[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




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                     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.

                                 
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