WASHINGTON – U.S. Senator Jerry Moran (R-Kan.) – chairman of the Senate Committee on Veterans’ Affairs – called on the U.S. Government Accountability Office (GAO) to continue its investigation into the Veterans Crisis Line (VCL) to determine how the VCL’s post-contact support efforts should be improved.

In November 2023, Sen. Moran initiated a GAO investigation after the VA Office of Inspector General (OIG) published a report regarding insufficient VCL staff management of a patient who died by suicide, a lack of standard operating procedures and policies and overall inadequate oversight. Whistleblowers also reported that the VCL was transferring veterans who presented with complex needs to a special unit within the VCL, which was reported to be severely understaffed and staff were undertrained.

GAO is expected to publish its initial investigation in the next few months, and VA is working to address gaps in the VCL’s operations, staffing, information technology and quality assurance programs. Sen. Moran’s request for a subsequent investigation would build on that work and assess how well the VCL performs at connecting veteran callers with appropriate support following their initial contact with crisis responders.

“Unfortunately, it is unclear how the VCL determines which veterans should receive what kind of support and appropriate level of care after contacting the VCL,” wrote Sen. Moran. “Furthermore, available VA data on veteran suicides raise questions about whether veterans referred to a suicide prevention coordinator are receiving timely mental health care and whether the VCL’s post-contact support efforts are effective. In light of these concerns, I am requesting that the Government Accountability Office conduct a review of the support that VA offers to veterans after they contact the VCL.”

Sen. Moran’s full letter to GAO can be found HERE and below.

February 12, 2025

Dear Mr. Dodaro,

I appreciate the expeditious work of your office in response to my November 6, 2023, request for a full investigation into mismanagement at the Department of Veterans Affairs’ (VA’s) Veterans Crisis Line (VCL). I look forward to GAO’s published report demonstrating how the presence and findings of your audit team have already successfully prompted VCL leaders to correct unacceptable gaps in this critical and lifesaving resource. I plan to work with my colleagues and VA to address remaining deficiencies and open recommendations with all due haste.

While GAO’s work on VCL’s operations, staffing, information technology and quality assurance winds down, we must not relent while our nation’s veteran suicide crisis continues. The suicide rate among U.S. veterans remains persistently and unacceptably high, averaging 17.5 suicides per day as of 2021. Since 2021, calls, chats, and texts to the VCL have increased 40 percent, further illustrating veterans’ growing need for mental health support and emergency crisis intervention.

After veterans contact the VCL to address an immediate crisis, it is crucial that they receive continued support to help address any underlying mental health issues and prevent further crises. When appropriate, VCL responders should refer veterans to a suicide prevention coordinator at a VA medical center (VAMC) who can arrange care with a mental health provider; send ‘caring letters’ to veterans following their initial interaction with the VCL; and have peer mentors proactively reach out to veterans who contacted the VCL.

Unfortunately, it is unclear how the VCL determines which veterans should receive what kind of support and appropriate level of care after contacting the VCL. Furthermore, available VA data on veteran suicides raise questions about whether veterans referred to a suicide prevention coordinator are receiving timely mental health care and whether the VCL’s post-contact support efforts are effective. In light of these concerns, I am requesting that the Government Accountability Office conduct a review of the support that VA offers to veterans after they contact the VCL. Specifically, I am interested in the following questions:

1. What policies and procedures does VA have for assigning post-VCL contact interventions to veterans, including which intervention to assign?
2. Over the past five years, how many veterans who contacted the VCL were assigned each type of post-contact intervention, including referral to a suicide prevention coordinator, a caring letter, or peer support?
3. How many veterans received mental health care at a VAMC or community provider after such a referral, and how is this information or other outcomes tracked, to make certain VA is proactively providing veterans with the support they may need?
4. Who is responsible for making certain that each type of post-contact intervention is provided to veterans and to what extent is this tracked within VA?
5. To what extent has VA assessed the effectiveness of its post-VCL contact interventions—including in accessing timely mental health care and in preventing veteran suicides—and acted to address any identified shortcomings?

The professionalism, transparency, and diligence demonstrated by your current VCL audit team instills great confidence in GAO’s ability to execute this difficult and important oversight. Thank you for your attention to this request.

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