Staff Sergeant Parker Gordon Fox Suicide Prevention Grant Program

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.

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

www.Regulations.gov.

Comments received will be available at

regulations.gov

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),

VASSGFoxGrants@va.gov.

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.regulations.gov.

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

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.regulations.gov.

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 § 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 § 78.130 and is consistent with how VA defines this in the Homeless Providers Grant and Per Diem Program and the SSVF Program (see §§ 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 § 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 § 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

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 § 78.10(a). As discussed later in this rulemaking, § 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 § 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 §§ 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

https://www.hrsa.gov/maps/quick-maps?config=mapconfig/MUA.jsondevelops.

See also,

https://data.hrsa.gov/tools/shortage-area/mua-find.

Because 42 U.S.C. 254b(b)(3) may be amended in the future, VA is not incorporating the actual definition in proposed § 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

grants.gov

in accordance with § 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 § 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

grants.gov.

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 § 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

https://www.ers.usda.gov/data-products/rural-urban-commuting-area-codes/.

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 § 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

include the following services provided to address the needs of a participant: (1) Outreach as specified under § 78.45, (2) baseline mental health screening as specified under § 78.50, (3) education as specified under § 78.55, (4) clinical services for emergency treatment as specified under § 78.60, (5) case management services as specified under § 78.65, (6) peer support services as specified under § 78.70, (7) assistance in obtaining VA benefits as specified under § 78.75, (8) assistance in obtaining and coordinating other public benefits and assistance with emergent needs as specified under § 78.80, (9) nontraditional and innovative approaches and treatment practices as specified under § 78.85, and (10) other services as specified under § 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 § 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 § 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 § 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 § 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 § 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 § 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 § 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 § 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 § 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

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 (

https://www.whitehouse.gov/wp-content/uploads/2021/11/Military-and-Veteran-Suicide-Prevention-Strategy.pdf

). 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

https://cssrs.columbia.edu.

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 § 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 § 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

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,

https://www.whitehouse.gov/wp-content/uploads/2021/11/Military-and-Veteran-Suicide-Prevention-Strategy.pdf. 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

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 § 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 § 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 §§ 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 § 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

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 § 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

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

Diem Program (38 CFR 61.14 and 61.94). However, the selection process under § 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 § 78.20 using the scoring criteria set forth in § 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 § 78.35 and in § 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 § 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

https://www.va.gov/vetdata/veteran_population.asp.

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

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 § 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, § 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 § 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.

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 § 78.20, VA will score the grantee using the scoring criteria set forth in § 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 § 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 § 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

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 § 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 § 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

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 § 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 § 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 § 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:

http://www.sprc.org/sites/default/files/migrate/library/SPRC_Gatekeeper_matrix_Jul2013update.pdf.

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, § 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 § 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 § 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 § 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 § 78.50(d), this language does not preclude the grantee from seeking to cover those expenses through other sources of funding and existing

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 § 78.80(a). As explained later in this discussion, § 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 § 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 § 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 § 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

https://www.healthquality.va.gov/guidelines/MH/srb/VADoDSuicideRiskFullCPGFinal5088212019.pdf

).

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

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

https://vaww.va.gov/OHRM/Directives-Handbooks/Documents/5005.pdf.

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), § 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 § 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 § 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 § 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

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 § 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 § 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 § 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

https://www.healthquality.va.gov/guidelines/MH/srb/VADoDSuicideRiskFullCPGFinal5088212019.pdf.

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

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 § 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 § 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 § 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 § 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.

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:

https://www.mentalhealth.va.gov/docs/data-sheets/2020/2020-National-Veteran-Suicide-Prevention-Annual-Report-11-2020-508.pdf.

) 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 § 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 § 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 § 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 § 78.50. Having this screening occur at the beginning (pursuant to § 78.50) and prior to services ending is important in evaluating the effectiveness of the

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 § 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 §§ 78.135 and 78.145), will be collected as part of the grantee's reporting requirements in § 78.145, and will be required to be maintained for at least three years (consistent with the recordkeeping requirements in § 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 § 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 § 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 § 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

https://www.mentalhealth.va.gov/suicide_prevention/docs/OMH-086-VA-OMHSP-Safe-Messaging-Factsheet-4-9-2019.pdf.

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

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 § 62.36(e)).

78.100 Fee Prohibition

In § 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 § 78.80(g); medical or dental care and medicines except for clinical services for emergency treatment authorized pursuant to § 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 § 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 § 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

grants.gov.

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

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 applic

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