[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]
POLYTRAUMA CENTER CARE AND THE
TRAUMATIC BRAIN INJURY PATIENT: HOW
SEAMLESS IS THE TRANSITION BETWEEN THE
U.S. DEPARTMENTS OF VETERANS AFFAIRS
AND DEFENSE AND ARE NEEDS BEING MET?
=======================================================================
HEARING
before the
SUBCOMMITTEE ON HEALTH
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED TENTH CONGRESS
FIRST SESSION
__________
MARCH 15, 2007
__________
Serial No. 110-9
__________
Printed for the use of the Committee on Veterans' Affairs
U.S. GOVERNMENT PRINTING OFFICE
34-311 PDF WASHINGTON DC: 2007
---------------------------------------------------------------------
For sale by the Superintendent of Documents, U.S. Government Printing
Office Internet: bookstore.gpo.gov Phone: toll free (866)512-1800
DC area (202)512-1800 Fax: (202) 512-2250 Mail Stop SSOP,
Washington, DC 20402-0001
COMMITTEE ON VETERANS' AFFAIRS
BOB FILNER, California, Chairman
CORRINE BROWN, Florida STEVE BUYER, Indiana, Ranking
VIC SNYDER, Arkansas CLIFF STEARNS, Florida
MICHAEL H. MICHAUD, Maine JERRY MORAN, Kansas
STEPHANIE HERSETH, South Dakota RICHARD H. BAKER, Louisiana
HARRY E. MITCHELL, Arizona HENRY E. BROWN, Jr., South
JOHN J. HALL, New York Carolina
PHIL HARE, Illinois JEFF MILLER, Florida
MICHAEL F. DOYLE, Pennsylvania JOHN BOOZMAN, Arkansas
SHELLEY BERKLEY, Nevada GINNY BROWN-WAITE, Florida
JOHN T. SALAZAR, Colorado MICHAEL R. TURNER, Ohio
CIRO D. RODRIGUEZ, Texas BRIAN P. BILBRAY, California
JOE DONNELLY, Indiana DOUG LAMBORN, Colorado
JERRY McNERNEY, California GUS M. BILIRAKIS, Florida
ZACHARY T. SPACE, Ohio VERN BUCHANAN, Florida
TIMOTHY J. WALZ, Minnesota
Malcom A. Shorter, Staff Director
______
SUBCOMMITTEE ON HEALTH
MICHAEL H. MICHAUD, Maine, Chairman
CORRINE BROWN, Florida JEFF MILLER, Florida, Ranking
VIC SNYDER, Arkansas CLIFF STEARNS, Florida
PHIL HARE, Illinois JERRY MORAN, Kansas
MICHAEL F. DOYLE, Pennsylvania RICHARD H. BAKER, Louisiana
SHELLEY BERKLEY, Nevada HENRY E. BROWN, Jr., South
JOHN T. SALAZAR, Colorado Carolina
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
official version. Because electronic submissions are used to prepare
both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
__________
March 15, 2007
Page
Polytrauma Center Care and the Traumatic Brain Injury (TBI)
Patient: How Seamless is the Transition between the U.S.
Departments of Veterans Affairs (VA) and Defense (DoD) and Are
Needs Being Met?............................................... 1
OPENING STATEMENTS
Chairman Michael H. Michaud...................................... 1
Prepared statement of Chairman Michaud....................... 33
Hon. Jeff Miller, Ranking Republican Member, prepared statement
of............................................................. 33
Hon. Nancy Boyda................................................. 9
Hon. John Kline.................................................. 11
Prepared statement of Congressman Kline...................... 34
WITNESSES
U.S. Department of Veterans Affairs, Barbara Sigford, M.D.,
Ph.D., National Program Director, Physical Medicine and
Rehabilitation, Veterans Health Administration................. 2
Prepared statement of Dr. Sigford............................ 35
U.S. Department of Defense, Department of the Army, Colonel Mark
Bagg, Chief, Department of Orthopaedics and Rehabilitation,
Brooke Army Medical Center, Fort Sam Houston, TX, and Director,
Center for the Intrepid........................................ 22
Prepared statement of Col. Bagg.............................. 46
______
Blinded Veterans Association, Thomas Zampieri, Ph.D., Director of
Government Relations........................................... 29
Prepared statement of Dr. Zampieri........................... 58
Disabled American Veterans, Adrian M. Atizado, Assistant National
Legislative Director........................................... 28
Prepared statement of Mr. Atizado............................ 55
George, Karyn, MS, CRC, Service Delivery Manager, Military One
Source/Severely Injured Services............................... 24
Prepared statement of Ms. George............................. 50
Lakeview Healthcare Systems, Inc., Effingham Falls, NH, Tina M.
Trudel, Ph.D., President and Chief Operating Officer, and
Principal Investigator, Defense and Veterans Brain Injury
Center at Virginia NeuroCare................................... 18
Prepared statement of Dr. Trudel............................. 37
Paralyzed Veterans of America, Carl Blake, National Legislative
Director....................................................... 26
Prepared statement of Mr. Blake.............................. 53
SUBMISSIONS FOR THE RECORD
Acquired Brain Injury Diversification, MENTOR Network, Debra
Braunling-McMorrow, Vice President, statement.................. 63
American Veterans (AMVETS), Kimo S. Hollingsworth, National
Legislative Director, statement................................ 64
Brown, Hon. Corrine, a Representative in Congress from the State
of Florida, statement.......................................... 66
Gagnier, John and Cindy, Valparaiso, IN, statement............... 66
MATERIAL SUBMITTED FOR THE RECORD
Post-Hearing Questions and Responses for the Record:
Hon. Michael H. Michaud, Chairman, Subcommittee on Health, to
Barbara Sigford, M.D., Ph.D., National Program Director,
Physical Medicine and Rehabilitation, Veterans Health
Administration, U.S. Department of Veterans Affairs, letter
dated April 10, 2007....................................... 71
Hon. Michael H. Michaud, Chairman, Subcommittee on Health, to
Colonel Mark Bagg, Director, Center for the Intrepid, and
Chief, Orthopedics and Rehabilitation, Brooke Army Medical
Center, Fort Sam Houston, TX, letter dated April 10, 2007.. 77
POLYTRAUMA CENTER CARE AND THE
TRAUMATIC BRAIN INJURY PATIENT: HOW
SEAMLESS IS THE TRANSITION BETWEEN THE
U.S. DEPARTMENTS OF VETERANS AFFAIRS
AND DEFENSE AND ARE NEEDS BEING MET?
----------
THURSDAY, MARCH 15, 2007
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Health,
Washington, DC.
The Subcommittee met, pursuant to notice, at 2:20 p.m., in
Room 334, Cannon House Office Building, Hon. Michael H. Michaud
[Chairman of the Subcommittee] presiding.
Present: Representatives Michaud, Hare, Salazar, Miller.
Also Present: Boyda, Kline, Herseth.
OPENING STATEMENT OF CHAIRMAN MICHAUD
Mr. Michaud. I call this hearing to order. I apologize for
the lateness. We were over voting. We had to wait for the
appropriators to get there before we could close the vote, so I
apologize.
The Subcommittee on Health will be hearing from
distinguished individuals this afternoon. I would like to
welcome the Ranking Member, Congressman Miller of Florida, of
this Subcommittee. I look forward to working with him on this
very important issue, as well as Congressman Phil Hare.
In order to expedite the process, since we are running
behind, I would ask unanimous consent to have my opening
remarks submitted for the record. Hearing no objection, so
ordered.
I would now like to recognize Mr. Miller, the Ranking
Member of the Subcommittee on Health, for an opening statement.
[The prepared statement of Chairman Michaud appears on p.
33.]
Mr. Miller. Thank you very much, Mr. Chairman. In lieu of
time, I have an opening statement that I would like to submit
for the record, and I ask unanimous consent to add it directly.
[The prepared statement of Congressman Miller appears on p.
33.]
Mr. Michaud. Without objection, so ordered. Without
objection, any member who wishes to submit an opening statement
for the record may do so.
I also ask unanimous consent that all written statements be
made part of the record. Without objection, so ordered. And I
ask unanimous consent that all members will be allowed 5
legislative days to revise and extend their remarks. Without
objection, so ordered.
The first panel we have here today I would like to welcome
Dr. Barbara Sigford of the Department of Veterans Affairs and
accompanying her is Dr. Lucille Beck. We look forward to
hearing your testimony and to having a frank discussion about
meeting the needs of our veterans.
So without further ado, Doctor.
STATEMENT OF BARBARA SIGFORD, M.D., PH.D., NATIONAL PROGRAM
DIRECTOR, PHYSICAL MEDICINE AND REHABILI-
TATION, VETERANS HEALTH ADMINISTRATION, U.S. DEPART- MENT OF
VETERANS AFFAIRS; ACCOMPANIED BY LUCILLE BECK, M.D., CHIEF
CONSULTANT FOR REHABILITATION, AND DIRECTOR, AUDIOLOGY/SPEECH
PATHOLOGY, VA MEDICAL CENTER, VETERANS HEALTH ADMINISTRATION,
U.S. DEPARTMENT OF VETERANS AFFAIRS
Dr. Sigford. Thank you. Good afternoon, Mr. Chairman and
members of the Committee. I am Dr. Barbara Sigford. And I serve
as----
Mr. Michaud. Could you turn your microphone on, please?
Dr. Sigford. It is on. Oh, is that----
Mr. Michaud. Pull it closer.
Dr. Sigford. Okay. I feel like I am yelling. But clearly
you are having trouble hearing. Is that better?
Mr. Michaud. Yes.
Dr. Sigford. Okay. I am the VA's National Program Director
for Physical Medicine and Rehabilitation. And joining me this
afternoon is Dr. Lucille Beck, the VA's Chief Consultant for
Rehabilitation.
I really want to thank you for this opportunity to talk
about the Veterans Health Administration seamless transition
process from the perspective of the polytrauma system of care.
The mission of the polytrauma system of care is to provide
the highest quality of medical, rehabilitation, and support
services for veterans and active duty servicemembers injured in
the service to our country.
This is a system consisting of four Polytrauma
Rehabilitation Centers at Tampa, Richmond, Minneapolis, and
Palo Alto. And they provide the most acute intensive medical
and rehabilitation care for the complex and severe
polytraumatic injuries, including brain injury.
We also have 21 Polytrauma Rehabilitation Network Sites,
which manage the post-acute sequelae of polytrauma, and 76
Polytrauma Support Clinic Teams located at local medical
centers throughout the 21 networks and across the country that
provide care closer to home for the stable sequelae of
traumatic brain injury and polytrauma.
Our system of care has been designed to balance the need of
our combat injured for highly-specialized care and their needs
for local access to lifelong rehabilitation care.
Facilities in the Polytrauma System of Care are linked
through a telehealth network that provides state-of-the-art
multipoint videoconferencing capabilities. We are able to use
this to extend our access into our local communities, and to
provide more specialized care closer to home for our combat
injured.
Case management is also a critical function in our
Polytrauma System of Care, and it is designed to ensure the
lifelong coordination of services for patients with polytrauma
and traumatic brain injury. Every patient seen in one of our
polytrauma rehabilitation programs is assigned a case manager
who maintains the contact with the patient and the family in a
proactive manner to assess their ongoing needs and emerging
problems, and provide any necessary supports and arrange for
any necessary continued or new treatment.
We transition people through our system from the most
intensive regional facilities to the more local facilities
through warm handoffs from case manager to case manager. Each
case manager remains actively involved until the new team is
well versed in the care of that patient.
A critical area is the transition from DoD to VA, and our
severely injured veterans and servicemembers and their families
make transitions that are really unknown in the civilian
sector. They must transition across space, time, and systems,
and we have put many processes in place to make sure that
patients moving from DoD to VA receive their care at the
appropriate time and under optimal circumstances for their
safety and convenience.
In looking at their needs, I have identified three key
elements in providing this transition: the continuity of
medical care, psychosocial support for the patients and
families, and logistical supports such as transportation and
housing. And we have addressed all of these needs.
In terms of medical care, the PRC's receive their advanced
notice of potential admissions. After notification, they
initiate a pre-transfer review and follow the clinical progress
of the patient until transfer. Our PRC clinicians are able to
complete a pre-transfer review of the electronic medical
records at the medical treatment facilities by a remote access
capability and up-to-date information about the patent in the
progress notes, about medications, laboratory studies, results
of imaging are all available.
We also identify or access additional clinical information
through the Joint Patient Tracking Application, which allows us
to see the care these individuals received in Iraq and
Landstuhl, Germany.
And in addition to the medical record review, it is very
important that we have clinician-to-clinician conversation
about medical issues. And this is also in place. So we talk
physician to physician, nurse to nurse.
We have stationed a certified rehabilitation registered
nurse at Walter Reed who follows the ongoing clinical progress
and reports to our teams at our Polytrauma Rehabilitation
Centers. And she is available for up-to-date information. We
also have VA social workers at ten of the military treatment
facilities (MTFs) who are able to assist with medical records.
In terms of psychosocial support for transition, the needs
for psychosocial support include the psychological support,
education about rehabilitation and the next setting of care,
and information about benefits and military processes and
procedures.
The VA social workers at the ten MTFs are able to do this.
Our Certified Rehabilitation Registered Nurse (CRRN) provides a
lot of in-depth counseling and education to our families and
patients while they remain at Walter Reed. We also have
admission case managers at our Polytrauma Rehabilitation
Centers who make initial contacts with the patients and
families so they can meet the team. And we assess what they
will need when they reach our PRCs, so we can have those
arrangements in place.
We also have veterans benefits liaisons in the MTFs to
provide early briefings on the benefits for patients and
families.
Upon admission to the Psychosocial Resource Center (PRC),
our senior leadership meets with the families to assure that
their needs are being met, and we have support services in
place to help meet those needs. We have an Army liaison
officer, a uniformed officer, at each one of our PRCs who can
address ongoing military issues and concerns such as housing,
military pay, and the non-medical attendant orders.
In terms of logistical support, when we transition
individuals, we coordinate with our social workers to provide
the necessary transportation and housing. We have Fisher Houses
at two of our PRCs. And they will be planned and under
construction at the other two PRCs.
Overarching all of these efforts is the addition of a new
OIF/OEF program manager at our sites who will oversee the
coordination of care and services provided to all of our
veterans and families, and really assure that all of them
receive the case management and support that they need.
We can't neglect then the transition from the Polytrauma
Rehabilitation Center to the community. This is also very
important, and the needs of the patient at this transition
remain the same. Records for our medical care are readily
available through remote access across the VA system. In
addition, our transferring practitioners have personal
communication to support the electronic record. Followup
appointments are made prior to discharge. Again, our proactive
case management system assists with on-going support and
problem solving in the home community while continually
assessing for new and emerging problems.
In terms of logistical support, each of our Polytrauma
Rehabilitation Centers team members carefully assesses the
expected needs at discharge for transportation, equipment, home
modifications, and makes arrangements for those needs.
Finally, I would like to again recognize that the VA is
committed to providing the highest quality of services to the
men and women who have served in our country. It is important
to note that last week the President created an Interagency
Task Force on Returning Global War on Terror Heroes, which is
chaired by the Secretary of Veterans Affairs, and this
Committee will respond to the immediate needs of returning
Global War on Terror servicemembers. The Heroes Task Force will
work to identify and resolve any gaps in service for
servicemembers.
And as Secretary Nicholson has said, ``No task is more
important to VA than ensuring our heroes receive the best
possible care and services.''
The VHA's work is to provide a seamless transition for
high-quality medical, rehabilitation, and support services for
veterans and active-duty servicemembers injured in the service
of our Nation. We are helping to ensure that our heroes do
receive the best possible care.
This concludes my statement. And at this time, I would be
pleased to answer any questions that you may have.
[The prepared statement of Dr. Sigford appears on p. 35.]
Mr. Michaud. Thank you very much, Doctor. We really
appreciate it. At this time I would ask unanimous consent that
Ms. Herseth of South Dakota, Mr. Kline of Minnesota, and Ms.
Boyda of Kansas be invited to sit at the dais for the
Subcommittee hearing today.
Hearing no objections, so ordered.
Doctor, I have a couple of questions. There are concerns
that the VA may not have sufficient programs in place to
monitor the mental healthcare needs of veterans with TBI,
especially in rural areas. What steps is the VA taking to
monitor the mental health of veterans with TBI? And what
mechanisms are there to monitor the mental health status of a
TBI veteran after the veteran returns home, especially in rural
and underserved areas?
Dr. Sigford. That is an important question. And we have put
in place what we are calling our Polytrauma Support Clinic
Teams, which will be--which is the third step that I mentioned
in the Polytrauma System of Care. These teams have--it is an
interdisciplinary team of clinicians who are trained to assess
and monitor all the needs of the polytrauma patient, which
include mental health needs in addition to perhaps their
physical or cognitive needs.
As necessary these teams will be seeing these patients in
regular followup. That is our expectation that they will see
them on a regular and routine basis to meet their needs,
identify any mental health needs. And if they are unable to
manage the needs, then identify the appropriate resources,
which they would need.
Mr. Michaud. I saw a list of the new polytrauma centers
that are going to be established. Is that where the teams are
going to work out of, or are they going into the rural areas to
help as far as addressing the access issue for veterans in
rural areas?
Dr. Sigford. Well, they will operate out of--out of the
medical centers to which they are assigned. They will have at
their disposal certainly the option to go out to other rural
areas if that meets the needs or if the need is identified in
those rural areas.
They also have, as I mentioned, telehealth at their
disposal, which I think is going to be an incredibly useful
tool to meet those needs in the rural communities.
We also have all of our primary care professionals trained
to screen and identify problems due to TBI and ensure that an
individual is referred to the appropriate resources.
One of the areas I would like to stress is that this is an
area that requires specialized care, and we want to make sure
that people get the specialized care they need. We will be
doing that through these specialized teams. It is a team
effort.
Mr. Michaud. What concerns me are the options. If you look
at a veteran, in northern Maine, they have to go to the VA
Medical Center in Maine. Then they move to Boston where they
would have to travel about 9 or 10 hours to get there. So, the
concerns I have with rural areas is making sure that veterans
have access to the help that they deserve, locally and without
an unnecessary travel burden.
Can you also tell us about the Department's staffing
capacity to meet the range of needs of these veterans? You
know, physical, rehabilitative, and mental health? And how can
the VA best address these needs?
Dr. Sigford. Well, we actually have quite a long history of
meeting the needs of traumatic brain injury and rehabilitation
patients. As we began to admit individuals with polytrauma,
brain injury plus other injuries, we had a good deal of
experience and knowledge about what types of resources we
needed to do this. We have based our staffing plans on our
experience, and have been able to and are providing those
appropriate staffing ratios.
Mr. Michaud. Mr. Miller.
Mr. Miller. Thank you. The DoD uses ICD-9. Does the VA use
the same diagnostic code?
Dr. Sigford. Yes. They are used nationwide, civilian, DoD,
VA.
[The information from Dr. Sigford follows:]
ICD-9-CM is used for diagnostic coding in all healthcare settings
including the VA and DoD health systems. It is used universally for
morbidity statistics, reimbursement, reporting, and research. While
most familiar as diagnostic codes, ICD-9 is also used for inpatient
procedure coding (ICD-9-CM, Volume 3).
Mr. Miller. Civilians, though, are moving to ICD-10, I
guess, or 11, and my concern is ICD-9 has no actual TBI code.
We are finding this out in DoD, in particular, where there
could be four or five different diagnoses, any of which could
be TBI, but they are all called organic psychiatric disorders.
My concern is why would we continue to use that code? It is
obviously not an organic psychiatric disorder for TBI patients.
Are we looking at what needs to be done? Somebody told me it
may even be statutorily necessary to change the codes, can you
explain that?
Dr. Sigford. To my knowledge, there is no code for TBI in
the ICD-9, or the ICD-10, or the ICD-11. There are codes that
reflect traumatic brain injury, such as intracerebral
hemorrhage. Typically those occur--intracerebral hemorrhage due
to trauma. That would be one of the codes that would tell us it
is the traumatic brain injury.
[The information from Dr. Sigford follows:]
No date has been set for implementation of ICD-10-CM for disease
coding by the United States. Implementation of ICD-10-CM will be based
on the process for adoption of standards under the Health Insurance
Portability and Accountability Act of 1996. There will be a 2 year
implementation window once the final notice to implement has been
published in the Federal Register.
VHA has identified several problems with TBI coding in ICD-9-CM:
(1) there are no actual TBI codes in ICD-9-CM, TBI is described as open
or closed skull fracture or intracranial injury without skull fracture;
(2) cognitive and memory disorders associated with TBI are coded as
mental health problems rather than neurological disorders or symptoms
of brain injury; and (3) under ICD-9-CM coding guidelines, injuries are
not associated with each episode of care, making it difficult to
associate symptoms with TBI and to track the costs of TBI.
ICD-10-CM offers significant improvements over ICD-9-CM. There are
specific codes for TBI differentiated as diffuse or focal brain injury,
cerebral edema, laceration, contusion, and hemorrhage of the brain by
side of injury. ICD-10-CM makes other important changes in TBI coding
such as utilizing the Glasgow Coma Scale for coding TBI and a new
category for post-traumatic headache. There is a mechanism to associate
symptoms (sequelae) with TBI that will allow VHA and DoD to track TBI
care.
However, limitations continue to exist in ICD-10-CM. Cognitive and
memory problems associated with TBI are still mapped to mental health
conditions (personality and behavioral disorders due to known
physiological conditions).
VHA is working with the National Center for Health Statistics
(NCHS), which has responsibility for the maintenance of the ICD-9-CM
diagnostic codes, to correct deficiencies in TBI codes. Perhaps the
most important consideration--and the one to which Mr. Miller refers--
is the overlap of TBI and psychological health conditions. The VHA
proposal creates two new symptoms classes: cognitive symptoms
associated with TBI and emotion/behavioral symptoms associated with
TBI. Common TBI symptoms such as memory disturbances, cognitive
deficits, irritability, emotional lability, and impulsivity are
currently coded as mental health conditions. In the VHA proposal, these
symptoms will be coded as neurological conditions when they are
associated with TBI.
The VHA proposal provides diagnostic alternatives to coding TBI
symptoms as mental health problems. In the VHA proposal, clinicians
will select the correct diagnosis and will not use a mental health code
to describe a neurological condition associated with brain injury.
Mental health conditions will continue to be used for some diagnoses.
Clinicians will decide when appropriate condition should be classified
as a neurological diagnosis or an organic psychological condition.
Statutory changes are not necessary to modify ICD-9-CM.
Improvements in ICD-9-CM are made through the maintenance process
outlined below. The decision to implement ICD-10-CM is made by the
Secretary of the Department of Health and Human Services. Congress has
been actively involved in ICD-10-CM implementation. There have been
several hearings and several bills have been introduced in Congress to
mandate implementation. Once ICD-10-CM is implemented, known problems
such as coding some symptoms of TBI as mental health conditions can be
corrected through the code maintenance process. To the extent that it
is feasible, changes in ICD-9-CM are incorporated into ICD-10-CM.
Mr. Miller. Could I ask, to interrupt you, could you get an
intracerebral hemorrhage from something else?
Dr. Sigford. Well, part of the code is intracerebral
hemorrhage due to trauma. Yes, you could have an intracerebral
hemorrhage due to something else. But there are a series of
codes that do reflect different mechanisms of traumatic brain
injury.
One of the reasons there is no single diagnostic code for
traumatic brain injury is because there are multiple mechanisms
of traumatic brain injury and different severities. There are
also codes for concussion and post-concussion syndrome.
And, yes, we are interested in necessary changes to reflect
the appropriate code for brain injury. We are--we are very
interested in pursuing that.
Mr. Miller. How does that happen? Can you give the
Committee any information? Or if you want to take it for the
record and get it back to us.
Dr. Sigford. I would like to take that for the record. It
is a very complex process.
[The information from Dr. Sigford follows:]
Many symptoms associated with TBI are caused by other diseases. For
example, headaches, memory problems, cognitive impairments, and mood
changes can be due to many diseases. ICD-10-CM links these symptoms to
brain injury and enables TBI symptoms to be tracked during the entire
course of treatment. This is not possible under current ICD-9-CM coding
guidelines because injuries are not coded each time a provider treats a
patient with TBI.
VHA is working with NCHS to create a mechanism in ICD-9-CM similar
to the one in ICD-10-CM. The VHA proposal will allow providers to
associate TBI symptoms with neurological brain injury. For example, an
acute trauma-induced memory disturbance would be represented as a pair
of codes: one for acute manifestation of TBI and one for the memory
loss itself. This change duplicates the ICD-10-CM code process and will
enable VHA to track the costs of TBI care during the entire course of
treatment.
VHA is working jointly with DoD brain injury and coding experts on
a code proposal that will:
Revise TBI codes to distinguish between conditions
related TBI and mental health disorders
Revise concussion codes to identify TBI and severity
classification
Add a new code for acute physical or sensory
manifestations of TBI
Add new codes for cognitive, emotional, and behavioral
manifestations of TBI
Revise and expand codes for persistent or residual
effects of TBI
The new TBI codes will significantly improve diagnosis of TBI and
operationalize the VA/DoD TBI definition within the existing structure
of ICD-9-CM. Clinicians will be able to classify TBI by severity and to
identify physical, cognitive, and emotional/behavioral manifestations
of TBI. These improvements will allow DoD and VHA to provide better
healthcare to servicemembers and veterans and to identify, track, and
report TBI more accurately than is possible with current ICD-9-CM
diagnostic codes.
One of the most important benefits of the proposal will be the
coding of cognitive and emotional/behavioral symptoms of TBI without
resorting to mental health diagnoses. The code proposal addresses the
concerns raised by veterans, veterans groups, and Congress that
veterans with brain injuries receive mental health diagnoses that cause
unintended stigma and may restrict access to necessary healthcare
services.
Code Revision Process
1. Disease codes are revised at least annually by the NCHS ICD-9-
CM Coordination and Maintenance Committee. Responsibility for
maintenance of the ICD-9-CM is divided between the NCHS and Centers for
Medicare and Medicaid Services (CMS), with classification of diagnoses
managed by NCHS and procedures (Volume 3) managed by CMS.
2. Suggestions for modifications come from both the public and
private sectors. Interested parties submit recommendations for
modification prior to a scheduled meeting. These meetings are open to
the public; comments are encouraged both at the meetings and in
writing. Recommendations and comments are carefully reviewed and
evaluated before any final decisions are made. No decisions are made at
the meetings. The ICD-9-CM Coordination and Maintenance Committee's
role is advisory. All final decisions are made by the Director of NCHS
and the Administrator of CMS.
3. NCHS is currently reviewing VHA's code proposal. The proposal
will be presented at the March meeting of the ICD-9-CM Coordination and
Maintenance Committee and will be considered for implementation in the
October 1, 2008 update. The implementation process involves posting the
proposal and committee minutes for public comment, consulting with
interested parties, and preparing the necessary changes in the tabular
list, index, and official guidance. If the codes cannot be implemented
in time for the October update, NCHS has the option to implement the
codes in a mid-year (April 2009) update. To the extent feasible,
changes in ICD-9-CM will be reflected in ICD-10-CM. In other words, the
improvements VHA is proposing for ICD-9-CM will also improve ICD-10-CM.
NCHS web links:
http://www.cdc.gov/nchs/about/otheract/icd9/maint/maint.htm
http://www.cdc.gov/nchs/data/icd9/draft_i10guideln.pdf
ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Publications/ICD10CM/
2007/
Mr. Miller. A 2006 report from the VA Office of Inspector
General (IG), found that long-term case management needed some
improvement. The question is, have you addressed the long-term
case management vulnerability reported by the IG's office? If
so, how? Also, I want to know is home-based care provided or
made available to TBI patients after their discharge from a
Polytrauma Center?
Dr. Sigford. Sure. Now, in terms of the IG Report, you are
speaking of the report from July of 2006; is that correct?
Mr. Miller. Correct.
Dr. Sigford. We have done a tremendous amount to address
those concerns, which really reflect the evolution of our
process of case management from the time that those individuals
were initially contacted.
We do now have a very formalized system of case management
in place, where we have two social work case managers and a
nurse case manager assigned to 12 inpatients, a ratio of
approximately two social workers for every 12 inpatient
patients. We have a dedicated outpatient social work case
manager and nurse case manager in each one of our Polytrauma
Network Sites. And at our Polytrauma Support Clinic Teams,
there will be dedicated case managers.
In addition, we have developed handbooks and training
materials for our social work case managers. We are expecting
proactive followup that they don't just wait for someone to
develop a problem. They make the phone call and check routinely
on each of the patients who have been in our Polytrauma System
of Care.
Oh, I'm sorry, the home-based. Thank you. Certainly all of
our patients are eligible for the same home-based care as any
other veteran or active duty servicemember who is eligible for
care in the system. We can put those services out into the home
for them, such as homemaker home health, home-based primary
care. We can send physical and occupational therapists out to
the home as needed. So it is available.
Mr. Miller. Thank you. I see the red light.
Mr. Michaud. Thank you, Mr. Miller. I want to thank Mr.
Hare for yielding his time to Ms. Boyda of Kansas, who has to
go to the floor shortly, for questions. Thank you.
STATEMENT OF THE HONORABLE NANCY BOYDA, A REP-
RESENTATIVE IN CONGRESS FROM THE STATE OF KANSAS
Ms. Boyda. Thank you so much, Mr. Hare. Thank you. And
thank you for inviting me, Congressman Michaud, and thank you
for your leadership as the Chairman of this Subcommittee. You
are a true friend and ally to America's veterans. Thank you.
I come before you today because our Nation's troops face a
grave and growing crisis due to a startling inadequacy in our
military healthcare system. The problem has simmered quietly
for a decade. But now in the flames of the war of Iraq, it has
disrupted into a full boil.
America's military hospitals are rightly renowned for their
near miraculous ability to heal bleeding wounds and fractured
limbs. Our military doctors have helped thousands of soldiers
recover from injuries they endured in the service to our
Nation.
But our doctors and expertise, while far reaching, is not
boundless. For all their remarkable ability to repair physical
wounds, they lack the background and the tools to deal with
the--to heal the damaged mind.
Since the Iraq war began in 2003, almost 1,900 soldiers
have suffered a traumatic brain injury or TBI. Their symptoms
are pervasive and heartbreaking. Soldiers that were once
outgoing, active individuals, are now introverted and without
energy. Mothers and fathers no longer recognize their sons and
daughters, and wives and husbands no longer recognize their
spouses.
For these troops, things that you and I take for granted,
our personalities, our attentiveness, our vocabulary, are
ability to walk and talk and use the bathroom unassisted has
vanished in the blink of an eye, lost in the crash of a Humvee
or in the flash of an IED. The wave of traumatic brain injuries
in Iraq flooded a military healthcare system that was sadly ill
prepared to treat TBIs.
As the Department of Defense has scrambled to upgrade their
capabilities, they have frequently turned to civilian experts
on TBIs for guidance. In some instances, the DoD has even
permitted soldiers to receive care at a civilian hospital where
doctors have decades of experience in treating traumatic brain
injuries.
But according to some very disturbing reports, the Army has
rushed other brain injured soldiers into medical retirement,
effectively terminating their access to civilian care. When
these reports are considered in the light of the recently
uncovered and deplorable conditions at Walter Reed, a picture
emerges of a military healthcare system that is overburdened,
underfunded, and inadequate for our soldier's needs.
It breaks my heart to imagine that soldiers who gave so
much to their Nation, who in the case of a TBI sufferer
sacrificed the very clarity of their thoughts, would receive
anything less than world-class treatment.
The hour has come for Congressional action. And the
responsibility for reform begins in this Subcommittee. I ask
you to approach this crisis with open minds and leave no option
off the table.
Perhaps veterans and active duty soldiers could benefit
from easier access to civilian care. Perhaps the Department of
Defense can mount an aggressive push to develop expertise in
TBIs. Or, perhaps, the best approach is something else
entirely. Regardless, any plan of action must recognize the
demands placed on a soldier's family when his mind is
fundamentally altered by injury.
I do not claim that even conscientious legislative action
can cure every troop afflicted with TBI. But relieve every--or
relieve every burden that families face as they care for a
wounded soldier. But this Subcommittee can call the attention
of their plight and ensure that they benefit from the very best
that our Nation can offer. We owe nothing less to our brave
soldiers and to our families.
So thank you again for speaking out. This is an issue that
I hear about often in my district, as we have many veterans of
both--of Vietnam and certainly now of the Iraq OEF and OIF. So
thank you for your service.
I know that you are doing what you can to pull all the
resources together. And this is an urgent request to do
everything that we can. And you have my full support on that.
Thank you so much.
Mr. Michaud. I want to thank the Congresswoman for your
interest in this very important issue. I look forward to
working with you.
Ms. Boyda. Thank you.
Mr. Michaud. And your Subcommittee on Military Personnel as
well.
Ms. Boyda. Thank you so much.
Mr. Michaud. Now, I am pleased to recognize Mr. Kline who
is also on the Military Personnel Subcommittee.
STATEMENT OF THE HONORABLE JOHN KLINE, A REPRESENT-
ATIVE IN CONGRESS FROM THE STATE OF MINNESOTA
Mr. Kline. Thank you. My microphone doesn't work. I'll
move. Let me scoot over here. Technology whips us again.
Thank you very much, Mr. Chairman, for allowing me to join
you today, add my remarks to the gentle lady's. It is nice to
look at problems from a different perspective sometimes.
We, of course, have been spending a lot of time and energy
in the HASC Military Personnel Subcommittee. But it is clear
there is an overlap.
Let me ask unanimous consent to just enter some prepared
remarks in the record, if I could.
Mr. Michaud. Without objection, so ordered.
Mr. Kline. Thank you, Mr. Chairman.
And then say how delighted--this is so complicated up here.
Mr. Michaud. That is quite all right.
Mr. Kline. How delighted I am that you are here. As you
know, we have a Polytrauma Center in Minneapolis that we are
actually very proud of. I think they are doing some innovative
work and some very good work. And I know that you are very
familiar with that.
I would like to, though, address my concerns and questions
to an issue, which you discussed in your remarks as I was
entering the room. And that is this break in care. This lapse
in care, if you will, that is occurring way too often. We
struggle with it on the Armed Services side. The gentle lady,
Ms. Boyda, was talking about defense medical care. You are here
as part of the Veterans Administration. It is veterans' care.
But to our men and women who have been injured, whether
traumatic brain injury or any other injury, it really ought to
be much more seamless than it is.
I visited that VA hospital in Minneapolis, that Polytrauma
Center, a couple of years ago with the former Chairman of this
whole Committee, Mr. Buyer, and talked to Steven Kleinglass who
heads that hospital.
And while we were--while we were discussing this sometimes
breakdown in coverage, Mr. Buyer and I stepped aside to talk to
a wounded soldier and his wife. And it was very clear in this
conversation that they didn't understand what was going to
happen next and who was responsible for it. There were
questions like, ``Well, we are supposed to go back to Walter
Reed, but where do we get the orders?'' And, ``Who is going to
pay for it?''
And it seemed--it occurred to me and to Mr. Buyer that that
is the kind of question that should never be asked, should not
have to be asked by any wounded soldier, or their spouse, or
family member. It should be a seamless issue for them. It ought
to be taken care of.
You mentioned there was an active duty officer now, which
is an important step toward fixing that. But even with that
step, we have soldiers who are falling through the cracks.
We had a terrible tragedy in Minnesota with a Marine
Reservist who had been back from combat and committed suicide.
He had been identified to the VA hospital and to the system.
And it seems to me that that just shouldn't happen. There is a
breakdown in there.
I wondered if you could take--I don't know how much time is
left in the green and red light system, but could you talk a
little bit more? You mentioned you had some teams and so forth.
We really have got to do better to fix that. And it may be a
coming together of this Committee and the Armed Services
Committee to weld this together. But I would be interested if
you would just expand a little bit on what you see the Veterans
Administration--what you are doing to fix that gap so we don't
have any more soldiers, sailors, airmen or Marines fall through
that crack and drop out of our care.
Dr. Sigford. Well, what we are doing from the VA side, as I
mentioned in the opening remarks, is we are putting together a
system of care, so that as soon as we are aware of an
individual needing polytrauma or traumatic brain injury care,
they are assigned a case manager who tracks them through the
system.
Mr. Kline. Let me interrupt just a minute. How are you
first made aware of this? What makes you aware of this, the
patient arriving, communication from the Department of Defense?
How does that happen?
Dr. Sigford. It happens in multiple ways. First of all,
from notification from--for our various--and it happens
differently depending on the severity of the injury. For
someone who is very severely injured, we receive direct contact
from the medical treatment facility at which they are being
cared for.
They contact our VA and assign social workers who then
contact our social workers in our Polytrauma System of Care.
And we then make all of the appropriate and necessary
arrangements for that transfer.
For those patients who are not--who don't enter the system
directly from a military treatment facility, they may enter on
a referral from a CBHOC, or a Community Based Health Care
Organization (CBHCO), or their medical command, their Guard
command, their Reserve command, a friend, a buddy. We are
willing to accept referrals from wherever they come.
And we are doing a tremendous--we have actually assigned
all of our polytrauma network sites, the assignment of reaching
out to their local communities, their Guard, their Reserve, the
bases, the military commands, to let them know that we would
like to care for these individuals.
Mr. Kline. Thank you very much. And I see the inevitable
red light has popped up. So thank you, Mr. Chairman. I do yield
back.
[The prepared statement of Congressman Kline appears on p. 3
4.]
Mr. Michaud. Thank you very much, Mr. Kline.
Mr. Hare.
Mr. Hare. Mr. Kline, if you would like to take some of my
time, because I am interested in the seamless transition too.
And I know you had some additional questions. I have one
question. And then I would refer the balance of my time to you.
In terms of the shortage of healthcare professionals, from
your perspective, one of the issues faced by all
neurobehavioral and the community-integrated rehabilitation
programs, involves the national shortage of key providers such
as occupational therapists, physical therapists, speech
language pathologists, and other professionals. What steps is
the VA taking to recruit and retain key providers in these
areas?
Dr. Sigford. Well, we have--we have a number of mechanisms
for recruiting providers. The majority of our facilities in the
polytrauma system have academic affiliates. We serve as
training grounds for PTs, OTs, speech therapists, physicians.
And that is an incredible recruitment tool, because individuals
come and they work with these patients at the VAs. And they
want to continue that work.
This is--as a matter of fact, in Minneapolis, the VA is the
prime spot right now for training PTs in training. And so once
they are there and they see the care we provide and the
opportunities, they love to come and work for us. We also are
able to touch the professional societies, to bring in skilled
professionals, which has also been very useful. In terms of
retention, we provide--I think--first of all, we--well, we
provide really challenging and interesting work opportunities
for individuals, as well as the opportunity for ongoing
education, which is important to professionals that they not
just stagnate in, you know, doing one type of care. We really
do provide them a wonderful opportunity in which to work. And
we have great retention in this particular area.
Mr. Hare. Thank you, Doctor. I would like to yield the
balance of my time to Mr. Kline.
Mr. Kline. I thank the gentleman. And I realize that I have
got way too big an elephant here to chew in these little bites.
But continuing on the theme of this continuous coverage,
could you just take one piece of that? You mentioned the active
duty officer that is assigned. Could you talk about the role of
that person? And what that is doing to fill some of these gaps?
Help us understand that role a little bit better. I had high
hopes for it. I am not sure it is doing what I thought it was
going to do.
Dr. Sigford. Right. We do have active duty Army officers
right now assigned to each one of the four Polytrauma
Rehabilitation Centers. They are the experts in military policy
and procedure. And they are there to meet with the families on
a day-by-day, hour-by-hour basis to solve any--to help them
fill out the paperwork, understand the paperwork, understand
the medical boarding process, get through the medical boarding
process, provide them advice on the system. They are there.
Mr. Kline. Is this a workload that they can handle? I mean,
one officer at Minneapolis, I have no idea if that is enough in
order to do that. But it is obviously addressing the problem
that I described earlier of the family who was supposed to go
back to Walter Reed, and they don't know where the orders are
going to come from, and who is going to pay for it.
This officer trained or perhaps MOS in personnel and
administrative policies could help with that. Is the officer
enough, or do we need to do something about that? Do we need
statute, or money, or is that--is one officer--is it working
fine, and one officer is able to take care of those things?
Dr. Sigford. Currently our--currently given the current
workload, one officer is fine. And this officer is part of the
VA team. And really our VA teams are also very knowledgeable
about many of the military. And they have really learned about
many of the military processes and procedures. But at this
time, and we constantly monitor and assess, one officer is
sufficient.
Mr. Kline. Okay. Thank you. I just have one last comment. I
have been very excited about a concept that the Marine Corps
has taken up with the will--recently called the Wounded Warrior
Regiment with a Wounded Warrior Battalion on each coast. And
dedicated Marine Corps personnel to help follow through and see
that people don't fall through the cracks.
And I just think that we ought to be exploring all of these
avenues, the activity duty officer assigned to the trauma
center, our efforts on the part of the active duty military,
the services, the efforts that are underway by the National
Guard. We have a wonderful example in Minnesota.
We here in Congress, and this Committee, and in the Armed
Services Committee, we really do need to be open to these ideas
and supporting them in every way we can with probably
legislation and resources.
Thank you. I yield back.
Mr. Michaud. I thank the gentleman. And I agree. This is an
important issue, one that everyone in this room, and in your
Committee, and our Committee as well, feel strongly about.
And if we are going to get to the bottom of it and do the
best that we can to make sure our men and women in uniform and
those veterans are taken care of, we have to do it in a
comprehensive, bipartisan manner. And I look forward to working
with the gentleman as we move forward this Congress.
I would now like to recognize Congresswoman Herseth.
Ms. Herseth. Well, thank you, Mr. Chairman. I want to thank
you and the Ranking Member for holding this hearing, and for
the testimony provided today. I know that there were hearings
in the prior Congress as well to explore the care that our men
and women who are receiving traumatic brain injuries are
receiving.
I appreciate the line of questioning and the focus of this
Subcommittee hearing today on the seamless transition. I have a
few questions that I think are related to that, but also go to
the issue of a certain category of servicemember who, I think,
is falling through the cracks.
And so if you could just answer these questions, if you
have the information with you today, and if not, if you could
take them for the record and provide the information.
What is the average length of stay at any of the four
Polytrauma Regional Centers by a servicemember receiving care
for traumatic brain injury?
Dr. Sigford. I would have to take that for the record.
[The information from Dr. Sigford follows:]
The average length of stay at our four Polytrauma Rehabilitation
Centers for inpatient servicemembers injured at a foreign theater with
a brain injury from March 2003 through September 30, 2007 is 43 days.
Ms. Herseth. And does certain progress have to be made
within 90 days for a servicemember to continue getting the full
regiment of therapies?
Dr. Sigford. That is not part of our policy. No.
Ms. Herseth. Are you aware that--well, it may not be part
of the policies. Is it a practice, if certain progress has not
been made by a servicemember within 90 days, to--that the case
management has tried to move an individual to a long-term care
department within a medical center or to another long-term care
facility within the VA?
Dr. Sigford. Let me have you rephrase that question.
Ms. Herseth. Your response to my first question is that it
is not a policy----
Dr. Sigford. Right.
Ms. Herseth [continuing]. Of the system of care to move
anyone to a long-term care department or other facility if
certain progress isn't made in 90 days. And so I will just
rephrase the question simply. I understand your response is
that it is not a policy. Are you aware of whether or not it has
been a practice in any of the four regional facilities?
Dr. Sigford. Our clinicians provide services based on what
an individual can tolerate and what they seem to be responding
to. And I--these are individual decisions made by the
individual clinicians and practitioners.
I am not aware that there is an automatic rule for staying
at a certain number of days or that people are operating under
those--you know, a certain number of days and you must go to
long-term care.
But they are using their clinical judgment, you know, day
in and day out to provide the appropriate or the right types of
care for the individual.
Ms. Herseth. And are you aware of--what is the percentage
of individuals transferred to long-term care facilities of
those that have received care at the Polytrauma Centers for
traumatic brain injuries since Operation Enduring Freedom and
Operation Iraqi Freedom?
Dr. Sigford. I would like to take that for the record as
well.
[The information from Dr. Sigford follows:]
According to the VA's national database for inpatient
rehabilitation, ten (10), or 2.2%, active duty servicemembers have been
discharged from a Polytrauma Rehabilitation Center (PRC) to a Long Term
Care (LTC) Facility between March 2003 and September 2007. This data
does not account for patients who may have subsequently transferred to
a LTC facility following initial discharge to an interim setting from a
PRC, or for those who later transferred to LTC from a less restrictive
care setting.
Ms. Herseth. And do you know the number that have been
transferred to private facilities ultimately?
Dr. Sigford. I will take that for the record and see.
[The information from Dr. Sigford follows:]
The four Polytrauma Rehabilitation Centers report that between
March 2003 and September 2007, 24 active-duty servicemembers have been
discharged to a private treatment facility.
Ms. Herseth. The reason I pose these questions is I do
think it relates to an issue of seamless transition. I have a
constituent who now is receiving care at a private facility.
And the sense from his family is that the Polytrauma Center in
Minneapolis had given up on him, because certain progress had
not been made by a certain period of time.
There was an effort by the case manager to--and they had to
go through a couple of different caseworkers to feel
comfortable that that person was actually serving as an
advocate for them rather than an advocate for the facility, or
for the DoD, or for the VA. It was very confusing to the
family.
And we intervened to stop the medical retirement process,
because for the full regiment of therapies to continue, they
can't be medically retired for TRICARE to cover the cognitive
therapy.
So he was transferred to Casa Colina in Pomona, California.
You may be familiar with that facility. And he has made
tremendous progress since.
And could you, perhaps, explain if you have tracked any of
the individuals that have been transferred to private
facilities, how you might explain their progress at these
private facilities that they were not experiencing within the
Polytrauma System of Care at the VA?
Dr. Sigford. Yes. I can't, obviously, comment on specific
patients or patient care. But I think that really a critical
point for people to understand is that when these patients are
transferred to Polytrauma Rehabilitation Centers, they still
have multiple medical problems, they are still recovering, and
this period takes a--this takes a significant period of time.
What we know physiologically from brain recovery, is that
there is--there is this lengthy period, particularly for the
severely injured, for the brain to recover sufficiently to
really get, you know, the most benefit out of rehabilitation.
And that may not be in the first 2 weeks, or the first month,
or maybe even sometimes the first 6 months before, you know,
people can remain so medically fragile that rehabilitation is
beyond them.
So there is a period, and oftentimes it happens in the
Polytrauma Rehabilitation Centers, where we are maximizing the
recovery of the brain to allow that progress to take place
later.
Ms. Herseth. I know my time is up. May I follow up with one
more question? If you could take this for the record, I would
appreciate your explanation.
My concern is that if there has been an effort, whether
because there are funding battles going on between DoD and VA
and there is a problem with this seamless transition, that
certain individuals who have been transferred to long-term care
departments or facilities within the VA never get the
aggressive therapy again after they reach the point in time
that you just described, where the brain is more fully
recovered and that they would actually be responding to a
greater degree to that regiment of therapy. Because they are
not getting it at a long-term care facility.
If Cory had been transferred to a different floor at the
medical center, he would have gotten up to an hour, 1 hour, of
physical therapy a day. No occupational therapy, no cognitive
therapy, and I am just concerned that there is something going
on in practice, perhaps not in policy, that we have a subset of
individuals who have fallen through the cracks who have far
greater potential. But they are not getting it, if they were
medically retired too early and for whatever reason aren't at
the point in time that they would respond more positively
getting that type of therapy.
So, again, thank you and if you had a further response to
that point that I made, I would appreciate hearing from you.
Dr. Sigford. Yes. As I said, I am unable to discuss
specific patients here.
Ms. Herseth. I understand you can't discuss specific cases.
However, in your explanation for why some are responding better
in private facilities, I think your explanation is primarily
that there is a time involved where had they stayed within the
Polytrauma System of Care in the VA, they eventually would have
made the same progress in your system.
Dr. Sigford. Mm-hmm.
Ms. Herseth. And my question back to that response is I
need to know then how many have been--how many didn't make it
to that certain level of progress, that have stayed in your
system, and whether or not they are making the kind of
progress, especially those that may have been transferred to
long-term care facilities?
Dr. Sigford. Now, those that stay within our system of
care, within our Polytrauma System of Care, they are monitored.
And they are brought back to the Polytrauma Rehabilitation
Centers at a point when they become more responsive and more
ready for that care.
Ms. Herseth. Perhaps you could provide those numbers then
more generally in terms of how many have returned and what
their progress has been once they do return.
Dr. Sigford. There are few--very few----
Ms. Herseth. Thank you.
Dr. Sigford [continuing]. That fall into that category.
Ms. Herseth. Thank you. Thank you, Mr. Chairman.
[The information from Dr. Sigford follows:]
Of the 10 active duty servicemembers who have been discharged from
a Polytrauma Rehabilitation Center (PRC) to a Long Term Care (LTC)
Facility between March 2003 and September 2007, 70% (7) of the cases
have been followed up for further services. The 3 cases that were not
followed were admitted early in the development of the Polytrauma
System of Care prior to initiation of the intensive case management
system now in place. All sites currently have a case manager who is
responsible for following all discharged cases for further services. Of
those seven who have been followed, one has expired, two cases were re-
admitted to the PRC, and the remaining cases continue to be monitored
at their geographically proximal Polytrauma Network Site/Polytrauma
Support Clinic Team locations for further services.
Mr. Michaud. Yes. Would you provide the actual numbers?
What might be considered very few to you might not be very few
to us. So if you could provide the numbers.
And I want to thank both of you for being here today. And
we will be submitting additional questions for the record to be
addressed. And just to give you an idea of where some of the
questions are coming from, the Presidential Task Force went to
great length, spent a lot of time, on the issue of seamless
transition. They did their report back in 2003.
And they made several recommendations. So a lot of the
questions that will be asked in writing will relate to what you
have done so far on each one of those recommendations.
So once again, I want to thank you very much for coming
this afternoon.
Dr. Sigford. Thank you.
Mr. Michaud. Okay. While they are setting up the table for
the next panel, the panelists are Tina Trudel, who is President
of the Lakeview Healthcare Systems, Inc.; Colonel Mark Bagg,
Director of the Center for Intrepid; Karyn George, who serves
as Delivery Manager, Military One Source/Severely Injured
Services; Mr. Carl Blake, who is the National Legislative
Director of Paralyzed Veterans of America; Mr. Adrian Atizado,
who is Assistant National Legislative Director for Disabled
American Veterans; and Mr. Tom Zampieri, who is the Legislative
Director for the Blinded Veterans Association.
So we want to thank you all for coming here this afternoon.
And we look forward to hearing your testimony. Once again, I
want to thank our group of panelists for coming today. And we
will start off with Tina Trudel.
STATEMENTS OF TINA M. TRUDEL, PH.D., PRESIDENT AND CHIEF
OPERATING OFFICER, LAKEVIEW HEALTHCARE SYSTEMS, INC., EFFINGHAM
FALLS, NH, AND PRINCIPAL INVESTIGATOR, DEFENSE AND VETERANS
BRAIN INJURY CENTER AT VIRGINIA NEUROCARE; COLONEL MARK BAGG,
CHIEF, DEPARTMENT OF ORTHOPAEDICS AND REHABILITATION, BROOKE
ARMY MEDICAL CENTER, FORT SAM HOUSTON, TX, AND DIRECTOR, CENTER
FOR THE INTREPID, DEPARTMENT OF THE ARMY, U.S. DEPARTMENT OF
DEFENSE; KARYN GEORGE, MS, CRC, SERVICE DELIVERY MANAGER,
MILITARY ONE SOURCE/SEVERELY INJURED SERVICES; CARL BLAKE,
NATIONAL LEGISLATIVE DIRECTOR, PARALYZED VETERANS OF AMERICA;
ADRIAN M. ATIZADO, ASSISTANT NATIONAL LEGISLATIVE DIRECTOR,
DISABLED AMERICAN VETERANS; AND THOMAS ZAMPIERI, PH.D.,
DIRECTOR OF GOVERNMENT RELATIONS, BLINDED VETERANS ASSOCIATION
STATEMENT OF TINA M. TRUDEL, PH.D.
Dr. Trudel. I am Tina Trudel. Thank you members of the
Committee on Veterans Affairs. I want to thank you for allowing
me the opportunity to participate as a private citizen.
As you are aware, I presently serve as Chief Operating
Officer of Lakeview Healthcare Systems, a national provider of
brain injury services from hospital to home. I also serve as
Principal Investigator of the Defense and Veterans Brain Injury
Center at Virginia NeuroCare, and have been in the field of
brain injury for the past 20 years.
Brain injury is a major health problem. Those with
traumatic brain injury are adversely impacted by the chronic
lack of funding and underdeveloped infrastructure in comparison
to other diagnostic and disability groups.
While blast injury and combat-related TBI are now in focus,
it is important to remember that military service runs a risk
of TBI even in peacetime. With thousands of military personnel
injured annually due to motor vehicle crashes, falls, training
mishaps, other causes, the VA has a history of collaborating
with private sector providers. I think some of that was alluded
to by previous speakers. And often that collaboration is for
some of the most difficult to treat.
A few veterans I am personally familiar with include a
Marine who was injured in a fight. He has been receiving
services through Lakeview since 1993. He had severe cognitive
and behavioral challenges, including a history of significant
self injury. He had been medically observed in VA settings, but
they were not able to successfully implement an effective
treatment plan.
Within our organization, he received intensive
neurobehavioral treatment, one-on-one supports, assistive
devices, skills training, and very successful collaboration
with the VA for surgical repair of his self injury once his
symptoms were under control. He now is able to reside in a
community-supported living setting as a volunteer in his
community and being able to visit his family.
I have also worked with a sailor who was injured in a
motorcycle crash who has received services since 2004 through
our organization. He had cognitive and behavioral problems,
including aggressive outbursts. Additionally, he is blind with
partial hearing loss. He was transferred among VA hospital
sites due to his assaultiveness, including assaulting nurses.
In our care setting, he is receiving intensive
neurobehavioral treatment and adaptive living skill training
and is now transitioning to a community-assisted living
setting.
A soldier recently was admitted to Lakeview who sustained a
brain injury after a fall from a barracks balcony with a skull
fracture and a frontal lobe injury that significantly impacted
his thinking and mood. He was deployed to Iraq approximately 6
months after the fall with complaints of headaches and evolving
poor task performance. He was declared insubordinate, and
charged with dereliction of duties, and then was sent on leave
where he ended up in a civilian psychiatric hospital that
diagnosed him with mood disorder and TBI. He was treated at
sites including Walter Reed and a VA Polytrauma Center, but was
unable to manage when he returned to home. His family advocated
for the opportunity for treatment in the private sector. He is
presently at Lakeview and was approved for 1 month of
rehabilitation.
That particular Lakeview program he is at is a contractor
with the Maine Medicaid program. So if he were one of Chairman
Michaud's civilian constituents, he would have been approved
for 6 months of care and probably would have had some
additional services available for transition. Also that would
be true if someone with a similar profile were to present to
our organization through most workers' compensation type
organizations and were injured on the job.
At Monday's roundtable discussion, Dr. Jean Langlois of the
CDC estimated 75,000 to 150,000 new brain injuries from the
current war. While many of these will be mild in nature and
have positive outcomes, some will need services beyond the
typical VA medical-focused infrastructure through models of
post-acute care that allow for further treatment after
hospital-level rehabilitation.
Such services in the private sector include neurobehavioral
programs, residential rehabilitation, day programs, and home-
based or outpatient services. While the VA provides some of
these, there are gaps in their service system, particularly in
more rural areas.
Research findings support that these models of care improve
outcome, even for people who are months to years post injury,
and especially for those who have the more severe injuries.
These programs also reduce neurobehavioral problems, and,
therefore, lower the risk for institutionalization, criminal
justice contact, and substance abuse.
Lakeview's brain injury model has included neurobehavioral,
residential, and community-integrated programs. We found it is
very successful to focus on a person-centered inclusionary
model that encourages the active participation of those with
brain injury and their families in all aspects of treatment.
At times in larger systems such as the VA, those can be
difficult things to accomplish. Program interventions
facilitate reintegration through enhancing functional life
skills, developing compensatory strategies, better self esteem
and self control, vocational rehabilitation and supports for
the family.
Along with licensed professionals, our program and many in
the private sector, use therapy extenders and life coaches who
actually deliver the services in real environments. This is
very helpful and goes along with discharge planning to ensure
success, because many people with brain injury cannot
generalize from something they have learned in a clinic, an
office, or a hospital to a real world environment. Therefore,
good treatment often has to occur within the context of the
real-world environment.
Lakeview has and continues to serve veterans. However, that
opportunity seems to arise only after the veteran has
experienced a time of treatment failures and often some
behavioral or functional deterioration.
We are also very pleased to be involved with the Virginia
Neurocare Defense and Veterans Brain Injury Center program.
That program has a dual effort including community-based
treatment of military personnel, while also advancing brain
injury rehabilitation through education and research, as well
as applied technology.
Our military participants are usually several months post
injury and no longer require acute medical intervention. They
present with complex cognitive, behavioral, and functional
living problems, often with some physical disability.
Depression, PTSD, substance abuse, fatigue, and stress are
common complications.
Through that program, we are developing educational and
therapy models that will be available for research and
dissemination to facilitate these services being enhanced and
spread in other settings. We are also working in collaboration
with the University of Virginia and applied for a number of
grants and assistive technology, including driver evaluation
and rehabilitation using simulators and web-based resources.
Additionally, through the Defense and Veterans Brain Injury
Center, we are advancing the use of portable wireless devices,
including a GPS technology project to allow people to access
the community without being lost or confused.
Neurobehavioral treatment and community-integrated
rehabilitation services are very much a challenge within the VA
system. Many survivors need a therapeutic approach that allows
for gradual, extended treatment and the possibility of long-
term supported living. Living in non-institutional
environments, and close to their home and family.
This treatment is not provided through a medical model but,
instead, is achieved through a model that targets functioning
on home and community settings. Such programs rely minimally on
physicians and heavily on allied health, behavioral health,
direct support staff, extenders, life coaches, a variety of
personnel, as was mentioned previously, that are often
difficult to recruit and retain with some national shortages.
It is a positive thing to note that there has been
evolution of some parts of this treatment model within the VA
Polytrauma Centers. And at the roundtable discussion, part of
the brain injury awareness events on Monday, it was reported
that four such programs are being implemented through the VA
Polytrauma Centers.
Private neurobehavioral and community-based programs are
available across the country. Some are funded through various
means with Medicaid plans, waivers, and so forth. The VA would
be wise to utilize some of these existing systems and to
utilize resources such as the Brain Injury Association of
America and the National Association of State Head Injury
Administrators, both of which are non-profit organizations that
have strong nationwide networks of brain injury service
knowledge to access resources.
Also, it would be helpful to mobilize the physician
education resources through such means as the CDC TBI toolkit.
It is a very solid tool, well developed, and really needs to be
out there as much as possible, as many National Guard members
are seeing community physicians who may not have the same
knowledge base and really need information on TBI.
As I mentioned before, there is a shortage of some of the
allied health providers, particularly those in the OT, PT,
speech professions, neuropsychology, behavior analysis, who are
actually trained in brain injury rehabilitation and understand
post-acute community environments and neurobehavioral care.
I know from my own experience that private sector providers
are increasing salaries and bonuses to compete with lucrative
practice opportunities in many states. The VA system, while
being one of exceptional training with many resources, will
continue to have to recruit and retain in this environment of a
qualified workforce shortage and rising demand.
Additionally, if the VA were truly to recruit everybody
that they would need to provide services that are needed
throughout the country, even in more rural areas, the supply
and demand problem would devastate the ability for the other
pieces of the healthcare system who are reliant on these same
personnel. We would then be running duplicate systems in some
of these more rural environments, where there is not a
population density to fully require services from both the
private and the VA system.
These population concentrations are quite a challenge. And
the VA clearly does the best job in developing regional TBI
teams, which take time and effort to successfully implement.
But it is not pragmatical for the VA in isolation to provide
these types of services, especially in more rural areas.
Optimal services should be as close to home, community, and
family as possible.
There is significant benefit in blending the resources of
regional VA services with private contractor services where
available and needed, as well as to encourage consultation with
experienced civilian providers so that a well-managed continuum
of TBI services is available to all veterans close to home.
Lastly, the scope and complexity of TBI in the military and
veterans community was recognized, years ago, and the Defense
and Veterans Brain Injury Center was established in the early
1990s. Their role as coordinator of research, clinical, and
educational development across the military and VA systems is
critical. Without unified data, projects, and tracking across
all branches of the military and VA, opportunities for research
to advance brain injury rehabilitation, dissemination of best
practices, and optimal service delivery to our men and women in
uniform are lost, along with the translation of these advances
to the civilian population.
I want to thank you, thank our men and women in uniform,
and for all of you to know that I am only one of many in the
civilian TBI community who are ready, willing, and able to help
our veterans. Thank you.
[The prepared statement of Dr. Trudel appears on p. 37.]
Mr. Michaud. Thank you very much, Doctor.
Colonel Bagg.
STATEMENT OF COLONEL MARK BAGG
Colonel Bagg. Thank you, Mr. Chairman, Mr. Miller, and
distinguished members of the Subcommittee. I am Colonel Mark
Bagg, the Chief of the Department of Orthopaedics and
Rehabilitation at Brooke Army Medical Center in San Antonio,
Texas, and also the Director of the new Center for the Intrepid
(CFI).
Thank you for inviting me here to testify before you to
explain our mission of the Center and our vision for providing
the absolute best outpatient rehabilitative care for our
wounded warriors and America's veterans.
The mission of the Center for the Intrepid is to provide
the highest quality of comprehensive outpatient rehabilitation
for wounded warriors and veterans and to conduct leading edge
research and continuing medical education in the field of
prosthetics and rehabilitation.
Advanced rehabilitative services will be provided
specifically to amputees and to those who sustain functional
limb loss as a result of severe open fractures, soft tissue
injuries, and burns.
Wounded warriors treated at the CFI are each assigned a
full-time case manager. These professionals work closely with
patients, families, and the staff to coordinate a customized
plan of care, guide them through the medical evaluation board
process, and facilitate a seamless transition of care from the
DoD to the VA healthcare system.
Our occupational therapy section focuses on restoring
health and function. Treatment activities are designed so that
patients can successfully perform all activities of daily
living.
To accomplish all of these tasks, we have a fully equipped
apartment where patients work with a therapist in a real world
living environment. Also available for use are two simulation
systems, a firearm simulator and a driver simulator.
The occupational therapy staff is responsible for our very
important community reintegration program. Our physical therapy
section provides the full spectrum of physical therapy
modalities. In addition, patients are challenged by a 21-foot
climbing tower and a six-lane swimming pool. Adjacent to the
pool, is an indoor surfing activity called the FlowRider, which
we believe will improve balance, strength, coordination, and
confidence.
PTs are also responsible for coordinating the adaptive
sports program, which includes a running program, volleyball,
swimming, scuba diving, kayaking, and basketball. And through
the volunteer support of a variety of charitable organizations,
patients have been offered the opportunity to snow and water
ski, fence, shoot, ride horses, golf, and participate in a
variety of other sporting events.
Our behavioral health section provides comprehensive mental
health support while patients are undergoing their demanding
physical rehabilitation.
Our prosthetic section utilizes standard production methods
augmented by computer-assisted technology for designing,
milling, and producing state-of-the-art prostheses on site.
We also have a military performance lab, which seeks to
analyze human motion. It is comprised of two functional areas,
the gait lab and a computer-assisted rehabilitation
environment, otherwise known as a CAREN system. This is a
three-dimensional rehabilitation simulator, which is the first
of its kind in the world. It allows patients to be immersed in
a whole host of virtual reality scenes. This lab will be
central to the research mission of the Center for the Intrepid.
The CFI is staffed by 49 personnel, including active duty
Army, GS civilians, contract providers, and nine full-time VA
healthcare professionals, all working side by side to maximize
patients' rehabilitative potential, ease the transition between
the DoD and the VA healthcare systems, and facilitate
reintegration back into society.
Over 600,000 Americans contributed to the fund, which
established this Center. Their generosity expresses the
profound appreciation America has for its gallant servicemen
and women who defend freedom.
This Center is dedicated to our severely wounded military
heroes whose selfless sacrifice entitle them to the best
rehabilitative care our Nation has to offer.
In closing, let me again express my sincere appreciation to
the Congress, to the Intrepid Fallen Heroes Fund, and to all
American citizens who have made this Center for the Intrepid
possible.
The Congress' strong support allows us to continue
providing world class rehabilitation for those who sustain
these very severe traumatic injuries.
The generosity of the Intrepid Fallen Heroes Fund allows us
to continue to build on our successes in an absolutely
incredible rehabilitation center. If you have not had the
chance to visit the Center for the Intrepid or Brooke Army
Medical Center, I invite you to do so.
Mr. Chairman, thank you very much for the opportunity to be
here today. And I look forward to answering your questions.
[The prepared statement of Col. Bagg appears on p. 46.]
Mr. Michaud. Thank you very much, Colonel, for your
testimony and thank you for serving our country as well. We
appreciate it.
Ms. George.
STATEMENT OF KARYN GEORGE, MS, CRC
Ms. George. Good afternoon, Mr. Chairman, and members of
the Committee. My name is Karyn George, and I am honored to be
here.
Before I begin, I need to clearly state that my testimony
is based on my personal views and does not represent the views
of the Department of Defense or the Administration. I am a
contract employee of the Department of Defense, and, therefore,
I am a private citizen. I appear before you in that capacity
today. My statements and opinions have not been cleared by the
Department of Defense or the Federal Government. I do not speak
on behalf of the Federal Government, the Department of Defense,
Military One Source, or any of the military services, or the
Military Severely Injured Center.
Again, thank you for the opportunity to present testimony
on the care of wounded servicemembers. I will be testifying
today from several perspectives. I am currently employed by
Ceridian Corporation as a Service Delivery Manager with the
Military One Source/Severely Injured Services, a virtual
extension of installation services provided by the Department
of Defense.
My professional and educational background includes a
masters degree in rehabilitation counseling and over 20 years
of experience providing case management and administrative
oversight of programs designed to treat brain injuries and
orthopedic impairments.
Thus, I am bringing you a varied perspective of one who has
cared for those with mild to severe brain trauma and other
related injuries.
As a service delivery manager, I provide oversight and
supervision for the severely injured specialists in the
Military One Source Arlington, Virginia Call Center, and for
on-site counselor advocates placed at several military
treatment facilities, and at the VA Medical Treatment Facility
at Palo Alto, California.
The counselor advocates are charged with providing face-to-
face advocacy, outreach, and support to wounded servicemembers
and their families, while the severely injured specialists
provide telephonic advocacy, support, short-term-problem
resolution, and long-term monitoring of the needs of wounded
servicemembers and their families. Prior to assuming this
management position, I myself was a counselor advocate at
Walter Reed Army Medical Center.
As counselor advocates were hired, they assimilated into
those treatment facilities, and they assisted servicemembers
and their families from injury through recovery and
reintegration and back to their communities. The counselor
advocates became familiar with programs, resources, and key
personnel at the medical treatment facilities and at the VA
Medical Center.
I personally found some needs to be as varied as money for
groceries to an individual needing to find educational or
employment opportunities as they had become the primary
breadwinner for the family.
A poignant comment from a wounded servicemember is that the
system is a hunt and peck system. If you know what to ask, you
will probably find and get the services. But many do not know
what to ask, or who to ask, or have the voice to ask the right
questions.
Military One Source/Severely Injured Services staff were
trained to not only know what to ask, but who to ask, and when
to ask in order to ensure that the servicemember continues to
progress along the recovery continuum.
I believe that the challenge that we face is the
leadership, acquisition, and coordination of all of the
resources to assist the wounded and their families. It is not
that there aren't existing programs. Each severely injured
program has their own severely injured program.
The VA has the Seamless Transition Program. Department of
Defense stood up the Military Severely Injured Center and
Heroes to Hometowns. Department of Labor has RealLifelines and
Operation Warfighter to assist with employment options.
Countless non-governmental organizations have rallied with
support of services, money, and goods.
I believe that the communication between the VA, Department
of Defense, the military treatment facilities, the service
programs, and non-governmental organizations is not fully
robust, fully defined, easily understood, or consistent. At
present, I believe the wounded and their families are not
getting the very best that our country can give them.
You have already heard much about traumatic brain injury
and its implications. So I would like to go straight to my
recommendations. I have three recommendations.
One, I feel we need a single, central focal point for
wounded and their families. A program that will provide injured
services that will transcend all service branches and include
Guard and Reserve units. This program must have clear direction
from senior-level VA and Department of Defense, as well as
Army, Marine, Navy, and Air Force command endorsement. This
program direction must include a system of coordination and
collaborations between the VA, Department of Defense, medical
treatment facilities, service branches, non-governmental
organizations, and Department of Labor, which will support a
seamless and equitable delivery of services to all wounded
veterans.
Two, I feel we need to expand options for care of veterans
with brain injuries. I personally do not feel that the existing
inpatient care units are meeting the needs of all traumatic
brain injury cases. The VA outpatient clinics are not designed
for this specialty population. I believe we need to establish
collaborative and cooperative relationships between private
community-based brain injury rehabilitation programs, Veterans
Affairs, and the Department of Defense that will allow
servicemen and women with TBI to receive treatment as close to
home as possible in a setting that is conducive to the
attainment of skills and with staff that are--have a specialty
in the rehabilitation of brain injury. This network of
community providers can then compliment existing acute and
outpatient services offered through the VA and Department of
Defense.
Third, and most important, these wounded warriors and their
families need a qualified advocate. The advocate must possess
the skill sets to help the families to think straight, navigate
through the systems, and transition successfully from the
Department of Defense care to the VA medical care and on to
productive quality lives in their communities.
Thank you for this opportunity.
[The prepared statement of Ms. George appears on p. 50.]
Mr. Michaud. Thank you very much for your testimony.
Mr. Blake.
STATEMENT OF CARL BLAKE
Mr. Blake. Mr. Chairman, Ranking Member Miller, thank you
for the opportunity for--to testify today on what I think many
here consider the signature health crisis of the Global War on
Terror.
I would like to focus on a few key issues that relate to
care being provided to servicemembers with traumatic brain
injury at the VA Polytrauma Centers. PVA is particularly
concerned about veterans who have experienced a traumatic brain
injury but whose symptoms have been masked by other conditions.
We have heard anecdotally that this is a particular problem
for veterans who have incurred a spinal cord injury at the
upper cervical spine. Veterans who have incurred this level of
injury as a result of a blast incident, often have experienced
a TBI as well. However, their symptoms may be diagnosed as a
result of their significant impairment at the cervical spinal
level.
Unfortunately, they may not get the critical treatment
needed at the earliest stage to address the TBI. We recognize
that this is a difficult challenge facing physicians, nurses,
and rehabilitation specialists, as they must decide what
condition must be treated first, even while not necessarily
realizing that other conditions exist.
PVA believes more research must be conducted to evaluate
the symptoms and treatment methods of veterans who have
experienced TBI. This is essential to allow VA to deal with
both the medical and mental health aspects of TBI, including
research into the long-term consequences of mild TBI in the
OIF/OEF veteran.
Furthermore, TBI symptoms and treatments can be better
assessed where previous generations of veterans have
experienced similar injuries. Ultimately, it is important to
point out that the care being provided to those severely
injured servicemen and women who have incurred a traumatic
brain injury at the VA is nothing short of extraordinary. This
care is primarily being handled at the level one Polytrauma
Centers located in Richmond, Virginia, Tampa, Florida,
Minneapolis, Minnesota, and Palo Alto, California. These lead
centers provide a full spectrum of TBI care for patients
suffering moderate to severe brain injuries. I know because I
have visited with a number of these patients at Richmond myself
personally.
PVA is pleased that VA is also taking steps to establish
level two Polytrauma Centers in each of its remaining VISNs for
followup care of polytrauma and TBI patients referred from the
four lead centers or from military treatment facilities.
PVA believes that the hub and spoke model used in the VA
spinal cord injury service serves as an excellent model for how
this network of Polytrauma Centers can be used.
Second level treatment centers, known as spokes, refer
spinal cord injured veterans directly to one of the 21 spinal
cord injury centers or hubs when a broader range of specialized
care is needed. These new level two centers will better assist
VA to raise awareness of TBI issues. There will also be
increased access points for TBI veterans that will allow VA to
develop a systemwide screening tool for clinicians to use to
assess TBI patients.
Unfortunately, the ability of VA to provide this critical
care has been called into question, particularly in recent
weeks. PVA recognizes that the VA's ability to provide the
highest quality TBI care is still in its development stages.
However, it continues to meet the veterans' needs while going
through this process.
We believe many of the problems highlighted in recent
newspaper articles regarding the TBI programs at the four
Polytrauma Centers is a result of Congressional inaction. The
VA is not being prepared for success by a Congress that is not
fulfilling its responsibility to provide proper funding in a
timely manner.
We are especially concerned about whether the VA has the
capacity and the staff necessary to provide intensive
rehabilitation services, treat the long-term emotional and
behavioral problems that are often associated with TBI, and to
support families and caregivers of these seriously brain
injured veterans.
Finally, the broader VA is unlike most, if not all, other
healthcare systems in America. While the quality of care may be
outstanding during early stage treatment at private facilities,
probably most private facilities, those same facilities
generally provide care in the short term.
On the other hand, the VA is the only real healthcare
system in America capable of providing complex, sustaining care
over the life of a seriously disabled veteran. The VA has
developed its long-term program across the broad spectrum of
services for many years.
Mr. Chairman and members of the Subcommittee, the task of
providing this critical care to this segment of the OIF/OEF
veteran population is certainly a daunting one. Without
coordinated efforts by both DoD and VA, and on some level the
private facilities, the backing of Congress through the
appropriations process, the VA will struggle to adequately
handle all of the expectations placed on it. Veterans with TBI,
as well as their families, should not have to worry about
whether the care they need will be there when they need it.
Mr. Chairman and Mr. Miller, I would like to thank you
again for the opportunity to testify. And I would be happy to
answer any questions that you may have.
[The prepared statement of Mr. Blake appears on p. 53.]
Mr. Michaud. Thank you very much, Mr. Blake.
Mr. Atizado.
STATEMENT OF ADRIAN M. ATIZADO
Mr. Atizado. Mr. Chairman, Ranking Miller, I am pleased to
be here today at your request to testify on behalf of Disabled
American Veterans on Polytrauma Center care and patients
suffering from traumatic brain injury.
As my colleague here just said, TBI is becoming the
signature injury of the Iraq war. Recently I had the
opportunity to view a DVD produced by VA about the impact of
TBI on a young soldier who was severely injured in Iraq. The
film is a poignant illustration of extreme physical and
emotional challenges faced by one brain injured veteran and his
family.
Veterans with polytrauma and severe TBI will require
extensive rehabilitation and life-long support. In our opinion,
it is an ongoing rehabilitation and personal struggle. To
recover is the best justification imaginable for ensuring a
strong and viable VA healthcare system.
Military personnel who sustain catastrophic physical
injuries and suffer severe TBI are easily recognized. However,
VA experts note that the milder form of TBI can occur without
any apparent physical injuries and when the soldier is in the
primary vicinity of an explosive blast.
Veterans suffering a milder form of TBI may not be as
readily detected. But symptoms can include headaches,
irritability, memory problems, and depression. These symptoms
are similar to but not inclusive of the symptoms for veterans
from post-traumatic stress disorder. Experts believe that many
returning soldiers from Iraq may have suffered multiple, mild
brain injuries or concussions that may have gone--that may have
gone undiagnosed and stress the need for a thorough screening,
including a military history to properly detect these more
subtle brain injuries.
We are concerned that DoD and VA lack a coordinated
systemwide approach for identification, management, and
surveillance of personnel who sustain mild-to-moderate TBI. We
urge both agencies to jointly develop a standardized protocol
to screen, diagnose, and treat these veterans and soldiers.
As mentioned earlier, there was a July 2006 Inspector
General report that cited a number of problems and called for
additional assistance to immediate family members of brain
injured veterans, including the need for additional caregivers
and improved case management.
We are pleased that Congress recently passed a caregiver
assistance pilot program as a first step to address the needs
of family members caring for severely brain injured veterans at
home. We hope VA will quickly move forward on this pilot and
suggest a focus group, including family caregivers, to help
evaluate the program and suggest ways to better meet the needs
of these disabled veterans and their families.
The VA reports that it is tailoring its programs to meet
the unique needs of severely injured OIF/OEF veterans and
putting a greater emphasis on understanding the problems of
families.
However, we remain concerned about whether VA has the
resources and sufficient specialized interdisciplinary staff
necessary to provide all these services. We must remain
vigilant to ensure that VA's specialized programs, particularly
the Polytrauma Rehab Centers, as it goes through the growing
pains to meet the needs, that these are properly funded and are
adapted to meet the unique needs of the newest generation of
severely injured veterans while continuing at the same time to
address the previous generations of combat disabled veterans.
In the Independent Budget, our organizations have made a
number of recommendations to Congress and the VA based on the
issues discussed today in my testimony, particularly for TBI. I
call your attention to these recommendations and ask that you
take them into consideration as you make your decisions on
funding for VA in the fiscal year 2008.
Mr. Chairman, this concludes my testimony. I would be happy
to answer any questions that you may have. Thank you.
[The prepared statement of Mr. Atizado appears on p. 55.]
Mr. Michaud. Thank you very much.
Mr. Zampieri.
STATEMENT OF THOMAS ZAMPIERI, PH.D.
Mr. Zampieri. Mr. Chairman and members of the Committee, I
appreciate the opportunity to present our testimony in front of
you today from the Blinded Veterans Association.
For 62 years, we have been an advocate for blinded veterans
and their families. Rather than read through the whole thing, I
thought what I will do is try to highlight. From our
perspective, we are concerned about a couple of aspects of the
``seamless transition.'' Some of the other members of the panel
have touched on that.
And that is that there are two concerns. I think once
individuals who have severe injuries end up going through from
the DoD medical treatment facilities to the VA Polytrauma
Centers and secondary centers, it is where they leave those and
go back to wherever they are from that the problems start. And
that is when you start to hear from the family members,
especially it is so hard to get the continued services that
they want.
And, you know, the other problem that we are concerned with
is mentioned also, is the individuals who were injured in Iraq
and were returned to duty because their injuries didn't appear
to be that severe. Then they returned back to the United
States, oftentimes with their unit, and they may not be getting
followup screening.
And, depending on what studies you look at, you know, the
percentage of some of the units have shown anywhere from
between 10 percent to 20 percent of the soldiers or Marines who
have returned from Iraq have been found to have different
symptoms from their injuries in Iraq or Afghanistan.
Oftentimes, you know, these can frequently manifest as
visual problems. Our major interest in this, in fact, is that a
lot of the--about 30 percent of the traumatic brain injured
have some sort of vision-related problems. And they can range
from as simple an issue as color blindness to blurred vision,
double vision, convergence disorders, unable to judge
distances, to the full spectrum of--I have met several who are
legally blind as a result of their traumatic brain injuries. So
it is a new part of the VA's ability to reach out and screen
those individuals and offer them outpatient services.
We appreciate that Secretary Nicholson and Dr. Kussman in
January announced a full continuum of outpatient low vision and
blind rehabilitative services.
And, by the way, we appreciated your passage of the blind
rehabilitative outpatient specialists bill, which will provide
the VA with an additional 35 outpatient blind specialists,
which we think is at a critical time right now. The other thing
is that, you know, I think each of the systems try to do so
much on their own. And maybe there is a time where you need to
step back and look at, you know, other ways or bringing in the
private sector expertise. You know, one of the things I have
been involved with here in Washington, DC, for example, is
there is a Presidential-appointed interagency task force and
counsel on emergency preparedness.
You have the Department of Labor, Department of Education,
the FCC, Federal Communications Commission, the VA is there,
the Department of Defense is there, and stakeholders in
organizations that are interested in emergency preparedness and
stuff all--you know, feed into this and come up with the best
plans. The best, you know, practices if you want to put it that
way. And I think that, you know, some more attention from that
aspect needs to be made. I will run out of time here.
I also want to stress that I think that, you know, from my
own experience, I was a physician assistant for 25 years, there
are a lot of dedicated VA medical staff and Department of
Defense medical professionals out there who, I think, have
suffered from the recent media blitz. I think that the
dedicated individuals have done a remarkable job in the face of
very complex problems. I think that sometimes in the frenzy to
try to fix things, you know, people who have done a great deal,
end up feeling like, you know, they failed.
And in my visits to Walter Reed, and Bethesda, and down at
Brooke Army Medical Center, I have just been impressed with the
dedication and commitment in visiting with the VA staff at
multiple locations. You know, everyone is trying very hard.
There needs to be, I think, improvements, which we all agree
with, and I think more collaboration.
Tomorrow morning, in fact, I am going to go out and speak
to, as she mentioned, the State Association of the Brain
Injured Administrators. I am very interested in their TBI
Tactical Assistance Center where they have developed best
practices, family education information. Those are, you know,
things that we could all benefit from and I think it needs to
be a collaborative effort.
Thank you for allowing us to testify. And, hopefully, if
you have questions, I would be happy to entertain those.
[The prepared statement of Mr. Zampieri appears on p. 58.]
Mr. Michaud. Thank you very much. And once again I would
like to thank all the panels. And I appreciate, Mr. Zampieri,
your final comments as far as thanking the hardworking men and
women who work both at DoD and the VA. They do do a great job.
However, they sometimes do it with fewer resources than what
they really need to do the job.
I have a few questions. Actually, the first few are for
Colonel Bagg regarding the operation of the Intrepid Center.
You had mentioned that at the Center there are nine VA
employees that work there. What are their responsibilities at
the Center?
Colonel Bagg. We have seven VHA employees and two VBA
employees. The seven employees--the VHA employees, we have one
prosthetist. We have two--well, one PT and a PT assistant, an
OT, and an OT assistant, a case manager who works with our case
managers, and then we have the two VBA. I may be missing one
person. I will probably have to take that for the record.
Mr. Michaud. And how many case managers are there? And are
they DoD employees, VA, or a combination?
Colonel Bagg. Both.
Mr. Michaud. How many patients is each case manager assigned
?
Colonel Bagg. Right now, I believe the last is one to
twenty-three. We try to get it around one to twenty. The burn
patients have about one to thirty. And they are hiring more
case managers right now to try to bring that down to a level
that is around one to twenty. That is what we are trying to
average.
Mr. Michaud. Great. Thank you. Ms. George, in your written
statement, you stated that there is a need for additional
counselor advocates at the treatment facilities. I have a few
questions regarding these counselor advocates.
My first is are all counselor advocates contract personnel,
or are they counselor advocates who are directly employed by
the DoD?
Ms. George. First of all, I don't believe I did state that
we need more. However, all of the counselor advocates are
contract employees, yes.
Mr. Michaud. On average, how many counselor advocates are
in each facility? What is the average workload for each of the
counselor advocates?
Ms. George. We look at a caseload of approximately one
counselor advocate to twelve at any given time. Keep in mind
that the counselor advocates connect with the severely injured
specialist in the call center. So the severely injured
specialist become that long-term connection for needs of the
family and the servicemember.
Mr. Michaud. Okay. And do you believe that there need to be
additional counselor advocates to handle the caseload?
Ms. George. I would probably go back to my recommendation
where I say that I believe there needs to be a program. Whether
it is through, you know, a contract with Ceridian, there needs
to be a program where you have counselor advocates or case
managers that are the individuals who link with all of the
resources.
Because, as we have listened today, there are case managers
everywhere and families get confused. Families need somebody
who looks at the whole picture and understands the recovery
continuum and is able to connect them and link them at the
appropriate time with the appropriate resources.
Mr. Michaud. Great. For the VSOs, there is a Seamless
Transition Office in the VHA. I do not believe there is a
comparable office in the DoD. Do your organizations recommend
that they have a similar one in DoD?
Mr. Blake. Sir, I would say the obvious answer to that is
yes. Now, keeping in mind we don't generally deal in the
Department of Defense's issue areas, but it only makes sense. I
mean, if we have identified what the problem is here and you
have one side that is doing its level best to make this happen,
and you don't have any kind of counterpart on the DoD's side, I
mean where is the sense in that?
Mr. Michaud. I agree, and sometimes the obvious doesn't
always happen. You heard me talk about the President's Task
Force, which a lot of time and effort was spent on the issue of
Seamless Transition. The report came out in 2003.
In that report, they made several recommendations on how to
have a seamless transition between DoD and the VA. Are you
familiar with the Presidential Task Force report? And how do
you feel about the progress made on the recommendations?
Mr. Atizado. Thank you for that question, Chairman. I
believe that as part of the Independent Budget, we do cover
that issue with regards to seamless transition. And I think
even the most rudimentary recommendations, which include the
electronic medical record that can be both by directional as
well as computable for the purposes of trending certain
injuries and disabilities in the population as opposed to just
receiving a text-based information that can be utilized for
longitudinal purposes with regards to healthcare, that is still
in process.
I believe they are doing a second cycle of what is called
the Federal health information exchange, which is actually well
underway.
I believe also that there is some discussion on both sides,
both agencies, between VA and DoD, with regards to coming up
with a single inpatient health record. I think that is on the
VA's side. It is actually leading that, I believe, because of
the robustness of the VistA, the CPRS system that they have
now.
Other than that, we still--they are looking--we are still
looking at the electronic version of the discharge papers,
which would allow the faster transition, at least with regards
to receiving benefits when a soldier is injured and requires
these VA benefits to subsist and move on as a transition in
veterans status. We are still looking forward to that.
Mr. Michaud. Great. Thank you. Mr. Miller.
Mr. Miller. Mr. Chairman, I have some questions for the
record that I will submit. And I just want to say thank you for
having this hearing. Thank you to the witnesses that came and
testified today. I am sure this is not the last time in the
very near future that we deal with this particular issue. And,
again, we thank you for your testimony.
[No questions were submitted.]
Mr. Michaud. Thank you very much, Mr. Miller. And once
again, I want to thank the panelists for your time here this
afternoon. It definitely has been enlightening. I look forward
to working with you as we move forward.
And I want to thank Mr. Miller for your advocacy for
veterans' issues and for all that you do for veterans, not only
in your home State of Florida, but nationwide. We really
appreciate that.
And please recognize in the back of the room former staff
persons for the Subcommittee on Health, Linda Bennett, as well
as Ralph Ibson. Would you both please stand? And thank you for
your service on this Committee as well.
The hearing is adjourned.
[Whereupon, at 4:02 p.m., the Subcommittee was adjourned.]
A P P E N D I X
----------
Opening Statement of the Honorable Michael H. Michaud
Chairman, Subcommittee on Health
The Subcommittee on Health will come to order. I would like to
thank everyone for coming today.
I would like to welcome the Ranking Member, Congressman Jeff Miller
of Florida.
We have a lot of hard work to do in the 110th Congress to ensure
that veterans receive the best healthcare available in a timely
fashion.
We must ensure that healthcare and services that meet the needs of
our returning servicemembers are available, and accessible, while never
forgetting the healthcare needs of our veterans from previous
conflicts.
The wounded from the wars in Afghanistan and Iraq are returning
with multiple injuries due to the use of Improvised Explosive Devices,
or IEDs. This often results in servicemembers and veterans needing
polytrauma care, and has caused an increase in veterans with traumatic
brain injury, or TBI.
Today, this Subcommittee hearing will provide us the opportunity to
explore, in more detail, the VA's Polytrauma System of Care, the
interaction between the VA and the Department of Defense, and the
barriers that exist--barriers that prevent not only a smooth transfer
phase between the agencies, but also impede the continuing care of our
veterans. Our focus is on the TBI patient.
We hope that we come away this afternoon with an idea of what these
barriers may be, and the steps that we can take, working together with
VA and DoD, to eliminate them and help fix the system where it needs to
be fixed.
In 2005, VA designated Polytrauma Centers at four sites around the
country to facilitate the coordination of care and specialized services
these grievously wounded servicemembers would need.
The polytrauma centers have grown to number 21, one in each
veterans integrated services network.
With that growth come problems with records transfers, patient
referrals, logistical and coordination of care issues.
There is a real need for the VA and DoD to work together, but we
are faced with two distinct agencies with two distinct missions. This
has resulted in coordination and treatment issues that have proven to
be very difficult to address over the last 2 years.
As many of you know, TBI is considered by many to be the signature
injury of the war. Among veterans and servicemembers from OEF/OIF
treated at Walter Reed for injuries of any type, approximately 65
percent have TBI as a primary or co-morbid diagnosis.
Survivors of TBI experience physical, cognitive, emotional, and
community integration issues. Because of their injury, their capacity
and initiative to seek appropriate care on their own is diminished.
Milder cases of TBI may often produce symptoms that mirror PTSD.
Frequently, family members are the caregivers for these wounded
servicemembers and veterans, as well as their advocates. Their
inability to sort through the many issues that come with a TBI and
transitioning from one agency to another, as well as knowing where to
turn to seek care, can often be frustrating.
Opening Statement of the Honorable Jeff Miller
Ranking Republican Member, Subcommittee on Health
Thank you, Mr. Chairman.
More soldiers of Operation Enduring Freedom and Operation Iraqi
Freedom are surviving battle injuries than in any previous wars. They
are coming home in part because of better vehicle and body armor and
because of the intense and rapid medical care being provided on the
front lines.
When they come home, because a majority of these battle injuries
are blast-related, the nature and extent of their injuries can be quite
severe and complex. They may be physical and mental and require a wide
range of medical treatments and rehabilitation.
Congress recognized that the frequency and unique nature of these
new emerging polytrauma/blast injuries requires an interdisciplinary
program to handle the medical, psychological, rehabilitation, and
prosthetic needs of the injured servicemember. Public Law 108-422
required VA to establish an appropriate number of centers for research,
education, and clinical activities to improve and coordinate
rehabilitative services for veterans suffering from complex multi-
trauma from combat injuries and to coordinate these services with the
Department of Defense. This law resulted in what is now known as VA's
Polytrauma System of Care.
Critical to these wounded soldiers getting the care they need is
the ability of the Department of Veterans Affairs and the Department of
Defense to work together. And, I can hardly put into words the level of
frustration I feel when I read media reports about obstacles individual
patients have encountered because of the bureaucracy and gaps that
still challenge the two departments to make the healthcare transfer
seamless.
These injured servicemembers and their families are relying on the
ability of the VA to provide a full continuum of first class care and
support for their complete recovery--from inpatient services at the
Polytrauma Rehabilitation Centers, to outpatient rehabilitation to
long-term care services in their home communities.
Last week, Secretary Nicholson directed a number of changes to
improve the way VA provides care to our newest combat veterans. This
includes: screening all OEF/OIF combat patients for Traumatic Brain
Injury (TBI) and PTSD; providing each Polytrauma patient with an
advocate to assist them and their family; mandatory training for all VA
healthcare personnel to recognize and care for patients with TBI; and
establishing an outside panel of clinical experts to review the VA
Polytrauma System of Care.
These actions are commendable and necessary. However, despite past
Congressional directive, there are still significant collaborative
actions that DoD and VA have failed to implement including: real-time,
fully interoperable electronic medical records; a single separation
physical; and the systematic sharing of reliable identifying medical
data for VA to know when seriously injured servicemembers are medically
stabilized, when they may be undergoing evaluation for a medical
discharge and when they are discharged from the military.
I want to thank all of the witnesses for appearing at this hearing
today. Your testimony is important and in the end will lead to more
consistent, comprehensive and compassionate care for our Nation's
veterans. It is our job to see that we get it right and we do not fail
those who have sacrificed so much for our country.
Statement of Hon. John Kline, a Representative in Congress
from the State of Minnesota
Thank you, Mr. Chairman and Ranking Member Miller, for giving me
the opportunity to join the Subcommittee on Health to discuss this
vitally important issue.
Today's hearing is an important one, especially since just Tuesday
we celebrated Brain Injury Awareness Day on Capitol Hill. Traumatic
Brain Injury has sadly been called ``the signature injury of the Global
War on Terror''--an injury that doesn't always present itself
immediately but which can be physically and mentally debilitating for
those who suffer from it. Just as our military has adapted to fight an
evolving counterinsurgency in Iraq and Afghanistan, so too, must we in
Congress and in the VA medical system adapt to treat this new medical
threat.
As last year's Defense Authorization bill went into conference, a
constituent from Minnesota alerted me to the decrease in funding for
the Defense and Veterans Brain Injury Center from the previous year's
spending level. Through the Armed Services Committee and the Military
Personnel Subcommittee, I campaigned to add an additional $12 million
in funding authority for the Defense and Veterans Brain Injury Center
through the Defense Authorization bill. It was an easy sell. Everyone I
spoke with--from then Armed Service Committee Chairman Duncan Hunter on
down--saw the immediate need for increased TBI funding. Authorization
for the additional funding was quickly added in conference. I was
disappointed to see this funding decreased in the recently passed
Continuing Resolution but am confident that we will restore increased
funding this year.
The Defense and Veterans Brain Injury Center has proven to be an
innovative joint program worthy of continued Congressional support.
The Minneapolis Veterans Medical Center, just outside of my
district in Minnesota, is home to one of only four of our Nation's
Polytrauma Rehabilitation Centers. This center provides rehabilitation
care for veterans returning from combat with severe injuries that can
include traumatic brain injuries, amputations, wounds, blindness or
hearing disorders, complex orthopedic injuries, and mental health
concerns. The high quality of care being given at this center is a
shining example of what can be accomplished through innovative
collaborations between DoD and the VA.
Mr. Chairman, as a veteran who has been through the veterans'
healthcare system, I am aware that we are making progress with
specialty care and services for our veterans. We must ensure that the
VA system is properly equipped and its staff is well trained to provide
our returning servicemembers with the best care possible.
I look forward to hearing from the witnesses today and learning
more about efforts to fight this increasingly pervasive injury.
Statement of Barbara Sigford, M.D., Ph.D.
National Program Director, Physical Medicine and Rehabilitation
Veterans Health Administration, U.S. Department of Veterans Affairs
Good afternoon, Mr. Chairman and Members of the Committee.
I am Dr. Barbara Sigford and I serve as VA's National Program
Director for Physical Medicine and Rehabilitation. Joining me this
morning is Dr. Lucille Beck, VA's Chief Consultant for Rehabilitation
Services.
Thank you for this opportunity to talk about the Veterans Health
Administration's (VHA) seamless transition process from the perspective
of the Polytrauma System of Care. Mr. Chairman, recent reports of
difficulties faced by servicemembers and veterans in receiving the care
they need and deserve have been deeply troubling. We at the VA are
working closely with DoD to do everything we can to address and resolve
problems in the delivery of care.
Polytrauma System of Care
The mission of the Polytrauma System of Care is to provide the
highest quality of medical, rehabilitation, and support services for
veterans and active duty servicemembers injured in the service to our
country. This is a system of care consisting of four regional
Polytrauma Rehabilitation Centers (PRC), which provide acute intensive
medical and rehabilitation care for complex and severe polytraumatic
injuries; 21 Polytrauma Rehabilitation Network Sites (PNS), which
manage post-acute sequelae of polytrauma; and 76 Polytrauma Support
Clinic Teams (PSCT) located at local medical centers throughout the 21
Networks, which serve patients with stable polytrauma sequelae. This
system of care has been designed to balance the needs of our combat
injured for highly specialized care with their needs for local access
to lifelong rehabilitation care.
The four PRCs are located in Minneapolis, MN; Palo Alto, CA;
Richmond, VA; and Tampa, FL. They have built on the experience of the
Traumatic Brain Injury (TBI) Lead Centers that had functioned at these
locations for 15 years. The PRCs serve as hubs for acute medical and
rehabilitation care, research, and education related to polytrauma and
TBI. They provide overall exemplary care for veterans with multiple
injuries including brain injuries. Due to the increasing needs for
transitional and community re-entry services, each PRC is currently
developing a transitional community re-entry program that will be
operational in July, 2007. Palo Alto already has such a program in
place.
The PNSs, which are located one in each of VHA's 21 Veterans
Integrated Service Networks (VISN), provide key components of specialty
rehabilitation care that address the ongoing specialty needs of
individuals with polytrauma, including, but not limited to inpatient
and outpatient rehabilitation, day programs, and transitional
rehabilitation. PNSs are responsible for coordinating access to VA and
non-VA services across the VISN to meet the needs of patients and
families with polytrauma.
Due to their wider geographical distribution, PSCTs play an
important role in improving access to local rehabilitation services for
veterans and active duty servicemembers closer to their home
communities. These teams are responsible for managing patients with
stable treatment plans, providing regular follow-up visits and
responding to new problems as they emerge. They provide consult with
their affiliated PNS or PRC when more specialized services are
required.
Facilities in the Polytrauma System of Care are linked through a
Telehealth Network that provides state-of-the-art multipoint
videoconferencing capabilities. The Polytrauma Telehealth Network (PTN)
ensures that polytrauma and TBI expertise are available throughout the
system of care and that care is provided at a location and time that is
most accessible to the patient. Clinical activities performed using the
PTN include remote consultations, evaluations, treatment and education
for providers and families.
Case management is a critical function in the Polytrauma System of
Care, designed to ensure lifelong coordination of services for patients
with polytrauma and TBI. Every patient seen in one of the polytrauma
programs is assigned a case manager who maintains scheduled contacts
with veterans and their families to coordinate services and to address
emerging needs. As an individual moves from one level of care to
another, the case manager at the referring facility is responsible for
a ``warm hand off'' of care to the case manager at the receiving
facility closer to the veteran's home. The assigned case manager
functions as the Point of Contact for emerging medical, psychosocial,
or rehabilitation problems, and provides patient and family advocacy.
Transition from DoD to VA
Severely injured veterans and servicemembers and their families
make transitions unknown in the civilian sector. They must make
transitions across space, time and systems. The Polytrauma System of
care has developed consistent and comprehensive procedures tor ensure
seamless transition of the combat injured from the Military Treatment
Facilities (MTFs) to the PRCs. Several processes have been put in place
to make it possible to transition patients from DoD to VA care at the
appropriate time and under optimal conditions of safety and convenience
for the patients their families. These processes address three key
elements: continuity of medical care, psychosocial support for patients
and families, and logistical supports such as transportation and
housing.
Transition of Medical Care
The PRCs receive advanced notice of potential admissions to their
sites through standardized mechanisms. After notification, the PRC team
initiates a pre-transfer review and follows the clinical progress until
the patient is ready for transfer. PRC clinicians are able to complete
pre-transfer review of the MTF electronic medical record via remote
access capability. Up to date information about medications, laboratory
studies, results of imaging studies and daily progress notes are
available. They are also able to access additional clinical information
through the web-based Joint Patient Tracking Application (JPTA) where
information from the field notes from Balad, Iraq and follow up at
Landstuhl, Germany are available and indispensable in determining the
severity of the TBI. In addition to record review, clinician-to-
clinician communication occurs to allow additional transfer of
information and resolution of any outstanding questions. VA has
stationed a Certified Rehabilitation Registered Nurse (CRRN) at Walter
Reed Army Medical Center to constantly monitor the clinical status of
patients awaiting transfer to a PRC. She is available to the PRC staff
for up-to-date information. Also, VA social workers are stationed at 10
MTFs to assist with necessary transmission of clinical information.
PRCs also have scheduled video teleconferences (VTC) with the MTFs to
discuss the referral with the transferring team and to meet the patient
and family members ``face to face'' whenever feasible.
Psychosocial Support for Transition
Families of injured servicemembers are stressed and require
particular assistance in making the transition from the acute medical,
life and death, setting of an MTF to a rehabilitation setting. This
support encompasses psychological support, education about
rehabilitation and the next setting of care, and information about
benefits and military processes and procedures. VA social workers are
located at 10 MTFs, including our most frequent referral sources,
Walter Reed Army Medical Center and National Naval Medical Center.
These individuals provide necessary psychosocial support to families
during the transition process. They advise the families and ``talk them
through'' the process. In addition, the CRRN provides education to the
family on TBI, the rehabilitation process, and the PRCs. The Admission
Case Manager from the PRC is in personal contact with the family prior
to transfer to provide additional support and further information about
the expected care plan. VA also has Benefit liaisons located at the
commonly referring MTFs to provide an early briefing on the full array
of VA services and benefits to the patients and families.
Upon admission to the PRC, the senior leadership of the facility
personally meets and greats the family and servicemember to ensure that
they feel welcome and that their needs are being met. Additionally, a
uniformed active duty servicemember is located at each PRC. The Army
Liaison Officers support military personnel and their families from all
Service branches by addressing a broad array of issues, such as travel,
non-medical attendant orders which pay for family members to stay at
the bedside, housing, military pay, and movement of household goods.
They are also able to advise on Medical Boards and assist with
necessary paperwork.
Two of the four PRCs (Minneapolis and Palo Alto) have Fisher Houses
to lodge visiting family members. The Tampa VA Fisher House is
scheduled for completion in April 2007, and ground-breaking for the
Richmond Fisher House is planned for this spring.
Logistical Supports for the Transition Process
The third element in a smooth transition is attention to logistical
supports. Through the coordination of the PPRC social workers and the
Voluntary Services Department, the individual needs of the family are
assessed and attended to. Supports provided include transportation,
housing, access to meals, and when needed specialized equipment such as
car seats, cribs, and so forth. Even child care can be arranged. In
addition, each PRC has added special activities for the families to
make their stay more relaxing.
Over arching all these efforts, is the addition of a new OIF/OEF
Program Manager to oversee coordination of the care and services
provided to all OIF/OEF veterans seen at the facility, and to assure
that severely injured/ill OIF/OEF veterans are case managed by a social
worker or nurse case manager. This individual will work closely with
the existing clinicians and PRC nurse and social work case managers,
adding an additional layer of security and coordination.
Transition from the Polytrauma Rehabilitation Center to the Community
The transition from the PRC to the home community is also of
critical importance. The needs at time of transition remain the same:
medical care, psychosocial support, and logistical. Records for medical
care are readily available through remote access across the VA system.
In addition, the transferring practitioners are readily available for
personal contact with the receiving provider to ensure full and
complete communication. Follow up appointments are made prior to
discharge. For psychosocial support, the proactive case management
system provides for ongoing support and problem solving in the home
community while continually assessing for new and emerging problems.
Finally, in terms of logistical support, each PRC team carefully
assesses the expected needs at discharge for transportation, equipment,
home modifications, and other such needs and makes arrangements for
assessed needs.
Conclusion
Finally, I would like to again recognize that the VA is committed
to providing the highest quality of services to the men and women who
have served our county. It is important to note that last week the
President created an Interagency Task Force on Returning Global War on
Terror Heroes (Heroes Task Force), chaired by the Secretary of Veterans
Affairs, to respond to the immediate needs of returning Global War on
Terror servicemembers. The Heroes Task Force will work to identify and
resolve any gaps in service for servicemembers. As Secretary Nicholson
said, no task is more important to VA than ensuring our heroes receive
the best possible care and services. The VHA's work to provide a
seamless transition process for high quality medical, rehabilitation,
and support services for veterans and active duty servicemembers
injured in the service of our Nation is helping to ensure that our
heroes do receive the best possible care.
Mr. Chairman, this concludes my statement. At this time I would be
pleased to answer any questions that you may have.
Statement of Tina M. Trudel, Ph.D.
President and Chief Operating Officer, Lakeview Healthcare System, Inc.
and Principal Investigator, Defense and Veterans Brain Injury Center at
Virginia NeuroCare
Representative Michaud, members and staffers of the Congressional
Subcommittee on Health of the Committee on Veterans Affairs, thank you
for allowing me the opportunity to participate in this briefing to
discuss the care of veterans with brain injury. My name is Dr. Tina
Trudel. I presently serve as President and Chief Operating Officer of
Lakeview Healthcare Systems, a national provider of brain injury
services from hospital to home. I also serve as Principal Investigator
of the Defense and Veterans Brain Injury Center at Virginia Neurocare,
a civilian brain injury rehabilitation site. I have been an advocate,
researcher, professor and clinician in the field of brain injury
rehabilitation for the past 20 years. This experience has heightened my
awareness of the disconnection between our investment and advances in
emergency management and acute care of brain trauma, versus the lack of
resources available for post-acute treatment, community integrated
rehabilitation and long term supports. Be it in the civilian or
military community, there is a longstanding gap in meeting the long
term needs of the growing population of brain injury survivors. It
appears we have yet to accept that saving lives has consequences.
As others in the media have noted, brain injury is perhaps our
greatest public health problem. It cuts across the age span, from
infant to elderly, and affects our military both during war and peace
time. Those with traumatic brain injury (TBI) are adversely impacted by
the lack of funding and underdeveloped infrastructure in comparison to
other diagnostic and disability groups. Not very long ago, individuals
with brain injury often died, and until the National Head Injury
Foundation (now Brain Injury Association of America) was founded by in
the 1980's, there was no organized voice of advocacy and
acknowledgement. While this recent era spawned improved survival and
the brain injury movement, our national and state health and human
services structures were already well-established. The funding train
had left the station, and people with brain injuries were still waiting
at the ticket counter.
[GRAPHIC] [TIFF OMITTED] 34311A.001
Brain injury has become a leading public health problem for
civilians and the military. In the United States civilian population,
1.4 million individuals sustain traumatic brain injury (TBI) annually
resulting in 235,000 hospital admissions and 50,000 deaths.\1\
Additionally, 80,000 survive with residual long-term impairments. The
Centers for Disease Control and Prevention estimate that long-term
disability as a result of brain injuries (necessitating assistance with
activities of daily living) affects 5.3 million Americans, with
thousands of new individuals affected every year.\2\ This population
continues to grow and age, creating greater challenges that must be met
by an already burdened health and human services system. Economically,
the total impact of direct and indirect medical and other costs in 1995
dollars is reported to exceed $56 billion.\3\ Such costs do not include
lost earning potential, family burden of care, special education,
vocational retraining and a host of related issues as now are being
recognized within the military. While blast injury and combat related
TBI are presently in focus, it is important to remember that military
service runs a risk of TBI even in peace time, with thousands of
military personnel injured annually due to motor vehicle crashes,
falls, training mishaps and other causes.
---------------------------------------------------------------------------
\1\ Langlois, J.A., Rutland-Brown, W., and Thomas, K.E. (2004).
Traumatic brain injury in the United States: emergency department
visits, hospitalizations, and deaths. Atlanta, GA: Centers for Disease
Control and Prevention, National Center for Injury Prevention and
Control.
\2\ Thurman, D., et al., (1999). Traumatic brain injury in the
United States: a public health perspective. Journal of Head Trauma
Rehabilitation, 14(6), 602-615.
\3\ Thurman D. (2001). The epidemiology and economics of head
trauma. In: In Miller L, Hayes R, eds. Head Trauma Therapeutics: Basic,
Preclinical and Clinical Aspects. New York (NY): Wiley and Sons.
---------------------------------------------------------------------------
With regard to Operation Iraqi Freedom, the Office of the Surgeon
General of the Army notes that 64% of wounded in action injuries have
occurred as a result of blast from improvised explosive devices (IED),
rocket propelled grenades, land mines and mortar/artillery shells
(Defense and Veterans Brain Injury Center (DVBIC): Providing care for
soldiers with traumatic brain injury. The Henry M. Jackson Foundation
for the Advancement of Military Medicine, Inc., 2006 http://
www.hjf.org/research/featureDVBIC.html). Given the improvements in body
armor, protective helmets and the resultant reductions in penetrating
head trauma, blast closed head injuries have become the signature
injury of these military operations.
Many individuals who sustain TBI in military and civilian settings
are treated and return to active duty, productive work, social roles,
family responsibilities and their pre-injury lifestyle. However, some
TBI survivors live with residual disability, have unmet care needs,
and/or are initially unsuccessful in re-entering home, vocational and
community life. Those TBI survivors at risk for unsatisfactory outcomes
or with continued rehabilitation needs, are candidates for community
integrated rehabilitation (CIR), a broad term encompassing various
approaches and contexts for post-acute treatment (through its
relationship with Virginia NeuroCare, Lakeview operates the Defense and
Veterans Brain Injury Center [DVBIC] CIR site in Charlottesville, VA,
discussed in some detail below).
While this introduction may sound ominous, there are many bright
lights of individual and programmatic success that demonstrate both the
power of the human spirit, and the value of effective treatment, as
elucidated by a growing body of peer-reviewed scientific
research.\4,5,6,7,8,9\ A 2005 Cochrane review of multi-disciplinary
rehabilitation for acquired brain injury in adults of working age
examining all relevant studies meeting methodological criteria
published since 1966 stated the following: \6\
---------------------------------------------------------------------------
\4\ Gray, D.S. (2000). Slow-to-recover severe traumatic brain
injury: A review of outcome and rehabilitation effectiveness. Brain
Injury, 14(11), 1003-1014.
\5\ Turner-Stokes, L. (2004). The evidence for the cost-
effectiveness of rehabilitation following acquired brain injury.
Clinical Medicine, 4(1), 10-12.
\6\ Turner-Stokes, L., Disler, P., Nair, A. & Wade, D. (2005).
Multi-disciplinary rehabilitation for acquired brain injury in adults
of working age. The Cochrane Database of Systematic Reviews, 3.
\7\ Gentleman, D. (2001). Rehabilitation after traumatic brain
injury. Trauma, 3, 193-204.
\8\ Laatsch, L., Little, D. & Thulborn, K. (2004). Changes in fMRI
following cognitive rehabilitation in severe traumatic brain injury: A
case study. Rehabilitation Psychology, 49(3), 262-267.
\9\ Shiel, A., et al. (2001). The effects of increased
rehabilitation therapy after brain injury: Results of a prospective
controlled trial. Clinical Rehabilitation, 15, 501-514.
For individuals with moderate to severe brain injury,
there is `strong evidence' of benefit from formal intervention.
For individuals with moderate to severe brain injury who
are already in rehabilitation, there is `strong evidence' that more
intensive programs are associated with earlier functional gains.
Reporting findings generally consistent with the later Cochrane
review, Douglas Gentleman noted in a 2001 article that, ``Clinical and
political responses to the worldwide epidemic of traumatic brain injury
need to recognize that the quality of outcome depends on both phases of
treatment: acute care and rehabilitation.'' \7\ Additionally, current
research further demonstrates the relationships among provision of
rehabilitation therapies, increased functioning, improved test scores
and even changes in brain activity on fMRI, as well as the improved
rate of recovery and functional independence from more intensive
therapies.\8,9\
COMMUNITY INTEGRATED REHABILITATION
Community integrated rehabilitation (CIR) is also referred to as
post-acute brain injury rehabilitation and generally includes a number
of approaches that allow for individuals with TBI to benefit from
further rehabilitation after medical stability is established and
initial acute (in-hospital) rehabilitation is completed. The most
common delineation of CIR programs is highlighted in Table 1. CIR
programs are notably lacking in the VA system.
Neurobehavioral CIR programs have historically focused on treatment
of mood, behavior and executive function, while ensuring supervision
and safety in a residential, non-hospital setting. Such programs focus
on psychosocial outcomes with emphasis on application of behavioral
principles and development of functional skills. Neurobehavioral CIR
programs typically have inter--or transdisciplinary treatment teams,
utilize direct support personnel as therapeutic extenders, and are
often led by neuropsychologists or behavior analysts.
Residential CIR programs were initially developed to meet the needs
of individuals who required extended comprehensive TBI rehabilitation,
24-hour supervision, or did not have access to adequate outpatient/day
services. The home-like environment and staff support served to
facilitate development of skills needed to negotiate everyday life
easing generalization across community environments.
Comprehensive holistic day treatment CIR programs provide a milieu-
oriented, multimodal approach, often with a neuropsychological focus.
Interventions target awareness, cognitive functions, social skills and
vocational preparation through individual, group and family involved
interventions delivered through an interdisciplinary or
transdisciplinary team in clinic and community settings. These programs
are among the most researched in the entire field of CIR, and while
treatment guidelines are often site specific, such resources are
invaluable, allowing discourse, analysis and dissemination of
techniques.
Home-based CIR involves a highly variable degree of services and
supports for the individual with TBI able to reside in a home
environment. Typically, such individuals do not require 24-hour
supports or supervision. Home-based CIR may include the spectrum of
outpatient services commonly accessed through individual treatment
providers or clinics, or minimal professional supports. There is
usually no identified `treatment team', although collaboration across a
number of health and social service systems may be evident. Behavioral
approaches using self-monitoring and cueing may be employed, as well as
models wherein family members or in-home paraprofessionals are engaged
as therapeutic change agents. Additionally, Home-based CIR involves
participant education and the growing use of telephonic, web-based, and
technological aides. Home-based programs may be supported by or serve
as a transition from, other CIR treatment settings.
TABLE 1. COMMUNITY INTEGRATED REHABILITATION MODELS
----------------------------------------------------------------------------------------------------------------
Model Participant Characteristics Description
----------------------------------------------------------------------------------------------------------------
Neurobehavioral Significant behavioral challenges Residential setting
Program Require 24-hour supervision Intensive behavioral treatment
----------------------------------------------------------------------------------------------------------------
Residential Cannot participate as outpatients Residential setting with community
Community Require 24-hour supervision or focus
Program available support Integrated comprehensive treatment
----------------------------------------------------------------------------------------------------------------
Comprehensive Need for intensive services Day program model
Holistic Benefit from improved awareness, Integrated, multimodal rehabilitation
Treatment practice and compensation
----------------------------------------------------------------------------------------------------------------
Home-based Able to reside at home Education and advisement
Program Able to self-direct care Telephonic and web-based support
and services
Home-based therapeutic activity
Availability of outpatient
supplemental services
Highly variable
----------------------------------------------------------------------------------------------------------------
Trudel, Nidiffer & Barth, in press.
Support for the effectiveness of community integrated
rehabilitation (CIR) post-TBI has gradually been established, with
limitations in research due to low level funding and the challenges
inherent to studying a diverse, individualized treatment approach.
Findings include: \10,11,12,13,14,15,16,17\
---------------------------------------------------------------------------
\10\ Coetzer, R. & Rush, R. (2005). Post-acute rehabilitation
following TBI: Are both early and later improved outcomes possible?
International Journal of Rehabilitation Research, 28, 361-363.
\11\ High, W. et al. (2006). Early versus later admission to post
acute rehabilitation: Impact on functional outcome after TBI. Archives
of Physical Medicine and Rehabilitation, 87, 334-342.
\12\ Malec, J. (2001). Impact of comprehensive day treatment on
societal participation for persons with ABI. Archives of Physical
Medicine and Rehabilitation, 82, 885-895.
\13\ Powell, J. et al. (2002). Community-based rehabilitation after
severe TBI: A randomized control trial. Journal of Neurology,
Neurosurgery and Psychiatry, 72, 193-202.
\14\ Sander, et al. (2001). Long-term maintenance of gains obtained
in post-acute rehabilitation by persons with TBI. Journal of Head
Trauma Rehabilitation, 16, 356-373.
\15\ Tiersky et al. (2005). A trial of neuropsychological
rehabilitation in mild-spectrum TBI. Archives of Physical Medicine and
Rehabilitation, 86, 1565-1574.
\16\ Willer, B. et al. (1999). Residential and home-based post
acute rehabilitation of individuals with TBI: A case control study.
Archives of Physical Medicine and Rehabilitation, 80, 399-406.
\17\ Wood, R. et al. (1999). Clinical and cost effectiveness of
post-acute neurobehavioral rehabilitation. Brain Injury, 13, 69-88.
CIR increases societal participation, community and home
skills, independence, productivity and improved functional outcome on
activity measures.
CIR related improvement is demonstrated in samples of
participants who range from months to years post-injury.
CIR appears to produce gains that are maintained over
time.
CIR improves self and family ratings on a variety of
measures and on tests of neuropsychological functions.
Comprehensive holistic/day treatment CIR has the
strongest research foundation for effectiveness, including randomized
control trials.
CIR demonstrates some benefit across the continuum, but
appears most to provide most benefit for those with moderate and severe
TBI.
Individuals with severe TBI demonstrate greater
functional improvement from a residential program model versus home-
based rehabilitation.
CIR reduces neurobehavioral problems, and therefore risk
for institutionalization, criminal justice contact and danger to self
or others.
LAKEVIEW'S NEUROBEHAVIORAL AND CIR SYSTEM
Lakeview's treatment sites (14 programs across 5 states) serve
individuals from hospital to home. The primary focus for post-acute TBI
care includes our residential and community integrated programs. These
specialized neurobehavioral and CIR programs serve those individuals
who require treatment, supervision and support related to their
significant cognitive and/or behavioral challenges. Physical disability
issues are also addressed. The emphases of the program include
cognitive remediation, functional skill acquisition, self-care,
positive approaches to behavioral self-management, informed
pharmacology, individualized treatment plan development and
implementation, community integration and family education/support. The
programs predominantly focus on the care of adults with neurobehavioral
diagnoses (typically brain injury related) who have not succeeded as
outpatients or with in-home supports.
The Lakeview programs are founded in a person-centered,
inclusionary model, encouraging the active participation of
participants and their families in all aspects of treatment
development, implementation and discharge planning. Program
interventions are designed to facilitate re-integration through
enhancement of life skills, compensatory strategies, self-esteem and
self-control throughout the therapeutic milieu. The program is
supported by the management and clinical expertise of Lakeview's
national and regional resources. The NeuroBehavioral Program serves
individuals with significant behavioral challenges in need of greater
supervision, support and treatment with a focus on safety and
functional skill development. The Community Integrated Rehabilitation
Program serves those individuals, who while still in need of 24 hour
support and supervision, pose less risk to self or others and typically
have less intense active treatment needs. It is anticipated that
program participants will be a blend of individuals receiving brief
treatment interventions and those in need of longer term strategies and
supports to insure quality of life in the least restrictive
environment.
All treatment provided at Lakeview is initiated based on clinical
recommendations following an assessment period, with agreement from the
program participant, guardian and funder. Treatment meets the standards
of each respective licensed profession, with goals and objectives
established by the program participant in concert with the clinical
team, through an individualized service plan that is transdisciplinary
and person-centered. Competent, supervised providers (including
extenders, such as life coaches, aides and other direct support staff),
in accordance with the highest ethical principles including informed
consent regarding the procedures, risks, potential benefits and
possible side effects of all treatments, deliver services across
various environments and activities. Discharge planning begins at the
time of admission in order to target treatment and maximize likelihood
of successful skill generalization. The participant, family and
treatment team, including external parties, discuss treatment goals,
possible discharge placements, and length of stay considerations.
Lakeview's policy is to provide a comprehensive discharge manual to the
individual served at time of discharge. Ongoing discharge planning is
coordinated by the Case Manager. It is recognized that some individuals
will be in need of longer term resources, including life care plans and
arrangements for community-based supported living with family, other
agencies or through the program.
THE DVBIC CIR PROGRAM AT VIRGINIA NEUROCARE
As previously noted, numerous research studies support the general
benefit of CIR following brain injury, especially for those with more
severe injuries. Questions remain as to the nature, scope, timing,
intensity and duration of CIR in relation to cost and outcome, as well
as the application of new technology and adaptive devices to the CIR
process. Progress in developing an evidence base for CIR has been
hampered by the diversity of approaches and lack of systematic,
detailed descriptions of actual treatment activities. This lack of
defined treatment limits options for replication, randomized control
trials, case series or multi-center studies. The task of
standardization of treatment for such an individualized treatment
approach as brain injury rehabilitation may initially seem onerous.
However, similar processes have successfully lead to extensive research
and dissemination of effective treatment in an equally complex and
individualized arena, cognitive behavior therapy (CBT).
The valuable clinical research characteristics identified early in
DVBIC's history (homogeneity, available records, infrastructure, multi-
site, outcomes measurement, tracking) provide an optimal foundation for
CIR research through Virginia NeuroCare, a DVBIC core civilian partner
program with a long history of CIR focus and expertise, operated
through resources provided by Lakeview, a national leader in brain
injury rehabilitation. The program's dual focus includes providing
optimal treatment of service men and women with TBI, while also
advancing brain injury rehabilitation through treatment research and
applied technology in community integrated settings. Research and
applied technology developed through DVBIC program such as VANC can be
rapidly disseminated and replicated in other community settings, as
well as to improve care in the civilian population. The DVBIC program
at Virginia NeuroCare, through its relationship with Lakeview, is
presently engaged in a research program on the Development and
Implementation of Brain Injury Community Integrated Rehabilitation
(CIR) Treatment Manual for Military Personnel.
The DVBIC at Virginia NeuroCare's Neurobehavioral CIR Clinical
Research Project is presently developing, implementing and analyzing
educational and treatment interventions with program participants from
the military who have suffered mild, moderate, and severe TBI primarily
from combat IED blast forces and motor vehicle accidents. The CBT
treatment manual approach is being applied to brain injury
rehabilitation. CBT manualized treatment has been implemented to
facilitate research and therapy technique dissemination for many
behavioral and medical conditions including: (1) anxiety and mood
disorders, anger management, domestic violence, substance abuse to
treatment and vocational training; (2) medically complicated problems
such as erectile dysfunction, obesity, eating disorders, diabetes
management, chronic fatigue and chronic pain; and (3) CBT treatment
manuals have even been targeted to specific treatment populations
including prisoners, low income and minority groups and persons with
developmental disabilities. Thus, the treatment manual model holds
significant potential to advance clinical research in brain injury
rehabilitation, as the approach has both the structure and flexibility
to address the comprehensive nature of brain injury CIR. The treatment
manual model also provides for ready dissemination, replication and
application of successful clinical practices to improve outcomes across
broad systems.
The military program participants we serve are typically several
months post injury and have made substantial recovery, yet still
experience mild to moderate neurobehavioral deficits typically
associated with frontal and temporal lobe dysfunction and executive
dyscontrol. These soldiers are still in the active stages of recovery
and no longer require acute medical intervention, but they may present
balance problems, ataxia, coordination impairment, impaired activities
of daily living functions, memory difficulties, attentional problems,
fatigue, problematic initiation and motivation, irritability,
frustration, depression, sleep disturbance, poor judgment,
impulsiveness, anosognosia, organizational problems, speech
difficulties, poor anger control and socialization skills, general
cognitive dysfunction, and family or work stress.
We are formalizing a 12-week pilot day program to address most of
these issues through education, functional therapeutic interventions,
applied technology, cognitive-behavioral treatment procedures, group
therapy and discussions, and individual treatment. The program is
divided into 12 independent educational and group interaction modules
followed by individual and group therapy sessions and functional
implementation using compensatory strategies and devices. Each of the
12 modules will be based on a detailed manual in order to facilitate
replication, research, multi-center work, treatment component analyses
and eventual dissemination as indicated across the DVBIC, military and
veteran's system and civilian rehabilitation community at-large.
Initial module development has been based on a review of the scientific
literature, clinical judgment and expertise, and program participant
feedback and outcomes. These educational and group sessions modules
include:
Introduction: Exploring the Problems and Initial
Evaluations
Wellness: Stress, Fatigue, Pain Management, and
Relaxation
Wellness: Coordination, Flexibility, Exercise, Nutrition,
and Sleep
Focusing Attention
Time Management
Memory: How to Compensate
Maximizing Memory in Functional Environments
Organizing Daily Life and Daily Living Skills
Problem Solving, Awareness, Judgment, Safety, and
Impulsivity
Social Interaction: Cognitive and Emotional Changes
(depression, anxiety, irritability, and anger management)
Social Interaction: Assertiveness/Picking Up The Pieces
Review and Synthesis
The manualized CIR treatment modules are practiced and enhanced
within the context of real life volunteerism, clubhouse membership,
supported work experiences, transportation skill development, community
navigation, and laundry, shopping, budgeting, banking and meal
preparation within the broad context of community re-entry. The program
focus includes supplementation with adaptive technology, as well as
formal evaluation of the acceptability of technological aides by the
user, as the quality of the rehabilitation technology--user interface
is a key predictor for success. The definitions and descriptions of
this enriched environment, therapeutic milieu and staff training
expectations will also be articulated in the relevant module treatment
manual. All program content will be structured, documented and
developed into a manual format to facilitate clinical research and
staff training.
Pre and post program assessments using behavioral and functional
measures, as well as levels of vocational success and independent
living skills are being used. Additionally active duty military members
are tracked for rates of return to active duty and medical board
decisions through discharge planning processes. Post discharge follow-
up data including residential and occupational outcomes, and
participant feedback, will also be solicited and analyzed in order to
further refine the model, treatment manuals, and staff training tools.
By tracking effective approaches to treating servicemen and women who
have experienced brain injuries in the course of their duties, we hope
the DVBIC program at Virginia NeuroCare will be the leader in
delineating effective, efficient strategies that can be utilized in
other CIR programs, both military and civilian.
ASSISTIVE TECHNOLOGY IN TBI REHABILITATION
CIR environments also provide the best opportunity to implement
technological aides in therapy environments. Low tech cognitive
supports such as memory journal, dry erase boards and checklists have
long been used in TBI rehabilitation. Presently there are a plethora of
new technological devices and applications. A primary focus for
assistive technology intervention with individuals post-TBI is to
ensure the match of technology and user, and involvement of skilled
clinicians is paramount. Approaches include both person oriented and
environmentally oriented applications. Current tools are best for
memory storage, task execution or scheduling and sequencing. There has
been some success with customized PDAs and memory compensation, voice
organizers and audible reminders, mobile phone and pager cueing
systems, datalink watches and adapted task-oriented programs for
scheduling, bill paying and similar functions. Telephonic
interventions, videoconferencing for individual and family
intervention, web-based resources for treatment and training and self-
help modules have also been implemented with some success.\18,19,20,21\
---------------------------------------------------------------------------
\18\ Gartland, D. (2004). Considerations in the selection and use
of technology with people who have cognitive deficits following
acquired brain injury. Neuropsychological Rehabilitation, 14, 61-75.
\19\ Kapur, N., Glisky, E. & Wilson, B. (2004). Technological
memory aids for people with memory deficits. Neuropsychological
Rehabilitation, 14, 41-60.
\20\ Kirsch et al. (2004). Web-based assistive technology
interventions for cognitive impairments after traumatic brain injury.
Rehabilitation Psychology, 49, 200-212.
\21\ Rizzo, et al. (2004). Analysis of assets for virtual reality
applications in neuropsychology. Neuropsychological Rehabilitation, 14,
207-239.
---------------------------------------------------------------------------
Presently the Defense and Veterans Brain Injury Center (DVBIC) at
Virginia Neurocare is part of two grants under review: (1) driver
evaluation and rehabilitation utilizing an advanced driving simulation
module; and (2) adaptation of a web-based educational and self-help
module for the assessment and treatment of sleep disorders (common
post-TBI). Additionally, through the DVBIC contract, we are advancing
portable and wireless devices to support participation in home and
community activities, including GPS, specifically through the VANC
Pilot Project on the Efficacy of Using Personal Global Positioning
System (GPS) Technology and Personal Data Assistants (PDAs)/Mobile
Phones.
As service men and women with TBI progress through the recovery
process, they frequently experience some level of confusion and
disorientation with regard to time, place, and direction. Even when
this confusion lifts, following directions in navigating the community
can be difficult and often requires supervision and maximum use of
staff resources, particularly when trying to track multiple individuals
who must practice and progress through the successful negotiation of
many community based tasks. In worst case scenarios, those who do not
develop community navigation skills are at risk of social isolation,
unemployment and the need for long term supervision and supports, often
placing excessive burden on care systems or family members. We will be
using available Global Positioning System wrist watch styled devices
and/or PDA/mobile phone integrated GPS to track patients who are
beginning to be independent in community walking privileges. Use of the
GPS frees patients from the need for in-person supervision by using the
internet to pinpoint where the patient is in the community. Patients
are given the opportunity for increased practice and functional
independence. The technology utilized and skills developed have the
potential to dramatically decrease the burden of care, economic cost
and facilitate the greater development of the patient's potential in
home, work and community roles. It is hoped that this technology will
speed progress in community integrated rehabilitation, reduce
rehabilitation length of stay and facilitate safe transition into the
home community. This pilot study will evaluate the efficacy of this
technology-based system for tracking and training these patients, as
well as provide a mechanism for in vivo coaching of persons who become
disoriented. As with other technological aides used within the program,
various GPS systems will be evaluated for their adaptive technology-
user interface. This case series of GPS users will provide the
foundation for descriptive articles to advance the field and promote
additional research and development.
NEROBEHAVIORAL AND CIR CHALLENGES WITHIN THE VA SYSTEM
Neurobehavioral treatment and CIR after TBI are a particular
challenge within the VA system. Individuals needing extended care
following moderate and especially severe TBI require a therapeutic
approach that allows for gradual, extended treatment and the
possibility of long term supports. Additionally, this treatment is not
provided in a medical model, but instead targets cognitive functions,
psychosocial elements, life skills and social/vocational roles.
Neurobehavioral and CIR programs rely minimally on physicians and
heavily on allied health, behavioral health, direct support staff
extenders and life coaches. These programs are typically support staff
intensive and require extensive personnel training at all levels.
Private neurobehavioral programs and CIR are available across the
country in an inconsistent manner, as presently such services are not
usually funded through mechanisms of Tricare, Medicare or typical
Medicaid, although many states have instituted Medicaid waiver programs
to address these needs within the civilian population. Rather than
reinventing the wheel to access the civilian system, the VA would be
wise to consider care coordination through facilitation of existing
systems such as the Brain Injury Association of America and its
national and state information and referral resources and the National
Association of State Head Injury Administrators, both non-profit
organizations with strong networks and the foundation knowledge of
brain injury services across the country.
A problem faced by all neurobehavioral and CIR programs involves
the national shortage of key providers such as occupational therapists,
physical therapists, speech-language pathologists, applied behavior
analysts and neuropsychologists familiar with brain injury
rehabilitation, especially in the post-acute phase and community
environments. These allied health provider shortages are increasing as
supply/demand is pressured due to an aging population, increased injury
and chronic illness survival rates, a growing disabled population in
the United States, and special education utilization for youth with
developmental disabilities. Further, professions are limiting the
number of graduates considering entering the field by increasing
academic requirements to enter the field (speech-language pathology and
applied behavior analysis remain at the master's level; rehabilitation
psychology and neuropsychology remain at the doctoral level with post-
doctoral training; occupational therapy is increasing from bachelor's
to master's level; and physical therapy is increasing from master's
level to doctoral level in many regions). The private and public sector
TBI rehabilitation providers are increasing salary rates, providing
sign-on and retention bonuses and are competing with lucrative private
practice opportunities in many states. The VA system is in a difficult
position to recruit and retain in this competitive environment with
existing qualified labor shortages and rising demand.
Another issue that impacts the VA is that of the population
concentration of veterans needing neurobehavioral or CIR services in a
particular area. Given population needs, the VA would need to recruit,
retain, train and implement effective teams as a regional endeavor, as
this is not pragmatic to do locally. Additionally it takes time,
leadership and expertise to develop an effective team in order to meet
the complex needs of individuals with more severe TBI and
neurobehavioral impairments, as well as to provide CIR. Optimal
services are as close to home, community and family as possible for
engagement, training and discharge planning. Thus, it has been and
remains pragmatic in many instances and regions, to contract with local
civilian resources, and a number of private sector organizations that
provide neurobehavioral, CIR and supported living services to veterans.
Issues of concern with civilian resources include inconsistencies in
service quality, lack of familiarity with military issues, risk of
overpricing if reimbursement is not standardized/managed and also the
lack of any resources in some regions. There is significant opportunity
of blending resources to include regional VA based services in more
populous regions, private contractor services where available and to
encourage consultation with experienced civilian providers to
facilitate and expedite VA development to ensure a continuum of
neurobehavioral and CIR services.
Key elements of effective neurobehavioral treatment and CIR vary in
terms of `fit' in military and VA healthcare environments. Elements of
treatment that are more readily amenable to adaptation in VA and
military settings include:
development and implementation of schedules
establishment of routines
breaking down more difficult activities into component
tasks for teaching and training
some environmental manipulations to foster success
introduction of compensatory devices and assistive
technology
Elements of effective neurobehavioral treatment and CIR that are
difficult to adapt and implement in military and VA healthcare settings
include:
life coach and functional skill development models
environmental enrichment models
community exposure for repeated practice (individuals
with TBI often have difficulty generalizing technology learned in
institutional/medical settings)
frequent distributed brief sessions rather than longer
therapy appointments
flexibility to work with natural cycles of alertness,
arousal and fatigue
sleep monitoring and behavioral data collection (requires
technician/aide staffing levels)
individualized learning strategies support by direct care
staff and focused on errorless learning approaches and chaining
procedures
teaching of mental rehearsal, self-talk and self-
monitoring strategies in small group, then real-life scenarios
application of compensatory devices and assistive
technology in real-life settings
long term supported living within the community
Last, the scope and complexity of TBI in the military and need for
a centralized resource was recognized when the DVBIC was established
over 15 years ago. Enhancement of DVBIC's role as the primary
coordinator and facilitator of research, clinical and education
development across the military Department of Defense and VA systems is
critical. Without unified data management and coordinated resource
facilitation across all branches of the military and VA sites,
opportunities for research advances in TBI rehabilitation, system
improvement, development/dissemination of best practices and optimal
service delivery to our men and women in uniform are lost, along with
opportunities for translating these advances to civilians with TBI.
DISCUSSION
Post-acute care for individuals with traumatic brain injury has
lagged behind virtually all other treatment and support services in
both civilian and military realms due to the low funding resources,
later/lack of identification of this group of trauma survivors, and
apparent difficulty in securing and sustaining a focus on this complex,
growing problem. The current increased national attention provides an
opportunity to foster collaborative efforts across private, public and
military systems to improve brain injury services for all Americans,
especially our veterans. Pragmatic issues and effective, efficient use
of resources supports the need for a well-managed blend of VA and
civilian sector services in order to maximize successful return to
home, family, employment and community life for our veterans with brain
injury.
Statement of Colonel Mark Bagg, Chief, Department of
Orthopaedics and Rehabilitation, Brooke Army Medical Center,
Fort Sam Houston, TX, and Director, Center for the Intrepid,
Department of the Army, U.S. Department of Defense
``The Center for the Intrepid was donated by over 600,000 Americans.
Their
generosity expresses the profound appreciation America has for its
gallant servicemen and women who defend freedom. This Center is
dedicated to our severely wounded military heroes whose selfless
sacrifices for our Nation entitle them to the best rehabilitative
care.''
Mr. Chairman, Mr. Miller, and distinguished members of the
Subcommittee, I am Colonel Mark Bagg, the chief of the Department of
Orthopaedics and Rehabilitation at Brooke Army Medical Center (BAMC) at
Fort Sam Houston, Texas. In my role at BAMC, I am also responsible for
the day-to-day operations of the new Center for the Intrepid (CFI),
arguably the most advanced outpatient rehabilitation facility in the
United States today.
Thank you for inviting me to testify before you today to explain
the services available at the CFI and our vision for providing
outpatient rehabilitative care for our combat casualties and America's
Veterans. Over the past four years, with Congress' strong support, we
have revolutionized amputee care for more than 560 military amputees.
The CFI allows us to continue that revolutionary change and extend our
lessons learned to America's veterans who suffer from non-limb loss
injuries and severe burn injuries.
BACKGROUND
In the spring of 2005, the board of directors of the Intrepid
Fallen Heroes Fund, a private, not-for-profit charitable foundation,
made it known they were interested in building a physical
rehabilitation center for the wounded warriors returning from Operation
Iraqi Freedom and Operation Enduring Freedom. A formal proffer for the
facility was accepted by the Secretary of the Army on 30 June 2005. The
facility was named the ``Center for the Intrepid'' (CFI) and during an
extensive fundraising campaign, funds to build and partially equip the
facility were donated by over 600,000 Americans.
Ground was broken for a four story, 65,000 square foot patient
rehabilitation facility as well as two new Fisher Houses on 22
September 2005. These homes, funded by the Fisher Foundation, were
built on the new footprint and each provides 21 handicap accessible
suites. The addition of the two new homes brought the total number of
homes at BAMC to four, and the total number of rooms available to 57.
The CFI and Fisher House complex is located on a 4.5 acre site adjacent
to BAMC.
These generous gifts were formally accepted and dedicated during a
ribbon cutting ceremony which took place 29 January 2007. Staff quickly
relocated operations from their previous locations embedded within BAMC
and patients began to receive their care in the facility on 15 February
2007.
MISSION
The mission of the CFI is to provide the highest quality of
comprehensive outpatient rehabilitation for eligible patients in a
state-of-the-world facility. Utilizing a multidisciplinary approach,
servicemembers who sustain severe traumatic injuries with resultant
amputation or loss of limb function, to include burn injury and limb
salvage procedures, will be afforded an opportunity to maximize their
functional improvement and perform at the highest level possible
whether they remain in the military or choose to reenter civilian life.
The staff at the CFI carries out this patient care mission while
conducting leading edge research in the fields of Orthopaedics,
prosthetics and physical/occupational rehabilitation, providing
Department of Defense and Department of Veterans Affairs professionals'
opportunities for continuing education on rehabilitation modalities,
and offering training programs and graduate medical education for the
full spectrum of rehabilitation professionals.
PROGRAMS
Amputee Patient Care Program. The Amputee Patient Care Program at
the CFI offers a full spectrum of amputee care ranging from initial
outpatient care through final prosthetic adjustment. Patients are
encouraged to progress from basic activities of daily living (ADL)
through advanced level sport and leisure activities with the goal of
maximizing potential either in the military or in civilian life.
Limb Reconstruction/Limb Salvage Program. The goal of the limb
reconstruction/limb salvage program is to assist those servicemembers
who have resultant functional limb loss after undergoing procedures to
save them. This category of patient will benefit from the advanced
therapy and functional activities.
Advanced Burn Rehabilitation. The CFI offers additional advanced
rehabilitative and functional training for servicemembers sustaining
burn injury. After completing a normal course of therapy following burn
injury, servicemembers may be referred to the CFI for advanced
conditioning and functional activities not available at other
locations.
SERVICES PROVIDED
Capitalizing on this generation's use of technology and virtual
reality, the facilities at the CFI are state-of-the-world. Patients are
challenged by state-of-the-art physical therapy and occupational
therapy, rigorous sports equipment, and virtual reality systems. They
will benefit from individualized case management, access to behavioral
medicine services, and in-house prosthetic fabrication. Out-patient
services at the CFI include Behavioral Medicine, Case Management,
Physical Therapy, Occupational Therapy, Physical Medicine and
Orthopaedics, Prosthetics, and Community Reintegration programming.
Advanced therapeutic activities available, as appropriate for specific
patients, include a motion analysis lab, Computer Assisted Rehab
Environment/Virtual Reality system, Firearms Training Simulator,
Vehicle Simulator, Climbing Wall, Pool, Flowrider, indoor track, and
outdoor sport court.
MEDICAL DIRECTION
The medical care provided in the CFI is under the direction of the
chairman of the Department of Orthopaedics and Rehabilitation at BAMC.
Physiatrists work closely with Orthopaedic Surgeons, Burn Surgeons, and
other physicians to coordinate all care.
BEHAVIORAL MEDICINE
The ultimate goal for the CFI Behavioral Medicine Service is to
enable patients to maximize their potential for emotional, mental,
spiritual, and physical recovery. Behavioral Medicine provides
comprehensive psychiatric support services to amputees and their
families. This is accomplished using individual therapy, support group
meetings, medication management, family support groups, and cognitive
assessment. The behavioral medicine staff is available for the
facilitation of all behavioral health needs.
CASE MANAGEMENT
A full-time case manager is assigned to each patient in the CFI.
These professionals work closely with the patients, their families, and
the entire staff of the Center for the Intrepid to coordinate the
development of a customized, multidisciplinary team plan of care and to
monitor the plan of care and report any problems. They also seek
solutions to improve the delivery of care and patient outcomes,
identify and assist with all needs of the patient and the family, and
function as the initial point of contact for multiple referrals
utilized to augment care at BAMC. Case managers also guide wounded
warriors through the medical evaluation board (MEB) process and help
ensure timely completion of MEBs.
MILITARY PERFORMANCE LAB
The Military Performance Lab (MPL) seeks to analyze human motion,
with particular emphasis on amputee gait (walking). The information
collected in the MPL is ultimately used to help physicians, physical
therapists, and prosthetists adjust their treatment plans and improve
patient function. The MPL is comprised of two functional areas, the
Gait and Motion Analysis lab and the Computer Assisted Rehabilitation
Environment or CAREN.
Physical Therapists and biomedical engineers in the Gait and Motion
Analysis Lab use 26 infrared cameras to track the position of
reflective markers placed on a patient's body. Joint angles are
calculated from the motion analysis. Ground reaction forces in multiple
directions are measured by force plates in the floor, parallel bars,
and treadmill. These forces, when combined with the calculated joint
angles, allow the analysis of the torque that muscles or prosthetic
components are producing. Electromyography (EMG) is used to assess the
electrical activity that is given off during muscular contraction and
can detect both the timing and intensity of muscular contractions. All
of this information is used to assess patient progress. It also serves
to validate new treatment protocols and prosthetic components.
The CAREN is a 3-D rehabilitation simulator and is the first of its
kind in the world. The CAREN consists of a 21 foot dome with a 300
degree screen upon which a variety of ``virtual realities'' may be
displayed. A movable platform in the center of the dome has a treadmill
and force plates identical to those in the gait lab. The visual display
and motion capture systems in the CAREN allow the patient to be
immersed into the virtual reality scene. The capabilities of the CAREN
will be central to the research mission of the center as investigators
study vestibular disturbances, and balance dysfunction, and responses
to varying levels of stress in patients with Post Traumatic Stress
Disorder.
OCCUPATIONAL THERAPY
Occupational Therapyfocuses on restoring health and function
following injury or illness. Treatment activities are designed so that
patients can successfully perform occupational tasks and ADLs like
bathing, dressing, shopping, cooking, writing, performing household
chores and everything needed to function on a day-to-day basis.
Therapists and technicians provide evaluation and treatment for
conditions including amputation, fracture, nerve injury, and soft
tissue injury. Utilizing activities to regain range of motion, increase
muscle strength, and decrease pain, Occupational Therapists help
patients perform functional tasks to reach their maximum potential and
independence.
One of the ways the Occupational Therapy staff encourages
independence is through the use of the ADL Apartment. In this space,
the patients are faced with a real-world living environment where
therapists evaluate their physical and/or mental ability to safely
perform specific tasks. The apartment has a computer workstation
equipped with state of the art voice recognition software, compact
keyboards, a height adjustable desk top, a fully equipped kitchen and
bathroom, and a comfortable living room.
In addition to the traditional occupational therapy modalities
available in most occupational therapy clinics, two simulation systems
are available to patients at the CFI. The first is the Firearms
Training Simulator. This state-of-the-art system allows Soldiers to
simulate firing different weapons in a host of virtual settings. Using
Bluetooth technology weapons, patients practice different firing
techniques and may experience everything from basic marksmanship
scenarios through very complex scenes requiring identification of
friend or foe. For those servicemembers who desire to remain on active
duty, this realistic training allows them to re-qualify with the weapon
systems common to all branches of the military. The second simulation
system is the driving simulator. Although actual driver's testing of
amputees is performed by the VA, this simulator allows patients the
opportunity to develop new driving skills and to practice prior to
formal testing.
The Occupational Therapy staff also coordinates a community re-
integration program for the patients. This program includes a wide
variety of experiences outside the clinic setting. Activities such as
horseback riding, paint-ball, archery, kayaking, and golf allow the
patients to be challenged and have fun at the same time.
PHYSICAL THERAPY
Physical Therapists provide evaluation, diagnosis, treatment, and
rehabilitation for patients who have sustained trauma and/or illness.
For the amputee and burn patient, the Physical Therapy team utilizes
multiple interventions focusing on patients' abilities and interests,
not their disabilities. In order to accomplish ``total
rehabilitation,'' the Physical Therapy team provides the full spectrum
of physical therapy modalities including amputation awareness, residual
limb care, wheelchair mobility and crutch training. They also perform
strengthening activities, pre-prosthetic training, balance,
proprioception, endurance activities, and gait training on a variety of
surfaces.
The Physical Therapy staff also coordinates an adaptive sports
program including a multi-phased running program, track and field,
volleyball, swimming, scuba diving, kayaking, and basketball. Through
the volunteer support of a variety of charitable organizations,
patients in the advanced stages of rehabilitation are offered the
opportunity to learn and enjoy snow skiing, water skiing, fencing,
archery, shooting, and golf.
The Physical Therapy staff utilizes several pieces of specialized
equipment. On the third floor of the CFI, there is a tread-wall and a
21 foot climbing tower with auto-belay to promote strengthening,
agility, and aerobic conditioning. In the natatorium there is a six
lane pool for pre-running activities, kayaking, water basketball,
volleyball, and general swimming. Adjacent to the pool is an indoor
surfing activity called the Flowrider . This unique indoor wave
machine is used to improve balance, coordination, strength, motivation,
and confidence.
PROSTHETICS
The Prosthetists and technicians at the CFI utilize a team approach
to provide state-of-the-art on-site fabrication of artificial limbs.
Standard production methods are augmented by computer assisted
technology for design, milling, and production of prosthetic devices
wireless technology for remote adjustment of upper and lower extremity
prostheses, design and fabrication of unique specialty limbs for sports
and other activities, high-tech materials in combinations of acrylic
resins, carbon fiber composites and titanium.
STAFFING
The staffing for the center was selected to provide building
provides the full spectrum of amputee rehabilitation as well as the
advanced outpatient rehabilitation for patients suffering residual
functional loss from burn injury or limb salvage procedures. The CFI is
an outpatient facility under the command and control of BAMC and
specifically the Department of Orthopaedics and Rehabilitation. The CFI
is staffed by 49 personnel including active duty Army medical staff,
Department of the Army civilians, contract providers, and nine full
time Department of Veterans Affairs employees. A recently signed MOA
between the Department of Veterans Affairs and Department of the Army
integrated seven full time Veterans Health Administration employees and
two full time Veterans Benefits Administration employees into the staff
of the CFI. Together these professionals work to maximize the patients'
rehabilitative potential and to facilitate reintegration whether that
is back to active duty or civilian life.
SCOPE OF CARE
The first priority of care at the CFI is for combat casualties who
sustain actual or functional limb loss as a result of traumatic
amputation, limb salvage procedures, or burn injury. As capacity
permits and as the circumstances of hostilities change, referral
procedures for veteran outpatients from Department of Veterans Affairs
medical centers across the country will be implemented. In concept at
the current time, these referral guidelines will provide benefits to
veterans who have sustained amputation and have not yet maximized their
potential for rehabilitation.
The CFI represents a tremendous advance in the quality of
facilities available for military and Department of Veterans Affairs
patients and providers. Much of the cutting edge technology available
at the CFI is integrated into the transitional Military Amputee
Training Center currently being built at Walter Reed Army Medical
Center.
In closing, let me again express my appreciation to the Congress,
the Intrepid Fallen Heroes Fund, and the more than 600,000 American
citizens who made the Center for the Intrepid possible. The Congress'
strong support of military and veterans' healthcare allows us to
continue a world-class amputee care program at Walter Reed Army Medical
Center and BAMC. The generosity of the Intrepid Fallen Heroes fund
allows us to continue to build on our successes in an incredible
physical setting. If you have not yet had a chance to visit the CFI and
BAMC I encourage and invite you to do so.
Mr. Chairman, thank you for inviting me here today. I look forward
to your questions.
Statement of Karyn George, MS, CRC, Service Delivery Manager
Military One Source/Severely Injured Services
Good afternoon, Mr. Chairman and members of the Committee. My name
is Karyn George and I am honored to be here. Before I begin, I need to
clearly state that my testimony is based on my personal views and does
not represent the views of the Department of Defense or the
Administration. I am a contract employee of the Department of Defense
and therefore I am a private citizen. I appear before you in that
capacity today. My statements and opinions have not been cleared by the
Department of Defense or the Federal Government. I do not speak on
behalf of the federal government, the Department of Defense, Military
OneSource, any of the Military Services, or the Military Severely
Injured Center.
Thank-you for the opportunity to present testimony on the care of
wounded servicemembers, in particular wounded servicemembers who have
sustained brain injuries, as they transition between Department of
Defense (DoD) and Department of Veterans Affairs (VA) medical care. I
will be testifying today from several perspectives. I am currently
employed by Ceridian Corporation as a Service Delivery Manager for
Military One Source/Severely Injured Services, a virtual extension of
installation services provided by DoD Military Community & Family
Policy, 24 hours a day, 7 days a week, at no cost to the servicemember
or family member. My professional and educational background includes a
Masters Degree in Rehabilitation Counseling, and over 20 years of
experience providing case management and administrative oversight of
programs designed to treat brain injuries and orthopedic impairments. I
also served as a director responsible for a 22 bed inpatient brain
injury facility, and as a consultant to start an outpatient brain
injury program in Northern Virginia. Thus, I'm bringing you a varied
perspective of one who has cared for those with mild to severe brain
trauma and other related injuries.
What I have to say today centers around the following four themes:
My experience with the Military Severely Injured and
Military OneSource
My experience with those who have sustained brain
injuries
Challenges presented along the continuum of care
My views on the best solutions to care for our wounded
and their families
As a Service Delivery Manager, I provide oversight and supervision
for the Severely Injured Specialists in the Military OneSource
Arlington, Virginia Call Center, and for on-site Counselor Advocates
placed at several Military Treatment Facilities (MTFs) and at the VA
Medical Center (VAMC) at Palo Alto, CA. The Counselor Advocates (CAs)
are charged with providing face to face advocacy, outreach, and support
to wounded servicemembers and their families, while the Severely
Injured Specialists provide telephonic advocacy, support, short term
problem resolution, and long term monitoring of the needs of wounded
servicemembers and their families. Prior to assuming this management
position, I, myself, was a Counselor Advocate at Walter Reed Army
Medical Center.
MOS/SI Services
In the fall of 2004, then Secretary of Defense Donald Rumsfeld
stated: ``I think we ought to put together a team to see that the
Services take care of their troops after they're wounded, and when they
return home and are discharged.'' Secretary Rumsfeld's statement
provided the genesis of what would become the Military Severely Injured
Center (MSIC), which was developed as a specialty service under the
Military OneSource contract. Deputy Secretary of Defense Paul Wolfowitz
further directed that OSD Personnel & Readiness provide support and
augmentation of the Service branch severely injured programs to ensure
seamless care as long as it takes. Special emphasis was placed on
support of families and on serving as a ``safety net.'' Counselor
Advocate qualifications are carefully considered. We (Ceridian) hire
masters degree trained individuals in a social service field of study
such as vocational rehabilitation, social work, or nursing, experience
with case management and disability pathways, and experience and/or
exposure to military culture. The first three Counselor Advocates were
hired in March 2005 and in April 2005, they were placed at Walter Reed
Army Medical Center. The first Military OneSource Severely Injured
Specialists were also hired in March 2005 and placed in the Arlington
call center. Training was developed collaboratively with DoD Quality of
Life personnel. Training included military treatment facility
protocols, an overview of existing Service branch injured programs, all
military and other government resources such as VA, DoL, DoD, community
resources, non-governmental organizations, case management and the
continuum of care, and tools/technology needed to be successful in
their roles providing services to the wounded and their families.
As the Counselor Advocates assimilated into the treatment
facilities, they assisted servicemembers and their families from
injury, through recovery and reintegration, back to quality of life. We
became familiar with programs, resources, and key personnel at the
medical treatment facility or VAMC. We extended ourselves to community
and government organizations gleaning knowledge of these resources as
well as education on the needs of the wounded servicemembers and their
families. I found some needs to be as small as money for groceries, to
as large as assisting a family in advocating for assessment of a yet-
to-be-diagnosed brain injury of a loved one, to exploration of
employment and/or training options for a spouse who had never entered
the job market and suddenly found herself the primary breadwinner. A
pointed comment from a wounded servicemember is that the system is a
hunt and peck process; if you know what to ask you will probably get
the services--but many do not know what to ask or do not have the
``voice'' to ask the questions. MOS severely injured staff know not
only what to ask, but who and when to ask, to ensure progress along the
continuum of care.
The CAs were able to build bridges that today still serve to assist
wounded servicemembers and their families. Counselor Advocates have
worked side by side, hand in hand with military systems, government
organizations, and community programs to meet the needs of the wounded
and their families. Another example is assisting in securing resources
for additional housing for families of the wounded while at WRAMC and
Fort Campbell, Kentucky. Counselor Advocates have facilitated a Heroes'
welcome and community support for wounded servicemembers reintegrating
into communities in at least four states working with the DoD Heroes to
Hometowns program and its American Legion partner.
I'd now like to focus on Traumatic Brain Injury. Not all injuries
bleed, and mild to moderate brain injuries are considered the ``walking
wounded''. While all injuries need special attention, the diagnosis and
treatment of TBI is complex and requires creative solutions. Traumatic
brain injury is unlike any other injury, illness, or disease.
Everyone's brain is just a little different than the next person's
brain. Therefore, two individuals with comparable insults to the brain
can produce very different long term sequelae, or consequences. With
advancements in battlefield medicine, severe brain injuries progress
along the recovery continuum from treatment in theatre, to Landstuhl,
and on home to the United States in a timely, seamless fashion. Once
medically stable and able to participate in rehabilitative services,
those wounded servicemembers with severe brain injuries most often
progress to one of the four VA Polytrauma centers. Acute, inpatient
rehabilitative care for brain injuries at the Polytrauma centers is
provided by a multi-disciplinary team. Social workers are able to
connect the servicemembers and families with the VA system and long
term benefits since these wounded will not be able to return to active
duty. When long term skilled care is necessary, the servicemember
either returns home with family members who are able to care for them,
or, if they do not have family or an appropriate support system, they
are placed in a VA long term care facility in a which was not designed
for this young population.
It should be noted that not all brain injuries sustained in theatre
are severe, and other more obvious injuries often necessitate
evacuation from theatre. These warriors receive inpatient treatment at
a MTF where mild to moderate brain injury may not be identified or
diagnosed. Once medically stable, the servicemember transitions to
outpatient status assigned to a Medical Hold or Holdover unit. Initial
symptoms may be minor or relatively non-existent, but may evolve over
time and begin to be more apparent. Headache, memory and concentration
difficulty, amnesia, sleep disturbance, reduced frustration tolerance
and impulsivity, periods of confusion or mental dullness, mood swings,
loss of self-confidence, fatigue and weakness, auditory and visual
deficits, and slow reactions are common characteristics following mild
to moderate head injury. Servicemembers with this level of brain injury
are compromised in their ability to navigate their environments and the
systems needed to make forward progress along the recovery continuum.
The servicemember is just not him/herself. Their ability to participate
in traditional therapies for orthopedic and other injuries is also
compromised. Diagnosis of brain injury is the first challenge. Usually,
there are no abnormalities on routine neurological examination. Those
closest to the servicemember with mild to moderate brain injury are
often the first ones to notice that something is not right. There are
many instances where families relate their concerns and frustrations
have been discounted by social workers, case managers, physicians,
Service branch representatives, and Command. Signs and symptoms of mild
to moderate brain injury may be confused with those of post traumatic
stress disorder. Until the servicemember has the correct diagnosis,
treatment options may not be appropriate or even offered. Once a
diagnosis has been made, the next step is to engage clinically
appropriate care for the servicemember. Social skills are a critical
indicator of success for any brain-injury survivor reintegrating into
their lives and their community. Brain injury alters social skills--the
ability to comprehend subtleties, to control emotions whether it is
anger or sadness, or possess awareness of what is right and what may
not be. These skills need to be worked on in real-life environments--
home, places of employment, church, and recreational settings--all with
the appropriate people. Only then can survivors of brain injury achieve
quality of life. The consequence of not recognizing mild to moderate
brain injury, treating it, and supporting these servicemembers and
their families 100% during recovery is that families will encounter
difficulty transitioning to quality of life. Families are at risk for
domestic failure, failure in employment environments, and failure in
social and emotional endeavors. Without treatment options and 100%
support, many of these service men and women will end up in psychiatric
units, homeless, or involved in criminal activity resulting in
incarceration.
Challenges
I think the challenge we face is the leadership, acquisition, and
coordination of all of the resources needed to help the wounded. It's
not that there aren't any existing resources--each service branch has a
severely injured program. The Army has the Army Wounded Warrior
Program, (AW2); the Marines, the Marine For Life Injured Support
Program (M4L-IS); the Navy Safe Harbor Program; and the Air Force
Palace HART Program. The VA established the Seamless Transition
Program. DoD stood up the Military Severely Injured Center and the
Heroes to Hometown program. The Department of Labor began the
ReaLifelines Program and Operation Warfighter. Countless non-
governmental organizations rallied with support of money, services, and
goods. What ensued was discord. There is no clear cut or single
definition of Severely Injured; the Army requires a wounded
servicemember to have a 30% military rating (PEB) in a single category
before they receive services from the program, and it is not unusual
for the MEB/PEB process to take 18 months to 2 years to complete. The
other Service programs are less stringent in their criteria. MOS/SI
services strive to assist those within and on the fringes of the
service definitions. I believe that not all wounded have received the
same level of care coordination after returning from theatre.
Communication between programs, NGOs, MTF resources, and VA systems is
not robust, fully defined, easily understood or consistent. At present,
the wounded and their families aren't getting the very best our country
can give them.
If I may provide an analogy: an orchestra is a family of musical
instruments each with its own distinctive sound and role. Total sound
must be in harmony. The musicians are experts in playing their
instruments but it is the conductor who sets the tempo, executes clear
preparations and beats, listens and shapes the sound of the ensemble
from the initial note to the conclusion. Similarly, the recovery
continuum begins at injury and stretches to attainment of quality of
life (an accessible home, vocational opportunities, and meaningful
relationships), and an effective recovery demands coordination. The
process of meeting the needs of the wounded requires a conductor who
orchestrates the personnel, resources, and services at the optimal
moment to advance the wounded and their families toward reintegration
and quality of life. I recall, for example, a Marine from Chicago who
was involved in a blast injury resulting in visual impairment. The CA
referred this Marine to the Defense and Veteran Brain Injury Center
(DVBIC) where he was diagnosed with a TBI. Initially not recommended
for outpatient rehabilitation, he began to have problems at work. The
Counselor Advocate was able to recognize the need for a second
evaluation which resulted in approval for outpatient treatment at a
community rehab program. After completion of the MEB/PEB process, the
Marine will return home to live with his parents where he will require
additional support until he is able to live on his own. Connected by
the CA, the family is also receiving funds from the Semper Fi Fund to
finish their basement to accommodate their son. The CA is now
addressing vocational options with VA Voc rehab and has secured
adaptive equipment and software through CAP to enhance the Marine's
quality of life. Without the orchestrated resources (MTF, DVBIC, Sharpe
Rehab, VA, CAP, Semper Fi Fund, and so forth.), and the leadership of
the conductor (CA), this Marine would still be struggling.
Recommendations
What I personally suggest is the following:
1. We need a single, central focal point for wounded and their
families. A program that goes across the ``colors'' of the various
service branches--a program to provide severely injured services that
will transcend all service branches including Guard and Reserve units,
24 hours a day, 7 days a week. This program must have clear direction
from senior level VA and DoD as well as Army, Marine, Navy and Air
Force command endorsement. The program direction must include a system
of coordination and collaboration between the VA, DoD, MTF's,individual
service branch programs, NGOs, and DoL which will support a seamless
and equitable delivery of service to all wounded men and women
returning from war.
2. We need to expand options for care of the brain injured men and
women returning from war. Existing inpatient care units are not meeting
the needs of all traumatic brain injury cases. Out-patient clinics are
too few, too far away, and not designed for this specialty population.
We need to establish collaborative and cooperative relationships
between private community based brain injury-rehabilitation programs,
DoD and the VA that will allow service men and women with TBI to
receive treatment as close to home as possible, in a setting that is
conducive to attainment of skills, and with staff that have a specialty
in brain injury rehabilitation. DoD has begun this collaboration with
the Defense and Veterans Brain Injury Center. They have established a
working relationship with Virginia Neuro Care and Lakeview Brain Injury
Programs. We need to expand this collaborative approach to include more
programs across the country. This network of providers can then
complement existing acute rehabilitation services offered by DoD and
the VA system, and expand to offer community re-entry programs.
3. Most importantly, these wounded warriors and their families
need a qualified Advocate. The Advocate must possess the skill sets to
help the families think straight, navigate through the systems, and
transition successfully from the Department of Defense care to VA
medical care and civilian communities.
Our wounded heroes have shown courage, determination and fortitude
to protect our Nation and its allies. Now it is our turn to show
courage, determination and fortitude in marshalling our very best
resources, systems and abilities to bring them home to a better quality
of life.
Statement of Carl Blake, National Legislative Director
Paralyzed Veterans of America
Mr. Chairman and members of the Subcommittee, on behalf of
Paralyzed Veterans of America (PVA), I would like to thank you for the
opportunity to testify today on an issue that we consider the signature
health crisis of the Global War on Terror. Many Operation Enduring
Freedom (OEF) and Operation Iraqi Freedom (OIF) veterans face difficult
challenges ahead as they learn to deal with traumatic brain injuries
that they have incurred during their combat service.
The Independent Budget devotes significant attention to the issue
of mental healthcare and specifically traumatic brain injury (TBI) in
the FY 2008 edition. In accordance with the policy information included
in this year's Independent Budget, most of my written statement will
reflect those points. However, I would like to focus on a few key
issues that relate to care being provided to servicemembers with
traumatic brain injury at the Department of Veterans Affairs polytrauma
centers.
Severe TBI results from blast injuries, particularly those caused
by improvised explosive devices (IED), which severely shake or compress
the brain within the skull. This often leads to significant and
sometimes permanent damage to the brain. Many servicemen and women also
experience traumatic brain injuries associated with a lack of oxygen to
the brain as they are being treated for other serious injuries.
Likewise, servicemembers who are in the vicinity of an IED blast or
involved in a minor motor vehicle accident can suffer from a milder
form of TBI that is not always immediately detected and can produce
symptoms that mimic PTSD or other mental health disorders.
Unofficial statistics also suggest that many OEF/OIF veterans have
suffered mild brain injuries that have gone undiagnosed. In many cases,
symptoms have manifested themselves after the veterans have returned
home. The Department of Defense (DoD) admits that it lacks a system-
wide approach for proper identification, management, and surveillance
for individuals who sustain mild to moderate TBI. It is essential that
VA and DoD coordinate to better address mild TBI and develop a
standardized follow-up protocol utilizing appropriate clinical
assessment techniques to recognize neurological and behavioral
consequences of TBI as recommended by the Armed Forces Epidemiological
Board.
PVA is particularly concerned about veterans who have experienced a
TBI but whose symptoms have been masked by other conditions. We have
heard anecdotally that this is a particular problem for veterans who
have incurred a spinal cord injury in the upper cervical spine.
Veterans who have incurred this level of injury as a result of a blast
incident often have experienced a traumatic brain injury as well.
However, their symptoms may be diagnosed as the result of their
significant impairment at the cervical spinal level. Unfortunately,
they may not get the critical treatment needed at the earliest stage to
address the TBI. We recognize that this is a difficult challenge facing
physicians, nurses, and rehabilitation specialists as they must decide
what condition must be treated first, even while not necessarily
realizing that other conditions exist. Furthermore, it is not uncommon
for DoD healthcare facilities to miss these masked conditions as well
because they do not have the specialized expertise to recognize
multiple severe conditions.
PVA believes more research must be conducted to evaluate the
symptoms and treatment methods of veterans who have experienced TBI.
This is essential to allow VA to deal with both the medical and mental
health aspects of TBI, including research into the long term
consequences of mild TBI in OEF/OIF veterans. Furthermore, TBI symptoms
and treatments can be better assessed for previous generations of
veterans who have experienced similar injuries.
Ultimately, it is important to point out that the care being
provided to those severely injured service men and women who have
incurred a traumatic brain injury at the VA is nothing short of
extraordinary. As explained in the Administration's budget submission
for FY 2008, in 2006, VA's Research and Development department
established a Polytrauma and Blast-Related Injury Quality Enhancement
Research Initiative (QUERI) that coordinates with the four polytrauma
centers providing advanced medical care to veterans with complex
disabilities, including traumatic brain injury. The QUERI links VA
researchers directly to the four centers located in Richmond, VA;
Tampa, FL; Minneapolis, MN; and Palo Alto, CA. These centers are
designated as level one trauma centers. These lead centers provide a
full spectrum of TBI care for patients suffering moderate to severe
brain injuries.
PVA is pleased that VA is also taking steps to establish level two
polytrauma centers in each of its remaining Veterans Integrated Service
Networks (VISNs) for follow-up care of polytrauma and TBI patients
referred from the four lead centers or from military treatment
facilities. PVA believes that the hub-and-spoke model used in the VA's
spinal cord injury service serves as an excellent model for how this
network of polytrauma centers can be used. Second level treatment
centers (spokes) refer spinal cord injured veterans directly to one of
the 21 spinal cord injury centers (hubs) when a broader range of
specialized care is needed. These new level two centers will better
assist VA to raise awareness of TBI issues. These increased access
points for TBI veterans will also allow VA to develop a system-wide
screening tool for clinicians to use to assess TBI patients.
To help facilitate access to these specialized services, VA assigns
a case manager to each OEF/OIF veteran seeking treatment at one of its
medical facilities. The case manager is responsible for coordination of
all VA services and benefits. Additionally, VA has created liaison and
social work positions at DoD facilities to assist injured
servicemembers. However, these case managers continue to report
problems related to transfer of medical records from referring military
facilities; difficulty in securing long-term placements of TBI patients
with extreme behavioral problems; difficulty in obtaining appropriate
services for veterans living in geographically remote areas; limited
ability to follow patients after discharge to remote areas; poor access
to transportation and other resources; and inconsistency in long-term
case management. The Office of the Inspector General (OIG) stated in
its July 2006 report Health Status of and Services for Operation
Enduring Freedom/Operation Iraqi Freedom Veterans after Traumatic Brain
Injury Rehabilitation that while many of the patients they assessed had
achieved a substantial degree of recovery, ``. . . approximately half
remained considerably impaired.''
Unfortunately, the ability of VA to provide this critical care has
been called into question, particularly in recent weeks. PVA recognizes
that the VA's ability to provide the highest quality TBI care is still
in its development stages; however, it continues to meet these
veterans' needs while going through this process. We believe many of
the problems highlighted in recent newspaper articles regarding the TBI
programs at the four polytrauma centers is a result of congressional
inaction. The VA is not being prepared for success by a Congress that
is not fulfilling its responsibility to properly fund it in a timely
manner. The VA is learning to do more and more with less and less every
year, and the TBI program is no exception.
We are especially concerned about whether the VA has the capacity
and the staff necessary to provide intensive rehabilitation services,
treat the long term emotional and behavioral problems that are often
associated with TBI, and to support families and caregivers of these
seriously brain injured veterans. As stated in the FY 2008 Independent
Budget:
During a September 2006 House Veterans' Affairs Subcommittee
on Health hearing, a statement was provided for the record that
indicated the 20-year healthcare costs for TBI could exceed $14
billion. As noted in the OIG report, ``these problems exact a
huge toll on patients, family members, and healthcare
providers.'' There are several challenges we face in ensuring
these veterans and their families get the specialized care and
support services they need. Clinicians indicate that in the
case of mild TBI, the [veteran's] denial of problems that can
accompany damage to certain areas of the brain often leads to
difficulties receiving services. Likewise, with more severe
injuries, the extreme family burden can lead to family
disintegration and loss of this major resource for patients.
To ensure a smoother transition for veterans with TBI and
their caregivers, VA should evaluate ways to provide additional
assistance to immediate family members of brain-injured
veterans, including additional resources and improved case
management, and continuous follow up. The goal of achieving
optimal function of each individual TBI patient requires
improved coordination and inter-agency cooperation between DoD
and VA. Veterans should be afforded the best rehabilitation
services available and the opportunity to achieve maximum
functioning so they can re-enter society or, at minimum,
achieve stability of function in an appropriate setting.
Finally, the broader VA is unlike most, if not all, other
healthcare systems in America. While the quality of care may be
outstanding during early stage treatment at some private facilities,
those same facilities generally provide care in the short term. On the
other hand, the VA is the only real healthcare system in America
capable of providing complex sustaining care over the life of the
seriously disabled veteran. Private treatment options often give no
consideration whatsoever to the long-term care needs of the veteran.
Meanwhile, the VA has developed its long-term care program across the
broad spectrum of services for many years.
Mr. Chairman and members of the Subcommittee, the task of providing
this critical care to this segment of the OEF/OIF veterans population
is a daunting one. Without coordinated efforts by DoD and VA and the
backing of Congress through the appropriations process, the VA will
struggle to adequately handle all of the expectations placed on it.
Veterans with TBI, as well as their families, should not have to worry
about whether the care they need will be there when they need it.
I would like to thank you for the opportunity to testify today. I
would be happy to answer any questions that you might have.
Statement of Adrian M. Atizado
Assistant National Legislative Director, Disabled American Veterans
Mr. Chairman and Members of the Subcommittee:
I am pleased to appear today at the request of the Subcommittee to
offer testimony on behalf of the Disabled American Veterans (DAV)
regarding the transition between the Department of Veterans Affairs
(VA) and the Department of Defense (DoD) of patients suffering from
traumatic brain injury (TBI) and Polytrauma Center Care.
Mr. Chairman, it has been said that TBI is the signature injury of
the Iraq war. Blast injuries that shake or compress the brain within
the closed skull often cause devastating and permanent damage to brain
tissue. Recently I had the opportunity to view a VA-produced DVD about
the impact of TBI on a young veteran who served in Iraq. The film is a
poignant illustration of the extreme physical and emotional challenges
faced by one brain-injured veteran and his family. Like many other
severely disabled veterans, that veteran will need a lifetime of care
for his injuries. In our opinion, his ongoing rehabilitation and
personal struggle to recover is the best justification imaginable for
continuation of a strong and viable VA healthcare system. We urge
Congress to remain vigilant to ensure that VA programs are sufficiently
funded and are adapted to meet the unique needs of Operations Iraqi and
Enduring Freedom (OIF/OEF) combat service personnel and veterans, while
concurrently addressing the needs of older veterans with severe
physical disabilities as well as PTSD and other combat-related mental
health challenges.
Traumatic Brain Injury
Veterans with severe TBI and polytrauma will require extensive
rehabilitation and lifelong personal and clinical support, including
neurological, medical and psychiatric services, and physical, psycho-
social, occupational, and vocational therapies. In an attempt to raise
awareness of TBI issues, VA requires mandatory training of all
healthcare professionals via a web-based independent study course.
However, VA has not yet begun screening all its patients for TBI who
are veterans of the Global War on Terror. We note the Secretary's press
announcement of February 27, 2007, indicates VA has launched a new
nationwide TBI initiative which includes a TBI course that is mandatory
for all healthcare professionals, establishing a panel of outside
experts to review VA's complete polytrauma system of care, including
its TBI program, and beginning this spring VA will initiate a program
at all 155 VA medical centers to screen all patients who served in the
combat theaters of Iraq or Afghanistan for TBI. VA also announced on
March 6 that it plans to hire 100 new patient advocates to help
severely injured veterans and their families navigate VA's systems for
healthcare and financial benefits. The veterans service organization
(VSO) community has not been briefed on what changes VA has made in its
approach to this problem, but we are encouraged that the Secretary
seems to be cognizant that the Independent Budget VSOs (IBVSOs) made a
series of recommendations on this topic in our most recent Independent
Budget document, and that he is acting early to get VA moving ahead.
The VA's Office of the Inspector General (OIG) issued a revealing
report in July 2006, titled: ``Health Status of and Services for
Operation Enduring Freedom/Operation Iraqi Freedom Veterans after
Traumatic Brain Injury Rehabilitation.'' The report assessed healthcare
and other services provided for VA patients with moderate-to-severe TBI
and then examined their status approximately 1 year following discharge
from inpatient rehabilitation. The OIG found that improvement and
better coordination of care were needed so veterans could make a
smoother transition between DoD and VA healthcare services. The report
called for additional assistance to immediate family members of brain-
injured veterans, including improved case management and additional
caregiver support services.
The importance of caregiver support and assistance is noted in the
July 2006 OIG report which states, ``Unlike with other types of injury,
brain injury often causes emotional difficulties and behavioral
problems which can be long lasting. These problems exact a huge toll on
patients, family members, and healthcare providers.'' Family care is
clearly a critically important factor in patient recovery and ability
to live at home, and that the lack of family support contributes to low
functioning of TBI patients. With more severe injuries, the extreme
family burden can lead to family disintegration and loss of this major
resource of continuing care for veterans. Without question there are
many challenges we face in ensuring these veterans and their families
get the specialized care and support services they need.
Congress passed a caregiver assistance pilot program in section 214
of Public Law 109-461, but it is likely that VA is only in the early
implementation phase of this program. It is a small program, limited to
$5 million per year over a 2-year period, but the potential in-home
assistance provided through that program could be of great help to
relieve many families caring for severely injured veterans from Iraq
and Afghanistan. In light of the current situation wherein VA is
authorized to provide family and caregiver support in very limited
situations, we hope the Subcommittee will urge VA to quickly move
forward on this pilot program and that Congress will provide oversight
and properly assess and adjust or extend the program as needed. A focus
group, which includes family caregivers, should be established to
evaluate the effectiveness of the pilot program, and to gather input
regarding gaps in services and how the program can better meet the
needs of these veterans' families and direct caregivers.
We are pleased that VA has designated TBI as one of its special
emphasis programs and is committed to working with DoD to provide
comprehensive acute and long-term rehabilitative care for veterans with
brain injuries. VA reports that it is tailoring its programs to meet
the unique needs of severely injured OEF/OIF veterans by assigning case
managers to each TBI and polytrauma patient and putting a greater
emphasis on understanding the problems of families during the initial
care and long-term rehabilitation of these patients. VA also plans to
utilize video conferencing that will allow top specialists to take an
active role in the treatment of patients living in remote areas.
However, we remain concerned about the level of support families and
caregivers of these seriously brain-injured veterans receive as well as
the caseload of clinical and social work case managers, particularly
when effective case management ensures quality medical care and
efficient use of healthcare resources.
Mild Traumatic Brain Injury
Military service personnel who sustain catastrophic physical
injuries and suffer severe TBI are easily recognized. However, VA
experts note that TBI can also be caused without any apparent physical
injuries when a veteran is in the vicinity of improvised explosive
device (IED) detonation where explosives jar the brain. Veterans
suffering a milder form of TBI may not be detected immediately but
symptoms can range from headaches to irritability and from sleep
disorders to memory problems and depression. It is believed that many
OEF/OIF soldiers and marines have suffered mild brain injuries or
concussions that have gone undiagnosed, and that symptoms may only be
detected when these veterans return home.
Our concern about emerging literature that strongly suggests that
even ``mild'' TBI patients may have long-term mental and other health
consequences is heightened by problems identified in the aforementioned
OIG report. According to VA's mental health experts mild TBI can
produce behavioral manifestations that mimic PTSD or other mental
health symptoms and the veteran's denial of problems that can accompany
damage to certain areas of the brain, often leads to difficulties
receiving services. The DoD has revealed that it still lacks a system-
wide approach for identification, management, and surveillance of
individuals who sustain mild-to-moderate TBI, in particular those with
the mild version. Therefore, theIBVSOs believe VA should coordinate
with DoD to better address mild TBI and concussive injuries and develop
a standardized protocol utilizing appropriately formed clinical
assessment techniques to recognize neurological and behavioral
consequences of TBI, as recommended by the Armed Forces Epidemiological
Board.
Also, the influx of OEF/OIF servicemembers returning with brain
injury and trauma has increased opportunities for research into the
evaluation and treatment of such injuries in newer veterans; however,
we suggest that any studies undertaken by VA and DoD include older
veterans of past military conflicts who may have suffered similar
injuries that thus far have gone undetected, undiagnosed, and
untreated. Their experiences could be of enormous value to researchers
interested in the progression of these injuries on a long term basis.
Likewise, such knowledge of historic experience could help both DoD and
VA better understand what is needed to improve screening, diagnosis and
treatment of mild TBI in the newest generation of combat veterans.
Polytrauma Centers and Access to Care
For well over a decade the VA has used multiple approaches to
provide specialty care to veterans and active duty members having
sustained a traumatic brain injury. Established in February 1992, the
Defense and Veterans Head Injury Program (DVHIP) was restructured in
2002 as the Defense and Veterans Brain Injury Center (DVBIC). This
program helps to ensure that all military servicemembers and veterans
with traumatic brain injury receive TBI-specific evaluation, treatment,
and follow-up through ten sites, which includes VA's TBI lead centers.
Currently VA has four designated TBI facilities collocated with its
polytrauma centers: in Minneapolis, Minnesota; Palo Alto, California;
Richmond, Virginia; and Tampa, Florida. These TBI lead centers provide
a full spectrum of TBI care for patients suffering from moderate to
severe brain injuries. VA has established 18 ``polytrauma network
sites''and is also establishing polytrauma support clinic teams in each
of its Veterans Integrated Service Networks (VISNs) for follow-up care
of polytrauma and TBI patients referred from the four lead centers or
directly from military treatment facilities.
We are encouraged by VA's response to the growing demand of TBI
care with the increasing number of TBI initiatives; however, resources
required to operate an effective VA polytrauma network are subject to
the needs of other programs and services at the local level.
Accordingly, we remain concerned about system capacity in terms of
space, resources and particularly staffing, and whether VA has fully
addressed these factors to provide intensive rehabilitation services,
treat the long-term emotional and behavioral problems that are often
associated with TBI, and to support families and caregivers of these
seriously brain injured veterans. It is imperative that in addition to
its intensive inpatient brain injury rehabilitation program, VA must
ensure proper establishment of an equally rigorous and complementary
outpatient brain injury program.
To facilitate access to services, VA assigns a case manager to each
OEF/OIF veteran seeking treatment at one of its medical facilities. The
case manager is responsible for coordinating all VA services and
benefits. Additionally, VA has hired liaison/social workers at DoD
facilities to assist injured servicemembers. In interviewing case
managers, the OIG found several problems that warrant attention. Case
managers reported continued problems related to transfer of medical
records from referring military facilities; difficulty in securing
long-term placements of TBI patients with extreme behavioral problems;
difficulty in obtaining appropriate services for veterans living in
geographically remote areas; limited ability to follow patients after
discharge to remote areas; poor access to transportation and other
resources; and inconsistency in long-term case management. The report
found that while many of the patients assessed had achieved a
substantial degree of recovery, ``. . . approximately half remained
considerably impaired.'' The report concluded that improved
coordination of care is necessary between agencies, and that families
need additional support in the care of TBI patients.
The IBVSOs are concerned about increasing number of media accounts
and reports from veteran patients with TBI and their family members who
claim that access to VA care for TBI is not up to par or non-existent--
requiring them to seek rehabilitation services in the private sector.
We encourage VA and Congress to address these types of complaints to
ensure severely wounded TBI veterans are receiving the best
rehabilitative care available. Numerous studies show that any delay in
providing comprehensive rehabilitation is a distinct predictor of long-
term outcomes for veterans suffering from TBI. The need for early
rehabilitative intervention is well justified and can avoid further
deterioration of these veterans in future years.
The DoD and VA share a unique obligation to meet the healthcare and
rehabilitative needs of veterans who are suffering from readjustment
difficulties as a result of combat service, and those who have been
wounded as a result of a TBI. Therefore, the DoD, VA, and Congress must
remain vigilant to ensure that federal programs are sufficiently funded
and adapted to meet the unique needs of the newest generation of combat
service personnel and veterans, while continuing to address the needs
of older veterans. We hope the Secretary's recent announcement of a new
VA focus on TBI will lead VA in a more coordinated direction with
respect to these particular challenges. Further, in The Independent
Budget for Fiscal Year 2008, our organizations have made a number of
specific recommendations to Congress and VA based on the issues
discussed today in my testimony. We invite you to consider them as you
develop your legislative and oversight plans for the 110th Congress.
Mr. Chairman, this concludes my statement. I will be happy to
address any questions this Committee may have.
Statement of Thomas Zampieri, Ph.D.
Director of Government Relations, Blinded Veterans Association
Introduction
Mr. Chairman and members of the House Veterans Affairs Subcommittee
on Health, on behalf of the Blinded Veterans Association (BVA), thank
you for this opportunity to present BVA's legislative concerns on the
topic ``Poly Trauma Center Care and the TBI Patient: How Seamless is
the Transition Between VA and DoD and Are Needs Being Met?'' BVA is the
only Congressionally chartered Veterans Service Organization
exclusively dedicated to serving the needs of our Nation's blinded
veterans and their families. This past year BVA has developed
increasing concern over improving VHA's ability to provide the full
continuum of both inpatient and outpatient rehabilitative service
programs and to increase resources to be commensurate with the growing
numbers of wounded and injured entering the VA healthcare and benefits
system from Department of Defense (DoD) care. The issue of Traumatic
Brain Injury (TBI) is of paramount concern to BVA. We appreciated this
hearing as a step in working together on improving the system.
Types and Causes of TBI
Last year, articles appeared and DoD reported that more than 11,852
returning wounded had been exposed to blast injuries, the most common
being from IEDs. This is an astounding number when one considers that
as of March 8, 2007, there was a reported 23,417 traumatic combat
injuries. TBI has become the ``signature injury'' of Operation Iraq
Freedom (OIF) and Operation Enduring Freedom (OEF) operations.
As BVA reported in our previous testimony on September 20, 2006,
blast-related injury is now the most common cause of trauma in Iraq.
One study found that 88 percent of the military troops treated at an
Echelon II medical unit in Iraq were from IED blasts. Of those, 47
percent suffered TBI injuries. Data from the screening of 7,909 Marines
with the 1st Marine Division showed that 10 percent of them suffered
from TBI-related injuries 10 months after returning from Iraq. At Fort
Irwin, 1,490 soldiers were screened last May with almost 12 percent of
them having suffered concussions resulting in mild to moderate TBI
injuries.
One statistic frequently overlooked and reported by the Iraq
Coalition Casualty Count website is that of the men and women wounded,
only 7,005 have required Aeromedical evacuation. A reported 6,835 non-
hostile injured required Aeromedical transportation. As in the history
of many previous conflicts and wars in our history, more servicemembers
(18,704) have been evacuated by air from Iraq due to medical diseases.
The reason BVA points to this data is that a large percentage of those
wounded and injured in Iraq (16,412) are Returned to Duty (RTD). These
troops usually complete the full tour in Iraq before redeploying back
to the base of departure. Those mild to moderately TBI-injured are,
therefore, at very high risk of not being screened for complications of
TBI upon return. The previous data outlined in this section were only
random screenings done. They were not mandated by DoD and, according to
the article detailing this issue, there is actual resistance to any
standardized screening programs of all servicemembers who have
sustained mild to moderate TBI-type concussions.
More than 1,882 of the total moderate to severe TBI-injured tracked
from January 2003 to January 2007, by the Defense and Veterans Brain
Injury Center (DVBIC) have sustained moderate enough TBI to result in
neurosensory complications. Epidemiological TBI studies have found that
about 30 percent of the injured have associated visual disorders of
diplopia, convergence disorder, photophobia, ocular-motor dysfunction,
and the inability to interpret print. Some TBIs have resulted in legal
blindness and other manifestations known as Post-Trauma Vision Syndrome
(PTVS). BVA applauds the efforts of the Defense and Veterans Brain
Injury Center (DVBIC), which has worked hard to develop an extensive,
multidisciplinary TBI team that will test all of the wounded arriving
at both Walter Reed Army Medical Center and the National Naval Medical
Center where reportedly 28% of all wounded have sustained TBI. We
support these efforts but also call attention to the need for
additional funding and resources to continue the collaborative efforts
of this ongoing program between DoD and several VA medical treatment
facilities.
As most members of this Committee know, a study in early 2006 by
researchers at Harvard and Columbia revealed that the cost of medical
treatment for servicemembers with TBI would be at least $14 billion
over the next 20 years. This is a conservative estimate. The now famous
Linda Bilmes' ``Long Term Costs of Providing Veterans Medical Care and
Disability Benefits,'' published by Harvard on January 5, 2007, states
the following: ``The budgetary costs of providing disability
compensation benefits and medical care to the veterans from Iraq and
Afghanistan over the course of their lives will be $350-$700 billion,
depending on the length of deployment of U.S. soldiers, the speed with
which they claim disability benefits, and the growth rate of benefits
and healthcare inflation.''
While some argue over the exact numbers utilized for the
aforementioned report, it is clear that additional wounded are being
added to the counts each week. After factoring in lost wages of the TBI
servicemember, family caregivers, various VBA benefits, long-term
disability and healthcare costs, specialized prosthetics and adaptive
equipment, various other state and other federal support programs
involved in providing services, BVA argues vehemently that these
figures are probably an accurate starting point for cost estimates for
the wounded--medical complications and mental health problems--from OIF
and OEF operations.
BVA emphasizes once again to this Committee that, in addition to
the above concerns, data compiled between March 2003 and April 2005
found that 16 percent of all causalities evacuated from Iraq had direct
eye injuries. Walter Reed Army Medical Center has surgically treated
approximately 700 soldiers with either blindness or moderate-to-severe
significant visual injuries. The National Naval Medical Center has a
list of more than 450 eye injuries that have required surgery. VA
reports that although 42 of these servicemembers have attended one of
the ten VA Blind Rehabilitation Centers, 88 are enrolled in local VA
Blind VIST Services. Others are in the process of being referred. It
should be obvious to members of this Committee that a new generation of
visually impaired, low-vision, or legally blinded veterans with PTVS
and complex neurological injuries will require a lifetime of
specialized services. TBI veterans (and their family members) injured
in blasts will require individualized rehabilitation programs that
could utilize the expertise from the wide variety of currently
available federal, state, and community resources.
Risks and Complications of Undiagnosed TBI
The lack of effective screening programs, coupled with inaccurate
diagnosis and treatment of TBI and its associated PTVS conditions, may
impair veterans' ability to perform basic activities of daily living.
If early detection and treatment are not initiated, further
consequences include increased unemployment, failure to succeed in
educational programs pursuits, greater dependence on government
assistance programs, depression and other psychosocial complications,
and homelessness. The effects of TBI on the veteran may be extended to
family members. It is well known that TBI causes intense stresses in
family and interpersonal relationships. All policy plans should
incorporate strong family support programs
Neurological Impact of Post-Traumatic Vision Syndrome
Perception plays a significant role in the way in which one
approaches life. Perception aids in providing information about the
properties of one's environment. It also allows one to act in relation
to those properties. In other words, perceptions allow individuals to
experience their environment and live within it. They perceive the
composition of their environment by a filtered process that occurs
through a complex neurological visual system. Although all senses play
a significant role, the visual system is one of the most important.
With various degrees of visual loss, the visually impaired are no
longer able to clearly adjust and see their environment, resulting in
increased risk of injuries, loss of functional ability, and employment.
Impairments range from losses in the visual field and visual acuity to
loss of color vision and the ability to recognize faces. There are
numerous ways in which one can acquire visual deficits. One leading
cause is injury to the brain. Damaging various parts of the brain can
lead to specific visual deficits. Although some cases have reported
spontaneous recovery, complete recovery is unlikely unless there is
early intervention. Current complex neuron-visual research is being
conducted in an attempt to improve the likelihood of recovery when
there is long-term follow up with specialized adaptive devices and
prescriptive equipment.
The brain is the most intricate organ in the human body. One of the
greatest complexities of the brain involves the visual pathways within
its structure. Due to the interconnections between the brain and the
visual system, damage to the brain can bring about various cerebral/
visual disorders. The visual cortex has its own specialized
organization, causing the likelihood of specific visual disorders if it
is damaged. The occipitotemporal area is connected to the ``what''
pathway. Thus, injury to this ventral pathway leading to the temporal
area of the brain is assumed to affect the processing of shape and
color. This can make the perception and identification of objects
difficult. The occipitoparietal area (posterior portion of the head),
is relative to the ``where'' or ``action'' pathway. Injury to this
dorsal pathway leading to the parietal lobe will increase the
likelihood of difficulties in position (depth perception) and/or
spatial relationships. In cases of injury, one will find it hard to
determine an object's location due to impaired visual navigation. In
addition, it is highly unlikely that a person with TBI will have only
one visual deficit. There is usually a combination of deficits due to
the complexity of organization between the visual pathway and the
brain. The most common cerebral/visual disorder following brain injury
involves visual field loss. The loss of peripheral vision can be
sufficiently severe as to result in legal blindness, requiring specific
visual field testing to correctly diagnose the loss and to prescribe
the devices to adapt to it.
Current and Future Programs for Comprehensive Services
BVA recommends an immediate and timely implementation of the full
continuum of outpatient services for all visually impaired veterans
through the following programs: Blind Rehabilitation Outpatient
Specialists (BROS), Visual Impairment Center To Optimize Remaining
Sight (VICTORS, which is a specialized low-vision optometry program),
and the Visual Impairment Services Outpatient Rehabilitation Program
(VISOR). Implementing Secretary Nicholson's directive of January 2007
could assist in the early screening for neurological complications
affecting the vision of servicemembers and veterans with a high risk or
history of TBI.
Visual Impairment Services Outpatient Rehabilitation (VISOR)
VISOR is a highly successful outpatient 9-day rehabilitation
program. It offers screening, skills training, orientation and
mobility, and low-vision therapy. The approach combines the features of
a residential program with those of outpatient service delivery. A VIST
Coordinator with credentials in the low-vision field manages the
program staff, which consists of a certified BROS trained in
Orientation and Mobility. Rehabilitation Teachers and Low-Vision
Therapists are also essential components of the teams. VHA has approved
central funding for three years to establish a VISOR program in each
network. We therefore request that Congress provide the funding to
ensure delivery of this service. Because new programs often face
internal fierce budget competition and planned program sections are
often cut or delayed, we ask for $16.5 million for 3 years to ensure
that VISOR can be fully implemented.
Visual Impairment Center to Optimize Remaining Sight (VICTORS)
Another important model of service delivery that does not fall
under VA Blind Rehabilitation Service is VICTORS, an innovative program
operated by VA Optometry Service. VICTORS has been successful for more
than 15 years. This special low-vision program is designed to provide
low-vision services to veterans, who, although not legally blind,
suffer from some degree of visual impairment. Veterans must generally
have a visual acuity of 20 over 70 or less to be considered for this
service.
VICTORS typically involves a short (5-day) outpatient program in
which the veteran undergoes a comprehensive, low-vision evaluation.
VICTORS can be established in any VA Medical Center outpatient eye
clinic area. The low-vision optometrists found in VICTORS programs are
have the specialized skills necessary for assessing, diagnosing,
treating, and managing the cases servicemembers with TBI or other
aforementioned low-vision injuries. The Palo Alto VA Poly Trauma Center
and Eye Clinic has already initiated the screening of TBI veterans,
reporting that 20 percent of all admissions had some form of PTVS that
required adaptive devices and technology.
VHA plans at least eight new VICTORS programs during FY 2007-2008.
All should be fully implemented by the end of that timeframe. BVA
strongly supports current VHA plans to increase the number of part-
time, Low-Vision Optometrists and Low-Vision Ophthalmologists in the
new VISOR and VICTORS programs. VISOR and VICTORS are high-quality,
cost--effective outpatient programs that screen, diagnosis, treat, the
expanding TBI population. The programs also conduct effective follow-up
after treatment. We reiterate our appreciation that new services are
being funded from existing accounts within VHA over the next 3 years
but would urge Congress to appropriate the necessary $16.5 million each
year to support the full implementation of these most vital services
for blind and visually impaired veterans.
Vision Rehabilitation Needs at VA/DoD Facilities
To better meet the current Traumatic Brain Injury/Low Vision
rehabilitation demands, increased access to specialty care at both DoD
and VHA Poly Trauma medical facilities is a must. Such access requires
a team of vision rehabilitation providers that includes TBI/Low-Vision
Rehabilitation Trained Optometrists, Neuro-Ophthalmologists, Low-Vision
Therapists, and Blind Rehabilitation Outpatient Specialists located at
each DoD TBI and VHA Polytrauma Rehabilitation Network site. These
highly specialized eye care providers will require education, training,
and consultation from TBI vision rehabilitation experts in universities
with the appropriate experience so that they can appropriately
diagnose, treat, and provide high-quality vision rehabilitation
services.
Electronic Health Records
BVA is very concerned about the growing backlog caused by the lack
of substantial progress in the exchange of healthcare records. We
believe that DoD and VA must speed up the development of electronic
medical records that are interoperable and bi-directional, allowing for
a two-way electronic exchange of health information and occupational/
environmental exposure data. Our military personnel are still in
theaters of operation and the numbers of wounded grow each week, but
the continued delays in getting complete medical, surgical, and
diagnostic records to VHA and VBA are inexcusable. The joint electronic
medical records should include an easily transferable electronic DD214
forwarded from DoD to VA. This would allow VA to expedite the claims
process and give the servicemember faster access to healthcare and
other critical benefits. The Armed Services Committees and VA
Committees should set clear benchmarks for full implementation. They
should then budget accordingly.
State Programs and Additional Federal Programs
Current estimates reveal that at least 5.3 million Americans
require long-term or lifelong assistance in performing activities of
daily living as a result of TBI. Each year 50,000 Americans die,
235,000 are hospitalized, and 1.1 million visit emergency rooms from
such injuries. The estimated total cost, both direct and indirect, of
such injuries is in the neighborhood of $56.3 billion. The problems
that confront us today, therefore, are not new to other state and
federal agencies that have tried to deal with them in the past.
Individuals who have suffered TBI, along with their families, are
often faced with the challenge of improper diagnosis, an inability to
access support or rehabilitation services, institutional segregation,
unemployment, and the daunting task of navigating complicated multiple
layers of county, state, and federal agency services. TBI patients and
their families face even greater challenges in rural regions of the
country where specialized services are sorely lacking. Returning
servicemembers are not immune to these challenges as DoD reports that
20 percent of the wounded are from communities with a population less
than 20,000.
Recognizing the large number of individuals and families struggling
to access appropriate and community-based services, Congress authorized
the Federal TBI Program in the TBI Act 1996 (PL 104-166). The TBI Act
1996 launched an effort to conduct expanded studies and to establish
innovative programs for TBI. It gave the Health Resources and Services
Administration (HRSA) authority to establish a grant program for states
to assist HRSA in addressing the needs of individuals with TBI and
their families. It also delegated responsibilities in the areas of
research, prevention, and surveillance to the National Institutes of
Health and the Centers for Disease Control and Prevention.
Title XIII of the Children's Health Act of 2000 (P.L. 106-310)
reauthorized the programs of the TBI Act 1996. The TBI Act
reauthorization also recognized the importance of Protection and
Advocacy (P&A) services for individuals with TBI and their families by
authorizing HRSA to make grants to state P&A systems. The HRSA Maternal
and Child Health Bureau administers the federal TBI Program. From an
original appropriation of $8,910,000, the final FY 2006 allocation for
the TBI Program was $8,467,448. This year, as well as in recent
previous years, key Members of Congress supportive of this meager
funding have had to fight for even small appropriations. In view of the
statistics presented in this testimony, we fully support the requested
$15 million recommended for HRSA TBI State Grants Program, and Center
for Disease Control and Prevention (CDC) TBI Surveillance, Registries,
Prevention and National Education/Public Awareness $9 million in FY
2008 and ask for your support.
Traumatic Brain Injury Technical Assistance Center (TAC)
The Federal TBI Program supports a TBI TAC at the National
Association of State Head Injury Administrators. The TBI TAC was
established to help states in the planning and development of effective
programs that improve access to health and other services for
individuals with TBI and their families. TBI TAC staff specialists
provide states with individualized technical assistance. Additionally,
the TBI TAC develops and disseminates a variety of specialized
documents and initiatives for the federal TBI Program. For example, TBI
TAC has developed a set of benchmarks that can be used by grantees to
assess their progress in meeting program goals and objectives. The TBI
TAC is also developing outcome measures that the program will be able
to use to better assess the impact of TBI state and Protection and
Advocacy grants on people-centered services and sustainable systems
change.
Collaboration
BVA believes that the federal TBI TAC program should become a
partner with DoD and VA leadership in the coordination of existing
programs, thus bringing about a more multidisciplinary approach. The
program already provides for the collaboration and communication
between various governmental, professional, and private organizations
representing leaders and policymakers concerned with TBI-related
issues. On February 12, 2007, VA Secretary Nicholson announced that VA
would begin partnering with the National Association of State Directors
of Veterans Affairs (NASDVA) to improve communication and coordination
of services. It would seem that this new effort in Seamless Transition
should incorporate the Federal TBI TAC program experience. Doing so
would greatly benefit veterans and all Americans with TBI as they
receive people-centered services and best practices learned from a
variety of ongoing research activities.
Oversight
The oversight priority should be to ensure that VHA has the ability
to provide the full scope of preventative and acute rehabilitation care
services. The expansion of these TBI specialized services provided by
VHA are critical now to meet the demands from OIF and OEF injuries, to
maximize independence, and to prevent costly misdiagnosis. These
critical Low Vision and Blind outpatient programs must be fully funded
as outlined since they can provide urgently needed screening,
treatment, and follow-up services. Mr. Chairman, the fact that the
milder to moderate TBI injury cases are not being screened at many DoD
bases is not acceptable. Members of this Committee should work with
other members of Congress to correct this deficiency. Under the model
we propose, the objective is to develop TBI patient and family-centered
measurements of individual functional abilities and then determine how
those abilities can be maximized through various rehabilitative,
vocational, educational, and employment services among DoD and VA.
Resources are infused into federal, state, and local programs to ensure
that such programs provide accessible treatment, rehabilitation, and
continued follow-up services.
Conclusions
Mr. Chairman, thank you for this opportunity to submit our
testimony for the record. BVA is extremely concerned that TBI-injured
veterans and family members from OIF, OEF, and previous wars are not
able to access the full continuum of services discussed here today. The
future strength of our Nation depends on the willingness of young men
and women to serve in our military, and that willingness depends in
part on the willingness of our government to meet its full obligation
to them as veterans. Waiting will only increase the problems and
expenses associated with this growing policy problem. This complex
healthcare issue has probably been one that long ago should have
received more emphasis and attention. Only when the recent media
spotlight forced it to the top of the agenda did it seem to rise to the
radar screen for most Americans. More research, screening, treatment,
and family support must occur. Improvements in rehabilitative
outpatient services and increased public awareness of such available
services are a must.
Recommendations
1. Authorize the $300 million in additional funding for the
development of designated TBI/VA Poly Trauma Centers to provide
veterans with comprehensive specialized inpatient and outpatient
rehabilitative services; ensure accreditation of these specialized
programs; provide educational funding for staffing; expand vocational
and educational programs for veterans with TBI; support caregiver
programs with family support counseling; improve case management; and
develop best practices.
2. Support an increase of $19.5 million for the Defense and
Veterans Brain Injury Center in the Defense authorization for FY 2008.
BVA believes that Congress should ensure high quality ongoing screening
of those at risk of TBI by their previous exposure history. DoD and VA
primary clinical medical staff should be educated on the
identification, history, diagnosis, and appropriate consultation
management of the TBI servicemember.
3. The federal TBI TAC Program should partner with DoD and VA. The
program already partners with other federal representatives in the
coordination of existing regulations, funding, and services to best
meet the needs of our veterans and their family members. Such
partnerships provide for effective collaboration and communication
among various governmental, professional, and private organizations
representing leaders and policymakers concerned with TBI-related
issues.
4. Congress must mandate with specified time benchmarks a single,
bi-directional, electronic healthcare record system for a truly
efficient Seamless Transition. DoD and VA must implement a mandatory
single separation physical examination, including a copy of DD 214, as
a prerequisite to prompt completion of the military separation process.
They should suggest a pilot joint DoD/VA medical and benefits
transition service in which the severely injured and their families
would have both DoD and VA benefits teams at these major medical
treatment facilities.
5. To better meet the current Traumatic Brain Injury/Low Vision
rehabilitation demands, access to this specialty care needs to be
improved. This requires a team of vision rehabilitation providers that
includes TBI-Low Vision rehabilitation-trained optometrists, Low Vision
Therapists, and BROS at each Lead TBI and VHA Polytrauma Rehabilitation
Network Site. These eye care providers will require education and
training from TBI-vision rehabilitation experts. Because VA has reduced
clinical continuing education funding for many non-physician
occupations, BVA urges increased budgeting and oversight on this type
of care by the Committee members.
6. Develop an accurate TBI registry of individuals with mild,
moderate, and all severe head injuries; increase the ability to provide
excellent vision rehabilitation care to optimize outcomes for patients
with TBI; and incorporate clinical research to document findings,
analyze data, and publish results so that TBI/Low Vision rehabilitation
of OIF/OEF veterans may continually improve.
Statement of Debra Braunling-McMorrow, Vice President
Acquired Brain Injury Diversification, MENTOR Network
Chairman Michaud, Ranking Member Miller and members of the
Subcommittee, my name is Dr. Debra Braunling-McMorrow. I am a licensed
clinical psychologist and am the Vice President of Acquired Brain
Injury Service Diversification for The MENTOR Network. Thank you for
the opportunity to provide testimony today.
The MENTOR Network is proud to be the largest, most diversified,
and experienced provider of after hospital rehabilitation and support
services for individuals with Traumatic Brain Injuries (TBI) in the
United States. We currently offer specialized Neurorehabilitation,
Neurobehavioral, and long-term Supported Living services in 13 states,
including Illinois, Florida, Tennessee and Massachusetts.
Many of our TBI services are an outgrowth of the Center for
Comprehensive Services (CCS), a partner of The MENTOR Network. CCS,
based in Carbondale, Illinois, is a nationally recognized, post-acute
brain injury rehabilitation program that was founded in 1977. It is
widely recognized as the first of its kind in the United States and is
noted for its innovative services and ability to help participants
achieve life-altering outcomes and remarkable levels of recovery.
As you know, Traumatic Brain Injury is the signature injury of the
war in Iraq, primarily due to the number of blast injuries that have
occurred from improvised explosive devices. Estimates suggest that as
many as 10 percent of servicemen and women who serve in the conflict
will be diagnosed with a brain injury. That's 150,000 Americans who
will be coping with the aftermath of a brain injury.
We can expect, based on our experience treating civilians, that of
those servicemen and women who suffer a brain injury, approximately 80
percent will suffer a mild brain injury and anywhere from five to 20
percent will be diagnosed with severe brain trauma that results in
long-term disabilities. It should be noted, however, that the
proportion of severely injured may be higher than average given the
increased risk factors for active duty servicemembers.
In addition to facing the challenges of caring for an influx of
injured service men and women, military hospitals and Veterans
Administration facilities are also coping with the challenges of
transforming hospitals and rehabilitation centers designed primarily as
orthopedic centers of excellence into neurotrauma units to meet the
unique needs of those injured in this war.
The military has established four polytrauma units across the
country that specialize in the care of soldiers with brain injuries.
These centers, along with the 21 satellite polytrauma units, are highly
regarded in the brain injury community and do a remarkable job during
the acute phase of care.
However, long term recovery requires both excellent hospital care
and continued access to a range of treatment models after discharge.
Access to community-based residential, outpatient, or in-home support
is critical to ensuring that these individuals achieve the highest
level of recovery possible.
Programs that focus on maximizing quality of life and encouraging
the development and the practice of life skills will help
servicemembers and their families adjust to the realities of living
with a brain injury. Providing these services in their home communities
also ensures that those going through rehabilitation and their loved
ones have family support to make the journey easier.
After caring for thousands of individuals we know first hand the
remarkable difference access to rehabilitative therapies can make in
the quality of life for Americans with brain injuries. The difference
in recovery level for individuals who have access to these services
versus the recovery level for individuals who don't is startling.
Individuals who have consistent access to comprehensive rehabilitative
services after their initial hospitalization are less likely to be
placed in a long-term care facility or be permanently disabled. They
have a better chance of returning to their families and leading
fulfilling lives.
Not only is providing these services the right thing to do for our
returning heroes, it makes sense from an economic perspective as well.
Our nation's long-term care facilities are already straining from the
demands of an aging population. Providing rehabilitative services that
allow our servicemen and women to return to their homes will reduce the
pressure on an already overburdened system and reduce the number of
individuals who require significant ongoing financial assistance.
As a nation we have an obligation to these men and women to do
everything we can to help them recover.
The MENTOR Network and other private providers like it stand ready
to join with the VA to serve our returning servicemen and women in
their home communities. Together we can ensure that these returning
soldiers receive the comprehensive care they deserve.
Thank you.
Statement of Kimo S. Hollingsworth, National Legislative Director
American Veterans (AMVETS)
Chairman Michaud, Ranking Member Miller, and members of the
Subcommittee:
Thank you for the opportunity for American Veterans (AMVETS) to
share its views on Traumatic Brain Injury.
Mr. Chairman, the term polytrauma has been utilized for years in
the private medical sector. Since 2001, the term has become common
among U.S. military doctors in describing the seriously injured
soldiers returning from Operation Iraqi Freedom (Iraq) and Operation
Enduring Freedom (Afghanistan). The fact that this Subcommittee is
holding a hearing on the existence of polytrauma injuries is a tribute
to improved protection for our servicepersonnel and also on the
advancements in medicine. In previous wars, personnel with multiple
injuries did not have the prospects of surviving these types of
injuries.
On today's battlefield, polytrauma often results from blast
injuries sustained by improvised explosive devices, or by other
exploding devices such as a rocket-propelled grenade or landmines. In
many of these incidents the injuries are readily apparent because the
injuries are directly related to exploding fragments or debris. Often
overlooked are injuries that result to the brain from high-pressure
waves or other non-evasive blows to the head. It has been reported that
approximately 60 percent of injured servicepersonnel will have some
degree of TBI. There VA currently utilizes four clinics that specialize
in polytrauma--Minneapolis, Minnesota, Palo Alto, California, Richmond,
Virginia and Tampa, Florida.
According to the VA, animal models of blast injury have
demonstrated damaged brain tissue and consequent cognitive deficits.
The limited data available suggests that brain injuries are a common
occurrence from blast injuries and often go undiagnosed and untreated
as attention is focused on more ``visible'' injuries. A significant
number of casualties sustain emotional shock and may also develop Post
Traumatic Stress Disorder (PTSD). Individuals may sustain multiple
injuries from the various types of explosions and the explosions will
produce unique patterns of injury seldom seen outside combat.
The overarching problem for the Department of Defense (DoD) and the
VA is identifying symptoms due to TBI or PTSD because the symptomology
can be similar. TBI is the result of a severe or moderate force to the
head where physical portions of the brain are damaged and functioning
is impaired. PTSD is a psychological condition that affects those who
have experienced a traumatizing or life-threatening event such as
combat, natural disasters, serious accidents, or violent personal
assaults. Overall, TBI has its own unique medical origin that should be
addressed through a multidisciplinary approach that recognizes TBI as
physical injury to the brain.
VA is one of the world's foremost-recognized authorities on PTSD
and the DoD has made great strides in this area over the last several
years. VA's focal point of excellence in PTSD has resulted in a
comprehensive PTSD screening and treatment program. VA now operates a
network of more than 190 specialized Post Traumatic Stress Disorder
(PTSD) outpatient treatment programs throughout the country. Vet
Centers are seeing a rapid increase in their enrollment.
However, AMVETS is extremely concerned about the lack of awareness
and screening among healthcare professionals for Traumatic Brain Injury
(TBI). It has been reported that about 10 percent of all service
personnel, and up to 20 percent of frontline personnel, suffer
concussions during combat tours. Studies show that multiple concussions
can lead to permanent brain damage. And, as previously discussed, PTSD
and TBI clinically present many of the same symptoms--fatigue,
headaches, memory loss, poor attention/concentration, sleep
disturbances, dizziness/loss of balance, irritability-emotional
disturbances, feelings of depression, and so forth. The problem for
medical personnel is trying to differentiae between PTSD and TBI.
According to the August 2006 Analysis of VA Health Care Utilization
Among U.S. Southwest Asian War Veterans: Operation Iraqi Freedom/
Operation Enduring Freedom, 184,524 veterans have sought care from a VA
Medical Center since the start of OEF in October 2001 through May 2006.
The August 2006 analysis reports 29,041 of the enrolled OIF/OEF
veterans who visiting VA Medical Centers or Clinics had a probable
diagnosis of PTSD. During this time, 1,304 OIF/OEF veterans were
identified as having been evaluated or treated for a condition possibly
related to TBI.
Overall, VA's approach to PTSD is to promote early recognition of
this condition for those who meet formal criteria for diagnosis and
those with partial symptoms. The goal is to make treatments available
early to prevent a lasting medical condition. The same must be done for
TBI. While VA is actively making progress in this area, there are
unique challenges. Fro example, there is no medical specific diagnostic
code for TBI. Because of the nature of polytrauma injuries, patients
are given more than one medical diagnostic code. AMVETS would recommend
that the VA consider adopting or assigning a new medical code for TBI,
similar to that of PTSD. AMVEST is also asking Congress to increase
funding for PTSD and TBI, with an emphasis on funding for VA to develop
improved screening technique, specifically for TBI.
Mr. Chairman, VA has a long history of providing excellent
specialty care. However, further work and research are required in
order to improve the nature of its treatments. Overall, AMVETS believes
that the medical community needs a better understanding of the effects
of stress and trauma on the brain and how complications arise from
these conditions. While VA is pursuing a more detailed and thorough
identification process for mild cases of TBI, there is still more to be
done. The advancements in protective armor, and science and medicine
have created new and unique medical circumstances that will carry
additional moral, legal, financial and other types of responsibilities.
Simply put, the very nature of polytrauma care is extremely slow,
complicated and expensive. AMVETS trusts that Congress will continue to
uphold its obligations to ``care for those that have borne the
battle.''
This concludes my testimony. Thank you.
Statement of the Honorable Corrine Brown, a Representative in Congress
from the State of Florida
Thank you, Mr. Chairman for calling this timely hearing on
Traumatic Brain Injury. TBI is being called the signature injury of
Operation Enduring Freedom/ Operation Iraqi Freedom.
I was pleased to have my friend Bill Pascrell speak at my Veterans
Braintrust last year. Rep. Pascrell is the chair of the Congressional
Brain Injury Task Force.
He spoke of the struggle of many people to get the care in a timely
manner. This is no small concern when dealing with TBI.
TBI can result when the head suddenly and violently hits an object,
or when an object pierces the skull and enters brain tissue
Nothing is more sudden and violent than war. The advances in
medicine and the ability to get the wounded care have made injuries,
mortal injuries just 10 years ago, survivable.
It is our job to make sure these soldiers have the best care
available as soon as possible. This gives the soldier the best chance
at as full a recovery as possible. It is not enough to make the injury
survivable, but give that veteran a positive quality of life.
The VA has some of the best resources for recovering from TBI,
including in my home state of Florida at the Tampa Polytrauma
Rehabilitation Center, inside the James A Haley Veterans Hospital, and
I hope DoD is taking full advantage of these and other centers around
the country.
I look forward to hearing your testimony today and learning what
more can be done to help our young men and women recovering from these
horrible injuries.
Statement of John and Cindy Gagnier, Valparaiso Indiana
(Parents of Veteran with TBI)
We would like to thank the Committee and the Veteran's
Administration for their time, efforts and concerns for all active duty
soldiers and veterans.
This testimony is submitted on behalf of your disabled veteran, our
son, Kristian J. Gagnier who suffered a traumatic brain injury. A
history dating back to January 2002 is necessary to show many
breakdowns in a system not understanding or sympathetic toward
traumatic brain injury and the soldier or their family.
The TBI was sustained on January 19, 2002, from a fall of about 12
feet over a balcony onto cement. The postoperative diagnosis was:
depressed right frontotemporal skull fracture with underlying acute
extradural hematoma. The surgery report indicates his skull fragments
were pieced/glued back together and he was unconscious for 48 hours or
more.
Other than the early follow up examinations for removal of the
staples holding together his skull and other miscellaneous injuries
sustained he received no information about the potential symptoms of a
TBI to watch for and returned to light duty in about 30 days. Even at
that time his complaints about frequent migraine headaches, nausea and
dizziness, to name a few, after his TBI elicited only medications like
Advil and pain medications. He denied taking pain medications because
it made him feel wrong and not able to do his job that he wanted to get
back to.
On July 17, 2002, 6 months after the injury, apparently since he
had tried so hard to return to his duties, he was deployed to Germany.
Only a year after his TBI he was on his way to Iraq and was still
working within his MOS as an Apache Helicopter Mechanic/crew chief.
September 2003, while still in Iraq, he was relieved from his duties
working on aircraft. We now know the effects of his TBI were becoming
too much for him to handle but he remained in Balad, aka: mortarville,
for the duration of his tour. Continued mortar blasts, heat,
dehydration and the hyper vigilance required while in Iraq exacerbated
his TBI.
Our son should never have been deployed to a war after
his TBI. Per the Army's own Regulation (AR) 40-501, 2-26 (e)(2) states
``applicants with a history of severe head injury are unfit for a
period of at least 5 years'' and one section indicates even possibly up
to 10 years. How could this have been overlooked? This is an area that
needs to be addressed with the frontline command along with the medical
staff that oversees soldiers on how to properly identify TBI and
concussion injuries. The proof of burden should not be placed upon the
soldier or their family.
On January 22, 2004, Kristian was reassigned back to Germany with
his troop and continued to deteriorate. There were many issues with
command and the medical community. For the sake of brevity we will try
to highlight only primary issues during 2004 that caused severe
additional problems and further deterioration of our son's health due
to his TBI.
Kristian was first misdiagnosed and placed on a medication that
only exacerbated his TBI. A diagnosis concerning his Traumatic Brain
Injury was still far off. His sleep disorder along with other issues
due to his TBI caused him to receive multiple counseling statements
resulting in an Article 15, UCMJ on July 16, 2004, and another on
December 14, 2004. This resulted in loss of rank, fines, extra duty and
restriction on both occasions. In fact he was confined to quarters
during Christmas of 2004 and he did not even think he could go to the
chow hall to eat so he sustained himself by using the vending machines
in his barracks. Who was even checking on him? This shows another
aspect of a TBI injured soldier concerning judgment. In a report back
to Congressman Visclosky and Senator Bayh dated May and June of 2005
respectively it stated Kristian was never denied leave or confined in
any fashion. We have since obtained documentation that contradicts
these statements. Our daughter even had to find someone to replace
Kristian in the wedding party for her July wedding since leave was
denied.
Due to the treatment Kristian received from command, the lack of
treatment for his undiagnosed TBI and improper medications, he
continued a spiral downward. At this point, as parents, we regret that
were still unaware that he actually had a TBI. However, it prompted us
to seriously start researching his injury and PTSD.
We are grateful that our Secretary is having the medical
system seriously reviewed. As you can see from this soldiers experience
the issues surrounding TBI need to be addressed at the time of the TBI
and not take a wait and see stand or pretend it never happened. Like
most soldiers our son just wanted to get back to his duties. This
should not be permissible for the traumatic brain injured
servicemember.
In January 2005, our son was finally allowed 30 days leave to come
home. We picked him up at the airport in Chicago and were in total
disbelief at his physical appearance. He was skin and bones with sunken
eyes and grayish pallor. It was blatantly clear that he needed medical
attention and we were committed to obtaining it. After our friend from
church, a Gulf War Vet, saw Kristian he told us we needed to
immediately bring him to the ER at the VA in Indianapolis. On January
17, 2005, we arrived at the VA and the first recommendation was to
discontinue a particular medication. In fact we were asked, ``Who
prescribed that medication with his type of brain injury''? He also
advised it would be a very long process for Kristian. This doctor
immediately identified a traumatic brain injury victim.
On February 4, 2005, our son had to be admitted to St. Anthony
Memorial Health Center to be stabilized. He was discharged from there
after 12 days with a diagnosis consistent with a TBI. Additional
consult by Dr. Daniel Schultz also confirmed diagnosis consistent with
a TBI.
Additional testing on February 25, 2005, by Stan Lelek also
indicated the need for medical testing and treatment for TBI.
Fort Knox and command in Germany were unable to coordinate a blood
test that was needed and the VA clinic in Merrillville that they sent
us to advised they could not do the blood test since it was non-
emergent. They advised to call Naval Hospital Great Lakes in Illinois.
On March 2, 2005, Kristian was seen by N. Anderson M.D. Head, Division
of Neurology. He states in his report the following, ``He (Kristian)
will need a medical board as he cannot function adequately in his
position in his present condition. Need to get neuropsychological
testing.'' He also states, ``severe head injury resulting in an
epidural hemorrhage requiring evacuation with multiple persistent
difficulties consistent with a brain injury that are significantly
interfering with his duties and, at times, ADL's.''
Dr. Anderson also advised us not to allow Kristian to get on a
plane back to Germany.
Even after all this Kristian was still forced to go back to
Germany. The explanation on this was given in an email on March 7,
2005, and is as follows. John--unfortunately the guidance from both the
medical and legal authorities within the U.S. Army in Europe is that
Kristian must return to Europe for completion of all required medical
treatment.
Another aspect that should be addressed is the
communication between the branches of service. Why would the Army
strike down Dr. Anderson's decisions, the Head of Neurology? Our only
response when we asked that question was, ``He is not Army.''
Communication and respect of other professionals between branches of
the Armed Services, including the VA, need to be bridged to better
serve our soldiers and veterans.
On March 8, 2005, Kristian boarded his flight back to Germany. I
was told he would given a few days off due to international flight,
however the next morning he was given more counseling statements. I
addressed this and the apparent intentional misinformation I was given
by command. At this point everyone was well aware of Kristian's medical
condition but no consideration was given to it. People put their
careers first and played God with our son's life.
A situation occurred that forced Kristian to be brought for
emergent care at Landstuhl Medical Center in Germany. Dr. Shaw Skully
told Cindy that Kristian would be sent to WRAMC and be under the care
of the DVBIC and Deborah Warden. This ended up not being the case. Upon
arrival at WRAMC he was admitted to the Psychiatric Unit.
Individuals with frontal lobe brain injuries often present a
psychiatric impairment, but indeed their issue is an organic brain
injury and not a chemical imbalance. It does not mean someone with an
organic brain injury cannot have a psychiatric component due to his or
her injury and life issues that need to be addressed after their
injury. Cindy contacted caseworker Kelly Gourdin and sent the surgical
reports and it was only then that the DVBIC gave Kristian some
attention.
The DVBIC along with other programs specifically set up
to work with traumatic brain injuries need to become involved
immediately with the soldier. A TBI/concussion assessment should be
done as part of the admission process.
The issues that have been brought to light recently by the media
are many of the same issues we have encountered and we will just list
some of them below. However, the most critical for us was Kristian's
safety and his executive functioning impairment due to his frontal lobe
injury. We had to care for our son at WRAMC and get him through medical
issues and board processes during his 16-month stay. We missed holidays
together, we had extended time away from our two younger children and
experienced extreme financial burdens as well as dealing with the
following at WRAMC.
Neurology: Ended up to be almost nonexistent even though Kristian
has a TBI and cysts in his brain. After Kelly Gourdin left it just
seemed to have changed.
Neurology: After a discussion with neurology, Kristian was ordered
to ASAP for caffeine abuse instead of being admitted to a neuro
behavioral program as recommended by Virginia Neuro.
Neurology: Changed the 6 month follow up for cysts as originally
ordered to 1 year.
Denial of medical care: Dr. Bahroo ordered a sleep study due to a
diagnosed sleep disorder and that department overrode the doctor and
refused the study.
Caseworker: Latonia Laffitte did not take care of scheduling an MRI
prior to Kristian leaving WRAMC. It should have been done May 2006 but
we ended up taking care of the MRI locally in September after he was
discharged.
Med Hold: The wounded were caring for the wounded and certainly
they received an undeserved burden that impeded their recoveries.
Peblo: I was told that by the counselor that it doesn't matter what
the board decides because you will end up going to the VA anyway. If
all you get is severance pay take it and leave.
Peblo: I was told by the counselor that he could not understand why
the corrections to the NARSUM were taking so long. When I asked Dr.
Bahroo he advised he never received any requests. Note: Dr. Bahroo was
the only doctor I dealt with that took care of issues in a timely
matter, returned phone calls/emails and came out of his office to talk
even on short notice.
Peblo: I hand delivered Kristian's NARSUM on December 6, 2005 to
Michael Thornton's office. It was lost and a 3-month follow examination
was needed for an addendum to the NARSUM.
Etc, etc, etc, etc.
Where in the world is the DVBIC in all of this.
Kristian's prolonged board resulted in extensive traveling to
WRAMC. After wandering down Georgia Ave in the middle of the night the
point that Kristian was not safe to be alone may have finally been
acknowledged by med hold. It was then permitted for Kristian to have
convalescent leave approximately 4 times in row. This meant come home
for 4 weeks and back to WRAMC for 2 weeks each time.
Thank God for Marie Wood and the Yellow Ribbon fund that provided a
place for Kristian and I to stay while back at Walter Reed.
The seamless Transproc was another nonexistent function for us. A
sergeant stepped up and finally took control to walk us through this
process that he advised would take 2 days. However, something happened
with him the 2nd day and he did not show up so again I was left to
figure that process out.
Cindy was contacted by Debra Crone and told that she was to speak
to a Katie Dinneger who was to help with Kristian's care for the VA.
Cindy spoke to Katie one time and then found out she went out on
maternity leave without even contacting us. Cindy took it upon herself
to find out what care was out there in the VA for Kristian. She
contacted Gretchen Stevens, head of the VA Brain Injury programs. After
a few conversations with her Gretchen contacted Amanda Sobel at Hines
VA for follow care within the VA. With Amanda Sobel's help we were able
to take care of the VA enrolment.
We had at least 3 different recommendations all advising the same,
that Kristian needed a Neuro-behavioral residential program and
Lakeview in New Hampshire would be a good fit for him. In fact Karyn
George of Military One Source had advocated for Kristian to go there
back in July 2005 as well as Virginia Neuro. In March Cindy contacted
the RIC of Chicago to ask for their recommendations on these programs
and they also recommended Lakeview.
We took it upon ourselves again, because we had to, and enrolled
Kristian in Tri-Care. We advocated for Tri-Care to approve Lakeview.
After 9 weeks he was denied healthcare at Lakeview by Tri-Care and to
this day we have not even heard back about our appeal. During this time
we were continuing a relationship with Amanda Sobel at the Hines VA and
she was aware of Kristian's situation.
We have found out there is no coverage for TBI
residential rehab. This needs to be addressed for our wounded warriors.
The Polytrauma Unit wanted to see and evaluate Kristian for his
healthcare needs so appointments were made. Due to the nature of
Kristian's brain injury the long ride to this facility makes it nearly
impossible to have valid testing/assessments. We were told to just
drive up when he is having a good day.
After a few months of back and forth and deciding what could be
done Hines, VA stepped up to the plate and approved some time for him
at Lakeview New Hampshire. For this we are truly grateful. Kristian has
been able to have the assessments done and a program designed for his
care. The professionals at Lakeview have been outstanding, caring and
genuine in their desire to help Kristian. They have respected both
Kristian's needs and ours. His program there has been individualized
specifically for him.
We would like to see brain injured servicemembers
transitioned into the care they need immediately following discharge,
even if it means outsourcing the care to private facilities. Each
patient needs to be treated individually because each TBI is a little
different. We would also like to see, within the transitional
authority, an office dedicated to TBI, properly staffed with case
managers and managed by Karyn George. She has over 20 years in the TBI
field and was one of most effective and helpful advocates we worked
with. She really knows her stuff.
We also would like to see a special residential facility
for our TBI servicemembers that will care for them mind, body and
spirit. We are very thankful for the facility at Brooke for our
amputees. We would like to also see a similar facility geared to our
TBI soldiers.
The mologne house and Walter Reed is no place for our TBI
outpatients to recover.
We believe if we care for them now we will have better outcomes and
not pay as great a price later on in ruined families, burdens on
communities and other public institutions.
A very wise man recently stated, ``History would be his judge.''
History will be our judge in how we take care of our wounded. Please
let us write a good story. Cindy and I have fallen in love with our
soldiers and it is not hard to do. They'll just tell you, ``I was just
doing my job.'' Well, we sent Kristian into Iraq with a brain injury
while others are coming out of theatre with brain injuries. We ask to
everyone concerned to do their best to plan and provide the best
possible healthcare for our all our wounded.
We have been asked to tell you how we are doing. We are forever
changed struggling through all this. We have not had vacations, hours
spent dealing with this turns into days and weeks it seems. I have lost
3 employees because of my situation and at this time trying to rebuild
my business with 3 new employees so we are needless to say, stretched
further today than ever. This really is another story and this is
submitted to you in hopes that soldiers and their families do not
experience the horrendous injustices and traumas we have had to endure.
Our focus has had to be taking care of our son.
Respectfully Submitted,
John and Cindy Gagnier
Valparaiso, IN
POST-HEARING QUESTIONS AND RESPONSES FOR THE RECORD
Committee on Veterans' Affairs
Subcommittee on Health
Washington, DC
April 10, 2007
Barbara Sigford, MD
National Program Director
Physical Medicine and Rehabilitation
Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420
Dear Dr. Sigford,
In reference to our Subcommittee on Health hearing on ``Polytrauma
Center Care and the TBI Patient: How Seamless is the Transition Between
VA & DoD and Are Needs Being Met?'' held on March 15, 2007, I would
appreciate it if you could answer the enclosed hearing questions by the
close of business on May 30, 2007.
In an effort to reduce printing costs, the Committee on Veterans'
Affairs, in cooperation with the Joint Committee on Printing, is
implementing some formatting changes for materials for all full and
Subcommittee hearings. Therefore, we would appreciate it if you would
provide your answers consecutively and single-spaced. In addition,
please restate the question in its entirety before the answer.
If you have any questions, please call Cathy Wiblemo on 202-225-
9154.
Sincerely,
Michael H. Michaud
Chairman
______
Questions from Hon. Michael H. Michaud, Chairman, Subcommittee on
Health, to Barbara Sigford, M.D., Ph.D., National Program Director,
Physical Medicine and Rehabilitation, Veterans Health Administration,
U.S. Department of Veterans Affairs
Polytrauma Center Care and the TBI Patient: How Seamless is the
Transition Between VA and DoD and Are Needs Being Met?
Question 1: Growth of the Polytrauma System of Care. We applaud VA
for their continued efforts to provide care as close as possible to
where the veteran lives. In your testimony, you indicated that there
are 76 Polytrauma Support Clinic Teams (PSCTs) located throughout the
21 Networks, which serve patients with stable polytrauma sequelae.
Question 1 (a): Please provide us with the interdisciplinary make-
up of the teams.
Response: The polytrauma support clinic teams (PSCT) include
specialists in physiatry, rehabilitation nursing, psychology, speech-
language pathology, occupational therapy, physical therapy, neurology,
and social work.
Question 1 (b): Did those medical centers where the teams will be
located receive any additional FTE to fill the teams? Did they receive
any additional funding to put teams together and ensure that they are
functional?
Response: Each PSCT received supplemental funding in fiscal year
(FY) 2007 to support staffing efforts already underway in establishing
the teams. The Department of Veterans Affairs (VA) surveyed facilities
to determine existing rehabilitation staffing, recommended a staffing
model and designated team sites. VA is currently assessing the need to
provide additional funding and staffing for PSCTs in FY 2008.
Question 2: Ensuring Proper Care for All Veterans. There has been a
lot of attention focused on the new generation of veterans and the
polytrauma patient. We have heard anecdotal stories that veterans from
previous conflicts may have been turned away from polytrauma centers
because caring for them would make the facilities numbers look bad
compared to the other center.
Question 2(a): Is this type of ``cherry picking'' happening out
there?
Response: No. Such allegations made about the polytrauma center at
Palo Alto were found to be unsubstantiated by the Department of
Veterans Affairs (VA) Office of the Medical Inspector for all referral
consultations for 2005 through 2007. Polytrauma centers adhere to
admission criteria specified in the Veterans Health Administration
(VHA) Polytrauma Rehabilitation Procedures Handbook 1172.1. Two
conditions exist for not admitting a patient to a polytrauma center:
(1) if the patient requires a ventilator or (2) if the patient requires
one to one staffing for medical or behavioral reasons. The admissions
nurse manager, in consultation with the polytrauma rehabilitation
center (PRC) medical director, reviews all requests for referral to the
PRC. If a treatment facility other than the PRC is determined to be
more appropriate, the PRC will recommend the most appropriate care
setting and assist the referral source with locating that treatment
site.
Question 2(b): What are the performance measures for the Polytrauma
Centers?
Response: The VA functional status and outcomes database (FSOD) is
used to assess outcomes of active duty and veterans receiving
rehabilitation services. This includes the functional independence
measure (FIM) which is the most widely accepted functional assessment
measure in rehabilitation. The FSOD allows comparison of rehabilitation
outcomes at the facility, network, and national level, for different
impairment groups (e.g., traumatic brain injury, traumatic amputation).
This database is also used to compare VA rehabilitation outcomes with
those from the private sector.
Two national performance measures that VA monitors for the
polytrauma rehabilitation centers (PRC) include: (1) the number of
hospitalized patients with brain injuries and amputations receiving
initial functional assessment for rehabilitation services, and (2) the
number who gain admittance to a formal comprehensive hospitalized
patient rehabilitation program.
Last, each PRC provides quarterly reports of such measures as
status of staffing, number of admissions and discharges, efficiency in
responding to consults, and other reporting requirements. Reports are
reviewed by VA Physical Medicine and Rehabilitation National Program
Office to identify concerns and ensure compliance.
Question 2(c): What are the consequences of a facility not meeting
the standards?
Response: The Physical Medicine and Rehabilitation National Program
Office reviews reports from each center, and provides corrective
guidance if deficiencies are noted. If problems persist, the Physical
Medicine and Rehabilitation National Program Office raises the issue to
the office of VA Deputy Under Secretary for Health for Operations and
Management to address.
In addition the centers are required to maintain Commission on
Accreditation of Rehabilitation Facilities (CARF) Accreditations. A
center that does not maintain compliance with CARF standards, would
lose accreditation status. To our knowledge VA has never had a facility
lose CARF accreditation. Facilities have requested extensions on the
survey date for up to 6 months if they were not ready for review. In
those instances the Physical Medicine and Rehabilitation National
Program Office and the Deputy Under Secretary for Health for Operations
and Management would work together with the facility to ensure
compliance.
Question 2(d): Is there associated funding with the performance
measures?
Response: Funding is not directly associated with performance
measures; however funds are not disbursed to facilities if they have
not hired and maintained the required staff.
Question 3: Long-term Care and the Traumatic Brain Injury (TBI)
Patient. One of the concerns that has been expressed is whether VA has
the capacity and the staff necessary to provide intensive long-term
emotional and behavioral services to the TBI patient
Question 3(a): What types of long-term programs does VA currently
have in place to treat TBI patients, including outpatient and community
integrated rehabilitation models and neurobehavioral programs?
Response: VA has treated 436 Operation Enduring Freedom/Operation
Iraqi Freedom (OEF/OIF) servicemembers and veterans with moderate to
severe polytrauma/traumatic brain injury (TBI), About 10 percent of
these veterans will require long term institutional care. Approximately
25 percent of veterans with moderate to severe polytrauma/TBI are
expected to require some level of non-institutional support services
after discharge from inpatient rehabilitation.
Residential transitional rehabilitation programs at each polytrauma
rehabilitation center are designed to help veterans successfully
integrate back into the community. This structured transitional
rehabilitation program focuses on restoring home, community, leisure,
psychosocial and vocational skills. The VA also provides various non-
institutional care services, including: (1) home-based primary care,
(2) adult day healthcare, (3) respite care/purchased skilled home
healthcare, (4) homemaker/home health aid, and (5) care coordination/
home telehealth.
VA recognized that additional community residential care services
are also required to meet the needs of some younger veterans; e.g.,
assisted living, community-based day programs for young adults, and
independent living skills programs. VA currently does not offer these
programs, and has requested a change in legislative authority to
purchase these services through the private sector in veterans' home
communities.
Question 3(b): What VA programs are there that have the capability
of taking care of the TBI patient with significant behavioral
challenges that require 24 hour supervision?
Response: The four VA polytrauma rehabilitation centers provide
appropriate level of care for patients who exhibit behavioral
challenges in the acute stages of recovery from TBI. VA currently does
not have programs for TBI patients with chronic behavioral problems
that require 24 hour supervision. The needs of such patients are
evaluated on an individual basis, and referrals are made to community
resources whenever indicated.
Question 3(c): What programs are available for the patients who
cannot participate as outpatients?
Response: VA collaborates with professional organizations such as
the American Medical Rehabilitation Providers Association and American
Academy of Physical Medicine and Rehabilitation to identify private
sector providers and facilities that can provide long term care support
as needed at the local or regional level.
Question 4: Shortage of Health Care Professionals. An issue that is
faced by all neurobehavioral and community integrated rehabilitation
programs involves the national shortage of key providers such as
occupational therapists, physical therapists, speech-language
pathologists and other allied professionals. What steps is VA
undertaking to recruit and retain key providers in this area?
Response: VHA uses a variety of financial recruitment incentives to
recruit and retain individuals in mission critical healthcare
occupations. Most of these incentives assist in recruitment of highly
qualified candidates and include service obligation periods of various
types and duration. VHA uses all of the following recruitment and
retention incentives:
Title 5--student loan repayment program (SLRP)
Title 38--education debt reduction program (EDRP)
Recruitment incentives
Relocation incentives
Group and individual retention incentives
Employee scholarships to obtain both initial and advanced
healthcare degrees
Special salary rates
Superior qualifications appointments
The VA's Health Professionals Education Assistance program (HPEAP)
is used as a component of VA's recruitment and retention program for
healthcare professionals. It consists of the education debt reduction
program (EDRP) and the employee incentive scholarship program (EISP).
Since it's inception in 1999 approximately 7DoD VA employees have
received EISP scholarship awards for academic education programs
related to title 38 and hybrid 38 occupations. This includes registered
nurses, pharmacists, and physicians. Focus group market research has
shown that the staff education programs offered by VA are considered
one of the major factors in individuals selecting VA as their choice of
employer. Scholarship recipients include 2DoD nurses pursuing masters
degrees in advanced practice. Of the 450 nurse practitioner
participants approximately 60 have focused on mental health specialty.
Scholarships have been provided for advanced degrees in physical
therapy, occupational therapy and pharmacy. All of these professions
will provide support to the current and emerging needs of OEF/OIF
veterans as well as veterans of other eras.
Additionally, review of program outcomes demonstrates the programs
impact on employee retention. For example, turnover of nurse
scholarship participants is only 7.5 percent compared to a non-
scholarship nurse turnover of greater than 10 percent. Less than 1
percent of nurses completing their service obligation (which ranges
from 1 to 3 years after completion of degree) leave the VA.
Education debt reduction program (EDRP) provides resources for
reimbursement of education loans/debt to title 38 and hybrid 38
employees recently hired by VA. Recently hired is defined by statute as
within 6 months of permanent appointment to VHA. Again, employees new
to the VA frequently cite this education benefit as a powerful
attractor for recruitment.
As of August 9, 2007, there were 5,658 employees participating in
EDRP, with reimbursements paid out over a 5 year period. The average
amount authorized per student for all years since the programs
inception is $17,368. The average award amount per employee has
increased over the years from $13,791 in FY 2002 to $27,125 in FY 2007.
While employees from 33 occupations have participated in the
program, 77 percent are from three occupations (registered nurse,
pharmacist and physician). The remaining awards--1074--are distributed
among 30 allied health occupations. Those occupations with more than 50
award recipients per occupation are:
Licensed practical/vocational nurse--285
Physical therapist--231
Physician assistant--204
Occupational therapist--105
Medical technologist--97
Diagnostic radiologic technologist--80
Certified registered nurse anesthetist--54
VHA's Healthcare Retention and Recruitment Office's (HRRO) mission
includes national recruitment outreach initiatives designed to enhance
and supplement local, facility based recruiting. The multi-tiered
recruitment marketing strategy includes national advertising, national
branding, print and online advertising campaigns, and recruitment
exhibiting at national professional association meetings and
conferences. VHA has a recruitment website where positions are posted
at www.vacareers.va.gov and is supplemented by posting jobs on online
recruitment websites such as the HealtheCareers and CareerBuilder. This
past year in conjunction with the Office of Patient Care Services, HRRO
initiated recruitment activities to support VA's mental health
enhancement initiative. This national recruitment campaign was designed
to attract qualified psychiatrists, psychologists, psychiatric nurses,
and social workers. A series of recruitment material were developed
under a unified national theme--Some battles begin after the war. The
materials developed for recruitment efforts include a mental healthcare
professionals recruitment brochure, various ads that are being used in
a national print and online advertising campaign, local classified ads
to advertise vacancies for facilities needing support; email blasts
which are being sent to medical schools, working professionals and
professional associations. Mental health recruitment initiative
advertising is being placed as follows this fall in the following
Journals:
Occupational Therapy
American Journal of Occupational Therapy
OT Advance
Physical Therapy
PT Magazine PT Advance
Pathology
American Journal of Clinical Pathology
Mental Health Professionals
Behavior Therapy
Journal of Interpersonal Violence
Journal of Psychosocial Nursing and Mental Health Services
Journal of the American Psychiatric Nurses Association
Archives of Psychiatric Nursing
NASW (National Association of Social Workers) News
APS Observer
Clinical Geropsychology Newsletter
Psychologists in Long Term Care
Professional Psychology: Research and Practice
PsycCareers.com--Free online listing with monitor print ads
Monitor on Psychology
Psychiatric News
Psychiatric Times
Psychiatric Services
American Journal of Psychiatry
Also, as VA employees are our number one source or new hires, an
employee referral program has been implemented to recruit qualified
applicants by word of mouth. Employees referring candidates who are
hired receive a cash incentive for that referral.
Question 5: Presidents Task Force to Improve Health Care Delivery
for Our Nation's Veterans. In 2001, the President's Task Force to
Improve Health Care Delivery for Our Nation's Veterans was appointed.
Their mission was to identify ways to improve benefits and services for
the beneficiaries of those two agencies through better coordination of
the activities of the two Departments. In 2003, they issued their final
report. The report contained several recommendations regarding
collaborative efforts and technology. There have been recent reports an
the delay in healthcare being delivered to returning soldiers and
veterans due to the lack of coordination and bi-directional data that
is available. Please expound on the efforts of the Department of
Veterans Affairs to further develop and see to completion the following
recommendations of the PTF:
Question 5(a): Recommendation 3.1 VA and DoD should develop and
deploy by fiscal year 2005 electronic medical records that are
interoperable, bi-directional, and standards-based.
Response: VA and the Department of Defense (DoD) are presently
sharing almost all of the electronic health data that are available and
clinically pertinent to the care of our beneficiaries from both
Departments. This includes the one way and bi-directional exchange of
viewable electronic health data and the bi-directional exchange of
computable standards-based allergy and pharmacy data that supports
automatic drug-drug and drug-allergy interaction checking.
VA receives electronic data through successful one-way and bi-
directional data exchange initiatives between existing legacy VA and
DoD systems. Data exchanges support the care of separated and retired
servicemembers who seek treatment and benefits from VA and the care of
shared patients who use both VA and DoD health systems to receive care.
Since beginning transfer of electronic health records to VA, DoD
has transferred data on approximately 3.9 million unique separated
servicemembers to VA clinicians and claims staff treating patients and
adjudicating disability claims. Of these individuals, VA has provided
care or benefits to more than 2.2 million veterans. Data include
outpatient pharmacy (government and retail), laboratory results,
radiology reports, consults, admission, disposition and transfer data,
and ambulatory coding data.
In 2006, DoD began transferring pre-and post-deployment health
assessment data and post deployment health reassessment data on
separated members and demobilized National Guard and Reserve members.
Leveraging some of the technical capability to transfer records one-
way, VA and DoD began the bi-directional sharing of electronic health
records on shared patients. Data shared bi-directionally include
outpatient pharmacy and allergy data, laboratory results and radiology
reports. This capability is now available at all VA sites of care and
is currently installed at 35 DoD host locations. These 35 locations
consist of 15 DoD medical centers, 28 DoD hospitals and over 230 DoD
outpatient clinics and include Walter Reed Army Medical Center,
Bethesda national Naval Center, Brooke Army Medical Center and
Landstuhl Regional Medical Center. VA is working closely with DoD to
expand this capability and by June 2008, VA will have access to data
from all DoD locations. VA is working with DoD to increase the types of
data shared bi-directionally. Additional work scheduled for the
remainder of FY 2007 and 2008 will add data such as progress notes,
problem lists and history data to the set of information that is shared
bi-directionally between DoD and VA facilities.
VA and DoD have accomplished the ground-breaking ability to share
bi-directional computable allergy and pharmacy data between next-
generation systems and data repositories. This capability permits VA
and DoD systems to conduct automatic drugdrug and drug-allergy
interaction check to improve patient safety of those active dual
consumers of VA and DoD healthcare who might receive prescriptions and
other treatment from both VA and DoD facilities. At present, we have
implemented this capability at seven locations and are working on
enterprise implementation schedules.
Our earlier efforts focused on the sharing of outpatient data, VA
and DoD have made significant progress toward the sharing of inpatient
data. Most recently, we began sharing significant amounts of the
available DoD electronic inpatient data on our most critically wounded
warriors. Previously, data were only available to VA from DoD in paper
format. Successful pilot projects demonstrated the capability to share
available electronic narrative documents, such as discharge summaries
and emergency department notes. This capability is now being used at 13
locations including all of DoD's major medical facilities. We have
successfully achieved the capability to support the transfer of medical
digital images and electronically scanned inpatient health records
between DoD and VA from key military treatment facilities, Walter Reed,
Bethesda, and Brooke Army Medical Center and all four Level 1 VA
polytrauma centers located in Tampa, Richmond, Palo Alto and
Minneapolis.
In addition to our joint work to share scanned documents and
digital radiology images, VA and DoD have undertaken a groundbreaking
challenge to collaborate on a common inpatient electronic health
record. On January 24, 2007, the Secretaries of VA and DoD agreed to
study the feasibility of conducting a joint acquisition for a new
common inpatient electronic health record system. During the initial
phase of this work, expected to last between 6 and 12 months, VA and
DoD are working to identify the requirements that will define the
common VA/DoD inpatient electronic health record. The Departments are
working to conduct the joint study and report findings as expeditiously
as possible. At the conclusion of the study, we will begin work to
develop the common solution.
Question 5(b): Recommendation 3.2 The Administration should direct
HHS to declare the two Departments to be a single healthcare system for
purposes of implementing HIPAA regulations.
Response: As a rule, there are no Health Insurance Portability and
Accountability Act (HIPAA) constraints on sharing electronic data
between VA and DoD. In general, the HIPAA Privacy Final Rule prohibits
covered entities--healthcare providers that conduct certain
transactions electronically, health plans, and healthcare
clearinghouses m from disclosing protected health information unless a
specific permitted disclosure is applicable. One special exemption
pertains to DoD's sharing data with VA. This permitted disclosure, 45
CFR 164.512(k) (1) (ii), allows DoD to ``disclose to VA the protected
health information on an individual who is a member of the Armed Forces
upon separation or discharge of the individual from military service
for the purpose of a determination by VA of the individual's
eligibility for or entitlement to benefits under laws administered by
the Secretary of Veterans Affairs,'' The VA and DoD HIPAA, privacy and
General Counsel staffs worked diligently to resolve any differences in
interpretation of these authorities. In June 2005, DoD and VA
implemented a data-sharing memorandum of understanding (MOU) that
outlines these agreed-upon authorities.
Question 5(c): Recommendation 4.6 The interagency leadership
Committee should identify those functional areas where the Departments
have similar information requirements so that they can work together to
reengineer business processes and information technology in order to
enhance interoperability and efficiency.
Response: VA and DoD have a robust interagency leadership structure
in the DoD/VA Joint Executive Council (JEC), cochaired by VA's Deputy
Secretary and Do D's Under Secretary for Personnel and Readiness. The
DoD/VA Health Executive Council (HEC), cochaired by VA's Under
Secretary of Health and DoD's Assistant Secretary of Defense, Health
Affairs, reports to the JEC and provides executive level direct
oversight of all interagency health data sharing initiatives. The
Information Management and Technology (IMIIT) work group of the HEC
provides day to day collaboration and management of existing and
planned data interoperability initiatives. This work includes the
identification and approval of information requirements and
reengineered business processes that support interoperability and data
exchange. In order to accelerate data exchange and to provide
additional support to our most seriously wounded and ill servicemembers
and veterans, DoD and VA have formed a Senior Oversight Committee (SOC)
that reports to the JEC. Pursuant to the leadership of SOC and the JEC,
VA and DoD are on target to share all essential and available
electronic health data by October 2008.
Committee on Veterans' Affairs
Subcommittee on Health
Washington, DC
April 10, 2007
Colonel Mark Bagg, Director
Center for the Intrepid
Brooke Army Medical Center
3851 Roger Brooke Road
Fort Sam Houston, TX 78234-6200
Dear Col. Bagg:
In reference to our Subcommittee on Health hearing on ``Polytrauma
Center Care and the TBI Patient: How Seamless is the Transition Between
VA and DoD and Are Needs Being Met?'' held on March 15, 2007, I would
appreciate it if you could answer the enclosed hearing questions by the
close of business on May 30, 2007.
In an effort to reduce printing costs, the Committee on Veterans'
Affairs, in cooperation with the Joint Committee on Printing, is
implementing some formatting changes for materials for all full and
Subcommittee hearings. Therefore, we would appreciate it if you would
provide your answers consecutively and single-spaced. In addition,
please restate the question in its entirety before the answer.
If you have any questions, please call Cathy Wiblemo on 202-225-
9154.
Sincerely,
Michael H. Michaud
Chairman
______
Questions from Hon. Michael H. Michaud, Chairman, Subcommittee on
Health, to Colonel Mark Bagg, Director, Center for the Intrepid, and
Chief, Orthopedics and Rehabilitation, Brooke Army Medical Center,
Fort Sam Houston, TX
Question: #1
Eligibility for Care at the Intrepid Center
Question: The stated mission of the Intrepid Center is to ``provide
the highest quality of comprehensive outpatient rehabilitation for
eligible patients in a state-of-the-world facility.'' Please explain
the referral process that occurs when a servicemember is in need of the
care that the Center provides. Who is eligible for care at the Center
and who is not? Does the Center turn servicemembers away? If so, where
are they referred?
Answer: All active duty amputee patients cared for at Brooke Army
Medical Center are automatically referred to the Center For the
Intrepid (CFI) for their outpatient care. Active duty burn and limb-
salvage patients are referred when appropriate to begin their advanced
rehabilitation. In addition, active duty servicemembers from other MTFs
sustaining delayed amputation as a result of failed limb salvage may be
referred to the CFI for advanced rehabilitation, usually on a TDY
basis. Although the current focus of the CFI is to care for active duty
servicemembers, all Department of Defense beneficiaries are eligible
for care.
Up to this point, no active duty patients in the amputee, burn, or
limb salvage categories have been denied care at the CFI.
Question: #2
Referral Procedures at the Center
Question: There are currently no referral procedures at this time
for veteran outpatients from VA. In your testimony, you stated that as
capacity permits and as the circumstances of hostilities change,
referral procedures for veteran outpatients from VA across the country
will be implemented. Do you believe they will be limited to the
veterans who have sustained amputation or do you foresee an expansion
of the eligibility and the scope of care?
Answer: The referral mechanism for veteran outpatients has been
drafted and would allow the VA to refer its patients to the Center for
the Intrepid for rehab associated with functional limb loss. It is true
that the referral mechanism has not been implemented, but it should be
ready to launch as soon as capacity allows.
I think maintaining the Center For the Intrepid (CFI) as a center
of excellence for functional and anatomical limb loss is the right
answer rather than expanding the scope of care. Nine percent of the
current amputee population is a result of non-combat related training
injuries, motor vehicle accidents, or other traumatic incidents.
Consideration must be given to consolidating all DoD functional and
anatomical limb loss care at the CFI when hostilities cease.
Question: #3
Intrepid Center as a Model of Care
Question: Do you feel that the Intrepid Center can serve as a model
for other types of healthcare delivery?
Answer: Absolutely, and for two reasons. First, the model of a
partnership between the civilian sector and the military for the actual
construction of the Center for the Intrepid allowed for rapid
completion and the inclusion of the most highly advanced technology on
the market. Second, the model of multidisciplinary care employed at the
Center for the Intrepid is vital to the provision of the complete
spectrum of care and resources required to fully rehabilitate our
Wounded Warriors. This is a great model for delivery of outpatient
rehabilitative healthcare, with interdisciplinary clinical and research
functions jointly housed and the layout facilitating communication
among providers and patients. The model of the Center also includes the
oversight of the patients by physicians who specialize in Physical
Medicine and Rehabilitation, as diagnosticians and managers of patient
care. Rehabilitation involving Physical Therapy, Occupational Therapy,
or Speech Language Pathology is often part of a treatment regimen for
many conditions seen by primary care specialists, to include Internal
Medicine, Family Practice, and Pediatrics. This model could apply to
those specialties as well, as long as there was ongoing oversight of
the contributions of the various disciplines in the overall management
of the patient's care. The most significant feature of this Center is
the successful application of this multidisciplinary collaborative
team.