[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]
U.S. DEPARTMENT OF VETERANS AFFAIRS
POLYTRAUMA REHABILITATION CENTERS:
MANAGEMENT ISSUES
=======================================================================
HEARING
before the
SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED TENTH CONGRESS
FIRST SESSION
__________
SEPTEMBER 25, 2007
__________
Serial No. 110-45
__________
Printed for the use of the Committee on Veterans' Affairs
U.S. GOVERNMENT PRINTING OFFICE
39-454 PDF WASHINGTON DC: 2008
---------------------------------------------------------------------
For Sale by the Superintendent of Documents, U.S. Government Printing Office
Internet: bookstore.gpo.gov Phone: toll free (866) 512-1800; (202) 512�091800
Fax: (202) 512�092104 Mail: Stop IDCC, Washington, DC 20402�090001
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 SANDLIN, South RICHARD H. BAKER, Louisiana
Dakota HENRY E. BROWN, Jr., South
HARRY E. MITCHELL, Arizona Carolina
JOHN J. HALL, New York JEFF MILLER, Florida
PHIL HARE, Illinois JOHN BOOZMAN, Arkansas
MICHAEL F. DOYLE, Pennsylvania GINNY BROWN-WAITE, Florida
SHELLEY BERKLEY, Nevada MICHAEL R. TURNER, Ohio
JOHN T. SALAZAR, Colorado BRIAN P. BILBRAY, California
CIRO D. RODRIGUEZ, Texas DOUG LAMBORN, Colorado
JOE DONNELLY, Indiana GUS M. BILIRAKIS, Florida
JERRY McNERNEY, California VERN BUCHANAN, Florida
ZACHARY T. SPACE, Ohio
TIMOTHY J. WALZ, Minnesota
Malcom A. Shorter, Staff Director
SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS
HARRY E. MITCHELL, Arizona, Chairman
ZACHARY T. SPACE, Ohio GINNY BROWN-WAITE, Florida,
TIMOTHY J. WALZ, Minnesota Ranking
CIRO D. RODRIGUEZ, Texas CLIFF STEARNS, Florida
BRIAN P. BILBRAY, California
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
__________
September 25, 2007
Page
U.S. Department of Veterans Affairs Polytrauma Rehabilitation
Centers: Management Issues..................................... 1
OPENING STATEMENTS
Chairman Harry E. Mitchell....................................... 1
Prepared statement of Chairman Mitchell...................... 26
Hon. Ginny Brown-Waite, Ranking Republican Member................ 3
Prepared statement of Congresswoman Brown-Waite.............. 27
Hon. Timothy J. Walz............................................. 5
Hon. Ciro D. Rodriguez........................................... 17
WITNESSES
U.S. Department of Veterans Affairs:
Elizabeth Joyce Freeman, Director, Veterans Affairs Palo Alto
Health Care System, Veterans Health Administration............. 7
Prepared statement of Ms. Freeman............................ 28
William F. Feeley, Deputy Under Secretary for Health for
Operations and Management, Veterans Health Administration...... 18
Prepared statement of Mr. Feeley............................. 32
MATERIAL SUBMITTED FOR THE RECORD
Post Hearing Questions and Responses for the Record:
Hon. Harry E. Mitchell, Chairman, and Hon. Ginny Brown-Waite,
Ranking Republican Member, Subcommittee on Oversight and
Investigations, Committee on Veterans' Affairs, to Hon. Gordon
H. Mansfield, Acting Secretary, U.S. Department of Veterans
Affairs, letter dated October 24, 2007......................... 35
U.S. DEPARTMENT OF VETERANS AFFAIRS
POLYTRAUMA REHABILITATION CENTERS:
MANAGEMENT ISSUES
----------
TUESDAY, SEPTEMBER 25, 2007
U. S. House of Representatives,
Subcommittee on Oversight and Investigations,
Committee on Veterans' Affairs,
Washington, DC.
The Subcommittee met, pursuant to notice at 10:06 a.m., in
Room 334, Cannon House Office Building, Hon. Harry E. Mitchell
[Chairman of the Subcommittee] presiding.
Present: Representatives Mitchell, Walz, Rodriguez, and
Brown-Waite.
OPENING STATEMENT OF CHAIRMAN MITCHELL
Mr. Mitchell. This hearing will come to order. I would like
to welcome everyone to the Subcommittee on Oversight and
Investigations. This hearing is on the U.S. Department of
Veterans Affairs (VA) Polytrauma Rehabilitation Centers.
I want to thank all of you for coming today. I am pleased
that so many folks could attend this oversight hearing on the
VA Polytrauma Rehabilitation Centers.
The VA polytrauma centers help reintegrate into society
servicemembers who have suffered among the worst that war can
inflict. The most severely injured servicemembers serving in
Iraq and Afghanistan were medivaced out of theater through
Germany to Walter Reed, Bethesda Naval Hospital and, when
ready, are sent to one of the four polytrauma centers which are
located in Richmond, Tampa, Minneapolis, and Palo Alto.
Most polytrauma patients have suffered traumatic brain
injury (TBI) in addition to a variety of other serious injuries
which must necessitate amputation. The soldiers, sailors,
airmen, and marines who are treated at the polytrauma centers
have paid a very high price for their service to their country
as have their families, both of whom face a long and difficult
path to recovery and sometimes a lifetime of care.
The Nation owes these servicemembers and their families
everything that a Nation as rich as ours can provide. The
Nation has many who need and deserve what we can give.
Survival rates for servicemembers injured in combat are
extremely high compared to previous conflicts, partly because
of greatly improved protective equipment, but also because the
military has moved surgical medical care practically to the
front lines. A soldier injured in an improvised explosive
device (IED) blast can be in surgery within 30 to 45 minutes or
even less.
With these advances, however, comes the need to treat
injuries that would have been fatal in the past. Injuries like
traumatic brain injury and post traumatic stress disorder
require medical treatment and long-term care of a new kind. The
VA polytrauma centers are an essential part of that care.
Congress has provided sufficient resources and is providing
more that have enabled the VA to establish and expand
polytrauma care. It must be said that the VA has stepped up to
the plate to meet this need.
In addition to the four polytrauma centers, the VA has
created a network of subacute polytrauma care centers in each
of the Veterans Integrated Service Networks and outreach
programs throughout the country. This is not to say that
everything is as it should be. We would not be having this
hearing if that were the case.
Polytrauma care is not perfect. There is also the sharing
of electronic medical information and other issues that have
been highlighted by Senator Dole and Secretary Shalala that the
Subcommittee and full Committee will be addressing in the near
future.
But there should be no misunderstanding. We are not here to
criticize the VA's care providers or to suggest that the
quality of care to the Nation's most severely injured
servicemembers is anything less than exemplary. The
Subcommittee has found some management issues that need to be
addressed and that is why the title of this hearing is what it
is. The Subcommittee's oversight is intended to ensure the
superb care the VA provides is provided to those who deserve
it.
Data provided by the VA shows that the Palo Alto VA's
Polytrauma Center from the beginning of this year through July
filled only 60 percent of its available beds while the three
other polytrauma centers combined have been running at 98
percent capacity. We have found no good reason why that should
be.
The VA's Palo Alto Hospital has a beautiful facility and
even more beautiful Fisher House where family members can stay
and is practically married to the Stanford Medical School. Palo
Alto has all the resources it needs to provide the care for all
the polytrauma patients it can take.
The Subcommittee has also found the Palo Alto Polytrauma
Center would not accept minimally responsive brain-injured
patients while the other polytrauma centers did so until the VA
created a treatment protocol for those patients in December of
2006 and effectively forced Palo Alto to accept these patients.
This past spring, the VA's Office of Medical Investigations
found disarray, morale problems, insufficient programs for
families, and lack of leadership. All of these raise obvious
issues not just about local management but also about VA's
Central Office. Why, for example, did the fact that Palo Alto's
failure to fill the beds while the other polytrauma centers
were at full capacity not raise a red flag at Headquarters?
We begin today by hearing from the senior management of the
Palo Alto Health Care System headed by its Director, Elizabeth
Freeman. Subcommittee staff has spent much time with Ms.
Freeman and her team, and they are to be commended for their
willingness to meet with and provide information to the
Subcommittee.
We hope, indeed expect, that their testimony will describe
sufficient progress in addressing the concerns of the Office of
Medical Investigations (OMI) and the Subcommittee.
The second panel is headed by William Feeley, Deputy Under
Secretary for Health and Operations and Management. The
Subcommittee extends its thanks to Mr. Feeley and the VA
witnesses with him for their efforts to provide the best care
possible to our injured servicemembers and appreciates their
cooperation to the Subcommittee in meeting with and providing
information to us.
We in no way doubt their good will and dedication, but
there are obvious management issues for the Central Office that
are raised by the fact that there were empty beds in Palo Alto,
and these witnesses will be asked to address these issues.
Dr. Barbara Sigford, Dr. Shane McNamee, both of whom are
personally involved in running polytrauma centers, are at the
witness table as well. We look forward to hearing from them
about the good things that are going on for those who have made
great sacrifices for our country.
On Sunday night, the Public Broadcasting System (PBS) began
a 15-hour presentation of Ken Burns' documentary on World War
II. America achieved great things in that war, but the
documentary reminds us, or perhaps more realistically teaches
us, of the terrible cost of war.
We, as a Nation, owe a debt that can never be repaid to
those who serve, an obligation that must be met to those, who
were injured in that service. We are here today to do our part
in making sure this happens. No one can doubt the dedication of
the men and women in the military and the VA who provide care
for our servicemembers.
[The prepared statement of Chairman Mitchell appears on
p. 26.]
Mr. Mitchell. Before I recognize the Ranking Republican
Member for her remarks, I would like to swear in our witnesses.
I ask that all witnesses stand and raise their right hand from
both panels, if they would, please.
[Witnesses sworn.]
Mr. Mitchell. Thank you.
Now I would like to recognize Ms. Brown-Waite for her
opening remarks.
OPENING STATEMENT OF HON. GINNY BROWN-WAITE
Ms. Brown-Waite. I thank the Chairman very much, and I also
thank him for holding this hearing.
I believe that the title of this hearing is very
appropriate and I am rather disappointed. I do not know if
there are any members of the media, but normally the room is
filled because this is a very, very important issue as we talk
about our wounded warriors from the Global War on Terrorism.
Obviously the quest for excellence should be of the utmost
important.
Our Subcommittee staff recently visited several polytrauma
rehabilitation centers located in Richmond, Virginia;
Minneapolis, Minnesota; and the subject center, Palo Alto,
California. They did this to provide insight on the level of
care being provided to our wounded servicemembers at those
units.
Last Congress, while serving as the Chairman of this
Committee, Ranking Member Buyer followed injured servicemembers
from a combat support hospital in Iraq through the Landstuhl
Army Medical Center in Germany, and on to Walter Reed and
Bethesda. Mr. Buyer has also visited the Minneapolis VA Medical
Center's Polytrauma Rehabilitation Center (PRC) to evaluate
care and services received by our most critically injured
servicemembers.
What I still see today is of great concern. The tracking of
medical records still includes the paperwork and hard copies of
medical records accompanying the servicemembers as they
transfer stateside and ultimately to the VA.
We know that that is U.S. Department of Defense's (DoD's)
fault, but it is still ongoing, Mr. Chairman, and I did not
know if you were aware of that. As much as this Committee has
said, ``Let us move on and have electronic records,'' they are
still doing the old paper records going with the veteran to the
veteran facilities.
The Committee hears that not all the critical medical
information is being forwarded to the polytrauma units by the
DoD and many of the VA facilities are not using or have not
heard of the Joint Patient Tracking Application (JPTA) and the
Veterans Tracking Application (VTA) systems.
At the PRC in Palo Alto, our staff found several issues
relating to lack of staffing and resources. This same concern
was detailed in the draft OMI report obtained by our staff
prior to their visit to Palo Alto.
I would like to have the witnesses address this deficiency
in care to the servicemembers and veterans who are being
treated at this facility and I am also interested in learning
how widespread this problem is.
During the staff visit to the PRC unit in Minneapolis, the
Committee learned about the unusually high turnover rate of
active-duty military liaison officers. I am concerned about how
this turnover rate affects continuity of care for our severely
injured servicemembers.
PRC staff told us that there were also no electronic
transfer of records between DoD and PRC in Minneapolis. I am
interested in learning what is being done to address this
issue.
I know that some of our PRCs are doing a great job while it
seems others are still having great difficulties.
How are the best practices being shared between PRCs, the
good PRCs to provide the best possible care for our severely
wounded servicemembers?
Let me give you one example. The district that I represent
is north of Tampa. And when I was down at the Haley Hospital
reviewing the polytrauma unit there, which, by the way, is
excellent, I met some families from the west coast, not the
west coast of Florida, but the west coast, Washington State.
They chose to have their wounded warrior go to Tampa to the
polytrauma unit there. When I asked why they did not choose to
go Palo Alto, their response was because they wanted the best
care available.
It is a shame that veterans and their families do not feel
that the best care available is not also the closest care that
would be available, namely at the Palo Alto center.
Mr. Chairman, we need to be concerned about the care our
wounded servicemembers are receiving as they move from the
battlefield through the line of care to our VA facilities.
Congress' responsibility to these men and women in uniform
does not end with their care at the PRC units. As the Oversight
Subcommittee, we must also ensure that they have a seamless
transition from active duty to civilian-veteran status.
I cannot stress enough the importance of working toward a
standard Benefits Delivery at Discharge or (BDD) documentation.
A standard BDD would include one physical to be shared between
the two departments, DoD and the VA, providing servicemembers
with documentation as to the benefits for which they may be
eligible.
With the use of a shared BDD, we could conceivably have the
claims backlog at the VA caught up in a few years. This program
was successfully tested between DoD and VA from 1995 to 1997.
It is also a strong recommendation coming from the President's
Dole-Shalala Commission report.
Again, Mr. Chairman, I thank you for calling for this
hearing and I look forward to learning from our witnesses how
the VA is working with the DoD to improve the care for our
Nation's heroes and how we can better share some of the best
practices from the superior polytrauma units to the remaining
polytrauma units.
Thank you, Mr. Chairman.
[The prepared statement of Congresswoman Brown-Waite
appears on p. 27.]
Mr. Mitchell. Thank you.
I understand Mr. Walz has to leave early today. So at this
time, if there are no objections, I would like to recognize him
for his brief opening statement.
OPENING STATEMENT OF HON. TIMOTHY J. WALZ
Mr. Walz. Thank you, Mr. Chairman and Ranking Member.
Thank you to each of you for being here today. Thank you
for making the choice to serve in the VA, to put your expertise
and your careers in service to our veterans and it is truly a
noble cause, and for those members from the VA here.
I say it every time we are here that our job is to be
partners with you in this. Our job is to help provide the
funding and the oversight and the guidance necessary to help
you do your jobs. And for what you do, I am truly appreciative
of that.
My State of Minnesota is fortunate to have a polytrauma
center in Minneapolis and it is one that I have been to many
times and am incredibly proud of what has been done.
All of us know that what we are doing, one soldier or one
Marine or one airmen or one seaman who does not get the care
that they need is one too many, and we are always dealing with
a very, very high expectation. But I do think it is important
to note how often we do things right and how often you are
serving that care.
We are fortunate to have Dr. Sigford. She is here
representing today in her position as National Program
Director, but she is based in Minneapolis, and for that, I am
very thankful because I have been there many times and I have
seen that care. I am looking forward to this discussion.
The one thing that I am encouraged about by the Palo Alto
experience is we appear to have the ability to be able to
correct and we appear to be making changes in the right
direction. And too often in this Committee, we identify issues,
we identify what we need to fix, and then it just takes so long
to see any changes that the frustration level grows.
And while we are not claiming that we have everything under
control, while we are not claiming we are doing things
perfectly, we are claiming that, I think, that the
communication that is happening between those of us who sat
here in our responsibility to provide you the resources and the
guidance and those delivering that care is starting to get
there. So I thank you for that.
All of us know that our ultimate responsibility, and I
always like to quote, I represent the district that the Mayo
Clinic is in, and their single charge on the wall everywhere
is, ``what is best for the patient is what is best.'' And that
comes from Dr. Will Mayo and those quotes and the way they do
everything is dependent on that.
And I said when I am up on the floor and the one thing I
can tell you that sticks in my mind, my last visit out to the
Minneapolis center, I met with a mother. She was from Michigan
and she was there with her son who was a double amputee and a
TBI patient. And the strain of the care was showing on her and
she said the only thing that gets her through is, she said the
floor that she was on with her son is staffed by angels.
And that care that she receives up there from those people
is absolutely heartwarming. We need to make sure we keep them
there. We need to make sure that the turnover rate is lowered.
We need to make sure that our nursing staff is adequate and the
resources are there. And that is why this oversight of this is
so important.
So I thank you all. I am sorry I am going to have to leave
a little early for a conflicting meeting. But we do have your
written testimony, and to know that this Committee takes very
seriously the work you are doing and appreciates it.
I yield back.
Mr. Mitchell. Thank you.
Mr. Rodriguez.
Mr. Rodriguez. I will yield until the second panel.
Mr. Mitchell. Thank you.
At this time, I would like to ask unanimous consent that
all Members have 5 legislative days to submit a statement for
the record. If there are no objections, so ordered.
We will now proceed to panel one. Ms. Elizabeth J. Freeman
is the Director of the VA Palo Alto Health Care System. Ms.
Freeman has been the Director of Palo Alto since 2001 and has
been with the VA since 1983.
We would like to thank you, Ms. Freeman, for being here and
for the many years of service to our veterans.
After you introduce your panel members, you will have 5
minutes then to make your presentation. Thank you.
STATEMENT OF ELIZABETH JOYCE FREEMAN, DIRECTOR, VETERANS
AFFAIRS PALO ALTO HEALTH CARE SYSTEM, VETERANS HEALTH
ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS;
ACCOMPANIED BY LAWRENCE L. LEUNG, M.D., CHIEF OF STAFF,
VETERANS AFFAIRS PALO ALTO HEALTH CARE SYSTEM, VETERANS HEALTH
ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; AND
STEPHEN EZEJI-OKOYE, M.D., DEPUTY CHIEF OF STAFF, VETERANS
AFFAIRS PALO ALTO HEALTH CARE SYSTEM, VETERANS HEALTH
ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS
Ms. Freeman. Thank you. Good morning.
I would like to introduce Dr. Larry Leung, who is our Chief
of Staff, and a name that is very difficult to pronounce, Dr.
Stephen Ezeji-Okoye, who is our Deputy Chief of Staff, to my
left.
And I will go ahead and read my oral statement.
Good morning, Mr. Chairman and other Members of the
Subcommittee. Thank you for the opportunity to appear before
you today to discuss the polytrauma rehabilitation center or
PRC located at the Department of Veterans Affairs, Palo Alto
Health Care System.
It is a privilege to be on Capitol Hill to speak and answer
questions about this vital program and other issues that are
important to veterans who have bravely served in Operation
Iraqi Freedom and Operation Enduring Freedom.
I would like to submit my written statement for the record.
The core of the PRC at the VA Palo Alto Health Care System
is a 12-bed ward located on the Palo Alto Division Campus. The
PRC is frequently the subject of interest by oversight bodies,
veterans' advocates, Department of Defense personnel, media,
and elected officials.
Nearly every week, we have the honor of hosting visits by
distinguished guests. The vast majority of these visits are
very positive and generate considerable praise for the PRC and
its dedicated staff.
The PRC is also subjected to the oversight of the Veterans
Health Administration or VHA. Earlier this year, the VHA Office
of the Medical Inspector or OMI came to Palo Alto and assessed
the PRC. The OMI reviewed allegations related to a delay in
accreditation, inappropriate declinations of referrals, and
lack of effective leadership at the program level.
I will comment briefly on these three areas.
Regarding accreditation, Palo Alto has been and continues
to be fully accredited. Palo Alto was due for its triennial
Commission on Accreditation of Rehabilitation Facilities or
CARF survey of rehabilitation programs in February of 2007.
Based on internal and external assessments, I determined we
needed additional time to prepare for the survey. Consequently,
I asked and received approval from CARF to delay its survey for
a few months.
I am pleased to report to the Subcommittee that the CARF
survey occurred July 19th and 20th, 2007, and resulted in full
accreditation for another maximum 3-year period. I would like
to emphasize that at no time did our accreditation with CARF
lapse.
Regarding referrals, I would like to note that the OMI did
not substantiate the allegation that the PRC was
inappropriately declining or otherwise cherry picking patients
to produce favorable outcomes. Nonetheless, I have instituted
changes that will make it easier for referring sites to send us
patients.
There is now a single point of contact for referrals to the
PRC and a clearly defined physician to accept them. The
acceptance decision will be promptly communicated to the
referring site, patient, and family. If, for any reason, the
referring site disagrees with a decision, the referring site
will be encouraged to appeal the decision to the Palo Alto
Chief of Staff.
We have improved our process for tracking the disposition
of all referrals to the PRC and will report results monthly to
the Veterans Integrated Service Network 21 Office and to VA's
Central Office.
I have instructed my staff to look for every possible way
to accept as many patients as possible in either the PRC or a
more appropriate setting. I have also intensified our
communication with and outreach to potential referring sites.
Just yesterday, I went to National Naval Medical Center in
Bethesda, Maryland, and met with senior medical and social work
staff. I was pleased to learn that the VHA Polytrauma System
are including the PRC at Palo Alto as their first choice for
referrals.
I will followup on this productive meeting by sending a
clinical team from my PRC to this and other referring sites to
foster collaboration and eliminate any impediments to
referrals. I will also invite and encourage referring sites to
send a clinical team from their facilities to Palo Alto.
Regarding leadership at the program level, the OMI
expressed concerns about the leadership and communication in
the PRC. I have addressed leadership challenges in both the
short-term and long-term horizons. I have established an
Associate Chief of Staff for Polytrauma. The Associate Chief of
Staff for Polytrauma will provide clear and stable leadership
and the Associate Chief of Staff designation will signal its
organizational importance.
I have already started recruitment for the Associate Chief
of Staff for Polytrauma and established a Search Committee. I
am pleased to report that Stanford University will participate
in the recruitment and offer a faculty position to the
successful candidate.
In the interim, I have appointed a physician to serve as
the PRC Program Director and to be responsible for day-to-day
operations in the PRC including the disposition of referrals.
This individual has the necessary leadership, team building and
interpersonal skills to achieve outstanding clinical results
and to meet the expectations of families. The PRC Program
Director has already generated widespread support from the PRC
staff.
In closing, I would like to emphasize the quality of care
provided at the PRC has been and continues to be outstanding.
As the referrals and needs of our patients change, the PRC
evolves.
My staff and I have developed a forward-looking plan to
significantly increase the intensity of services and associated
staffing. We have also received funding for significant
equipment purchases and infrastructure improvement.
My staff and I are fully committed to making any
improvements necessary to meet the needs and exceed the
expectations of our Nation's heroes and their families.
Again, thank you, Mr. Chairman, for the opportunity to
testify at this hearing. I and the staff who accompanied me
would be delighted to address any questions.
[The prepared statement of Ms. Freeman appears on p. 28.]
Mr. Mitchell. Thank you, Ms. Freeman. And I appreciate you
being here today. I appreciate it very much.
And we appreciate the good work that all of your colleagues
at Palo Alto are doing to provide the care to our veterans. And
we are particularly appreciative of the care that Palo Alto's
Polytrauma Unit has provided to our most seriously injured Iraq
and Afghanistan veterans.
As I said in the opening statement, we are not here to
question you or your colleagues' dedication or suggest that the
care at Palo Alto's Polytrauma Unit provides anything short of
what is the best.
That said, however, we cannot ignore the fact that Palo
Alto has a history of empty beds in sharp contrast to the full
beds at the other polytrauma centers.
The Office of Medical Investigations may have concluded
that Palo Alto has not been cherry picking patients, but that
just begs the question of why Palo Alto had empty beds.
I appreciate very much that Palo Alto currently has more
than its allocation of polytrauma patients, but I am
disappointed that it took the scrutiny of this Subcommittee to
make that happen.
I can assure you that the scrutiny that you are getting now
will continue and that our staff will be visiting Palo Alto
again soon.
What we need and what our servicemembers giving their all
to this war need is not only your assurance that Palo Alto will
never again have empty beds, but also how your specific plans
for operating the polytrauma center will ensure those results.
And I heard you outline your plan and what you plan to do
hopefully.
When the Subcommittee staff visits you again in a few
months, what can we expect them to find?
Ms. Freeman. Thank you. Thank you for the question.
We have been aware that our average daily census has been
less than 12 and we have 12 beds on the Polytrauma Unit. And
the number of beds that are occupied, that average daily census
or ADC is dependent on the number of patients we accept and
that is dependent on the number of patients that are referred.
And we are now aware of this perception that we had been
receiving less referrals. And so the outreach efforts that we
have made in order to increase the number of referrals and thus
increase the number of admissions is the outreach that I
described in my oral statement and by personally reaching out
to those at other military treatment facilities beginning with
the case managers in trying to identify any difficulties there.
I will follow that up with sending my clinical team to
Walter Reed, Bethesda, Madigan, and other referring centers. I
will also invite the clinical teams from those centers to come
to Palo Alto and to be assured that the quality of care that we
provide is excellent.
Mr. Mitchell. Thank you.
Ms. Brown-Waite.
Ms. Brown-Waite. I thank the Chairman very much.
I am going to have to leave the Subcommittee to go to a
markup, so I will be leaving in a few minutes. But before
leave, I had a few questions.
Ms. Freeman, I understand that the Under Secretary for
Health asked VHA National Center of Organizational Development
to visit all four polytrauma centers and assess current
structure and staff.
Would you share with us the findings and recommendations of
this visit?
My second question--actually, if you would answer them in
reverse--I understand that last February, you asked for a delay
in the scheduled triennial accreditation.
Knowing this important accreditation process was upcoming,
what were the reasons for the requested delay? And I also
understand that you just recently successfully passed the
accreditation.
Would you elaborate what specific steps were taken between
February and July to mitigate your concerns about passing the
accreditation?
Ms. Freeman. Certainly. Thank you for that question, and I
will go ahead and answer the question about accreditation
first.
First of all, I just want to assure the Subcommittee that
our accreditation, as I said in my statement, it never lapsed
and we remain fully accredited.
We had performed some internal and external assessments. We
had an external consultant help us prepare for CARF and she
commented that the quality of the care was outstanding, but she
thought there were some structural components that needed to be
put in place.
So my reason in asking for the delay was to give us time to
get the paperwork and other processes in place to be able to
demonstrate to CARF that we should continue our accreditation.
And as I reported, when they did visit on July 19th through
20th, we did successfully pass that survey. And they were very,
very complimentary.
I would also comment that requesting that sort of delay is
something I would do in any other area where we are preparing
for an external survey. If I had similar information, I would
make the same decision.
Regarding your question on the National Center for
Organizational Development (NCOD), we very much appreciated the
Under Secretary asking them to come and visit us and the other
four polytrauma centers. I think it was terrific for the staff
morale. They very much enjoyed it. I believe we had 48 staff on
the unit and 43 of them interviewed with the NCOD staff.
And as far as their recommendations, the areas that the
staff identified that were of concern to them were most focused
on building and maintaining appropriate boundaries between the
care team and the families. There were also issues about
referral patterns and the discharge process and also concerns
about training.
And so we have taken all of those recommendations. We have
an internal team that is going to develop action plans on those
recommendations. And we are making progress as we speak.
Ms. Brown-Waite. And if I may follow-up. Could you
elaborate a little bit more on the review that you had where it
was suggested that there be a change in structural components?
Could you elaborate a little bit more on that?
Ms. Freeman. Sure. Thank you for that question.
Some of the structures that we need to put in place were
data management and evaluation of data and quality improvement
processes. So not that those were not occurring, but the
documentation of them and making it easy for a surveyor to
identify and recognize and give us credit for.
Ms. Brown-Waite. Are you aware of family reluctance to have
the polytrauma veteran treated at Palo Alto?
Ms. Freeman. I am not aware of any individual case where a
family expressed concern about Palo Alto, but I would be very
happy to follow-up with you, if I may, after the hearing about
that family situation.
Ms. Brown-Waite. So no one has ever said, I am not going to
go to the polytrauma unit closest to my home city, my home
state, but rather travel across the country to another one? You
have never heard this? This is the first time you have heard
this?
Ms. Freeman. I cannot speak for what a family member
expressed to a referral coordinator as to their reason as to
why they would select one polytrauma center over another.
Ms. Brown-Waite. Would you not want that information?
Ms. Freeman. I would be very happy to get that information
and act on that information and understand what that family's
concerns were and correct them.
Ms. Brown-Waite. Well, Mr. Chairman, Ms. Freeman, with all
due respect, I would think that that would be a primary focus
which might help to determine what some of the problems are at
Palo Alto.
Well over a year ago, because I have the polytrauma unit so
close to me, I began to look at, okay, why are there so few
there and there is a waiting list at some of the other
facilities. And so this is nothing new to me nor any of the
Members who have been on the Committee for a while. So I would
think in your position, you would want to know this.
Ms. Freeman. Again, I am not aware of any particular family
stating that they did not want to be referred to Palo Alto. And
if that information was conveyed to me, I would promptly act
upon it.
Mr. Mitchell. Excuse me.
Ms. Brown-Waite. I yield back the balance of my time.
Mr. Mitchell. Thank you.
I would like to just kind of follow-up. Do you know of any
other patients that were denied access to Palo Alto but ended
up at either Richmond, Tampa, or Minneapolis?
Ms. Freeman. One of the programs that we had not initiated
that the other four polytrauma centers initiated was in the
area of emerging consciousness, so there could have been
patients that might have been referred to Palo Alto that were
referred to those other programs before we instituted our
program.
Mr. Mitchell. What does that mean?
Ms. Freeman. Emerging consciousness?
Mr. Mitchell. The question was, were there people who were
rejected at Palo Alto?
Ms. Brown-Waite. Or rejected Palo Alto.
Mr. Mitchell. Well, yes. You asked that.
But I am saying who you did not accept, did they end up at
any of the other polytrauma centers?
Ms. Freeman. We have received 173 referrals from the time
we became a polytrauma center in February of 2005. And we have
accepted 143 or about 81 percent of those patients.
And while I do not recall every instance of the 30 some who
were not accepted at our polytrauma center, in general, the
reason would be that they might have had--there might have been
a more threatening, life-threatening condition that needed to
be addressed first before they were referred into the
polytrauma unit such as substance abuse or post traumatic
stress disorder.
Mr. Mitchell. Let me follow-up. Excuse me for taking this
privilege here.
Would they have been released from Bethesda or Walter Reed
under those conditions and sent out to you if they did not feel
that they should be in the center?
Ms. Freeman. I am sorry. Could you repeat the question?
Mr. Mitchell. I think the patients that you receive or are
referred to you are referred from Walter Reed, Bethesda.
Ms. Freeman. Walter Reed, Bethesda, Madigan----
Mr. Mitchell. Okay.
Ms. Freeman [continuing]. Other--of the 173 referrals----
Mr. Mitchell. Right.
Ms. Freeman [continuing]. I described, it is many
locations, not just Walter Reed and----
Mr. Mitchell. And you are saying that some of those
referred from those particular hospitals probably should not
have been referred? They should have stayed in those hospitals?
Why would--just one example--why would Walter Reed refer
someone to a polytrauma center that they did not feel was ready
to be referred?
Ms. Freeman. Some of the referrals that I am speaking of
with the other symptoms or other disease states that needed to
be treated, they might not have been from Walter Reed or
Bethesda. They could have been from another place.
Mr. Mitchell. Okay. Any of them, any number of them. Are
you saying that some of those people would be referred when
they should not have been?
Ms. Freeman. I am going to ask Dr. Ezeji-Okoye to help me
because I am not doing a good job of explaining this to you.
But there could be other reasons that I am not explaining.
Mr. Mitchell. Let me ask this question. The people that you
get are referred; is that correct?
Ms. Freeman. Yes.
Mr. Mitchell. And what you are saying is some that are
referred, I get the impression, should not have been referred
because they were not ready to be referred to this next level
of treatment; is that right?
Ms. Freeman. Could you help me?
Dr. Ezeji-Okoye. Sure.
Thank you, Congressman.
The VA operates a polytrauma system of care and that system
of care encompasses multiple areas as well as multiple
disciplines. Patients are referred in for evaluation and
appropriate placement into the correct area within the
polytrauma system of care.
Patients who initially may be referred from an outpatient
setting, for example, may have conditions, as Ms. Freeman
mentioned, such as substance abuse which would interfere or
prevent them from being able to fully benefit from the acute
inpatient rehabilitation on a PRC and so they are directed to
the most appropriate setting either within Palo Alto or within
another health care system within VA.
Mr. Mitchell. So what you are saying is that those
hospitals that are doing the referring are not really doing the
job they should when they referred them to the next level of
treatment; is that correct?
Dr. Ezeji-Okoye. No, sir. That is not what I was meaning to
imply. The centers when they refer in some cases such as many
of the cases we get from Walter Reed and Bethesda, it is clear
that the patient is suffering from polytrauma and that is the
major and overwhelming issue. And they are accepted.
Other sites refer to the polytrauma network or the
polytrauma system of care because they want assistance in
evaluating what are the deficiencies and deficits that the
veteran may be suffering from and help in assessing what the
correct placement for that patient may be.
The polytrauma system of care may take that initial
admission information and then in reviewing the documentation
and discussing with the team make a determination that the most
appropriate setting is actually not the PRC but perhaps a
substance abuse center or post traumatic stress disorder
center, and then after completion of that treatment would then
come to the PRC.
Mr. Mitchell. Would you say that you have a higher level of
rejection of those referred than the other centers?
Dr. Ezeji-Okoye. I do not know the information, sir, on the
acceptance and rejection rate of other centers. We have tried
to accept every----
Mr. Mitchell. Excuse me. It seems to me it is kind of
obvious when you have 60 percent of the beds filled, the others
have in the 90s, that you must be rejecting more or they are
just not referring more to you to begin with, one or the other.
Dr. Ezeji-Okoye. We have not been denying patients. We have
been trying to find the most appropriate setting for each of
those patients. As Ms. Freeman mentioned, we have been
concerned of this recent information about the perception that
we were not accepting or were difficult to refer to. And then
that is why we have been doing the outreach to the other
centers to make sure that perception is not continued.
Mr. Mitchell. Well, it must be a perception because either
one or the other. Either you are rejecting more than everybody
else or you are getting less referrals, one or the other.
Thank you.
Mr. Rodriguez.
Mr. Rodriguez. Thank you very much.
And let me say that, first of all, I guess, to the next
panel, thank you very much. We are looking forward to being the
fifth polytrauma center in San Antonio, so we look forward to
working with our soldiers that are in need.
Let me just, I guess, from a political perspective, I have
always judged politicians based on those that get elected
because they want to be there and those that want to make
something happen and actually do the work.
One of the biggest problems we find is veterans going and
feeling like they are being neglected or not wanted there. And
that attitude of, I guess, maybe also that reflects on the work
ethic of the people that are there in terms of not wanting to
deliver the work.
And that would be, you know, the biggest concerns that I
would have. Not only you say there is a perception, but there
is a reality also that you have only had 60 percent.
Do you communicate at all with the other four centers? Do
you meet at all and discuss, you know?
Ms. Freeman. Yes, sir. There are conference calls between
our leadership at our PRC and Headquarters that all of the
polytrauma sites are participating in.
Mr. Rodriguez. You get to see what the others are doing and
not doing?
Ms. Freeman. Yes, sir.
Mr. Rodriguez. One of the things that I would be concerned
in terms of your staffing there is in terms of their attitudes
and, you know, how aggressive they might be or the lack of
aggressiveness in terms of responding as to why they are there.
And that is to work and work for our veterans.
And so I would be concerned in terms of no matter what you
do, if that attitude is not there and it is not brought up from
the leadership perspective and if you are just there to be
there for the sake of having a job, you know, I tell the staff
that I have, and, again, the only analogy I can give you of my
own, and that is that when staff comes to me, they are only on
board as long as I am there, which is only 2 years at a time,
and I expect them to have that aggressive attitude in terms of
trying to make things happen versus just being there and biding
their time while they are being employed.
And so I would hope that your attitude there is also in
terms of service to our constituents and service to our
veterans that are out there. And that requires--I do not know
how you can change that attitude, but it has to come from the
leadership.
Ms. Freeman. Yes, sir. And I want to assure you that our
staff are highly motivated to accept as many patients as
possible. They are extremely, extremely committed to providing
outstanding care to those patients. I would invite you to come
and visit our unit and see for yourself the close connection
between our case managers and the families and the patients
that they care for, the close connection among the therapy
staff, the physician staff, and the patients and families that
we have the honor to serve.
Mr. Rodriguez. Yeah, because nothing worse than an attitude
of you do not want to go there, I want to go somewhere else,
and/or with the occupancy rates. That also says that if you
have the same workload, you know, and the others are carrying
much more of a workload, there is something wrong with that
picture also, especially when the need is there.
And I can tell you in San Antonio, we have a large number
of veterans at Brooke Army Medical Center and both out there at
Wilford Hall and the other trauma centers as well as the Audie
Murphy veteran needs in terms of services.
And so we look forward to doing that. So I would, you know,
hope that as you move forward, you know, there continues dialog
with the others and seeing what they are doing or not doing or
whether a shift in staff needs to occur in order to make that
happen in terms of the type of clientele.
Now, you mentioned some connection in terms of the type of
clients that are being referred and why the others might be at
a higher rate and you are not. And you mentioned, was that some
type of designation?
Ms. Freeman. Emerging consciousness.
Mr. Rodriguez. Yes. Tell me about that.
Ms. Freeman. I am going to let Dr. Ezeji-Okoye describe
emerging consciousness patients.
Dr. Ezeji-Okoye. Thank you.
Thank you, Congressman.
The Emerging Consciousness Program is a program that was
developed through VA that encompasses family support, the care
of the injured patient through programs such as Multi-Sensory
Stimulation as well as other rehabilitation efforts.
Palo Alto offered many components or most components of the
Emerging Consciousness Program, but we did not offer the Multi-
Sensory Stimulation Program. At that time, it was the opinion
of our clinical leadership that the evidence was not sufficient
to support that program. However, over time and with discussion
with the other VA centers, it was agreed that the situation had
evolved and that we thought it would be beneficial to also
include this service at Palo Alto. And so in the fall of 2006,
we began to put in place our own Multi-Sensory Stimulation
Program and accepted our first emerging consciousness patient
in November of that year.
Mr. Rodriguez. Thank you. I think I have run out of time.
Thank you.
Mr. Mitchell. Thank you.
Ms. Brown-Waite.
Ms. Brown-Waite. Thank you.
You may have said this and I missed it. We are supposed to
have a vote and I am trying to find out when I have to leave
for the other Committee. But how many current inpatients are
there in the polytrauma unit?
Ms. Freeman. Actually, as of last night, there were 17. We
have 12 beds designated for polytrauma. There are 17
inpatients. We have three polytrauma patients on our spinal
cord injury unit and one patient in our intensive care unit.
Ms. Brown-Waite. And how many are outpatients? Do you have
outpatients in the polytrauma unit?
Ms. Freeman. We have a transitional program, and bear with
me for just one moment. Within our transitional program, we
have 12 beds in the transitional program and I believe--I can
check with you for the record the exact number as of yesterday,
but we had five participants who were using our lodger beds and
I believe there are others who are using that program but
reside in the community.
Ms. Brown-Waite. One of the other questions is, I believe I
heard you say that you have conferences regularly with the
other polytrauma units. I understand that is a weekly
teleconference; is that correct?
Ms. Freeman. Yes.
Ms. Brown-Waite. At some point, do you discuss the patient
count, the utilization rate, and has this come up in your
conversation with other polytrauma units about the difference
in the number of patients that you treat versus the other
facilities?
Ms. Freeman. Thank you.
I do not personally participate in those conferences. The
Program Director and Medical Director participate in the
conferences. And so to my knowledge, I have not been personally
aware of the difference between the ADC for our center and the
other centers until Mr. Bestor brought it up on his visit.
And I do not know if Dr. Ezeji-Okoye wants to comment on
that.
Dr. Ezeji-Okoye. I participated in some of the conference
calls and the conference calls have generally focused on making
sure that we are developing quality programs across all of the
polytrauma centers. And that has been the primary focus of the
calls that I have been on.
Ms. Brown-Waite. So are best practices shared during these
conference calls?
Dr. Ezeji-Okoye. Part of the conference call has been
focusing on each polytrauma site taking a leadership role in
developing what would be best practices within the polytrauma
sites overall and then sharing those. We have been charged with
looking at some of the educational and training portions of the
polytrauma system of care and developing those.
Ms. Brown-Waite. Thank you.
I yield back, Mr. Chairman.
Mr. Mitchell. Does anyone have any other questions they
would like to ask?
[No response.]
Mr. Mitchell. Thank you, and thank you very much for being
here.
And I do want you to know that, as I mentioned in my
opening statement, that members of this Subcommittee staff will
probably be out to visit again.
Very good. Thank you.
Ms. Freeman. Thank you.
Dr. Ezeji-Okoye. Thank you very much.
Mr. Mitchell. At this time, I would like to welcome the
second panel to the witness table.
Mr. William Feeley is the Deputy Under Secretary for Health
of Operations and Management at the VA and the Chief Operations
Officer for the VHA. Deputy Under Secretary Feeley has over 30
years as a career civil servant, spending the majority of that
time in the VA.
And I want to thank you, Mr. Feeley, for your commitment to
help our Nation's veterans and welcome you.
And before we start your 5-minute presentation, would you
please introduce the staff that you brought with you.
Mr. Feeley. Thank you, Mr. Chairman.
I have Dr. Ed Huycke from the----
Ms. Brown-Waite. You might want to turn your microphone on,
sir.
Mr. Feeley. Sorry. I have Dr. Ed Huycke to my right from
the Office of Seamless Transition; Dr. Shane McNamee, Medical
Director at the Richmond Polytrauma Center. I've got Lu Beck,
Chief Consultant of Rehabilitation Services in Headquarters and
Dr. Barbara Sigford, National Program Director for Physical
Medicine and Rehabilitation.
Mr. Mitchell. Thank you.
Before you begin, I would like to recognize Mr. Rodriguez,
if it is all right.
OPENING STATEMENT OF HON. CIRO D. RODRIGUEZ
Mr. Rodriguez. Thank you, Mr. Chairman. Thank you for
allowing me to make some opening comments that I did not make
initially. I just first want to thank you.
And I think it was the right thing for San Antonio to be
selected as the next site for the fifth polytrauma center as
they announced recently, you know, the fifth one.
But first off, I also want to express my extreme
disappointment with the fact that I, and the Committee, were
not informed about the new polytrauma center in San Antonio,
only after the media inquiry asked me to comment on it. And I
think that the VA could have been more courteous to the Members
of the Committee especially to letting us know in terms of the
selection process.
And since the designation, my office has been in touch with
the VA staff. And from what I have been told, the VA has little
information in terms of the new facility. And so I am glad
today that I will have the opportunity to be able to ask you
some questions and be able to dialog with you and work with you
to make that happen because there is no doubt that there is a
tremendous need out there and we are hoping to fill that need.
So thank you very much for allowing me to make those
opening comments. Thank you, Mr. Chairman.
Mr. Mitchell. Thank you.
Mr. Feeley.
TESTIMONY OF WILLIAM F. FEELEY, DEPUTY UNDER SECRETARY FOR
HEALTH FOR OPERATIONS AND MANAGEMENT, VETERANS HEALTH
ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS;
ACCOMPANIED BY EDWARD HUYCKE, M.D., CHIEF DEPARTMENT OF DEFENSE
COORDINATION OFFICER, VETERANS HEALTH ADMINISTRATION, U.S.
DEPARTMENT OF VETERANS AFFAIRS; LUCILLE B. BECK, PH.D., CHIEF
CONSULTANT, REHABILITATION STRATEGIC HEALTH CARE GROUP,
VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS
AFFAIRS; BARBARA SIGFORD, M.D., PH.D., NATIONAL PROGRAM
DIRECTOR, PHYSICAL MEDICINE AND REHABILITATION, MINNEAPOLIS
POLYTRAUMA REHABILITATION CENTER, VETERANS HEALTH
ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; AND SHANE
McNAMEE, M.D., MEDICAL DIRECTOR, RICHMOND POLYTRAUMA
REHABILITATION CENTER, HUNTER HOLMES McGUIRE, VETERANS AFFAIRS
MEDICAL CENTER, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT
OF VETERANS AFFAIRS
Mr. Feeley. Good morning, Chairman and Members of the
Subcommittee. I want to thank you for the opportunity to
discuss the Veterans Health Administration's ongoing efforts to
improve the quality of care that we provide to veterans
suffering from traumatic brain injury and complex multiple
trauma.
The focus of my testimony today will be on treatment and
rehabilitation provided by VA to veterans recovering from TBI
and complex multiple trauma and the current initiatives to
further enhance these services to our veterans within the
system of care.
The mission of the VA Polytrauma System of care is to
provide the highest quality of medical rehabilitation and
support services for veterans and active-duty servicemembers
injured in service to our country.
This integrated, nationwide system of care has been
designed to produce access for life-long rehabilitation care
for veterans and active-duty servicemembers recovering from
polytrauma and TBI.
The four VHA polytrauma centers located in Minneapolis,
Palo Alto, Richmond, and Tampa and soon to be San Antonio are
the flagship facilities of the polytrauma system of care. These
centers serve as hubs for acute medical and rehabilitation
care, research and education related to polytrauma and TBI.
During fiscal year 2007, the four PRCs added transitional
rehabilitation programs at these sites. These programs serve
veterans and active-duty servicemembers with polytrauma and/or
TBI who have physical, cognitive, or behavioral difficulties
that persist after the acute phase of rehabilitation and
prevent them from effectively reintegrating into community or
returning to active duty.
Transitional residential rehabilitation offers a
progressive return to independent living through a structured
program focused on restoring psychosocial and vocational skills
in a controlled therapeutic setting.
All remaining VHA medical centers provide an aspect of the
continuum of polytrauma system of care based on the levels of
intervention available at the site. The definition of these
levels was included in my written testimony and in the interest
of time, I will not elaborate on those definitions now.
The coordination of transition of care is critical. Care
management across the entire continuum is a critical function
in the polytrauma system of care to ensure lifelong
coordination of services for patients recovering from
polytrauma and TBI.
At the direction of the Secretary, 100 transitional patient
advocates (TPAs) have been recruited nationwide. The TPAs
contact the patient and family while in the military treatment
facility. One of their responsibilities is to ensure that all
questions concerning VA are answered and each case is expedited
through the VA benefits process.
If necessary, the transitional patient advocate will travel
with the family and veteran from the military treatment
facility to their home and provide transportation to all VHA
appointments.
Psychosocial support for families of injured servicemembers
is paramount as decisions are made to transition from the acute
medical setting of a military treatment facility to a
rehabilitation setting.
VA social workers or nurse liaisons are located at the ten
military treatment facilities including our most frequent
referral sources, Walter Reed Army Medical Center and Bethesda
National Naval Medical Center. These individuals provide
necessary psychosocial support to families during the
transition process, advising the families through the process.
The admissions case manager from the polytrauma
rehabilitation center maintains personal contact with the
family prior to transfer and to provide additional support and
further information about the expected care plan.
Upon admission to the VHA PRC, the senior leadership of the
facility personally meets with the family and servicemember to
ensure that they feel welcomed and that their needs are being
met.
A care manager is also assigned to each patient. The care
manager coordinates services and addresses emerging needs as
the patient engages the various levels and types of VHA
services necessary to support their rehabilitation. The care
manager will also coordinate the ultimate transition to home.
Mr. Mitchell. Mr. Feeley, I hate to cut you off, but we are
going to be voting pretty soon and I would like to get some
questions in. And we have your written testimony, if you do not
mind----
Mr. Feeley. I would be glad to end now and let you ask any
questions you might like to ask.
Mr. Mitchell. Thank you.
Mr. Feeley. Thank you.
[The prepared statement of Mr. Feeley appears on p. 32.]
Mr. Mitchell. And I have a couple questions. And I
appreciate you being here as well and thanks for your testimony
regarding the polytrauma system.
The description you have given is very interesting, very
valuable. We have your written testimony.
But the data provided by your staff shows that Palo Alto
has been leaving beds empty while other polytrauma centers have
been offering full capacity. And this data is not just about
last week. It goes all the way back to 2005.
In 2007, Palo Alto had filled 60 percent of its beds while
the other polytrauma centers were at full capacity. And you
have the data. You understand all this.
And the question is, why wasn't anything done about it?
Mr. Feeley. I will tell you that my concentration has been
on opening up the transitional rehabilitation beds, on making
sure that additional resources were added to the polytrauma
center, and to assure all the infrastructure and space needs
were where they needed to be.
I would indicate that your point is very well taken related
to monitoring the number of referrals and the type of referrals
and the disposition of referrals.
And starting with this fiscal year 2008, I have asked Dr.
Beck to create a monthly report that will show the utilization
in each site, the number of referred and the dispositions.
I have looked at the data related to October 1, 2005, to
July of 2007, and note the point you are making, so this is a
lesson learned for us on a headquarters' level.
Mr. Mitchell. Is there any legitimate reason why Palo Alto
should have been different from any of the other polytrauma
centers?
Mr. Feeley. I really do not have any explanation for why
that is the case. I think that your point earlier with the
previous panel, it is either the number of referrals in or the
outreach may not have been as aggressive. But I am very
comfortable that Palo Alto has a very strong leadership team
and they have the message. The census today is at 12 beds. The
outreach to Bethesda yesterday will be followed by many other
outreach efforts to ensure a maximum utilization of bed
capacity.
Mr. Mitchell. And what I heard you say, I thought earlier,
was that the reason you really did not do much about this is
you were busy doing something else, getting the actual
facilities in place, so you were not really looking at----
Mr. Feeley. What I would say to you, this data did not come
to my attention until very recently and there was not a
capacity issue with all beds being full throughout the system.
We have 48 beds and there was not a complaint coming up through
any of our data systems. And it is my understanding there are
no waiting lists to get into the program, at least right now.
So what I was trying to convey that my primary interest was
developing transitional rehabilitation housing for veterans who
had been through acute rehab and needed an additional runway.
Palo Alto was one of the first facilities that had the
transitional housing put in place because they had one of the
first day hospital programs for TBI injured patients.
Mr. Mitchell. And are you telling us that there will be
people looking at this data from now on and that, you know----
Mr. Feeley. Absolutely correct.
Mr. Mitchell. Obviously you said you did not get the data,
so either no one gave it to you or you just did not look at it,
one or the other.
Mr. Feeley. The data was not coming forward, but it will be
starting October 1st on a monthly basis by facility, so I will
know what the average daily census is, what the utilization
rate is. We will know who needs to outreach and we will also
know what type of dispositions we are challenged with and we
may need to beef up our resources to meet those needs.
Mr. Mitchell. Thank you.
Ms. Brown-Waite.
Ms. Brown-Waite. Thank you very much.
Mr. Feeley, I just talked to another Member of Congress
about a clinic that was opening up in their district that the
VA never even attempted to cooperate with that Member's
schedule. I am embarrassed that you never informed the Member
of Congress and Mr. Rodriguez who I served with before on this
Committee. I am glad that he is back.
You should not do that. You need to be involved whether it
is a Republican or a Democrat. You need to let the Members of
Congress know what is going on so they do not hear it from the
press. Please take that away and share it with other executives
in the VA.
Mr. Feeley. I understand the lesson learned.
Ms. Brown-Waite. Maybe I just instill the fear of God or
Ginny Brown-Waite in the people in Florida, but they would
never ever do that. Please just do not ever let that happen
again.
This question is for Dr. McNamee and/or Dr. Huycke. I
understand that our staff paid you a visit a couple of weeks
ago and that it went pretty well.
Would you care to touch upon the ability for your staff to
receive complete and critical medical information about our
wounded warriors transferring to your polytrauma center?
Dr. McNamee. Thank you for the question, ma'am.
I did have the opportunity to meet with Mr. Bestor and Mr.
Wu about a week ago and sat them down and went through the
transfer of medical records with them and specifically the
pieces of medical record that we are indeed receiving.
The item that we use most frequently now which is a
complete medical record potentially from what Mr. Bestor told
me and with the exception of some psychological data that I had
not been able to verify on our end yet, but is a complete
medical record that is scanned at both Bethesda and Walter Reed
into a PDF file and is loaded into our medical record system at
the VA. It can be sorted. It can be searched to some degree and
also printed off.
This is direct documentation of medical care at the
military treatment facility before they are discharged to us.
These documents range anywhere from 500 to I have seen 2,500
pages that come down through. This also is accompanied by full
imaging, so all imaging from Bilad and battlefield up through
the military treatment facilities are also loaded into our
computer system which we use on a very frequent basis which Mr.
Bestor and Mr. Wu also had the opportunity to see.
Ms. Brown-Waite. One other question. Do you know why DoD
installed their server in your facility? Does any other
polytrauma center have the same setup to receive medical
information from DoD facilities?
Dr. McNamee. I can answer what happens in our facility
specifically, ma'am. I would direct your question otherwise for
that.
Ms. Brown-Waite. So the answer is you do not know why they
chose your facility?
Dr. McNamee. I know that they chose our facility because we
are receiving these individuals. My answer is, is I do not know
what specifically the setup is at the other four polytrauma
centers. I would assume that they have the same setup that we
do, but I cannot verify that.
Ms. Brown-Waite. Mr. Feeley, can you?
Mr. Feeley. I do not know the answer, but I do not know if
any other panel member does.
Dr. Sigford. Yes. Is my microphone--there you go. I am
sorry. I thought the green light was on.
Yes. All four of the polytrauma rehabilitation centers have
the same capacity to receive that scanned PDF file and load it
in their electronic record.
Ms. Brown-Waite. What about the images? Are they also----
Dr. Sigford. Yes.
Ms. Brown-Waite [continuing]. Available?
Dr. Sigford. Yes.
Ms. Brown-Waite. So it comes from DoD?
Dr. Sigford. Yes.
Ms. Brown-Waite. You can get them though?
Dr. Sigford. Yes.
Ms. Brown-Waite. Okay. I think this question is for Mr.
Feeley. What exactly is the timeline in preparing the newly
announced facility in San Antonio? When will patients begin
being received there?
Mr. Feeley. I will be hopeful that I think the dollar
amount is $67 to $70 million and hopefully we would be seeing
patients the beginning of fiscal year 2011. It is about a 36-
month runway. Now, we were pressed to do this sooner. That
would be the far-out date.
Ms. Brown-Waite. And thank you.
I am going to yield back the balance of my time.
Mr. Mitchell. Thank you.
Mr. Rodriguez.
Mr. Rodriguez. Thank you, Ms. Brown-Waite, for those
questions and those comments.
Congressman Chet Edwards on Appropriations, and I sit on
Appropriations also, worked and we put $30 million initially to
get going on the Supplemental.
Do you have those resources in hand to start up the San
Antonio facility?
Mr. Feeley. I believe those dollars and resources are in
hand to get launched.
Mr. Rodriguez. Okay. You should have them in hand. And you
are saying it is going to be until 2011?
Mr. Feeley. It is a huge project with major renovation. So
it could be done in 24 months, but I would rather give you the
outside number of 36. I think that is more accurate.
Mr. Rodriguez. Okay.
Mr. Feeley. This is a huge renovation.
Mr. Rodriguez. Is it a priority for the VA in terms of
making this happen as quickly as possible?
Mr. Feeley. Absolutely.
Mr. Rodriguez. Okay. And the priority means at the most, 36
months----
Mr. Feeley. Correct.
Mr. Rodriguez [continuing]. Less, 24? In spite of the fact
that you already have half of that in hand or you should have?
Mr. Feeley. The half that we have in hand was received----
Mr. Rodriguez. In the Supplemental.
Mr. Feeley [continuing]. Almost 8 weeks ago. It is not
exactly like it arrived 10 months ago.
Mr. Rodriguez. Yeah. The Supplemental.
Mr. Feeley. But we will accelerate as aggressively as we
can to get it done realizing we have the Intrepid Brook and
major needs there.
Mr. Rodriguez. Are you putting the next 36 as part of the
existing 2008 or 2009 budget?
Mr. Feeley. That I do not know the answer to, but I can get
back to you on that.
[The information was provided in the response to Question 7
in the post-hearing questions for the record, which appears on
p. 40.]
Mr. Rodriguez. Okay, because we will have another
Supplemental. We will see what we can work out, but I would be
glad if you can maybe look at using some of those resources
there since you already have the first $30 million.
Mr. Feeley. We also have an excellent Network Director in
Mr. Shay, who was the former Director at San Antonio, who is
very committed to this initiative, so----
Mr. Rodriguez. No. He is a great guy. You have some good
people there trying to make that happen. So I know they are
looking forward to making that a reality. And so I want to
thank you for that.
And overall, I know I tell my veterans that there is a new
day at the VA and for those that have been shunned in the past
to go back, especially a lot of our Vietnam veterans that have
had a rough time getting access and, you know, and for a good
reason. We also, you know, did not fund it appropriately. But I
am hoping that we can start making some inroads to these
veterans that are coming out of both Afghanistan and Iraq.
So the indication is hopefully by 2011 or before then. Do
you know when we might start breaking ground?
Mr. Feeley. There is actually a ceremony, I believe, this
Friday, the 28th down in San Antonio to make this announcement.
But I do not know when the ground breaking would actually
occur.
Mr. Rodriguez. Yeah. Again, I would really appreciate if
you would let me know when those ceremonies are occurring, you
know, since I am on the Committee. So I would appreciate it.
And I know that the Secretary, I think, informed the Chairman,
I think afterward, but I did not get that until much later.
Mr. Feeley. I understand how sensitive it is. Thank you.
Mr. Rodriguez. Okay. I would appreciate it. And I would
also appreciate if you have any areas of problems, you know, to
let us know what we can do because there is nothing worse than
for us to find out that in terms of utilization rates that are
out there because at those rates, the Capital Asset Realignment
for Enhanced Services (CARES) Commission was going around the
country, you know, and closing facilities that were at 50 and
60 percent utilization.
And so if that is the case, then, you know, you got to be
looking at that real closely because I remember those
recommendations from the CARES Commission that if it was only
60 percent, you know, they were going to get recommended to get
closed.
Mr. Feeley. The Congress has been very benevolent with
resources. We have the money to do the job right. We are adding
additional staff to all of these programs including Palo Alto.
And I understand the need to get capacity up.
Mr. Rodriguez. Yeah. And the fact that, you know, you
construct this one in terms of--is 12 beds sufficient?
Mr. Feeley. I think we are going to go with 12 beds. By
history, the same as the other sites, with 12 transitional
beds, that will give us, I guess I will describe an accordion
capacity to grow if we need to.
In addition, we are going to put additional resources in to
be able to treat moderate brain injury that has a need for a
lot of psychological support and cognitive work on an
outpatient basis. So this is something that is very exciting
that is going to happen at San Antonio.
Mr. Rodriguez. Okay. We are looking forward to it and
looking forward to working with you. Thank you.
Mr. Mitchell. Thank you, Mr. Rodriguez.
We have one last question from Ms. Brown-Waite and that
will conclude this hearing.
Ms. Brown-Waite. As you can tell, we have votes, so we will
be leaving for that.
Mr. Feeley, our staff has informed me that not all
facilities are using, or not even aware of the use and
availability of JPTA and VTA programs to track incoming
patients from DoD.
How widely would you say has VA educated the outlying
medical centers and outpatient clinics on this patient tracking
application? And for the polytrauma units, which obviously this
information is very important, how much data is transferred
from DoD using this application when a servicemember is
transferred between the two organizations?
Mr. Feeley. Thank you. I am going to let Dr. Huycke comment
on that.
Dr. Huycke. Ma'am, thank you for the question because I
think the JPTA/VTA initiative in the VA has truly been one of a
good news story.
Right now in the VA, we have 49 individuals at 15 VA
medical centers who have access to the joint patient tracking
application. Of course, that is the DoD version. And on top of
that, we have more than 1,200 individuals in the VA system
spread throughout the country who have access to the veterans
tracking application. As you know, the veterans tracking
application is the VA image of the joint patient tracking
application.
We have prioritized the rolling of this capability out to
the polytrauma units because of the acuity and the necessity of
getting it out to those folks first. And so that is where the
priority has been and continues to be. And all of the
polytrauma units have more than a single individual with access
to the joint patient tracking application and to VTA.
So on top of that, there have been, for instance, at the
last national call, Mr. Feeley's last national call, we put out
the information on the veterans tracking application. So
although we are probably not where we would like to be with
VTA, we believe that to be a very good news story between the
collaboration of DoD and VA.
Mr. Mitchell. Just one follow-up. My understanding is that
Palo Alto as well as--who is the other--Minneapolis, have not
even heard of these programs. So I do not know if fault lies
with them or with you, but I would think that there ought to be
better coordination of all of these.
And with that, I want to thank all of you for what you are
doing because, you know, our veterans deserve nothing but the
very finest from what this country has to offer. And there may
be more questions that will be asked by the staff that we did
not get to ask today, so it may be in writing, but I want you
to know that we are very concerned about this. And so expect
some follow-up from both of our staffs.
Thank you, and this meeting is adjourned.
[Whereupon, at 11:22 a.m., the Subcommittee was
adjourned.]
A P P E N D I X
----------
Prepared Statement of Hon. Harry E. Mitchell,
Chairman, Subcommittee on Oversight and Investigations
This hearing will come to order.
Thank you all for coming today. I am pleased that so many folks
could attend this oversight hearing on VA Polytrauma Rehabilitation
Centers. The VA polytrauma centers help mend and reintegrate into
society servicemembers who have suffered among the worst that war can
inflict. The most severely injured servicemembers serving in Iraq and
Afghanistan are medevac-ed out of theater through Germany to Walter
Reed and Bethesda Naval Hospitals and, when they are ready, are sent to
one of the four polytrauma centers, which are located in Richmond,
Tampa, Minneapolis, and Palo Alto. Most polytrauma patients have
suffered traumatic brain injury in addition to a variety of other
serious injuries, some which necessitate amputation. The soldiers,
sailors, airmen, and Marines who are treated at the polytrauma centers
have paid a very high price for their service to their country, as have
their families, both of whom face a long and difficult path to recovery
and sometimes a lifetime of care. The Nation owes these servicemembers
and their families everything that a Nation as rich as ours can
provide.
The Nation has many who need and deserve what we can give. Survival
rates for servicemembers injured in combat are extremely high compared
to previous conflicts, partly because of greatly improved protective
equipment, but also because the military has moved surgical medical
care practically to the front lines. A soldier injured in an IED blast
can be in surgery within 30 to 45 minutes or even less. With these
advances, however, comes the need to treat injuries that would have
been fatal in the past. Injuries like traumatic brain injury and post-
traumatic stress disorder require medical treatment and long-term care
of a new kind. The VA polytrauma centers are an essential part of that
care.
Congress has provided significant resources, and is providing more,
that have enabled the VA to establish and expand polytrauma care. It
must be said that the VA has stepped up to the plate to meet this need.
In addition to the four polytrauma centers, the VA has created a
network of sub-acute polytrauma care centers in each of the Veterans
Integrated Services Networks and outreach programs throughout the
country. This is not to say that everything is as it should be--we
would not be having this hearing if that were the case. Polytrauma care
is not perfect. There is also the sharing of electronic medical
information and other issues that have been highlighted by Senator Dole
and Secretary Shalala that the Subcommittee and the Full Committee will
be addressing in the near future. But there should be no
misunderstanding--we are not here to criticize the VA's care providers
or to suggest that the quality of care that the Nation's most severely
injured servicemembers is anything less than exemplary. The
Subcommittee has found some management issues that need to be
addressed--that is why the title of this hearing is what it is. The
Subcommittee's oversight is intended to ensure that the superb care the
VA provides is provided to those who deserve to receive it.
Data provided by the VA shows that the Palo Alto VA's polytrauma
center, from the beginning of this year through July, filled only 60
percent of its available beds, while the three other polytrauma centers
combined have been running at 98 percent of capacity. We have found no
good reason why that should be. The VA's Palo Alto hospital has a
beautiful facility, an even more beautiful Fisher House where family
members can stay, and is practically married to the Stanford Medical
School. Palo Alto has all the resources it could need to provide care
for all the polytrauma patients it can take. The Subcommittee has also
found that the Palo Alto polytrauma center would not accept minimally
responsive brain injured patients while the other polytrauma centers
did so, until the VA created a treatment protocol for those patients in
December 2006 and effectively forced Palo Alto to accept these
patients. This past spring, the VA's Office of Medical Investigations
found disarray, morale problems, insufficient programs for families,
and lack of leadership. All of this raises obvious issues not just
about local management but also about VA's central office. Why, for
example, did the fact that Palo Alto's failure to fill its beds while
the other polytrauma centers were at full capacity not raise a red flag
at headquarters?
We begin today by hearing from the senior management of the Palo
Alto Health Care system, headed by its Director, Lisa Freeman.
Subcommittee staff has spent much time with Ms. Freeman and her team
and they are to be commended for their willingness to meet with and
provide information to the Subcommittee. We hope, indeed expect, that
their testimony will describe significant progress in addressing the
concerns of the Office of Medical Investigations and this Subcommittee.
The second panel is headed by William Feeley, Deputy Under
Secretary for Health for Operations and Management. The Subcommittee
extends its thanks to Mr. Feeley and the VA witnesses with him for
their efforts to provide the best care possible to our injured
servicemembers and appreciates their cooperation with the Subcommittee
in meeting with and providing information to us. We in no way doubt
their good will and dedication. But there are obvious management issues
for the central office that are raised by the fact that there were
empty beds in Palo Alto and these witnesses will be asked to address
these issues. Dr. Barbara Sigford and Dr. Shane McNamee, both of whom
are personally involved in running polytrauma centers, are at the
witness table as well. We look forward to hearing from them about the
good things they are doing for those who have made great sacrifices for
their country.
On Sunday night, the Public Broadcasting System began a 15 hour
presentation of Ken Burns' documentary on World War Two. America
achieved great things in that war, but the documentary reminds us, or,
perhaps, more realistically, teaches us of the terrible cost of war. We
as a Nation owe a debt that can never be repaid to those who serve, and
an obligation that must be met to meet the needs of those injured in
that service. We are here today to do our part in making sure that this
happens.
No one can doubt the dedication of the men and women in the
military and the VA who provide care for our servicemembers.
Prepared Statement of Hon. Ginny Brown-Waite,
Ranking Republican Member
Thank you, Mr. Chairman, for yielding.
Mr. Chairman, I believe the title of this hearing is very
appropriate. When we talk about our wounded warriors from the Global
War on Terrorism, the quest for excellence should be of utmost
importance.
Our Committee staff recently visited several Polytrauma
Rehabilitation Centers located in Richmond, Virginia, Minneapolis,
Minnesota, and Palo Alto, California. They did this to provide
oversight on the level of care being provided to our wounded
servicemembers at those units. Last Congress, while serving as Chairman
of this Committee, Ranking Member Buyer followed injured servicemembers
from a combat support hospital in Iraq through Landstuhl Army Medical
Center in Germany, and on to Walter Reed and Bethesda. Mr. Buyer has
also visited the Minneapolis PRC to evaluate care and services received
by our most critically injured servicemembers.
What I still see today is of great concern. The tracking of medical
records still includes the paperwork and hard copies of medical records
accompanying the servicemembers as they transfer stateside and
ultimately to the VA. The Committee hears that not all the critical
medical information is being forwarded to the Polytrauma units by the
Department of Defense, and many of the VA facilities are not using or
have never heard of the Joint Patient Tracking Application and the
Veteran Tracking Application systems.
At the PRC unit in Palo Alto, our staff found several issues
relating to lack of staffing and resources. This same concern was
detailed in the draft OMI report obtained by our staff prior to their
visit to Palo Alto. I would like to have the witnesses address this
deficiency in care to the servicemembers and veterans who are being
treated in this facility, and am interested in learning how widespread
this problem is.
During the staff visit to the PRC unit in Minneapolis, the
Committee learned about the unusually high turnover rate of the active
duty officers' military liaison. I am concerned about how this turnover
rate affects the continuity of care for our severely injured
servicemembers. PRC staff told us that there were also no electronic
transfer of records between the DoD and the PRC in Minneapolis. I am
interested in learning what is being done to address this situation. I
know that some of our PRCs are doing a great job, while it seems that
others are still having great difficulties. How are best practices
being shared between PRCs to provide the best possible care for our
severely wounded servicemembers and veterans?
Mr. Chairman, I am quite concerned about the care our wounded
servicemembers are receiving as they move from the battlefield through
the line of care to our VA facilities. As I have stated in the past,
the hand-off between DoD and VA should be seamless and transparent to
the servicemembers and their families receiving care and treatment . .
. not a fumble. Repeatedly, the Committee has heard that many of these
transfers require multiple phone calls, emails, faxes, and
videoconferencing. Our veterans must have this seamless transition to
maintain a continuum of care between the two departments. Committee
Members have been fighting this recurring battle on the home front for
our servicemembers and veterans.
Mr. Chairman, Congress' responsibility to these men and women in
uniform does not end with their care at the PRC units. As the Oversight
Committee, we must also ensure that they have a seamless transition
from active duty to civilian/veteran status.
I cannot stress enough the importance of working toward a standard
Benefits Delivery upon Discharge (BDD) documentation. A standard BDD
would include one physical to be shared between the DoD and the VA,
providing servicemembers with documentation as to the benefits for
which they may be eligible. With the use of a standard shared BDD, we
could conceivably have the claims backlog at the VA caught up in just a
few years. This program was successfully tested between DoD and VA from
1995-1997. It is also a strong recommendation for the President's Dole-
Shalala Commission report.
Again, Mr. Chairman, thank you for calling this hearing, and I look
forward to hearing from our witnesses about how VA is working with the
DoD to improve care for our Nation's heroes.
Prepared Statement of Elizabeth Joyce Freeman, Director,
Veterans Affairs Palo Alto Health Care System,
Veterans Health Administration, U.S. Department of Veterans Affairs
Mr. Chairman and Members of the Committee, thank you for the
opportunity to appear before you today to discuss the Polytrauma
Rehabilitation Center (PRC) located at the Department of Veterans
Affairs Palo Alto Health Care System (VAPAHCS). It is a privilege to be
on Capitol Hill to speak and answer questions about this vital program
and other issues that are important to veterans who have bravely served
in Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF).
Mr. Chairman, I would also like to thank you and your Committee for
your advocacy on behalf of our Nation's veterans. The Committee and its
staff have been actively involved in many issues affecting veterans
this year. Several weeks ago, I had the pleasure of hosting a visit by
senior staff from the Committee, including Mr. Geoffrey Bestor and Mr.
Art Wu. They toured VAPAHCS and interviewed several patients, family
members and staff. I appreciated their interest, insights and
suggestions.
Today, I will provide a brief overview of VAPAHCS and the PRC. I
will present some of our successes, challenges and upcoming
enhancements at the PRC. I will also specifically discuss areas of
particular interest and recent scrutiny, including accreditation,
referral process, emerging consciousness program, family support and
programmatic leadership.
VA Palo Alto Health Care System (VAPAHCS)
VAPAHCS is one of the largest and most complex health care systems
in the Veterans Health Administration (VHA). It provides primary,
secondary and tertiary care services across a large geographic area
(i.e., 10 counties over 13,500 square-miles) in the South San Francisco
Bay area. VAPAHCS operates facilities at three inpatient divisions
(i.e., Palo Alto, Menlo Park and Livermore) and six outpatient clinics
(i.e., Capitola, Modesto, Monterey, San Jose, Sonora and Stockton).
VAPAHCS offers most of the highly specialized services in VHA,
including traumatic brain injury (TBI), blind rehabilitation, hospice,
palliative care, spinal cord injury (SCI), post-traumatic stress
disorder (PTSD), gero-psychiatric inpatient care, war-related illness
and injuries, domiciliary care and organ transplantation.
In fiscal year (FY) 2006, VAPAHCS had enrolled more than 85,000
veterans and provided care to 53,000 unique veterans. VAPAHCS staff
includes nearly 3,000 full-time equivalent employees (FTEE) and more
than 1,700 volunteers. The FY 2007 operating budget for VAPAHCS is
approximately $600 million. VAPAHCS has particularly strong academic
programs, including the third most highly funded research program in
VHA. VAPAHCS and the veterans it proudly serves benefit from a balanced
relationship with Stanford University School of Medicine and
affiliations with more than 100 other academic institutions.
Polytrauma Rehabilitation Center (PRC)
VA established the Polytrauma System of Care (PSC) in 2005 to
address the biopsychosocial needs of the most severely injured OEF/OIF
veterans. The PSC consists of PRCs, Polytrauma Network Sites (PNSs),
Polytrauma Support Clinic Teams (PSCTs) and Polytrauma Points of
Contact (PPOCs). PRCs serve as a regional referral center for acute
medical and rehabilitative care for patients with polytrauma (defined
as two or more injuries, one of which might be life threatening,
resulting in significant physical, cognitive, psychological or social
impairments and functional disability) and TBI. PRCs maintain a full
team of dedicated rehabilitation specialists and experts from other
specialties related to polytrauma. PRCs also serve as consultants to
other facilities across the PSC.
The PRC at VAPAHCS is one of four PRCs in VHA (the other three are
located in Minneapolis, MN; Richmond, VA; and Tampa, FL). A fifth
polytrauma site was just recently announced for San Antonio, TX. The
PRC offers a continuum of acute rehabilitative services in a variety of
venues, including inpatient wards, outpatient clinics and residential
transitional settings. Clinical care is provided by a dedicated
interdisciplinary team with specific expertise in physiatry,
rehabilitation nursing, neuro-psychology, psychology, speech-language
pathology, occupational therapy, physical therapy, social work,
therapeutic recreation therapy, prosthetics, SCI, blind rehabilitation
and PTSD.
The core of the PRC at VAPAHCS is a 12-bed ward located in Building
7D on the campus of the Palo Alto Division. The PRC building also has
four general rehabilitation beds that are available to polytrauma
patients on a priority basis, plus two additional beds for residential
rehabilitation and/or women veterans. Since its inception (i.e., from
February 2005 through early September 2007), the PRC has accepted 143
patients. The average daily census (ADC) has steadily increased since
FY 2005. Through the third quarter of FY 2007, the PRC ADC has been 7.9
for an occupancy rate of 65 percent.
Another important component of the PRC is the Polytrauma
Residential Transitional Rehabilitation Program (PRTRP). PRTRP is
designed for veterans and active duty servicemembers who have completed
their acute rehabilitation but have lingering impairments that prevent
them from safely re-integrating into their community or returning to
active duty. PRTRP has the goal of establishing independent living
through a structured program that focuses on restoring home, community,
leisure, psychological and vocational skills in a controlled,
therapeutic setting. Services typically provided include individual and
group therapies, case management, care coordination and vocational
rehabilitation. Through the third quarter of FY 2007, the ADC in the
PRTRP has been 4.7 and therefore the combined ADC for both the PRC and
PRTRP is 12.6.
In part due to the ongoing war in southwest Asia and our country's
deep concern for injured veterans, the PRC at VAPAHCS has received
considerable attention from domestic and international media outlets.
Since the establishment of the PRC in 2005, more than 200 print and
broadcast stories have been disseminated about the PRC, its patients
and its staff. Stories from respected organizations such as Associated
Press, New York Times, Jim Lehrer NewsHour, National Public Radio, NBC
Nightly News and British Broadcasting Company, have all portrayed the
quality of the care at the PRC as outstanding.
One poignant example is the story of Marine Corps Corporal (Cpl.)
Jason Poole. Cpl. Poole was on his third tour in Iraq in 2004, 10 days
shy of coming home, when his patrol was hit by a roadside bomb. The
explosion and resulting injuries (e.g., shrapnel went into his left ear
and out his left eye) left him in coma for two months. When he arrived
at VAPAHCS, he was unable to walk, talk or breathe without a tube in
place. Two years and seven reconstructive surgeries later, he was
interviewed by the local NBC news affiliate. ``I've been treated
amazingly here,'' he said. ``These people [staff at the PRC at VAPAHCS]
gave me my life. They are everything to me. I would not be where I am
today without their help.'' \1\ The accomplishments of Cpl. Poole and
so many other courageous men and women at the PRC are extraordinarily
gratifying to me.
---------------------------------------------------------------------------
\1\ NBC Channel 11: ``The Bay Area at 11'', KNTV-San Francisco 02/
07/2007.
---------------------------------------------------------------------------
Challenges and Improvements
While the PRC at VAPAHCS has enjoyed considerable success, it has
experienced and continues to face challenges. Staffing is a major area
of concern. VAPAHCS expends considerable effort to attract and retain
the ``best and the brightest.'' The health care labor market in the
greater San Francisco Bay Area is highly competitive and compounded by
an exceedingly high cost of living. In part due to our affiliations
with prestigious academic partners such as Stanford University School
of Medicine, Washington State University and the University of
California San Francisco School of Medicine; VAPAHCS generally has been
successful in recruitment. However, recruitment for some positions
(e.g., physiatry) has been especially problematic.
While work on the PRC is fulfilling, it is also inherently
demanding. Knowledgeable and well-intended individuals can have
different opinions and these differences can be exaggerated in the PRC
environment. Consequently, the VHA Under Secretary for Health (USH)
recently asked the VHA National Center of Organizational Development
(NCOD) to visit all four PRCs to assess current structure and staff.
NCOD came to VAPAHCS and met with senior leadership and front line
staff. The initial visit was beneficial and we look forward to
continuing our partnership with NCOD.
Also, as noted earlier, the PRC is a highly visible endeavor. The
PRC is frequently the subject of scrutiny by oversight bodies,
veterans' advocates, Department of Defense (DoD) personnel, media and
elected officials. Nearly every week, VAPAHCS has the honor of hosting
visits by interested parties. The vast majority of these visits are
very positive and generate considerable praise and compliments for PRC
staff and leadership.
However, earlier this year, the VHA Office of the Medical Inspector
(OMI) received a letter from the Senate Committee on Veterans' Affairs
expressing concern about the delivery of care at the PRC at VAPAHCS.
OMI was asked to look into several allegations, including delays in
accreditation, inappropriate declinations of referrals and lack of
effective leadership at the program level. As a result, OMI came to
VAPAHCS in March 2007 and assessed the PRC. Some of the allegations
were validated (e.g., delay in accreditation survey), while others were
not substantiated (e.g., OMI concluded VAPAHCS did not ``cherry pick''
referrals). I will discuss these and other issues in the following
sections.
Accreditation. One of the concerns expressed in the OMI report was
the delay in the accreditation survey by the Commission on
Accreditation of Rehabilitation Facilities (CARF). CARF confers up to
(i.e., a maximum) 3-year accreditation status to rehabilitation
facilities that undergo a successful survey. VAPAHCS was due for its
triennial CARF survey of rehabilitation programs (including the PRC) in
February 2007. Based on internal and external assessments (e.g., a
``mock survey'' by a contracted private health care organization), I
determined we needed additional time to prepare for the survey.
Consequently, I asked CARF to delay its survey for a few months.
I am pleased to report to the Committee that the CARF survey
occurred July 19-20, 2007, and resulted in full accreditation for the
maximum 3-years for all of the four programs surveyed (i.e.,
outpatient, inpatient and residential brain injury rehabilitation, as
well as inpatient rehabilitation). As noted in the August 24, 2007,
notification letter from CARF, ``This achievement is an indication of
your organization's dedication and commitment to improving the quality
of the lives of the persons served. Services, personnel, and
documentation clearly indicate an established pattern of practice
excellence.'' I am especially pleased that areas that were previously
considered weaknesses (e.g., program leadership, staff education), are
now cited by CARF to be organizational strengths.
Referrals. I and my staff at VAPAHCS consider our selection as a
PRC site to be a distinct privilege. We are fully committed to having
an active, vibrant and highly effective rehabilitation program. We
recognize that the historical level of activity at the PRC has been
below capacity and we have evaluated the circumstances associated with
this situation.
I would like to emphasize that we are highly motivated to receive
referrals to our PRC and we make every effort to accept them. Since the
PRC began operations in 2005 (through September 14, 2007), VAPAHCS has
received a total of 177 referrals to its PRC and accepted 143 patients
(81 percent). The PRC declined or redirected 25 patients (14 percent)
and the referring site withdrew 9 referrals (5 percent). The most
common reasons for the PRC not accepting referrals have been another
form of treatment was needed (e.g., care for PTSD, substance abuse
treatment), another venue was more appropriate (e.g., Polytrauma
Network Site, different PRC for geographic reasons) or the desired
service was not available at the time (e.g., coma stimulation). I would
like to emphasize that the OMI reviewed this issue earlier this year
and concluded that the disposition of referrals was appropriate. And,
while the acceptance of some referrals was delayed due to concerns
regarding medical stability (in the context of long flights from the
East Coast), OMI did not substantiate the allegation that VAPAHCS was
``cherry picking'' referrals to achieve good outcomes.
Currently, recent changes I have initiated will make it easier for
referring sites to send us patients. There is now a single point of
contact for all PRC referrals at VAPAHCS who has the requisite customer
service skills. This individual collects all of the relevant
information and presents it to an interdisciplinary team of polytrauma
experts. The team makes a recommendation to the PRC Program Director
and the PRC Program Director makes a decision within 2 business days
from the time of the referral (i.e., when the needed medical
information is available). I have instructed my staff to look for every
possible way to accept all patients to VAPAHCS, either at the PRC or
another program (e.g., PRTRP, National Center for PTSD). The decision
will be promptly communicated to the referring site. If for any reason
the referring site disagrees with the decision, the referring site will
be encouraged to appeal the decision to the Chief of Staff, VAPAHCS. We
will fully document the disposition for each referral and will report
the outcomes to the Veterans Integrated Service Network (VISN) 21
Office and VA Central Office (VACO) monthly.
Emerging consciousness program. VHA formally introduced the
Emerging Consciousness (EC) following its polytrauma conference in
December 2006. EC is a program developed by VHA to optimize the long-
term functional outcomes of brain-injured patients by attempting to
improve responsiveness, return to consciousness and advance to the next
level of rehabilitation care. EC is intended for patients who range
from fully comatoese to minimally conscious. EC utilizes appropriate
medical and nursing rehabilitation services, individualized
multisensory stimulation and prevention of complications related to
immobilization. EC also emphasizes support to families and caregivers.
Some patients in the EC program, even with the most optimal care may
not regain consciousness or advance to the next level of care.
The PRC at VAPAHCS has been providing many components of the EC
program since its inception (e.g., rehabilitation services, prevention
of complications and family support). However, the PRC at VAPAHCS did
not initially offer the multisensory component. In the summer of 2006,
VAPAHCS noted anecdotal reports of the success of multisensory
stimulation and reassessed its potential value. VAPAHCS began offering
this service in November 2006 and fully instituted the EC program
following the polytrauma conference in December 2006. The PRC has
accepted 12 patients into its EC program since November 2006, including
a patient declined by private rehabilitation sites. At the time of this
testimony, VAPAHCS had a census of six EC patients with five in the PRC
and one in the intensive care unit.
Family support. VAPAHCS recognizes that the presence and support of
family members are critical components of the successful rehabilitation
of injured patients. VA has inherent constraints on its ability to
provide certain services to non-veteran family members. Fortunately,
since the PRC began operations, VAPAHCS has developed innovative
programs to support families of PRC patients.
A wonderful example is the construction and opening of a Fisher
HouseTM directly across from the PRC on the VAPAHCS campus.
Fisher HousesTM are ``comfort homes'' with individual rooms
for families of patients receiving medical care at major military and
VA medical centers. Prior to the opening of the Fisher
HouseTM in April 2006, many families complained of the
inability to find affordable accommodations near VAPAHCS. Thanks to the
generosity of donors and the Fisher House Foundation, families of OEF/
OIF patients now have access to a stunning 21-suite Fisher
HouseTM. There is no charge to guests and families of OEF/
OIF patients are given priority admission. The Fisher
HouseTM is filled to capacity nearly every night.
We have also been able to provide limited monetary support from
donations to our General Post Fund. The donations come from individuals
and organizations such as Rotary Club. We have established a Fisher
HouseTM Fund and an OEF/OIF Fund. These funds are used to
pay for lodging, groceries, rental cars, day care for children and
other incidentals.
As part of our ongoing reorganization and staffing enhancements, we
are increasing the support and services to families who are with their
loved ones in the PRC. We are enhancing access to the Internet (e.g.,
to check e-mails, communicate with other family members), offering
caregiver education and training, providing a ``quiet room,'' offering
family counseling, spiritual support (e.g., chaplain services) and
assistance with recreational activities. Another important benefit to
families has been the placement of Department of Defense (DoD) liaisons
in the PRC. The DoD liaisons are able to assist active duty patients
and their families with myriad questions and services important to
them.
Organization and leadership. In response to recommendations by both
internal and external entities (OMI, CARF) we continue to evaluate
services and shape our service delivery to meet the needs of our
patient population.
In closing, Mr. Chairman, I would like to note that it is an
incredible honor to host one of the four (soon to be five) PRCs in VHA.
I am very proud of the talented and dedicated staff at VAPAHCS who
provide outstanding and compassionate care to our Nation's heroes. They
do incredible work in challenging circumstances. I believe we have made
a positive difference in the lives of so many veterans and their
families. I acknowledge that we are not perfect. In VHA, when mistakes
occur we ``own them'' and make the requisite system changes. This same
philosophy holds true in the PRC at VAPAHCS and our investment of
resources, service enhancements and organizational changes are evidence
of that approach.
Again, Mr. Chairman, thank you for the opportunity to testify at
this hearing. I and the staff who accompany me would be delighted to
address any questions you might have for us.
Prepared Statement of William F. Feeley,
Deputy Under Secretary for Health for Operations and Management,
Veterans Health Administration, U.S. Department of Veterans Affairs
Good morning Mr. Chairman and Members of the Committee.
Thank you for this opportunity to discuss the Veterans Health
Administration's (VHA) ongoing efforts to improve the quality of care
that we provide to veterans suffering from traumatic brain injury (TBI)
and complex multiple trauma. Joining me today is Dr. Edward Huycke,
Chief Officer for VA's Office of Seamless Transition, Dr. Lucille Beck,
VA's Chief Consultant for Rehabilitation Services, and Dr. Barbara
Sigford, National Program Director for Physical Medicine and
Rehabilitation.
VA offers comprehensive primary and specialty health care to our
veterans and active duty servicemembers, and is an acknowledged
national leader in providing specialty care in the treatment and
rehabilitation of TBI and polytrauma. Since 1992, VA has maintained
four specialized TBI Centers that have served as the primary VHA
receiving facilities for military treatment facilities seeking
specialized care for brain injuries and complex polytrauma. In 2005, VA
established its Polytrauma System of Care, leveraging and enhancing the
existing expertise at these TBI centers to meet the needs of seriously
injured veterans and active duty servicemembers from operations in,,
and elsewhere. This new era of combat and the resulting casualties have
required adaptations in our approaches to care that we provide for this
brave new generation of veterans. We readily accept the challenge and
opportunity to adapt VA's existing integrated system to provide the
best available continuum of care. The focus of my testimony today will
be on treatment and rehabilitation provided by VA for veterans
recovering from TBI and complex multiple trauma, and the current
initiatives to further enhance these services to our veterans within
this system 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 integrated nationwide system of care has been designed to
provide access to lifelong rehabilitation care for veterans and active
duty servicemembers recovering from polytrauma and TBI.
Component 1--Regional. Currently the four Polytrauma/TBI
Rehabilitation Centers (PRC)--located in Minneapolis, MN; Palo Alto,
CA; Richmond, VA; and Tampa, FL--are the flagship facilities of the
Polytrauma System of Care. A fifth polytrauma site was just recently
announced for San Antonio, TX. These centers serve as hubs for acute
medical and rehabilitation care, research, and education related to
polytrauma and TBI. The specialized services provided at each PRC
include: comprehensive acute rehabilitation care for complex and severe
polytraumatic injuries, emerging consciousness programs, outpatient
programs, and residential transitional rehabilitation programs.
Clinical care is provided by a dedicated staff of rehabilitation
specialists and medical consultants with expertise in the treatment of
the physical, mental and psychosocial problems that accompany
polytrauma and TBI. This team includes specialists in physiatry,
rehabilitation nursing, neuropsychology, psychology, speech-language
pathology, occupational therapy, physical therapy, social work,
therapeutic recreation, prosthetics, and blind rehabilitation.
One of the newest programs within the PRCs is the treatment program
for patients with severe disorders of consciousness. Provision of
rehabilitation services for patients who are minimally conscious or
minimally responsive is currently based on expert opinion rather than
scientific evidence. Cornerstones of treatment for patients with severe
disorders of consciousness include: aggressive medical care to treat
potential reversible causes of impaired consciousness (infection,
sedation, etc.); prevention of complications (contracture, pressure
sores, malnutrition); family support and education. Additional
interventions often include structured sensory stimulation, and trials
with medications to increase responsiveness. Programs providing
specialized care for severe disorders of consciousness must also have a
mechanism for monitoring response to treatment. A commonly used
instrument for this purpose is the Disorders of Consciousness Scale
(DOCS). VA developed its program through a process of reviewing the
experience and expertise developed at those VA sites that had an
established protocol, reviewing the literature, and consulting with
private expert professionals providing these services. Development of
the formalized program culminated with a face-to-face working
conference in December 2006, at which time the protocol was established
that is currently being utilized, and the requirement was set that all
Polytrauma Rehabilitation Centers would participate. The workgroup for
this new program continues to meet monthly.
In 2007, staffing for the PRC teams was increased at each center in
response to increased demands of patient workload, coordination of
care, and support for family caregivers. The PRCs have affiliations and
collaborative relationships with academic medical centers. A
significant number of PRC clinical providers share VA and affiliated
positions in training and medical rehabilitation. The inpatient
rehabilitation programs at the PRCs maintain accreditation by the
Commission on Accreditation of Rehabilitation Facilities (CARF) for
both Traumatic Brain Injury and Comprehensive Rehabilitation.
Component 2--Network. The Polytrauma/TBI Network Sites (PNS),
designated in December 2005, represent the second echelon within the
Polytrauma System of Care, with one PNS located within each of VA's 21
Veterans Integrated Service Networks (VISN). The PNS provides key
components of post-acute rehabilitation care for individuals with
polytrauma/TBI, including, but not limited to inpatient and outpatient
rehabilitation, and day programs. The PNS is responsible for
coordinating access to VA and non-VA services across the VISN to meet
the needs of patients recovering from polytrauma and TBI, and their
families. The PNS consults, whenever necessary, with the PRC.
Components 3 and 4--Facility. The Polytrauma System of Care network
was expanded in March, 2007, to include two new components of care:
Polytrauma Support Clinic Teams (PSCT) and Polytrauma Points of Contact
(PPOC). With their geographical distribution across the VA, the 75
Polytrauma Support Clinic Teams facilitate access to specialized
rehabilitation services for veterans and active duty servicemembers at
locations closer to their home communities. These interdisciplinary
teams of rehabilitation specialists are responsible for managing the
care of patients with stable treatment plans, providing regular follow-
up visits, and responding to new medical and psychosocial problems as
they emerge. The PSCT consults with their affiliated Polytrauma Network
Site or Polytrauma Rehabilitation Center when more specialized services
are required.
The remaining 54 VA medical centers have an identified Polytrauma
Point of Contact who is responsible for managing consultations for
patients with polytrauma and TBI, and assisting with referrals of these
patients to programs capable of providing the appropriate level of
services.
The Polytrauma Rehabilitation Centers and the Polytrauma Network
Sites are linked through the Polytrauma Telehealth Network (PTN) that
provides state-of-the-art multipoint videoconferencing capabilities.
This Network 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. This Network further
provides such clinical activities that include remote consultations and
evaluations of patients, and education for providers and families.
Coordination and Transition of Care
Care management across the entire continuum is a critical function
in the Polytrauma System of Care to ensure lifelong coordination of
services for patients recovering from polytrauma and TBI. Consistent,
comprehensive procedures and processes have been put in place to ensure
transition of patients from military treatment facilities to VA care at
the appropriate time, and under optimal conditions of safety and
convenience for the patients and their families.
At the direction of the Secretary, 100 Transition Patient Advocates
(TPAs) have been recruited nationwide. The TPAs contact the patient and
family while in the Military Treatment Facility. One of their
responsibilities is to ensure that all questions concerning VA are
answered and the case is expedited through the VA benefits process. If
necessary, the TPA will travel with the family and veteran from the MTF
to their home, and provide transportation to all VHA appointments.
The VA assigns a care manager to every patient admitted within the
VA Polytrauma System of Care. This care manager 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 care manager at the referring facility is responsible
for a ``warm hand off'' to the care manager at the receiving facility
closer to the veteran's home. The assigned care manager functions as
the point of contact for emerging medical, psychosocial, or
rehabilitation coordination of care, and provides patient and family
advocacy.
To facilitate continuity of medical care, the Polytrauma
Rehabilitation Center receives advanced notice of potential admissions
to their sites. Upon 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 military treatment facility medical record, including up
to date information about medications, laboratory studies, and daily
progress notes. In addition to record review, clinician-to-clinician
communication occurs to allow additional transfer of information and
resolution of any outstanding questions.
DoD and VA also have made significant progress sharing available
electronic health information to further coordinate care of these
patients. DoD and VA are now supporting the electronic transfer of DoD
inpatient data to VA clinicians at polytrauma centers. DoD is currently
transferring DoD medical digital images and electronically scanned
inpatient health records to the VA polytrauma centers from Walter Reed
Army Medical Center, National Naval Medical Center Bethesda and Brooke
Army Medical Center. This effort provides VA clinicians receiving these
combat veterans with immediate access to critical components of their
inpatient care at DoD military treatment facilities. In the future, VA
hopes to add the capability to provide this data bidirectionally to
support any patients returning to DoD for further care. Additionally,
VA and DoD are supporting the secure direct connection of authorized
providers at VA polytrauma centers into the health information systems
at Walter Reed Army Medical Center and National Naval Medical Center.
This direct connection provides the most timely access to much needed
DoD clinical information in support of care of critically injured
patients coming from combat theaters.
Psychosocial support for families of injured servicemembers is
paramount as decisions are made to transition from the acute medical,
life and death, setting of a military treatment facility to a
rehabilitation setting. This encompasses psychological support,
education about rehabilitation and the next setting of care, and
information about benefits and military processes and procedures. VA
social worker or nurse liaisons are located at 10 military treatment
facilities, 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, advising the families through the process. In
addition, VA has a Certified Rehabilitation Registered Nurse assigned
at Walter Reed Army Medical Center to provide education to the family
on TBI, the rehabilitation process, and the PRCs. The Admission Case
Manager from the PRC maintains 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 military treatment facilities 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 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.
The transition from the PRC to the home community is of critical
importance to ensure that the treatment plan, including continued
rehabilitation and medical care, psychosocial and logistical support is
maintained. Records for VA medical care are readily available through
remote access across the VA system. Follow up appointments are made
prior to discharge, and the transferring practitioners are readily
available for personal contact with the receiving provider to ensure
full and complete communication. Care managers at the Polytrauma
Network Site and the home VA medical center provide for ongoing support
and problem resolution in the home community, while continually
assessing for new and emerging issues. Finally, 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
The VA Polytrauma System of Care is a recognized leader in health
care for its expertise in treating combat-related injuries, and
managing the overlapping effects of combat stress response. Today, an
expanded system of care is available to provide more services and to
develop new, innovative approaches to these potentially debilitating
conditions. Our clinicians and researchers strive to provide the
highest standard of rehabilitation care for those recovering from
polytrauma and TBI, while concurrently evaluating ways to enhance
services. The VA continually assesses the unique needs of all
polytrauma patients, and has responded decisively to the increased
demand for services with this new generation of combat-injured
veterans. The VA is committed to providing the necessary level of
resources and scope of services that ensure a continuum of world-class,
lifelong care extending from acute rehabilitation to vocational and
transitional community rehabilitation programs for veterans at
locations closer to their home communities.
Thank you for your time and attention. I will be glad to respond to
any questions that you or other Members of the Committee may have.
Committee on Veterans' Affairs
Subcommittee on Oversight and Investigations
Washington, DC.
October 24, 2007
Honorable Gordon H. Mansfield
Acting Secretary
U.S. Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420
Dear Secretary Mansfield:
On Tuesday, September 25, 2007, the Subcommittee on Oversight and
Investigations of the House Committee on Veterans' Affairs held a
hearing on VA's Polytrauma Rehabilitation Centers: Management Issues.
During the hearing, the Subcommittee heard testimony from William
F. Feeley, Deputy Under Secretary for Operations and Management; and
Elizabeth J. Freeman, Director of the Palo Alto Health Care System
(PAHCS). Mr. Feeley was accompanied by Dr. Edward Huycke, Chief
Department of Defense Coordination Officer for VHA; Dr. Lucille B.
Beck, the Chief Consultant for Rehabilitation Services; Dr. Barbara
Sigford, National Program Director for Physical Medicine and
Rehabilitation; and Dr. Shane McNamee, Medical Director of the Richmond
Polytrauma Rehabilitation Center. Ms. Freeman was accompanied by Dr.
Lawrence Leung, Chief of Staff for the PAHCS; and Dr. Stephan Ezeji-
Okoye, Deputy Chief of Staff for the PAHCS. As a follow-up to that
hearing, the Subcommittee is requesting that the following questions be
answered for the record:
1. Prior to the hearing, VA provided Subcommittee staff with a
spreadsheet showing referrals to the PAHCS Polytrauma Rehabilitation
Center (PRC). The spreadsheet included, along with other information, a
column entitled ``Referral Decision (Accepted or Declined)'' and
another entitled ``Admission Date and Location.'' For patients listed
in rows numbered 1, 3, 4, 12, 20, 34, 43, 47, 50, 57, 59, 70, 82, 91,
98, 102, 111, 121, 126, 127, 132, 137, 149, 150, 125, and 154, please
provide information about the medical treatment of the patient
subsequent to PAHCS PRC's decision to decline acceptance, including
whether the patient was referred to/accepted by another medical
facility and the outcome of any subsequent treatment.
2. Mr. Feeley testified at the hearing that, beginning with FY08,
he will be receiving a report on the utilization of and disposition of
referrals to each of the PRCs. Please provide the Subcommittee with a
copy of the first two reports.
3. Please provide the Subcommittee with an update on the hiring
of the Associate Chief of Staff for PAHCS's Polytrauma System of Care.
In the event that PAHCS has not yet hired someone for this position,
please provide the Subcommittee periodic updates (not less than once
every 2 months) on the hiring process.
4. Prior to the hearing, VA provided Subcommittee staff with
PAHCS's list of polytrauma staffing requests, which included the ACOS
for the overall program, the Polytrauma Medical Director, social
workers, therapists, and others (a total of 38 FTEs). Please provide
the status (e.g., approved or not; advertised; position filled) for
each one of these positions.
5. Each PRC currently has 12 beds. Given the continued operations
in OIF/OEF. Is this a sufficient number of PRC beds?
6. In Secretary Nicholson's letter to House Committee on
Veterans' Affairs Chairman Bob Filner informing the Chairman of the
designation of San Antonio for the next Polytrauma Rehabilitation
Center site, the Secretary stated that Audie Murphy VA Medical Center
would be the host for the new PRC. Will the new PRC be located adjacent
to the hospital or is it possible that the PRC will be placed at a
location outside of the medical campus?
7. One of the major obstacles in funding of any project is how
the administration prioritizes its proposed budget to Congress. The VA
recently received $30 million toward the new San Antonio PRC as part of
the Iraq supplemental bill enacted earlier this year. From what funding
source does the Administration intend to request the additional $67
million needed to build the PRC?
8. When does the VA expect the new PRC to be operational? Is
there any way, for example, by accelerating funding, to complete the
project earlier?
9. In Dr. Feeley's testimony, it was mentioned that each
Polytrauma Center has a physiatrist on staff. Are all centers staffed
accordingly? What are critical staff vacancies at any of the PRCs that
need to be filled? What is the process for hiring staff at such
centers? What criteria are used to base the hiring decisions on for
these positions? Please list all vacant positions during the last 180
days, and length of vacancies.
10. Please provide the Committee with a listing of the locations
of the Polytrauma Support Clinic Teams (PSCT) and Polytrauma Points of
Contact (PPOC).
11. On average how many patients are assigned to each care
manager? Are the care managers able to handle their current caseloads,
or does VHA need additional funding to increase the number of care
managers at the VAMCs, particularly those with the Polytrauma units?
12. What is the relationship of the Palo Alto VAMC with the
Department of Defense, and please provide the sharing agreement that is
in place.
13. Does the PRC in Palo Alto use VTA/JPTA to track the patients
being transferred from DoD?
14. When Subcommittee staff traveled to Palo Alto in August, one
of the issues discussed was the transportation of patients from the
East Coast Washington, DC Metro Area (Bethesda/Walter Reed) to the PRC,
they were told much of this transport went through Travis Air Force
Base. Please provide some specifics on how the transfer of patients
occurs, e.g., how the transfer works, who coordinates the transfer to
VA, and patient medical care during travel. What problems have arisen
during transfer of patients from the East Coast to the West Coast, and
have there been problems with continuity of care en route? Furthermore,
how well does the handoff from the Department of Defense work?
We request you provide responses to the Subcommittee no later than
close of business, Monday, November 26, 2007.
If you have any questions concerning these questions, please
contact Subcommittee on Oversight and Investigations Staff Director,
Geoffrey Bestor, Esq., at (202) 225-3569 or the Subcommittee Republican
Staff Director, Arthur Wu, at (202) 225-3527.
Sincerely,
HARRY E. MITCHELL
Chairman
GINNY BROWN-WAITE
Ranking Republican Member
__________
Questions for the Record
Hon. Harry E. Mitchell Chairman and Hon. Ginny Brown-Waite,
Ranking Republican Member
Subcommittee on Oversight and Investigations,
House Committee on Veterans' Affairs
September 25, 2007
VA's Polytrauma Rehabilitation Centers: Management Issues
Question 1: Prior to the hearing, VA provided Subcommittee staff
with a spreadsheet showing referrals to the PAHCS Polytrauma
Rehabilitation Center (PRC). The spreadsheet included, along with other
information, a column entitled ``Referral Decision (Accepted or
Declined)'' and another entitled ``Admission Date and Location.'' For
patients listed in rows numbered 1, 3, 4, 12, 20, 34, 43, 47, 50, 57,
59, 70, 82, 91, 98, 102, 111, 121, 126, 127, 132, 137, 149, 150, 152,
and 154, please provide information about the medical treatment of the
patient subsequent to PAHCS PRC's decision to decline acceptance,
including whether the patient was referred to/accepted by another
medical facility and the outcome of any subsequent treatment.
Response: The information requested includes personally
identifiable information that is protected under the Privacy Act.
Accordingly, this information will be provided to Chairman under
separate cover.
Question 2: Mr. Feeley testified at the hearing that, beginning
with FY08, he will bereceiving a report on the utilization of and
disposition of referrals to each of the PRCs. Please provide the
Subcommittee with a copy of the first two reports.
Response: Each polytrauma rehabilitation center (PRC) tracks bed
census and submits a monthly report. The following is the summary
report per site for the month of October 2007:
Average Weekly Bed Census--October 2007
----------------------------------------------------------------------------------------------------------------
Not admitted
Number -----------------------
Number of Number of Number of Number of accepted/ Needed a
PRC patients new discharges new awaiting more Chose to
admissions referrals transfer appropriate go
level elsewhere
----------------------------------------------------------------------------------------------------------------
Richmond 11.5 2.5 1.5 5.5 3.0 2.0 .5
----------------------------------------------------------------------------------------------------------------
Tampa 16.0 1.5 1.0 6.0 5.25 0.5 0.75
----------------------------------------------------------------------------------------------------------------
Minneapolis 7.5 1.25 1.75 2.75 2.0 0.75 0.75
----------------------------------------------------------------------------------------------------------------
Palo Alto 8.25 0.25 0.5 1.0 1.75 0 0.5
----------------------------------------------------------------------------------------------------------------
Question 3: Please provide the Subcommittee with an update on the
hiring of the Associate Chief of Staff (ACOS) for PAHCS's Polytrauma
System of Care. In the event that PAHCS has not yet hired someone for
this position, please provide the Subcommittee periodic updates (not
less than once every 2 months) on the hiring process.
Response: Dr. Jerome Yesavage, Chief of Psychiatry at the VA Palo
Alto Health Care System (PAHCS), is serving as the Chair of the Search
Committee for the ACOS for Polytrauma and Operation Enduring Freedom/
Operation Iraqi Freedom (OEF/OIF) Program. The search Committee met for
the first time on October 11, 2007, to review the general guidelines
associated with the recruitment and interview process, and to establish
the role of committee members. Additionally, Committee members reviewed
the functional statement associated with the position, the vacancy
announcements and advertisements, and performance based interview (PBI)
questions.
Dr. Lawrence Leung, Chief of Staff at the VA PAHCS, stated in the
October 11, 2007, search committee meeting that filling this position
is of the highest priority. The search committee is conducting a
national search and has advertised in several relevant journals.
The search committee's next meeting was held on Wednesday, December
12, 2007, at 10:00 a.m. At this meeting, search committee members
prioritized the applications that have been received and ranked. The
search committee plans on conducting in-person interviews with the best
qualified candidates the week of January 7, 2008.
Question 4: Prior to the hearing, VA provided Subcommittee staff
with PAHCS's list of polytrauma staffing requests, which included the
ACOS for the overall program, the Polytrauma Medical Director, social
workers, therapists, and others (a total of 38 FTE's). Please provide
the status (e.g., approved or not; advertised; position filled) for
each one of these positions.
Response: All 38 positions are approved.
----------------------------------------------------------------------------------------------------------------
Program Position title Status
----------------------------------------------------------------------------------------------------------------
Polytrauma System of Care (PSC)/OEF/OIF ACOS for Polytrauma System of Care/OIF/OEF Advertised,
national
search
underway
----------------------------------------------------------------------------------------------------------------
PSC/OEF/OIF Administrative Officer Filled
----------------------------------------------------------------------------------------------------------------
PSC/OEF/OIF Health Sys Specialist/Research Coordinator On hold
until ACOS
search is
complete
----------------------------------------------------------------------------------------------------------------
PRC--Inpatient Nurse Educator Advertised
----------------------------------------------------------------------------------------------------------------
PRC--Inpatient Clinical Nurse Specialist Advertised
----------------------------------------------------------------------------------------------------------------
PRC--Inpatient Staff Physician (Pain Management) Filled
----------------------------------------------------------------------------------------------------------------
PRC--Inpatient Staff Physician (ENT Vestibular Specialist) Filled
----------------------------------------------------------------------------------------------------------------
PRC--Inpatient Staff Physician (Orthopedics) Filled
----------------------------------------------------------------------------------------------------------------
PRC--Inpatient Physical Therapist #4 Advertised
----------------------------------------------------------------------------------------------------------------
PRC--Inpatient Physical Therapist #5 (evening/weekend) Filled with
contract
staff
----------------------------------------------------------------------------------------------------------------
PRC--Inpatient Physical Therapist #6 (evening/weekend) Filled with
contract
staff
----------------------------------------------------------------------------------------------------------------
PRC--Inpatient Physical Therapy Aide Advertised
----------------------------------------------------------------------------------------------------------------
Polytrauma Unit Physical Therapy Assistant Advertised
----------------------------------------------------------------------------------------------------------------
PRC--Inpatient Speech/Lang PatFilled
----------------------------------------------------------------------------------------------------------------
PRC--Inpatient Speech/Lang PatFilled
----------------------------------------------------------------------------------------------------------------
PRC--Inpatient LeadAdvertisedn Therapist (Community/Volunteer Coord/
Family Care Coord)
----------------------------------------------------------------------------------------------------------------
PRC--Inpatient Occupational Therapist #4 Advertised
----------------------------------------------------------------------------------------------------------------
PRC--Inpatient Occupational Therapist #5 (evening/weekend) Advertised
----------------------------------------------------------------------------------------------------------------
PRC--Inpatient Massage Therapist--Health Technician Filled with
contract
staff
----------------------------------------------------------------------------------------------------------------
PRC--Inpatient Recreation Therapist #1 (Supervisor) Advertised
----------------------------------------------------------------------------------------------------------------
PRC--Inpatient Recreation Therapist #4 Advertised
----------------------------------------------------------------------------------------------------------------
PRC--Inpatient Rec Therapist #5 (evening/weekend) Advertised
----------------------------------------------------------------------------------------------------------------
PRC--Inpatient Family Therapist--Social Worker (SocWk) or Clinical Advertised
Psychologist (Psychology)
----------------------------------------------------------------------------------------------------------------
PRC--Inpatient Staff Support--Clinical Psychologist (Psychology) or Advertised
Social Worker (SocWk)
----------------------------------------------------------------------------------------------------------------
PRC--Inpatient Sexuality Therapist--specializing TBI--Clinical Advertised
Psychologist (Psychology) or Physician-Urologist
(Surgical)
----------------------------------------------------------------------------------------------------------------
OEF/OIF Program Program Manager Filled
----------------------------------------------------------------------------------------------------------------
OEF/OIF Program Program Support Asst Advertised
----------------------------------------------------------------------------------------------------------------
OEF/OIF Program OIF/OEF Social Work Case Manager/Outreach Duty Filled
station: Palo Alto
----------------------------------------------------------------------------------------------------------------
OEF/OIF Program OIF/OEF Social Work Case Manager/Outreach Duty Advertised
station: San Jose/Monterey
----------------------------------------------------------------------------------------------------------------
OEF/OIF Program OIF/OEF Social Work Case Manager/Outreach Duty Filled
station: Livermore
----------------------------------------------------------------------------------------------------------------
OEF/OIF Program OIF/OEF Nurse Case Manager Duty station: LiveAdvertised
----------------------------------------------------------------------------------------------------------------
Polytrauma Network Site (PNS)--Outpatient Physiatrist: Increase to 1.0 Advertised
----------------------------------------------------------------------------------------------------------------
PNS--Outpatient Social Worker--Case Mgr Filled
----------------------------------------------------------------------------------------------------------------
PNS--Outpatient Psychologist (Neuro) Filled
----------------------------------------------------------------------------------------------------------------
PNS--Outpatient Occupational Therapist Filled
----------------------------------------------------------------------------------------------------------------
PNS--Outpatient Physical Therapist Filled
----------------------------------------------------------------------------------------------------------------
PNS--Outpatient Speech/Lang PatFilled
----------------------------------------------------------------------------------------------------------------
PNS--Outpatient Program Support Asst Advertised
----------------------------------------------------------------------------------------------------------------
PNS--Outpatient RN Case Manager Advertised
----------------------------------------------------------------------------------------------------------------
PNS--Outpatient Recreation Therapist Advertised
----------------------------------------------------------------------------------------------------------------
PNS--Outpatient Social Worker Advertised
----------------------------------------------------------------------------------------------------------------
PSC Supr. Orthotist Prosthetist (PAD) Filled
----------------------------------------------------------------------------------------------------------------
This represents a total of 38 FTE, as some positions
will be part time
----------------------------------------------------------------------------------------------------------------
Total 38
----------------------------------------------------------------------------------------------------------------
Question 5: Each PRC currently has 12 beds. Given the continued
operations in OEF/OIF, is this a sufficient number of PRC beds?
Response: Yes. Currently, there is a sufficient number of PRC beds,
and bed capacity is increased as necessary. The PRCs at Minneapolis,
Palo Alto and Richmond currently operate 12 beds. Tampa PRC increased
capacity and began operating 18 beds on November 5, 2007. Average
occupancy rate at the PRCs is 81.6 percent (range 62.5 percent-95.8
percent). Occupancy rate for October, 2007 is generally consistent with
the trend observed during the last two quarters of fiscal year (FY)
2007. All four existing PRCs have the flexibility of using some of its
comprehensive inpatient rehabilitation beds for patients with
polytrauma/traumatic brain injury (TBI), if needed.
In addition to the four existing PRCs, construction of a new PRC in
San Antonio is expected to be complete in December 2010.
Question 6: In Secretary Nicholson's letter to House Committee on
Veterans' Affairs Chairman Bob Filner informing the Chairman of the
designation of San Antonio for the next Polytrauma Rehabilitation
Center site, the Secretary stated that Audie Murphy VA Medical Center
would be the host for the new PRC. Will the new PRC be located adjacent
to the hospital or is it possible that the PRC will be placed at a
location outside of the medical campus?
Response: The new PRC will be located on the medical center
grounds.
Question 7: One of the major obstacles in funding of any project is
how the administration prioritizes its proposed budget to Congress. The
VA recently received $30 million toward the new San Antonio PRC as part
of the Iraq supplemental bill enacted earlier this year. From what
funding source does the Administration intend to request the additional
$67 million to build the PRC?
Response: The new PRC in San Antonio will require $66 million in
major construction funding. VA does not intend to request additional
construction funds for the new PRC because section 230 of Div. I of the
Consolidated Appropriations Act, 2008, rescinded $66 million from the
Medical Services account appropriated by Public Law 110-28 and re-
appropriated the $66 million to the Construction, Major Projects
account.
Question 8: When does the VA expect the new PRC to be operational?
Is there any way, for example, by accelerating funding, to complete the
project earlier?
Response: Construction of the new PRC is expected to be completed
in December 2010. The project will not likely be completed earlier,
even with accelerated funding, due to time required to comply with
government regulations and procedures, and to design, develop and build
the PRC. The current project schedule is as follows:
------------------------------------------------------------------------
Activity Date
------------------------------------------------------------------------
Architect & Engineer (AlE) Advertisement (completed) 10/07
------------------------------------------------------------------------
Select AE Team 2/08
------------------------------------------------------------------------
Award AlE Contract 4/08
------------------------------------------------------------------------
Begin Schematic Design 4/08
------------------------------------------------------------------------
Complete Schematic Design 8/08
------------------------------------------------------------------------
Begin Design Development 8/08
------------------------------------------------------------------------
Complete Design Development 12/08
------------------------------------------------------------------------
Begin Construction Documents 12/08
------------------------------------------------------------------------
Complete Construction Documents 4/09
------------------------------------------------------------------------
Award Construction Contract 6/09
------------------------------------------------------------------------
Complete Construction* 12/10
------------------------------------------------------------------------
*18 month anticipated construction contract
Question 9: In Mr. Feeley's testimony, it was mentioned that each
Polytrauma Center has a physiatrist on staff. Are all centers staffed
accordingly? What are critical staff vacancies at any of the PRCs that
need to be filled? What is the process for hiring staff at such
centers? What criteria are used to base the hiring decisions on for
these positions? Please list all vacant positions during the last 180
days, and length of vacancies.
Response: The four PRCs have a full time physiatrist, who leads the
interdisciplinary rehabilitation team. Veterans Health Administration
(VHA) Directive 2005-024 Polytrauma Rehabilitation Centers recommends a
staffing model with 36 dedicated positions representing all
rehabilitation specialty areas. The PRCs have had stable dedicated
teams, with occasional vacancies as listed in the table below.
Core PRC Staffing Vacancies
--------------------------------------------------------------------------------------------------------------------------------------------------------
Palo Alto Minneapolis Richmond Tampa
-------------------------------------------------------------------------------
Core PRC Staff Type Target 36 # vacant # vacant # vacant # vacant
positions in last # mths in last # mths in last # mths in last # mths
180 days vacant 180 days vacant 180 days vacant 180 days vacant
--------------------------------------------------------------------------------------------------------------------------------------------------------
Physiatrist 1 0 0 0 0 0 0 0 0
--------------------------------------------------------------------------------------------------------------------------------------------------------
RN's 11 0 0 0 0 0 0 0 0
--------------------------------------------------------------------------------------------------------------------------------------------------------
LPN's/CNA's 8 0 0 0 0 0 0 0 0
--------------------------------------------------------------------------------------------------------------------------------------------------------
Admission & F/U CRRN Case Manager 1 1 1 0 0 0 0 1 4
--------------------------------------------------------------------------------------------------------------------------------------------------------
Counseling Psychologist 1 1 5 0 0 0 0 0 0
--------------------------------------------------------------------------------------------------------------------------------------------------------
Neuropsychologist 3 0 0 0 0 0 0 0 0
--------------------------------------------------------------------------------------------------------------------------------------------------------
SW Case Manager 3 1 6 0 0 0 0 0 0
--------------------------------------------------------------------------------------------------------------------------------------------------------
Physical Therapist 2.5 1 3 1 4 0 0 0 0
--------------------------------------------------------------------------------------------------------------------------------------------------------
Occupational Therapist 2.5 2 3 0.5 1 0 0 0 0
--------------------------------------------------------------------------------------------------------------------------------------------------------
Speech Therapist 2 0 0 0 0 0 0 0 0
--------------------------------------------------------------------------------------------------------------------------------------------------------
Recreation Therapist 2 2 0 0 0 0 0 0 0
--------------------------------------------------------------------------------------------------------------------------------------------------------
BROS 1 0 0 0 0 1 3 0 0
--------------------------------------------------------------------------------------------------------------------------------------------------------
Total 36 8 1.5 1 1
--------------------------------------------------------------------------------------------------------------------------------------------------------
Hiring actions for PRCs follow guidelines established by the Office
of Human Resource Management, and hiring is based on the applicants'
qualifications and specialized experience. Recruiting efforts typically
include internal and external job postings, specialized advertising in
trade publications, and local newspaper advertising that feature
information about the rewarding work of the PRCs.
Question 10: Please provide the Committee with a listing of the
locations of the Polytrauma Support Clinic Teams (PSCT) and Polytrauma
Points of Contact (PPOC).
Response:
----------------------------------------------------------------------------------------------------------------
Polytrauma/TBI
Regional Polytrauma/TBI Rehab Center VISN Polytrauma/TBI Support Clinic Polytrauma/TBI
Network Site Teams Point of Contact
----------------------------------------------------------------------------------------------------------------
Richmond VISN 1 Boston West Haven Bedford
Togus Manchester
White River Providence
North Hampton
----------------------------------------------------------------------------------------------------------------
VISN 2 Syracuse Albany
Buffalo
Bath
Canandaigua
----------------------------------------------------------------------------------------------------------------
VISN 3 Bronx Hudson Valley HCS/**All facilities
Montrose in VISN 3 have
Hudson Valley HCS/ appropriate
Castservice levels
NJHCS/to be classified
NJHCS/Lyas at least a
NY Harbor HCS/New Polytrauma
York Support Clinic
NY Harbor HCS/ Team.
Brooklyn
NY Harbor HCS/St
Albans
Northport VAMC
----------------------------------------------------------------------------------------------------------------
VISN 4 Philadelphia Pittsburgh Clarksburg
Wilmington
Erie
Lebanon
Coatesville
Altoona
Butler
Wilkes-Barre
----------------------------------------------------------------------------------------------------------------
VISN 5 Washington, DC Baltimore **All facilities
Martinsburg in VISN 5 have
appropriate
service levels
to be classified
as at least a
Polytrauma
Support Clinic
Team.
----------------------------------------------------------------------------------------------------------------
VISN 6 Richmond Hampton Ashville
Salisbury Beckley
Durham Fayetteville
Salem
----------------------------------------------------------------------------------------------------------------
Tampa VISN 7 Augusta Tuscaloosa Dublin
Columbia Tuskegee
Charleston
Atlanta
Birmingham
----------------------------------------------------------------------------------------------------------------
VISN 8 Tampa Bay Pines Orlando
San Juan Gainesville
Miami
West Palm
----------------------------------------------------------------------------------------------------------------
VISN 9 Lexington Huntington **All facilities
Louisville in VISN 9 have
Memphis appropriate
TVHC-Naservice levels
TVHC-Mto be classified
TVHC-Mountaat least a
Home Polytrauma
Support Clinic
Team.
----------------------------------------------------------------------------------------------------------------
VISN 16 Houston Alexandria Gulf Coast
Jackson (Biloxi)
CenFayetteville, AR
Little Rock New Orleans
Muskogee Oklahoma City
Shreveport Waco
----------------------------------------------------------------------------------------------------------------
VISN 17 Dallas Temple Kerrville
San Antonio
----------------------------------------------------------------------------------------------------------------
Palo Alto VISN 18 Southern New Mexico HCS- Amarillo
Arizona HCS Albuquerque West Texas HCS
(Tucson) (Big Spring)
El Paso
Northern Arizona
HCS (Prescott)
Phoenix
----------------------------------------------------------------------------------------------------------------
VISN 19 Denver Salt Lake Cheyenne
Grand Junction Montana HCS-Ft.
Harrison
Sheridan
----------------------------------------------------------------------------------------------------------------
VISN 20 Seattle Portland Alaska
Boise American Lake
Roseburg
Spokane
Walla Walla
White City
----------------------------------------------------------------------------------------------------------------
VISN 21 Palo Alto Sacramento Sierra Nevada
San Francisco HCS
Honolulu
Manila
Central
California HCS
(Fresno)
----------------------------------------------------------------------------------------------------------------
VISN 22 West LA Long Beach Southern Nevada
San Diego HCS
Loma Linda Sepulveda
----------------------------------------------------------------------------------------------------------------
Minneapolis VISN 10 Cleveland Cincinnati Columbus
Dayton Chillicothe
----------------------------------------------------------------------------------------------------------------
VISN 11 Indianapolis Detroit Battle Creek
Danville (Iliana) NICHS-Marion
Ann Arbor Saginaw
----------------------------------------------------------------------------------------------------------------
VISN 12 Hines Milwaukee Iron Mountain
North Chicago
Tomah
Madison
Chicago HCS
(Jesse Brown)
----------------------------------------------------------------------------------------------------------------
VISN 15 St. Louis Kansas City Wichita
Poplar Bluff
Columbia, MO
Eastern Kansas/
Topeka
Marion
----------------------------------------------------------------------------------------------------------------
VISN 23 Minneapolis Sioux Falls Fargo
Black Hills St. Cloud
Iowa City Central Iowa-Des
Central IowaMoines
Knoxville Greater Nebraska-
Grand Island
Greater Nebraska-
Lincoln
Omaha
----------------------------------------------------------------------------------------------------------------
Question 11: On average how many patients are assigned to each care
manager? Are the care managers able to handle their current caseloads,
or does VHA need additional funding to increase the number of care
managers at the VAMCs, particularly those with the Polytrauma units?
Response: A ratio of one social worker care manager to six
polytrauma inpatients is the established standard determined to be
sufficient to ensure appropriate care management of OEF/OIF inpatients
(VHA Directive 2006-043 Social work case management in VHA Polytrauma
Centers). The PRC staffing model is consistent with this recommended
ratio, and the social worker case manager to patient ratio at the PRCs
ranged from 1:3 to 1:6 in October 2007.
Question 12: What is the relationship of the Palo Alto VAMC with
the Department of Defense, and please provide the sharing agreement
that is in place.
Response: VA Palo Alto Health Care System (PAHCS) has a
longstanding relationship with the Department of Defense (DoD). VA
PAHCS has served as one of four lead traumatic brain injury (TBI)
centers and as a Defense and Veterans Brain Injury Center (DVBIC) site
since 1992. The mission of DVBIC is to serve active duty military,
their dependents and veterans with TBI through state-of-the-art medical
care, innovative clinical research initiatives and educational
programs. In 2005, VA PAHCS was designated as a PRC and has continued
to build a relationship with DoD. VA liaisons, located at each military
treatment facility (MTF), play a central role in facilitating referrals
to the PRC as well as participating in a pre-transfer video
teleconferences for patients, families, and the treatment teams to
discuss pertinent clinical or psychosocial challenges. The Palo Alto
PRC program director continues to build relationships with MTF
referring physicians. The Walter Reed Army Medical Center (WRAMC)
Physical Medicine and Rehabilitation Director works directly with the
PRC program director to ensure a smooth transition during patient
transfers. VA's PAHCS PRC program director and chief of neurosurgery
are in direct and frequent communication with the neurosurgeon at
National Naval Medical Center (NNMC), regarding patients transferring
between the two medical centers. The Palo Alto PRC program director
visited NNMC and WRAMC on November 7 to continue to enhance the working
relationships with the referring physicians.
The Memorandum of Agreement is attached (see Attachment 1 at the end).
Question 13: Does the PRC in Palo Alto use VTA/JPTA to track the
patients being transferred from DoD?
Response: The PRC receives an e-mail notification from the VA
liaison to access veterans tracking application (VTA) for severely
injured servicemembers for admission to the PRC. These patients are
contacted and assigned a PRC case manager within 7 days. Through the
joint patient tracking application (JPTA), the PRC military liaison can
view the servicemember's status, location (operating room/emergency
room/intensive care unit), date of status, facility location (combat
support hospital, medical brigade, Landstuhl Regional Medical Center
(LRMC), WRAMC) and view the dates of the evacuation transport
itinerary. The PRC military liaison uses VTA in much the same way to
view notes annotating the servicemember's record through their
transition (combat support hospital, medical brigade, LRMC, etc.).
Question 14: When Subcommittee staff traveled to Palo Alto in
August, one of the issues discussed was the transportation of patients
from the East Coast Washington, DC Metro Area (Bethesda/Walter Reed) to
the PRC, they were told much of this transport went through Travis Air
Force Base. Please provide some specifics on how the transfer of
patients occurs, e.g., how the transfer works, who coordinates the
transfer to VA, and patient medical care during travel. What problems
have arisen during transfer of patients from the East Coast to the West
Coast, and have there been problems with continuity of care en route?
Furthermore, how well does the handoff from the Department of Defense
work?
Response: Transfers from WRAMC and NNMC to the Palo Alto's VA PRC
are coordinated by DoD Military staff through the Med Evac system at
the MTF. The VA liaison at the MTF communicates with the MTF treatment
team when servicemembers/veterans are accepted for admission to Palo
Alto. DoD coordinates the transportation through military staff and
information such as the accepting VA physician's name and contact
number, receiving ward and contact number as well as a 24 hour travel
number at the receiving PRC is provided at the time of coordination.
The point of contact at the accepting PRC or the transportation
coordinator arranges for transportation from the Air Force Bases (AFB)
to the PRC. For example, once the flight arrives at Travis AFB,
patients are often kept overnight to assess how the patient tolerated
the flight and to allow the patient to rest as it is approximately a 3
hour drive to the Palo Alto PRC. To further enhance the transportation
process from the East Coast MTFs to Palo Alto PRC, both WRAMC and NNMC
have recently made arrangements to include staff from Travis AFB on the
video teleconferences that take place with the PRC prior to the
patient's transfer. Palo Alto PRC does not report any problems with
continuity of care in between DoD and VA. The major challenge is pain
management due to the length of the trip.
VA defers to DoD for more specific details regarding procedures and
processes associated with their Med Evac system.
ATTACHMENT 1
MEMORANDUM OF AGREEMENT
Department of Veterans Affairs (VA) and Department of Defense (DoD)
Memorandum of Agreement (MOA) Regarding Referral of Active Duty
Military Personnel Who Sustain Spinal Cord Injury, Traumatic
Brain Injury, or Blindness to Veterans Affairs Medical
Facilities for Health Care and Rehabilitative Services
1. PURPOSE: This document establishes procedures regarding active
duty military personnel with spinal cord injury (SCI), traumatic brain
injury (TBI), or blindness treated at VA medical facilities under
direct resource sharing agreements under the authorities noted in
paragraph 2. Active duty military personnel will receive timely and
high quality specialty care within a continuum of health care dedicated
to the needs of persons with SCI, TBI, and blindness. Note: This MOA
does not pertain to the transfer of active duty military personnel to
VA facilities for care or treatment related to alcohol or drug abuse or
dependence in accordance with Title 38 U.S.C Sec. 620A(d)(l). This MOA
pertains to direct resource sharing agreements only, and not to
agreements between the VA and TRICARE Managed Care Support Contractors
(MCSCs).
2. AUTHORITIES:
a. Department of Veterans Affairs (VA) and Department of
Defense (000) Health Resources Sharing and Emergency Operations Act (38
U.S.C. Sec. 8111)
b. Section 3-105 of the VA/DoD Health Care Resource Sharing
Guidelines of July 29, 1983.
3. BACKGROUND: There has been a longstanding MOA between VA and
DoD associated with specialized care for active duty sustaining BCI,
TBI, and blindness. VA is known for its integrated system of health
care for these conditions. The VA/DoD Health Executive Council has
identified the need for referral procedures governing the transfer of
active duty military inpatients from military or civilian hospitals to
VA medical facilities, and the treatment of active duty military
patients at such facilities. This MOA supersedes all previous VA/DoD
MOAs relating to active duty military referrals to VA health care
facilities for TBI, SCI, and blindness.
4. DoD RESPONSIBILITIES:
a. Care management services will be provided by the Military
Medical Support Office (MMSO), the appropriate Military Treatment
Facility (MTF), and the admitting VAMC as a joint collaboration as
appropriate to each individual servicemember's case. The referring MTF
and the VA health care facility shall notify MMSO when a member is
referred for care under this agreement. MMSO will provide any required
care authorizations relating to care provided under this MOA once the
member is admitted to a VA facility.
b. The referring MTF will identify and contact the VA TBI
(Appendix A), SCI (Appendix B), or Blind Rehabilitation Center
(Appendix C) as soon as possible to begin the referral process, to
present the case, and to gain admission approval. The medical and
administrative personnel of the MTF must establish immediate contact
with their counterparts at the designated VA health' care facility to
discuss and make specific arrangements. Whenever possible the VA health
care facility closest to the active duty member's home of record or
location selected by the active duty member, guardian, conservator, or
designee should be contacted first. The servicemember's command
ordinarily determines whether the servicemembers injury and/or
condition occurred while in the line of duty and not due to own
misconduct which may affect eligibility for VA health care according to
provisions of Title 38 U.S.C. Chapter 17.
c. The referring MTF will provide a copy of all pertinent
patient medical record documentation requested by the VA health care
facility needed to make a medical decision. This includes the patient's
history and physical, diagnostics, laboratory findings, hospital
course, daily documentation of progress, etc. When the VA facility
accepts a patient, the referring DoD/MTF case manager will provide the
VA case manager with current clinical information along with the case
management plan of care and discharge plan.
d. Pre-requisites for transfer, in addition to identifying an
accepting staff physician at the VA health care facility, are
stabilization of the patient's injuries and, the acute management of
the medical and physiological conditions associated with the Sel, TBI,
or blindness. Stabilization is an attempt to prevent additional
impairments while focusing on prevention of complications. The criteria
for the transfer of patients with SeI, TBI, or blindness require:
1. Attention to ailWay and adequate oxygenation;
2. Treatment of hemorrhage, no evidence of active bleeding;
3. Adequate fluid replacement;
4. Maintenance of systolic blood pressures (>90 mm mercury
hydrargyrum (Hg));
5. Foley catheter placement, when appropriate, with adequate
urine output;
6. Use of an asogastric tube, if paralytic ileus develops;
7. Maintenance of spinal alignment by immobilization of the
spine, or adequate stabilization to prevent further neurologic injury
(traction, tongs and traction, halo-vest, hard cervical collar, body
jacket, etc.); and
8. Approval by the SCI Center Chief, TBI Center Medical
Director or Designee, or Blind Rehabilitation Chief in consultation
with other appropriate VA specialty care teams.
e. The referring MTF must notify the VA health care facility
of any changes in medical status. Patients are not to be transferred if
there is:
1. Deteriorating neurologic function; incomplete;
2. An inability to stabilize the spine, especially if the
neurologic injury is
3. Bradyarrhythmias are present;
4. An inability to maintain systolic blood pressure >90 mm
Hg;
5. Acute respiratory failure is present; or
6. New onset of fever, infection and/or change in medical
status (e.g., deteriorating physiological status).
f. Following the VA health care facility's agreement to accept
the patient, the MTF commander or designee is responsible for arranging
transportation to the VA facility in accordance with governing policies
for movement of patients. This normally will include notifying and
submitting a patient movement request to the Global Patient Movement
Requirements Center (GPMRC), or when overseas, to the Theater Patient
Movement Requirement Center (TPMRC), without regard to weekend or
holiday, to schedule the transport of the patient from either an MTF or
a civilian hospital. If the patient is moved by other than an Air Force
aircraft or is an emergency patient, information reported to GPMRC will
be the minimum required to allow GPMRC to develop referral patterns.
This notification may be made after the fact for emergency patients.
g. The MTF commander and GPMRC are responsible for
coordination with the receiving VA facility for ground transportation
from the airfield to the VA facility. Whenever possible, the
originating MTF should arrange with any MTF within a reasonable
distance to provide needed transportation. If that is not possible, the
receiving VA health care facility shall obtain appropriate local
transportation. NOTE: DoD will be responsible for payment of any costs
incurred by VA for the transport of active duty personnel.
h. To ensure optimal care, active duty patients are to go
directly to a VA medical facility without passing through a transit
military hospital.
i. In emergencies, GPMRC will expedite transfers from MTFs or
civilian hospitals to VA facilities through telephone communications.
MTFs will report directly to the GPMRC for CONUS transfers, but MTFs
will report to the TPMRC at Ramstein Air Base, or to the TPMRC at
Yokota Air Base for a-CONUS transfers. The TPMRC will then coordinate
with the GPMRC for transportation. An after-the-fact report will be
made to GPMRC within 48 hours.
j. DoD will ensure meeting the goal of transfer within 3 days
(4 days from overseas), whenever the patient's medical condition
permits, but not exceeding 12 days. The ability to complete medical
review board processing is not a prerequisite for transfer to a VA
medical facility.
k. DoD will assure that each Surgeon General's office or her/
his designee provides necessary assistance to VA facilities in the
preparation and transmittal of the patient's medical boards or as a
point of contact should problems arise.
l. DoD will assure that the appropriate Service provide
telephone and written notification to VA facilities when active duty
members are discharged or released from active duty. This notification
shall be made before the separation date and will include the date,
type of separation, and the periods of active duty served. The DD214
will be provided to VA in a timely manner.
5. VA RESPONSIBILITIES:
a. The Rehabilitation Services Chief Consultant and the Spinal
Cord Injury and Disorders Chief Consultant will provide annually to
DoD, a list of VA Spinal Cord Injury Centers, Traumatic Brain Injury
Lead Centers, and Blind Rehabilitation Centers including their
telephone numbers and points of contact. These lists will be updated if
changes occur.
b. The Veterans Integrated Service Network (VISN) Directors
will adhere to policies in this MOA.
c. The designated VA facility with an SCI Center, TBI Center,
or Blind Rehabilitation Center will assist military authorities in the
following manner:
1. Respond (following receipt of necessary medical records)
to requests for admission from military medical authorities or their
designees without regard to weekends or holidays. NOTE: Concurrent
notification of the GPMRC will be provided.
2. Accept appropriate active-duty patients without regard
to hour of the day, day of the week, or holidays. NOTE: The acceptance
of local transfers from MTFs to VA facilities should be mutually agreed
upon. At MTF's where VA staff are assigned, the VA/DoD Social Worker
liaison will assist with the transfer.
3. Coordinate the transfer of active duty patients to VA
health care facilities with the MTFs and GPMRC. NOTE: Concurrent
notification of the GPMRC will be provided.
4. Coordinate with civilian hospitals and GPMRC so that
active duty patients, who are ready for transfer to a VA specialty care
center are transported directly from a civilian hospital to the
appropriate VA facility.
5. Assist the MTF in identifying the most appropriate VA
SCI, TBI, or Blind Rehabilitation Center. Active duty patients need to
be referred to the designated VA medical facility closest to the active
duty member's home of record or location selected by the active duty
member, guardian, conservator, or designee, subject to availability of
beds. If the preferred Center is unable to accept the patient, that VA
medical facility will assist in locating an appropriate placement.
NOTE: The Chief Consultant, Rehabilitation Services, or Chief
Consultant, SCI&D Services, VA Central Office, 810 Vermont Avenue, NW,
Washington, DC 20420, will assist when necessary.
6. The accepting VA staff physician will review military
transportation arrangements and make recommendations if it is believed
that the patient's care will be compromised due to delays or other
clinical considerations. VA will assist referring military authorities
and GPMRC in coordinating the medically indicated mode of
transportation and arranging local ground transportation to VA
facilities, such as from local airfields.
7. Provide immediate notification to the appropriate MTF
Case Manager and MMSO, when an active duty member is admitted. The VA
will assign a case manager responsible for coordinating care through a
continuum of health care services for each member admitted. The VA case
manager will provide the DoD/MTF case manager periodic updates, no less
than once a month depending on the acuity or complexity of the case,
until the medical determination or the medical board process is
complete. This continued coordination is necessary to aid in
communication to the DoD, primary care manager, command, other program
managers, and medical board personnel.
8. Coordinate the hospital discharge of an active duty
member with the appropriate MTF and the Military Medical Support Office
(MMSO).
9. Assist with medical boards when requested by the
military authority having cognizance over the member.
10. Notify DoD of the active duty member's absences, medical
discharge, and change of location.
11. Prior to discharge, the VAMC where the patient is being
treated will facilitate the patient appropriately enrolling to TRICARE
in the region of his/her final destination.
6. PROGRAM DESCRIPTIONS:
a. Spinal Cord Injury and Disorders: The mission of the Spinal
Cord Injury and Disorders Program within VA is to promote the health,
independence, quality of life, and productivity of individuals with
spinal cord injury and disorders. There are twenty SCI Centers
available throughout VA to provide acute rehabilitative services to
persons with new onset SCI (see Appendix B). VA offers a unique system
of care through SCI Centers, which includes a full range of health care
for eligible persons who have sustained injury to their spinal cord or
who have other spinal cord lesions. Persons served in these centers
include those with: stable neurological deficit due to spinal cord
injury, intraspinal, nonmalignant neoplasms, vascular insult, cauda
equina syndrome, inflammatory disease, spinal cord or cauda equina
resulting in nonprogressive neurologic deficit, demyelinating disease
limited to the spinal cord and of a stable nature, and degenerative
spine disease.
b. Traumatic Brain Injury: VA offers a full range of traumatic
brain injury rehabilitation to ensure that military and veteran
personnel with brain injuries receive coordinated, comprehensive care.
The goal is to return the brain injury survivor to the highest level of
function and to educate family and caregivers in the long-term needs of
the patient. VA has four lead Traumatic Brain Injury Centers (see
Appendix A). These facilities provide comprehensive assessment, medical
care, TBI specific acute rehabilitation, access to state of the art
treatment, clinical trials, and leadership for a nationwide system of
TBI care through case management. Each participating medical center has
a designated TBI case manager who facilitates patient participation in
the program and expedites facility transfers and community placement.
Persons served in these Centers and covered under this MOA include
individuals sustaining a brain injury caused by an external physical
force resulting in open and closed injuries, and damage to the central
nervous system resulting from anoxic/hypoxic episodes, related to
trauma or exposure to chemical or environmental toxins that result in
brain damage. This MOA does not include brain injuries/insult related
to chronic illnesses (i.e., hypertension, tumors, diabetes, etc.).
Patients with other acquired brain injury due to chronic disease or
infectious processes are not covered under this MOA, but are eligible
for care in these centers.
c. Blind Rehabilitation: Blind Rehabilitation Service offers a
coordinated educational training and health care service delivery
system that provides a continuum of care for veterans with blindness
that extends from their home environment, to the local VA facility, to
the appropriate rehabilitation setting. These services include
adjustment to blindness counseling, patient and family education,
benefits analysis, assistive technology, outpatient programs, and
residential inpatient training. There are ten residential, inpatient VA
Blind Rehabilitation Centers (BRCs) (see Appendix C). The mission of
each BRC program is to educate each veteran on all aspects of Blind
Rehabilitation and address the expressed needs of each veteran with
blindness so they may successfully reintegrate back into their
community and family environment. To accomplish this mission, BRCs
offer a comprehensive, individualized adjustment-training program along
with those services deemed necessary for a person to achieve a
realistic level of independence. BRCs offer a variety of skill courses
including: orientation and mobility, communication skills, activities
of daily living, manual skills, visual skills, leisure skills, and
computer access training. The veteran is also assisted in making an
emotional and behavioral adjustment to blindness through individual
counseling sessions and group therapy meetings. Each VA medical center
has a Visual Impairment Services Team Coordinator who has major
responsibility for the coordination of all services for visually
impaired veterans and their families. Duties include arranging for the
provision of appropriate treatment modalities (e.g. referrals to Blind
Rehabilitation Centers and/or Blind Rehabilitation Outpatient
Specialists) and being a resource for all local service delivery
systems in order to enhance the functioning level of veterans with
blindness. Referrals can be directed to the Program Analyst in the
Blind Rehabilitation Program Office in the VA Central Office at 202-
273-8482.
7. DURATION:
a. This MOA will remain in force unless terminated at the
request of either party after thirty (30) days written notice. In event
this MOA is terminated, DoD shall be liable only for payment in
accordance with provisions of this agreement for care provided before
the effective termination date.
b. This agreement supersedes all local resource sharing
agreements.
8. REIMBURSEMENT:
a. DoD will reimburse CHAMPUS Maximum Allowable Charge (CMAC)
rates less 10 percent (CMAC-I 0%) for outpatient and professional care.
Inpatient care will be reimbursed using the VA interagency rates
approved by the Office of Management and Budget, which is periodically
updated. Updates are provided via a Federal Register Notice. Although
the Federal Register Notice indicates that the interagency billing
rates do not apply to sharing agreements between VA and DoD, it has
been determined that these rates are appropriate for care provided
under this MOA. VAMCs will provide all documentation required for
billing medical claims. At a minimum, this will include an itemized
bill for each member on Form CMS 1500 for outpatient/professional
services and Form DB 92 for inpatient services. Transportation,
prosthetics, durable medical equipment, orthotics, dental services,
home care, personal care attendants and extended care/nursing home care
will be billed at the interagency rate if one exists, or at actual cost
as appropriate.
b. VA facilities providing care to active duty servicemembers
in accordance with this agreement will be paid by the TRICARE Managed
Care Support Contractors (MCSCs). Claims should be forwarded to the
MCSC for the TRICARE Region to which the member is enrolled in TRICARE
Prime. If the member is not enrolled, the claim will be paid by the
regional MCSC where the member resides. Prior to paying a claim, MCSCs
will verify that the care is payable through MMSO. MMSO can be reached
at 888-647-6676, P.O. Box 88699, Great Lakes, IL 60088-6999.
c. The VAMC will obtain authorization for non-network care
from MMSO for the billing to go to the VAMC and be forwarded to the
MCSC for payment. This is particularly applicable if there are no
TRICARE providers, MTFs, or VAMCs/clinics capable of providing the
needed services in the destination area.
d. VA facilities should send claims for payment to:
North Region: North Region Claims, PGBA, P.O. Box
870140, Surfside Beach, SC 29587-9740.
South Region: TRICARE South Region, Claims
Department, P.O. Box 7031, Camden, SC 29020-7031.
West Region: WPS/West Region Claims, P.O. Box
77028, Madison, WI 53707-7028.
9. EFFECTIVE DATE: This MOA is effective 1 January 2007.
William Wikenwerder, Jr., M.D.
Assistant Secretary for Health Affairs
Department of Defense
Date: 27 November 2006
Michael J. Kussman, MD, MS, MACP
Acting Under Secretary for Health
Department of Veterans Affairs
Date: 13 December 2006
__________
VA-DoD MOA Appendix A
TRAUMATIC BRAIN INJURY (TBI) CENTERS ACCEPTING DEPARTMENT OF DEFENSE
REFERRALS
1. Minneapolis VA Medical Center (117), One Veterans Drive,
Minneapolis, MN 55417, Telephone 612-467-3562.
2. VA Palo Alto HCS (117), 3801 Miranda Avenue, Palo Alto, CA
94304, Telephone 650-447-7114.
3. HH McGuire VA Medical Center (117), 1201 Broad Rock Boulevard,
Richmond, VA 23249, Telephone 804-675-5332.
4. James A. Haley VA Medical Center (117), 13000 Bruce B. Downs
Blvd., Tampa, FL 33612-4798, Telephone 813-972-7668 or 1-866-659-2156.
__________
VA-DoD MOA Appendix B
SPINAL CORD INJURY (SCI) CENTERS ACCEPTING DEPARTMENT OF DEFENSE
REFERRALS
1. Department of Veterans Affairs (VA) New Mexico Health Care
System (HCS) (128), 1501 San Pedro Southeast, Albuquerque, NM 87108,
Telephone 505-256-2849.
2. Augusta VA Medical Center (128), One Freedom Way, Augusta, GA
30904-6285, Telephone 706-823-2216.
3. VA Boston HCS (128), 1400 VFW Parkway, West Roxbury, MA 02132,
Telephone 617-323-7700 Extension 5128.
4. VA Medical Center (128), 130 West Kingsbridge Road, Bronx, NY
10468.
5. Louis Stokes VA Medical Center (128W), 10701 East Boulevard,
Cleveland, OR 44106.
6. VA North Texas HCS (128), 4500 South Lancaster Road, Dallas,
TX 75216.
7. Edward Hines, Jr. VA Medical Center (128), Fifth Avenue and
Roosevelt Road, Hines, IL.
8. Houston VA Medical Center (128), 2002 Holcombe Boulevard,
Houston, TX 77030-4298.
9. VA Long Beach RCS (128), 5901 East 7th Street, Long Beach, CA
90822.
10. VA Medical Center (128), 1030 Jefferson Avenue, Memphis, TN
38104.
11. VA Medical Center (128), 1201 Northwest 16th Street, Miami, FL
33125.
12. Clement J. Zablocki VA Medical Center (128),5000 West National
Avenue, Milwaukee, WI 53295, Telephone 414-384-2000 Extension 41230.
13. VA Palo Alto HCS (128), 3801 Miranda Avenue, Palo Alto, CA
94304, Telephone 650-493-5000 Extension 65870.
14. HH McGuire VA Medical Center (128), 1201 Broad Rock Boulevard,
Richmond, VA, Telephone 804-675-5282.
15. South Texas Veterans HCS (128), 7400 Meront Minter Blvd., San
Antonio, TX 78284, Telephone 210-617-5257.
16. VA San Diego HCS (128), 3350 La Jolla Village Drive, San
Diego, CA 92161, Telephone 858-642-3117.
17. VA Medical Center (128), 10 Casia Street, San Juan, PR 00921-
3201, Telephone 787-641-7582 Extension 14130.
18. VA Puget Sound RCS (128), 1660 South Columbian Way, Seattle,
WA 98108-1597, Telephone 206-764-2332.
19. Saint Louis VA Medical Center (128JB), One Jefferson Barracks
Drive, St. Louis, MO 63125, Telephone 314-894-6677.
20. James A. Haley VA Medical Center (128), 13000 Bruce B. Downs
Blvd., Tampa, FL 33612-4798, Telephone 813-972-7517.
__________
VA-DoD MOA Appendix C
BLIND REHABILITATION CENTERS (BRC) ACCEPTING DEPARTMENT OF DEFENSE
REFERRALS
1. Augusta VA Medical Center (324), One Freedom Way, Augusta, GA
30904-6285, Telephone 706-733-0188 Extension 6660.
2. Birmingham VA Medical Center (124), 700 South 19th Street,
Birmingham, AL 35233, Telephone 205-933-8 101.
3. Edward Hines, Jr. VA Medical Center (124), Fifth Avenue and
Roosevelt Road, Hines, IL 60141-5000, Telephone 708-202-8387 Extension
22112.
4. Central Texas VA Health Care System, 1901 Veterans Memorial
Drive, Temple, TX 76504, Telephone 254-297-3755. Blind Rehabilitation
Center, 4800 Memorial Drive, Waco, TX 76711. Telephone 254-297-3755.
5. San Juan VA Medical Center (124), 10 Casia Street, San Juan,
PR 00921-3201, Telephone 787-641-8325.
6. Southern Arizona VA Health Care System (3-124),3601 South 6th
Avenue, Tucson, AZ 85723, Telephone 520-629-4643.
7. VA Connecticut Health Care System (124), West Haven Campus,
950 Campbell Avenue, West Haven, CT 06516, Telephone 203-932-5711
Extension 2247.
8. VA Palo Alto RCS (124), 3801 Miranda Avenue, Palo Alto, CA
94304, Telephone 650-493-5000 Extension 64218.
9. VA Puget Sound RCS (124), 1660 South Columbian Way, Seattle,
WA 98108-1597, Telephone 253-583-1203. (A-l12-BRC), American Lake
Division, 9600 Veterans Drive, Tacoma, WA 98493, Telephone: 253-983-
1299.
10. West Palm Beach VA Medical Center (124), 7305 North Military
Trail, West Palm Beach, FL 33410-6400, Telephone 561-422-8425.
__________
[Federal Register: January 7, 2004 (Volume 69, Number 4)] [Notices]
[Page 1062-1064]
[Page 1062]
OFFICE OF MANAGEMENT AND BUDGET
Charges to Tortiously Liable Third Parties for Hospital, Medical,
Surgical, and Dental Care and Treatment Furnished by the United States
(Department of Veterans Affairs)
AGENCY: Office of Management and Budget, Executive Office of the
President.
ACTION: Notification of charges to tortiously liable third parties
for hospital, medical, surgical, and dental care and treatment
furnished by the Department of Veterans Affairs.
SUMMARY: By virtue of the authority vested in the President by
section 2(a) of the Federal Medical Care Recovery Act, Public Law 87-
693 (76 Stat. 593; 42 U.S.C. 2652), and delegated to the Director of
the Office of Management and Budget by Executive Order No. 11541 of
July 1, 1970 (35 FR 10737), the charges to tortiously liable third
parties for hospital, medical, surgical, and dental care and treatment
(including prostheses and medical appliances) furnished by the
Department of Veterans Affairs are the ``reasonable charges'' generated
by the methodology set forth in 38 CFR 17.101 and published from time
to time in the Federal Register, most recently on April 29, 2003 (68 FR
22774). These charges are for use in connection with the recovery from
tortiously liable third persons of the reasonable value of hospital,
medical, surgical, and dental care and treatment furnished by the
United States through the Department of Veterans Affairs (28 CFR 43.1-
43.4). These charges have been established in accordance with the
requirements of OMB Circular A-25, which requires charges that are at
least as great as the full cost of the services provided.
There are two basic reasons for this change. First, VA's community-
based ``reasonable charges'' more accurately reflect the reasonable
value of the medical care and treatment furnished by VA to the injured
person, consistent with 42 U.S.C. 2651 and 2652, than do VA's cost-
based per-diem tort rates.
Second, VA's present dual-rate billing system (tort feasor and
health plan), using significantly different charges, is confusing and
difficult to justify. VA claims, for example, may be made both against
the tort feasor who caused the injury, using the current FMCRA per-diem
rates, and against the veteran's health plan, using the significantly
higher reasonable charges, for the same VA medical care. This not only
is confusing to VA billing officials and makes settling claims more
difficult, but such dual billing also may disadvantage veterans by
providing a per-diem rate bill to assert against the tort feasor while
exposing veterans to subrogation claims from their health plans who
paid at the higher reasonable charges rates. Making the charges billed
to all liable parties in FMCRA cases uniform will eliminate confusion
and remove an impediment to allowing injured veterans to assert the
higher reasonable charges rates for their causally related health care
as a necessary and proper element of damages in their cases against the
responsible tort feasors.
Beginning on January 7, 2004, the charges prescribed herein
supercede those established by the Director of the Office of Management
and Budget for the Department of Veterans Affairs on November 1, 1999
(64 FR 58862).
Joshua B. Bolten, Director.
[FR Doc. 04-317 Filed 1-6-04; 8:45 am]
BILLING CODE 3110-01-P
__________
OFFICE OF MANAGEMENT AND BUDGET
DEPARTMENT OF VETERANS AFFAIRS
Cost-Based and Interagency Billing Rates for Medical Care or Services
Provided by the Department of Veterans Affairs
AGENCIES: Office of Management and Budget, Executive Office of the
President and the Department of Veterans Affairs.
ACTION: Notice.
SUMMARY: This document provides cost-based and interagency billing
rates for medical care or services provided by the Department of
Veterans Affairs (VA):
(a) In error or on tentative eligibility;
(b) In a medical emergency;
(c) To pensioners of allied Nations;
(d) For research purposes in circumstances under which VA medical
care appropriation is to be reimbursed by VA research appropriation;
and
(e) To beneficiaries of the Department of Defense or other Federal
agencies, when the care or service provided is not covered by an
applicable sharing agreement.
In addition, until such time as charges for outpatient dental care
and prescription drugs are implemented under the provisions of 38 CFR
17.101, the applicable cost-based billing rates provided in this notice
will be used for collection or recovery by VA for outpatient dental
care and prescription drugs provided under circumstances covered by
that section. This notice is issued jointly by the Office of Management
and Budget and the Department of Veterans Affairs.
EFFECTIVE DATE: The rates set forth herein are effective January 7,
2004, and until further notice.
FOR FURTHER INFORMATION CONTACT: David Cleaver, Chief Business
Office (168), Veterans Health Administration, Department of Veterans
Affairs, 810 Vermont Avenue, NW., Washington, DC 20420, (202) 254-0361.
(This is not a toll free number.)
SUPPLEMENTARY INFORMATION: VA's medical regulations at 38 CFR
17.102(h) set forth a methodology for computing rates for medical care
or services provided by VA:
(a) In error or on tentative eligibility;
(b) In a medical emergency;
(c) To pensioners of allied Nations;
(d) For research purposes in circumstances under which VA medical
care appropriation is to be reimbursed by VA research appropriation;
and
(e) To beneficiaries of the Department of Defense or other Federal
agencies, when the care or service provided is not covered by an
applicable sharing agreement.
Two sets of rates are obtained via application of this methodology:
Cost-Based Rates, for use for purposes (a) through (d), above, and
Interagency Rates, for use for purpose (e), above. Government employee
retirement benefits and return on fixed assets are not included in the
Interagency Rates, and the Interagency Rates are not broken down into
three components (Physician; Ancillary; and Nursing, Room, and Board),
but in all other respects the Interagency Rates are the same as the
Cost-Based Rates.
When medical care or service is obtained at the expense of the
Department of Veterans Affairs from a non-VA source under circumstances
in which the Cost-Based or Interagency Rates would apply if the care or
service had been provided by VA, then the charge for such care or
service will be the actual amount paid by VA for that care or service.
Inpatient charges will be at the per diem rates shown for the type
of bed section or discrete treatment unit providing the care.
Prescription Filled charge in lieu of the Outpatient Visit rate will be
charged when the patient receives no service other than the Pharmacy
outpatient service. This charge applies whether the patient receives
the prescription in person or by mail.
Current rates obtained via the above methodology are as follows:
[[Page 1063]]
------------------------------------------------------------------------
Cost-based Interagency
rates rates
------------------------------------------------------------------------
A. Hospital Care, Rates Per Inpatient
Day
------------------------------------------------------------------------
General Medicine:
------------------------------------------------------------------------
All Inclusive Rate $1,815 $1,668
------------------------------------------------------------------------
Physician 217
------------------------------------------------------------------------
Ancillary 473
------------------------------------------------------------------------
Nursing, Room and Board 1,125
------------------------------------------------------------------------
Neurology:
------------------------------------------------------------------------
All Inclusive Rate 2,289 2,098
------------------------------------------------------------------------
Physician 335
------------------------------------------------------------------------
Ancillary 604
------------------------------------------------------------------------
Nursing, Room, and Board 1,350
------------------------------------------------------------------------
Rehabilitation Medicine:
------------------------------------------------------------------------
All Inclusive Rate 1,723 1,574
------------------------------------------------------------------------
Physician 196
------------------------------------------------------------------------
Ancillary 526
------------------------------------------------------------------------
Nursing, Room, and Board 1,001
------------------------------------------------------------------------
Blind Rehabilitation:
------------------------------------------------------------------------
All Inclusive Rate 1,254 1,162
------------------------------------------------------------------------
Physician 101
------------------------------------------------------------------------
Ancillary 623
------------------------------------------------------------------------
Nursing, Room, and Board 530
------------------------------------------------------------------------
Spinal Cord Injury:
------------------------------------------------------------------------
All Inclusive Rate 1,237 1,136
------------------------------------------------------------------------
Physician 153
------------------------------------------------------------------------
Ancillary 311
------------------------------------------------------------------------
Nursing, Room, and Board 773
------------------------------------------------------------------------
Surgery:
------------------------------------------------------------------------
All Inclusive Rate 3,513 3,255
------------------------------------------------------------------------
Physician 387
------------------------------------------------------------------------
Ancillary 1,065
------------------------------------------------------------------------
Nursing, Room, and Board 2,061
------------------------------------------------------------------------
General Psychiatry:
------------------------------------------------------------------------
All Inclusive Rate 971 888
------------------------------------------------------------------------
Physician 92
------------------------------------------------------------------------
Ancillary 153
------------------------------------------------------------------------
Nursing, Room, and Board 726
------------------------------------------------------------------------
Substance Abuse (Alcohol and Drug
Treatment):
------------------------------------------------------------------------
All Inclusive Rate 1,206 1,106
------------------------------------------------------------------------
Physician 115
------------------------------------------------------------------------
Ancillary 279
------------------------------------------------------------------------
Nursing, Room, and Board 812
------------------------------------------------------------------------
Psychosocial Residential
Rehabilitation Treatment Programs:
------------------------------------------------------------------------
All Inclusive Rate 276 252
------------------------------------------------------------------------
Physician 17
------------------------------------------------------------------------
Ancillary 29
------------------------------------------------------------------------
Nursing, Room, and Board 230
------------------------------------------------------------------------
Intermediate Medicine:
------------------------------------------------------------------------
All Inclusive Rate 801 733
------------------------------------------------------------------------
Physician 39
------------------------------------------------------------------------
Ancillary 118
------------------------------------------------------------------------
Nursing, Room, and Board 644
------------------------------------------------------------------------
B. Nursing Home Care, Rates Per Day
------------------------------------------------------------------------
All Inclusive Rate 451 411
------------------------------------------------------------------------
Physician 14
------------------------------------------------------------------------
Ancillary 61
------------------------------------------------------------------------
Nursing, Room, and Board 376
------------------------------------------------------------------------
C. Outpatient Medical and Dental
Treatment
------------------------------------------------------------------------
Outpatient Visit (other than 300 282
Emergency Dental)
------------------------------------------------------------------------
Emergency Dental Outpatient Visit 185 167
------------------------------------------------------------------------
D. Prescription Filled, Per 45 45
Prescription
------------------------------------------------------------------------
[[Page 1064]]
Beginning on the effective date indicated herein, these rates
supercede those established for the Department of Veterans Affairs by
the Director of the Office of Management and Budget on November 1, 1999
(64 FR 58862).
Approved: September 17, 2003.
Anthony J. Principi, Secretary, Department of Veterans Affairs.
Approved: December 30, 2003.
Joshua B. Bolten, Director, Office of Management and Budget.
[FR Doc. 04-318 Filed 1-6-04; 8:45 am]
BILLING CODE 3110-01-P