disease Control (CDC) estimates since 2010, a suicide occurs every 11 to 15 minutes (or about 105 suicides daily).  Consequently, suicide has risen from the fifteenth to the tenth leading cause of death in the United States.

Making matters worse, the Lehigh Valley and Northeastern Pennsylvania are already known for their high suicide rates in their populations. The Wilkes-Barre VAMC has 35 active cases currently being closely monitored, but over the last year, there have been six ‘completions’ and more than 60 “serious attempts” at suicide have occurred – “ideations” being in the hundreds.  Therefore, the Wilkes-Barre VAMC Coordinators alternate to provide a 24/7 service, the only ones in the Department of Veterans Affairs (VA) system to do so other than those in the national Crisis Call Center.

He went on to say the VA has responded in several ways.  First, it created a Veterans Crisis Line which is manned 24/7 and is part of the National Suicide Prevention Lifeline and has existed for years. One dials 1-800-273-TALK (8255), then presses “1” if he/she or a family member wishes VA assistance.  Canandaigua VA Medical Center in upstate New York operates the VA’s Crisis Control Center, the first point of referral for the Crisis Line.

Second, it introduced Suicide Prevention Coordinators such as himself.  Every VA Medical Center now has at least one.   As mentioned, Wilkes-Barre VAMC, whose network serves 19 counties in Pennsylvania and New York, has two.

To keep up with the younger generation of veterans, the VA added a CHAT LINE in 2009, a free text messaging service in 2011, and a Facebook page by 2012.  All are monitored to determine if a person is in crisis and these systems provide the additional advantage of geographical tracking as well.

He added the VA must be “dirty fighters” to prevent suicide – hence these seeming invasion-of-privacy techniques all for the good of the veteran.  The reach is also a long one.  He has actually helped with overseas cases in theater: getting a servicemember transferred for treatment in Germany, for example.

But the efforts of the VA have not ended there.  Morales said the VA now ensures clinical and non-clinical employees are trained on how to handle a call.  It was observed that even clinicians needed training. It has become a requirement for employment that every new employee undergo Suicide Prevention training.

Furthermore, all ongoing services at clinics and hospitals are monitored for indications through data mining. Computer monitoring and flagging operations are a major weapon in the arsenal nowadays.

Yet in some ways we continue to be mired in the past and still dealing with overcoming the stigma of acknowledging the need for mental health treatment. Morales pointed out many veterans unfortunately will not seek out help if they are in the military service.  He was referring to our Reserve and National Guard units in particular.  Sergeants still tell their subordinates they will not get home to their loved ones if during or after a deployment they report they are having coping problems; and there is a not meanly intended, natural tendency of units to keep things in-house. The result has been Suicide Prevention Coordinators are forced to go to the units rather than unit leadership coming to them with a request for assistance, when their personnel are in inactive status [when the VA can treat them].

How the system works routinely was then explained once identification of someone as high risk occurs through a crisis line referral to the closest VA Medical Center or data mining. Veterans are extremely closely monitored for the first ninety, following days.  It is recognized, through statistical analysis, the first thirty days’ actions are the most critical in such a situation, especially when the diagnosis is a new one.

For one thing, high risk veterans are seen by both the Suicide Prevention Coordinator and the service provider weekly.  Nor is this done in isolation of one another, for the Suicide Coordinator coordinates his actions with the service provider.  The service provider can be arranged to be either VA or a private doctor. In this area of endeavor, unlike in other situations, it does not matter, for the patient comes first.  It is a pragmatic solution because many do not wish to deal with the VA for one reason or another.  Realizing that proximity of service can drive use of service, Suicide Prevention Coordinators try to ensure veterans get the needed help as close to their homes as possible.

Those at high risk are also seen by a VA mental health provider every month. If they have family issues, arrangements are made to see a family therapist. If they have sexual trauma issues, they see someone for that. Finally, a watch list database has been developed to follow up on these veterans at 3, 6, 15, 18, and 24 months and every two years thereafter, regardless.

The Suicide Prevention Coordinators have been given extraordinary powers and at Wilkes-Barre VAMC report directly to the Director.  If a client does not respond within 24 hours of a telephone call and they cannot find him or her themselves, they are authorized to  employ “health and welfare” measures, working with the VA police, community police and other agencies to locate the individual and bring him in. Working with the counties, when needed by law, they can involuntarily commit a high risk veteran for five days.

Morales realizes he needs good working relations with the communities in his area to perform effectively.  That is why he and Carey are willing to give presentations to interested groups that might help no matter where in the service area.  This method takes on additional significance because unlike in New York, “the Pennsylvania social services network is fractured in comparison.”   What he meant was that when he worked in New York organized resource databases for social services were more readily available. Suicide Prevention often involves a series of interrelated issues, some simple, some complex, not all dealing with mental health services alone.

In speaking about what is occurring more locally in the Lehigh Valley, he stated each community requires unique tailoring to ensure immediate handling of the veteran when most critical  For example, the Allentown VA Outpatient Clinic has arranged for Lehigh Valley Hospital – Cedar Crest to provide emergency services.  In addition, the Wilkes-Barre VA Medical Center is trying to make patient transfer and less stressful, for it already has had dealings with the Behavioral Health Science Center (LVHN-Muhlenberg) in transferring veterans to Wilkes-Barre VA Hospital. Transfers have increased and the hospital plans to increase its Health Systems Specialist staffing in their Business Office from one to three in an effort to respond.

Carey and Morales also conduct monthly psycho-educational groups to train family members to properly respond when the veteran starts “de-compensating.”  While this training is only done at Wilkes-Barre VA hospital site presently, it is hoped with the coming advent of evening hours for the Allentown VA Clinic – part of realigning services to become more patient-centric and responsive generally – he expects to do the same in the Lehigh Valley in the future.  For the time being, the Coordinators visit each Community Based Outpatient Clinic (CBOC) quarterly and sometimes monthly.

As he came to the end of his talk, Adalberto Morales reminded the Council if they know of families  having a problem with a loved one and who are encountering barriers to access to care to not to be afraid to call him no matter the issue, for it may avert further complications down the road.  Suicide Prevention Coordinators can act as liaisons to solve a host of issues and “they do pick up the phone and are well known for being responsive.”  He and his associate can even engineer “skeleton eligibility” to ensure the veteran gets serviced, while the paperwork trail is being handled, when necessary.

However there are five things to remember if referring a veteran:  the name of the individual, the last four of the Social Security number, a phone number to reach them or where you are calling from, if the person has a weapon with him, and who is with him.

He concluded by saying the new health legislation, the Patient Protection and Affordable Care Act of 2010 (ACA, commonly but improperly called “Obamacare”), will give veterans more choices on where they receive their health care starting in 2014. It is unknown with certainty what this all portends, despite analysis[1], but Community Based Outpatient Clinics are being added in the local network, and the VA will need to become more adept at patient transfers in both directions.  Regardless, our Suicide Prevention Coordinators are already ahead in their thinking as they are embody the concept of patient-centric service.

LVMAC provides these numbers to call:

1. When in Crisis:

  • Veterans Crisis Line:  1-800-273-8255
  • Lehigh County Crisis Intervention Hotline: 610-782-3127
  • Northampton County Crisis Intervention Hotline: 610-252-9060
  • 911

2. Otherwise:

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RJH

As of 16 May 2013
Corrections made 9 June 2013


[1] Editor’s Addition:  “Some veterans may become eligible for Medicaid while others may become eligible for tax credits to purchase health care coverage [under the ACA] through the health insurance marketplace [Health Insurance Exchanges],” Dr. Robert A. Petzel, the VA’s Under Secretary for Health, told the House Veterans Affairs Committee in April 2013. He went on to say veterans make their choices on healthcare on a number of things, including their proximity to a VA facility and the kinds of care they want and need.  Regardless, the VA sees an expansion of their services is needed.  It has asked for a $570 million budget increase to handle a 66,000 veteran increase nationally, after migration losses.  However, Rep. Dan Benishek, R-Mich., who is also a doctor, said it is “ridiculous” to think any veteran eligible for VA healthcare might choose a state Medicaid program (that is, leave VA health care).  Others foresee where Medicaid Expansion does not occur (Pennsylvania being currently one of the affected states) new veterans will overwhelm the VHA’s healthcare networks.

What the future holds for the VA is unsure and there are also some worries ACA will lead to fragmentation of veterans’ health care. Yet others take another stance. They believe choice and competition works to the veterans’ advantage – justifiably forcing the VA to adapt to 21st Century needs of its clients and to work with community partners in a new fashion.

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