[House Hearing, 109 Congress]
[From the U.S. Government Publishing Office]



 
                           SEAMLESS TRANSITION

============================================================================
                               HEARING

                             before the

                            COMMITTEE ON
                         VETERANS' AFFAIRS

                      HOUSE OF REPRESENTATIVES

                            SUBCOMMITTEE ON
                    OVERSIGHT AND INVESTIGATIONS

                     one hundred ninth congress

                             first session

                                 -------

                              May 19, 2005

                                 -------

         Printed for the use of the Committee on Veterans' Affairs

                           Serial No. 109-9


                                -------

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Seamless Transition

Thursday, May 19, 2005

U.S. House of Representatives,     
Subcommittee on Oversight and Investigations,
Committee on Veterans' Affairs,
Washington, D.C.

    The Subcommittee met, pursuant to notice, at 10:00 a.m., in Room 334, Cannon House Office Building, Hon. Michael Bilirakis [Chairman of the Subcommittee] presiding.

    Present: Representatives Bilirakis, Reyes, and Bradley.

    Mr. Bilirakis. Today's hearing will provide an opportunity to learn firsthand about the efforts by the Department of Defense and the Department of Veterans' Affairs in assisting military service personnel transitioning from active military service to veteran status.
 One of my goals as chairman, and I might add it's probably the top goal of the Committee, particularly the Oversight Committee at this time, is to ensure that these efforts are transparent to the servicemember, a constant generally referred to as seamless transition.  Over the past several years this Subcommittee has aggressively pursued implementation of seamless transition.  Past efforts have been met with mixed results.
    Let me be very clear, I intend to ensure that seamless transition becomes a reality.  Time does fly up here and we have our causes, and the regular routine stuff sometimes keeps us from meeting the goal that we set for ourselves.  But I hope that with the help of the great staff and the work of minority members, Mr. Strickland and Mr. Reyes, we will be able to do it.  Our service personnel and their families deserve nothing less.
    Separating from military service can be a very stressful event.  It's often filled with apprehension, trepidation, and a great deal of uncertainty.  It's something that I experienced many, many years ago.  This is especially true for personnel that are injured or disabled in the performance of their duty.  It's also true for the families of military personnel whose loved ones may have received severe injuries, like traumatic brain injuries, spinal cord, or other debilitating injuries.
    We are all too familiar with stories in the national press about wounded servicemembers falling through the cracks in the process of transitioning from DOD with regard to health care and compensation and disability benefits.  It's heartbreaking to see these young men and women with serious injuries left destitute at the most trying time of their young lives.
    So one of my first initiatives as chairman of the Subcommittee was to conduct field oversight activities, and recently we completed field visits at the James A. Haley VA Medical Center in Tampa, Florida and the Walter Reed Army Medical Center.
    I was pleased by the initiatives by both the DOD and the VA and their efforts to achieve seamless transition.  I look forward to hearing from the dedicated personnel that work hard every day behind the scenes to ensure that our nation's veterans receive the care that they deserve.
    While I applaud the two agencies for their work, more can be done.  Overall, the goal of a seamless transition is to educate servicemembers about VA benefits and to provide the servicemember a single emphasis, a single comprehensive medical examination that meets the requirements for DOD discharge physicals and VA's disability and compensation examination.  You will be surprised at the difficulty we are having to get that simple thing done.  That should also extend to other VA programs such as the GI Bill and vocational rehabilitation.
    Ideally, servicemembers who elect to file for disability and compensation would have a VA decision under a disability claim at the time of discharge.  In cases of severe injuries and disabilities, seamless transition should encompass the continuity of care and benefits when transferring from one health care system to another.
    Today's hearing will focus on the timely transfer of servicemembers from military hospitals to VA Medical Centers, a review of the benefits and delivery of discharge programs and service specific initiatives.  DOD and VA must get serious -- they must get serious about working together to make this a reality, and this Subcommittee stands ready to make that happen.
    I would now like to recognize Mr. Reyes from Texas, who is Ranking Member today, and with whom it has really been a pleasure throughout the years to work with on this Committee.  Mr. Reyes.
    Mr. Reyes. Thank you, Mr. Chairman.  Likewise, it has been my privilege to work alongside you and all the other members of this Committee, to try to address issues that are so important to our veterans and those coming out of the military, and they will be taking advantage of the work that we do here in this Committee.
    I apologize for running a little bit late, but as you know, Mr. Chairman, we've got conflicting hearings this morning.  Mr. Strickland sends his apology.  But last week when we were evacuated, that bottled up and doubled up a lot of the hearings, and we are all affected by that.  In fact, I came here from one of the rare open hearings that we have in the intelligence community.
    Last night, we worked on the Armed Services Authorization Bill until almost 1 o'clock.  So those are the kinds of things that are going on here.  So I know I will have to go back to my intelligence hearing.  But I would ask, Mr. Chairman, if our counsel can ask questions since Mr. Strickland is not going to be able to attend.
    Mr. Bilirakis. Yes, that has been mentioned to me previously, and I understand that there is a lot of this in this Committee.  By all means, that certainly will be the case.
    Mr. Reyes. Thank you so much, Mr. Chairman.  We appreciate that courtesy.
    I would also ask, Mr. Chairman, that my complete statement be placed in the record, and I will make some brief comments.
    Mr. Bilirakis. Yes.  Without objection, the statements of all members of the Subcommittee, whether they be here or not, can be made part of the record.  Please proceed, sir.
    Mr. Reyes. Thank you, Mr. Chairman. First of all, I would like to welcome all of those testifying. I would also like to specifically recognize those who have served in uniform for being here this morning. The issue of servicemen transitioning back to civilian life is a very important and sometimes a very complicated one.  It is not a new issue.  America has the duty to ensure that this transition is smooth and accessible to all who served, as well as a duty to make each and every soldier, sailor, airman, or Marine who was injured or otherwise harmed while serving their country whole again.
    While ongoing combat activities in Iraq and Afghanistan provide us with a constant stream of wounded and disabled GIs, this reality is not different from any past war of this country's history.  Having said that, the injuries received in theater are sometimes different than in previous battles due to the ever-changing technology that is available for the protection of our troops.  Different protective equipment and different modes of transportation that we see each and every day in both theaters.
    Not only must we adapt as necessary to treat those injuries in a timely manner, we must create a system that will embrace all of their needs.  We justifiably proclaim our healthcare system is one of the best in the world.  Its capacity to cure the sick and to restore the injured has very few rivals anywhere.  But Mr. Chairman, we do not always assure that those in need who have served in uniform benefit from the excellent system of health care.  We need to remain vigilant to this.
    How well are we doing in terms of seamless transition?  VA and DOD coordination on this effort is generally good.  For the average transitioning servicemember that is a testament to their abilities.  For the severely injured, the system is excellent, yet we are often reminded of instances where someone has fallen through the safety net. The Government Accountability Office observes that VA can utilize no systemwide official source of data on the returning servicemembers, but achieves its results by targeting individual facilities.  This information can be shared locally, why can't it be shared systemwide?  It seems to me a simple enough system to be able to give us that kind of information.  Each agency needs to accommodate the other in an environment free from any types of barriers.
    We also must remain conscious that not all battle injuries are visible.  These individuals must be identified, engaged in the seamless transition, and receive treatment from a caring and adequately funded Veterans Administration.  We also must maintain a vigil for emerging problems.  We must assure that when the transition to civilian life seems complete, the elements of that transition require monitoring and sometimes action to mitigate emerging service-related problems.
    We should learn from our past experiences and help these individuals complete the transition successfully and early.  If we don't, the costs in both human and monetary terms will be much, much higher.
    With that, Mr. Chairman, thank you very much for yielding me the time, and I yield back the balance of my time.
    [The statement of Mr. Reyes appears on p. 36]

    Mr. Bilirakis. Thank you, sir, and you certainly made many, many good points.  There are no other members here, so I won't ask if any other members wish to speak.  It's a small Subcommittee.  We only have four or five members on it. We may have another one or two coming in at one time or another.
    I would like to recognize at this time our first panel.  Ms. Cynthia Bascetta is the Director of Health Care, Veterans' Health and Benefits Issues, with the General Accountability Office.  Ms. Brenda Faas is the Veterans' Health Administration Social Worker currently assigned to Walter Reed, and we met the other day.  Ms. Linda Petty is a Veterans' Benefits Administration Benefits Counselor currently assigned to Walter Reed, and we met the other day; and Maj. Ladda Tammy Duckworth, who is an Operation Iraqi Freedom veteran currently receiving care at Walter Reed.  Again, we met the other day.  It's really wonderful to see you all here today.
    I'm going to ask you to limit your oral testimony to five minutea.  Obviously, if you're on a roll on something significant, I'm not going to cut you off.  But your complete written statement will be made part of the record.  So hopefully, you will complement or supplement that.
    With that being the case, we will start off with Ms. Bascetta.



STATEMENTS OF CYNTHIA A. BASCETTA, DIRECTOR OF
    HEALTH CARE, VETERANS' HEALTH AND BENEFITS 
    ISSUES, GOVERNMENT ACCOUNTABILITY OFFICE; 
    BRENDA FAAS, VETERANS' HEALTH ADMINISTRATION 
    SOCIAL WORKER, WALTER REED MEDICAL CENTER; 
    LINDA  PETTY, VETERANS' BENEFITS ADMINISTRATION 
    BENEFITS COUNSELOR, WALTER REED MEDICAL 
    CENTER; AND MAJ. L. TAMMY DUCKWORTH, OPERA-
    TION IRAQI FREEDOM VETERAN

STATEMENT OF CYNTHIA A. BASCETTA

    Ms. Bascetta. Thank you, Mr. Chairman and Mr. Reyes.  We appreciate being here today to discuss GAO's work on the seamless transition.
    Today, I would like to focus on VA's efforts to expedite vocational rehabilitation services to those seriously injured in Afghanistan and Iraq, and the related issue of its progress in developing a data sharing agreement with DOD. As you know, more than 12,000 servicemembers have been injured in combat since 2001, and a top priority is the continuity of their medical care between DOD and VA, as well as their smooth access to other VA benefits if they should  decide to separate from the military.
    My comments today are based on a report that we issued this January on VA's efforts to expedite vocational rehabilitation services.  To do our work, we reviewed the VA's formal and informal procedures and conducted interviews with officials at 12 of VA's regional offices.  Five of these offices were located near the Military Treatment Facilities that provide medical care to the majority of seriously injured servicemembers. We are also reporting on our ongoing review of the VA and DOD efforts to develop a data sharing agreement that would comply with the Health Insurance Portability and Accountability Act's privacy rule which governs the sharing of individually identifiable health data.  We discussed the information contained in this statement with DOD and VA officials who concurred with our findings.
    In September 2003, VA asked if its regional offices could learn the identities, medical conditions and military status of seriously injured servicemembers in their areas by coordinating with staffs at the MTF.  The regional offices were instructed to focus on servicemembers who were definitely or likely to separate from the military, and to assign case managers to them.  VA underscored the importance of early intervention and the provision which allows VA to provide services even before discharge.
    Lack of systematic data from DOD, however, proved challenging.  So in the spring of 2004, VA requested that DOD provide personal identifying data, medical data, and DOD's injury classification for servicemembers.  We found that in the absence of systematic data from DOD, the completeness and reliability of VA's data was dependent upon the nature of their local relationships.
    For example, one regional office received from the MTF only the names of new patients, but no data on the severity of their medical conditions.  In contrast, another regional office reported receiving lists of MTF patients with information on the severity of their injuries, as well as lists of servicemembers for whom the Army had initiated a medical separation.
    We noted that in the absence of a data sharing agreement, VA cannot reliably identify all seriously injured servicemembers, or know with certainty when they are medically stable, when they may be undergoing evaluation for medical discharge, or when they have been discharged.  As a result, VA cannot reasonably assure that some of these servicemembers who may benefit from vocational rehabilitation have not been overlooked.
    To remedy this, we recommended that VA and DOD collaborate to reach an agreement for VA to have access to information that both agencies agree is needed to promote the servicemember's recovery and return to work in whether they remain in the military or transition to the civilian sector.  However, DOD and VA have not yet developed a data sharing agreement even though they have been discussing the issue for more than two years.  We identified their different understandings of the HIPAA Privacy Rule as an impediment to their progress.
    Two examples illustrate the nature of their disagreement.  First, the privacy rule permits government agencies providing public benefits to disclose individually, identifiable health data to each other when the program serves the same or similar populations.  VA officials told us that they believed DOD can share health data because the Departments do serve the same or similar populations, and both provide public benefits.
    On the other hand, the DOD official responsible for implementing the privacy rule contends that serving the same or similar populations would apply only to servicemembers who were duly eligible for both DOD and VA services.  He also said that the services provided by DOD are not public benefits because they are unlike the examples in the preamble to the privacy rule, which does not define public benefits. The second example involves the Departments' differing views regarding when in the separation process DOD could share health data with VA.  DOD is reluctant to do so until it is certain that a servicemember will separate, while VA believes DOD could share the data sooner.
    Mr. Chairman, VA and DOD are currently working on a memorandum of understanding that they tell us moves them closer to a data sharing agreement.  Unfortunately, we found that the draft MOU essentially restates many of the legal authorities already contained in the privacy rule. Consequently, VA and DOD will still have to resolve the details of what health data can be shared and when it can be shared.  Until then we believe that the transition of servicemembers from DOD to VA for vocational rehabilitation and for other necessary services and benefits may not be as seamless as possible.
    That concludes my remarks, and I will be happy to answer your questions.
    [The statement of Ms. Bascetta appears on p. 38]

    Mr. Bilirakis. Well, you know, when I inquired about DOD, I think it would be a good idea to have the VA representative and the DOD representative sitting at the same table to try to explain to us why in the hell it takes two years to even get to the point where they're even close to an agreement.  But that will come, possibly at the next hearing. You know the unexpected consequences of our acts sometimes, when we came up with HIPAA, I'm not sure that God was on our shoulder, I think somebody else was probably on our shoulder. But it's really caused an awful lot of problems, obviously, in health care.
    Ms. Faas.

STATEMENT OF BRENDA FAAS

    Ms. Faas. Yes.  Mr. Chairman and members of the Committee, I am privileged to appear before you today to discuss my role as a VA/DOD Liaison for Health Care stationed at Walter Reed Army Medical Center.  I am honored to serve the injured soldiers, sailors, airmen, and Marines who are returning from theaters of combat and who may benefit from VA services.
    My role is one of two VA/DOD Liaisons at Walter Reed involves partnering with the MTF staff, active-duty servicemembers, veterans, family members and the VA Medical Center staff across the country to ensure a seamless transition of care and services.
    Together with the Walter Reed social work staff and other interdisciplinary team members, we develop a treatment plan, which I help to expedite within the VA Health Care System.  I am assigned full-time, on-site at Walter Reed Army and meet face-to-face with patients and staff.  I provide consultation to staff regarding the availability of health care and I also educate servicemembers and their families regarding VA health care benefits.
    When the MTF staff identifies a servicemember who will need a VA health-care, a referral is generated.  Which also includes medical records and a treatment plan.  Referrals may involve servicemembers who require medical care while on convalescent leave who are being separated or retired from the military and will need continuous medical care.
    Transfers of care may involve patient services such as acute rehabilitation for dramatic brain injuries, spinal cord injuries, visual impairment, and loss of limbs or function, as well as acute inpatient psychiatry.  Outpatient service may include primary care, orthopedics, physical occupational therapy, neurology, oncology, and mental health.
    An important part of coordination of care involves meeting with the servicemember and the family to review this treatment and transfer plan.  I pay particular attention to any special needs that the family member or servicemember may have.
    Once I have received a referral, the servicemember is enrolled in the VA Health Care System and the transfer of care is coordinated with the OIF/OEF point of contact at the designated VA Medical Center.  The point of contact arranges for outpatient appointments and/or inpatient admission.  I then meet with the patient and the family member at Walter Reed to conform the appointments being made, to provide them with the point of contact information, and to continue to address any issues or concerns they may have about the transition process.  I remain available to answer any questions while they remain at Walter Reed before they're transferred.
    I also monitor the transfer through our computerized Patient Record System that the VA has, so is a patient is being transferred say from here to California, I can monitor that transfer and actually look in the computer system and see if they actually attend their appointment or were they admitted properly.
    Due to the renowned Amputee Clinic at Walter Reed, we have a high volume of patients with amputations from all branches of the service.  These patients will require long-term medical and prosthetic care.  I work closely with Walter Reed in the Washington, DC VA Medical Center to provide prosthetic equipment, such as ultra-light wheelchairs, collapsible canes and crutches, and hand-cycles for cardiovascular exercise.
    I collaborate with Walter Reed Department of Physical Medicine and Rehabilitation and the VA-Maryland Health Care System to schedule driving evaluations for patient with amputation, traumatic brain injuries and visual impairments.  I also communicate with the VA Blind Rehab Specialist who visits the visually impaired patients at Walter Reed to provide education about VA's Blind Rehab Services.
    I also work with the Veterans Benefits counselor and Vocational Rehab Educational counselor from the Veterans Benefits Administration who are located at Walter Reed.  We communicate on a daily basis to review the needs of the patients and how we can coordinate our services to support an optimal level of functioning and independence.
    Change provokes anxiety, and my goal as a VA/DOD liaison is to help the OIF/OEF veterans faced their new lives with enthusiasm, hope and optimism.  Enhancement of coordinated services between DOD and VA promotes a positive transition from military to civilian life and ultimately has a lasting effect on our veterans' families and community.  I am honored to serve those who have served our country.
    Mr. Chairman, this concludes my statement.  I look forward to answering any questions.
    [The statement of Ms. Faas appears on p. 52]

    Mr. Bilirakis. Thank you very much, Ms. Faas.
    Ms. Petty, please proceed.

STATEMENT OF LINDA S. PETTY

    Ms. Petty. Mr. Chairman and members of the Subcommittee, it is a privilege to appear before you today to discuss my role as the supervisor of the Veterans Benefits Administration's Outreach Team at Walter Reed.  I retired from the United States Army in 2003 after 28 years of both active and reserve service.  I am honored that VBA gave me the opportunity to work at Walter Reed supporting these servicemen and women, our newest veterans.
    VBA detailed a full-time benefits counselor from the Washington Regional Office to Walter Reed Army Medical Center in August of 2003.  I joined the Walter Reade staff in March 2004 as a supervisor.  My role was to coordinate support requirements, develop administrative procedures, and provide a single point of contact for both the military and VA issues. We currently have four full-time, permanent staff members at Walter Reed and one at Bethesda.  We also have a contract for Vocational Rehabilitation and Employment counselor to provide early testing and evaluations.
    We strive to meet every injured servicemember returning from the theater of operations with special emphasis on those designated by the military as very seriously injured, seriously injured or special category persons as soon as medically appropriate.
    From the beginning, we tried to schedule visits within 72 hours of the patient's arrival.  This was an unrealistic and inappropriate goal.  We found that few patients were physically or emotionally ready to discuss veteran benefits that soon after arrival.
    We now attempt to see every impatient as soon as medically possible.  We receive referrals from the military social workers, from the case managers, and the VA social workers, and periodically we check with the ward nurses to see if there's anyone we need to visit.
    At the first visit, we introduce ourselves and gather some basic contact and personal information.  We try to follow up every few days with a short visit to gauge when they are ready for more information or to start the claim.  It's often weeks or even months before someone is ready to start a benefits claim.  Our goal is to build a relationship based on the servicemember's needs.
    One of our unique aspects is our full-time Vocational Rehabilitation and Education and Employment counselor.  This counselor provides vocational evaluation and testing, rï¿½sumï¿½ review, and employment referrals.  We issue ergonomic computers and equipment is on his eligibility is established.  The VR&E program at Walter Reed also arranges volunteer employment opportunities so servicemembers can get valuable civilian work experience prior to separation.  The VR&E program gives both servicemembers and their families reassurance that they do have employment options after separation.
    In July of 2004 the clinic physicians invited VBA counselors to participate in their weekly outpatient amputee clinic.  These meetings allow us to see patients we might have otherwise have missed, to follow both those who have started a benefits claim, and to answer questions about the claims process.  The VBA counselor at Bethesda attends similar interdisciplinary meetings.
    We work very closely with the VHA social workers and health-care liaisons.  Often the VBA counselors have worked with the patient long before they're ready for referral to the VHA.  VHA contacts us when they find a patient with benefits questions and we do the same with health-care questions.
    I periodically attend the Fisher House Family Support Group meetings to provide information on the VA benefits available in the claims process.  We prepare claims for compensation, automobile grants, long guarantee and adapted housing, and voc rehab.  We gather all available medical evidence needed to support the claims.  Claims from both Bethesda and Walter Reed are processed from the Washington VA Regional office.  They process as much of the claim as possible before separation, and finalize it upon receipt of proof of service.  Our goal is to have the benefits waiting for the servicemember, not the servicemember waiting for benefits.
    Each VBA regional office also has an OIF coordinator and an alternate.  We notify the coordinator when a patient leaves Walter Reed or Bethesda, even if it's just for a few weeks of convalescent leave.  We tell the regional office how to contact the servicemember, what we have done to date, and let them know of any special needs they might have.
    The Under Secretary for benefits established very specific guidelines for outreach and claims processing for all of these special category casualties.  These claims are case managed and receive priority processing at the regional offices.
    The VBA regional services at Walter Reed and Bethesda are not limited to -- awaiting to those OIF/OEF servicemembers.  We counsel all other servicemembers awaiting medical boards, provide transition services to include Transition Assistance Program briefings and pre-retirement briefings.  We also counsel retirees and surviving family members.
    Mr. Chairman, this concludes my statement.  I look forward to answering any questions that you or other Committee members might have.
    [The statement of Ms. Petty appears on p. 55]

    Mr. Bilirakis. Thank you so much, Ms. Petty.  As time goes on we're going to have questions for all three of you, certainly.
    Before getting to Maj. Duckworth, first, Major, I would like to thank you for your extraordinary courage, your sense of duty, your desire to continue to serve your country, and it's just wonderful that you brought your Mom with you here today.  Ma'am, would you please rise so that we can give you what you deserve, applause?

    [Applause.]

    Mr. Bilirakis. Thank you, ma'am, for loaning Maj. Duckworth to her country.
    Major, your personal story of your tour of duty in OIF needs to be heard today.  You can do so as briefly as you wish or whatever.  The story of your medical care in the military medical system, from the MEDEVAC helicopters, to combat support hospitals, Landstuhl Regional Medical Center in Germany, and finally here at Walter Reed, also needs to be told from your eyes.
    We also want to hear what you have seen and experienced in your rehabilitation at Walter Reed, specifically DOD's and VA's efforts to facilitate, educate, and aid you and your fellow heroes, the only true heroes, I might add, in our society.  They and the law enforcement people and the fire people.  In returning to duty, or transitioning to the VA medical system and civilian life.
    Major, I realize that you are still in the service. I hope that you can share with us, you know all the positives as well -- also the negatives, and that your branch of service will allow you to do that, because our effort here is to not scold anybody or hit anybody over the head.  Our effort is to try to get things fixed.  So hopefully, you can help us in that regard.  The microphone is yours, I'm not even going to turn on the light.  So you just take your time.  Please proceed.

STATEMENT OF MAJ. L. TAMMY DUCKWORTH

    Maj. Duckworth. Thank you.  Mr. Chairman, Acting Ranking Member Reyes.
    Mr. Bilirakis. Move the mike little closer, we want to make sure everybody can hear your comments.
    Maj. Duckworth. I'll try to sit forward.
    Mr. Chairman, Acting Ranking Member Reyes, thank you for the opportunity to come before you today to discuss the care of wounded servicemembers injured in Operations Enduring Freedom and Iraqi Freedom and our efforts to facilitate the transition between the military and the Department of Veterans' Affairs health care facilities and between military and veteran status.
    On November 12th, 2004 I was flying a mission in Baghdad on the way back to home base.  At the end of the mission I was hit by an RPG, which amputated my legs in flight, came up through the floor of the aircraft, the window that is between the pilot's legs which we use in order to land the aircraft and do close hover work.  My pilot in command, the other pilot in the aircraft, successfully landed the aircraft.  Chop II, which is a second aircraft in our flight, took all of the injured on board, transferred us to Taji, at which point I entered the military health care system, which was quite remarkable.
    The MEDEVAC aircraft, even though I had lost over 50 percent of the blood in my body, and had been what my crew members thought was dead -- they thought they were recovering a body -- the MEDEVAC aircraft, which is a flying hospital of sorts, a flying trauma room, was able to actually revive me in the five-minute flight from Taji to Baghdad to the CSH, and I was actually rolled into the Combat Support hospital (CSH) alert and talking.  This is from being what people thought I was dead.
    At the hospital in Baghdad they performed emergency amputations of the remainder of my right leg, and cleaned up my left leg, at which point the doctors determined that I was probably going to become a triple amputee and lose my right arm also.  So they very quickly transferred me to Landstuhl.  After getting to Landstuhl, I stayed there 16 hours, and from Landstuhl I was sent right on to Walter Reed because of the very same fear that I would lose my right arm. I arrived at Walter Reed within 60 hours of my initial injury. I arrived in the CSH in Baghdad within approximately 25 minutes from when I was hit.
    So due to the rapidness of this health-care system and the forward placement of surgeons in Baghdad and Landstuhl, they were able to save my arm.  I hope to have at least 75 percent recovery and use of my right arm, which is vital to me because I wish to stay in the military, serve in the National Guard and continue to fly helicopters.  So having my right arm is a major development for me, and I'm grateful. Every day that I see my surgeon who works on my arm, I thank him and I tell him, thank you for my arm.
    So that's my background.  I feel that the core component of the seamless transition is our nation's investment in its finest citizens, the past and present members of the military.  I believe we must continue to fund and support the military treatment facilities.
    Military treatment facilities are a crucial part of integrated medical system, which has performed so well during this conflict.  In any previous conflict I would not be alive. It is a testament to the superior protective equipment that I was wearing, and to the medical care pipeline from the frontline that I can be here today.
    I would urge you to think of the efforts of the Army Medical Department and the VA as a force multiplier in two ways.  First, these organizations can help us retain good soldiers, Marines, airmen and sailors who would have otherwise not been able to continue to physically accomplish their missions and remain in the service of the United States. These wounded have already been trained a great expense, as well as been tested and gained invaluable experience in the crucible of combat.
    Second, our warriors must be able to focus completely and single-mindedly on the mission at hand, serving the people of the United States of America.  When that mission is to close with and destroy our nation's enemies, I believe that we want our warriors to be secure in the knowledge that, when they are hurt we will take care of them.
    As disabled soliders transition to veteran status, we will look to the VA to provide continued access to health care, health technology, assisted-living devices and social services.  The VA will have to face the challenge of providing care at the high level set by the military health care facilities.  This is a challenge that the VA can meet if it is given enough resources and if it listens to the disable servicemembers and puts forth the effort to meet our needs.
    The first, most easily identified need that the VA will have to support is continued access to technology, such as in prosthetics research.  Disabled veteran will require access to involving technology as they age, and as the available technology undergoes renovation and changes.
    Second, as I look around at other wounded soldiers, it is clear that the majority of them are young with long lives ahead of them.  Whether we will continue to have the honor of serving in uniform, or return to productive civilian lives, we will require continued access to technology as we age.  The VA will need to support this need over the long-term as currently wounded soldiers will be making use of its services over a lifetime.
    Third, disabled soldiers will need access to assisted-living devices.
    Fourth, the VA will need to provide access to social services such as job counseling and psychological support. Those that sustained brain injury as well as those that developed psychological trauma will need long-term counseling and support.
    Fifth, it does the disabled veteran no good if he or she is unable to access the various programs provided by the VA.  For disabled veterans living in areas far from VA hospitals and facilities, travel itself is a significant obstacle to their continued care.
    I can only hope and implore that the VA's steps up to receive disabled veterans as we transition into its care from the military medical system.  In order to do so, the VA will have to identify and develop specific programs and those programs will have to be funded into the future.  I also asked that his system such as a checklist be created to give to injured soldiers or their next of kin, to give them a roadmap to follow as they move from the military medical system into the VA.
    While I currently cannot comment from personal experience on the quality of care available in veterans' hospitals, I have been witness to the outreach efforts of the VA.  These efforts have been highly personal, and as a result, my concept of the VA is not that of the faceless bureaucracy.
    At this point the face of the VA as a veteran and amputee that befriended my husband and mother even as I lay unconscious in the Intensive Care Unit.  The VA is a former Army ranger and his wife who came to visit me and all the other wounded in a hospital rooms.  The VA is a vet who wheels in to check on the condition of my wheelchair and tells me from his personal experience the importance of a good seat cushion.
    I applaud the VA and the Department of Defense partnership that assists military servicemembers who have served in combat and aims to provide them with a seamless transition to civilian life and veteran status.
    Selecting individuals from amongst the American people who would willingly serve in the armed services are a limited resource.  Our warriors are expensive and indispensable.  I believe we must jealously guard this resource, retaining as many as possible in the service, and sparing little in the effort to return one of them to duty.
    The investment in training dollars represented by even one junior non-commissioned officer could easily be several hundred thousand dollars over the course of five to six years.  Such are the expense of assets that the military treatment facilities is in the business of fixing and maintaining, and I believe the American people's tax dollars are well spend there.
    Additionally, once out of the military, our veterans make up a highly trained and disciplined pool of workers ready to add to the productivity of the civilian work force. Veterans supported by the VA and able to lead productive lives are valuable contributors to the economy.  The cost of providing wheelchairs and prosthetics to veterans through the VA system is an investment recouped through taxes paid by those same veterans who can now work as a result of these devices.
    Finally, on behalf of our injured, wounded, or ill servicemembers and their families, I thank members of this great institution for this opportunity to address their concerns for medical care of our nation's veterans, soldiers, Marines, sailors and airmen.
    Thank you for the opportunity to be here today, and I look forward to your questions.
    [The statement of Maj. Duckworth appears on p. 60]

    Mr. Bilirakis. Thank you so much, Major.  The chair recognizes himself and the light can go on now.  Let me switch this on here.
    Ms. Bascetta, do you believe that DOD's concern regarding the HIPAA Privacy Rule provisions have merit?
    Ms. Bascetta. That's a very important question.  I think that you mentioned in your opening statement that there might have been unintended consequences of HIPAA, and we understand why DOD takes this law very seriously.
    Surely, there is nothing more important than the privacy rights of an individual's health information.  But it is hard for us to understand how in more than two years DOD could not figure out a HIPAA-compliant way to share data with VA, which is ultimately for the benefit of the servicemember.
    If they couldn't do this on their own, or they were fearful of being in violation of HIPAA, we believe that they could have and should have contacted HHS's Office of Civil Rights who could have helped them by interpreting the HIPAA privacy rule, which is in HHS's jurisdiction.
    So I guess the bottom line is that HIPAA certainly requires strict attention, and it might have even been an obstacle early on, but we don't believe it was an insurmountable one.
    Mr. Bilirakis. Do you think that it should have taken as long as it has, a couple of years, to really not even reach -- as I understand that they were supposed to reach some sort of agreement by today.  I don't know whether that's just a coincidence and that we are having a hearing today.  But I'm not sure really, what took place as far as that is concerned. What do you think, is there something more that the Congress should do in this regard?  I mean, you know we all realize that probably HIPAA is not perfect.  Of course, it is the law and we do appreciate DOD's problem that they want to abide by the law.  They don't want to bear any undue risks or whatever the case may be.
    Should we be doing more in that regard, I mean, they have come up to us as far as I know.  They may have gone to the Armed Services Committee, but as far as I know they have not come to the Veterans Committee and sat down with us and said, hey these are changes or maybe clarifications we need, or what was the intent of the legislation, so to speak, et cetera.
    Ms. Bascetta. We don't think at this point that there is a legislative fix that is required in HIPAA. Certainly not without the Department's asking first for consultation from HHS on the matter.  It would be premature to say that HIPAA is the problem or needs a legislative fix.  I would add that it could be that you'll have to legislate to tell the DOD, to direct DOD to develop a HIPAA-compliant agreement to share data.  But we think they can do it.
    Mr. Bilirakis. We're you involved in the regional visits to help determine whether the, you know the single medical physical thing was taking place?
    Ms. Bascetta. Actually another team did that work, but I'm familiar with it.
    Mr. Bilirakis. You're familiar with it.
    Ms. Bascetta. Mm-hmm.
    Mr. Bilirakis. Now the statistics as I -- I don't recall the statistics.  I guess there is some 100 and some bases out there and I think you told us, GAO told us 12 of them were in compliance, or eight of them were compliant or something like that.  Then it was ultimately determined that, I think that only what, one was?
    Ms. Bascetta. Four.
    Mr. Bilirakis. Four?  Four were actually in compliance in other words.  So they were sharing data, I guess, adequately so that the physical -- that there was one physical that both groups, that both Departments agreed with, is that right?
    Ms. Bascetta. Yes.
    Mr. Bilirakis. Please explain that.
    Ms. Bascetta. I know that you are interested -- 
    Mr. Bilirakis. Whatever it is that you know in that regard, because it kind of blows my mind.
    Ms. Bascetta. Right.  I know that you are interested in this topic because it was mentioned in your invitation to the hearing.
    Mr. Bilirakis. Yes.
    Ms. Bascetta. So I brought the report with me.  I don't have information on the accuracy of the number of BDD sites.  There are either 139 or 140, or there may be even 144. But what we found in our report was that 20 military installations with BDD programs were supposed to have the single separation exam, which is a component of the BDD sites.
    When we evaluated programs at eight of the 28 installations who had the single separation exam, we found that four of installations did not actually have the program in place.  I can provide for you the -- 
    Mr. Bilirakis. They didn't even know what BDD stood for as I understand it.
    Ms. Bascetta. Uhmm.
    Mr. Bilirakis. They not only didn't have it in place?
    Ms. Bascetta. I'm not sure about that.  That specific language isn't in this report.  But for example, at one location officials told us that a single separation exam was in place prior to our visit, but when we got there we discovered that it wasn't being followed, and the single separation exam wasn't even in operation.  So there is documentation about that at the four locations. We also identified another military installation that had a single separation program, even though it wasn't included in their list.  So there were errors of omission as well as other errors.
    Mr. Bilirakis. Yeah.
    Ms. Bascetta. So we're not confident in the numbers that we're getting from VA on that program.
    Mr. Bilirakis. Thank you very much, Ms. Bascetta.
    Ms. Bascetta. Mm-hmm.
    Mr. Bilirakis. Mr. Reyes to inquire.
    Mr. Reyes. Thank you, Mr. Chairman.  I regret that I am going to have to leave after I asked this question.  But I'm going to focus mostly on you, Maj. Duckworth.  Just last night we marked up the Armed Services budget.  Next week part of that bill, there is a provision there that we are trying to redefine the role of women in the military and in particular combat.  It just strikes me that you're the perfect example. Your personal testimony and your personal courage and dedication to this country is exactly what I hope to talk about next week on the floor, because in my district, regrettably, I've attended two funerals for two women that had been killed in Iraq.
    It strikes me that when we talk about, I think to use your words, the spectacular care that you received and the ability to have you back here 60 hours I believe you said after you were injured.  I'm going to assume that you are a Black Hawk helicopter pilot?
    Maj. Duckworth. Yes, sir.
    Mr. Reyes. The question that I have is the care that you have been provided and by your statement the MTF's being spectacular, you also state that you do not believe it can be duplicated at a civilian hospital at any price.
    I guess my first question, Major, is, is it fair to say that some of your concerns may be based on medical expertise and some of your concerns are based on cultural needs of servicemembers?  In other words there is a relationship there given the kind of care that is required after being traumatically injured in combat, 60 hours later you are in the hands of military doctors that really know, understand and empathize with your situation.  Is that fair to say?
    Maj. Duckworth. Yes, sir, it is, exactly.  First off, I'm a helicopter pilot because I chose the only combat arms branch that would allow women into combat, which is aviation.  At the time that I was being commissioned, I requested aviation because I didn't want to face fewer risks than the male soldiers, so that's how I became a helicopter pilot.
    My concerns with transitioning away from the military treatment facilities are two-fold.  Just as you have mentioned, first and foremost, these facilities have the expertise to deal with the very peculiar wounds that come out of combat.
    For example, I actually sat in on a training program for peer visitors just within the last couple of weeks where we talked with other amputees.  We actually spoke with a gentleman who had been dealing in prosthetics for about 25 years.  He makes prosthetic legs.  He was unfamiliar with a condition called HO that many of the soldiers who are amputees have.
    What it is, HO is when bone starts to grow into the tissue were a blast injury happened.  Because this man had never dealt with anybody who had been an amputee as a result of a blast injury, he was not familiar with this condition, which is so pervasive amongst the population at Walter Reed that it is a matter of course that they understood what to do.
    I also believe that my arm would probably had not been saved if it had not been for the surgeons at Walter Reed, because they were very familiar with the effects of blast injuries and the shrapnel that I incurred.  It is very different from losing your limbs from diabetes or losing your limbs in a car accident.  That's my completely nonprofessional, non-medical opinion.
    The second issue is the cultural issue.  The doctors at Walter Reed, where I am personally being treated, many of the doctors and nurses have been in Baghdad.  They were at the very same CSH and they understood what it meant to have to wear the body armor.  They understood what it means to have been the target of mortar and rocket attacks themselves, because that medical hospital is one of the main targets for the insurgents.  So there is that cultural background that is a big help.
    Also to be as part of a population, a concentration of other amputees who have gone through the same thing that you have gone through, who are just like yourself generally healthy prior to being -- undergoing this traumatic injury is a source of encouragement for one another.  I can sit in that room, in the physical therapy room because I am learning to walk with the other soldiers, and we all know and understand what we have gone through.
    So it is not just the health-care providers, it is also being with other soldiers, as well.
    Mr. Reyes. Thank you, Major.  Mr. Chairman, can I follow up with one question?
    Mr. Bilirakis. By all means.
    Mr. Reyes. Major, when the transition is made and the servicemembers care comes under the VA, are those two same rationales that are of concern to you, are they still important in your opinion?
    Maj. Duckworth. I think once I had transitioned to the VA system, sir, I had gone to the initial phases of recovery when those items are the most crucial, having the other soldiers, having the military doctors.  Once I've transitioned into the health-care, the VA system, I believe that I will be much more able and more self-reliant than I am within the initial first months.
    For example, I received my first legs in January, just two months after I was injured, and I was able to see that is something that I can do, I can learn to walk again because the other soldiers were doing it.  I doubt if I were by myself, one of -- maybe one or two amputees in a hospital someplace, that I would have actually been able to conceive of doing that.  Whereas being at Walter Reed where I saw people doing it all the time, it was of course, you know two months after having my legs blown off I'm going to be walking again.
    Mr. Reyes. Thank you very much, Major.  Thank you for your testimony.  Thank you for your service.  You're an American hero.  Thank you.
    Maj. Duckworth. It's an honor to wear the uniform, sir.
    Mr. Bilirakis. You know, we all feel that way. Here they are, you know with a limb missing and other sets of problems and they just feel that way.
    Major, do you have -- maybe sort of trying to hitchhike a little bit on Mr. Reyes' question.  Do you have any concerns that the expertise that you have experienced in the military facilities will not be there with the VA?  I mean, do you have a concern with that regard?  Do you expect the same sort of expertise that you have experienced?
    Maj. Duckworth. In the initial stages, sir, I do.
    Mr. Bilirakis. You do.
    Maj. Duckworth. Just because of the volume of patients that come through initially.  For example, there has been approximately over 250 amputees in this latest conflict and they had generally been divided between, I believe, Brook Army Medical Center and Walter Reed.
    If you separate or distribute those amputees over all of the VA hospitals, you now have a population of two or three perhaps in each hospital across the 50 United States. So I would think that the expertise that are being gained by the physical therapists, for example my personal physical therapist she's seen 15 other blast injury and amputees prior to this.
    Mr. Bilirakis. Yes.
    Maj. Duckworth. But if she was working at a VA hospital, in the initial months I think that it is a significant factor.  But again -- 
    Mr. Bilirakis. It would be something new to her, to that physical therapists.
    Maj. Duckworth. Yes, sir, and she would see -- not be able to pick up on some of the problems that I am having, because she would not have seen it and someone else, having seen just maybe two or three in her local VA hospital.
    However, I think that once I graduated from the military treat-
ment system and had moved on to the next stage in my life, moved on to the VA system, then I don't think it's an issue once you make that transition.  I just believe that in the beginning, this is my first six-month right now, I think that it's vital for me to be with other soldiers, and be with a large enough population, that the people providing the medical care have seen that many people going through and understand the injuries.
    Mr. Bilirakis. In the follow-ups, Ms. Faas and Ms. Petty, in the follow-ups that you have, and I understand that you have got that in effect at Walter Reed, I hope that's all over the system maybe we could find out about that as we go on.  Have you run into this problem that we're talking about? In other words, that the resources in the VA may not be as adequate, mainly because of lack of experience, if you will, with you know certain conditions, et cetera?
    Ms. Faas. Anytime in my experience of transferring any patients, you know, I do pass along those medical records to the facilities so that they are aware of what injuries the patient has.  To my experience, I haven't had any VA staff say they could not manage the care.
    As Maj. Duckworth mentioned with some of the amputees, the bulk of their care is at the MTF and then once they've recovered, then they're going on to the VA hospitals.
    Mr. Bilirakis. But no problems as far back you know?
    Ms. Faas. From my experience they have all been very receptive.
    Mr. Bilirakis. Mm-hmm.  Brenda, anything you want to add to that?  I mean, Lynda.  Lynda, did you want to add anything to that?  
    Ms. Petty. No.
    Mr. Bilirakis. Okay.  All right, Mr. Bradley to inquire.
    Mr. Bradley. Thank you very much, Mr. Chairman.  I apologize for not being here for the earlier part of your testimony, but I have two questions for Ms. Faas. To what extent do you facilitate the sharing of medical information between Walter Reed Army Medical Center and the VA Health Care Facilities where injured service personnel are being transferred?
    Ms. Faas. I received medical records specific to the treatment that is being requested.  In the referral packet, we have referral form and when I get the information from the MTF staff, particularly usually the social worker, I received the medical records at that time, and then I transfer them to the VA.
    Mr. Bradley. Secondly, in your written testimony you stated that the DOD participated at times on the VA's Seamless Transition Task Force.  Could you please explain that in what you mean by ``at times'' in what could be done to perhaps better facilitate that?
    Ms. Faas. I'm sorry.
    Mr. Bradley. I'm sorry, that was a question for the GAO representative.
    Ms. Faas. Okay.
    Mr. Bradley. I'm sorry.
    Ms. Bascetta. I can respond to that.  In our January report on
vocational rehabilitation we characterized DOD's participation as ad hoc.  In other words, the Seamless Transition Task Force was a unilateral initiative of a VA, and it was actually formed in response to some negative media about certain veterans who were, in fact, falling through the cracks.
    DOD had some participation in the task force but they weren't formal members.  Of course, we are aware that there are other avenues for DOD and VA to talk about the seamless transition at the executive level through the Joint Executive Committee, the Health Executive Committee and the Benefits Executive Committee.
    Mr. Bradley. Thank you.  That's all I have.
    Mr. Bilirakis. Before I yield to Mr. Sistek to ask Mr. Strickland's questions, I would advise Ms. Duckworth, Maj. Duckworth, that as I understand it, VA I guess also has the same concerns that you have.  I failed to mention to you that as I understand that there are four -- VA has designated four, what they call Polytrauma Centers, and I know that Haley in Tampa is one of them, in my area.
    So we're probably, hopefully we're talking about the 250 not going, not being spread that thin, in other words, probably four centers and hopefully they will be able to handle things.
    Maj. Duckworth. Okay.
    Mr. Bilirakis. Just to make you feel a little better.  It certainly makes me feel a little better.  Mr. Sistek, please proceed.
    Mr. Sistek. Thank you very much, Mr. Chairman. I would like to follow up on your very first question with GAO concerning HIPAA.  Ms. Bascetta, you stated there is no systemwide sharing of information, but that information is shared due to the efforts of the regional offices in coordinating with the MTF's, to gather data specific for that MTF, to allow for an information exchange.
    So we have an information exchange working locally, and seemingly producing some pretty good results.  But there is nothing working systemwide.  Does HIPAA distinguish between local informal agreements and the systemwide agreement, and can the informal agreements already in place serve as a precedent to perhaps help DOD find its way through the HIPAA maze?
    Ms. Bascetta. Well, I think that's a good point. I don't have the specifics on the local arrangements that have been worked out with regard to HIPAA.  But for example, some of them may have authorizations from servicemembers to release information.  Others may be less formal than that. I point out that we've found the need for the systematic data sharing because the local arrangements were not always very successful.  It did impede the ability of VA to provide early intervention, and to be able to follow up with servicemembers as they left the MTF's or the VA hospitals and went back to their homes.
    But I think you pointed out, looking at some of those arrangements to see whether they could serve as models or as precedents is a good one.
    Mr. Sistek. Your testimony on page three mentions the Joint Executive Committee and the Joint Executive Committee has produced a Joint Strategic Plan in 2004.  There is a series of initiatives under that Joint Strategic Plan that have milestones that have already passed, some of which includes the sharing of best practices between the DOD and VA; performance measures for communications plan; defining GME and training needs; developing operational procedures.  Do you know if these particular milestones have been met?
    Ms. Bascetta. No, I don't.  We haven't been tracking this in a way that I am able to report on that today. We do have work that was mandated in the National Defense Authorization Act last year, for us to look at sharing that goes on between VA and DOD, not the data sharing agreement that we're talking about today, but the broader resource sharing.  So we are following up and reviewing the communication at the executive levels.
    Mr. Sistek. Thank you very much.  I believe information sharing is a major part of the Joint Strategic Plan.  Mr. Chairman, thank you very much.
    Mr. Bilirakis. Thank you, Mr. Sistek.  Well, Major and ladies, thank you so very much.  You have been awfully helpful.
    We have a series of questions, which, you know, we felt just wouldn't be enough time to ask them orally.  So we will be furnishing them to you as per the usual, and we would hope that you would respond in a timely fashion.
    Again basically, you're dedicated folks.  Otherwise, you wouldn't be doing what you're doing.  So help us sort of help you do your job better, where you feel a lot better about your job, that the right things are being done.
    So feel free to recommend to us, answer our questions.  If you feel that there is any kind of a problem internally that prevents you from making a recommendation that you would like to make, we obviously would like to know about that.  Not that I think anything like that would happen.
    Thanks so very much.
    Ms. Bascetta. Thank you.
    Ms. Petty. Thank you.
    Ms. Faas. Thank you.
    Maj. Duckworth. Thank you.
    Mr. Bilirakis. Okay.  We would ask the second panel to come forward.  Col. Gwendolyn Fryer, United States Army's Southern Regional Medical Command Military Liaison to the James E. Haley Veterans' Affairs Medical Center in Tampa, Florida.  I have already welcomed her to Tampa.
    Col. Timothy Frank, United States Marine Corps' Liaison Officer to the Secretary of Veteran Affairs.  Col. Frank, thanks for being here and thanks for taking on that chore.  We probably won't be spending a lot of time with you.
    Mr. John Brown is the Director of the Office of Seamless Transition, Direct Department of Veteran Affairs. Certainly, sir, we will be spending a lot of time with you.
    Ms. Linda Boone is the Executive Director of the National Correlation for Homeless Veterans.
    Okay, again, your written statement as part of the record.  We would turn the clock on for five minutes and we would hope that you would sort of complement or supplement your statement, your written statement.  Then, I will call on you, Col. Fryer, to start us off.

STATEMENTS OF COL. GWENDOLYN FRYER, SOUTHERN 
    REGIONAL MEDICAL COMMAND MILITARY LIAISON TO
    JAMES E. HALEY VETERANS' AFFAIRS MEDICAL CENTER,
    UNITED STATES ARMY; COL. TIMOTHY FRANK, LIAISON 
    OFFICER TO THE SECRETARY OF VETERANS' AFFAIRS,
    UNITED STATES MARINE CORPS; JOHN BROWN, DIREC-
    TOR, OFFICE OF SEAMLESS TRANSITION, DEPARTMENT
    OF VETERANS' AFFAIRS; AND LINDA BOONE, EXECUTIVE
    DIRECTOR, NATIONAL COALITION FOR HOMELESS VET-
    ERANS

STATEMENT OF COL. GWENDOLYN FRYER

    Col. Fryer. Good morning, Mr. Chairman, Congressman Bradley, distinguished Committee members.
    I am Col. Gwendolyn Fryer and I to as the others am very honored to appear before you today to discuss the new and evolving role of the Army Polytrauma Liaison.  This role was established in March 2005 through the collaboration, partnership and collective wisdom of Lieutenant General Kevin Kiley, The Surgeon General of the Army; Dr. Jonathan D. Perlin, Under Secretary of Health for the VA; and the VA Office of Seamless Transition.
    Today, I represent one of four Army Polytrauma Liaisons.  We are strategically assigned to one of the four Department of Veterans' Affairs Polytrauma Centers.  I am assigned, of course, to the James E. Haley Veterans Hospital in Tampa, Florida, and my counterparts are assigned at either the Richmond Virginia, Minneapolis, Minnesota, or Palo Alto, California Centers.
    Although assigned to separate and distinct locations the four of us agree that this role is extremely valuable as it directly and positively impacts the successful seamless transition of our injured servicemembers and their families.
    In the initial establishment of this role the partnership and collaboration efforts between the Department of Defense, represented by the staff of the Office of the Surgeon General and the Department of Veterans' Affairs, represented by the staff of the VA Office Seamless Transition were very obvious to the four of us.  These two organizations spoke with one voice as they provided the necessary training to the four liaisons, and ensured that we understood that we were to:
    (1) manage and care for all active duty inpatient servicemembers regardless of branch of service or components, but those specifically assigned to the traumatic brain injury or spinal cord injury units of our specific facilities.
    (2) to care for the whole family, not just the servicemembers.
    In addition, OTSG and the Office of Seamless Transition ensured the development of a framework for success as I have termed it.  This framework involves the designation and utilization of VA employees to serve as an internal VA mentor and external program manager, through which the Polytrauma Liaisons could themselves have a smooth transition into the VA system and between the DOD/VA leaderships.
    Since arrival at the Tampa VA, I have been able to further develop and expand my role of Polytrauma Liaison Officer in the same atmosphere of collaboration in partnership with the VA leadership and subordinate staff, the servicemembers and their families, the interdisciplinary clinical staff, volunteer service organizations, regional and local agencies, and of course, the line leadership of the servicemembers' parent unit.
    Each of these groups represent sources through which key administrative, clinical or care management issues of the servicemember or family member can be resolved; and likewise, they represent the multifaceted functions I am involved in on a daily, weekly or monthly basis as this role continues to evolve, develop and mature.
    Over the past five weeks, I have been embraced as a key member of the Tampa VA's Leadership and Health Care Teams,allowing me to work closely with OEF, OIF Transition Teams and Committees, attend Haley House (equivalent to the Fisher House) committee meetings, gain access to patient database systems, attend selected nursing meetings; assist in facilitating Purple Heart award ceremonies and retirement ceremonies; and of course, facilitate resolutions for the military issues that impact the quality of life of the servicemember and family such as pay, travel, transportation, distribution of household goods, legal assistance and board actions.
    Clearly, this role has made difference.  As a green-suitor in the facility, I am the boots on the ground, real-time, real-life helper and voice for the servicemembers and their families.  I am their advocate and serve to remind others involved in their care, that the servicemembers volunteered to serve their nation, but this transition is unplanned and represents a psychological transition, which is over and above the physical trauma.
    In thirty years as a registered professional nurse, 24 years on active duty, this role has clearly been the most rewarding and fulfilling role of my career.  It is my honor to serve those servicemembers and their families.  So Mr. Chairman, this concludes my statement and I am happy to respond to any questions you or other Committee members may have.
    [The statement of Col. Fryer appears on p. 68]

    Mr. Bilirakis. Thank you very much, Col. Fryer. Col. Frank.

STATEMENT OF COL. TIMOTHY E. FRANK

    Col. Frank. Thank you, Mr. Chairman.
    Mr. Bilirakis. You'll have to pull that closer, I guess.
    Col. Frank. Can you hear me now, Mr. Chairman.
    Mr. Bilirakis. Yes.
    Col. Frank. Thank you, Mr. Chairman, Congressman Bradley, and distinguished members of the Subcommittee. I appreciate this opportunity to present to you today my perspective on how we can best support or wounded warriors and their families as they transition from military hospitals to VA Medical Centers, and for many ultimately from active duty to a veteran status.
    As I reflected on the issue of seamless transition, I drew from my 23 years of experience in both the active and reserve component, and my assignment as the Officer In-charge of Marine Casualty Services at the National Naval Medical Center, where our Marines and sailors are provided their acute casualty care.
    The Marine Corps remains highly focused on caring for our injured Marines and sailors, and ensuring that their family members are provided for and comforted in the wake of their injury.  Supporting injured Marines and their families is a complex task as their specific needs vary from case to case.  We do our best to tailor our support to fit their individual needs and those of their families, showing flexibility whenever and wherever possible.
    The Marine Corps continuously evaluates its processes and makes adjustments where necessary to ensure that the appropriate level of support is provided.  While we have encountered problems, we are actively collecting lessons learned and incorporating needed changes.
    I would like to make five key points.  First, thanks to significantly advanced medical capabilities the survival rate for our seriously wounded Marines and sailors has seen a dramatic increase.  They are, however, returning with severe debilitating injuries much more so than in past conflicts. The complexity of these injuries coupled with the individualized nature of recovery has required a more comprehensive, multidisciplinary program of casualty care.  As we support and care for these Marines and their families, we've learned from experience that we must remain flexible and be ready to adapt to an ever-changing situation. Secondly, Military Treatment Facilities are not resourced to provide the specialized care for our servicemembers who sustained spinal cord injuries, dramatic brain injuries, and loss of sight.  The VA is known for its integrated system of health care for these conditions.  Therefore, we rely on them to provide continued care and rehabilitation for our wounded Marines and sailors who have progressed from the acute care stage.
    The magnitude of these injuries and the lengthy rehabilitation and recovery periods involved have not only taxed the Military Treatment Facility, but the VA Health Care System as well.  Both military medicine and the VA will have to continue implementing new programs and initiatives as they strive to broaden coordination of care and family support.
    My third point is that quality casualty care requires extensive planning and coordination, which begins upon arrival at the MTF, through transition to the VA Medical Center, and continues even after discharge.  Over the course of time, a positive and very cooperative relationship has been forged between the Military Treatment Facility, the Marine Corps, and the VA, with significant progress made towards achieving a seamless continuum of care.  We are all working together and remain committed to keeping the treatment, recovering and transition of our injured servicemembers as our highest priority.
    My fourth point is that the Marine Corps realizes that the injuries our Marines and sailors receive would have a significant impact on them for the rest of their lives, and that they and their families will need support and assistance long after they left the Military Treatment Facility.
    The Marine for Life Injured Support Program provides continuity of support for our wounded as they continue with their recovery, make their transition to the Department of Veterans' Affairs and reconnect to their communities. Together with DOD's Military Severely Injured Joint Support Operations Center, Marine for Life Injured Support will bridge any gaps and provide around-the-clock advocacy and assistance.
    And finally, the recovery and successful transition of our wounded is not the responsibility of any single organization.  It is a partnership between the Department of Defense and the Department of Veterans' Affairs.  The assignment of two Marines at the VA Central Office was a collaborative decision between the Commandant of the Marine Corps and the Secretary of Veterans Affairs, and the Director of the Office of Seamless Transition.
    As one of those officers, I bring experience in casualty care and support, in addition to a background in both personal and family readiness, and hope to be a valuable asset to the dynamic, dedicated and professional seamless transition team under the direction of Mr. John Brown.
    In conclusion, I consider it a precious, a very precious privilege to serve the many brave Marines and sailors who have given so much in the service of our great nation.  I look forward to continuing this support from within the VA's Office of Seamless Transition.
    Mr. Chairman, I look forward to answering any questions you or the other Committee members might have.
    [The statement of Col. Frank appears on p. 77]

    Mr. Bilirakis. Thank you so very much, Col. Frank.
    Mr. Brown, please proceed, sir.  You have a big job.

STATEMENT OF JOHN BROWN

    Mr. Brown. Mr. Chairman and the members of the Subcommittee, I appreciate the opportunity to appear before you to discuss the VA's efforts towards affecting a seamless transition for separating servicemembers from the DOD to the VA.
    I retired from the U.S. Army in 2002 after 26 years of service.  I am proud and honored to serve as the Director of the Seamless Transition Office.  Mr. Chairman, the VA has no higher calling, no more important mission then to provide the best health care and benefits to our nation's combat veterans.  We will honor these heroes and their families by providing them with the compassion and the dignity that they have earned.
    In August of 2003, VA created the Task Force for the Seamless Transition of Returning Servicemembers.  This task force focused on the internal coordination efforts to ensure that VA approached the seamless transition mission in a comprehensive manner.  In January of this year, VA established a permanent Seamless Transition Office to assume the duties of the Task Force.  The Seamless Transition Office report to Deputy Under Secretary for Health.  It is composed of representatives from across the entire department.  It is a 1-VA endeavor.
    The Seamless Transition Task Force and the Seamless Transition Office have achieved many successes.  These include outreach and communications, trimming workload, data collection and staff education.  The VA has put into place a number of strategies, policies and programs to provide timely services to these returning servicemembers and veterans.  And throughout the process, we have greatly improved dialogue and collaboration between VA and DOD.
    Today, the VA is reaching out to all new combat veterans in unprecedented ways.  Since fiscal year 2002, we have spoken to more than 700,000 active-duty and National Guard reserve members in discharge planning and orientation sessions.
    Secretary Principi and Secretary Nicholson have sent more than 290,000 thank you letters with information brochures to OEF/OIF veteran identified by DOD as having left active duty.  We have prepared to videos, wallet cards, and web sites to ensure that they are all aware of their eligibility for VA health care.
    Each VA Health Center has identified a point of contact to coordinate activities locally, and to ensure that no person is left during or lost during transition.  VA has also assigned full-time social workers and benefit counselors to seven Military Treatment Facilities to facilitate immediate, comprehensive and compassionate care, and family support. VA social workers have coordinated more 2000 transfers of OEF/OIF servicemembers and veterans to VA Medical Facilities and BDA benefit counselors have interviewed almost 5000 OEF servicemembers hospitalized at Medical Treatment Facilities.
    To ensure that our commitment is understood and shared at every level of the Department, we have developed training materials and other tools for our frontline staff to assist them in identifying combat veterans so that they take the steps necessary to provide all veterans approach access to VA services and benefits.
    Although the Seamless Transition Initiative was created to support servicemembers who served in OEF/OIF, it is intended to become an enduring process.  Therefore, VA is working with DOD to obtain a list of servicemembers who enter the Physical Evaluation Board process.  The list will enable VA to contact the servicemembers and initiate benefit applications and transfer of health care to VA prior to discharge from the military.  VA is strengthening its support for the veterans and their families to accommodate them in Fisher houses and hotels as the veterans continue the rehabilitation process.
    Finally, the Seamless Transition Office will guide the VA's activities in meeting the expectations of our newest veterans and their families.
    Mr. Chairman, this concludes my statement.  I will be happy to respond to any questions that you or other members of the Committee might have.  Thank you.
    [The statement of Mr. Brown appears on p. 87]

    Mr. Bilirakis. Thank you very much, Mr. Brown.
    Ms. Boone.

STATEMENT OF LINDA BOONE

    Ms. Boone. Thank you.  The VA estimates approximately 250,000 veterans are homeless on any given night.  More than 500,000 experience homelessness over the course of a year.  Male veterans are twice as likely to become homeless as their non-veteran counterparts, and female veterans are four times as likely to become homeless as their non-veteran counterparts.  Like their non-veteran counterparts, veterans are at high risk of homelessness due to extremely low or no income, dismal living conditions and a lack of access to health care.
    In addition to these shared factors, a large number of at risk veterans live with post-traumatic stress disorders and addictions acquired during or aggravated by their military service.  In addition, their families and social networks are fractured due to lengthy periods away from their communities. These problems are directly traceable to their experience in the military service or to their return to civilian life without appropriate transitional supports.
    Take Sgt. Vanessa Turner.  She was deployed to Iraq and while serving in combat theater, she collapsed and fell into a coma and nearly died of heart failure.  She was evacuated to Europe and then to Walter Reed and release with a pending medical discharge.  That is the good part of Ms. Turner's story.  Ms. Turner was released from Walter Reed with neither a place to live nor ongoing health care in place. Without a home she and her daughter bounced from place to place.  When she went to the VA Medical Center she was told that she would have to wait three months to see a doctor.
    When she asked the Army to ship her possessions from her unit based in Germany, where she had lived, they told her that she had to fly back at her own expense to get them for herself.  When she sought help to secure a veteran's loan for a house in Boston, she was told that the only real option was to move to another part of the state.  Ms. Turner's situation was partially resolved only by the persistent intervention of a member of Congress.
    Regrettably, there are dozens of more Vanessa Turners returning from Iraq and Afghanistan without a place to call home.
    Though community-based Homeless Veterans Service Providers that National Coalition for Homeless Veterans represents, are reporting servicemembers from OEF and OIF among their service users.  Some of these newly homeless veterans are seriously injured.  Others are fighting PTSD and other emotional and addictive impairments.  Still others simply have been unable to find work.  Regardless of the cause is a country as wealthy as the United States with the best military personnel and veterans support systems in the world, it is simply outrageous that any servicemember or former servicemember becomes homeless.
    NCHV is generally supportive of the various Federal government wide joint service-specific initiatives underway to assist severely injured servicemembers and transitioning to civilian life.  We are interested in knowing, however, what these various initiatives are doing to support seriously injured servicemembers and their families facing a housing crisis.
    What housing counseling assistance does each initiative presently provide?  How are seriously injured servicemembers and eminent risk of homelessness assisted in securing permanent housing in the communities from which they will be returning?  Have any of the services succeeded in involving the Department of Housing and Urban Development in their efforts?
    What connections are these initiatives making with local public housing authorities or nonprofit housing providers? Is housing even on the radar of these various initiatives? As this Committee is well aware of information of resource sharing between DOD and VA, while improving in recent years, remains a challenge for the two Departments resulting in redundancy, inefficiency, higher costs and ultimately less than excellent health care for both our nation's servicemembers and veterans.
    In 2001, President Bush established the President's Task Force to Improve Health Care for Our Nation's Veterans and charged it to identify ways to improve health care delivery to DOD and VA beneficiaries.  The Task Force released its report in 2003.  Regrettably, DOD and VA have made slow progress on several of the Task Force's recommendations, including some that are directly applicable to the seamless health care transition.
    The servicemembers separating from the Armed Services have available to them to transition services programs.  Pre-separation Counseling and the Transition Assistance Program.  Former servicemembers with whom homeless veterans service providers are in daily contact report that pre-separation counseling and transition assistance programs are lacking any number of areas.
    Among their concerns is the depth and the content of pre-separation counseling is quite variable cross the delivery sites.  Pre-separation counseling may be limited to brief group level presentations rather than individualized transition planning.  Servicemember participation in the Transition Assistance Program is at the will of the unit commander and often allowed only during off-duty time. Neither program includes content on homelessness awareness or housing counseling assistance and referral.
    Weaknesses in both the content and delivery of the servicemember separation program results in many servicemembers failing to receive information necessary to ensure their stable health care and steady employment, and secure housing upon their return to civilian life.  This places servicemembers at risk of homelessness.
    In response to these concerns, Representative Andrews has introduced H.R. 2074, The Servicemembers Enhanced Transition Services Act, to improve transition assistance.  We urge this Committee members to cosponsor H.R. 2074 and ensure its enactment this session.  Thank you.
    [The statement of Ms. Boone appears on p. 100]


    Mr. Bilirakis. Thank you, Ms. Boone. The chair yields time to himself.  Col. Frank, Mr. Brown, Col. Fryer, if you wish, a response to Ms. Boone.  She asked an awful lot of questions she wanted answers to and I don't blame her.  So responses.
    Mr. Brown. Certainly.
    Mr. Bilirakis. Maybe I'm catching you by surprise here.
    Mr. Brown. Yes, sir, the testimony did, too.
    Mr. Bilirakis. Yes.
    Mr. Brown. But this is a very serious area that I think America has to look at.  I was unaware of all of the questions and concerns that are in your testimony.  I know we do have a homeless problem in America today.
    I would like to review your testimony, ma'am, and look at all of the questions that you have asked.  Then reply for the record, sir.
    Mr. Bilirakis. Yes.  In the process of your function as Director of Seamless Transition for the VA, homelessness is a part of that?  I mean, you know the concern for homelessness?  In other words, the follow-through thing that Colonel Frank explained so very well, and that I saw at Walter Reed which includes homelessness, not just health care and some of the other things.
    Mr. Brown. The entire process includes homelessness.
    Mr. Bilirakis. Mm-hmm.
    Mr. Brown. But what I have been charged to do within the first four months of my tenure is to build his office, to put people in them, and my first object was to not let anyone fall through the crack.
    Mr. Bilirakis. Yes, you've been there for four months?
    Mr. Brown. Yes, sir.
    Mr. Bilirakis. Oh, boy.
    Mr. Brown. In the position.
    Mr. Bilirakis. Yes.
    Mr. Brown. From 3 January.
    Mr. Bilirakis. Well, I said you have a tough job, but it's even tougher if you've only been there for four months.
    Mr. Brown. Yes, sir.  So the primary objective was to make sure that as I transitioned from the Task Force Initiatives, I use resources from the Task Force as I built the office.
    Mr. Bilirakis. Yes.
    Mr. Brown. And as I began -
    Mr. Bilirakis. Well, I'm glad that you're able to hear this testimony.
    Mr. Brown. Yes, sir.
    Mr. Bilirakis. So I guess that will be a factor in your building.
    Mr. Brown. I would like to look at your concerns, ma'am in detail.
    Mr. Bilirakis. Okay.  I know that Colonel Frank was looking at you with great earnestness in your comments. Go ahead ma'am.
    Col. Frank. I would just like to comment on the Transition Assistance Program.  I know that in the Marine Corps that's a mandatory program, and there is pre-separation counseling, and there is a transition assistance workshop, both of which are required for any servicemember who completes 180 days of continuous active duty.
    It was at one time a requirement for reserves who were mobilized.  However, that is now optional. Pre-separation counseling is still a requirement, and certainly a leadership responsibility to make sure that that happens.  For our mobilized Marines Transitional Assistance Workshop is to be made available to them should they want to take it.
    I used to do some personal and family readiness programs, and I think the Marine Corps -- I can speak for the Marine Corps only, has a very strong Transition Assistance Program.  She was correct in some -- it is group.  It's a group session.  However, there is a transition assistance program manager with a staff who at any time a Marine or anybody, a sailor attached to the Marine unit, seeks out specific transition assistance guidance and perhaps help with direction on developing a personal plan for their transition, there is someone there to help them.
    A lot of our Marines, unfortunately, think that the transition is going to be easier than it turned out to be.  I don't think that they look ahead.  But the resources and the support mechanism is in place for them to address those issues.
    The Marine Corps also has the Marine for Life program, which the Marine for Life Injured Support program has kind of piggybacked off of, and that is a transition program. General Jones Institute of that program specifically to give our Marines a better transition, and to ensure that those Marines who honorably wore the eagle, globe and anchor were able to meld back into their communities with jobs, with a reconnect to their community resources.  It covers almost, you know topic or subjects that you can imagine.
    So I feel like Marines Corps-wise, anyway, that we have good transition assistance programs in place.  Maybe a lot of it is -- there's more there than maybe the Marines are aware of, and again, that is something we can work to rectify.
    Mr. Bilirakis. Yes, what a great slogan, Marine for Life.  I know that every Marine considers themselves a Marine regardless, and I found that to be true at the veterans post and what not.
    Col. Frank. Right.
    Mr. Bilirakis. But I believe that the Corps seriously takes that it is dedicated to the slogan.  It's not just a slogan, it's something they live.
    Col. Frank. Absolutely.  It becomes ingrained into your heart from the moment you put on that eagle, globe and anchor.
    Mr. Bilirakis. Col. Fryer, do you want to add anything?
    Col. Fryer. Sir, I'm simply going to add that I did  what Col. Frank has said.  In fact, programs like that are set up for our servicemembers in the Army.
    Mr. Bilirakis. Yes.
    Col. Fryer. However, because the area of discussion is not in the area of my expertise, I will take it for the record.
    Mr. Bilirakis. Sure.  I know that you've just recently arrived in Tampa and what not.  There is a homeless problem down there.  I mean, I'm aware of that.
    Mr. Brown, do you care to comment?  You know, my emphasis of course, is the seamless transition.  But a major part of that, of course is this one physical, the one joint physical, if you will, that both DOD and VA agreed to.  Four out of approximately 140 military installations, for those have BDD in effect apparently, or something to that effect. Would you care to comment.
    Mr. Brown. Yes, sir.
    Mr. Bilirakis. You know, we're not here to throw, again stones at DOD as I said earlier.  They have a tough job, particularly these days.  There's no question about that.  But your job, you seem to be dedicated to it, but you need cooperation.  Are you getting adequate cooperation?  Comment please.
    Mr. Brown. Yes, sir.  I am not the expert on benefits delivery at discharge.  But I do believe it is a good program.  We do have 140 sites that are able to process our physicals.  We have 50 MOUs, 53 MOUs to date that have been signed between VA and DOD.  We have another 80 MOUs that are in the process of being signed.  They should be signed in the near future.
    Mr. Bilirakis. What does that mean, MOUs?
    Mr. Brown. MOUs is between VA and DOD facilities on who's going to actually perform -- 
    Mr. Bilirakis. The physicals and what not?
    Mr. Brown. -- the physicals at the facilities.
    Mr. Bilirakis. I see.  You have those signed, but they're not in effect yet?  In the real world, this is taking place in more than four facilities?  Out of 140, GAO targeted 20, looked at eight of them, and discovered that four out of the eight did not even know what BDD stood for.
    Mr. Brown. Yes, sir.  As I said, Sir, at my opening comments I am not the resident expert on this.
    Mr. Bilirakis. Yes.
    Mr. Brown. But generically I know exactly what has been done overall.
    Mr. Bilirakis. Yes, but see, you know that's very important of the seamless transition, is it not?
    Mr. Brown. Yes, sir.
    Mr. Bilirakis. As far as getting or applying for their benefits and all of that stuff.
    Mr. Brown. It supports the seamless transition process.
    Mr. Bilirakis. Yes.  Well, all right, we need your help in terms of getting these things done.  We'll be talking to the Armed Services Committee.  I guess that is what we still call them?  Isn't it still Armed Services?  Yes, we will be talking to the Armed Services Committee about this, and maybe meet with them and possibly have a joint hearing.  I don't know, but I have mentioned that to them before. I will yield to Mr. Sistek.
    Mr. Sistek. Thank you again, Mr. Chairman.  One very quick question for Ms. Boone.
    Focusing on recently separated or discharged servicemembers, why do they become homeless?  What are the root causes?  You've had experience with your organization since, basically 1990, what emerges as ``root cause'' of them becoming homeless recently after separating?
    Ms. Boone. For this current war's veterans we think it's sort of (1) is that they don't have information when they are leaving.  Their separation process is flawed. The pre-separation counseling process is flawed.  The TAP programs are flawed and in fact, they're not really being done.  Consistently across the board, TAP programs are not mandatory if several the Marines Corps.  The pre-separation counseling people can opt out of it.  The checkoff list that DOD uses lets people opt out of it, which was not the intent of the law.
    The other thing, the veterans that we have interacted with, our servicemen are community-based providers are working with, the majority of them are looking for employment, and that ends up being you know a very basic necessity in order to have housing, and to have all of the other things is you need income.  It's about economics and they need jobs.  They are coming to them because they don't have those transferable skills.
    Many of them also have issues around health, post-traumatic stress disorder, and we're starting to see substance abuse also as an issue.
    Mr. Sistek. Thank you, Ms. Boone.  No further questions.
    Mr. Bilirakis. All right, ladies and gentlemen, thank you so much.  There's so much more here.  We have an awful lot of questions and were going to submit them to you in writing.
    But I would ask you, you know, Col. Frank, for instance, in your written testimony you have talked about encountering problems in addressing the needs the Marines have in an effort to achieve seamless transition and whatnot.  So we're talking about experience that you are having with your Marines.  We need that information from you.
    I understand that you're collecting data and collecting lessons learned from them, and that sort of thing. This could be very helpful to us.  Hopefully, of course, you are working with Mr. Brown as far as those areas are concerned.  But that's really what we need.
    You know, there are problems out there and no matter what we do.  I mean, bigness usually connotates lack of perfection, so nothing is going to be perfect.  But we ought to be a little better, doing a lot better than we are doing. The BDD concept of the one physical that's agreed upon between the two, so that a person in the military who's about to be discharged, it's basically all of the paperwork -- the physical and all of the paperwork has all been taking care of before almost they are even discharged to start their benefits thing rolling.  The big back log that we now have would be cut down drastically and whatnot.  It makes sense to concentrate on areas like that, and that's why we raise these points.
    I know that bureaucracy and everything of that nature, heck, I've had 23 years of it.  It's horrible.  But, I guess what I am saying is that we can do better, and we should do better and you can help us.
    Mr. Brown. Yes, sir.
    Mr. Bilirakis. So please respond to the questions we submit to you.  But also don't hesitate to make any recommendations to us.  Share with us some of things that you are running into and whatnot, so we can do a better job. If there isn't anything further, will excuse you and declare this hearing over, and hope that we can see better things resulting from it.  Thank you very much.
    Col. Fryer. Thank you, Mr. Chairman.
    Col. Frank. Thank you, Mr. Chairman.
    Mr. Brown. Thank you, Mr. Chairman.
    Ms. Boone. Thank you, Mr. Chairman.

    [Whereupon at 11:35 a.m., the Subcommittee was adjourned.]


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