Rule2022-04477
Staff Sergeant Parker Gordon Fox Suicide Prevention Grant Program
Primary source
Metadata and text below are from the Federal Register, a public-domain U.S. government work. Always verify the official published version before relying on it for any legal matter.
Published
March 10, 2022
Effective
April 11, 2022
Issuing agencies
Veterans Affairs Department
Abstract
The Department of Veterans Affairs (VA) is issuing this interim final rule to implement a new authority requiring VA to implement a three-year community-based grant program to award grants to eligible entities to provide or coordinate the provision of suicide prevention services to eligible individuals and their families for the purpose of reducing veteran suicide. This rulemaking specifies grant eligibility criteria, application requirements, scoring criteria, constraints on the allocation and use of the funds, and other requirements necessary to implement this grant program.
Full Text
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[Federal Register Volume 87, Number 47 (Thursday, March 10, 2022)]
[Rules and Regulations]
[Pages 13806-13844]
From the Federal Register Online via the Government Publishing Office [<a href="http://www.gpo.gov">www.gpo.gov</a>]
[FR Doc No: 2022-04477]
[[Page 13805]]
Vol. 87
Thursday,
No. 47
March 10, 2022
Part II
Department of Veterans Affairs
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38 CFR Part 78
Staff Sergeant Parker Gordon Fox Suicide Prevention Grant Program;
Final Rule
Federal Register / Vol. 87 , No. 47 / Thursday, March 10, 2022 /
Rules and Regulations
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DEPARTMENT OF VETERANS AFFAIRS
38 CFR Part 78
RIN 2900-AR16
Staff Sergeant Parker Gordon Fox Suicide Prevention Grant Program
AGENCY: Department of Veterans Affairs.
ACTION: Interim final rule.
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SUMMARY: The Department of Veterans Affairs (VA) is issuing this
interim final rule to implement a new authority requiring VA to
implement a three-year community-based grant program to award grants to
eligible entities to provide or coordinate the provision of suicide
prevention services to eligible individuals and their families for the
purpose of reducing veteran suicide. This rulemaking specifies grant
eligibility criteria, application requirements, scoring criteria,
constraints on the allocation and use of the funds, and other
requirements necessary to implement this grant program.
DATES:
Effective date: This interim final rule is effective on April 11,
2022.
Comments: Comments must be received on or before May 9, 2022.
ADDRESSES: Comments must be submitted through <a href="http://www.Regulations.gov">www.Regulations.gov</a>.
Comments received will be available at <a href="http://regulations.gov">regulations.gov</a> for public
viewing, inspection or copies.
FOR FURTHER INFORMATION CONTACT: Sandra Foley, Supervisory Grants
Manager--Suicide Prevention Program, Office of Mental Health and
Suicide Prevention, 11MHSP, 810 Vermont Avenue NW, Washington, DC
20420, 202-502-0002 (This is not a toll-free telephone number),
<a href="/cdn-cgi/l/email-protection#ca9c8b99998d8ca5b28db8aba4beb98abcabe4ada5bc"><span class="__cf_email__" data-cfemail="520413010115143d2a1520333c26211224337c353d24">[email protected]</span></a>.
SUPPLEMENTARY INFORMATION:
Background on Governing Statute and Public Input
On October 17, 2020, the Commander John Scott Hannon Veterans
Mental Health Care Improvement Act of 2019, Public Law (Pub. L.) 116-
171 (the Act), was enacted in law. Section 201 of the Act, codified as
a note to section 1720F of title 38, United States Code (U.S.C.),
mandated VA establish the Staff Sergeant Parker Gordon Fox Suicide
Prevention Grant Program (SSG Fox SPGP), a community-based grant
program that would support certain eligible entities to provide or
coordinate the provision of suicide prevention services to eligible
individuals and their families. Section 201 of the Act specified which
entities are eligible for grants and those individuals eligible to
receive suicide prevention services, defined the suicide prevention
services that may be provided, described grant application
requirements, and explained instances in which eligible entities must
refer individuals to VA for additional care, among other requirements.
This grant program is authorized for a period of three years starting
on the date on which the first grant is awarded. The maximum amount per
grant is capped by section 201(c)(2) of the Act at $750,000 per fiscal
year.
Section 201 of the Act required that VA consult with certain
entities to assist in developing a plan for the design and
implementation of the provision of grants; establishing criteria for
the selection of eligible entities; developing a framework for
collecting and sharing information about grantees; and developing
measures and metrics to be used by grantees to determine the
effectiveness of programming provided pursuant to the suicide
prevention services grant.
Section 201(h)(3) of the Act specifically required VA consult with
the following entities: (1) Veterans service organizations; (2)
National organizations (including national organizations that advocate
for the needs of individuals with or at risk of behavioral health
conditions; and those that represent mayors, unions, first responders,
chiefs of police and sheriffs, governors, a territory of the United
States, or a Tribal alliance) representing potential community partners
of eligible entities in providing supportive services to address the
needs of eligible individuals and their families; (3) National
organizations representing members of the Armed Forces; (4) National
organizations that represent counties; (5) Organizations with which VA
has a current memorandum of agreement or understanding related to
mental health or suicide prevention; (6) State departments of veterans
affairs; (7) National organizations representing members of the Reserve
Components of the Armed Forces; (8) National organizations representing
members of the Coast Guard; (9) Organizations, including institutions
of higher education, with experience in creating measurement tools for
purposes of advising the Secretary on the most appropriate existing
measurement tool or protocol for VA to utilize; (10) The National
Alliance on Mental Illness; (11) A labor organization (as such term is
defined in section 7103(a)(4) of title 5, U.S.C.); (12) The Centers for
Disease Control and Prevention (CDC), the Substance Abuse and Mental
Health Services Administration (SAMHSA), and the President's Roadmap to
Empower Veterans and End a National Tragedy of Suicide (PREVENTS) Task
Force; and such other organizations as the Secretary deems appropriate.
On April 1, 2021, VA published a Notice of Request for Information
on the Department of Veterans Affairs' Staff Sergeant Parker Gordon Fox
Suicide Prevention Grant Program (RIN 2900-AR16) in the Federal
Register (FR), requesting information and comments from the public to
meet the requirements for consultation in the Act. 86 FR 17268 (April
1, 2021). Through this notice, VA asked the public, including those
organizations listed in the previous paragraph, to comment on various
aspects of the suicide prevention services grant program, such as
distribution and selection of grants; administration of the grant
program, including development of measures and metrics; training and
technical assistance; referrals for care; degrees of risk of suicide
and processes for determining degrees of risk of suicide; and
nontraditional and innovative approaches and treatment practices that
may be appropriate under this grant program. VA directly contacted
various organizations that met the categories of organizations listed
under section 201(h)(3) of the Act to notify them that VA was seeking
input through this FR notice. VA received 124 comments, including
comments outside the scope of the questions posed. Many commenters
expressed support for awarding grants to entities with prior relevant
experience. Many commenters also provided suggestions for training and
technical assistance related to suicide prevention, evaluation and
reporting requirements, and referrals to VA for further care.
Additionally, numerous commenters provided suggestions for non-
traditional and innovative treatment and services under this grant
program. The comments received from this notice are publicly available
online at www.<a href="http://regulations.gov">regulations.gov</a>.
On May 11, 2021, VA published a Notice of Listening Sessions on the
Department of Veterans Affairs Staff Sergeant Parker Gordon Fox Suicide
Prevention Grant Program (RIN 2900-AR16) in the FR notifying the public
of two related listening sessions, which were held on May 25, 2021 and
May 26, 2021. 86 FR 25938 (May 11, 2021). The topics for the first
listening session included distribution and selection of grants,
administration of the grant program, and training and technical
assistance. The topics for the second listening session included
referrals for
[[Page 13807]]
care, risk of suicide, and suicide prevention services. Similar to the
April 1, 2021 notice, this second notice included specific questions
for the public to consider and upon which to comment at the listening
session. VA directly contacted various organizations that met the
categories of organizations listed under section 201(h)(3) of the Act
to notify them that VA was seeking input through these listening
sessions. Thirty-two individuals presented oral comments at these
listening sessions. Many of these comments were similar to those
received in response to the April 1, 2021 notice. Commenters expressed
support for awarding grants to entities with demonstrated experiences
and capacity to implement evidence-based programs. Commenters also
expressed support for awarding grants to entities that have experience
working with veterans at risk of suicide and have or plan to have
culturally competent care. Additionally, commenters supported awarding
grants to entities that utilized validated assessment tools and
entities that had area partnerships (including at local, regional, and
national levels) as well as with VA. Many commenters also provided
suggestions for training and for assessment tools. Additionally,
numerous commenters provided suggestions for non-traditional and
innovative treatment and services under this grant program. The
transcript for these listening sessions is publicly available online at
www.<a href="http://regulations.gov">regulations.gov</a>.
VA appreciates the time and attention from commenters who shared
their opinions on how to implement section 201 of the Act. In
developing this interim final rule, VA considered the feedback received
from the April 1, 2021, Notice of Request for Information on the
Department of Veterans Affairs' Staff Sergeant Parker Gordon Fox
Suicide Prevention Grant Program (RIN 2900-AR16) and the listening
sessions held on May 25, 2021, and May 26, 2021.
Part 78 of Title 38, Code of Federal Regulations
Through this interim final rule, VA is establishing and
implementing, in new part 78 of title 38, Code of Federal Regulations
(CFR), SSG Fox SPGP required by section 201 of the Act. Establishment
of this new part ensures organization and clarity for implementation of
this new grant program. The interim final rule is establishing
regulations authorizing VA to award suicide prevention services grants
to eligible entities who will provide or coordinate the provision of
suicide prevention services to eligible individuals and their families.
Consistent with section 201 of the Act, part 78 is titled the Staff
Sergeant Parker Gordon Fox Suicide Prevention Grant Program.
78.0 Purpose and Scope
Section 78.0 of this IFR explains the purpose and scope of new part
78.
Paragraph (a) states that this part implements SSG Fox SPGP with
the purpose of reducing veteran suicide by expanding suicide prevention
programs for veterans through the award of suicide prevention services
grants to eligible entities to provide or coordinate the provision of
suicide prevention services to eligible individuals and their families.
This purpose is consistent with section 201(a)(1) and (b) of the Act.
Section 201(a)(1) states that its purpose is to reduce veteran suicide
through a community-based grant program to award grants to eligible
entities to provide or coordinate suicide prevention services to
eligible individuals and their families. Section 201(b) states that the
Secretary shall provide financial assistance through grants to eligible
entities to provide or coordinate the provision of services to eligible
individuals and their families to reduce the risk of suicide.
Paragraph (b) states that suicide prevention services covered by
this part are those services that address the needs of eligible
individuals and their families and are necessary for improving the
mental health status and wellbeing and reducing the suicide risk of
eligible individuals and their families. This broadly defines the
intended effects of the program, is consistent with the intent of the
law, and ensures that those services authorized under this grant
program are those that meet the purpose of this grant program--to
reduce suicide risk.
78.5 Definitions
Section 78.5 contains the definitions for key terms that apply to
new part 78 and to any Notice of Funding Opportunity (NOFO) for this
grant program. The definitions are listed in alphabetical order,
beginning with the definition of applicant.
VA is defining applicant to mean an eligible entity that submits an
application for a suicide prevention services grant announced in a
NOFO. VA is defining applicant in this manner since only an eligible
entity (as that term is defined later in this rulemaking) that submits
an application for a suicide prevention services grant under part 78
will be able to apply for such a grant. This is based on a plain
language understanding of the term ``applicant'' and is consistent with
how VA defines this in the Supportive Services for Veteran Families
(SSVF) Program. See 38 CFR 62.2. As explained in Sec. 78.15, VA will
require submission of an application similar to other grant programs
that VA administers.
Direct Federal financial assistance means Federal financial
assistance received by an entity selected by the Government or a pass-
through entity as defined in 38 CFR 50.1(d) to provide or carry out a
service (e.g., by contract, grant, or cooperative agreement). This is
used for purposes of Sec. 78.130 and is consistent with how VA defines
this in the Homeless Providers Grant and Per Diem Program and the SSVF
Program (see Sec. Sec. 61.64(b)(2) and 62.62, respectively).
Eligible child care provider is defined to mean a provider of child
care services for compensation, including a provider of care for a
school-age child during non-school hours, that (1) is licensed,
regulated, registered, or otherwise legally operating, under State and
local law; and (2) satisfies the State and local requirements,
applicable to the child care services the provider provides. This is
consistent with the definition of eligible child care provider that VA
uses in the SSVF Program. See 38 CFR 62.2. This definition of eligible
child care provider is also consistent with the broader definition used
by the Department of Health and Human Services (HHS) for its Child Care
and Development Block grant. See 42 U.S.C. 9859(2).
This term is used for purposes of Sec. 78.80(h), which includes
among suicide prevention services certain child care services. Pursuant
to section 201(q)(11)(A)(ix)(VIII) of the Act, child care services (not
to exceed $5,000 per family of an eligible individual per fiscal year)
are authorized as assistance with emergent needs under this grant
program, and VA explains in Sec. 78.80(h) the limitations on such
services and payments.
Eligible entity is defined to mean an entity that meets the
definition of an eligible entity in section 201(q) of Public Law 116-
171. VA refers to section 201(q) of Public Law 116-171 rather than
include the exact definition from subsection (q)(3) of section 201, as
this would allow VA to immediately implement any changes made by
Congress to that definition without requiring amendment to these
regulations. Currently, under section 201(q)(3) of the Act, an eligible
entity must be one of the following: (1) An incorporated private
institution or foundation (i) no part of the net earnings of which
incurs to the benefit of any member, founder, contributor, or
[[Page 13808]]
individual, and (ii) that has a governing board that would be
responsible for the operation of the suicide prevention services
provided under this part; (2) a corporation wholly owned and controlled
by an organization meeting the requirements of clauses (i) and (ii)
above; (3) an Indian tribe; (4) a community-based organization that can
effectively network with local civic organizations, regional health
systems, and other settings where eligible individuals and their
families are likely to have contact; or (5) a State or local
government.
Eligible individual is defined to mean an individual that meets the
requirements of Sec. 78.10(a). As discussed later in this rulemaking,
Sec. 78.10(a) describes the eligibility criteria to be an eligible
individual under part 78. These criteria are consistent with section
201(q)(4) of the Act.
Family is defined to mean any of the following: A parent, spouse,
child, sibling, step-family member, extended family member, and any
other individual who lives with the eligible individual. This is
consistent with section 201(q)(6) of the Act.
Grantee is defined to mean an eligible entity that is awarded a
suicide prevention services grant under part 78. This is consistent
with how VA defines grantee for other VA grant programs and the plain
meaning of this term. See, e.g., 38 CFR 62.2; 38 CFR 61.1.
Indian tribe is defined to mean an Indian tribe as defined in 25
U.S.C. 4103. Section 4103(13)(A) of title 25, U.S.C., defines Indian
tribe in general to mean a tribe that is a Federally or a State
recognized tribe. Section 4103(13)(B) of title 25, U.S.C., further
defines Federally recognized tribe to mean any Indian tribe, band,
nation, or other organized group or community of Indians, including any
Alaska Native village or regional or village corporation as defined in
or established pursuant to the Alaska Native Claims Settlement Act (43
U.S.C. 1601 et seq.), that is recognized as eligible for the special
programs and services provided by the United States to Indians because
of their status as Indians pursuant to the Indian Self-Determination
and Education Assistance Act (25 U.S.C. 450 et seq.). Section
4103(13)(C) of title 25, U.S.C., also defines State recognized tribe to
mean any tribe, band, nation, pueblo, village, or community--(1) that
has been recognized as an Indian tribe by any State; and (2) for which
an Indian Housing Authority has, before the effective date under
section 705, entered into a contract with the Secretary of Housing and
Urban Development pursuant to the United States Housing Act of 1937 (42
U.S.C. 1437 et seq.) for housing for Indian families and has received
funding pursuant to such contract within the 5-year period ending upon
such effective date. This definition also includes certain conditions
set forth in 25 U.S.C. 4103(13)(C)(ii). This definition of Indian tribe
is consistent with section 201(q)(7) of the Act.
Indirect Federal financial assistance means Federal financial
assistance in which a service provider receives program funds through a
voucher, certificate, agreement or other form of disbursement, as a
result of the genuine, independent choice of a participant. This is
used for purposes of Sec. 78.130 and is consistent with how VA defines
this in the VA Homeless Providers Grant and Per Diem Program and the
SSVF Program. See Sec. Sec. 61.64(b)(2) and 62.62, respectively.
Section 201(d)(1)(A)(iv) of the Act authorizes VA to prioritize
distribution of grants to medically underserved areas. While section
201 of the Act does not define medically underserved areas, VA is
defining medically underserved areas consistent with the definition of
medically underserved population that is set forth in other Federal
law. Section 254b(b)(3)(A) of 42 U.S.C. defines medically underserved
population to mean the population of an urban or rural area designated
by the HHS Secretary as an area with a shortage of personal health
services or a population group designated by the HHS Secretary as
having a shortage of such services. While section 254b(b)(3)(A) uses
the term medically underserved population, section 254b(b)(3) generally
establishes a process for identifying medically underserved areas that
are designated by the United States Health Resources and Services
Administration (HRSA), the HHS sub-agency responsible for issuing data
and maps on medically underserved populations and areas in a combined
manner. See HRSA's maps on medically underserved areas/populations at
<a href="https://www.hrsa.gov/maps/quick-maps?config=mapconfig/MUA.jsondevelops">https://www.hrsa.gov/maps/quick-maps?config=mapconfig/MUA.jsondevelops</a>.
See also, <a href="https://data.hrsa.gov/tools/shortage-area/mua-find">https://data.hrsa.gov/tools/shortage-area/mua-find</a>. Because
42 U.S.C. 254b(b)(3) may be amended in the future, VA is not
incorporating the actual definition in proposed Sec. 78.5. Rather, VA
is defining medically underserved areas to mean an area that is
designated as a medically underserved population under 42 U.S.C.
254b(b)(3). This term is defined consistently with its use in 38 U.S.C.
7601 note, and is widely known, commonplace, and established. It also
allows VA to defer to the expertise of another agency that specializes
in analyzing and identifying medically underserved areas and
populations.
VA is defining Notice of Funding Opportunity (NOFO) to mean a
Notice of Funding Opportunity published on <a href="http://grants.gov">grants.gov</a> in accordance
with Sec. 78.110. This is consistent with how VA defines a similar
term, Notice of Funding Availability (NOFA), in other grant regulations
and with the plain meaning of this term. This definition references
Sec. 78.110, which explains that VA will publish a NOFO when funds for
suicide prevention services grants are available and indicates the type
of information that must be included in the application for this
program. Pursuant to 2 CFR 200.203, all NOFOs must be posted on
<a href="http://grants.gov">grants.gov</a>.
Participant is defined to mean an eligible individual or their
family who is receiving suicide prevention services for which they are
eligible from a grantee. This definition is necessary for purposes of
understanding part 78 and SSG Fox SPGP.
VA is defining rural communities to mean those communities
considered rural according to the Rural-Urban Commuting Area (RUCA)
system as determined by the United States Department of Agriculture
(USDA). This is consistent with section 201(q)(9) of the Act. VA will
use this term and its definition in Sec. 78.30 for purposes of
prioritizing the distribution of grants to rural communities pursuant
to section 201(d)(1)(A)(i) of the Act. For more information on RUCA,
please refer to <a href="https://www.ers.usda.gov/data-products/rural-urban-commuting-area-codes/">https://www.ers.usda.gov/data-products/rural-urban-commuting-area-codes/</a>.
VA is defining State to mean any of the several States of the
United States, the District of Columbia, the Commonwealth of Puerto
Rico, any territory or possession of the United States, or any agency
or instrumentality of a State exclusive of local governments. This is
identical to most of the definition of the same term for the SSVF
Program (see Sec. 62.2), except that we do not include here the
exception that is present in the SSVF regulations to public and Indian
housing agencies under the United States Housing Act of 1937, as that
portion of the definition is not relevant to the suicide prevention
grant program established under these regulations. This definition is
understood by VA and grantees.
Suicide prevention services is defined consistent with the
definition of this term in section 201(q)(11) of the Act. VA is setting
forth each of the suicide prevention services in their own individual
sections (see 38 CFR 78.45 through 78.90) for clarity. Thus, VA is
defining suicide prevention services to
[[Page 13809]]
include the following services provided to address the needs of a
participant: (1) Outreach as specified under Sec. 78.45, (2) baseline
mental health screening as specified under Sec. 78.50, (3) education
as specified under Sec. 78.55, (4) clinical services for emergency
treatment as specified under Sec. 78.60, (5) case management services
as specified under Sec. 78.65, (6) peer support services as specified
under Sec. 78.70, (7) assistance in obtaining VA benefits as specified
under Sec. 78.75, (8) assistance in obtaining and coordinating other
public benefits and assistance with emergent needs as specified under
Sec. 78.80, (9) nontraditional and innovative approaches and treatment
practices as specified under Sec. 78.85, and (10) other services as
specified under Sec. 78.90.
VA is defining suicide prevention services grant to mean a grant
awarded under part 78. This definition is based on the plain language
understanding of this term.
VA is defining suicide prevention services grant agreement to mean
the agreement executed between VA and a grantee as specified under
Sec. 78.115. This definition is based on the plain language
understanding of this term and is consistent with the definition of
similar terms in other VA regulations. See Sec. 62.2.
Suspension is defined to mean an action by VA that temporarily
withdraws VA funding under a suicide prevention services grant, pending
corrective action by the grantee or pending a decision to terminate the
suicide prevention services grant by VA. Suspension of a suicide
prevention services grant is a separate action from suspension under VA
regulations or guidance implementing Executive Orders 12549 and 12689,
``Debarment and Suspension.'' This definition is consistent with the
SSVF grant program's definition for this term. See Sec. 62.2. However,
with regards to implementing Executive Orders 12549 and 12689, VA has
added the language, guidance, as not all of VA's implementations of
Executive Orders are regulatory.
Territories is defined to mean the territories of the United
States, including Puerto Rico, Guam, the U.S. Virgin Islands, American
Samoa, and the Northern Mariana Islands. This is consistent with how
the Federal government commonly describes U.S. territories (in
comparison to States). This term is necessary to define as it is used
in the Act, although not defined within section 201, and in Sec.
78.30. VA is defining this term as VA has authority under section
201(d)(1)(A)(iii) of the Act to prioritize distribution of grants to
territories of the United States. As explained in Sec. 78.30, VA may
prioritize territories, along with other areas such as medically
underserved areas and tribal lands, for purposes of this grant program.
While there is some overlap between this definition and the definition
of State above--all territories are considered States under part 78 (as
provided for under 38 U.S.C. 101(20)), but not all States are
territories--the specific application of this potential priority under
Sec. 78.30(d)(2)(iii) reflects the only meaningful distinction between
the two terms.
Veteran is defined to mean veteran under 38 U.S.C. 101(2). This is
based on section 201(q)(4)(A) of the Act. Section 101 of title 38,
U.S.C., defines veteran as a person who served in the active military,
naval, air, or space service, and who was discharged or released
therefrom under conditions other than dishonorable. This term is used
for purposes of peer support services in part 78.
The term Veterans Crisis Line is defined to mean the toll-free
hotline for veterans in crisis and their families and friends
established under 38 U.S.C. 1720F(h). This is consistent with section
201(q)(12) of the Act. This term is used in Sec. 78.30(d)(2)(vi) for
purposes of prioritizing selection of applicants for this grant
program.
VA is defining withholding to mean that payment of a suicide
prevention services grant will not be paid until such time as VA
determines that the grantee provides sufficiently adequate
documentation and/or actions to correct a deficiency for the suicide
prevention services grant. This term is defined in this manner, as it
is intended to provide a general description of how this term is used
in 2 CFR part 200, which governs VA grant programs including the SSG
Fox SPGP. This term relates to withholding payment of a suicide
prevention services grant pursuant to Sec. 78.160, described later in
this rulemaking.
78.10 Eligible Individuals
Section 78.10 explains the criteria for determining the eligibility
of individuals under part 78 consistent with the definition of eligible
individual in section 201(q)(4) of the Act. As explained in the
definitions section, an eligible individual is an individual that meets
the requirements of Sec. 78.10(a).
Paragraph (a) states that to be an eligible individual under this
part, a person must meet criteria that determine that person is at risk
of suicide and further meet the definition of eligible individual in
section 201 of Public Law 116-171. VA refers to section 201(q) of
Public Law 116-171 rather than include the exact definition from
subsection (q)(4), as this would allow VA to immediately implement any
changes made by Congress to that definition without requiring amendment
to these regulations. Subsection (q)(4) of section 201 currently states
that an eligible individual must be one of the following: (1) A veteran
as defined in 38 U.S.C. 101, (2) an individual described in 38 U.S.C.
1720I(b), or (3) an individual described in 38 U.S.C. 1712A(a)(1)(C)(i)
through (iv).
Section 101(2) of title 38, U.S.C. defines veteran as a person who
served in the active military, naval, air, or space service, and who
was discharged or released therefrom under conditions other than
dishonorable. Section 1720I(b) requires VA furnish to certain former
member of the Armed Forces (1) an initial mental health assessment and
(2) mental health care or behavioral health care services authorized
under 38 U.S.C. chapter 17 that are required to treat the mental or
behavioral health care needs of these former service members, including
risk of suicide or harming others. Such former members of the Armed
Forces, including reserve components, are those who (1) while serving
in the active military, naval, air, or space service, were discharged
or released therefrom under a condition that is not honorable but not a
dishonorable discharge or a discharge by court-martial; (2) are not
enrolled in VA health care; and either served in the Armed Forces for a
period of more than 100 cumulative days and were deployed in a theater
of combat operations, in support of a contingency operation, or in an
area at a time during which hostilities were occurring in that area
during such service, including by controlling an unmanned aerial
vehicle from a location other than such theater or area; or (3) while
serving in the Armed Forces, were the victim of a physical assault of a
sexual nature, a battery of a sexual nature, or sexual harassment.
Section 1712A details the individuals to whom VA is required to furnish
readjustment counseling. These include any individual who is a veteran
or member of the Armed Forces, including a member of a reserve
component of the Armed Forces, who served on active duty in a theater
of combat operations or an area at a time during which hostilities
occurred in that area; any individual who is a veteran or member of the
Armed Forces, including a member of a reserve component of the Armed
Forces, who provided direct emergency medical or mental health care, or
mortuary services to the
[[Page 13810]]
causalities of combat operations or hostilities, but who at the time
was located outside the theater of combat operations or area of
hostilities; any individual who is a veteran or member of the Armed
Forces, including a member of a reserve component of the Armed Forces,
who engaged in combat with an enemy of the United States or against an
opposing military force in a theater of combat operations or an area at
a time during which hostilities occurred in that area by remotely
controlling an unmanned aerial vehicle, notwithstanding whether the
physical location of such veteran or member during such combat was
within such theater of combat operations or area; and any individual
who is a veteran or member of the Armed Forces, including a member of a
reserve component of the Armed Forces, who served on active service in
response to a national emergency or major disaster declared by the
President or in the National Guard of a State under orders of the chief
executive of that State in response to a disaster or civil disorder in
such State.
For purposes of eligible individuals, paragraph (b) defines risk of
suicide. Consistent with section 201(q)(8) of the Act, risk of suicide
means exposure to, or the existence of, any of the following factors,
to any degree, that increase the risk of suicidal ideation and/or
behaviors: (1) Health risk factors, including mental health challenges,
substance use disorder, serious or chronic health conditions or pain,
and traumatic brain injury; (2) environmental risk factors, including
prolonged stress, stressful life events, unemployment, homelessness,
recent loss, and legal or financial challenges; and (3) historical risk
factors, including previous suicide attempts, family history of
suicide, and history of abuse, neglect or trauma, including military
sexual trauma.
While section 201(q)(8) uses the language, substance abuse, VA
instead uses the language, substance use disorder, in paragraph (b) to
reduce stigma and discrimination related to substance use. For purposes
of paragraph (b), an individual will not be required to have a
diagnosis of substance use disorder. This definition is necessary to
meet the intent and purpose of the program to provide grants to
eligible entities to provide or coordinate the provision of suicide
prevention services to eligible individuals who are considered at risk
of suicide and is consistent with feedback received from commenters
during consultation. This provision is thus used for determining
eligibility of eligible individuals for receipt of suicide prevention
services under this grant program. VA notes that this definition is
overly inclusive, as to define this term otherwise could exclude
individuals who may need these critical services prior to a crisis.
Section 201(q)(8)(iii)(III) includes a history of trauma as a
potential historical risk factor for suicide. VA interprets this, for
purposes of this grant program, to include military sexual trauma. VA
notes that survivors of military sexual trauma are at higher risk of
suicide. See the National Military and Veteran Suicide Prevention
Strategy (<a href="https://www.whitehouse.gov/wp-content/uploads/2021/11/Military-and-Veteran-Suicide-Prevention-Strategy.pdf">https://www.whitehouse.gov/wp-content/uploads/2021/11/Military-and-Veteran-Suicide-Prevention-Strategy.pdf</a>). This reference
is not intended to exclude other forms of trauma, but rather serves as
an example of how this language is interpreted by VA.
As noted in the previous paragraph, section 201(q)(8) of the Act
defines risk of suicide based on exposure to, or the existence of,
certain factors, to a degree determined by the Secretary pursuant to
regulations. Thus, section 201(q)(8)(A) of the Act authorized VA to
determine the degree required for these risk factors, and VA will
require that grantees use the health, environmental, and historical
risk factors just described and the impact thereof to determine the
degree of risk of suicide for eligible individuals. This is explained
in a note to paragraph (b). The note also explains that the degree of
risk depends on the presence of one or more suicide risk factors and
the impact of those factors on an individual's mental health and
wellbeing.
VA will require grantees determine an individual's degree of risk
of suicide through the use of a screening tool approved by the
Department. To assist grantees in determining risk of suicide (and thus
an individual's eligibility for suicide prevention services), VA will
provide grantees with a screening tool that will determine the presence
of suicide risk. This tool will be a validated tool that can be
administered by non-clinical staff and/or a self-report tool such as
the Columbia Suicide Severity Rating Scale. See <a href="https://cssrs.columbia.edu">https://cssrs.columbia.edu</a>. VA is not identifying the specific tool in
regulation, as the screening tool may change due to an evolving field
of study and VA may approve the use of several tools. This tool is
subject to the Paperwork Reduction Act because it is an information
collection. As such, the public may comment on this screening tool as
part of the information collections associated with this rulemaking,
and VA welcomes public comment on use of this screening tool. VA will
ensure that grantees are provided this tool before providing or
coordinating suicide prevention services under this grant program and
have access to publicly available training materials to support the
grantees' use of this tool.
VA would not require a clinical tool to be used to determine
eligibility because many of the authorized suicide prevention services
are not clinical in nature. To require a clinical tool to determine the
degree of risk of suicide would severely limit the number of applicants
and grantees for this grant program, which VA does not believe was the
intent of section 201 of the Act. This screening tool is not the same
as the tool that will be used for purposes of the baseline mental
health screening conduct pursuant to Sec. 78.50, which is described
later in this discussion. This screening tool will assess health,
environmental, and historical risk factors and the impact thereof. An
individual's degree of risk of suicide can vary hour to hour, day to
day, and thus, requiring a certain degree of risk of suicide to be
eligible for services could result in the ineligibility of individuals
whom this program was intended to cover. This is a non-clinical tool
that will be used by grantees regardless of whether their staff are
licensed, independent clinical providers.
78.15 Applications for Suicide Prevention Services Grants
Under Sec. 78.15(a), applicants must submit a complete application
package for a suicide prevention services grant under this new part 78,
as described in the NOFO. Paragraph (a) also explains the information
that must be included in the application to be considered a complete
suicide prevention services grant application package. This list of
items described in paragraph (a) is derived from section 201(d)(2),
(f), and (h)(2) of the Act, and it ensures that VA can adequately
evaluate applicants for the purposes of this grant program (that is, to
provide or coordinate the provision of suicide prevention services to
reduce the risk of suicide among eligible individuals).
The following information must be included in the application
package: (1) Documentation evidencing the experience of the applicant
and any identified community partners in providing or coordinating the
provision of suicide prevention services to eligible individuals and
their families; (2) a description of the suicide prevention services
proposed to be provided by the applicant and the identified need for
those services; (3) a detailed plan
[[Page 13811]]
describing how the applicant proposes to coordinate or deliver suicide
prevention services to eligible individuals, including (i) if the
applicant is a State or local government or an Indian tribe, an
identification of the community partners, if any, with which the
applicant proposes to work in delivering such services, (ii) a
description of the arrangements currently in place between the
applicant and such partners with regard to the provision or
coordination of the provision of suicide prevention services, (iii) an
identification of how long such arrangements have been in place, (iv) a
description of the suicide prevention services provided by such
partners that the applicant must coordinate, if any, and (v) an
identification of local VA suicide prevention coordinators and a
description of how the applicant will communicate with local VA suicide
prevention coordinators; (4) a description of the location and
population of eligible individuals and their families proposed to be
provided suicide prevention services; (5) an estimate of the number of
eligible individuals at risk of suicide and their families proposed to
be provided suicide prevention services, including the percentage of
those eligible individuals who are not currently receiving care
furnished by VA; (6) evidence of measurable outcomes related to
reductions in suicide risk and mood-related symptoms utilizing
validated instruments by the applicant (and the proposed partners of
the applicant, if any) in providing suicide prevention services to
individuals at risk of suicide, particularly to eligible individuals
and their families; (7) a description of the managerial and
technological capacity of the applicant to (i) coordinate the provision
of suicide prevention services with the provision of other services,
(ii) assess on an ongoing basis the needs of eligible individuals and
their families for suicide prevention services, (iii) coordinate the
provision of suicide prevention services with VA services for which
eligible individuals are also eligible, (iv) tailor (i.e., provide
individualized) suicide prevention services to the needs of eligible
individuals and their families, (v) seek continuously new sources of
assistance to ensure the continuity of suicide prevention services for
eligible individuals and their families as long as the eligible
individuals are determined to be at risk of suicide, and (vi) measure
the effects of suicide prevention services provided by the applicant or
partner organization on the lives of eligible individuals and their
families who receive such services provided by the organization using
pre- and post-evaluations on validated measures of suicide risk and
mood-related symptoms; (8) clearly defined objectives for the provision
of suicide prevention services; (9) a description and physical address
of the primary location of the applicant; (10) a description of the
geographic area the applicant plans to serve during the grant award
period for which the application applies; (11) if the applicant is a
State or local government or an Indian tribe, the amount of grant funds
proposed to be made available to community partners, if any, through
agreements; (12) a description of how the applicant will assess the
effectiveness of the provision of grants under this part; (13) an
agreement to use the measures and metrics provided by VA for the
purposes of measuring the effectiveness of the programming to be
provided in improving mental health status, wellbeing, and reducing
suicide risk and suicide deaths of eligible individuals and their
families; (14) an agreement to comply with and implement the
requirements of this part throughout the term of the suicide prevention
services grant; and (15) any additional information as deemed
appropriate by VA.
The items in paragraph (a) generally are consistent with
requirements in section 201(f) and (h)(2) of the Act and are necessary
for VA to properly evaluate whether applicants will be able to meet the
requirements in this part to provide or coordinate suicide prevention
services if they are awarded a grant under this new part 78. While
language similar to paragraph (a)(1) does not appear in section 201(f)
or (h)(2) of the Act, it does appear in section 201(d)(2) of the Act,
where VA is instructed to give preference to eligible entities that
have demonstrated the ability to provide or coordinate suicide
prevention services. Paragraph (a)(14) similarly does not appear
explicitly in section 201(f) or (h)(2) of the Act, but section
201(f)(1) authorizes the Secretary to include such commitments as the
Secretary considers necessary to carry out this section. Compliance
with the requirements of the new part 78 is such a commitment. Section
201(f)(2)(M) also authorizes the Secretary to include additional
application criteria as the Secretary considers appropriate. Again, an
agreement to comply with the requirements of this part is an
appropriate obligation. VA notes that technical assistance with
completing applications will be available for applicants, including how
to determine the required estimates under paragraph (a)(5).
For purposes of paragraph (a)(7)(iv), VA notes that tailoring
(i.e., providing individualized) suicide prevention services to the
needs of eligible individuals and their families, includes how services
would be tailored (provided) to priority sub-populations, including but
not limited to survivors of military sexual trauma, women veterans
under the age of 35, and other groups identified in the National
Military and Veteran Suicide Prevention Strategy. See, <a href="https://www.whitehouse.gov/wp-content/uploads/2021/11/Military-and-Veteran-Suicide-Prevention-Strategy.pdf">https://www.whitehouse.gov/wp-content/uploads/2021/11/Military-and-Veteran-Suicide-Prevention-Strategy.pdf</a>. Such services may include but not be
limited to care and support with military sexual trauma, employment,
and housing.
For purposes of paragraphs (a)(4) and (a)(10) of this section, as
well as for other sections of this rule, VA is requiring applicants to
provide information regarding the location of eligible individuals and
a description of the geographic area the applicant plans to serve.
Section 201(d)(1)(C) of the Act permits VA to provide grants to
eligible entities that furnish services to eligible individuals and
their families in geographically dispersed areas; this authority is
discretionary. At this time, VA is choosing not to exercise this
authority. While there may be some applicants who desire to serve a
population that is geographically dispersed, it would be logistically
difficult for such organizations to provide necessary services, and a
number of other provisions in section 201 of the Act clearly state
requirements related to geographic locations. For example, section
201(d)(1)(A) and (B) of the Act permit and require, respectively, VA to
prioritize grants to geographic areas, such as rural communities,
Tribal lands, territories of the United States, medically underserved
areas, areas with a high number or percentage of minority veterans or
women veterans, areas with a high number or percentage of calls to the
Veterans Crisis Line, and areas that have experienced high rates of
suicide by eligible individuals. Each of these descriptions clearly
requires a geographic description or scope. Other provisions of section
201 of the Act also clearly refer to geographic areas. For example,
section 201(f)(2)(I) requires applicants to provide ``a description of
the geographic area the eligible entity plans to serve during the grant
award period for which the application applies.'' Section 201(h)(2)(A)
requires the Secretary to develop a framework for
[[Page 13812]]
collecting and sharing information about grantees for purposes of
improving the services available for eligible individuals and their
families set forth by locality, among other factors. Section
201(q)(11)(A)(iv), which defines suicide prevention services, includes
the provision of clinical services for emergency treatment as a suicide
prevention service, and these services would generally need to be
furnished in-person. Additionally, applicants seeking grant funds to
support non-geographically focused populations would likely have higher
overhead and administrative costs due to the need to conduct outreach
across a broader area, maintain information and connections with more
VA facilities and other entities, and deliver services in different
locations. Higher overhead costs mean fewer available resources
dedicated to the delivery of suicide prevention services, which, given
the population being served by this program, would be less than ideal
as those resources could be better utilized elsewhere to serve this
unique population. Given the short period of time in which VA is
authorized to operate this program, only three years from the date of
the first grant award (see section 201(j) of the Act), it would be
prudent to ensure these resources are used to maximal effect.
This does not prohibit organizations that function at a national
level or in multiple geographic areas from applying for a grant in one
or more location as long as they meet the requirements necessary to
implement suicide prevention services for the specific geographic area.
However, VA notes that many of the suicide prevention services,
particularly emergent services for those at immediate risk of suicide,
could not be furnished by entities without a physical presence in the
area or could only be furnished at a greater risk of the loss of life
of a participant and the services required by law and by the targeted
population require engagement with local VA medical centers and
community.
Paragraph (b) states that subject to funding availability, grantees
may submit an application for renewal of a suicide prevention services
grant if the grantee's program will remain substantially the same. To
apply for renewal of a suicide prevention services grant, a grantee
must submit to VA a complete suicide prevention services grant renewal
application package, as described in the NOFO. This is consistent with
how VA administers the SSVF Program under part 62 and will allow VA to
renew grants in an efficient and timely manner so that there will be no
lapse in the provision or coordination of the provision of suicide
prevention services by grantees to participants from year to year.
Paragraph (c) establishes that VA may request in writing that an
applicant or grantee, as applicable, submit other information or
documentation relevant to the suicide prevention services grant
application. This is authorized by section 201(f)(1) of the Act, which
permits VA to require such commitments and information as the Secretary
considers necessary to carry out this section. This provides VA with
the authority to request additional information that may not be in the
initial or renewal application but will be necessary for VA to properly
evaluate the applicant or grantee for a suicide prevention services
grant.
78.20 Threshold Requirements Prior To Scoring Suicide Prevention
Services Grant Applicants
Pursuant to section 201(h) of the Act, VA, in consultation with
various entities listed in the Act, is required to establish selection
criteria for this new grant program. As explained earlier in this
rulemaking, VA conducted this consultation through an FR notice and
through listening sessions. See 86 FR 17268 (April 1, 2021); 86 FR
25938 (May 11, 2021). Section 78.20 sets forth the threshold
requirements for further scoring applicants pursuant to Sec. 78.25.
Section 78.20 explains that VA will only score applicants for
suicide prevention services grants if they meet certain threshold
requirements as set forth in paragraphs (a) through (g).
These threshold requirements in paragraphs (a) through (g) include
that the application is filed within the time period established in the
NOFO, and any additional information or documentation requested by VA
under Sec. 78.15(c) is provided within the time frame established by
VA; the application is completed in all parts; the activities for which
the suicide prevention services grant is requested are eligible for
funding under this part; the applicant's proposed participants are
eligible to receive suicide prevention services under this part; the
applicant agrees to comply with the requirements of this part; the
applicant does not have an outstanding obligation to the Federal
government that is in arrears and does not have an overdue or
unsatisfactory response to an audit; and the applicant is not in
default by failing to meet the requirements for any previous Federal
assistance.
These are minimum requirements that must be met before VA will
score applications, and applicants will be able to understand whether
they meet these threshold requirements in advance of application
submission. VA anticipates this will reduce the amount of time and
resources that VA will dedicate to evaluating and scoring applicants
for suicide prevention services grants. These requirements are
authorized by section 201(f)(1) of the Act, which permits VA to include
such commitments and information as the Secretary considers necessary
to carry out section 201. These threshold requirements are consistent
with other VA grant programs, such as the Homeless Providers Grant and
Per Diem Program and the SSVF Program (See Sec. Sec. 61.12 and 62.21,
respectively).
78.25 Scoring Criteria for Awarding Grants
Section 201(h)(1) of the Act requires the VA Secretary to establish
criteria for the selection of eligible entities that have submitted
applications for a suicide prevention services grant. Consistent with
that authority, in Sec. 78.25, VA sets forth the criteria to be used
to score applicants who are applying for a suicide prevention services
grant, as the amount of funds available for grants each year will be
limited and VA may receive a higher number of applicants than there are
available grant funds. Scoring criteria will allow VA to award grants
to those who are most qualified and will ensure that VA administers
grants in a manner consistent with the intent and purpose of SSG Fox
SPGP. The scoring criteria were developed based on the scoring criteria
used for other VA grant programs, such as the SSVF Program (38 CFR
62.22) and Homeless Providers Grant and Per Diem Program (38 CFR
61.13), but tailored to the purpose and requirements of section 201 of
the Act. These criteria are consistent with feedback received from
commenters during consultation that expressed support for awarding
grants to entities with prior experience working with veterans,
including those at risk of suicide, entities that had partnerships
within the area and with VA, and entities that have or plan to have
culturally competent care related to veterans.
While this section does not include specific point values for each
criterion, the regulation provides that such point values will be set
forth in the NOFO. This will allow VA to retain flexibility in
determining those point values each year of the grant program in the
event that such point values need to change. At all times, VA will
comply with the requirements in section 201(d) of the Act regarding
prioritization of and
[[Page 13813]]
preference for certain applicants. VA will establish in each NOFO a
minimum number of points that an applicant must be awarded, both in
each category and in total, to ensure that all applicants who are
awarded a grant can perform all necessary elements of the program, and
that their program as a whole is likely to be successful. These dual
requirements will ensure that VA is giving preference to applicants
that have demonstrated the ability to provide or coordinate suicide
prevention services, as required by section 201(d)(2) of the Act.
Paragraph (a) explains that VA will award points based on the
background, qualifications, experience, and past performance, of the
applicant and any community partners identified by the applicant in the
suicide prevention services grant application, as demonstrated by the
following: (1) Background and organizational history, (2) staff
qualifications, and (3) organizational qualifications and past
performance, including experience with veterans services. These scoring
criteria are important to determine whether applicants have the
necessary and relevant background and experience to administer a
suicide prevention services program consistent with section 201 of the
Act and 38 CFR part 78.
In scoring an applicant's background and organizational history
under paragraph (a)(1), VA will consider the applicant's, and any
identified community partners', background and organizational history
that are relevant to the program; whether the applicant, and any
identified community partners, maintain organizational structures with
clear lines of reporting and defined responsibilities; and whether the
applicant, and any identified community partners, have a history of
complying with agreements and not defaulting on financial obligations.
Under paragraph (a)(2), VA will score applications based on staff
qualifications. This includes determining the applicant's staff's, and
any identified community partners' staff's, experience providing to, or
coordinating services for, eligible individuals and their families; and
the applicant's staff's, and any identified community partners'
staff's, experience administering programs similar to SSG Fox SPGP.
VA will score applicants' organizational qualifications and past
performance, including experience with veterans services, under
paragraph (a)(3) based on the applicant's, and any identified community
partners', organizational experience providing suicide prevention
services to or coordinating suicide prevention services for eligible
individuals and their families; the applicant's, and any identified
community partners', organizational experience coordinating services
for eligible individuals and their families among multiple
organizations and Federal, State, local, and tribal governmental
entities; the applicant's, and any identified community partners',
organizational experience administering a program similar in type and
scale to SSG Fox SPGP to eligible individuals and their families; and
the applicant's, and any identified community partners', organizational
experience working with veterans and their families.
Examples of experience VA will consider under paragraph (a) may
include but are not limited to participation in VA-SAMHSA's Governors'
and Mayors' Challenges to Prevent Suicide among service members,
veterans, and their families; endorsement by a local or State public
health agency or State Department of Veterans Affairs recognizing care
coordination experience; and participation in the SSVF Program and
Homeless Providers Grant and Per Diem Program.
While experience providing suicide prevention services to eligible
individuals and their families is an important scoring criterion, we
acknowledge that some organizations may not have such experience.
However, they may have experience working with veterans and their
families (other than those eligible under this grant program) for
purposes other than those related to this grant program. Having an
understanding of the veteran population as a whole and demonstrating
related military cultural competency is critical for ensuring that the
needs of eligible individuals and their families are met through this
grant program. This is consistent with the feedback received through
consultation as described earlier. This also allows VA the ability to
award points at various levels (local, regional, State) since the types
of experience entities at those levels may have can vary. Thus,
pursuant to paragraph (a), VA will score applicants not only based on
their experience administering similar programs to the suicide
prevention grant programs and providing or coordinating services to
eligible individuals, but also based on their experience working with
veterans and their families.
Paragraph (b) explains that VA will award points based on the
applicant's program concept and suicide prevention services plan. The
scoring criteria under this paragraph are important for VA to use to
determine whether the applicant has a fully developed program concept
and plan that will meet the requirements of section 201 of the Act and
38 CFR part 78.
VA will award points based on the applicant's program concept and
suicide prevention services plan, as demonstrated by the (1) need for
the program, (2) outreach and screening plan, (3) program concept, (4)
program implementation timeline, (5) coordination with VA, (6) ability
to meet VA's requirements, goals and objectives for SSG Fox SPGP, and
(7) capacity to undertake the program.
VA will score the need for the program under paragraph (b)(1) based
on whether the applicant has shown a need amongst eligible individuals
and their families in the area where the program will be based and
whether the applicant demonstrates an understanding of the unique needs
for suicide prevention services of eligible individuals and their
families.
VA will score the outreach and screening plan under paragraph
(b)(2) based on whether the applicant has a feasible plan for outreach,
consistent with Sec. 78.45, and referral to identify and assist
individuals and their families that may be eligible for suicide
prevention services and are most in need of suicide prevention
services, has a feasible plan to process and receive participant
referrals, and has a feasible plan to assess and accommodate the needs
of incoming participants. As part of scoring the application based on
whether the applicant has a feasible plan to assess and accommodate the
needs of incoming participants, VA notes that this may include but not
be limited to addressing language assistance needs of limited English
proficient individuals, physical accommodation needs, and
transportation needs.
Pursuant to paragraph (b)(3), VA will score the program concept
based on whether the applicant's program concept, size, scope, and
staffing plan are feasible; and that the applicant's program is
designed to meet the needs of eligible individuals and their families.
VA will score the program implementation timeline under paragraph
(b)(4) based on whether the applicant's program will be implemented in
a timely manner and suicide prevention services will be delivered to
participants as quickly as possible and within a specified timeline. VA
will also score this based on whether the applicant has a feasible
staffing plan in place to meet the
[[Page 13814]]
applicant's program timeline or has existing staff to meet such
timeline.
Pursuant to paragraph (b)(5), VA will score applications based on
whether the applicant has a feasible plan to coordinate outreach and
services with local VA facilities.
In paragraph (b)(6), scoring criteria will include the applicant's
ability to meet VA's requirements, goals, and objectives for SSG Fox
SPGP. This will be based on whether the applicant demonstrates
commitment to ensuring that its program meets VA's requirements, goals,
and objectives for SSG Fox SPGP as identified in this part and the
NOFO.
Under paragraph (b)(7), VA will score the applicant's capacity,
including staff resources, to undertake its program.
Paragraph (c) states that VA will award points based on the
applicant's quality assurance and evaluation plan, as demonstrated by
(1) program evaluation, (2) monitoring, (3) remediation, and (4)
management and reporting. This scoring criterion is important to ensure
that applicants can meet any requirements for evaluation, monitoring,
and reporting contained in section 201 of the Act and in 38 CFR part
78, will help VA ensure that grant funds are being used appropriately,
and will assist in the overall assessment of the grant program.
Pursuant to paragraph (c)(1), VA will evaluate whether the
applicant has created clear, realistic, and measurable goals that
reflect SSG Fox SPGP's aim of reducing and preventing suicide among
veterans against which the applicant's program performance can be
evaluated; and the applicant has a clear plan to continually assess the
program.
The scoring criterion regarding monitoring in paragraph (c)(2) will
be based on whether the applicant has adequate controls in place to
regularly monitor the program, including any community partners, for
compliance with all applicable laws, regulations, and guidelines;
whether the applicant has adequate financial and operational controls
in place to ensure the proper use of suicide prevention services grant
funds; and the applicant has a feasible plan for ensuring that the
applicant's staff and any community partners are appropriately trained
and stay informed of SSG Fox SPGP policy, evidence-informed suicide
prevention practices, and the requirements of 38 CFR part 78.
Paragraph (c)(3) includes the scoring criterion of remediation.
This will be based on whether the applicant has an appropriate plan to
establish a system to remediate non-compliant aspects of the program if
and when they are identified.
Under paragraph (c)(4), VA will score the applicant's management
and reporting, based on whether the applicant's program management team
has the capability and a system in place to provide to VA timely and
accurate reports at the frequency set by VA.
Paragraph (d) explains that VA will award points based on the
applicant's financial capability and plan, as demonstrated by (1)
organizational finances (based on whether the applicant, and any
identified community partners, are financially stable); and (2)
financial feasibility of the program (based on whether the applicant
has a realistic plan for obtaining all funding required to operate the
program for the time period of the suicide prevention services grant;
and whether the applicant's program is cost-effective and can be
effectively implemented on-budget). These are important to ensure that
funds are not provided to an applicant that is financially unstable and
that the applicant has considered the costs and necessary funding for
administering a suicide prevention services program.
Paragraph (e) states that VA will award points based on the
applicant's area linkages and relations, as demonstrated by the (1)
area linkages, (2) past working relationships, (3) local presence and
knowledge, and (4) integration of linkages and program concept. This is
important for ensuring success of the suicide prevention services
program. VA acknowledges that applicants may not have these existing
linkages and relationships, but they may develop them over time. VA
also acknowledges that certain applicants without these existing
linkages and relationships may obtain them through community partners
with which they enter into agreements (to the extent permitted under
section 201 of the Act).
Area linkages under paragraph (e)(1) will include whether the
applicant has a feasible plan for developing or relying on existing
linkages with Federal (including VA), State, local, and tribal
government agencies, and private entities for the purposes of providing
additional services to participants within a given geographic area.
Past working relationships under paragraph (e)(2) will include
whether the applicant (or applicant's staff), and any identified
community partners (or community partners' staff), have fostered
similar and successful working relationships and linkages with public
and private organizations providing services to veterans or their
families in need of services. These may include but not be limited to
housing assistance non-profits and agencies, housing crisis centers,
local food banks, employment assistance non-profits and agencies, rape
crisis centers, and sexual assault and domestic violence programs with
a history of serving veterans and military-connected victims of sexual
trauma and abuse.
Local presence and knowledge under paragraph (e)(3) will be based
on whether the applicant has a presence in the area to be served by the
applicant and understands the dynamics of the area to be served by the
applicant. This presence and knowledge does not necessarily mean the
applicant has an address or physical office in the area, but rather
that they are operating in the area such that they have sufficient
knowledge of the area and that their staff has a presence in the area.
For example, staff may travel from a nearby area to serve eligible
individuals in the targeted area, or a national organization may have a
local office through which it intends to make services available.
Evaluation of whether an applicant understands the dynamics of the area
to be served by the applicant will be based on information including
but not limited to the applicant's description of the area, including
mental health centers, and relationships with local mental health
centers. These criteria under paragraph (e)(3) may be met through
letters of support and documented coordination of care.
Integration of linkages and program concept under paragraph (e)(4)
will be based on whether the applicant's linkages to the area to be
served by the applicant enhance the effectiveness of the applicant's
program.
78.30 Selection of Grantees
Section 201(c) of the Act requires the VA Secretary to award a
grant to each eligible entity for which the Secretary has approved an
application to provide or coordinate the provision of suicide
prevention services. Section 201(d) of the Act sets forth how VA may
and shall distribute grants based on certain priorities, areas, and
geography. Section 201(d)(2) requires the Secretary give preference to
eligible entities that have demonstrated the ability to provide or
coordinate suicide prevention services. Section 201(h) of the Act
requires the Secretary to establish criteria for the selection of
eligible entities that have submitted applications for a suicide
prevention services grant. In accordance with these subsections of
section 201 of the Act, 38 CFR 78.30 sets forth the process for
selecting applicants for suicide prevention services grants, which will
be a process similar to that of the SSVF Program (38 CFR 62.23) and the
Homeless Providers Grant and Per
[[Page 13815]]
Diem Program (38 CFR 61.14 and 61.94). However, the selection process
under Sec. 78.30 will also incorporate preference, priority, and
distribution requirements from section 201(d) of the Act.
As part of the process for selecting applicants to receive suicide
prevention services grants, paragraph (a) explains that VA will first
score all applicants that meet the threshold requirements set forth in
Sec. 78.20 using the scoring criteria set forth in Sec. 78.25.
Next, paragraph (b) states that VA will group applicants within the
applicable funding priorities if any are set forth in the NOFO. As
funding priorities can change annually, VA will set forth any funding
priorities in the NOFO, which will allow VA flexibility in updating
priorities in a quick and efficient manner every year that funds are
available under this grant program.
Then, as set forth in paragraph (c), VA will rank those applicants
that receive at least the minimum amount of total points and points per
category set forth in the NOFO, within their respective funding
priority group, if any. As noted above, VA will set forth the minimum
amount of total points and points per category in the NOFO as these can
change annually. Setting forth these points in the NOFO will provide VA
flexibility in updating the minimum amount of points in an efficient
and quick manner. The applicants will be ranked in order from highest
to lowest scores, within their respective funding priority group, if
any.
Paragraph (d) explains that VA will use the applicant's ranking as
the primary basis for selection for funding. However, consistent with
section 201(d)(1) and (d)(2) of the Act, paragraph (d) further explains
that VA: (1) Will give preference to applicants that have demonstrated
the ability to provide or coordinate suicide prevention services; (2)
may prioritize the distribution of suicide prevention services grants
to rural communities, Tribal lands, territories of the United States,
medically underserved areas, areas with a high number or percentage of
minority veterans or women veterans, and areas with a high number or
percentage of calls to the Veterans Crisis Line; and (3) to the extent
practicable, will ensure that suicide prevention services grants are
distributed to provide services in areas of the United States that have
experienced high rates of suicide by eligible individuals, including
suicide attempts, to eligible entities that can assist eligible
individuals at risk of suicide who are not currently receiving health
care furnished by VA, and to ensure services are provided in as many
areas as possible.
As explained above, pursuant to section 201(d)(2) of the Act, in
paragraph (d)(1), VA will give preference to applicants that have
demonstrated the ability to provide or coordinate suicide prevention
services. This preference may be met by such experience that includes
but is not limited to entities that are part of VA-SAMHSA's Governors'
and Mayors' Challenge to Prevent Suicide among service members,
veterans, and their families; entities that are part of local or State
coalitions for suicide prevention; and entities that support suicide
prevention services through receipt of local, State, and Federal
funding. Additionally, entities may demonstrate this ability if they
are currently providing or coordinating suicide prevention services
that align with the National Strategy for Preventing Veteran Suicide,
VA-Department of Defense (DoD) Clinical Practice Guideline for the
Assessment and Management of Patients at Risk for Suicide, or CDC's
Preventing Suicide: A Technical Package of Policy, Programs, and
Practices. This is consistent with feedback received from commenters
during consultation in which several commenters suggested awarding
grants, or providing preference for grants, to entities with prior
experience providing or coordinating suicide prevention services and
programs, including those who are part of Governors' Challenges.
Pursuant to section 201(d)(1), VA has discretionary authority to
prioritize the distribution of grants to rural communities, Tribal
lands, territories of the United States, medically underserved areas,
areas with a high number or percentage of minority veterans or women
veterans, and areas with a high number or percentage of calls to the
Veterans Crisis Line. This will be a consideration for the distribution
of grants, as described in paragraph (d)(2), and is consistent with
feedback received from commenters during consultation.
Due to funding limitations, VA may choose to utilize this
discretionary authority in distributing grants. However, VA does not
want to mandate use of this discretionary authority because it is
important to ensure that grants can be distributed equitably across the
country and provided to areas where the grants may be best utilized. If
VA prioritized these areas for all awarded grants for this program, it
may exhaust all of its funding annually with none of the grants being
distributed to any other grantees that may also be deserving. VA does
not want to limit itself by mandating this, but rather retain the
discretion to distribute to these areas as warranted. As explained in
paragraph (b) of Sec. 78.35 and in Sec. 78.110, VA would establish
any priorities in a NOFO.
For purposes of this discretionary authority, VA will use the
definitions for rural communities, Tribal lands, territories of the
United States, and medically underserved areas in Sec. 78.5. In
determining areas with a high number or percentage of minority veterans
or women veterans, VA will base such determinations on the veteran
population data from VA's National Center for Veterans Analysis and
Statistics (NCVAS). VA will use the most recent data that NCVAS has
published, which is made publicly available at <a href="https://www.va.gov/vetdata/veteran_population.asp">https://www.va.gov/vetdata/veteran_population.asp</a>. In determining areas with a high number
or percentage of calls to the Veterans Crisis Line, VA will use
internal data that VA maintains to determine where these areas are and
will consider the most recent data VA has for purposes of using this
discretionary authority when making these annual funding
determinations. VA anticipates making this information available to the
public and through technical assistance to grantees.
Consistent with section 201(d)(1)(B) of the Act, paragraph (d)(3)
explains that to the extent practicable, VA will ensure that suicide
prevention services grants are distributed to (1) provide services in
areas of the United States that have experienced high rates of suicide
by eligible individuals, including suicide attempts; and to (2)
applicants that can assist eligible individuals at risk of suicide who
are not currently receiving health care furnished by VA. Paragraph
(d)(3) also explains that to the extent practicable, VA will ensure
that suicide prevention services grants are distributed to ensure
services are provided in as many areas as possible.
While the Act requires, to the extent practicable, distribution of
grants to provide services in areas with high rates of suicide,
including suicide attempts, by eligible individuals, VA notes that data
on suicide attempts is generally insufficient, incomplete, and
generally unavailable for purposes of determining areas with high rates
of suicide. This is because this data is collected only when veterans
report suicide attempts, and there is no requirement to report such
attempts. Given the issues with the data on suicide attempts as
explained above, for purposes of implementing section 201(d)(1)(B), VA
will not utilize data on suicide attempts solely. If such data become
available in a sufficient and complete manner, VA will utilize such
[[Page 13816]]
data to determine areas with high rates of suicide attempts.
Until and if such data become available, in order to meet the
requirement of section 201(d)(1)(B) of the Act, VA will determine areas
with high rates of suicide based on VA's most recently published
National Veteran Suicide Prevention Annual Report, which is based on
CDC's mortality and death index. This report is published annually, and
the most recent report will be utilized by VA for purposes of paragraph
(d)(3)(i).
For purposes of paragraph (d)(3)(ii) and determining whether
applicants can assist eligible individuals at risk of suicide who are
not currently receiving VA health care, VA will consider the
information included in applicants' applications for this grant
program. Such information could include, but not be limited to,
existing arrangements (such as Memorandums of Understanding) with, or
linkages to, VA and/or community partners in providing services to
these individuals, plans on how the entity would coordinate with local
VA medical facilities to identify these individuals, and plans to
include these individuals as part of the population to be provided
suicide prevention services if awarded a grant. VA will consider past
and current actions as well as future plans to serve these individuals
when determining whether to distribute a grant to an applicant that can
assist eligible individuals at risk of suicide who are not currently
receiving health care furnished by VA.
Paragraph (d)(3)(iii) allows VA, to the extent practicable, to
ensure grants are distributed to provide services in as many areas as
possible. This will allow VA to consider geographic location, in some
cases, when determining distribution of grant awards. VA anticipates
receiving applications from numerous applicants in the same location or
serving the same population, and VA will not be able to award grants to
every applicant due to funding limitations. If VA received five high-
scoring applications from applicants proposing to serve eligible
individuals in the same location, but one of those applicants alone can
provide or coordinate suicide prevention services to the eligible
population in that location, VA will be able to use this discretionary
authority to distribute grants to applicants in other locations that
can provide or coordinate services to eligible individuals and their
families. This will allow VA to ensure that as many veterans as
possible throughout the country are able to receive services under this
grant program.
VA notes that suicide prevention services grant applications must
include applicants' identification of the target populations and the
area the applicant proposes to serve. VA will use this information in
determining the distribution of suicide prevention services grants
consistent with paragraph (d).
Paragraph (e) explains that subject to paragraph (d) of this
section, which sets forth the preference and distribution requirements
and considerations, VA will fund the highest-ranked applicants for
which funding is available, within the highest funding priority group,
if any. Under Sec. 78.110 (discussed later in this interim final
rule), in order to meet the requirements of section 201 of the Act and
the goals of SSG Fox SPGP, VA will be able to choose to include funding
priorities in the NOFO. If VA establishes funding priorities in the
NOFO, to the extent funding is available and subject to paragraph (d)
of this section, VA will select applicants in the next highest funding
priority group based on their rank within that group.
Similar to existing processes in other VA grant programs, such as
the Homeless Providers Grant and Per Diem Program (38 CFR 61.63) and
the SSVF Program (38 CFR 62.61), paragraph (f) authorizes VA to select
an applicant for funding if that applicant is not selected because of a
procedural error by VA. An applicant would not be required to submit a
new application in this situation. This will ease any administrative
burden on applications and could be used in situations where there is
no material change in the information that would have resulted in the
applicant's selection for a grant under this part.
78.35 Scoring Criteria for Grantees Applying for Renewal of Suicide
Prevention Services Grants
Section 201(h) of the Act requires the VA Secretary to establish
criteria for the selection of eligible entities that have submitted
applications for a suicide prevention services grant. Based on this
requirement, Sec. 78.35 describes the criteria that VA will use to
score those grantees who are applying for renewal of a grant. Such
criteria will assist with VA's review and evaluation of grantees to
ensure that those grantees have successful existing programs using the
previously awarded grant funds and that they have complied with the
requirements of this part and section 201 of the Act. The criteria in
paragraphs (a) through (c) ensure that renewals of grants are awarded
based on the grantee's program's success, cost-effectiveness, and
compliance with VA goals and requirements for this grant program. This
is consistent with how VA awards renewals of grants in the SSVF Program
(38 CFR 62.24).
While this section does not include specific point values for the
criteria, such point values will be set forth in the NOFO. This will
allow VA to retain flexibility in determining those point values each
year of the grant program.
Under paragraph (a), VA will award points based on the success of
the grantee's program, as demonstrated by the following: (1) The
grantee made progress in reducing veteran suicide deaths and attempts,
reducing all-cause mortality, reducing suicidal ideation, increasing
financial stability; improving mental health status, well-being, and
social supports; and, engaging in best practices for suicide prevention
services; (2) participants were satisfied with the suicide prevention
services provided or coordinated by the grantee, as reflected by the
satisfaction survey conducted under Sec. 78.95(d); (3) the grantee
implemented the program by delivering or coordinating suicide
prevention services to participants in a timely manner, consistent with
SSG Fox SPGP policy, the NOFO, and the grant agreement; and (4) the
grantee was effective in conducting outreach to eligible individuals
and their families and increasing engagement of eligible individuals
and their families in suicide prevention services, as assessed through
an SSG Fox SPGP grant evaluation. VA notes that for purposes of
paragraph (a)(1), best practices for suicide prevention services will
include, but not be limited to, best practices recommended by the
National Strategy for Preventing Veteran Suicide, VA-DoD Clinical
Practice Guideline for the Assessment and Management of Patients at
Risk for Suicide VA, CDC's Preventing Suicide: A Technical Package of
Policy, Programs, and Practices, and the Surgeon General's Call to
Action to Implement the National Strategy for Suicide Prevention.
Paragraph (b) states that points will be awarded based on the cost-
effectiveness of the grantee's program, as demonstrated by the
following: The cost per participant was reasonable and the grantee's
program was effectively implemented on-budget. This criterion is
important as it will assist with VA's review and evaluation of grantees
to ensure that grantees have been fiscally responsible. This is also
consistent with similar criterion used in the SSVF program. See 38 CFR
62.24.
[[Page 13817]]
Paragraph (c) states that VA will award points based on the extent
to which the grantee's program complies with SSG Fox SPGP goals and
requirements, as demonstrated by the following: The grantee's program
was administered in accordance with VA's goals for SSG Fox SPGP as
noted in the NOFO; the grantee's program was administered in accordance
with all applicable laws, regulations, and guidelines; and the
grantee's program was administered in accordance with the grantee's
suicide prevention services grant agreement. This criterion is
important to ensure that renewals of grants are awarded to those who
comply with VA's goals and requirements for SSG Fox SPGP and who have
shown competence regarding grant program implementation. This criterion
is consistent with how VA awards renewals in the SSVF program. See 38
CFR 62.24.
78.40 Selection of Grantees for Renewal of Suicide Prevention Services
Grants
Section 201(c) of the Act requires the VA Secretary to award a
grant to each eligible entity for which the Secretary has approved an
application to provide or coordinate the provision of suicide
prevention services. Section 201(h) of the Act requires the Secretary
to establish criteria for the selection of eligible entities that have
submitted applications for a suicide prevention services grant. Based
on these sections of the Act, section 78.40 describes the process for
selecting grantees that have received suicide prevention services
grants and are applying for renewal of such grants. It is important to
note that this is a simpler process than awarding the initial grant.
This is consistent with how VA awards renewals of grants in the SSVF
Program (38 CFR 62.25).
Paragraph (a) explains that so long as grantees meet the threshold
requirements in Sec. 78.20, VA will score the grantee using the
scoring criteria set forth in Sec. 78.35. This ensures that grantees
are still eligible to participate in the program.
Under paragraph (b), VA will rank those grantees who receive at
least the minimum amount of total points and points per category set
forth in the NOFO, and such grantees will be ranked in order from
highest to lowest scores.
Paragraph (c) explains that VA will use the grantee's ranking as
the basis for selection for funding, and that VA will fund the highest-
ranked grantees for which funding is available.
In paragraph (d), at its discretion, VA may award any non-renewed
funds to an applicant or existing grantee. If VA chooses to award non-
renewed funds to an applicant or existing grantee, VA will first offer
to award the non-renewed funds to the applicant or grantee with the
highest grant score under the relevant NOFO that applies for, or is
awarded a renewal grant in, the same area as, or a proximate area to,
the affected area if available. Such applicant or grantee will be
required to have the capacity and agree to provide prompt services to
the affected area. Under Sec. 78.40, the relevant NOFO is the most
recently published NOFO that covers the affected area, or for multi-
year grant awards, the NOFO for which the grantee, who is offered the
additional funds, received the multi-year award. If the first such
applicant or grantee offered the non-renewed funds refuses the funds,
VA will then offer to award the funds to the next highest-ranked such
applicant or grantee, per the criteria in paragraph (d)(1) of this
section, and continue in rank order until the non-renewed funds are
awarded. VA notes that it does not anticipate offering multi-year
awards at this time, but may choose to do so at a later point. To avoid
the need for further rulemaking to authorize multi-year awards, such
language is included now to allow for future flexibility.
Similar to existing processes in other VA grant programs, such as
the Homeless Providers Grant and Per Diem Program (38 CFR 61.63) and
the SSVF Program (38 CFR 62.61), paragraph (e) authorizes VA to select
an existing grantee for available funding, based on the grantee's
previously submitted renewal application, if that grantee is not
selected for renewal because of a procedural error by VA. A grantee
would not be required to submit a new renewal application in this
situation. This will ease any administrative burden on grantees and
could be used in situations where there is no material change in the
renewal application that would have resulted in the grantee's selection
for renewal of a grant under this part.
78.45 Suicide Prevention Services: Outreach
As indicated in the definition of suicide prevention services,
there are ten categories of suicide prevention services that can be
provided or coordinated under this grant program. Each one has its own
separate section in this regulation, and each will be discussed
subsequently for clarity and readability.
In accordance with section 201(q)(11)(A)(i) of the Act, 38 CFR
78.45 describes outreach, which is the first of ten sections describing
the types of suicide prevention services that grantees may be approved
to provide or coordinate the provision of through this grant program.
In paragraph (a), grantees providing or coordinating the provision
of outreach must use their best efforts to ensure that eligible
individuals, including those who are at highest risk of suicide or who
are not receiving health care or other services furnished by VA, and
their families are identified, engaged, and provided suicide prevention
services. This is consistent with how outreach services are addressed
in the definition of suicide prevention services in section
201(q)(11)(A)(i) of the Act. Based on the assessment of suicide risk
conducted by grantees to determine eligibility for services, eligible
individuals that should be considered at highest risk of suicide are
those with a recent suicide attempt, an active plan or preparatory
behavior for suicide, or a recent hospitalization for suicidality.
Paragraph (b) explains that outreach must include active liaison
with local VA facilities; State, local, or tribal government (if any);
and private agencies and organizations providing suicide prevention
services to eligible individuals and their families in the area to be
served by the grantee. This can include, for example, local mental
health and emergency or urgent care departments in local hospitals or
clinics. Paragraph (b) effectively requires grantees to have a presence
in the area to meet with individuals and organizations to create
referral processes to the grantee, similar to VA's suicide prevention
coordinators.
This section is consistent with how VA defines outreach in the SSVF
Program (38 CFR 62.30). Outreach is important for ensuring that
eligible individuals and families receive suicide prevention services
to reduce the risk of suicide. Outreach also ensures that grantees are
able to identify participants that may be eligible and in need of
suicide prevention services. Working with local entities, including VA,
that serve eligible individuals and their families can help grantees
identify and reach potential participants.
78.50 Suicide Prevention Services: Baseline Mental Health Screening
In accordance with section 201(q)(11)(A)(ii) of the Act, under
Sec. 78.50(a), grantees must provide or coordinate the provision of a
baseline mental health screening to all participants they serve at the
time those services begin. For purposes of this grant program, all
grantees will be required to provide, or coordinate the provision of, a
baseline mental
[[Page 13818]]
screening to participants. This baseline mental health screening
ensures that participants' mental health needs can be properly
determined, and that suicide prevention services can be further
tailored to meet the individual's needs.
This baseline mental health screening must be provided using a
validated screening tool that assesses suicide risk and mental and
behavioral health conditions. Information on the specific tools to be
used will be included in the NOFO, as the tools VA will approve for
baseline mental health screenings may vary from year to year as the
screening tools may evolve over time due to emerging evidence through
research. VA will provide these tools to grantees providing or
coordinating the provision of baseline mental health screenings. These
tools will be those that a non-clinician can administer, as many
grantees may not be clinicians and may not be able to administer a
clinical screening for suicide risk and mental or behavioral health
conditions. These tools will also indicate when a participant must be
referred for additional care, as explained in paragraph (b) of this
section. These tools will ensure consistent screening and reporting of
suicide risk and the need for referral for additional care or care
coordination. It is also important to note that this is consistent with
feedback VA received through consultation. These tools used to conduct
the baseline mental health screening are different than the tool used
to determine risk of suicide for purposes of eligibility and will be
administered to participants after they have been deemed an eligible
individual pursuant to Sec. 78.10.
Paragraph (b) states that if an eligible individual is at risk of
suicide or other mental or behavioral health condition pursuant to the
baseline mental health screening conducted under paragraph (a) of this
section, the grantee must refer such individual to VA for care. If the
eligible individual refuses the grantee's referral to VA, any ongoing
clinical services provided to the eligible individual by the grantee is
at the expense of the grantee. This is based on section 201(m)(1) and
(3) of the Act, which explain that if a grantee determines that an
eligible individual is at-risk of suicide or other mental or behavioral
health condition pursuant to a baseline mental health screening, the
grantee must refer the eligible individual to VA for additional care as
authorized under the Act or any other provision of law, and if the
eligible individual refuses the referral, any ongoing clinical services
provided to the individual by the grantee will be at the grantee's
expense. It is important to note that this is only required for
eligible individuals and not the family of eligible individuals.
Section 201(m)(1) of the Act requires referral when the grantee
determines that an eligible individual is at-risk of suicide or other
mental health or behavioral health condition, consistent with the
language in paragraph (b). This reflects Congressional intent that
these referrals for care be required for those eligible individuals who
are not only at risk of suicide but also those who have additional
needs that require further evaluation by VA for additional care.
Whether an eligible individual has additional needs that require
referral for further evaluation by VA for additional care will be
determined pursuant to the baseline mental health screening conducted
under paragraph (a). For example, should the baseline mental health
screening indicate a potential mental health disorder related to
depression, the participant would need to be referred for further
evaluation for diagnosis and treatment.
This baseline mental health screening will be performed by grantees
using various VA-approved validated tools. These tools will indicate to
the grantee if the eligible individual must be referred for additional
evaluation and care based on the outcome of the screening for mental or
behavioral health and suicide risk.
When referrals are made by grantees to VA, to the extent
practicable, those referrals are required to be a ``warm hand-off'' to
ensure that the eligible individual receives necessary care. This
``warm hand-off'' may include providing any necessary transportation to
the nearest VA facility, assisting the eligible individual with
scheduling an appointment with VA, and any other similar activities
that may be necessary to ensure the eligible individual receives
necessary care in a timely manner. This is consistent with feedback
received from commenters during consultation. This ``warm hand-off'' is
also consistent with other suicide prevention services that grantees
may provide, such as assistance in obtaining any VA benefits and
assistance with emergent needs, authorized under section
201(q)(11)(A)(vii) and (ix), respectively.
To the extent that a veteran referred to VA for care is eligible
for care in the community through VA's Community Care Program, that
veteran may elect to receive care in the community under VA's Community
Care Program regulations located at 38 CFR 17.4000 through 17.4040. For
purposes of section 201(m)(3), this election would not be considered a
refusal to receive care from VA.
Paragraph (b) further explains that if an eligible individual
refuses referral to VA for care by a grantee, any ongoing clinical
services provided to the eligible individual by the grantee are at the
grantee's expense. This is based on section 201(m)(3) of the Act and
ensures that grantees understand their responsibilities regarding the
baseline mental health screening of an eligible individual.
Similar to the language in paragraph (b), paragraph (c) explains
that if a participant other than an eligible individual is at risk of
suicide or other mental or behavioral health condition pursuant to the
baseline mental health screening conducted under paragraph (a) of this
section, the grantee must refer such participant to appropriate health
care services in the area. To the extent that the grantee is able to
furnish such appropriate health care services on an ongoing basis and
has available funding separate from funds provided under this grant
program to do so, they would be able to furnish such services using
those non-VA funds without being required to refer such participants to
other services. VA requires that grantees refer those individuals (that
is, families of eligible individuals) for further care as appropriate
and will codify this in paragraph (c) to ensure that grantees do so.
This ensures that those individuals' needs can be met by further care
as needed.
Under paragraph (d), except as provided for under Sec. 78.60(a),
funds provided under this grant program may not be used to provide
clinical services to participants, and any clinical services provided
to such individuals by the grantee are at the expense of the grantee.
Paragraph (d) explicitly states that any clinical services provided by
the grantee are at its expense and not VA's. Further, this language in
the Act and in the regulation clarifies that grantees may not charge,
bill, or otherwise hold liable eligible individuals for the receipt of
such care or services; we interpret the phrase ``at the expense of the
entity'' in section 201(m)(3) to bar the entity from billing, charging,
or holding liable eligible individuals for the receipt of such care or
services. This will also ensure that the relationship between the
grantee and the eligible individual is not adversely affected through
collections or other efforts. It also provides an incentive for
grantees to work with eligible individuals to refer them to VA for
their health care needs.
While grantees that provide participants ongoing clinical services
pursuant to paragraphs (b) and (c) do so
[[Page 13819]]
at their own expense, this does not preclude the grantee from seeking
to cover those expenses through other sources of funding and existing
agreements. For example, a grantee that provides a participant with
ongoing clinical services may bill a third-party payor, such as the
participant's other health insurance, for the ongoing clinical services
provided by the grantee. However, as explained in the previous
paragraph, the grantee may not charge, bill, or otherwise hold liable
participants for the receipt of ongoing clinical services under Sec.
78.50. In the instance that a grantee bills a third-party payor (e.g.,
health insurance) for ongoing clinical services provided to the
participant, certain cost-sharing, such as copayments, imposed on the
participant by a third-party payor, may be covered by the grantee at
its discretion. VA does not interpret the language ``at the expense of
the entity'' in section 201(m)(3) to preclude grantees from covering
such copayments for participants for ongoing clinical services. VA
would not require that grantees cover such costs, but rather, would
permit grantees to do so if it chooses and has the funds to do so.
However, as noted above, section 201(m)(3) bars the entity from
billing, charging, or holding liable eligible individuals for the
receipt of such care or services. Pursuant to Sec. 78.50(a), the
grantee would be unable to use grant funds to cover such costs.
VA notes that while section 201(m)(3) is specific to eligible
individuals, paragraph (d) applies to all participants because this
would ensure that the potential liabilities of a family member would
not deter a veteran from seeking services from a grantee and to make
administration easier. VA has authority to extend this protection to
include participants other than eligible individuals pursuant to
section 201(f)(1) of the Act, which authorizes VA to require grantees
to make such commitments as the Secretary considers necessary to carry
out this section.
78.55 Suicide Prevention Services: Education
In accordance with section 201(q)(11)(A)(iii), under Sec. 78.55,
grantees providing or coordinating the provision of education must
provide or coordinate the provision of suicide prevention education
programs to educate communities, veterans, and families on how to
identify those at risk of suicide, how and when to make referrals for
care, and the types of suicide prevention resources available within
the area. Education can include gatekeeper training, lethal means
safety training, or specific education programs that assist with
identification, assessment, or prevention of suicide.
Gatekeeper training generally refers to programs that seek to
develop individuals' knowledge, attitudes, and skills to prevent
suicide. Gatekeeper training is an educational course designed to teach
clinical and non-clinical professionals or gatekeepers the warning
signs of a suicide crisis and how to respond and refer individuals for
care. For more information, see: <a href="http://www.sprc.org/sites/default/files/migrate/library/SPRC_Gatekeeper_matrix_Jul2013update.pdf">http://www.sprc.org/sites/default/files/migrate/library/SPRC_Gatekeeper_matrix_Jul2013update.pdf</a>.
Defining education in this manner is consistent with how education
is administered in the community and is commonly understood by those in
the community who work in the area of suicide prevention. Education is
important because learning the signs of suicide risk, how to reduce
access to lethal means, and to connect those at risk of suicide to care
can improve understanding of suicide and has the potential to reduce
suicide.
78.60 Suicide Prevention Services: Clinical Services for Emergency
Treatment
In accordance with section 201(q)(11)(A)(iv) of the Act, Sec.
78.60(a) requires that grantees providing or coordinating the provision
of clinical services for emergency treatment must provide or coordinate
the provision of clinical services for emergency treatment of a
participant.
Consistent with section 201(m)(2) and (3) of the Act, paragraph (b)
explains that if an eligible individual is furnished clinical services
for emergency treatment under paragraph (a) of this section and the
grantee determines that the eligible individual requires ongoing
services, the grantee must refer the eligible individual to VA for
additional care. If the eligible individual refuses the grantee's
referral to VA, any ongoing clinical services provided to the eligible
individual by the grantee is at the expense of the grantee. This aligns
with section 201(m)(2) of the Act, which explains that if a grantee
furnishes clinical services for emergency treatment to an eligible
individual and determines ongoing services are required, the grantee
must refer the eligible individual to VA for additional care as
authorized under the Act or any other provision of law. VA notes that
this is only required for eligible individuals, not the family of
eligible individuals. To the extent that an eligible individual
referred to VA for care is eligible for care in the community through
VA's Community Care Program, that eligible individual may elect to
receive care in the community under VA's Community Care Program
regulations located at 38 CFR 17.4000 through 17.4040. As stated above,
such election is not considered a refusal to receive care from VA.
Subsection (m)(3) of section 201 of the Act further states that if
an eligible individual refuses a referral by a grantee, any ongoing
clinical services provided to the eligible individual by the grantee is
at the grantee's expense. That is codified in paragraph (b) to ensure
that grantees understand their responsibilities regarding clinical
services of an eligible individual. Paragraph (b) further includes the
same language as Sec. 78.50(d) regarding limitations on charging,
billing, or otherwise holding liable eligible individuals for the
receipt of such care. As explained in the discussion on Sec. 78.50(d),
a grantee is not precluded from seeking to cover those expenses through
other sources of funding and existing agreements.
In paragraph (c), if a participant other than an eligible
individual (that is, the family member of an eligible individual) is
furnished clinical services for emergency treatment under paragraph (a)
of this section and the grantee determines that the participant
requires ongoing services, the grantee must refer the participant to
appropriate health care services in the area for additional care.
Except as provided for under paragraph (a) of this section, funds
provided under this grant program may not be used to provide ongoing
clinical services to family, and any ongoing clinical services provided
to the family by the grantee is at the expense of the grantee. VA
expects that grantees will refer those participants for further care as
appropriate and is codifying this requirement in this paragraph to
ensure that grantees do so. This ensures that these participants' needs
can be met by further care as needed. Except as provided for under
Sec. 78.60(a), funds provided under this grant program may not be used
to provide clinical services to such participants, and any ongoing
clinical services provided to the participant by the grantee is at the
expense of the grantee. This is because VA does not have authority to
cover such expenses under this grant program. However, to the extent
that a grantee can and desires to provide ongoing clinical services to
such participants, they may do so, but it will be at their expense. As
explained in discussion on Sec. 78.50(d), this language does not
preclude the grantee from seeking to cover those expenses through other
sources of funding and existing
[[Page 13820]]
agreements (for example, billing a participant's health insurance).
Grantees also are not precluded from covering any copayments imposed on
participants by their health insurance for ongoing clinical services
provided by the grantee if the grantee so chooses and has the funds to
cover such costs. However, the grantee may not charge, bill, or
otherwise hold liable such participants for the receipt of such care or
services. This is consistent with similar language in paragraph (b)
relating to eligible individuals.
Consistent with section 201(q)(5) of the Act, paragraph (d)
explains that for purposes of this section, emergency treatment means
medical services, professional services, ambulance services, ancillary
care and medication (including a short course of medication related to
and necessary for the treatment of the emergency condition that is
provided directly to or prescribed for the patient for use after the
emergency condition is stabilized and the patient is discharged) was
rendered in a medical emergency of such nature that a prudent layperson
would have reasonably expected that delay in seeking immediate medical
attention would have been hazardous to life or health. This standard is
met by an emergency medical condition manifesting itself by acute
symptoms of sufficient severity (including severe pain) that a prudent
layperson who possesses an average knowledge of health and medicine
could reasonably expect the absence of immediate medical attention to
result in placing the health of the individual in serious jeopardy,
serious impairment to bodily functions, or serious dysfunction of any
bodily organ or part.
The description and standard are consistent with VA's description
of medical emergency for purposes of payment or reimbursement for
emergency treatment furnished by non-VA providers to certain veterans
with service-connected disabilities pursuant to 38 CFR 17.120 and for
nonservice-connected disabilities pursuant to 38 CFR 17.1000 et seq. It
is important to note that emergency medical conditions includes
emergency mental health conditions.
Paragraph (e) explains that the direct provision of clinical
services for emergency treatment by grantees under this section is not
prohibited by Sec. 78.80(a). As explained later in this discussion,
Sec. 78.80(a) prohibits grantees from directly providing health care
services, which include health insurance and referral to a governmental
entity or grantee that provides certain services. As clinical services
for emergency treatment under Sec. 78.60 are considered health care
services and section 201 of the Act specifically authorizes the
provision of clinical services for emergency treatment, paragraph (e)
clarifies that such services do not fall under the prohibition in Sec.
78.80(a). VA acknowledges that while some grantees may not be able to
provide these services directly, others will. This ensures that if a
grantee is capable of furnishing emergency treatment and needs to do
so, there will be no delay in the delivery of such services.
78.65 Suicide Prevention Services: Case Management Services
In accordance with section 201(q)(11)(A)(v), case management
services are described in Sec. 78.65. These definitions are similar to
case management services in the SSVF Program (see 38 CFR 62.31), but
they are focused on suicide prevention to effectively assist
participants at risk of suicide. The SSVF Program derived its
definition from similar definitions of case management services
provided in other Federal programs, such as the Department of Health
and Human Services' Medicare and Medicaid Services Program, the
Department of Housing and Urban Development's Congregate Housing
Services Program, and the Housing and Urban Development--Veterans
Affairs Supported Housing (see 42 CFR 440.169 and 24 CFR 700.105). 75
FR 24514, 24518 (May 5, 2010). This description of case management
services is also consistent with VA-DoD Clinical Practice Guidelines
for the Assessment and Management of Patients at Risk for Suicide (see
<a href="https://www.healthquality.va.gov/guidelines/MH/srb/VADoDSuicideRiskFullCPGFinal5088212019.pdf">https://www.healthquality.va.gov/guidelines/MH/srb/VADoDSuicideRiskFullCPGFinal5088212019.pdf</a>).
Grantees providing or coordinating the provision of case management
services must provide or coordinate the provision of such services that
include, at a minimum: (a) Performing a careful assessment of
participants, and developing and monitoring case plans in coordination
with a formal assessment of suicide prevention services needed,
including necessary follow-up activities, to ensure that the
participant's needs are adequately addressed; (b) establishing linkages
with appropriate agencies and service providers in the area to help
participants obtain needed suicide prevention services; (c) providing
referrals to participants and related activities (such as scheduling
appointments for participants) to help participants obtain needed
suicide prevention services, such as medical, social, and educational
assistance or other suicide prevention services to address
participants' identified needs and goals; (d) deciding how resources
and services are allocated to participants on the basis of need; (e)
educating participants on issues, including, but not limited to,
suicide prevention services availability and participant rights; and,
(f) other activities, as approved by VA, to serve the comprehensive
needs of participants for the purpose of reducing suicide risk. This
list ensures that grantees have the same understanding of what
activities are considered case management services, but it also
provides VA authority to approve other activities that may be
considered case management services. Such other activities will be
included in any NOFO published as well as incorporated into any
agreement with grantees.
78.70 Suicide Prevention Services: Peer Support Services
Consistent with section 201(q)(11)(A)(vi) of the Act, 38 CFR 78.70
explains the peer support services authorized under this grant program.
Paragraph (a) explains that grantees providing or coordinating the
provision of peer support services must provide or coordinate the
provision of peer support services to help participants understand what
resources and supports are available in their area for suicide
prevention. Peer support services must be provided by veterans trained
in peer support with similar lived experiences related to suicide or
mental health. Peer support specialists serve as role models and a
resource to assist participants with their mental health recovery. Peer
support specialists function as interdisciplinary team members,
assisting physicians and other professional and non-professional
personnel in a rehabilitation treatment program. This is consistent
with how VA defines peer support services for its programs, including
its peer support program pursuant to 38 U.S.C. 1720F(j).
Paragraph (b) further explains that each grantee providing or
coordinating the provision of peer support services must ensure that
veterans providing such services to participants meet the requirements
of 38 U.S.C. 7402(b)(13) and meet qualification standards for
appointment or have completed peer support training, are pursuing
credentials to meet the minimum qualification standards for
appointment, and are under the supervision of an individual who meets
the requirements of 38 U.S.C. 7402(b)(13). Section 7402(b)(13)
establishes standards for
[[Page 13821]]
appointment as a VA peer support specialist. Qualification standards
include that the individual is (1) a veteran who has recovered or is
recovering from a mental health condition, and (2) certified by (i) a
not-for-profit entity engaged in peer support specialist training as
having met such criteria as the Secretary shall establish for a peer
support specialist position, or (ii) a State as having satisfied
relevant State requirements for a peer support specialist position. VA
has further set forth qualifications for its peer support specialists
in VA Handbook 5005, Staffing (last updated July 17, 2012). See <a href="https://vaww.va.gov/OHRM/Directives-Handbooks/Documents/5005.pdf">https://vaww.va.gov/OHRM/Directives-Handbooks/Documents/5005.pdf</a>.
Meeting minimum qualification standards for appointment under 38
U.S.C. 7402(b)(13) ensures that participants receive peer support
services in a safe and effective manner consistent with VA's standards
and with those required by law. However, VA would also allow grantees
to provide peer support services through veterans who have completed
peer support training, are pursuing credentials to meet the minimum
qualification standards for appointment, and are under the supervision
of an individual who meets the minimum qualification standards. VA
would allow this as a way to build capacity in the community for peer
support services, particularly as there are individuals who may be
supervised and working toward meeting the requirements of 38 U.S.C.
7402(b)(13), but who have not yet met those conditions. Grant funds may
be used to provide education and training for employees of the grantee
or the community partner who provide peer support services based on the
terms set forth in the grant agreement. VA believes the use of these
funds to support education and training for peer support specialists is
authorized by section 201(b) of the Act, which directs VA to provide
financial assistance to eligible entities approved under this section
to provide or coordinate the provision of suicide prevention services
to eligible individuals and their families. Because the requirements to
be a VA peer support specialist, as generally described above, are more
specific than many community organizations might require, we believe
the use of grant funds to support education and training is appropriate
as it may be necessary to ensure these services are provided by
appropriately qualified individuals. VA would set forth conditions
regarding the use of funds, such as any limits on the amount of funds
that may be used for these purposes or documentation requirements, in
the NOFO and terms of the grant agreement.
These appointment requirements for those veterans providing peer
support services would be included in the NOFO so that those applicants
who apply to provide peer support services understand and know the
applicable requirements for purposes of providing or coordinating such
services. These requirements would also be included in any program
guides developed for purposes of administering services under this
grant program.
78.75 Suicide Prevention Services: Assistance in Obtaining VA Benefits
In accordance with section 201(q)(11)(A)(vii), Sec. 78.75 sets
forth the requirements associated with suicide prevention services
authorized under this grant program related to assistance in obtaining
VA benefits. The provision of this assistance will provide grantees
with additional means by which VA can notify participants of available
VA benefits and is consistent with the SSVF Program (see 38 CFR 62.32).
Paragraph (a) requires grantees assisting participants in obtaining
VA benefits to assist participants in obtaining any benefits from VA
for which the participants are eligible. Such benefits include but are
not limited to: (1) Vocational and rehabilitation counseling; (2)
supportive services for homeless veterans; (3) employment and training
services; (4) educational assistance; and, (5) health care services.
Under paragraph (b), grantees will not be permitted to represent
participants before VA with respect to a claim for VA benefits unless
they are recognized for that purpose pursuant to 38 U.S.C. 5902.
Employees and members of grantees are not permitted to provide such
representation unless the individual providing representation is
accredited pursuant to 38 U.S.C. chapter 59. Consistent with 38 U.S.C.
5902, VA does not interpret section 201 of the Act to allow grantees to
represent veterans in benefit claims before VA unless they are
recognized under 38 U.S.C. 5902. VA also does not interpret section 201
of the Act as requiring that grantees become recognized organizations
pursuant to 38 U.S.C. 5092 or that their employees or members become
accredited service organization representatives, claims agents, or
attorneys. Instead, assistance in obtaining benefits may include
providing information about available benefits, helping individuals
locate a recognized veterans services organization or other accredited
individual, and other services short of actual representation before
VA, unless the grantee is accredited pursuant to 38 CFR 14.629 (that
is, VA's regulation implementing 38 U.S.C. 5902), which sets forth
requirements for accreditation of service organization representatives,
agents, and attorneys.
78.80 Suicide Prevention Services: Assistance in Obtaining and
Coordinating Other Public Benefits and Assistance With Emergent Needs
Consistent with section 201(q)(11)(A)(viii) and (ix) of the Act,
under Sec. 78.80, grantees assisting in obtaining and coordinating
other public benefits or assisting with emergent needs will be required
to assist participants to obtain and coordinate the provision of other
public benefits. For purposes of this section, VA considers other
public benefits and emergent needs to be the same types of benefits. At
a minimum, grantees are required to assist participants in obtaining
and coordinating the provision of benefits listed in paragraphs (a)
through (h) of Sec. 78.80 that are being provided by Federal, State,
local, or tribal agencies, or any other grantee in the area served by
the grantee by referring the participant to and coordinating with such
entity. If a public benefit is not being provided by Federal, State,
local, or tribal agencies, or any other grantee in the area, the
grantee is not required to obtain, coordinate, or provide such public
benefit. Grantees may elect to provide directly to participants the
public benefits identified in paragraphs (c) through (h) of Sec.
78.80.
In accordance with section 201(q)(11)(A)(ix)(I) of the Act,
paragraph (a) describes health care services, which include: (1) Health
insurance, and (2) referral to a governmental entity or grantee that
provides any of the following services: (i) Hospital care, nursing home
care, outpatient care, mental health care, preventive care,
habilitative and rehabilitative care, case management, respite care,
and home care; (ii) the training of any eligible individual's family in
the care of any eligible individual; and (iii) the provision of
pharmaceuticals, supplies, equipment, devices, appliances, and
assistive technology. This is consistent with how VA administers the
SSVF Program (see 38 CFR 62.33(a)). VA believes services in paragraph
(a) should not be provided directly by grantees as these services are
commonly available in the area, including at VA. It also would be cost-
prohibitive for grantees to provide these directly and would thus
impact grantees' ability to provide
[[Page 13822]]
suicide prevention services to participants.
In accordance with section 201(q)(11)(A)(ix)(II) of the Act,
paragraph (b) describes referral of a participant, as appropriate, to
an entity that provides daily living services relating to the functions
or tasks for self-care usually performed in the normal course of a day,
including, but not limited to, eating, bathing, grooming, dressing, and
home management activities. This is identical to how VA administers the
SSVF Program (See 38 CFR 62.33(b)). VA believes that daily living
services should not be provided directly by grantees as these services
are commonly available in the community, including at VA. It also would
be cost-prohibitive for grantees to provide these directly and would
thus impact grantees' ability to provide suicide prevention services to
participants. Thus, referrals for these services would be appropriate.
In accordance with section 201(q)(11)(A)(ix)(III) of the Act,
paragraph (c) describes personal financial planning services, which
include, at a minimum, providing recommendations regarding day-to-day
finances and achieving long-term budgeting and financial goals. Grant
funds may pay for credit counseling and other services necessary to
assist participants with critical skills related to household
budgeting, managing money, accessing a free personal credit report, and
resolving credit problems. This is consistent with how VA administers
the SSVF Program (see 38 CFR 62.33(c)).
In accordance with section 201(q)(11)(A)(ix)(IV) of the Act,
paragraph (d) describes transportation services. Paragraph (d)(1)
explains that the grantee may provide temporary transportation services
directly to participants if the grantee determines such assistance is
necessary; however, the preferred method of direct provision of
transportation services is the provision of tokens, vouchers, or other
appropriate instruments so that participants may use available public
transportation options. Paragraph (d)(2) explains that if public
transportation options are not sufficient within an area, costs related
to the lease of vehicle(s) may be included in a suicide prevention
services grant application if the applicant or grantee, as applicable,
agrees that: (i) The vehicle(s) will be safe, accessible, and equipped
to meet the needs of the participants; (ii) the vehicle(s) will be
maintained in accordance with the manufacturer's recommendations; and
(iii) all transportation personnel (employees and community partners)
will be licensed, insured, and trained in managing any special needs of
participants and handling emergency situations. This is consistent with
how VA administers the SSVF Program (see 38 CFR 62.33(d)). However,
unlike Sec. 62.33(d) which refers to subcontractors, VA refers to
community partners under paragraph (d)(2)(iii).
Paragraph (d)(3) permits grantees to provide transportation
services through reimbursement for transportation furnished through
ride-sharing services, taxi services, or other similar sources if two
conditions are met: First, the participant must lack any other means of
transportation, including transportation or reimbursement for
transportation from VA under part 70 of this title, and second, the
grantee must document the participant's lack of other means. Such
documentation would be maintained as part of the participant's case
file, and consistent with the recordkeeping requirements in Sec.
78.150. VA includes this provision to allow for flexibility in
situations where transportation options may be limited, but the two
conditions are intended to limit this support as a matter of last
resort given that the expenses for such transportation are likely
higher than other methods of transportation, and VA does not believe it
would be an optimal use of grant funds. If beneficiary travel under
subpart A of part 70 of title 38, Code of Federal Regulations, or
transportation through the Veterans Transportation Service under
subpart B of part 70 of title 38, Code of Federal Regulations, are
available to the participant, the participant would be ineligible for
assistance under paragraph (d)(3).
In accordance with section 201(q)(11)(A)(ix)(V) of the Act,
paragraph (e) describes temporary income support services, which may
consist of providing assistance in obtaining other Federal, State,
tribal, and local assistance, in the form of, but not limited to,
mental health benefits, food assistance, housing assistance, employment
counseling, medical assistance, veterans' benefits, and income support
assistance. This is consistent with how VA administers the SSVF Program
(see 38 CFR 62.33(e)). However, unlike the SSVF Program, this suicide
prevention services grant program will include food assistance because
of the correlation between food insecurity and mental health issues
including suicide risk. See Bergmans, R.S., Jannausch, M. and Ilgen,
M.A. (2020), Prevalence of suicide ideation, planning and attempts
among Supplemental Nutrition Assistance Program participants in the
United States. Journal of Affective Disorders, 277, 99-103. The suicide
prevention services grant program also expressly includes housing
assistance, which does not appear in Sec. 62.33(e) because part 62 is
designed in general to provide housing assistance and supportive
services for very low-income veteran families who are occupying
permanent housing.
In accordance with section 201(q)(11)(A)(ix)(VI) of the Act,
paragraph (f) describes fiduciary and representative payee services,
which may consist of acting on behalf of a participant by receiving the
participant's paychecks, benefits or other income, and using those
funds for the current and foreseeable needs of the participant and
saving any remaining funds for the participant's future use in an
interest-bearing account or saving bonds. This is consistent with how
VA administers the SSVF Program (see 38 CFR 62.33(f)).
In accordance with section 201(q)(11)(A)(ix)(VII) of the Act,
paragraph (g) explains that legal services includes those services to
assist an eligible individual with issues that may contribute to the
risk of suicide, including issues that interfere with the eligible
individual's ability to obtain or retain permanent housing, cover basic
needs such as food, transportation, medical care, and issues that
affect the eligible individual's employability and financial security
(such as debt, credit problems, and the lack of a driver's license).
These bio-psychosocial stressors are suicide risk factors noted within
the VA/DoD Clinical Practice Guidelines for the Assessment and
Management of Patients at Risk for Suicide. See <a href="https://www.healthquality.va.gov/guidelines/MH/srb/VADoDSuicideRiskFullCPGFinal5088212019.pdf">https://www.healthquality.va.gov/guidelines/MH/srb/VADoDSuicideRiskFullCPGFinal5088212019.pdf</a>.
However, with the exception of legal assistance with resolving
outstanding warrants, fines, expungements, and drivers' license
revocations symptomatic of reentry obstacles in employment or housing,
authorized legal services do not include legal assistance with criminal
matters nor matters in which the eligible individual is taking or has
taken any adversarial legal action against the United States (that is,
the Federal government). Authorized legal services also do not include
legal assistance with matters in which the United States (that is, the
Federal government) is prosecuting an eligible individual. Thus, even
with respect to the limited legal assistance for certain criminal
matters otherwise permitted (for example, legal assistance
[[Page 13823]]
with resolving outstanding warrants), legal services do not include
legal assistance in those criminal matters in which the United States
is prosecuting the eligible individual.
Legal services under Sec. 78.80(g) are described in this manner to
include those types of services VA believes are most relevant and
applicable to the legal needs of eligible individuals. VA will limit
these legal services to issues that contribute to the risk of suicide,
which is consistent with the overall intent of this grant program. VA
will authorize those services that support the legal needs of the
eligible individual to address those issues that contribute to their
risk of suicide, such as issues with housing, employability, and
financial security.
With certain exceptions as noted and explained above, VA excludes
legal assistance with most criminal matters and excludes all matters in
which the eligible individual is taking or has taken any adversarial
legal action against the United States, as VA does not believe it is
reasonable to expect VA to pay for such services, especially for those
situations in which an eligible individual takes adversarial legal
action against the Federal government, including VA and other Federal
agencies or in situations in which the Federal government is
prosecuting an eligible individual. If VA covered such legal services,
it could result in conflicts of interest. This restriction does not
include non-adversarial legal assistance provided in pursuit of VA
benefits or appeals to the Board of Veterans' Appeals. If legal
assistance is needed with a matter for which grant funds are not
authorized, the grantee should make referrals to other organizations,
such as Legal Aid and local Bar Associations, to ensure that legal
needs can be met.
In accordance with section 201(q)(11)(A)(ix)(VIII) of the Act,
paragraph (h) describes the provision of child care, consistent with
how VA administers these services in the SSVF Program (see 38 CFR
62.33(h)). Child care will be authorized for children under the age of
13, unless the child is disabled. Disabled children must be under the
age of 18 to receive assistance under this paragraph. This is
consistent with the SSVF Program's regulations at Sec. 62.33(h) as
well as similar regulations issued by the Department of Housing and
Urban Development. See 24 CFR 576.102(a)(1)(ii).
Child care includes the: (1) Referral of a participant, as
appropriate, to an eligible child care provider that provides child
care with sufficient hours of operation and serves appropriate ages, as
needed by the participant; and (2) payment by a grantee on behalf of a
participant for child care by an eligible child care provider.
Consistent with the financial cap in section 201(q)(11)(A)(ix)(VIII) of
the Act, payment may not exceed $5,000 per family of an eligible
individual per Federal fiscal year.
In paragraphs (h)(2)(i) through (iii), certain limitations for
payments for child care services are identified, which is consistent
with the SSVF Program's regulations at 38 CFR 62.33(h). Pursuant to
paragraph (h)(2)(i), payments for child care services must be paid by
the grantee directly to an eligible child care provider. Unlike Sec.
62.33(h), VA would not include the language that payments for child
care services cannot exceed a maximum of 6 months in a 12-month period,
and 10 months during a 2-year period. As payments are capped at $5,000
per family per Federal fiscal year under section
201(q)(11)(A)(ix)(VIII) of the Act, VA believes the financial cap
imposed by the statute is a sufficient constraint to ensure proper use
of resources for these services.
Under paragraph (h)(2)(ii), payments for child care services will
not be provided on behalf of participants for the same period of time
and for the same cost types that are being provided through another
Federal (including VA), State or local subsidy program. The reference
to the ``same period of time'' means the same dates and times in which
child care benefits are being provided under another program. For
example, a participant may be eligible for Arkansas's Child Care
Assistance Program, which provides financial assistance for quality
child care to certain individuals. If that participant was using those
benefits under Arkansas's Child Care Assistance Program on a specific
date and time, it would not render the participant ineligible for child
care support generally under the suicide prevention services grant
program. The only result would be that the individual could not receive
a subsidy under VA's program for the same period of time for which
child care services were being provided under the Arkansas program.
Paragraph (h)(2)(iii) further explains that as a condition of
providing payments for child care services, the grantee must help the
participant develop a reasonable plan to address the participant's
future ability to pay for child care services. Grantees must assist the
participant to implement such plan by providing any necessary
assistance or helping the participant to obtain any necessary public or
private benefits or services. Because the payments for child care
services provided under paragraph (h) are intended to be temporary, VA
would require that grantees assist in developing and implementing such
plan to ensure that participants are able to plan for such services in
the long-term as needed.
78.85 Suicide Prevention Services: Nontraditional and Innovative
Approaches and Treatment Practices
Section 78.85 explains that grantees providing or coordinating the
provision of nontraditional and innovative approaches and treatment
practices may provide or coordinate the provision of nontraditional and
innovative approaches and treatment, including but not limited to
complementary or alternative interventions with some evidence for
effectiveness of improving mental health or mitigating a risk factor
for suicidal thoughts and behavior, as set forth in the NOFO or as
approved by VA that are consistent with SSG Fox SPGP. Applicants may
propose nontraditional and innovative approaches and treatment
practices in their suicide prevention services grant application, and
grantees may propose these additional approaches and treatment
practices by submitting a written request to modify the suicide
prevention services grant in accordance with Sec. 78.125.
VA is authorized under section 201(f)(1) of the Act to include such
commitments as it considers necessary to carry out this section. VA is
exercising this authority here by reserving the right to approve or
disapprove nontraditional and innovative approaches and treatment
practices to be provided or coordinated to be provided using funds
authorized under SSG Fox SPGP. These approaches and treatment practices
can evolve, and by maintaining the right to approve or disapprove these
treatment practices or approaches, VA can ensure that participants
receive approaches and treatment practices that are safe and effective.
VA is not providing a broad list of approved innovative approaches and
treatment practices to allow for emerging services with some evidence
in suicide risk reduction the opportunity for review and selection. It
is also important for VA to note that any approaches and treatment
practices approved will need to be consistent with applicable Federal
law. For example, the use of grant funds to provide or coordinate the
provision of marijuana to eligible individuals and their families will
be prohibited, as marijuana is currently illegal under Federal law.
[[Page 13824]]
78.90 Suicide Prevention Services: Other Services
The definition of suicide prevention services in section
201(q)(11)(A)(xi) of the Act includes other services necessary for
improving the mental health status and wellbeing and reducing the
suicide risk of eligible individuals and their families as the
Secretary considers appropriate.
Consistent with section 201(q)(11)(A)(xi) of the Act, section
78.90(a) explains general suicide prevention assistance that may be
provided under this grant program. Pursuant to paragraph (a), a grantee
may pay directly to a third party (and not to a participant), in an
amount not to exceed $750 per participant during any 1-year period,
beginning on the date that the grantee first submits a payment to a
third party, the following types of expenses: (i) Expenses associated
with gaining or keeping employment, such as uniforms, tools,
certificates, and licenses; and (ii) expenses associated with lethal
means safety and secure storage, such as gun locks and locked
medication storage.
A limit of $750 per participant per year is an appropriate amount
because such items as gun storage and locks can cost anywhere from $20
to several hundred dollars. Similarly, for purposes of employment,
licenses and uniforms can range from several dollars to several hundred
dollars. The amount of $750 per year also is consistent with the amount
of similar assistance authorized under the SSVF program of $1,500 every
2 years. See 38 CFR 62.34(e)(2).
VA would allow payment for expenses associated with gaining or
keeping employment as extended unemployment may lead to mental health
issues and financial hardship. See Haw, C., K. Hawton, D. Gunnell, and
S. Platt. 2015. Economic recession and suicidal behavior: Possible
mechanisms and ameliorating factors. International Journal of Social
Psychiatry 61, no. 1:73-81. Thus, it would be appropriate to cover
these as other services as these would be necessary for improving the
mental health status and wellbeing and reducing the suicide risk of
eligible individuals and their families.
VA would also allow payment for expenses associated with lethal
means safety and secure storage, as these would also be services
necessary for improving the wellbeing and reducing the suicide risk of
eligible individuals and their families. In 2018, 68.2 percent of
Veteran suicide deaths were due to a self-inflicted firearm injury,
while 48.2 percent of non-Veteran adult suicides resulted from a
firearm injury. In 2018, 69.4 percent of male veteran suicide deaths
and 41.9 percent of female veteran suicide deaths resulted from a
firearm injury. In 2018, firearms were used in 41.9 percent of suicide
deaths among women veterans, compared to 31.7 percent of suicide deaths
among non-veteran women. See VA's 2020 National Veteran Suicide
Prevention Annual Report. (Available online: <a href="https://www.mentalhealth.va.gov/docs/data-sheets/2020/2020-National-Veteran-Suicide-Prevention-Annual-Report-11-2020-508.pdf">https://www.mentalhealth.va.gov/docs/data-sheets/2020/2020-National-Veteran-Suicide-Prevention-Annual-Report-11-2020-508.pdf</a>.) Research has shown
that when lethal means are made less accessible or lethal, suicide
rates by those means decline. See, Gunnell D and Eddleston M. Suicide
by intentional ingestion of pesticides: A continuing tragedy in
developing countries. International Journal of Epidemiology.
2003;32:902-909; Gunnell D, Fernando R, Hewagama M, Priyangika WD,
Konradsen F, Eddleston M. The impact of pesticide regulations on
suicide in Sri Lanka. Int J Epidemiol. 2007;36(6):1235-42; Kreitman N.
The coal gas story. United Kingdom suicide rates, 1960-71. Br J Prev
Soc Med. 1976 Jun;30(2):86-93; Hawton K. United Kingdom legislation on
pack sizes of analgesics: Background, rationale, and effects on suicide
and deliberate self-harm. Suicide and Life-Threatening Behavior.
2002;32(3):223-229. Furthermore, increasing time and space between
individuals facing a suicidal crisis and a firearm has been shown to
prevent suicide. Lubin, G., Werbeloff, N., Halperin, D., Shmushkevitch,
M., Weise, M, & Knobler, H. (2010), Suicide & Life-Threatening
Behavior, 40(5), 421-424. Thus, VA believes it is appropriate to allow
payment for expenses associated with lethal means safety and secure
storage, as these would also be services necessary for improving the
wellbeing and reducing the suicide risk of eligible individuals and
their families.
Paragraph (b) explains that grantees providing or coordinating the
provision of other suicide prevention services may provide or
coordinate the provision of other services as set forth in the NOFO or
as approved by VA that are consistent with SSG Fox SPGP. Applicants may
propose additional services in their suicide prevention services grant
application, and grantees may propose additional services by submitting
a written request to modify the suicide prevention services grant
program in accordance with Sec. 78.125. VA reserves the right to
approve or disapprove other suicide prevention services to be provided
or coordinated to be provided using funds authorized under SSG Fox
SPGP. This is consistent with how VA authorizes additional services for
the SSVF Program (see 38 CFR 62.34) and is authorized by the statute as
noted above.
Section 201(q)(11)(A)(xi) includes as examples of services the
Secretary may include adaptive sports, equine assisted therapy, or in-
place or outdoor recreational therapy; substance use reduction
programming; individual, group, or family counseling; and relationship
coaching. VA is not identifying these services as expressly covered in
its regulations, but applicants may propose these services in their
grant application. VA believes Congress included these as examples of
other services to ensure that applicants proposing to furnish these
services would be able to do so if VA determines that such services are
appropriate and likely for the purpose of reducing veteran suicide. VA
believes the list in section 201(q)(11)(A)(xi) also is indicative of
the types of other services that may be approved. VA believes the
intent of this section of law is to provide flexibility for different
approaches; thus, VA is not regulating these services further to
preserve that flexibility. Paragraph (b) will control the disposition
of any requests by applicants and grantees to offer these or other
services.
78.95 General Operation Requirements
In Sec. 78.95, VA establishes requirements for the general
operation of suicide prevention services programs. Paragraph (a)
explains that prior to providing suicide prevention services, grantees
must verify, document, and classify each participant's eligibility for
suicide prevention services and determine and document each
participant's degree of risk of suicide using tools identified in the
suicide prevention services grant agreement. Such documentation must be
maintained consistent with Sec. 78.150. This ensures that grantees are
providing services and using grant funds for those who are eligible for
such services under this grant program and consistent with the Act.
Paragraph (b) explains that prior to services ending, grantees must
provide or coordinate the provision of a mental health screening to all
participants they serve, when possible. This screening must be
conducted with the same tool used to conduct the baseline mental health
screening under Sec. 78.50. Having this screening occur at the
beginning (pursuant to Sec. 78.50) and prior to services ending is
important in evaluating the effectiveness of the
[[Page 13825]]
services provided, when possible. VA acknowledges that some
participants may leave services early or opt out of screening so
meeting this requirement may not always be possible. Thus, the language
``when possible'' is included in paragraph (b).
Under paragraph (c), for each participant who receives suicide
prevention services from the grantee, the grantee must document the
suicide prevention services provided or coordinated, how such services
are provided or coordinated, the duration of the services provided or
coordinated, and any goals for the provision or coordination of such
services. Such documentation must be maintained consistent with Sec.
78.150. This is information eligible entities typically maintain
regarding the provision or coordination of these or similar services.
Additionally, this information may be requested by VA for purposes of
monitoring the grantee's operation and compliance with these
regulations (under Sec. Sec. 78.135 and 78.145), will be collected as
part of the grantee's reporting requirements in Sec. 78.145, and will
be required to be maintained for at least three years (consistent with
the recordkeeping requirements in Sec. 78.150), and may be requested
by VA for auditing and evaluation purposes.
Consistent with section 201(e) of the Act, in paragraph (d)(1),
prior to initially providing or coordinating suicide prevention
services to an eligible individual and their family, the grantee is
required to notify each eligible individual and their family that the
suicide prevention services are being paid for, in whole or in part, by
VA; the suicide prevention services available to the eligible
individual and their family through the grantee's program; any
conditions or restrictions on the receipt of suicide prevention
services by the eligible individual and their family; and in the
instance of an eligible individual who receives assistance from the
grantee under this program, that the eligible individual is able to
apply for enrollment in VA health care pursuant to 38 CFR 17.36. If the
eligible individual wishes to enroll in VA health care, the grantee
must inform the eligible individual of a VA point of contact for
assistance in enrollment. These requirements concerning information
about enrollment are consistent with section 201(e)(3) of the Act.
While not every eligible individual may be able to enroll in VA health
care under Sec. 17.36, they can apply to determine their eligibility.
It may not be possible to know at the time the eligible individual
expresses an interest in enrolling in VA health care whether or not the
person is a veteran under 38 U.S.C. 101(2), so VA is using the term
eligible individual, as it is more inclusive and potentially a more
accurate description of the person at the point of time this
information is provided. Other than members of the Armed Forces who are
included as an eligible individual through reference to 38 U.S.C.
1712A(a)(1)(C)(i)-(iv), eligible individuals may be able to enroll in
VA health care. Consequently, VA includes an exception in paragraph
(d)(1)(iv) stating that the requirements in this clause do not apply to
eligible individuals who are members of the Armed Forces described in
section 1712A(a)(1)(C)(i)-(iv) of title 38, United States Code.
In paragraph (d)(2), grantees must provide each participant with a
satisfaction survey, which the participant can submit directly to VA,
within 30 days of such participant's pending exit from the grantee's
program. This is required to assist VA in evaluating grantees'
performance and participants' satisfaction with the suicide prevention
services they receive. This is consistent with the SSVF Program (see 38
CFR 62.36(c)(2)).
Paragraph (e) requires that grantees regularly assess how suicide
prevention services grant funds can be used in conjunction with other
available funds and services to assist participants. This is consistent
with the SSVF Program (see Sec. 62.36(d)) and encourages grantees to
leverage other financial resources to ensure continuity of program
operations and assistance to participants.
Paragraph (f) requires that for each participant, grantees must
develop and document an individualized a plan with respect to the
provision of suicide prevention services provided under this part.
Consistent with section 201(e)(2) of the Act, this plan must be
developed in consultation with the participant and must be maintained
consistent with Sec. 78.150. This requirement would ensure that a plan
is developed to address the needs of participants. Such plan would
include, but not be limited to, the suicide prevention services needed,
the goals and objectives of the plan, and the applicable services. This
plan would allow grantees and VA to monitor the delivery of suicide
prevention services to participants. VA would include information about
the suicide prevention services plan in the program guide developed for
grantees. This requirement for a suicide prevention services plan is
also authorized under section 201(f)(1) of the Act, as VA has authority
to include such commitments as it considers necessary to carry out this
section.
In paragraph (g), VA requires grantees to coordinate with VA with
respect to the provision of health care and other services to eligible
individuals under 38 U.S.C. Chapters 17 and 20. This is consistent with
the requirements in section 201(e)(3)(A), (m), and (n) of the Act. VA
expects that grantees will work with local VA facilities on a regular
basis to coordinate care when needed for eligible individuals.
Consistent with section 201(e)(4) of the Act, VA requires in
paragraph (h) that the grantee submit to VA a description of the tools
and assessments the grantee uses or will use to determine the
effectiveness of the suicide prevention services furnished by the
grantee. These include any measures and metrics developed and provided
by VA for the purposes of measuring the effectiveness of the
programming to be provided in improving mental health status and
wellbeing, and reducing suicide risk and suicide deaths of eligible
individuals. While the Act uses the phrase ``completed suicides'', VA
uses the term ``suicide deaths'', as that is the terminology commonly
used by VA. VA recognizes that messaging and language around suicide
attempts and suicide death has an impact on beliefs and attitudes
related to suicide. Thus, VA has developed a Safe Messaging Best
Practices guide for public use regarding this topic. See <a href="https://www.mentalhealth.va.gov/suicide_prevention/docs/OMH-086-VA-OMHSP-Safe-Messaging-Factsheet-4-9-2019.pdf">https://www.mentalhealth.va.gov/suicide_prevention/docs/OMH-086-VA-OMHSP-Safe-Messaging-Factsheet-4-9-2019.pdf</a>.
Consistent with section 201(o) of the Act, under paragraph (i),
only grantees that are a State or local government or an Indian tribe
are able to use grant funds to enter into an agreement with a community
partner under which the grantee may provide funds to the community
partner for the provision of suicide prevention services to eligible
individuals and their families.
Paragraph (j) explains that grantees may enter into contracts for
goods or services under this part. Section 201(o)(2) of the Act states
that the ability of a grantee to provide grant funds to a community
partner is limited to grantees that are a State or local government or
an Indian tribe. VA does not interpret section 201(o)(2) of the Act to
prohibit a grantee from using funds provided under this part to pay
vendors or contractors for certain services, as VA does not interpret
the term ``community partner'' to limit such arrangements. Indeed, VA
believes that if the term ``community partner'' prohibited the use of
grant funds to be used to pay vendors and other contractors, section
201(o)(2) of the Act would effectively bar any entity that was not a
State or local
[[Page 13826]]
government, or an Indian tribe, from participating in the grant
program, or at least from providing many of the suicide prevention
services defined in this rule. VA understands that the intent behind
section 201(o)(2) of the Act was to clarify that only State or local
governments and Indian tribes are able to provide sub-grants to
community partners. VA's interpretation, which permits grantees to use
grant funds to pay vendors and contractors for goods and services, is
consistent with this intent and is necessary for effective operation of
the program. No non-governmental entity, and likely no governmental
entity, would be able to provide the full range of services identified
as suicide prevention services in section 201(q)(11) of the Act absent
the ability to pay vendors and contractors for goods and services. For
example, assistance with emergent needs related to transportation
services under section 201(q)(11)(A)(ix) often involves the provision
of tokens or vouchers for use of transportation services such as buses
or rail. However, no non-governmental entity, and few governmental
entities, actually operate the transportation systems that would be
needed to provide this assistance, so any effort to provide support
with transportation services would require the use of grant funds to
obtain goods or services from another party that is not a community
partner. Similarly, Congress authorized up to $5,000 in assistance per
family of an eligible individual per fiscal year for child care in
section 201(q)(11)(A)(ix)(VIII) of the Act. Including a cap on the
amount of funds that could be used for such services would not make
sense unless Congress intended for grantees to be able to use grant
funds to purchase goods and services like child care. Taken to its
logical extreme, if section 201(o)(2) of the Act were to prohibit non-
governmental grantees from providing any grant funds to any other
party, these grantees would be prohibited from using grant funds to pay
their utility bills, purchase office supplies, or pay rent. VA does not
believe that such a result could possibly have been intended by
Congress.
VA further believes that existing Federal regulations concerning
the use of grants, set forth in 2 CFR part 200, support VA's
interpretation. For example, 2 CFR 200.1 provides definitions
applicable to the uniform administrative requirements, cost principles,
and audit requirements for Federal awards. These regulations define the
term ``contract'', for purposes of Federal financial assistance, as a
legal instrument by which a recipient or subrecipient purchases
property or services needed to carry out the project or program under a
Federal award. This is clearly distinguished from a subaward, which is
an award provided by a pass-through entity to a subrecipient for the
subrecipient to carry out part of a Federal award received by the pass-
through entity; subawards do not include payments to a contractor or
payments to an individual that is a beneficiary of a Federal program.
In this context, VA interprets section 201(o)(2) of the Act as limiting
the use of subawards but not contracts by grantees. Grantees may choose
to enter into contracts because in some situations, resources may be
more readily available at a lower cost, or they may only be available,
from another party in the community.
Lastly, in paragraph (k), VA requires grantees to ensure that
suicide prevention services grants are administered in accordance with
the requirements of part 78, the suicide prevention services grant
agreement, and other applicable Federal, State, and local laws and
regulations, including Federal civil rights laws. Grantees must ensure
that any community partners carry out activities in compliance with
this part. This is consistent with how VA administers the SSVF Program
(see Sec. 62.36(e)).
78.100 Fee Prohibition
In Sec. 78.100, VA prohibits grantees from charging a fee to
participants for providing suicide prevention services that are funded
with amounts from a suicide prevention services grant. VA believes this
prohibition is appropriate because charging a fee could be a barrier to
receiving care and services. There may be eligible individuals who may
not be able to afford to pay any fees or those who do not otherwise
seek care and services under this grant program because they do not
want to pay a fee. Because of the importance of the services, including
referrals to VA care as appropriate, provided under this grant program
to eligible individuals at risk of suicide, VA does not want financial
liability for fees to result in an eligible individual not receiving
such critical services that may save such individual's life, as doing
so would be inconsistent with the purpose of this grant program under
section 201 of the Act to reduce suicide among veterans. This
prohibition is authorized by section 201(f)(1) of the Act, which
permits VA to include such commitments as the Secretary considers
necessary to carry out this section. This is also similar to other
prohibitions that have been implemented for other, similar grant
programs, such as the SSVF Program (see 38 CFR 62.37). VA also notes
that collecting and processing fees would increase administrative costs
and time for the grantee, which would negatively affect the provision
of services to eligible individuals.
78.105 Ineligible Activities
Section 78.105 sets forth certain activities for which grantees
will not be authorized to use suicide prevention services grant funds.
Pursuant to section 201(q)(11)(B) of the Act, direct cash assistance to
participants is prohibited, which is reflected in paragraph (a). Other
prohibited activities are set forth in paragraphs (b) through (d) to
include those legal services prohibited pursuant to Sec. 78.80(g);
medical or dental care and medicines except for clinical services for
emergency treatment authorized pursuant to Sec. 78.60; and any
activities considered illegal under Federal law. Some of the items on
this list of ineligible activities are consistent with those prohibited
under the SSVF Program (see 38 CFR 62.38). However, VA does not feel it
is necessary to include all of the activities that are ineligible under
the SSVF program as these programs have distinct purposes, and many of
those ineligible activities (for example, mortgage costs) are not
necessarily applicable to the suicide prevention grant program. If VA
wanted to include any of those activities under this grant program,
such activities would be subject to Sec. 78.90. Similarly, VA does not
think it is necessary to list every ineligible activity as all
activities would be subject to the requirements in part 78. VA also
notes that 2 CFR part 200 prohibits the use of grant awards for certain
activities, such as entertainment. Such prohibitions are applicable to
suicide prevention services grants awarded under part 78. However, it
is unnecessary to include that language in Sec. 78.105 because 2 CFR
part 200 controls the administration of these grants regardless of
whether explicit language exists in part 78.
78.110 Notice of Funding Opportunity
Consistent with existing processes for other VA grant programs, VA
will notify the public, through a NOFO, when funds for this grant
program are available. Section 78.110 explains that when funds are
available for the grant program, VA will publish a NOFO on <a href="http://grants.gov">grants.gov</a>.
It also describes the information that will be included in such NOFO,
including the location for obtaining suicide prevention services grant
applications; the date, time, and place for submitting completed
suicide
[[Page 13827]]
prevention services grant applications; the estimated amount and type
of suicide prevention services grant funding available; any priorities
for or exclusions from funding to meet the statutory mandates of
section 201 of the Act and VA's goals for SSG Fox SPGP; the length of
term for the suicide prevention services grant award; the minimum
number of total points and points per category that an applicant or
grantee, as applicable, must receive for a suicide prevention services
grant to be funded; any maximum uses of suicide prevention services
grant funds for specific suicide prevention services; the timeframes
and manner for payments under the suicide prevention services grant;
and other information necessary for the suicide prevention services
grant application process as determined by VA.
This is consistent with the requirements and recommendations within
2 CFR part 200 regarding notices of funding opportunity (see 2 CFR
200.204).
78.115 Suicide Prevention Services Grant Agreements
Consistent with other the SSVF Program (see 38 CFR 62.50) and 2 CFR
200.201, section 78.115 explains that VA and the selected applicant
will enter into an agreement prior to obligating funds under part 78
and sets forth requirements that will be included in such agreement.
Section 200.201 requires that Federal awarding agencies must decide on
the appropriate instrument for Federal awards. Such appropriate
instruments include grant agreements, which VA uses for the SSVF
Program (see 38 CFR 62.50). This is also authorized by section
201(f)(1) of the Act, which permits VA to include such commitments as
the Secretary considers necessary to carry out this section.
This agreement will be enforceable against the grantee, providing
VA assurance that the grantee will use the suicide prevention services
grant funds in the manner described in the application and in
accordance with the requirements of part 78.
Paragraph (a) states that after an applicant is selected for a
suicide prevention services grant in accordance with Sec. 78.30, VA
will draft a suicide prevention services grant agreement to be executed
by VA and the applicant. Upon execution of the suicide prevention
services grant agreement, VA will obligate suicide prevention services
grant funds to cover the amount of the approved suicide prevention
services grant, subject to the availability of funding. Such agreement
will provide that the grantee agrees, and will ensure that each
community partner agrees, to operate the program in accordance with the
provisions of part 78 and the applicant's suicide prevention services
grant application; comply with such other terms and conditions,
including recordkeeping and reports for program monitoring and
evaluation purposes, as VA may establish for purposes of carrying out
SSG Fox SPGP, in an effective and efficient manner; and provide such
additional information as deemed appropriate by VA.
Paragraph (b) explains that after a grantee is selected for renewal
of a suicide prevention services grant in accordance with Sec. 78.40,
VA will draft a suicide prevention services grant agreement to be
executed by VA and the grantee. Upon execution of the suicide
prevention services grant agreement, VA will obligate suicide
prevention services grant funds to cover the amount of the approved
suicide prevention services grant, subject to the availability of
funding. Such grant agreement will contain the same provisions
described in paragraph (a) of this section.
Pursuant to paragraph (c), no funds provided under part 78 may be
used to replace Federal, State, tribal, or local funds previously used,
or designated for use, to assist eligible individuals and their
families.
78.120 Amount and Payment of Grants
Consistent with section 201(c)(2)(A) of the Act, Sec. 78.120(a)
states that the maximum funding that a grantee may be awarded under
part 78 is $750,000 per fiscal year. VA may provide less than $750,000
per award per its discretion under section 201 of the Act. As explained
in Sec. 78.110, the NOFO will identify the estimated amount of grant
funding available. However, because of the statutory restriction, VA
will not provide more than $750,000 per grantee per fiscal year.
Section 78.120(b) explains that grantees are to be paid in
accordance with the timeframes and manner set forth in the NOFO.
Section 201(c)(2)(B) of the Act authorizes VA to establish intervals of
payment for purposes of this grant program, and VA will do so in the
NOFO, which is consistent with how VA establishes payment in other
grant programs. See 38 CFR 62.51. Including such information in the
NOFO provides VA with the flexibility to determine the time and manner
of payment for suicide prevention services grants that is appropriate
for each funding cycle.
78.125 Program or Budget Changes and Corrective Action Plans
Section 78.125 sets forth the requirements if there are changes to
the program or budget that alter the grantee's suicide prevention
services grant program. This section is consistent with 2 CFR 200.308
which establishes policy and processes for revision of budget and
program plans for Federal awards. These requirements are authorized by
section 201(f)(1) of the Act, which permits VA to include such
commitments as the Secretary considers necessary to carry out this
section. These requirements are also consistent with how VA handles
program and budget changes and corrective action plans in the SSVF
Program (see 62 CFR 62.60) and allow VA to ensure that grant funds are
used appropriately and to maintain control over the quality of suicide
prevention services provided by the grantee.
Paragraph (a) states that a grantee must submit to VA a written
request to modify a suicide prevention services grant for any proposed
significant change that will alter the suicide prevention services
grant program. It further explains that if VA approves such change, it
will issue a written amendment to the suicide prevention services grant
agreement. A grantee must receive VA's approval prior to implementing a
significant change. Significant changes include, but are not limited
to, a change in the grantee or any community partners identified in the
suicide prevention services grant agreement; a change in the area
served by the grantee; additions or deletions of suicide prevention
services provided by the grantee; a change in category of participants
to be served; and a change in budget line items that are more than 10
percent of the total suicide prevention services grant award. VA's
approval of changes will be contingent upon the grantee's amended
application retaining a sufficient rank to have been competitively
selected for funding in the year that the application was granted, and
each suicide prevention services grant modification request will be
required to contain a description of, and justification for, the
revised proposed use of suicide prevention services grant funds.
Under paragraph (b), VA may require that the grantee initiate,
develop, and submit to VA for approval a Corrective Action Plan (CAP)
if, on a quarterly basis, actual suicide prevention services grant
expenditures vary from the amount disbursed to a grantee for that same
quarter or actual suicide prevention services grant activities vary
[[Page 13828]]
from the grantee's program description provided in the suicide
prevention services grant agreement. Paragraph (b) also sets forth
specific requirements related to the CAP. These include that the CAP
must identify the expenditure or activity source that has caused the
deviation, describe the reason(s) for the variance, provide specific
proposed corrective action(s), and provide a timetable for
accomplishment of the corrective action. After receipt of the CAP, VA
will send a letter to the grantee indicating that the CAP is approved
or disapproved. If disapproved, VA will make beneficial suggestions to
improve the proposed CAP and request resubmission or take other actions
in accordance with this part.
Paragraph (c) explains that grantees are required to inform VA in
writing of any key personnel changes (e.g., new executive director,
suicide prevention services grant program director, or chief financial
officer) and grantee address changes within 30 days of the change.
78.130 Faith-Based Organizations
As VA anticipates that religious or faith-based organizations may
apply for grants under part 78, Sec. 78.130 explains that religious or
faith-based organizations are eligible for suicide prevention services
grants and describes the conditions for use of these grants as they
relate to religious activities. This is similar to the language used in
the Homeless Providers Grant and Per Diem Program (38 CFR 61.64) and
the SSVF Program (38 CFR 61.62). However, VA has moved the definitions
of indirect financial assistance and direct federal financial
assistance to the definitions section of part 78.
Under paragraph (a), organizations that are faith-based will be
eligible, on the same basis as any other organization, to participate
in SSG Fox SPGP under part 78. Decisions about awards of Federal
financial assistance must be free from political interference or even
the appearance of such interference and must be made on the basis of
merit, not on the basis of religion or religious belief or lack
thereof.
Paragraph (b)(1) states that no organization may use direct
financial assistance from VA under this part to pay for any of the
following: (i) Explicitly religious activities such as, religious
worship, instruction, or proselytization; or (ii) equipment or supplies
to be used for any of those activities. Paragraph (b)(2) states that
references to financial assistance are deemed to be references to
direct Federal financial assistance, unless the referenced assistance
meets the definition of indirect Federal financial assistance in part
78.
Under paragraph (c), organizations that engage in explicitly
religious activities, such as worship, religious instruction, or
proselytization, must offer those services separately in time or
location from any programs or services funded with direct financial
assistance from VA under this part, and participation in any of the
organization's explicitly religious activities must be voluntary for
the participants in a program or service funded by direct financial
assistance from VA under part 78.
Paragraph (d) states that a faith-based organization that
participates in SSG Fox SPGP under part 78 will retain its independence
from Federal, State, or local governments. It further states that such
organizations may continue to carry out its mission, including the
definition, practice and expression of its religious beliefs, so long
as the organization does not use direct financial assistance from VA
under part 78 to support any explicitly religious activities, such as
worship, religious instruction, or proselytization. Faith-based
organizations may use space in their facilities to provide VA-funded
services under part 78, without concealing, removing, or altering
religious art, icons, scripture, or other religious symbols. In
addition, a VA-funded faith-based organization retains its authority
over its internal governance, and it may retain religious terms in its
organization's name, select its board members and otherwise govern
itself on a religious basis, and include religious reference in its
organization's mission statements and other governing documents.
Under paragraph (e), an organization that participates in a VA
program under this part must not, in providing direct program
assistance, discriminate against a program participant or prospective
program participant on the basis of religion or religious belief.
Under paragraph (f), if a State or local government voluntarily
contributes its own funds to supplement Federally funded activities,
the State or local government has the option to segregate the Federal
funds or commingle them. However, if the funds are commingled, this
provision applies to all of the commingled funds.
Under paragraph (g), to the extent otherwise permitted by Federal
law, the restrictions on explicitly religious activities set forth in
this section do not apply where VA funds are provided to faith-based
organizations through indirect assistance as a result of a genuine and
independent private choice of a participant, provided the faith-based
organizations otherwise satisfy the requirements of this part. A faith-
based organization may receive such funds as the result of a
participant's genuine and independent choice if, for example, a
participant redeems a voucher, coupon, or certificate, allowing the
participant to direct where funds are to be paid, or a similar funding
mechanism provided to that participant and designed to give that
participant a choice among providers.
78.135 Visits to Monitor Operation and Compliance
Section 78.135(a) authorizes VA, at all reasonable times, to make
visits to all grantee locations where a grantee is using suicide
prevention services grant funds to review grantee accomplishments and
management control systems and to provide such technical assistance as
may be required. VA may also conduct inspections of all program
locations and records of a grantee at such times as are deemed
necessary to determine compliance with the provisions of this part. In
the event that a grantee delivers services in a participant's home, or
at a location away from the grantee's place of business, VA may
accompany the grantee. If the grantee's visit is to the participant's
home, VA will only accompany the grantee with the consent of the
participant. If any visit is made by VA on the premises of the grantee
or a community partner under the suicide prevention services grant, the
grantee must provide, and must require its community partners to
provide, all reasonable facilities and assistance for the safety and
convenience of the VA representatives in the performance of their
duties. All visits and evaluations will be performed in such a manner
as will not unduly delay services.
Paragraph (b) explains that the authority to inspect carries with
it no authority over the management or control of any applicant or
grantee under this part.
These provisions are critical for VA oversight over suicide
prevention services grants and are consistent with how VA administers
other grant programs (see 38 CFR 61.65 and 62.63). These provisions are
authorized by section 201(f)(1) and 201(g) of the Act, which authorize
VA to require eligible entities seeking grants to provide such
commitments and information as VA considers necessary and require VA to
provide training and technical assistance to eligible entities in
receipt of grants. These provisions are also consistent with 2 CFR
200.329 regarding
[[Page 13829]]
monitoring and reporting program performance for Federal awards.
78.140 Financial Management and Administrative Costs
Section 78.140 sets forth requirements with which grantees must
comply and ensures that grantees are aware of these requirements. These
requirements are consistent with other grant programs, such as the SSVF
Program (see 38 CFR 62.70) and the Homeless Providers Grant and Per
Diem Program (see 38 CFR 61.66).
Paragraph (a) requires grantees to comply with applicable
requirements of the Uniform Administrative Requirements, Cost
Principles, and Audit Requirements for Federal Awards under 2 CFR part
200. Part 200 of 2 CFR establishes the uniform administrative
requirements, cost principles, and audit requirements for Federal
awards to non-Federal entities.
Paragraph (b) requires grantees use a financial management system
that provides adequate fiscal control and accounting records and meets
the requirements set forth in 2 CFR part 200.
Under paragraph (c), payment up to the amount specified in the
suicide prevention services grant must be made only for allowable,
allocable, and reasonable costs in conducting the work under the
suicide prevention services grant, and the determination of allowable
costs must be made in accordance with the applicable Federal Cost
Principles set forth in 2 CFR part 200.
Paragraph (d) prohibits costs for administration by a grantee from
exceeding 10 percent of the total amount of the suicide prevention
services grant. Administrative costs include all costs associated with
the management of the program and include the administrative costs of
community partners.
VA has determined this limitation on administrative costs to be
reasonable and consistent with the purpose of SSG Fox SPGP, as VA
believes it is important that almost all of funding provided by VA goes
towards providing services for participants. This requirement ensures
that the vast majority of suicide prevention services grant funds (at
least 90 percent) are used to provide suicide prevention services to
participants. These requirements are also consistent with the SSVF
Program, which allows only 10 percent of the grant funds to be used for
specified administrative costs. See 38 CFR 62.10. VA has not identified
any issues with this limitation in the context of the SSVF program. VA
believes that 10 percent is a reasonable maximum for administrative
costs, and any additional funds needed by grantees to administer the
suicide prevention services should be provided by non-VA funds.
78.145 Grantee Reporting Requirements
Section 78.145 sets forth reporting requirements regarding the
projects carried out using grant funds provided under part 78. Such
reporting requirements ensure that grants funds are being properly used
in accordance with the Act and with part 78, and that VA is being a
good fiscal steward of the taxpayer dollar. These reporting
requirements are consistent with subsections (e)(5) and (k) of section
201 of the Act. Section 201(e)(5)(A) mandates that VA require each
entity receiving a suicide prevention services grant to submit to VA an
annual report that describes the projects carried out with such grant
during the year covered by the report. Section 201(e)(5)(C) further
authorizes VA to require each such entity to submit to VA such
additional reports as VA considers appropriate. Section 201(k) of the
Act requires VA to submit an interim report and final report on the
provision of grants to eligible entities under part 78 to the
appropriate committees of Congress. Subsection (k)(1)(C) further
provides VA with the authority to require eligible entities to provide
to Congress such information as VA determines necessary regarding
certain information that must be included in such reports. These
provisions of section 201 of the Act are implemented in paragraphs (b)
and (c), as explained in more detail below. Additionally, these
reporting requirements are consistent with how VA administers the SSVF
Program. See 38 CFR 62.71.
In paragraph (a), VA reserves the right to require grantees to
provide, in any form as may be prescribed, such reports or answers in
writing to specific questions, surveys, or questionnaires as VA
determines necessary to carry out SSG Fox SPGP.
Consistent with section 201(e)(5)(A) of the Act, paragraph (b)
requires that at least once per year, each grantee must submit to VA a
report that describes the projects carried out with such grant during
the year covered by the report; and information relating to operational
effectiveness, fiscal responsibility, suicide prevention services grant
agreement compliance, and legal and regulatory compliance, including a
description of the use of suicide prevention grant funds, the number of
participants assisted, the types of suicide prevention services
provided, and any other information that VA may request. The
information gathered in this report should also support VA in carrying
out its responsibilities under section 201(k) of the Act in providing
necessary information to Congress to facilitate its oversight of this
program.
Under paragraph (c), VA retains the discretion to request
additional reports or information to be able to fully assess the
provision or coordination of the provision of suicide prevention
services under part 78. This is a catch-all provision to allow VA to
request additional reports or information that it may need to further
assess the project and the pilot program. These will vary on a case-by-
case basis dependent on the project and its progression. Additionally,
if VA is required to submit additional reports to Congress on this
pilot program, VA reserves the right under this paragraph to request
such information as needed to respond to Congress. This also provides a
safeguard in instances where there may be confusing, misleading,
inconsistent, or unclear statements in submitted reports. VA reserves
the right to request additional reports to clarify any such information
it receives in other reports that are submitted by a grantee. This
requirement is authorized by section 201(f)(1) of the Act, which
authorizes VA to require applicants to provide such commitments and
information as VA considers necessary, and by section 201(e)(5)(C) of
the Act, which authorizes VA to require eligible entities to submit to
VA such additional reports as VA considers appropriate.
Paragraph (d) requires that all pages of the reports must cite the
assigned suicide prevention services grant number and be submitted in a
timely manner as set forth in the grant agreement. Including the
assigned grant number on each page of the report is important for
tracking reports and to ensure that all pages of the relevant report
are received by VA for each grant.
Paragraph (e) further requires that grantees provide VA with
consent to post information from reports on the internet and use such
information in other ways deemed appropriate by VA. Grantees shall
clearly mark information that is confidential to individual
participants. This is consistent with the SSVF program (see 38 CFR
62.71(f)).
78.150 Recordkeeping
Section 78.150 requires grantees, consistent with 2 CFR 200.334, to
keep records and maintain such records for at least a three-year
period, to document compliance with SSG Fox SPGP requirements in part
78. Grantees will need to produce these records at VA's
[[Page 13830]]
request. This will assist VA in providing oversight of grantees and is
consistent with section 201(k)(1)(B)(i) of the Act, which requires VA
to assess the effectiveness of this grant program, as well as the
requirements for recordkeeping in 2 CFR 200.334.
78.155 Technical Assistance
Consistent with section 201(g) of the Act, Sec. 78.155 explains
that VA will provide technical assistance, as necessary, to applicants
and grantees to meet the requirements of part 78. Section 201(g) of the
Act specifically requires VA to provide training and technical
assistance, in coordination with the Centers for Disease Control and
Prevention (CDC), to grantees regarding (1) suicide risk identification
and management, (2) the data required to be collected and shared with
VA, (3) the means of data collection and sharing, (4) familiarization
with and appropriate use of any tool to be used to measure the
effectiveness of the use of grants, and (5) the requirements for
reporting on services provided via such grants. Section 78.155 further
explains that such technical assistance will be provided either
directly by VA or through contracts with appropriate public or non-
profit private entities. Technical assistance may consist of activities
related to the planning, development, and provision of suicide
prevention services to participants.
In addition to other forms of technical assistance that will be
provided, such as training and assistance with the five categories
described above, VA will develop a program guide to be used by
applicants, grantees, VA staff members, and other interested third
parties to assist with understanding and implementing SSG Fox SPGP.
This technical assistance will be conducted in coordination with the
CDC, as required by section 201(g)(1) of the Act. CDC will be available
on technical assistance calls, including those relating to the
availability of data on suicide in grantees' local areas. This is
consistent with the technical assistance VA provides in the SSVF
Program. See 38 CFR 62.73.
78.160 Withholding, Suspension, Deobligation, Termination, and Recovery
of Funds by VA
Section 78.160 explains that VA will enforce part 78 through such
actions as may be appropriate. Appropriate actions include withholding,
suspension, deobligation, termination, recovery of funds by VA, and
actions in accordance with 2 CFR part 200.
As suicide prevention services grants are subject to the
requirements of 2 CFR part 200, VA explicitly references 2 CFR part 200
in Sec. 78.160 to ensure that grantees understand and know where to
locate these requirements related to withholding, suspension,
deobligation, termination, and recovery of funds. The specific sections
of 2 CFR part 200 on withholding, suspension, deobligation,
termination, and recovery of funds are 2 CFR 200.208, 200.305, and
200.339 through 200.343, and 200.346, respectively. VA refers to 2 CFR
part 200 rather than include those requirements in this section as
those requirements in 2 CFR part 200 may change. Referencing 2 CFR part
200 provides VA the ability to implement those changes without having
to conduct further rulemaking.
VA acknowledges that when certain actions (such as suspension and
termination) are taken against grantees pursuant to this section and 2
CFR part 200, a disruption in services to participants may occur. While
VA is not regulating responsibilities for grantees to continue to
provide services or to coordinate the transfer of participants to other
sources of support, VA will include such requirements and
responsibilities in the grant agreement that VA and the grantee enter
into pursuant to this part. This will ensure that the disruption and
impact upon participants is minimized as much as possible.
78.165 Suicide Prevention Services Grant Closeout Procedures
Section 78.165 explains that suicide prevention services grants
will be closed out in accordance with 2 CFR part 200. Procedures for
closing out Federal awards are currently located at 2 CFR 200.344 and
200.345. As suicide prevention services grants are subject to the
requirements of 2 CFR part 200, VA explicitly references 2 CFR part 200
in Sec. 78.165 to ensure that grantees understand and know where to
locate these requirements. VA refers to 2 CFR part 200 rather than
include those requirements in this section as those requirements in 2
CFR part 200 may change, and referencing 2 CFR part 200 provides VA
ability to implement those changes without having to conduct further
rulemaking.
Administrative Procedure Act
The Administrative Procedure Act (APA), codified in part at 5
U.S.C. 553, generally requires agencies publish substantive rules in
the Federal Register for notice and comment. These notice and comment
requirements generally do not apply to ``a matter relating to agency
management or personnel or to public property, loans, grants, benefits
or contracts.'' 5 U.S.C. 553(a)(2). However, 38 U.S.C. 501(d) requires
VA comply with the notice and comment requirements in 5 U.S.C. 553 for
matters relating to grants, notwithstanding section 553(a)(2). Thus, as
this rulemaking relates to the grant program required by section 201 of
the Act, VA is required to comply with the notice and comment
requirements of 5 U.S.C. 553.
However, pursuant to 5 U.S.C. 553(b)(B), general notice and the
opportunity for public comment are not required with respect to a
rulemaking when an ``agency for good cause finds (and incorporates the
finding and a brief statement of reasons therefor in the rules issued)
that notice and public procedure thereon are impracticable,
unnecessary, or contrary to the public interest.''
In accordance with 5 U.S.C. 553(b)(B), the Secretary has concluded
that there is good cause to publish this rule without prior opportunity
for public comment. This rule implements the mandates of section 201 of
the Act to establish a new suicide prevention services grant program.
This new grant program, SSG Fox SPGP, will provide eligible individuals
and their families with suicide prevention services that will aim to
reduce and prevent suicide by providing outreach, mental health
screenings, education on suicide risk and prevention, clinical services
for emergency treatment, case management services, peer support
services, and assistance with obtaining VA and other government
benefits, among other services.
Suicide is a national public health concern, and it is preventable.
The rate of veteran suicide in the United States remains high, despite
great effort. It is critical that this rulemaking publish without
delay, as these grants will result in increased engagement with a
specific population at risk of suicide, which is especially needed
during the Coronavirus Disease-2019 (COVID-19) pandemic and the
immediate period following this pandemic. The COVID-19 pandemic has
caused significant psychological distress related to economic
hardships, physical safety concerns, illness, and death of family and
friends, uncertainty about the future, and isolation from social
supports. See Panchal, N., Kamal, R., Orgera, K., Cox, C., Garfield,
R., Hamel, L., Mu[ntilde]ana, C. & Chidambaram, P. (2021). The
implications of COVID-19 for mental health and substance use. Kaiser
Family Foundation. <a href="https://www.kff.org/coronavirus-covid-19/issuebrief/the-implications-of-covid-19-for-mental-health-and-substance-use">https://www.kff.org/coronavirus-covid-19/issuebrief/the-implications-of-covid-19-for-mental-health-and-substance-use</a>;
[[Page 13831]]
See also, Brooks, S.K., Webster, R.K., Smith, L.E., Woodland, L.,
Wessely, S., Greenberg, N., & Rubin, G.J., (2020). The psychological
impact of quarantine and how to reduce it: Rapid review of the
evidence. Lancet, 395, 912-920. COVID-19 has had a detrimental effect
on mental health in the United States. See id.; see also, Czeisler,
M[Eacute], Lane, RI, Petroski, E, et al. Mental Health, Substance Use,
and Suicidal Ideation During the COVID-19 Pandemic--United States, June
24-30, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1049; See also, National
Center for Health Statistics (2021). Anxiety and depression: Household
Pulse Survey. U.S. Centers for Disease Control and Prevention. <a href="https://www.cdc.gov/nchs/covid19/pulse/mental-health.htm">https://www.cdc.gov/nchs/covid19/pulse/mental-health.htm</a> (Last accessed May 17,
2021).
According to a recent CDC report, more Americans are reporting
negative mental health impacts, including higher rates of suicidal
thoughts, during the COVID-19 pandemic. Czeisler M[Eacute], Lane RI,
Petrosky E, et al. Mental Health, Substance Use, and Suicidal Ideation
During the COVID-19 Pandemic--United States, June 24-30, 2020. MMWR
Morb Mortal Wkly Rep 2020;69:1049-1057. DOI: <a href="http://dx.doi.org/10.15585/mmwr.mm6932a1">http://dx.doi.org/10.15585/mmwr.mm6932a1</a>. While this report examined the general
population of America, there is also evidence of increased distress
among the veteran population. For instance, there has been an increase
in call volume to the Veterans Crisis Line (VCL). In fiscal year (FY)
2019, VCL answered an average daily call volume of 1590.67 calls
compared with 1765.02 FY 2020 and 1807.52 in FY 2021, with VCL call
volume increasing over 22% in direct-date comparisons from FY 2019 to
FY 2021.
Veterans, in particular, may be uniquely vulnerable to negative
mental health effects of the pandemic such as suicidality due to their
older age, previous trauma exposures, and higher pre-pandemic
prevalence of physical and psychiatric risk factors and conditions. Na,
P.J., Tsai, J., Hill, M.L., Nichter, B., Norman, S.B., Southwick, S.M.,
& Pietrzak, R.H. (2021). Prevalence, risk and protective factors
associated with suicidal ideation during the COVID-19 pandemic in U.S.
military veterans with pre-existing psychiatric conditions. Journal of
Psychiatric Research, 137, 351-359. In an analysis of data from the
National Health and Resilience in Veterans Study, researchers found
that 19.2% of veterans screened positive for suicidal ideation peri-
pandemic, and such veterans had lower income, were more likely to have
been infected with COVID-19, reported greater COVID-19-related
financial and social restriction stress, and increases in psychiatric
symptoms and loneliness during the pandemic when compared to veterans
without suicidal ideation. Id. Additionally, they found that among
veterans who were infected with COVID-19, those aged 45 or older and
who reported lower purpose in life were more likely to endorse suicidal
ideation. Id. These researchers noted that monitoring for suicide risk
and worsening psychiatric symptoms in older veterans who have been
infected with COVID-19 may be important, and that interventions that
enhance purpose in life may help protect against suicidal ideation in
this population. Consistent with the recommendations of this research,
SSG Fox SPGP will support monitoring for suicide risk and worsening
psychiatric symptoms by providing support to more organizations who can
reach veterans who do not seek or obtain care through VA. Through this
grant program, organizations' efforts can also help protect this
population against suicidal ideation by enhancing purpose in life.
Furthermore, studies have shown increased suicide after pandemics
such as the 1918 Influenza (H1N1) pandemic and the 2003 Severe Acute
Respiratory Syndrome (SARS) outbreak, in which increased risk factors
associated with negative impacts of epidemics were believed to
contribute to suicide. See Wasserman IM. The impact of epidemic, war,
prohibition and media on suicide: United States, 1910-1920. Suicide
Life Threat Behav. 1992 Summer;22(2):240-54. PMID: 1626335.; See also,
Cheung YT., Chau PH., and Yip PS. A revisit on older adults suicides
and severe acute respiratory syndrome (SARS) epidemic in Hong Kong. Int
J Geriatr Psychiatry. 2008; 23: 1231-1238. Thus, increased suicide
death could occur after the COVID-19 pandemic unless action is taken.
See Gunnell, D., Appleby, L., Arensman, E., Hawton, K., John, A.,
Kapur, N., Khan, M., O'Connor, R.C., & Pirkis, J. (2020). Suicide risk
and prevention during the COVID-19 pandemic. The Lancet Psychiatry,
7(6), 468-471.
It is therefore critical that VA publish this rulemaking without
delay to ensure the services provided through this grant program will
assist the growing number of eligible individuals who are suffering
from mental health concerns and may be at risk of suicide as a result
of the COVID-19 pandemic, particularly as the period immediately
following a pandemic can result in elevated risk of suicide. Publishing
this rulemaking without delay will help ensure that services under this
grant program can be provided to eligible individuals during the
pandemic or in the immediate aftermath of it when they can have the
most impact. As noted earlier in this section, efforts and actions
supported through this grant program will be consistent with recent
findings and recommendations on the impact of the COVID-19 pandemic on
veterans and can help protect this population against suicidal
ideation. See, Na, P.J., Tsai, J., Hill, M.L., Nichter, B., Norman,
S.B., Southwick, S.M., & Pietrzak, R.H. (2021). Prevalence, risk and
protective factors associated wi
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This is legal information, not legal advice. Laws vary by jurisdiction and change frequently. Always verify current law with official sources and consult a licensed attorney in your jurisdiction for advice on your specific situation.