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Reducing Veteran Suicide through 21st Century MET Outreach Strategies

David Weiner, Chief of Police Veterans Affairs Police Department VA Long Beach Health Care System

John Gannon, Lieutenant Los Angeles County Sheriff’s Department

Mental Evaluation Teams

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Contents

Introduction ........................................................................................................... 3

Los Angeles selected for new nationwide SAMSHA program .............................. 3

History and Scope of the Problem ......................................................................... 5

LASD/DMH MET Statistical Data ............................................................................ 6

First Quarter Data for 2018 – ALL LASD............................................................... 6

Call Summary Data During Q1 of 2018 ................................................................ 7

Patient Demographics During Q1 of 2018 ........................................................... 7

Other Patient Information Logged During Q1 of 2018 ........................................ 8

Crisis Negotiations Team (CNT) Incidents During Q1 of 2018 .............................. 8

Type-I Jail Facility Incidents During Q1 of 2018 ................................................... 9

“Use of Force” Incidents ..................................................................................... 9

Risk Assessment & Management Program (RAMP) Incidents ........................... 10

The Proposed Solution ......................................................................................... 11

Feedback – Case Studies ...................................................................................... 13

CASE STUDY #1 ................................................................................................. 13

CASE STUDY #2 ................................................................................................. 16

Implementation ................................................................................................ 19

Training ................................................................................................................ 21

Future Possibilities ............................................................................................... 22

Conclusion ........................................................................................................... 23

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Introduction

The majority of veterans who committed suicide were not receiving services at the

Department of Veterans Affairs (VA) Hospital recently (SAMHSA). This proposal details

a new approach for outreach to veterans who demonstrate a pattern of behavior that

reflects increased risk for suicide without intervention.

Following up on missed appointments using the proposed model is the equivalent of

outreach to veterans who likely need services the most – to prevent them from

becoming detached from the VA care and services, which may result in becoming one

of the 20+ per day who resort to suicide. In this effort, the proposal is consistent

with the VA mission and the goals of the SAMHSA program entitled, “Mayors Challenge

to End Veterans Suicide.” Specifically, this proposal seeks to focus on those veterans

in crises who likely need services the most.

Los Angeles selected for new nationwide SAMSHA program

In December of 2017, the Substance Abuse and Mental Health Services Administration

(SAMHSA) and the Department of Veterans Affairs (VA) announced the cities that will

participate in the first nationwide group for the “Mayor’s Challenge to Prevent Suicide

Among Service Members, Veterans, and their Families.” Los Angeles was selected as a

city to form an interagency team to increase suicide prevention support for veterans.

SAMHSA and the VA selected Los Angeles County and City based on the sizable veteran

population data, suicide prevalence rates and capacity of the involved entities to lead

the way in this first year of the Mayor’s Challenge.1

The goal of the SAMHSA “Mayor’s Challenge” is to reduce suicides among service

members, veterans and their families using a public health approach to suicide

prevention. Funded entirely by SAMHSA, eight city teams were selected nationwide to

meet in Washington DC from March 14-16, 2018. The framework for a strategic action

plan was developed to benefit veterans in the County and City of Los Angeles.

Lieutenant John Gannon attended as a delegate from Los Angeles County representing

the LASD Mental Evaluation Team (MET). Chief Dave Weiner attended as a

representative for the VA Police Department.

In July of 2016, the VA conducted an analysis of veteran suicide rates. They reviewed

over 55 million veteran records from 1979 to 2014, from every state around the

country. This initiative combines the VA’s previously collected data from 2012, which

looked at three million veteran records from 20 different states. The 2012 data

revealed that veteran deaths by suicide averaged 22 per day. The more recent

1 SAMHSA announcement URL: https://www.samhsa.gov/newsroom/press-announcements/201802200200

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review indicates that in 2014, roughly 20 veterans per day committed suicide. We can

all agree that one veteran suicide is too many.

While the VA has made great strides in working to reduce the number of veteran

suicides through the development of the Veterans Crisis Hotline, expanding capacity

for same day mental health appointments and hiring additional clinicians to address

these critical issues, one element has been overlooked. That element is the proactive

utilization of VA Police Department (VAPD) officers in conjunction with mental health

clinicians to conduct outreach contacts and follow-up on cases of veterans

experiencing mental health issues/crises.

VA Police officers routinely come in contact and/or intervene with veterans who are

in mental health crises; often they are exhibiting threatening, suicidal or homicidal

behaviors. These interactions sometimes lead to the use of force, prosecution or

incarceration of the veteran involved. This is not the desired outcome for those who

have served our country honorably and have fallen on tough times. Many veterans do

not know how or where to seek the help they desperately need, which complicates

their situations even further.

This proposal outlines the use of a crisis response model that is currently used by

community partners nationwide, such as local police, sheriffs and mental health

departments, with immense success. Essentially, a mental evaluation team (MET) is a

collaboration pairing deputies or police officers with mental health clinicians. That

pair co-responds to calls that require special handling of mentally ill people who are a

danger to others, a danger to themselves, or unable to care for themselves due to

mental illness. The hope is that by routing those individuals to mental health services,

rather than jail, those patients will get the treatment they need and their mental

health should improve rather than cycling in and out of the criminal justice system.

We propose having a VA Police officer partnered with a VA clinician acting as co-

responders in partnership with local agencies, co-responding to crises involving

veterans. This outreach strategy should help reduce veteran suicides.

The benefits of this initiative would have multiple positive impacts in a variety of

areas. It saves taxpayer dollars by avoiding unnecessary incarceration, court visits and

helps to channel veterans toward needed services such as substance abuse treatment,

mental health services and employment resources. In addition, VAPD officers have the

unique ability to engage and interact with veterans on a level that other non-veteran

law enforcement officers are unable to relate with veterans. The daily interactions

with veterans and the keen understanding of their culture, both in the service and

after discharge, provides the VAPD officers with relevant subject matter expertise

that is highly beneficial to local law enforcement when they encounter veterans in

crisis.

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History and Scope of the Problem

In 2016, members of the Los Angeles County Sheriff’s Department (LASD) MET unit

started to regularly interact with members of the Veterans Affairs Police Department

(VAPD) offices in Long Beach and West Los Angeles when those offices were forming

new Crisis Negations Teams (CNT). VAPD middle management personnel from both

West Los Angeles and Long Beach attended a “Mental Health Update” class where MET

Sergeant Briz was an instructor. After that class, there were many conversations that

followed; it soon became apparent, the LASD MET and VAPD had overlapping interests

about helping veterans during mental health crises. In 2017, following the West Los

Angeles team, the VAPD Long Beach stood up its own Veteran Crisis Response Team

(VMET) pilot program.

The LASD MET unit(s) responds to virtually every mental health crisis call in-progress

Countywide. The VAPD has been sending personnel out in the field when requests

come in from the LASD to co-respond to CNT and/or VMET “call-outs” with increasing

frequency. The early results are such that the LASD MET and VAPD personnel now

enjoy an unprecedented level of interoperability working side-by-side at multiple

major incidents. This model works well today in Los Angeles County.

The VA Police Department Long Beach office responded to 178/290 calls for service in

FY16 and FY17 respectively that involved veterans in mental health crises. Out of

that number VA Long Beach VMET has responded to roughly 70 calls for service since

early 2017, at the request of our community law enforcement agency partners, to

aide in de-escalating veterans in crises. Each situation was carefully evaluated and

later resolved peacefully. The result has been our realized mutual goal of de-

escalating the veterans successfully and transporting them immediately to a VA

mental health treatment facility.

To give a true sense of the need for this type of intervention strategy, the following

section provides key data points from the Los Angeles County Sheriff’s Department

regarding the increasing volume of calls for service involving those is mental health

crisis - including veterans experiencing mental health crises in the community.

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LASD/DMH MET Statistical Data

First Quarter Data for 2018 – ALL LASD The following table illustrates the increase in reported mental health crises calls

Countywide within all of the LASD jurisdictions during the first quarter of the past

four years. During the first quarter of 2018, calls for mental health crises have

increased by 46% over the first quarter of 2017.

The actual number of calls to each respective division is shown, followed by the overall

percentage of all calls handled in LASD patrol areas during the first quarter of 2018.

It is important to note that Los Angeles County is the most populated County in the

nation with over 10.1 million people2, which also includes a high number of veterans

residing in Southern California. Data analysis from the LASD indicates there are well

over 400,000 people in Los Angeles County suffering from “Serious Mental Illness”

(SMI), which are the most serious cases of mental illness, often with recurring crises

and chronic interactions with law enforcement and EMS first responders, as well as

hospital emergency room staffs. The LASD considers veterans to be among the

highest risk group for negative outcomes with first responders when suffering from

SMI. This is one of the major factors that motivated the LASD to request consistent

2 https://mynewsla.com/government/2018/03/22/l-a-county-maintains-title-of-nations-most-populous-county/

139 124 148

229

189193

302376

201

163

231

423

455

371

470

654

0

100

200

300

400

500

600

700

2015 2016 2017 2018

Mental Health Crises in LASD JurisdictionsDuring Q1

Central Patrol South Patrol East Patrol North Patrol

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co-responses from the VMET to help the LASD MET personnel engage with the veteran

population, showing them greater understanding of their unique concerns, and to de-

escalate potentially volatile encounters in the hopes of linking them with immediate

treatment options.

To truly appreciate the scope of the problem of increasing mental health crises in Los

Angeles County, and the need for MET support, one must consider the staggering

statistics regarding MET calls during the first quarter of 2018.

Call Summary Data During Q1 of 2018

• 2,293 calls were logged by the MET Triage Desk

• 434 of the calls were resolved by the Triage Desk through consultation alone

(19%)

• 1,425 patients were evaluated by the MET during this quarter

o 998 patients were evaluated by MET clinicians (70%)

o 427 patients were evaluated by MET deputies (30%)

• 869 (54%) of incidents resulted in a patient being placed on a 72-hold and

transported to a medical and/or mental health treatment center

• 93% of patients placed on a “hold” were diverted away from the criminal

justice system (not jailed)

• 231 patients required transportation by ambulance (16%) – 2.8 per day on

average

Patient Demographics During Q1 of 2018

• 59% of patients evaluated by MET were males

• 41% of patients evaluated by MET were females

• 29.1 was the average age of patients evaluated by the MET during this quarter

• 18% of patients evaluated by the MET were juveniles

• 29% of patients evaluated by the MET were between 18-29 years old

• 36% of patients evaluated by the MET were between 30-49 years old

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• 13% of patients evaluated by the MET were between 50-65 years old

• 4% of patients evaluated by the MET were over 65 years old

• 18% of patients evaluated by the MET were homeless

• 22 patients evaluated by the MET this quarter were veterans in crises,

suffering from PTSD. Most had access to dangerous weapons.

o 19 of the veterans had attempted, threatened or considered suicide

and/or armed with weapons

Other Patient Information Logged During Q1 of 2018

• 137 patients were suicidal

• 6 were attempting to provoke “suicide-by-cop”

• 22 had threatened public officials

• 101 had threatened to commit acts of violence

• 10 had specifically threatened to commit acts of violence at LA County schools

• 18 patients were barricaded (at least initially) when encountered by the MET

unit

• 24 patients still had deadly weapons in their possession upon the arrival of MET

• 90 patients were reportedly high utilizers of police services – as reported by

patrol deputies to the MET

• 86 patients were reportedly engaged in increasingly high-risk behaviors since

prior contacts with deputies

Crisis Negotiations Team (CNT) Incidents During Q1 of 2018

• 19 of 30 calls that would meet CNT criteria (63%) were handled by MET units

alone without the need to activate SEB and/or CNT teams off duty (overtime

and cost savings)

• MET was on scene as the first CNT-trained negotiators at 11 out of 11 CNT

response incidents this quarter

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Type-I Jail Facility Incidents During Q1 of 2018

• MET was called to assist at 42 Type-I jail facility incidents during this quarter

(court lock-up or station jail)

• 25 calls this quarter involved a pending jail extraction where use of force

appeared imminent at a Type-I jail facility when an inmate refused to exit the

cell.

• MET was able to de-escalate and eventually gain the cooperation of 24 out of

25 inmates (96%) who then exited the cell voluntarily.

The time required to resolve such incidents ranged from 30 minutes de-

escalating to over three (3) hours.

“Use of Force” Incidents

• MET handled 213 incidents where patrol deputies and/or sergeant (supervisor)

first responders felt that the use of force was imminent until the MET unit

(along with VMET in several cases) arrived on scene and de-escalated the

patient’s behavior.

o This represented 12.8% of all MET field responses during the first

quarter.

• MET responded to 14 incidents this quarter which resulted in less use of force

than patrol deputies and/or sergeants believed was going to be necessary to

get the patient under control prior to MET arrival and assistance in de-

escalating the patient.

o At least three (3) of those incidents involved a deadly weapon that

could have ended in the use of deadly force before the MET and VMET

personnel de-escalated the patient.

o Neither MET deputies nor VMET officers used force during detentions

of patients/suspect during the first quarter of 2018.

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Risk Assessment & Management Program (RAMP) Incidents

• 413 reported crises involving 208 patients met one or more criteria for RAMP

case during the first quarter. Veterans suffering from PTSD meet the high-risk

criteria to be considered RAMP incidents.

• Only 62 crises could be made “Active” RAMP cases during the first quarter.

• 20 of the “Active” RAMP cases were resolved during the first quarter.

• 42 of “Active” RAMP cases were yet unresolved at the end of the first quarter

(lack of personnel).

• 371 cases that met the criteria for RAMP follow-up resulted in no action from

MET – unable to handle due to the lack of dedicated RAMP person

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The Proposed Solution

Based on the early feedback from the pilot for VMET deployment, from first

responders and patients alike, establishing a permanent VMET (Veteran Mental

Evaluation Team) team mobile outreach program at the VA Long Beach is a natural

next step in this process to reduce veterans’ suicides. While a Crisis Negotiations

Team (CNT) tends to deal with situations that require immediate intervention, the

VMET would have a similar mission with additional proactive tasks to help prevent

veterans’ untreated mental illness from escalating to become crises in the first place.

The VMET proposes to conduct daily outreach follow-up contacts with veterans and

provide necessary support for those same veterans and families that were

experiencing crises – largely due to untreated serious mental illness including PTSD.

The added benefit of the VMET is the ability to follow up with suicidal, high-risk

veteran patients in a post care environment.

One requirement for these patients in a post-care environment would be four (4)

mandatory positive contacts with the patient by the VA Suicide Prevention case

managers. The follow-up contacts with veterans are extremely important to each

patient to ensure care strategies are having the desired effect of reducing

unmitigated symptoms that may lead to future crises, which could lead to suicide.

A significant challenge to the VMET program is that a number of veterans in need of

treatments are homeless. The ability to make routine follow-up contacts with those

veterans may not be viable given their transient status and circumstances. The VMET

team will work with the Suicide Prevention team and local law enforcement homeless

outreach teams to ensure that these veterans are located and contacted regularly, as

much as possible, which will generally be contacts made in-person, to ensure those

veterans are receiving the care they need. This approach has the added benefit of

face-to-face contact and establishment of a positive rapport with many veterans,

giving them a true sense of genuine care, support and hope for recovery.

The effectiveness of this mobile outreach effort and improved care strategies may be

gauged by the reduced number of reoccurring crises and negative encounters

involving veterans, the reduction of veterans presenting in emergency rooms for

mental health care, the number of positive contacts made with veterans who are

following their prescribed treatment plans, with continued care and monitoring by

VMET, and a reduction in suicides by veterans within the County.

Each “Veteran Mental Evaluation Team” (VMET) would consist of a VA police officer

and a licensed clinician/social worker from the VA Mental Health whose primary

assignment would be to intervene in mental health crisis situations that police

agencies might typically be dispatched to handle today. This approach is also

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different in that VA police officers assigned to VMET duty will have a more patient-

centric approach with less “cop-like” attributes. They will be more engaging and help

establish a “patient-friendly” atmosphere in their daily contacts with mentally ill

veterans.

The stigma associated with mental illness is minimized and typical concerns about

being seen talking to the police and/or the appearance of going to jail are mitigated

by following this model. In California, this low-key approach to reduce stigma

involves the use of plain clothed officers and unmarked vehicles, which are both

mandated by law, per section 5153 WIC.

In this model, the VA officers are seen in a new light; veterans will better associate

with the VMET officer(s) and develop a rapport during de-escalation such that future

engagements with the same patient may end more favorably, even de-escalate more

quickly in the future, and the same patient in crisis is likely to cooperate when there

have been past dealings with the VAPD in this capacity. When on site and visiting the

VA facilities and a patient has trouble with staff, the responding VMET officers can

leverage their past rapport with the patient, using tactical communications to gain

their cooperation and reduce the likelihood of using force, which may result in

injuries to the patient and VA staff.

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Feedback – Case Studies

There is recent evidence and lived-experiences to support this model from two

different veterans’ feedback. Both veterans were recently de-escalated in the field

by VMET staff while assisting local law enforcement patrol officers at 9-1-1 calls

involving veterans in crises.

Interviews were conducted with both veterans in post-care conditions. Their

statements below are powerful indicators of the value and benefits of this proposed

program.

PATIENT FEEDBACK FOR HANDLING OF RECENT CRISIS INVOLVING MET & VMET

CASE STUDY #1

One of the most recent successful co-responses by the MET and the VMET unit this

spring involved Carson Sheriff’s Station patrol units who had responded to a call of a

mentally ill woman running in traffic, threating motorists and wielding a knife. The

Carson Station field training officer who initially got the call had recently attended

the 32-hour LASD Crisis Intervention Training (CIT) class. His training helped in his

approach to handling the call. He had a plan to neutralize the threat and de-escalate

the patient; he also requested MET to respond immediately. The LASD MET unit

arrived on scene within minutes and the patient was detained without any use of

force.

The patient was temporarily placed into the back of a patrol car where she then

became verbally abusive and obstinate, refusing to exit the car or transfer to the MET

unit for transport to a hospital. The patient became increasingly agitated, verbally

abusive and resistive to reasoning. The MET deputy ultimately determined the

patient was a veteran with PTSD. Upon learning the patient had received care at the

VA Hospital in Long Beach, the VMET was immediately summoned and responded late

on a Sunday night - within 30 minutes.

The VMET response team quickly established a rapport with the patient; she was de-

escalated and transferred to the MET unit for transport. The MET and VMET units

responded in tandem to the Emergency Department in Long Beach where the patient

was admitted to the VA hospital. No use of force was required.

A few days after the aforementioned crisis incident (in Carson) involving a veteran in

crisis threatening motorists with a knife, the VMET lieutenant contacted the patient,

who was then receiving mental health treatment at the VA Hospital facility. She

appeared to be doing much better.

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The patient agreed to an interview to provide quality of service feedback about how

the VMET and MET co-response model was perceived from the unique standpoint of a

veteran in crisis, suffering from PTSD and another serious mental illness (SMI)

diagnosis. Her response is summarized below and serves as evidence that this new co-

response model is indeed very beneficial for veterans. Her comments provide

invaluable insights worth sharing in this progress report. Continuing this co-response

practice may lead to further positive outcomes, as this veteran explained:

QUESTION: During your contact with LASD uniformed Deputies, were you scared,

nervous or angry?

PATIENT: I was acting strange. The Carson Sheriff showed up and got me under

control quick. I think they recognized I had mental issues. They were like, get your

hands up! Turn around! Then got me. I mean, I was doing some strange stuff. They

took care of it quick. Like I said, I think they knew I was having a mental problem.

They could have shot me, hurt me or beat me up, but just real quick, they took

control of me. I am thankful for that.

QUESTION: Did they advise you a MET unit was coming out to assist you?

PATIENT: Yeah. They said something like that. They were cool.

QUESTION: From your perspective, did the intervention in the field help calm you or

settle your fears?

PATIENT: Yes. They knew I had issues. Then, they had (2) County workers, (MET

Deputy and Clinician is what she meant), come out and talk to me. They had a good

tone in their voice and a good approach. Then they told me they were calling the VA

and I liked that.

QUESTION: How did you feel about LASD/MET Deputy and Clinician’s attempt in

helping you, when they arrived at your location?

PATIENT: I did not know they were deputies. Wait, the guy and girl that came? Oh,

they were Deputies? I thought they said, they worked for the county. I thought they

were just other county employees. They were good, but I was really agitated. I

wasn’t agitated with them, I was just agitated. So, I really didn’t speak with them. I

think they went into the psych questions too fast. I wanted them to just talk with me

some more. I did like it when she said, she was going to call the VA hospital, but I

thought she was going to talk to a doctor, not the police there. The VA cops were

cool when they came out though. The one guy, (Chris Berry – VA Police Dept), he

really calmed me down. He was good, and he just spoke to me. I think Veterans know

Veterans issues. The Sheriff needs maybe, like some Veterans on their force.

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QUESTION: Could the Deputy and Clinician have done anything different or anything

better?

PATIENT: They were cool, and they weren’t in uniform, so I didn’t think they were

going to hurt me. Naw, they did a great job. If I remember right, they spoke real nice

with me, but they could have made more small talk. They pretty much went right

into (mental health) questions. It would be nice to get vets into that stuff they do.

I ADVISED {PATIENT} LASD MET UNIT IS VERY BUSY AND GREATLY IN DEMAND.

THEY HAVE OTHER CALLS PENDING AND NEED TO GET YOU THE HELP YOU

DESERVE AS SOON AS THEY CAN. THEN, THEY GO HELP OTHERS.

PATIENT RESPONDED: Yes. I understand that. I know. Vets got issues and stuff they

need to talk about though. The Carson Sheriffs were great. The guy and the clinician

were too. Like I said, they could have shot me!

QUESTION: What was the difference between this experience than any prior

experience or visit?

PATIENT: I don’t think I’ve had an experience like this one before. I can’t say. I

mean they were cool and got me to where I need to be.

QUESTION: Is there anything the Sheriff’s Department or VA Police could do in the

future to calm or de-escalate others in similar circumstances in the future?

PATIENT: They did good. I like that they identified me as having mental issues. Man,

they could have shot me! They could have at least beat me up. They knew I was

having issues. That’s good. The “County employees” (MET) immediately called VA.

QUESTION: Have you been hospitalized for mental observation in a Non-VA hospital

before?

PATIENT: Yeah. I’ve been to Harbor General. I was brought there by the police,

(Uniformed Deputies), not the other guys, (MET MEMBERS).

QUESTION: Is there a difference between the Non-VA hospital and the VA Hospital? If

so, do you prefer one over the other?

PATIENT: At Harbor, they put you in like a holding cell. Almost like being in jail.

When you come to the VA, like I did, they put you in a bed and nurses help you.

Then, you guys, (VA Police), were there and talked with me.

QUESTION: Do you think it is good for Veterans, having the Sheriff’s Department and

other police agencies work with VA Police in these types of situations?

PATIENT: Yes. Absolutely! I think the VA Police working with Carson Sheriff’s (and

MET) is real good. VA Police officers know what veterans are going through. I mean

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the Sheriff was great, but it was good, real good you guys showed up too. It helped a

lot!

CASE STUDY #2

On 12 July 2018, the VMET from Long Beach responded to the City of San Gabriel to

assist in de-escalating a veteran with PTSD in crisis. He was at-risk of being

incarcerated and the likelihood of the local police using force was high – had the

VMET not responded. Through the actions and intervention of the VMET, the veteran

was safely de-escalated and transported to the VA hospital for care without any new

criminal charges or use of force involved.

Following the incident, Lieutenant Burns and Captain Chris Berry (VAPD Long Beach),

arranged a meeting with the patient, who was being treated at the VA Hospital. He

was making good progress in his treatment and consented to the following interview

in the hopes of seeing the VMET concept expanded:

QUESTION: During your contact with SGPD (San Gabriel Police Department)

uniformed officers, were you scared, nervous or angry?

PATIENT: I was scared and very nervous with the uniformed police officers. The

uniformed police officers make me nervous, “Cause, police officers sometimes jump

to conclusions. You know what I mean?”

Castro continued saying, that uniformed officers made him nervous.

QUESTION: Did they advise you a MET unit was coming out to assist you?

PATIENT: Yeah, but they didn’t really explain that. I was still nervous.

QUESTION: From your perspective, did the intervention in the field (involving

uniformed local police) help calm you or settle your fears?

PATIENT: No. Not really. I was still nervous. They didn’t try to make me

comfortable. They were just like real quick about it.

QUESTION: How did you feel about the SGPD MET Officer and clinician’s attempt in

helping you, when they arrived at your location?

PATIENT: They were all uniformed police officers there. (SGPD MET unit did not

adhere to WIC 5153 standards, apparently).

QUESTION: Was there a female at your location in plain clothes, with the uniformed

police officers?

PATIENT: Oh yeah. There was a female in plain clothes there. She talked to me.

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VA POLICE: That was the clinician that was there to help you and evaluate you.

PATIENT: “I didn’t know that.”

QUESTION: Could the Officer and Clinician have done anything different or anything

better?

PATIENT: They were real fast and quick. She asked me like 6 quick questions and

that was it. They could have talked to me more. They were quick and could have had

more of a “Personal” conversation with me. They really didn’t take much time

talking with me.

QUESTION: What was the difference between this experience than any prior

experience or visit?

PATIENT: I don’t have any prior experiences.

QUESTION: Is there anything the SGPD or VA Police could do in the future to calm or

de-escalate others in similar circumstances in the future?

PATIENT: Just spend more time talking and finding out about me.

QUESTION: Have you been hospitalized for mental observation in a Non-VA hospital

before?

PATIENT: Yeah, I have.

QUESTION: Is there a difference between your treatment experience at the Non-VA

hospital and the VA Hospital? If so, do you prefer one over the other?

PATIENT: Yes. I am glad to be at a VA hospital. I am around other Veterans here and

could relate better around other veterans.

QUESTION: Do you think it is good for veterans, having the SGPD and other police

agencies work with VA Police in these types of situations?

PATIENT: Yes. I think it is a real good idea. The VA Police came to the hospital that

the other police officers took me to. They took me to Whittier Presbyterian hospital,

then you guys, (VA Police), came and picked me up. You guys talked to me on a

personal level and then I wasn’t nervous anymore. I think it’s a good idea to have

“Veterans Police” work with other police departments and help out with Veterans

issues. It makes me less nervous. If it happened again, I would want you guys to come

out.

At the start of the interview/questions with the patient, he seemed apprehensive

about participating in the quality of service audit. When he learned that his feedback

could directly benefit other veterans and the VMET ability to expand and assist other

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law enforcement agencies dealing with veterans in crisis, the patient became at ease

and was eager to answer the questions. PATIENT concluded by saying, “It’s a great

idea to have you guys work with other police departments!”

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Implementation

Since early 2018, the VAPD embarked on a new collaborative venture – a pilot

program with the LASD/DMH MET, which quickly was expanded to include the LAPD

SMART teams. These collaborative efforts with community partners has yielded

positive outcomes for the veteran community as well as created better relationships

within the community. This new collaboration began as a “soft-launch” during the

first quarter of 2018. The pilot was to test and further mutually develop this concept

and allow the involved agencies to adapt and learn how best to co-respond to critical

incidents involving veterans in crisis Countywide.

The co-response model is premised on the understanding that most military veterans

prefer to relate with other veterans. The VA hospitals are best suited to serving the

needs of military veterans’ mental health treatment needs with highly specialized

programs and resources to benefit veterans. The VA hospitals are funded to provide

mental health care for veterans and many veterans prefer the VA services over other

public or private treatment options.

The VAPD officers are nearly all veterans themselves while only a fraction of other

local law enforcement MET teams are staffed by veterans. Virtually all of the VAPD

officers can relate well to veterans by leveraging that bond from prior service in the

military and ability to share their mutual experiences with VA hospital operations.

Since the VAPD officers work within the VA systems daily and most VAPD officers are

familiar with the doctors and professionals who provide the veterans’ care at the

local VA hospital, their officers are able to speak to veterans with a measure of extra

credibility to help de-escalate veterans in crisis. VA personnel can provide assurances

to veterans and help them navigate VA services like no other MET personnel can.

Officers can not only help get them to the VA hospital for care, but the VAPD officers

and VA staff can also help guide them within the VA system to ensure proper follow-

up care for the patient. At the LASD MET, this is referred to as continuity of care or

“linkage” to ongoing mental health services to help prevent reoccurrences of crises.

Such linkage is every bit as important as the initial crisis team response and de-

escalation to help reduce the drain on resources caused by chronic users of policing

and ED services due to untreated mental illness.

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During the first quarter of 2018, the LASD MET unit was able to seamlessly incorporate

the VA Police Department notification and 24-hour team “call-out” capability into

their new Triage Desk computer-aided dispatch (CAD) program in use today within LA

County. The LASD Triage Desk dispatcher is able to electronically transmit any new

call information about crises directly to on-call VAPD lieutenant(s) who, in

combination with the VA Chief of Police, then determine whether or not a response is

needed.

Below is a screen shot showing an example of the newly developed Triage Desk

database program in use today in LA County:

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Training

It is necessary to train MET outreach teams to a higher level for handling de-

escalation and tactical communications, among other skills. The following is a

summary of the minimum specialized training requirements for LASD MET deputies,

which the VAPD proposes to replicate to the extent needed to meet VMET program

objectives. Both LASD and LAPD have offered to provide their courses to VA Police

MET personnel at no cost.

MINIMUM REQUIREMENTS - YEAR 1 FOR MET DEPUTIES 200 Field work with mentor

160 Field work being "shadowed" by mentor (partnered with clinician) 32 Crisis Intervention Training (CIT) [LASD provides]

40 Crisis Negotiations Team (CNT) Basic [FBI or D-Prep provides] 20 Transit Mental Health Training [LASD or LAPD provides]

20 Jail Mental Evaluation Team (JMET)Training [LASD provides] 10 Homeless Outreach Training with DMH HOME or CPB/COPS Unit

4 Mental Health Court Training at Department 95 (LA County Courts) 4 Unit Orders specific to MET

4 Field Operations Directives, Dept. Policies 8 RCPI Class: Mental Health Update [LASD provides]

8 RCPI Class: POST DVD, de-escalation simulator & autism w/interactions [LASD provides] 6 Stepping In Conference - College Hospital (Norwalk in April) 6 MILES Conference - (San Gabriel in the Fall)

20 Crisis Prevention Institutes (CPI) "Train-the-Trainer" – de-escalation to national standard 30 Advanced De-Escalation to a National Standard (Train-the-trainer) 10 Veterans Affairs - Advanced Level Class on Military Culture & PTSD [pending- 2018]

582 Minimum hours of formal training during 1st Year 1,190 Minimum hours of MET experience (field work & engagement) during 1st Year 1,772 Minimum hours of MET formal training & experience by end of 1st Year (Milestone)

MINIMUM REQUIREMENTS - YEAR 2 FOR MET DEPUTIES 32 Mental Health Intervention Training (MHIT)[LAPD provides] 24 Crisis Negotiations Team (CNT) Advanced 56 Minimum hours of formal training during 2nd Year

638 Minimum hours of formal mental health training by the end of 2nd Year (Milestone) 1,716 Minimum hours of MET experience (field work & engagement) during 2nd Year

3,488 Minimum hours of training & experience by the end of 2nd Year (Milestone)

MINIMUM REQUIREMENTS - YEAR 3 FOR MET DEPUTIES 8 Mental Health First Aid for Public Safety (National Council for Behavioral Health)

16 CNT Team Leader training (FBI or D-Prep) 40 Specialization mental health sub-topic(s) training

64 Minimum hours of formal training during 3rd Year 702 Minimum hours of formal mental health training by the end of 3rd Year (Milestone)

1,708 Minimum hours of MET experience (field work & engagement) during 3rd Year

5,260 Minimum hours of training & experience by the end of 3rd Year (Milestone)

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Future Possibilities

Thought has been given as to how to implement this VMET program concept in more

rural areas of the nation. Utilizing Tele-Mental Health infrastructure, which is already

in place3, that can be leveraged to help veteran patients living in remote areas who

have a variety of mental health diagnoses. This is already a proven successful

application of technology within the VA.4 5

In the field, using a 2-way electronic means of connecting the patient to a centralized

clinician (such as an iPad used as the platform) may allow local law enforcement

officers to have the benefits of a consultation directly linked to the VA from a remote

location (could be states away). It is possible to provide consultation in a patrol car,

in a field environment, or in an office to assess and obtain professional guidance on

how best to handle the patient’s crisis and determine the best treatment plan. This

is similar to the model used by paramedics, who communicate with local ED doctors

while in the field. Doctors direct the paramedic on actions to be taken prior to

transport and arrival at the ED. The same is possible to ensure police officers and

patients are following VA psychiatrist orders and transporting to an acute facility, or

following up in an outpatient setting, as determined by the VA physician.

This concept may be quite unique and should be investigated for trial in areas of the

country served by VA hospitals in rural surroundings. Arguably, there might even be

Tele-Mental Health applications in suburban and urban environments, but those in

remote areas have the most obvious need for this trial approach.

3 https://pdfs.semanticscholar.org/24a3/2c19e7f0bb5c8576b5c1310dfc3e5e3ad336.pdf 4 https://www.ptsd.va.gov/professional/treatment/overview/ptsd-telemental.asp 5 https://www.va.gov/opa/pressrel/pressrelease.cfm?id=2789

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Conclusion

We already know most veterans who committed suicide were not getting the mental

health care they needed by coming to the VA facilities for care.6 This proposal offers

a unique approach to deploying VA police officers and clinicians following the

collaborative nationwide “best-practice” MET outreach model. The early results are

promising and worth exploration and further trial at other VA hospitals.

Veteran suicides may be preventable through pro-active community policing efforts,

effective suicide prevention programs and collaboration with key stakeholders. While

the VMET program has had more of a grass roots beginning in Los Angeles County, we

have already seen compelling evidence that these strategies can be widely successful

and easily expanded upon to include a proactive patient-outreach component to

become the VMET program. This program is highly adaptable and may be employed

on a national scale where similar positive impacts for veterans are anticipated.

It is hereby suggested that this program be adopted by the VA in key areas of the

nation to prove the efficacy of this model longer term in a wide variety of

geographical areas. If determined successful using benchmark data, determined

metrics and achievable milestones, this program could potentially be replicated at

virtually all VA hospitals nationwide with the ultimate goal of eliminating veterans’

suicides through this highly engaging, mobile outreach effort.

The risk of implementing the VMET is relatively low considering the multiple

advantages to this outreach approach to help veterans who need VA mental health

treatment the most: those in crisis and those not regularly receiving the follow-up

mental health care they need at the VA hospital.

We already know the alternative, waiting for troubled veterans to self-admit and/or

seek VA mental health services on their own volition, results in an unacceptably high

suicide rate. We propose this more collaborative, proactive approach as a proposed

remedy.

6 https://www.va.gov/opa/pressrel/pressrelease.cfm?id=2951