[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]
CARE OF SERIOUSLY WOUNDED
AFTER INPATIENT CARE
=======================================================================
HEARING
before the
SUBCOMMITTEE ON OVERSIGHT AND
INVESTIGATIONS
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED TENTH CONGRESS
SECOND SESSION
__________
MARCH 13, 2008
__________
Serial No. 110-76
__________
Printed for the use of the Committee on Veterans' Affairs
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41-376 PDF WASHINGTON : 2008
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COMMITTEE ON VETERANS' AFFAIRS
BOB FILNER, California, Chairman
CORRINE BROWN, Florida STEVE BUYER, Indiana, Ranking
VIC SNYDER, Arkansas CLIFF STEARNS, Florida
MICHAEL H. MICHAUD, Maine JERRY MORAN, Kansas
STEPHANIE HERSETH SANDLIN, South HENRY E. BROWN, Jr., South
Dakota Carolina
HARRY E. MITCHELL, Arizona JEFF MILLER, Florida
JOHN J. HALL, New York JOHN BOOZMAN, Arkansas
PHIL HARE, Illinois GINNY BROWN-WAITE, Florida
MICHAEL F. DOYLE, Pennsylvania MICHAEL R. TURNER, Ohio
SHELLEY BERKLEY, Nevada BRIAN P. BILBRAY, California
JOHN T. SALAZAR, Colorado DOUG LAMBORN, Colorado
CIRO D. RODRIGUEZ, Texas GUS M. BILIRAKIS, Florida
JOE DONNELLY, Indiana VERN BUCHANAN, Florida
JERRY McNERNEY, California VACANT
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
__________
March 13, 2008
Page
Care of Seriously Wounded After Inpatient Care................... 1
OPENING STATEMENTS
Chairman Harry E. Mitchell....................................... 1
Prepared statement of Chairman Mitchell...................... 49
Hon. Ginny Brown-Waite, Ranking Republican Member................ 2
Hon. Cliff Stearns............................................... 3
Hon. Nick Lampson................................................ 5
Prepared statement of Congressman Lampson.................... 50
WITNESSES
U.S. Department of Veterans Affairs, Mahdulika Agarwal, M.D.,
MPH, Chief Officer, Patient Care Services, Veterans Health
Administration................................................. 40
Prepared statement of Dr. Agarwal............................ 57
______
Iraq and Afghanistan Veterans of America, Todd Bowers, Director
of Government Affairs.......................................... 33
Prepared statement of Mr. Bowers............................. 55
Owens, Corporal Casey A., USMC (Ret.), Houston, TX............... 6
Prepared statement of Corporal Owens......................... 51
Wade, Sarah, Chapel Hill, NC, on behalf of Sergeant Edward Wade,
USA (Ret.)..................................................... 9
Prepared statement of Ms. Wade............................... 52
Wounded Warrior Project, Meredith Beck, National Policy Director. 30
Prepared statement of Ms. Beck............................... 54
MATERIAL SUBMITTED FOR THE RECORD
Memorandum entitled, ``Acceptance Requirements for VA
Volunteers'' from the William F. Feeley, MSW, FACHE, Deputy
Under Secretary for Operations and Management (10N), dated
February 22, 2007.............................................. 63
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. James
B. Peake, Secretary, U.S. Department of Veterans Affairs,
letter dated April 17, 2008, and VA responses.................. 65
CARE OF SERIOUSLY WOUNDED
AFTER INPATIENT CARE
----------
THURSDAY, MARCH 13, 2008
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Oversight and Investigations,
Washington, DC.
The Subcommittee met, pursuant to notice, at 10:00 a.m., in
Room 340, Cannon House Office Building, Hon. Harry E. Mitchell
[Chairman of the Subcommittee] presiding.
Present: Representatives Mitchell, Space, Walz, Brown-
Waite, Stearns, Bilbray.
OPENING STATEMENT OF CHAIRMAN MITCHELL
Mr. Mitchell. Good morning. This hearing will come to
order. This is the Subcommittee on Oversight and Investigations
and the hearing today is on the care of seriously wounded after
inpatient care.
We are here today to hear from veterans, their families,
and the U.S. Department of Veterans Affairs (VA) about the
long-term care of our most severely wounded Afghanistan and
Iraqi veterans.
We do know that the U.S. Department of Defense (DoD) and VA
provide excellent inpatient healthcare for these warriors, but
many of the most seriously injured require extensive outpatient
care, some for the rest of their life. Their families need care
and assistance as well.
Unfortunately, once these veterans leave the hospital, the
care they receive does not seem to be on par with what they
receive directly following their injury. And I think we can do
better.
Planning for veterans health care was not planned very well
at the outset of this war. The need to provide care and
assistance to wounded servicemembers and their families in
significant number and for the long term has been largely
ignored.
We will hear today what it has been like for some of them.
Their stories are inspiring, but also discouraging. They are
inspiring because even after they suffered terrible injuries,
they carry no bitterness, only pride from their service,
discouraging because they have been left to fend for themselves
for too long.
The DoD and the VA are large organizations with an
overwhelming bureaucracy. Their care and services often overlap
in messy, unpredictable ways. At a time of enormous stress,
this bureaucracy only hurts the injured warrior and his family.
When our troops return from theater with serious injuries,
they are met with a dozen seemingly unrelated people with
different services. We addressed much of these problems last
year with the passage of the Wounded Warrior provisions in the
Defense bill, but there is obviously still more to be done.
We need to realize that families are an integral part of
treatment and recovery and have their own needs. Unfortunately,
the VA is restricted from providing the many services families
need and deserve when their sons and daughters, siblings, and
parents return with service-connected injuries.
We have been playing catch-up since the beginning of this
war. It is irresponsible that the only support structure
available to a 19-year-old wife of an injured soldier is the
wife of a similarly injured soldier. We are going to hear from
people that have been dealing with the difficulties of the
system for a long time.
On February 14, 2004, Sergeant Ted Wade lost his right arm
and suffered severe traumatic brain injury (TBI), along with
many other injuries in an improvised explosive device (IED)
explosion in Iraq. Sergeant Wade is here today with his wife,
Sarah.
Marine Corporal Casey Owens of Houston, Texas, lost both
his legs when his unarmored Humvee struck a landmine in Iraq on
September 20, 2004.
Corporal Owens and Ms. Wade will tell us about the
frustrations and difficulties they have faced and we look
forward to their testimony.
Sarah and Ted Wade have devoted themselves to helping
hundreds of other injured servicemembers and their families.
Just 2 weeks after he was injured, Casey Owens told his
family that he wanted a camcorder so he could document his
progress from start to finish. He could only communicate by
writing at the time of his request. He wanted to show his
future children how far he had come and how good he had it.
Today you can find Casey gliding down the slopes at Aspen.
We owe Corporal Owens and Sergeant Wade a great debt. We
cannot repay that debt, but we can make sure that Corporal
Owens and Sergeant Wade, their families, and everyone like them
get long-term care and services that are also world class.
[The prepared statement of Chairman Mitchell appears on p.
49.]
Mr. Mitchell. Before I recognize Ranking Republican Member
for her remarks, I would like to swear in our witnesses. And I
would ask all witnesses if they would please stand, and raise
their right hand.
[Witnesses sworn.]
Mr. Mitchell. Thank you.
Next I would like to ask unanimous consent that Mr. Lampson
be invited to sit at the dais for the Subcommittee hearing
today. Hearing no objection, so ordered.
Mr. Lampson, please join us at the dais.
I would now like to recognize Ms. Brown-Waite for opening
remarks.
[Microphone technical difficulties.]
OPENING STATEMENT OF HON. GINNY BROWN-WAITE
Ms. Brown-Waite. Let us hope this works a little bit
better. I am sorry.
Good morning. Mr. Chairman, I thank you for holding this
hearing and also for yielding. I am going to keep my comments
short because I am looking forward to hearing from our
witnesses on how we can make the system better.
Over the past several years, this Committee has watched
over the development of the Polytrauma Rehabilitation Care
(PRC) units throughout the VA system. It has seen good work
including one in my own neighborhood in Tampa, Florida.
We are happy that we are doing better on inpatient care for
our severely wounded servicemembers. What we have observed
during our oversight visits is a dedicated staff and resources
that are necessary to make sure that the care given to our
veterans is second to none.
However, this Subcommittee is concentrating its focus on
what happens after the servicemember or veteran is discharged
from the VA. How are these severely injured veterans and their
families actually integrating back into their communities and
back with their families? What kind of post hospitalization
care and support services are they receiving? What avenues do
they find opened or closed to them? Basically, what are the
challenges that the veterans are facing?
We are all looking forward to hearing from our first panel
as to what they have encountered since their discharges.
Hearing their stories is not only important to the Committee
but also to the VA as they develop their Federal Care
Coordinator Program to reach out to our severely injured
veterans and assist them whenever and however they need it.
Those who are serving on the front lines of battle do not
consider where their actions will take them in the future. Our
Nation's heroes have sacrificed their time, energy, and often
physical health to secure freedom and democracy throughout the
world.
And I think every American believes that they deserve the
best possible care that we can give. Our obligation to care for
severely injured servicemembers does not end when they leave
the PRC but continues long after the discharge care process.
Again, Mr. Chairman, thank you for holding this hearing and
I yield back my time. And I apologize for the problematic
microphone here and it is not my Blackberry because I handed it
over.
Mr. Mitchell. Thank you.
Congressman Walz.
Mr. Walz. I will reserve my time.
Mr. Mitchell. Congressman Stearns.
OPENING STATEMENT OF HON. CLIFF STEARNS
Mr. Stearns. Yeah. Let us see if this works. Thank you, Mr.
Chairman, for holding this hearing.
Obviously today we are addressing a very critical issue
facing our heroic wounded warriors and their families and, of
course, their transition back into civilian life.
A recent article in which former U.S. Department of Health
and Human Services (HHS) Secretary Shalala commented, she
indicated if we are asking people to risk their lives and their
future, then we ought to be willing to make this investment.
And that is what we are trying to do here.
Families are the most important factor in the successful
transition back to civilian life for our warriors. Obviously
they deserve all the support we can provide for them.
I am very glad that on our first panel of witnesses, we
will hear the personal testimonies from two individuals who
have experienced these issues firsthand, Corporal Casey Owens,
and Ms. Sarah Wade will be speaking on behalf of herself and on
behalf of her heroic husband, Sergeant Edward Wade.
And I want to thank both of them for traveling the distance
to come here and take the time to testify before us.
My colleagues, since 2003, I have been pleased at some of
the initiatives that the VA has established to serve wounded
warriors and their families.
In June of 2005, the VA issued a directive expanding the
scope of care it would provide to include psychological
treatment for family members. This is very important. In
addition, the VA has expanded their team of caseworkers, but we
do need more.
Intensive clinical and social work case management services
have been created for the four regional traumatic brain injury
rehabilitation centers now named the polytrauma rehabilitation
centers. VA also established joint programs with the Department
of Defense to ease the transfer of injured servicemembers to
the VA medical facilities.
In August of 2003, VA and DoD established a program
assigning VA social workers to select military treatment
facilities to coordinate patient transfers between DoD and the
VA medical facilities. The social workers make appointments for
care, ensure continuity of therapy and medications, and
followup with the patients after their discharge.
But I am concerned, first of all, that caseworkers seem to
have too large a caseload which may inhibit the amount of time
and focus they are able to spend with each and every family.
Particularly when servicemembers are discharged from the VA
polytrauma rehabilitation centers, most, if not all, still
require followup care at the VA, at DoD, or private-sector
facilities.
I want to know if this transition system functions
smoothly, whether the patient is going back to the military or
is the patient going back to the private sector.
In addition, most of the most severely wounded patients
require long-term care and will become veterans eligible for VA
care when discharged from active duty.
So I look forward to this hearing, Mr. Chairman.
I have had the opportunity, as I am sure many members have,
to participate in the VA winter sports clinic out at Snow Mass,
Colorado, and seeing the enormous energy disabled veterans put
into that skiing clinic and to see how successful they are and
it is inspiration for all of us. And so I welcome our witnesses
today and I look forward to their testimony, Mr. Chairman.
Mr. Mitchell. Thank you.
Mr. Space.
[No response.]
Mr. Mitchell. Thank you.
I ask unanimous consent that all Members have five
legislative days to submit a statement for the record. Hearing
no objection, so ordered.
At this time, I would like to recognize Congressman Nick
Lampson of Texas who is here to introduce his constituent,
Corporal Casey Owens.
Congressman Lampson.
OPENING STATEMENT OF HON. NICK LAMPSON
Mr. Lampson. Thank you, Mr. Chairman. Hopefully this one
works.
I want to thank Chairman Mitchell and Ranking Member Brown-
Waite and Members for allowing me to come and sit in on this
hearing with you today. I am honored to join you on this
distinguished Subcommittee and very proud to introduce Corporal
Casey Owens of Missouri City, Texas.
Casey is an extremely exemplary young man and I commend him
for his willingness to continue to serve his country and his
fellow veterans. We are proud of his service to this Nation in
many, many ways.
I was impressed when we met yesterday for the first time by
all of his accomplishments. A graduate of May Creek High
School, he went to the University of Texas. But following the
attacks on September 11, he decided to join the Marines.
He was deployed twice, the first time from February 2003 to
October of 2003 and the second time from August of 2004 until
September 20, 2004, when he sustained his injuries. During this
time in the Marine Corps, he received several medals in
recognition of his distinguished service.
Less than a year after sustaining his injuries, Casey
successfully completed the Marine Corps marathon in 2005 using
a hand-cranked wheelchair with a time of approximately 2\1/2\
hours, probably better than any of us here could do. I know
better than I could do.
He is currently training as a member of the competitive ski
team in Colorado that has been recognized by the Paralympics
and the VA as an official training center.
Even more impressive than the three accomplishments, than
all of these accomplishments in my opinion, is Casey's advocacy
for veterans' care. He has worked with Mayor Bill White,
Houston Mayor Bill White's Veterans Task Force which was
established last year to address the needs of Houston's
veterans, both young and old, when it comes to housing, health
and mental care, job training, and other issues.
And he has come here today to testify before Congress about
the challenges new veterans in this country continue to face as
they transition from DoD to the VA system and try to navigate
it.
The most impressive, though, is the concern for his fellow
veterans and those that will come after him. He is here today
to ensure that our Nation's future wounded warriors will not go
through the same frustrations and feelings of neglect that he
and his friends have experienced at the DoD and the VA and have
struggled to adapt to a new breed of patients as they have
struggled to adapt. So they deserve much more in return for
their service. And I commend Casey for his advocacy on their
behalf.
And, again, I thank the Subcommittee for allowing me to sit
in and I yield back my time, Mr. Chairman.
[The prepared statement of Congressman Lampson appears on
p. 50.]
Mr. Mitchell. Thank you.
At this time, I would like to recognize our first panel,
Corporal Owens, Ms. Wade, and Sergeant Wade.
And I just want to say that last evening, I met with all
three in my office and we had a great visit. And I hope that
you convey in a very matter-of-fact way what you told me
yesterday because I think it is a very compelling story and
everyone should hear it.
So thank you very much. And we will start with Corporal
Owens.
STATEMENTS OF CORPORAL CASEY A. OWENS, USMC (RET.), HOUSTON, TX
(U.S. MARINE CORPS COMBAT VETERAN); AND SARAH WADE, CHAPEL
HILL, NC, ON BEHALF OF SERGEANT EDWARD WADE, USA (RET.) (U.S.
ARMY COMBAT VETERAN)
STATEMENT OF CORPORAL CASEY A. OWENS, USMC (RET.)
Corporal Owens. Good morning. Thank you, Chairman Mitchell
and Members of the Subcommittee, for coming.
I was injured September 20, 2004. I was serving with the
1st Battalion, 7th Regiment Weapons
Company. I was in Al Anbar Province out west on the Syrian
border. We were on a reconnaissance mission, dropped off a
reconnaissance team. Minutes later, we got a call to pick them
back up for a medivac mission. A Sergeant from reconnaissance
had been shot in the throat who later succumbed to his
injuries.
On the way back to base, we were engaged again and ran over
two anti-tank mines, which resulted in the loss of both my
legs. I was flown to a field hospital in Iraq, stabilized,
treated there, and to Landstuhl, Germany. I was there for 3 to
4 days and then flown to the Bethesda, Maryland Naval Hospital.
I woke up about a month later from a coma to find my legs
were missing. I had suffered two collapsed lungs, a pulmonary
embolism, serious head trauma, broken my clavicle and my jaw,
which now has a metal plate, and my teeth were knocked out,
several shrapnel wounds to my neck and torso.
From there, I had several surgeries over the next 2 to 3
months to stabilize me and was transferred to Walter Reed to
join the amputee program there and to walk again.
Over this time, I was a patient at Walter Reed and Brooke
Army Medical Center and was discharged and retired February 26
of 2006. And I did not have my right leg completed yet. I was
still experiencing problems.
Upon retiring in February, I needed another surgery, about
March, early April. My right leg, which is my myodesis, which
is kind of the muscle flap that goes over the end of your
femur, kind of gives you a padding, it had previously, once
about a year earlier, had torn completely off my femur and I
had my leg amputated again about an inch, and my sciatic nerve
cut. They reattached it. It looked good.
Over the next year, I still had more surgeries. I had
problems with heterotrophic ossification, which is a bone
growth which kind of held me back with my prosthetic care, my
prosthetic progress.
So when I was retired, I had a 60-day window that you are
still under the Department of Defense care. So I was able to
return to Brooke Army Medical Center to have it repaired. That
is where it had been done the first time. I went back there.
They repaired it.
Within a month, it had failed again for the third time. And
when I say third time, the myodesis was performed on the
initial injury. Failed the first time, second time, now third,
so this would be the fourth time to fix it.
I was now enrolled in the VA as of April 1, 2006. I went to
the VA, said, you know, I think it is failing again. I know it
is failing again. I can feel the bone coming through the muscle
this time and you could see it.
They instructed me to work with prosthetics, and that is
use their standard procedure is prosthetics, you know,
adjusting your prosthetics before, you know, surgery. I told
them that, you know, this is the third time. I have been down
this road. I know what I need.
They did not agree with me. The first day, they did not
agree with me. I said, I will be back in about 4 to 5 weeks.
The condition is going to be worse. Sure enough, about 5 weeks
later, over the weekend, the muscle started retracting, pulling
back, leg, you know, was very painful.
It was the weekend, so my choices were to go to the
emergency room, which I knew would be come back Monday, see an
orthopedic doctor. So I drove to Brooke Army Medical Center
about 3 hours away, found one of my orthopedic surgeons that
had performed the surgery the first two times. He looked at it
right away and said, yes, failed myodesis. And I said, well,
what are you going to do and what procedure. And he said, we
will do what is called a Goshock procedure named after the
doctor who invented it.
He said, well, this has failed four times now or failed
three times. This will be the fourth time to do the procedure.
I said, you know, I do not have any more of my leg to give, so
he pretty much said, well, that is what we can do.
So I went home disappointed. I spoke to a prosthetist who
told me about a new procedure, the Ertle procedure. Because he
was prosthetics, he said, you know, this advice did not come
from me and because in the past, he had been reprimanded for
giving advice from an orthopedic because for some reason, that
is not his field, even though prosthetics, orthopedics go hand
in hand.
So I found it. On the Internet, I found Dr. Ertle. I went
to my doctors at the VA and said I would like to get this Ertle
procedure done. They did not agree with me.
So over the next 6 months, I debated with the VA until I
finally got my surgery done, which the previous two times had
taken me less than 72 hours to get it done.
So during this time, I cannot move forward. I cannot go to
work, school. I am in pain. I got back on my pain meds which I
had already gotten off of. And also my insurance, my TRICARE
insurance supposedly through a clerical error, was canceled. So
that was another deal to deal with.
I did not have a social worker for the first 3 months, so I
sought the advocacy of a friend with Marine for Life who kind
of took over my case and Marine for Life, Wounded Warrior
Project and other people who just stepped up to the plate and
helped me out that were not even government agencies or people
from the VA.
I had the surgery done in Oklahoma. The doctor, well, he
has VA benefits, so, you know, I was not really going outside
the box. So, you know, I cannot understand what took so long
for the approval. I never really got an answer other than
sorry, we made a mistake.
And I have had the surgery done. It has performed. It is
doing well. But they had to amputate two more inches of my leg
and cut another 3 inches of my sciatic nerve which now I suffer
from chronic phantom pain.
And I returned home. I went out to Aspen. I had to recover.
I had several months before I could work with prosthetics, so I
went out to Aspen. And I was invited out there to train for the
Paralympics skiing, mono skiing.
I returned home early summer. I went to the VA and said I
am home. I am here to work solely on my prosthetics. This is my
number one goal. I am not working. I am not in school. I had
appointments about once a week, you know, for an hour which was
not sufficient to me, so I said, you know, I need to get this
done, you know. I am technically retired from the military,
but, you know, I am ready to go back to school and move on, you
know, with a job and career. And I cannot do it until I have
this done because it is going to take several months of rehab.
So they outsourced me because they said they had too many
patients and not enough staff to meet my needs. So they
outsourced me to a prosthetist in Houston, which there is only
one prosthetist there. And he did not have a technician at the
time either, which even slowed the process more.
I spent the following summer, the next 8 months up until
about December. And I had prior engagements with my race team
starting early November and, you know, prior commitments to my
sponsors for my racing.
I put it off for 2 months until January, still trying to
work on my prosthetics which finally resulted in him telling me
I cannot fit you. You should look elsewhere.
So I returned back to Colorado and finished my skiing. And
next week I go to Oklahoma to a company, some specialists that
other guys I know go to. But I am going there on the bill of
the Wounded Warrior Project because it is too much of a hassle
to deal with the VA and which it should be their
responsibility. They are the ones who have failed to fit me.
But, like I say, at times, it gets, you know, it is not
even worth dealing with the VA because it so much of a hassle
and that is how it has been.
You know, I suffer from post traumatic stress disorder
(PTSD) and the VA and all the problems I have dealt with have,
you know, furthered it even more. And in that 6 months that I
dealt with, you know, wondering why no one is helping me, why
the government is not stepping up to the plate, and it just
feels like I was abandoned.
And, you know, I did my duty and those that are in place
are not doing theirs. And it is a very frustrating feeling to
go through. And for me, it has been a harder battle coming back
to the States and dealing with everything I have dealt with
than it was going to the war both times. That was a cake walk
compared to this.
And so here I am now and my struggles, I have gone through
and done on my own or a lot of my own through the help of, you
know, advocates, but I do not want others to go through it
either. So here I am.
[The prepared statement of Corporal Owens appears on p.
51.]
Mr. Mitchell. Thank you. Thank you very much.
Sarah, are you or Ted going to talk?
STATEMENTS OF SERGEANT EDWARD AND SARAH WADE
Sergeant Wade. Chairman Mitchell, Members of the
Subcommittee, thank you for the opportunity to speak to you
today regarding our experiences following my injury in Iraq.
My name is Edward Wade, or Ted, as I prefer to be called.
And this my wife, Sarah Wade.
Ms. Wade. Hello. I am not as brave as Casey. I am going to
actually read my comments because I am worried I will get off
course.
Ted sustained a very severe traumatic brain injury or TBI
and his right arm was completely severed above the elbow. He
suffered a fractured leg, broken right foot, shrapnel injuries,
visual impairment, complications due to acute anemia,
hyperglycemia, infections, and was later diagnosed with post
traumatic stress disorder.
Ted remained in a coma for over 2\1/2\ months and
withdrawal of life support was considered. But thankfully he
pulled through.
As an above-elbow amputee with severe TBI, Ted was one of
the first major explosive blast polytrauma cases from Operation
Iraqi Freedom that Walter Reed or the Department of Veterans
Affairs had to rehabilitate.
Much of his treatment was by trial and error and there was
no model system of care for a patient like Ted. And there still
does not appear to be a long-term model today.
His situation was an enormous challenge as Walter Reed was
only able to rehabilitate an amputee, not a TBI. The VA was
able to nominally treat a TBI but not an above-elbow amputee
and neither were staffed to provide appropriate behavioral
healthcare for a patient with a severe TBI.
Because Ted could not access the necessary services where
and when he needed them, he suffered a significant setback in
2005 that put him in the hospital for 2 weeks and would later
take him probably a year to rebound from.
Ted has made a remarkable recovery, by any standards,
because we strayed from standardized treatment and developed
our own patient-centered path. I had to educate myself about
and coordinate additional outside care. Often access to the
necessary services required intervention from the highest
levels of government or pressed to personally finance them
ourselves.
But despite our best efforts, Ted is still unable to easily
receive comprehensive care for all of his major healthcare
issues due to shortcomings in the current system. And because
of the time his needs demand of me, I have been unable to
return to regular work or school.
We have been blessed to have family with the means to see
us through these difficult times and to help with the expenses.
I was fortunate to have the education of growing up in
Washington, DC, and learning about the workings of the various
Federal agencies, but our situation is not typical.
We do have a few ideas to provide better long-term care for
people like Ted that we would respectfully like to share.
The first one is about special monthly compensation,
particularly for reasons of integration, quality of life,
dependent's educational assistance, and respite care.
Individuals like Ted who required someone to be available
for assistance at all times are not compensated appropriately.
These veterans would require residential care otherwise, but
are not granted the higher level of aid and attendance because
they do not require daily healthcare services provided in the
home by a person licensed to perform these services or someone
under regular supervision of a licensed healthcare
professional.
I would be more than willing to be supervised if that is
what it took. But we feel the criteria should be clearly
outlined so appropriate compensation may be granted in the case
of an individual whose needs of assistance are managing their
care and personal affairs or they require support outside of
the home to rehabilitate and integrate into their community or
to achieve a better quality of life.
Both in the past and at present, we have paid someone to
assist Ted outside of the home. This allows him the flexibility
to hire a peer of his choice to provide community support and
accompany him on sightseeing outings he has researched and
planned with his therapist as part of his community
reintegration, to provide transportation to the store to
purchase books for homework assignments, go to the community
center to swim laps, or help him balance his checkbook at the
end of a day.
Not only has this enabled Ted to come closer to achieving
independence, but it has greatly improved symptoms of
depression by restoring hope and self-confidence, allowed him
to attain fitness goals and control his blood sugar without
insulin injections, all while providing much needed respite
care for me.
Unfortunately, the current VA respite programs are not
appropriate for a veteran like Ted. My option for that is to
put him in an extended care facility for 30 days a year or, as
my husband says, I could kennel him and the dogs and go on
vacation. And that is not really something that I am interested
in doing. I would rather go on vacation with him, or I could
also have someone come provide care in the home, but they
cannot take him to the places he needs to go and do the things
he needs to do.
And with better resources, I might be able to access the
dependent's educational assistance for which I qualify, but
under the circumstances, I cannot use. And I think one of my
great concerns is that these benefits do expire and I am, you
know, already probably 4 years into the expiration time.
I would like to see a change maybe in that, but also
someone provide the assistance we need for me to go to school
because not only would it give me the education that I have
available to me, but I think it would also help increase the
standard of living for Ted by increasing my earning capacity.
Another suggestion we have is about the Compensated Work
Therapy Program in the VA system. Largely due to the success of
the program we have created for Ted, the next phase of his
recovery will probably include some sort of vocational
rehabilitation. He has already had the opportunity to
participate in volunteer work through counseling and job
coaching provided by a private practice near our home where he
attends a day treatment program for behavioral health and TBI.
But now he is ready for the next stepping stone to
employment. The current Department of Veterans Affairs'
vocational rehabilitation and employment service is more of a
challenge than is healthy for someone like Ted, with
significant cognitive deficits and significant emotional needs.
VA work therapy programs, while developing work tolerances
and promoting effective social skills for more seriously
impaired patients, are set in insulated environments. A work
therapy program expanded to other community settings to
accommodate patients like Ted who are better served outside of
a sheltered atmosphere would be more effective.
Volunteer internship positions or later a part-time job
that sparks his interest would be more therapeutic. Not only
would this help him acquire the confidence and independence he
needs to someday become gainfully employed, but it would also
aid in his reintegration by providing constructive, meaningful
activities for him to participate in outside of the home.
I think my last comment will be about counseling and life
skills for patients like Ted with TBI and really patient-
specific case management.
Although many basic therapies are offered, rarely do they
include teaching socially appropriate behaviors which are
commonly an issue after TBI. This task often falls on the
veteran's family member or spouse, increasing the
responsibility of the caregiver, and causing conflict with the
veteran who feels like they are being treated like a child.
Ted has had the advantage of a community support peer, but
also a counselor at the private practice I previously mentioned
to help him redevelop age-appropriate social skills and allow
me to be his spouse while maintaining his dignity.
She has also worked with Ted to develop healthy coping
skills, to manage cognitive deficits, improve mental health,
and develop patient-centered treatment plans, which focus
specifically on his unique challenges.
Again, our situation is not typical, though. This is
something difficult to provide in an institutional care
environment like the Veterans Health Administration without
greater flexibility and more resources to provide increased
face time with the patients and better injury-specific
expertise.
The challenges we have faced are the same as countless
other veterans, many of whom have not had the resources Ted has
had available to him or an advocate capable of negotiating the
system.
A veteran I often think about who had a young wife with a
newborn baby and nothing more than a high school education
should have received the same world-class care as my husband
but sadly did not nor will not. Despite my best efforts to be a
support to his spouse, who is overwhelmed by motherhood while
trying to negotiate a seemingly impossible system, she
eventually left him because it was more than she could handle.
I think it is a lot to ask any mother to neglect their child.
A veteran's care should not depend on what family they were
born into, who they married, or whether or not family
obligations allow their loved one to advocate for them, but
sadly it does.
Though we will never be able to fully compensate seriously
wounded veterans for the sacrifice they have made on our
behalf, we can certainly do a better job of managing their
care, rehabilitating them to the fullest potential in a timely
manner, and providing the necessary resources to maximize their
quality of life.
I am very pleased to see that the Subcommittee is taking a
look back to explore ways to learn from the past and address
the needs of the veterans injured yesterday. I think this will
make a tremendous change for the people who are being injured
today.
And I want to thank you all again for having us here and
look forward to answering any questions.
[The prepared statement of Ms. Wade appears on p. 52.]
Mr. Mitchell. Thank you very much.
And let me just ask a question of all of you very quickly
because we know that Congressman Walz has to leave. But
yesterday in talking to all of you, you all have some
individual needs. You are saying that the VA, in a way, has a
number of things set up, but nothing to deal individually.
And I would just like, Corporal Owens, for you to tell the
story that you told us yesterday about when you went to the
methadone clinic, when they sent you out there because they did
not know what else to do with you or something like that. But
would you tell that story?
Corporal Owens. During the time, I was, you know, that 6
months, waiting for my surgery, got too much to deal with
anymore, so I started taking my pain meds again, still
suffering from phantom pains and just the muscle tearing and
just grinding against the bone and whatnot.
So I was back on them. I had my surgery done, so I was
still recovering. About 2, 3 months later, went to the VA, went
to my doctor, primary care doctor, said I think it is time I
want to get off these, but they are very, very strong narcotic
medications. So, you know, your blood pressure elevates, you
know, your body goes through a lot, you know, lack of sleep,
sweating, shakes.
So I said I would just like to be monitored, you know, I am
ready to get off it. He said okay. So gives me an appointment.
So a couple days later, I go up to see a doctor, to the floor,
to the substance abuse program. First, they say, well, what are
you here for. I said I do not know. I said I just want to get
off my meds. I thought I was coming to see a doctor to monitor
me.
So he says, no, you must have been flagged. Do you have a
problem? I said no. I said call my doctor, put him on speaker
phone. He calls him, asks my doctor. My doctor is saying, no,
he does not have a problem, I just do not have the time, you
know, big patient load. He said he just wants to be monitored
and, you know, helped and, you know, blood pressure medicine,
whatnot.
So he gets off the phone. The guy says, well, we want to
put you in the methadone clinic where you will come in every 6
days and you will get 6 days worth of methadone. I said I do
not want any more drugs. I want to get off of them.
So I left there and, again, went to an outside nonprofit
veteran group and they sent me to a doctor and to a detox
center and I got off of them, have not been on them since.
But, you know, it amazed me that just a simple week-long
monitoring could have taken care of it, but instead just led to
more problems, more frustration, and giving me more of an
attitude to not deal with the VA which I really do not do. And
most of all my care since I have gotten retired has been from
outside doctors and outside sources. I rarely use the VA.
Mr. Mitchell. Thank you.
I just wanted you to kind of finish that and then we will
get into our regular questions.
Mr. Walz.
Mr. Walz. I thank the Chairman. I thank the Ranking Member
for her courtesy.
I do have another appointment, but I can tell you with
absolute certainty there is no place more important in this
country right now than being right in this room. And I am
humbled to hear your testimony. I am also ashamed that this
would happen to our warriors.
We have talked about it time and time again that dealing
with our wounded warriors is a zero sum proposition, that if
one is not treated with all the care and all the dignity and
their issues are addressed with the utmost concern, then we
have failed. And that has been obvious in these cases,
especially with Corporal Owens. I am not even sure what to say.
And to make matters worse even, coming to this hearing
today, we just came from over in the Rotunda where we had an
Iraq and Afghanistan war remembrance where a lot of people
spoke and talked about a lot of nice things and you are sitting
over here telling us this story.
And I think Senator Dole summed it up best when he came in
and testified. He said you spent billions putting them in
harm's way, do whatever is necessary to get them out of harm's
way. And obviously we failed you.
And Sergeant Wade, Ms. Wade, you brought up some very good
points. I just have a couple of quick questions on this.
Corporal Owens, you talked about how your TRICARE was
canceled. And what is so troubling to me about this whole thing
is that you have come to expect that we are going to fail you.
I mean, that is obvious that your experience has showed that we
are going to fail you. That means we failed. Our job is to
provide that oversight. It does not matter.
Last year, we talked about how much we were able to do in
the VA. It obviously did not help you and that is a concern,
this Committee's primary concern.
So what happened with that, with TRICARE?
Corporal Owens. Supposedly it was when I got my medical ID,
it was supposed to be if you are discharged with a hundred
percent from the military, you only get care at--this is how it
was explained to me--that you can only get care at the VA. So
they discharged me with 90 percent and the VA found me a
hundred percent disabled. And that way, with TRICARE, I can go
to outside the VA.
And when I got my ID, they gave me a hundred, the military,
or I do not know who it was, gave me a hundred percent and so
it canceled it. But it took several, I do not know how long,
month, 2 months or longer to reestablish it.
Mr. Walz. What happened during that time, I mean, as far as
your care and bills and things like that?
Corporal Owens. I was going to the VA, so I was not billed
anything, but it was just one more hassle, setting up
appointments, calling people, and having to deal with it.
Mr. Walz. You mentioned a couple of times, too, about this
resource issue and people are telling you we are just
overburdened, we just cannot do it.
Would it surprise you that members of the VA have sat in
front of us and we have asked them if they needed more
resources and they said no?
Corporal Owens. That is a good point. You know, I hear all
the time about reports that 100, 200 new people have been added
to the system to Operation Iraqi Freedom/Operation Enduring
Freedom (OIF/OEF) patients. It looks good on paper, but in
reality, that is just an extra nurse or something to the
hospital, you know, a new doctor, delegate of the hospital that
can treat OIF patients, not to OIF patients, you know.
I mean, it is for us, but, you know, it is good for reports
and good for Committees because it sounds like you are making
progress. But the reality is, I do not see any results. I do
not see any changes. You know, there are now OIF/OEF
coordinators at all the VAs and whatnot, but the problem is,
and this is a solution that I find, they need to have an OIF/
OEF center.
You know, they have psychologists, this and that set aside
for us, but they are in all different parts, different wings of
the building. There is no correlation or communication among
each other.
And, like I wrote in my testimony, a good example would be
Johnny is not going to, say, his prosthetic appointments or
other appointments and so he gets reprimanded, written up. They
are like why are you not going, you are not doing anything to
further your care. And the reality is he may be suffering from
severe PTSD or his own emotional problems and so he just sits
in his room.
And what they need is they need to come together like they
do at Walter Reed and Brooke where all, social worker,
prosthetist, orthopedic, vocational worker, they all meet every
week and discuss their cases and the patients. And it helps
give insight into some of the people's problems and the avenues
of care they could give them.
Mr. Walz. Thank you.
And then a final question as my time expires here. Ms.
Wade, I think you have given a really powerful testimony and a
really strong insight into an area that I think we are not
addressing. And it is the issue of respite care and what
happens with the family and the caregivers, what happens to
their career, what happens to their well-being. And there has
been talk about that.
And this country means well and all of my constituents want
to do whatever they can to help, but I know what happens to you
as you see people and they will say, oh, it is good to see you,
you are looking good. It looks like Ted is doing well and all
that. And then they see you another 4 or 5 months later and
they say, gee, how are you doing, are things going well. They
do not realize every hour of every day of the intensity that
goes into that and this is all part of the care. It is all part
of taking care of that veteran.
So I appreciate your testimony. And I can tell you there
are Members up here that definitely share this concern and
believe this is the area, maybe the next big area where we
should be focusing as quickly as possible to address that.
So I thank the Chairman and Ranking Member. I do thank you
again for your kindness to let me speak.
And, of course, I am not sure what to say to you. Sorry is
not good enough in this case. And everybody is going to stand
in front of you and tell you that. You said you have heard it
many a time.
The only thing we can say to you is that we are going to
give every ounce of effort that we can to address this and make
sure that you do not go through this. And I know we may never
gain your trust back in that system, but we owe it to those
that follow you to do that.
So thank you for being here.
Mr. Mitchell. Thank you.
Ms. Brown-Waite.
Ms. Brown-Waite. I will try this one again.
[Microphone technical difficulties.]
I guess I will not.
All three of you, your statements certainly were riveting
and sad, very sad. I visit the various hospitals as many other
Members do and I have to ask a basic question.
When you were going through this, did you ever contact your
Member of Congress' office for help? Because I know that many
Members of Congress take the care of the veteran to be very,
very personal.
As a matter of fact, I have the VA hopping in giving me a
report every 2 weeks on a veteran in my district that I know
kind of slipped through the cracks. And I think it is very
important that we know about it because I do not think there is
a Member of Congress who, if he or she knew that this was going
on would have not immediately jumped into action.
So did any of you contact your Member of Congress about the
problems you were having with care?
Corporal Owens. Well, for me, did I contact my Member of
Congress, no. I do not know if other people on my behalf did. I
know one incident, I had written the President and wrote a
letter and gave it to Colin Powell to give to him, but it was
returned the following week. But, no, I cannot say I did.
Ms. Brown-Waite. Sergeant or Ms. Wade.
Ms. Wade. I guess I have worked some with Senator Byrd's
office, one of our Senators from North Carolina. He came to me
and offered to help. I had tried to contact Senator Dole's
office and there was just too many hoops to jump through and
too much red tape.
And honestly I think this is one of the problems with
people with severe brain injuries or someone that requires a
lot of intensive long-term care. I do not have time. There is a
lot of people that I need to ask for help in a lot of different
areas. And I just gave up.
I had contacted Senator Dole's office about a military-
related issue since she is on the Armed Services Committee and
I was sent a VA waiver. And I just did not have time to explain
that it was not a VA issue.
And so I mean, honestly, the people that have helped me
also, Senator Hagel, I had met by accident. It is an
interesting story. I was quarantined with him during an anthrax
scare, but, you know, there is a couple of Senators that I met
that offered me help. And those are the people that I have gone
to because there are just people that are trying mightily to
get by every day and we do not have the time to get these
things done.
Ms. Brown-Waite. The reason I ask that is because every
Member of Congress has staff that work on these kinds of issues
and get the elected Member involved to make sure that things
happen.
I am sorry that you did not have a positive reaction and
that you did not have action by the Congressional staff and the
Members of Congress, the Senators that you mention.
You know, maybe the House Members are so much closer and
our districts are so much smaller that maybe we have the luxury
that the Senators do not. I honestly do not know. But I know
that every Member of Congress, every Member in this House on
both sides of the aisle deeply care about veterans and followup
on veterans' care.
Absolutely. Mr. Bilbray, Representative Bilbray from
California just said, ``that is what we are here for.''
Let me ask each of you if you had any outreach from either
the Department of Defense or the Department of Veterans Affairs
after your discharge from inpatient care and what kind of
support or care was offered to you or your family.
Corporal, would you like to go first?
Corporal Owens. Nothing really stands out. I cannot say
that they did not. But nothing stands out because when I was
discharged, you know, this all happened within a month. You
know, with my leg tearing, the muscle failing again all
happened within a month and 6 months it took to get this done.
So I cannot really think if they had, you know, I do not
see what it would have taken this long. I went to them, to the
VA, and told them, so they were aware of everything. It was
obvious what was wrong with me. No, not that I can think of.
Ms. Brown-Waite. Sergeant or Ms. Wade.
Sergeant Wade. I do not----
Ms. Wade. Do you want me to start from the beginning since
you were asleep? Okay.
For Ted, he had a social worker initially at Walter Reed
and Ted was retired from the military before he regained
consciousness. So he quickly was not their responsibility. We
did have a social worker at Walter Reed, who even though he was
not her jurisdiction, she still kept in touch with me and tried
to help me out.
I will say the person, the group that has been in touch
with us from start until now is the amputee service at Walter
Reed. That is the only group of people that have been with us
through the whole ride. The amputee case manager there, I am
convinced knows everything in the world. But Steve Springer,
the amputee case manager, and the physician who ran the amputee
program at Walter Reed who is now the Chief of Rehabilitation,
Colonel Paul Paswena, they are the ones that have been with us
throughout this whole ride.
Ted's care was very fragmented. We had a social worker when
he was in Richmond where one of the level one polytrauma sites
is now. But, you know, once we left there, there was not any
contact with them anymore.
When we got home, there is an OEF/OIF case manager at our
VA hospital. She is there when I go to her for issues, but she
is not really there for any kind of really injury-specific case
management. It is out of her realm of expertise. So she was
there when we were at Durham the first time and she was there
when we were at Durham the second time. We have been through
seven facilities.
And really, I guess the last 3 years, our continuity has
been the civilian place where Ted goes, the civilian practice
he goes to. They have a brain injury case manager who from the
first day we went there until just Monday was the last time I
talked to her.
Even when Ted is at a different facility for treatment,
like right now he is at Walter Reed getting a new prosthesis
and doing prosthetic training and rehabbing from some surgery,
she still talks to Ted for an hour once a week regardless of
where he is in the United States.
So the amputee case manager at Walter Reed and the case
manager at our civilian facility for TBI have been our most
continuity.
And what we are very hopeful about is the Federal Recovery
Coordinator Program. Ted was recently assigned someone in the
Federal Recovery Coordinator Program. And that has been maybe
2, 2\1/2\ weeks. She has already passed her first couple of
tests which is a big thing with me.
But we are hopeful that that will maybe create some better
continuity. My concern, though, with that, is there are good
reasons why they are starting off slowly with this program,
because it is hard to get a hundred people out there, training
them when you do not even know what you need to train them for
yet and what kind of services people need.
But one of my concerns is in starting off slowly and where
a lot of the case management focus has been after the Walter
Reed articles in the Washington Post, a lot of the focus has
been on the military treatment facilities and the polytrauma
sites. Polytrauma network sites, only a small handful, a few
hundred people have been through those. It is a relatively
small number compared to the large group of people being
wounded.
And needless to say, the military treatment facilities are
short lived.
My concern with the changes in case management, I know that
I hear patients at Walter Reed are currently complaining that
they have to check in with five different case managers in 1
day and doctors complaining that the case managers are getting
underfoot and they do not have time.
Ms. Brown-Waite. Excuse me. Is that currently----
Ms. Wade. Yes, ma'am.
Ms. Brown-Waite [continuing]. They are complaining about
that?
Ms. Wade. And so what I feel like is that it would be smart
to have some sort of visibility of all the case managers that
exist from all these different programs. I mean, Ted
theoretically has five or six, because there are a lot of
people who left the military treatment facilities like my
husband who just dropped off a cliff.
I really think that if some of these groups of case
managers could be restructured and reassigned that someone
needs to have the job of reaching back and finding the people
that have been lost for the last few years and finding out if
they ever got the treatment they needed. And if they did not,
make it happen now.
Ms. Brown-Waite. Thank you very much.
Did you get a copy of the case plan for your husband when
he was leaving the hospital, a case management plan, what they
were going to do?
Ms. Wade. No, ma'am. I do not think they were doing that.
Ms. Brown-Waite. So there was no case management plan with
followup care?
Ms. Wade. I will say our Federal Recovery Coordinator, the
first day I met with her, that was our first conversation was
what were our immediate goals for the next 6 months and what
were our goals for the next 5 years. And one of the big
improvements, but it was about my goals too. It was the first
time anyone has ever asked about me and, you know, what was
going to happen to me in all of this.
Ms. Brown-Waite. Thank you very much.
I have exceeded my time and I thank the Chairman for being
understanding. And I yield back.
Mr. Mitchell. Thank you.
Congressman Space.
Mr. Space. Thank you, Mr. Chairman.
Corporal Owens, Sergeant Wade, Ms. Wade, I am really struck
by your testimony. By the way, you did a wonderful job. I know
this was not easy for you. I am struck by your sacrifice and
your courage and your heroism.
I think that Tim Walz, what he said is right. There is
really no more important place in America than right here,
especially for a Member of Congress.
What you have done, what you have given up, and what you
have gone through are quite remarkable. It is really important
for you to be here. It is really important for me and my
colleagues to hear your stories, again because it is important
for us to know the kind of sacrifice that you are all making
and you have made.
Certainly it is important for us to understand what we have
to do better to live up to our obligation to you that
tragically we have not been as good as we should have been on.
And perhaps most importantly, it is important for us, for the
Members of Congress, to see firsthand the price that is being
paid for this war.
And I thank you for being here.
Corporal, I had one question I wanted to ask you about in
response to your testimony. You had indicated that time and
again, you differed in your own assessment of your own injuries
and your own need for treatment from what VA hospital doctors
were advising you on and that I think you had three or four
different amputative procedures on the same leg and that as a
result of what appear to be flawed procedures or diagnoses or
opinions, you have endured a lot of pain and a lot of suffering
that might not have otherwise occurred.
And my question is this: You know, was there an avenue? Did
you feel that there was an appropriate avenue for you to obtain
a second opinion? I mean, it is something that many of us who
are not within the veterans' system take for granted.
Did you feel that you had that kind of recourse that you
could have seen a doctor efficiently, quickly, just to get a
different assessment or did you feel that your options were
limited in that respect?
Corporal Owens. It was kind of limited. And there is a team
at an amputee clinic, you know, an orthopedic and kind of a
primary doctor, so that is my point of reference or contact.
And that is who did not approve of, you know, our--you know,
who referred me back to Brooke who wanted to do the same
procedure. And I said, well that is not what I want. So, I was
really there and then come back to the VA and say, well, this
is what they are going to do. It is not what I want.
And so from there, I was just kind of on my own, you know.
I did not really know where else to turn to find someone to
back me up and say this is the procedure, you know, that I
found and want. And the way I feel, it is my right to choose
what care and what procedure I want.
I mean, it is not like it was going to be something harmful
or something that was just blatantly just going to be wrong. I
mean, it is my preference and I researched it and read up on
it. It is a medically proven procedure. It is not like some
quack procedure or anything. It is done by qualified
professionals.
So, no, I did not really feel I had a lot of places to turn
for a second opinion.
Mr. Space. Okay. Thank you.
And I just want to close. Corporal, are you the one from
Congressman Lampson's district? You know, I heard your
testimony that you had not reached out to his office. I can
tell you that you have one of the most compassionate and
concerned Members in this body and I know that he would have
been there for you had you reached out to him.
But I think the point is that you should not have to reach
out to your Member of Congress to get adequate just
satisfactory base-level care within the administration. And we
want to make sure that we do everything we can to allow you to
get that care without having to take those extraordinary steps.
Thank you. I yield back.
Mr. Mitchell. Thank you.
Mr. Stearns.
Mr. Stearns. Thank you, Mr. Chairman.
I had my staff here, so I had to go to another hearing, but
I am very glad to be back. And I had some notes that she took
and particularly with Corporal Owens. In your testimony, you
talked about dealing with the VA and it is a bit of a hassle. I
think those are your words. You also said that sometimes you
feel like you are on your own and almost there is no support
system.
I notice in some of the notes here that the VA is trying to
improve that and one of the things they have talked about is
developing several Web-based applications, including a Federal
Individual Recovery Plan and National Resource Directory.
They are going to team with military healthcare personnel
to use the recovery plan to create in one set of documents on
the Web a so-called map for recovery for wounded veterans ill
or perhaps obviously ones that are injured and their families.
And I guess my question for you, I guess for both of you,
Ms. Wade and Corporal Owens, would this Web portal that would
provide all these benefits in one area be helpful for you?
I have a bill, H.R. 3646, where you could go to the VA and
find every job in the country that is giving affirmative action
for veterans. So if you are in my hometown of Ocala and you
have a disability and you want to find work in the government
or in the private sector that is giving special preference to
veterans, this Web site, this bill was established so that you
could go and find this work. And it might be in Colorado, it
might be in New Hampshire, it might be in Florida, but you
could go to one area and find it.
And so I think the Department of Veterans Affairs is trying
to develop all this in one Web site and I guess it is sort of a
clearinghouse.
And so my question to you is, this Web-based application
for individual recovery plans and National Resource Directory,
health records, and creating one set of documents, sort of a
recovery map for you, perhaps each of you might talk a little
bit about that if that would be helpful.
Corporal Owens. It cannot hurt, but that is not where the
effort and money and time needs to be spent. It is nice, but it
is something to try to glitz and glamour, you know, just making
a Web site. No one is going to go look at it. There are tons of
Web sites out there. I can tell you that. I get papers all the
time, go to this Web site, go to that.
With the VA and stuff, there are vocational rehab jobs and,
you know, several other places. That is not a problem finding a
job or places that will take you. The problem lies on the
ground. They need more foot soldiers. They need more people
that are experienced and know the system and know how to work
it and advocate for you when you need something, not turning to
a computer or calling a hotline.
You need someone. You call up and say here is my problem.
You tell them that day and then you go carry on with your job
and what you have else and leave it to them because with a Web
site, that is just leaving stuff to you. And that is not our
job to do this. Our job was to recover and move on with our
life, which all of us wanted to do and put this behind us.
And the problem is not all these programs. The problem is
the accessibility to the healthcare and the bureaucracy and red
tape is what needs to be fixed. And I see all the time they are
setting up this program, they are setting up that. I think that
is just a way to get more funding to make it look like
attention has been going places.
And I think probably what you hear at all these hearings
is, because I know at least from my experience and all my
friends, they do not have problems finding a job or training or
education. They have a problem getting their benefits, getting
their ratings.
I know she is still dealing with it, you know, still trying
to get his proper rating and what he is entitled to. And that
was a problem for me. It took me a year and a half to finally,
through the VA, to get my claims and everything processed.
You know, I went through several months to do my med board.
It took 3 to 5 months of meetings, addendums, talk to the
psychologist, rehashing everything, getting ready only----
Mr. Stearns. So you are just saying it is a multitude of
bureaucracy and you have to jump through all these hoops,
families do, to eventually get service which at some point is a
breaking point for families because they are so frustrated.
Ms. Wade.
Ms. Wade. I have some concerns with this. I do think it
would have helped me narrow down where to look for things, but
you also have to keep in mind that I am someone who loves to
research things and there are other people that are not very
good at that.
I think also a very important point to make and I think
that the culture of the VA has to change. The culture of DoD
has to change in expecting people to come to them. Someone like
my husband is not capable of using a Web site like that. It is
part of the impairment from his brain injury.
And so for him, it would not be useful. And, again, it
means then that it is falling on somebody else to do it for
him. And there are also a lot of people with TBI who just are
not able to initiate things. And so that is one of the
difficulties with something like that.
I do think it would be useful for someone like myself who
likes to hunt down information.
But part of the problem with it also is that so often, I
just had this happen a couple of weeks ago when I was talking
to some VA people in the polytrauma system, that, you know, it
is we have X, Y, and Z. And I will say, well, I was actually
looking for A, B, and C.
I think that part of the problem with consolidating how to
get to these programs is you have to know what program you
need. You also have to have someone who knows the patient well
enough to know when one of those programs is not available, you
know, when there is something else they need that is not there.
There just has to be more. You need a case manager who
really, really knows the individual. I do not think it should
be up to the individual to identify what their needs are. They
may not know better.
Mr. Stearns. What happened if the VA provided a proactive
person to help you with the portal, that that person would come
over, go through the Web, show you everything, go through all
the programs, and on a regular basis in one spot sit down with
you and do it for you?
Ms. Wade. Three hours later, my husband would not remember
how to do it. He has memory issues. So for him, that would not
help.
Mr. Stearns. But the family would benefit by seeing it and
seeing the networking that they could go through.
Ms. Wade. If they do not have a full-time job and children
to take care of and they have the time to. I mean, I do think
that it is a useful resource. I am just concerned that it is
going to become some sort of catch-all.
Mr. Stearns. Both of you seem to be advocating that the VA
should have more personnel to come into the home, help the
families in a way to go through the bureaucracy without them
having to funnel the attack against the bureaucracy.
Ms. Wade. And to know the patient better. I mean, just
recently, Ted had some issues with medication. Anybody who
would have encountered him at the VA hospital would have just
assumed that he was being agitated, getting easily agitated
because that happens with TBI.
His amputee case manager at Walter Reed who has known him
for years encountered my husband and knows what his individual
baseline is and knew that that was not how he usually is and
asked me. Well, he actually looked up that there were some
medication changes and he called me about it.
But it is not just having anyone there to show me. Someone
has to really know my husband.
Mr. Stearns. Someone that knows the history. Yeah, knows
your husband.
Ms. Wade. And really know him.
Mr. Stearns. Yeah.
Thank you, Mr. Chairman.
Mr. Mitchell. Thank you.
Mr. Bilbray.
Mr. Bilbray. Thank you, Mr. Chairman.
First, I want to say to the panel, I want to thank you very
much. And I do not think you realize what a service you are
providing this Nation by being here today and by doing what you
have been doing over the last how many months. It is a very
measured, very effective message.
I also have got to say that as somebody who grew up in the
Navy and still hear my mother to this day as an 88-year-old
lady talking about having to sit in the emergency room from six
in the morning until six at night waiting for somebody to see
you that bureaucracies, especially Federal bureaucracies, and
even the military can be very frustrating sometimes.
It is inherent that in a system where people neither get
fired for doing the wrong thing nor get more pay for doing the
right thing, the system inherently tends to be very insensitive
to outcome and service.
But I think that, you know, Ms. Wade, you have given us
some good insight into two things. First, the concept of having
a clearinghouse is something that some people could use and
could help to improve it.
But I think when it comes down to it is while we may have a
triage team to talk about the multi facets, we need to have a
designated caseworker who is delegated the responsibility of
being basically an ombudsman of making sure that when there is
a glitch, you have somebody that you can contact. When there is
a frustration with a certain bureaucrat, there is always that
person you can come back to as your team or your advocate to
help you in the system.
And I guess the frustration always with working with
government, any kind of bureaucracy is to have somebody to be
your advocate who knows your case and your situation and knows
the bureaucracy and how to navigate through it.
And when we get too many people playing the games where you
have five or six or ten people, you do not know who to go to to
specifically address those issues. So you need to have that go-
to person. And I hope that we can talk about that.
And I have got to apologize to you, Ms. Wade, because you
have really been very measured at the fact of starting this
small process with a few trainees and working out. And the
reason why they have to do that is that if we do train, we do
have a big program and it does not work out, nobody wants to go
back and correct those problems.
You know, the biggest problem in Washington is not that we
try new things and it is not that we make mistakes. The problem
is when we try new things and make mistakes, we never want to
be brave enough to go back and correct it and say we have had a
problem.
I really do not have any specific question except for the
fact that, you know, am I right to assume that we really do
need to give the returning heroes the ability to have one
person and somebody that they can kind of rely on in this
situation, because sadly, as the Congresswoman pointed out, we
do not teach our kids in school which government agency to go
to when you take care?
I know Richard very well. The Senator is a good friend of
mine and we sat together for 6 years in the House. But it is
your representative in the House of Representatives who has a
small enough district to be more responsive than a Senator.
And sadly the people will call us about traffic lights and
potholes in Congress and I say I do not do that anymore. I used
to be a Mayor and now I am not.
But then do not call when it is a specific issue and do not
understand that Congressman are not up here. They are here to
serve and that is why we are here to be your ombudsman until we
can get you one in the system.
So the question is, am I right to assume that the
clearinghouse is a good thing, but what we really do need to do
is simplify the oversight part and try to give a designee, one
designee for you to go to?
Corporal Owens. Yeah. What you have to understand is that
our needs are newer needs than past veterans. You know, we are
a whole new breed of patients. Our survival rate is a lot
higher. The type of injuries are different. And so it is going
to require a new game plan and different mode of thinking than
what has been implemented in the past. And that is what, I
think, a lot of people do not understand because they are not
opening themselves up to a newer--that we need newer programs,
a newer way of doing things.
Mr. Bilbray. Maybe our thing is we need to make sure their
job reflects more on doing the right thing and less on worrying
about making mistakes if they make mistakes. You know, that is
the biggest problem we have is the bureaucracy tends to say the
less I do, the less exposure I have of making a mistake and
they only judge me by mistakes, not by successes.
Ms. Wade. My only----
Mr. Mitchell. Go ahead. We have got to go. And I want Mr.
Lampson very quickly. Go ahead.
Ms. Wade. My only comment with the one person is I do not
want that to be misunderstood. I do need more than one person.
I need a single point of contact. My husband's amputee case
manager is a very important thing for him.
You know, like, for instance, the issue that Casey was
having with his leg, an amputee case manager who has worked a
lot with amputees that are recently injured would have known
what to do in that situation.
For me, I need a TBI case manager for Ted's TBI
rehabilitation plan. So what I have told many people is I need
a case manager for my case managers.
Mr. Mitchell. Thank you.
Ms. Wade. So I just do not need it to be one person.
Mr. Bilbray. That is good.
Mr. Mitchell. Thank you.
We have to go vote and we will be back. And I want those
people here to stay here.
But, Mr. Lampson, before we go, would you like to make a
comment?
Mr. Lampson. I would like to make a comment, actually two
very short comments and one question. And it follows up really
on what Congressman Bilbray was just talking about.
But, first, you know, it is as if the care they do receive
has been by trial and error. And I think that is their point.
It is something new. Corporal Owens just made the comment that
it is a new set of problems. They are polytrauma patients today
that we have not known how to take care of in the past.
I am very impressed by your concern about those who you are
trying to be a representative for and coming here to Congress
in the hopes that someone else will not have to come here later
on.
My other point is the comment that both Congressmen
Bilbray, Stearns, and Zach Space made about how we really do
want to know about what is going on and try our best to be
responsive to what is happening.
I carry a card in my pocket, and have for more than a year
now, with the names of the 19 men who have died from my
district. I walk the halls of the veterans' hospital in
Houston, Texas, and at Walter Reed visiting with folks like
this recovering from their injuries. Yet, it took being
contacted by this Committee to find out that I had a person in
my district who was having this kind of problem.
So there is something that is even further broken. How do
we get information? Here is my question of you all. How do we
get information out to other members of the service to know
that they should be able to turn to any level of this
government, whether it is their Representative, their Senator,
their President, or whoever else, to be able to say something
is wrong and I need special attention? Do you have any further
comment that you can make about that?
Corporal Owens. It just never really crossed my mind
because there is the hospital, the VA. That is what it is, for
medical needs. So I do not think of my Senator or Congressman
to turn to for medical needs, you know. And I have no doubt
that you or any other person want to serve me. It is just I----
Mr. Lampson. My point is that we need to find a way that we
can make sure that other folks in your situation know to
contact us. We want to reach out to you.
Ms. Wade. I guess part of the difficulty with that is
patient confidentiality and overcoming those barriers. But I do
know that somehow or other, one of our Senators does--I do not
know if they scour newspapers to find out who has been wounded
or what, but, I mean, we got a letter offering assistance if we
needed it in the mail.
Mr. Lampson. Well, we do both as well. And I have a retired
Marine who returned from Iraq and went to work on my staff as
the outreach person. And we even meet with on a bimonthly basis
about 15 organizations of veterans, their leaders in my offices
every other month. Still there are things that are falling
through the cracks.
I have a physician at home who has actually volunteered to
repair the face, he is a plastic surgeon, of anybody who needs
that special attention. Getting that information out is
something that I think that we need to pay attention to.
I think you are magnificent people for being willing to
give your lives to our country. You should not have to be going
through the difficulties that you are facing today. If there is
ever anything that any Member of Congress can do, ask your
friends to ask us to respond. I think we will do so.
Thank you, Mr. Chairman and Ranking Member, for allowing me
to come today.
Mr. Mitchell. Hopefully you will all be able to stay here.
We are going to finish this up and we have got some other
questions. And we will be back right after the vote. Thank you.
[Recess.]
Mr. Mitchell. We are going to go ahead and get started.
Others are on their way.
One of the things that I wanted to ask both the groups here
are, first of all, Corporal Owens, you mentioned last night
that you have been trying to get your medical records and you
have never received your records; is that correct?
Corporal Owens. Right. I have not. I have been trying to
get my med board which is about four inches thick. I have not
gotten it yet.
Mr. Mitchell. And I would hope that those of you who are
here that have some responsibility of that make sure that
Corporal Owens gets his medical records. He has never had them.
About four inches thick. He has asked for them and asked for
them.
And when were you injured?
Corporal Owens. September 2004.
Mr. Mitchell. September of 2004 and he does not have them.
That is one of the things we have been trying to deal with, to
get some kind of a seamless transition with DoD records and the
VA records. There is no way he can get the right and proper
care without all the records and he does not have them.
The other thing that is interesting you told me last night
is that you found in your records that you were not even
awarded the Purple Heart; is that correct?
Corporal Owens. When I got to the VA, this was about a year
ago or so or I do not know how long ago, several months ago, I
was looking through my case manager's computer and scrolled
down. It said I did not have the Purple Heart. It said I did
not have dental injuries. It did not have any of my claims. All
it had was I lost both legs and that is it.
Mr. Mitchell. That is amazing that they have on there you
lost both legs, but not a Purple Heart. And they rebuilt your
jaw and your mouth and it had nothing about your dental.
Corporal Owens. No PTSD, no dental, no scars, nothing.
Mr. Mitchell. And I will tell you it is the lack of records
and the continuity of them that has caused--you can imagine
what it does to people who have PTSD and traumatic brain
injury. It does not help.
And, Ms. Wade, I think you suggested a similar situation
with you.
Ms. Wade. And I think what is hard for us, too, is that I
have had so much on my plate trying to manage all Ted's medical
affairs that there are things that have just simply slipped my
mind.
I am trying to get a hold of some records. I want to get
his PEV, his physical evaluation word file as well. There are
some records from Germany I have never been able to get a hold
of. Particularly I wanted his MRIs of his brain after his brain
surgery.
But, I mean one of the things that is difficult with this,
I guess, lack of continuity in the records is I had a therapist
recently comment that it seems like my husband was tracking
strangely with his eyesight when they were working on a
crossword puzzle. And it triggered a memory. And I went back
and read an article that his speech therapist from the
polytrauma center had written about him. And I had completely
forgotten that my husband was having vision issues back in
Richmond. Well, there was no followthrough. He had never been
seen by an ophthalmologist.
And come to find out Walter Reed referred Ted to a neuro-
ophthalmologist and he has visual impairment. He has a blind
spot in his vision and he also has some other visual
impairment.
But, you know, in this jumping from hospital to hospital
and the lack of case management, the lack of records, you know,
a nice, concise record and maybe a list of just his major
injuries, it would have been nice.
But we are also dealing with having his VA rating fixed. He
just had his new one updated. I guess it was a 3-year update.
And it was simply done on his VA medical records. Well, really
the only thing he goes to the VA for anymore is speech therapy.
And so they did not have access to any of his other records. So
I am going to have to file an appeal to have other things added
in.
And like Casey, there were new things that came up. There
is not a complete record and there is not a complete diagnosis
of all his issues.
Corporal Owens. But the problem with that is, and in my
case, and it has got to be for her, since they do not have
those records, you have to then be reevaluated by the VA. So
since they did not have anything other than my legs, I had to
go to the dentist, you know, or to, you know, dental. I had to
set up an appointment, wait like a month for it.
I had to have MRIs for different things. I had to see the
dermatologist. I had to see all these different doctors,
psychologists for my PTSD, another stranger I have never met,
have to tell my story again, rehash old memories, and it just
gets old time and time again doing it over and over when you
have done it once for your med board by qualified, competent
people. It is just like why can it not pass on to other people?
And, you know, that is----
Ms. Wade. And Medicare included, I think, because we--I
mean, I do not know if you had to do this, but we had to go
through the whole welcome to Medicare exam also. There is a lot
of repetition.
Mr. Mitchell. Right. And, you know, this hearing is not
only to hear your story here, but it is also to send a message
to those that can do something about it. And they are sitting
behind you and they will be testifying later. And I hope that
they look at this, that both of you are unique and that you
have worked through the system. In spite of the system, you
have gotten things done. A lot of them, as you said, do not
have the time. They do not have the resources. They just cannot
do it.
And this is you serving as a model, that if this has
happened to you and you are people who know how to work the
system, think of how many others that it is happening to. And
it should not.
Okay. If there is anything else that either one of you
would like to say? Okay. Yes, Ms. Brown-Waite?
Ms. Brown-Waite. Thank you, Mr. Chairman.
Ms. Wade, what disability rating did Ted receive?
Ms. Wade. He was given both a hundred percent by the
military and the VA. I had a couple people look at his rating
that actually told me, and I am going to have to have this
fixed, but based on the way his rating is written, I had a
couple former raters read it and a couple----
Mr. Walz. It is all in the wording.
Ms. Wade. Yeah. It is all in the wording. They said that
Ted actually may qualify for a next level of special monthly
compensation if his injuries are worded differently.
But part of the problem is and one of the reasons I brought
up about the special monthly compensation is that those things
are written based on physical residuals, not cognitive
residuals. They have not been updated for the current injuries.
I mean, again, even in some of the vocational rehab
aspects, the Independent Living Program for vocational rehab is
really designed for physical needs, not cognitive needs. And I
think all of these things need to be updated to fit the current
injuries.
And I think part of that with the special monthly
compensation and needing more assistance is one of the
important things to keep in mind is that not everyone has
family to help them out and they might need to hire someone to
lend them a hand.
Ms. Brown-Waite. Another question. Having served as
basically a patient advocate for family members, I know it is
all in the questions that you ask. Certainly when I was taking
care of my mom and now my husband and I know you have to be
specific and you have to press for the right answers.
Along the line, did you find anybody purposely gave you
incorrect information, Corporal?
Corporal Owens. No.
Ms. Brown-Waite. Sergeant or Ms. Wade.
Ms. Wade. I have been given incorrect information. Whether
or not it was done on purpose, I do not know. I have been given
incorrect information quite a few times, though, and I do not
know if it is the people do not know the rules or if someone
has interpreted them differently than I have when I have read
them. But I have been given a lot of incorrect information.
Ms. Brown-Waite. And I would like to ask both of you, on a
scale of one to five, five being the highest, how would you
rate the orthotic and prosthetic department of the facilities
that you were treated in?
Corporal Owens. Well, I was treated at Walter Reed or
Brooke. Five.
Sergeant Wade. Five as well.
Ms. Wade. We do not use the VA orthotics and prosthetics. I
mean, like Casey's situation, it was just too much of a hassle.
And part of that is because of the nature of Ted's injury, that
the closest VA contractor to work on his arm is maybe about a
6-hour drive from us. It is easier for us to come to Walter
Reed than to wait a few weeks to have someone work on his
prosthesis.
And there also is not a therapist with the expertise that
they need for his prosthetic training at our VA hospital. So we
just do not even bother. It is just easier to go back to the
military because there are no hassles and we can just walk
right in the door.
Corporal Owens. The problem for me is, and other people
like us, is we are a different patient than what they usually
deal with because they are usually dealing with diabetics,
people that are older in age, that are retired. And so, you
know, I want my stuff. I want to see them 4 or 5 days a week
for an hour or two and get done, whereas some people are just,
you know, they can come in, get fitted once, twice a week, and,
you know, they are not as active and not as, I will not say
motivated, but are not requiring them as much and needing them
expedited, you know, not needing them as quick and as fast
because I need it done so I can get back to school and go back
to work. So it is accessibility, I guess.
Ms. Brown-Waite. One of my concerns about the orthotic and
prosthetic service providers is in many States, they have to be
licensed. I know Florida when I was in the State legislature,
we were like the second State to license them, but we had no
effect on licensing for the Federal Government.
And the Federal Government still does not require in States
where a license is required that the VA providers or even the
DoD providers have to be licensed and meet all of the State
qualifications. That is why I asked about how you would rank
the level of service.
Thank you very much. I have no further questions, Mr.
Chairman.
Mr. Mitchell. Thank you.
Just one last thing. I think it is something you are going
through, but also for some of our next panelists. And that is
how do inaccurate records, your medical records affect the
ability to get VA benefits?
Corporal Owens. Well, you know, like I said, since they
only had me under, you know, just missing my legs, I was a
hundred percent, but if you do not have those other records and
those claims, you can only go to a hundred percent, but having
those claims, you get extra compensation. If you have all your
claims, but you cannot get treatment for them unless it is
claims because then it is not service connected.
Ms. Wade. I think it is also, like my husband, I was
looking at his records because I need to appeal his final
medical board and we are looking at about 3,500 pages, and so
it seems like there needs to be a better way to really
highlight the major issues.
But part of what is difficult with that, again, is the
physicians have to know what exactly it is they need to
document. They are not raters. And the raters have their set
guidelines they are using and if the doctor does not know those
guidelines, then they do not know how they are supposed to be
documenting things.
I mean, one of the things with my husband is, yes, he got a
hundred percent for the traumatic brain injury, but he also
has, one of the things we were discussing last night, he has
very bad muscle spasticity. And at times, he loses voluntary
control of his limbs.
Well, his records say muscle spasticity. A friend of ours,
it says loss of voluntary control of two limbs. His friend is
rated as hemiplegic which gives him the next level of special
monthly compensation. Ted just has muscle spasticity and,
therefore, is not given anything for that residual.
It means that he cannot use his prosthesis when he is
having trouble. It gives him loss of use of his limb he has
already lost. It is harder for him to compensate for the loss
of his arm because of this medical condition. But if the person
documenting this does not know how they are supposed to be
wording it to meet what a rater is looking for, then it becomes
an issue.
Ms. Brown-Waite. Just one other thing. I would strongly
suggest in getting your husband's records that you do engage
your Member of Congress. As many of us have said, that is what
we are here for. And the congressional staff and the
Congressperson do get involved in this.
And I always apologize to my veterans that they have to
come to me to get the records that they should be able to get.
But getting records from DoD is not easy. And that is something
that every Member of Congress on both sides of the aisle that
their offices do regularly.
Now, you will have to fill out a privacy form that
authorizes your Member of Congress to help you, but it sure
will speed things up if you have had a problem. And please pass
that word on to other families that you are in touch with.
Please use us. We are here and we are grateful to help those
who sacrificed so much for our country while in the military
and the families. And with all you have been through, I am
surprised you do not have gray hair.
And I yield back.
Mr. Mitchell. Thank you.
And I want to thank you not only for the sacrifice for the
country, but what you are doing for other veterans. You are
speaking for a lot of people, a lot of people. And I appreciate
that.
And I also in my opening statement, I pointed out that, you
know, you may be disappointed, but you are not bitter. You are
very proud to have served your country and that is admirable.
And I appreciate everything that you are doing.
And with that, we will conclude this panel. Thank you very
much.
And the second panel, Meredith Beck and Todd Bowers. And,
Meredith, would you care to go first?
Ms. Beck. Yes, sir.
STATEMENTS OF MEREDITH BECK, NATIONAL POLICY DIRECTOR, WOUNDED
WARRIOR PROJECT; AND TODD BOWERS, DIRECTOR OF GOVERNMENT
AFFAIRS, IRAQ AND AFGHANISTAN VETERANS OF AMERICA
STATEMENT OF MEREDITH BECK
Ms. Beck. Mr. Chairman, distinguished Members of the
Subcommittee, thank you for the opportunity to testify before
you regarding post-acute care for seriously injured
servicemembers.
My name is Meredith Beck and I am the National Policy
Director for the Wounded Warrior Project (WWP), a nonprofit,
nonpartisan organization dedicated to assisting the men and
women of the United States Armed Forces who have been injured
in the recent conflicts around the world.
During those conflicts in Iraq and Afghanistan, there have
been approximately 30,000 soldiers, sailors, airmen, and
Marines wounded in action. Fortunately, due to the advances in
medical technology, the number of those killed in action are
far fewer.
However, in many cases, the wounded have suffered
devastating injuries and require long-term outpatient care and
rehabilitation. As they have suffered these injuries, WWP is
pleased that the Subcommittee has chosen to focus on this
aspect.
As a result of our direct daily contact with these wounded
warriors, we have a unique perspective on their needs and
obstacles they face as they attempt to transition, reintegrate,
and live in the communities where they have served.
I also want to note that my job as the Policy Director is
to speak directly to these families across the board. What I
then do is create policy themes and proposals based on the
themes that they have demonstrated.
Unfortunately, my job is easy these days because the themes
that the families are presenting are almost uniform in what
they are presenting. The Wades, Casey, they are prime examples
of that.
However, as Sarah noted, it is very important for you all
to understand that these two, the Wades and Casey, are not
typical of your daily average wounded veteran and their
families.
Sarah is very well-spoken. Casey is incredible at what he
does. And the families that we deal with, and they represent
them well, but the families they deal with do not in many cases
have the capacity to be able to navigate these systems as well
as they have.
Because of our contact with these servicemembers, we have
identified a number of areas, and you will probably hear some
repetition from the two of them because they have come directly
from people like them, and the following areas are common
themes among these families.
The options for care specifically with respect to those
with traumatic brain injury, those suffering from TBI require
individualized comprehensive care. And while the VA has made
progress in this area, the Agency is still in the process of
establishing extensive, consistent, long-term continuum of care
available throughout the Nation.
As such and due to the need for long ongoing therapy and
rehabilitation, many seriously injured veterans and families
have indicated that their number one request is increased
access to options for care, including access to private
facilities previously available to them while on active duty.
The next topic is discrepancies in benefits. Many veterans
and families of the seriously injured have indicated confusion,
frustration, and disappointment upon learning that they are not
eligible for the same benefits and care as veterans as they
were on active duty and vice versa.
For example, consider that an active-duty patient can be
seen at a VA polytrauma center to treat his traumatic brain
injury. However, while at the VA facility, the servicemember,
due to his duty status, cannot enjoy VA benefits such as
vocational rehabilitation or independent living services. They
can be assessed for those benefits, but they cannot have them
until they are actually retired.
Alternatively, as mentioned previously, and unbeknownst to
most families, a medically retired servicemember cannot use his
or her TRICARE benefits to access private care as TRICARE does
not cover cognitive therapy once retired.
While there is an obvious need for and advantage to an
active-duty service, those who are severely injured as a result
of their service in an all-volunteer force deserve special
consideration.
The recently passed NDAA contained a provision intended to
address those discrepancies. Specifically section 1631
authorizes for a limited period of time the Secretary of
Defense to provide any veteran with a serious injury or illness
the same medical care and benefits as a member on active duty
and entitles the severely injured still on active duty to
receive those veterans' benefits, excluding compensation, to
facilitate their long-term recovery and rehabilitation.
While the provision recognizes the strengths of each
Agency, and they do both have strengths, and the necessity of
basing an individual's care and benefits on his or her medical
condition rather than on their status as active duty or
retired, it is subject to significant regulation and will
require oversight to ensure its success.
The next topic is respite care. I will say personally my
brother is currently a Marine major serving in Fallujah. He has
four children under the age of seven. If something happens to
him, I want to know, and this is why I do this and why I talk
to these families, I want to know that he is going to be taken
care of and that his wife will have the ability to take care of
their children and take care of him.
For those who have suffered and who are seriously injured,
one cannot discuss their care without discussing their
caregiver. While the VA currently offers some respite care, the
available options are often not entirely appropriate given the
average age and types of injuries of those serving in Iraq and
Afghanistan.
For example, similar to the Wades, retired Army Sergeant
Eric Edmondson from North Carolina suffered a severe brain
injury in Iraq several years ago, but he is aware and
responsive. In fact, he enjoys spending time with his family
and recently went fishing with his 3-year-old daughter, Gracie.
Eric's family is unwilling to place him in a respite
facility for fear it could cause a regression in his
rehabilitation and cause Eric distress, which ultimately means
his family does not get any form of respite.
However, WWP has noted that similar to others, Eric's
family has used their personal funds to pay for an innovative
type of individualized therapy that also provides a unique form
of respite to the caregiver.
In Eric's case, rather than staying indoors all day, his
family pays an individual out of their own funds to take him to
the park and watch his daughter play. Eric thrives each time
and his progress and enjoyment are noticeable.
As a result of Eric's success as well as others in similar
situations, WWP proposes that the Department of Veterans
Affairs initiate a pilot program partnering with local
universities that the VA already has partnerships with to
provide such a care and respite initiative for those with brain
injury.
As part of the veteran's ongoing therapy, the program would
draw graduate students from the appropriate fields, i.e.,
social work, nursing, psychology, train them to interact with
the veterans and match them with the eligible veterans in their
local area so that an individualized program can be developed.
In return for making the requisite reports to the veteran's
physician on his or her status, the graduate student would
receive course credit for doing such work.
The creation of a program would have several positive
effects. In recognition of the individual nature of brain
injury, the program would encourage an innovative means of
providing age-appropriate maintenance therapy to those
suffering from TBI, which for the long term is absolutely
necessary. Their rehab is never finished.
While the veteran is benefiting from the therapy aspects of
the program, the family caregiver would be offered much needed
respite.
And, three, interaction with the graduate students would
increase general community awareness of the sacrifices of our
Nation's veterans and the needs of those suffering from TBI.
Mr. Mitchell. Could you wrap it up?
Ms. Beck. Yes, sir.
Last, the oversight aspect of this. Finally, consistent
with the recommendations of the Veterans' Disability Benefits
Commission and to ensure the best care and benefits for those
who have sacrificed for our Nation, it is imperative that a
joint permanent structure be in place to evaluate the changes,
monitor the systems, and make further recommendations for
process improvement.
It should not require Casey and the Wades to be the ones
who find the problems. They should be able to rely on the
people who are providing their care to provide that oversight
and the ability to give those recommendations for change.
With the passage of time, as veterans' issues fade from the
national spotlight, it is necessary to have that structure so
that we can all make sure that we are coordinating future
intra- and interagency coordination.
Thank you, and I look forward to your questions.
[The prepared statement of Ms. Beck appears on p. 54.]
Mr. Mitchell. Thank you.
Mr. Bowers, you have 5 minutes.
STATEMENT OF TODD BOWERS
Mr. Bowers. Mr. Chairman, Ranking Member, and distinguished
members of the Subcommittee, on behalf of the Iraq and
Afghanistan Veterans of America (IAVA) and our tens of
thousands of members nationwide, I thank you for the
opportunity to testify today regarding this important subject.
I would also like to point out that my testimony today is
as Director of Government Affairs for the Iraq and Afghanistan
Veterans of America and does not reflect the views and opinions
of the United States Marine Corps of which I currently serve as
a Sergeant in the Reserves.
The tremendous advancements in frontline medical care have
made many combat injuries more survivable. In Vietnam, the
mortality rate of combat injuries was one in four while the
mortality rate in Iraq is one in ten. That means today's
battlefield medicine has saved approximately 6,000 American
lives that would have been lost if they were still using
Vietnam era medical techniques. This is a tremendous success
story for the DoD medical system.
But the corollary of improved survival rate is an increase
in the number of severely wounded troops returning home. As the
Independent Budget states, and I quote, ``We are seeing
extraordinarily disabled veterans coming home from Iraq and
Afghanistan with levels of disability unheard of in past
wars.''
Many of these young wounded veterans will require long-term
care, not just at Walter Reed and Bethesda, but in their
communities across this country.
At the VA, these veterans with traumatic brain injury and
blast injuries are confronting a system designed to treat
diabetes and Alzheimer's.
The DoD and the VA have already taken some crucial steps to
improve inpatient care for these young, severely wounded
patients. There are four major polytrauma rehabilitation
centers in Florida, Virginia, Minneapolis, Minnesota, and Palo
Alto, California, which use teams of physicians and specialists
that administer individually tailored rehabilitation plans,
including full spectrum care, for traumatic brain injuries.
These centers are also part of the defense and veterans
brain injury center network. These key centers offer cutting-
edge treatment for severely wounded troops who are receiving
inpatient care. But what is available to troops near their
homes?
As of 2003, according to the U.S. Government Accountability
Office, more than 25 percent of veterans enrolled in VA
healthcare, over 1.7 million, live over 60 minutes driving from
a VA hospital. This number is likely higher today because the
mission in Iraq has relied heavily on recruits from rural areas
and under-served by VA hospitals and clinics.
This places a tremendous burden on the families and also
the veteran. With the current gasoline prices, for example, and
many treatment centers hours away, treatment is often
impossible to facilitate.
Imagine, if you will, that your loved one has returned from
combat wounded and it is your responsibility to make sure they
are receiving the proper treatment. This is too much to ask of
our servicemembers and their veteran families.
In response, the VA has created regional network sites that
work with major polytrauma centers to cater to patients closer
to their homes. The VA is also planning to add new polytrauma
support clinics to provide followup services for those who no
longer require inpatient care but still need rehabilitation.
The 75 polytrauma support clinic teams help veterans get
access to specialized rehabilitation services closer to their
homes and communities and also are responsible for ensuring
these patients do not fall through the cracks after leaving
full-time care.
For hospitals without a polytrauma support clinic, a single
person has been designated as the point of contact to
coordinate care for local veterans with polytraumas. These are
good first steps, but much more has to be done to get these
wounded veterans the care they need. A single point of contact
that can offer referrals to distant hospitals and clinics is
simply not an adequate response to a wounded veteran's
healthcare needs.
IAVA joins the other Independent Budget of veterans service
organizations in calling for an increase in funding for home
and community-based care and a detailed plan from the VA
regarding their long-term response to the need of today's
veterans.
I would be happy to answer any questions at this time.
[The prepared statement of Mr. Bowers appears on p. 55.]
Mr. Mitchell. Thank you very much.
I have a question of both of you. Both of your
organizations came about as a result of the wars in Afghanistan
and Iraq. How many other organizations like that have spurred
up as a result of this war?
Ms. Beck. Probably countless numbers of organizations. I am
not sure that the number, though, who have--there are countless
organizations that provide care support services benefits for
servicemembers. Of the organizations that actually do policy
work related to this area, I would say that we are probably the
only two.
Mr. Bowers. Uh-huh. And we are good friends.
Ms. Beck. And we are friends.
Mr. Mitchell. The reason I ask that is that with this war,
which is relying solely on volunteers and the growth in the
number of organizations like yours to serve this war, it really
seems that it is kind of market driven. The government is not
doing its job and as a result, volunteers from the private
sector are stepping forward. And that is really not a very good
story.
And I listened to Corporal Casey Owens, many times saying
that he has completely given up on the government services and
has gone completely to the private services and all those
services are organizations like you.
That is a sad commentary. And just a comment on that.
Ms. Beck. If I could, sir, one thing about that, and, yes,
the government certainly needs to be providing a lot of these
benefits in a more organized, better fashion, and quality of
care obviously in the past two situations we have seen.
There is one aspect for the organizations, though, to make
sure that the communities are aware. I know that Todd has a
large campaign to make sure that the communities are aware of
the needs of these servicemembers and to provide a means
through which individuals can contribute and understand.
So there is hopefully a need for them. But at the same
time, I certainly agree that the government should be providing
a better, more structured form of quality benefits for the
individuals.
Mr. Mitchell. Well, and to comment along with that, most
people are not personally affected----
Ms. Beck. No, sir.
Mr. Mitchell [continuing]. By this war. And very few are.
And we see how affected those that are involved in this area.
And I applaud you for doing that because we need to make people
aware. It is just not a typical war.
It has been said before by the first panel that it looks
like they are dealing with a government organization or the VA
that is not aware. Times have changed. It is a different war,
different wounds, different conditions, and that we need to
catch up.
And I applaud your organizations because at least I gather
that you are trying to do that very thing, to really turn
things around and come up to speed with today's war and today's
needs.
Mr. Bowers. Just to add on that, Meredith mentioned
something that we are doing actually with IAVA is communication
is key to let individuals know what resources are available not
only through the VA or DoD but also what other veterans service
organizations are there to help.
And we have partnered with the Ad Council on a 3-year
campaign that is going to communicate to the American public to
let them know what services are available and also to
destigmatize, and I emphasize this, to destigmatize the stigma
related to servicemembers seeking mental health treatment.
Mr. Mitchell. Absolutely.
Mr. Bowers. Until that is broken, we are really going to
have a hard time getting people to step into the doors to
receive the treatment they need. And we are hoping that this
campaign will be a good way to do that.
Mr. Mitchell. Absolutely. And you all are doing a very
admirable job. And it is unfortunate. I have heard from hearing
after hearing where the veterans do not know what is available.
Unless they know the right questions to ask, they do not know
what is available.
And I understand that is what you all are doing is
reminding people what is available and how to ask the questions
and how to access what it is that they should have because the
government is not doing that. They are not telling everyone
what they should get.
Ms. Beck. The government tends to be in its own stovepipe
essentially. So it is not only DoD and VA. DoD and VA, you
know, for the most part recognize that there is a problem here
and they are working on fixing it and they have got a ways to
go, but they are working on it.
These guys, they do not just have to deal with the DoD and
VA, especially as the most severely injured. You have Medicare,
Social Security Disability Insurance, the Department of Labor,
the Department of Education, all of those agencies right in a
row, and any one of them is difficult to navigate much less
seven or eight of them as a severely injured servicemember or a
19-year-old spouse.
Mr. Mitchell. And I appreciate the fact that you are saying
the VA recognizes they need to change. But, you know, that is
in the long run. In the short run, you know, there are the
Wades, the Owens. There are 19-year-old mothers. They have to
live every day. And it is great that they see that they need to
turn the ship around, but we have got people who are living
right now. And that is who we need to take care of.
Ms. Beck. Which is why it is so important, sir, that when
we are creating--there is a common misperception out there that
people like the Wades and Casey who were injured a little while
ago that all of their problems are fixed now because they were
injured a while ago. But it is so important that as we put
these new policies and programs into place that we are reaching
back to those families who came before and making sure that
they are taken care of because they are the reason those
programs were created in the first place. So that is of the
utmost importance to the Wounded Warrior Project is to find
those families who came before.
Mr. Mitchell. And just one last comment before I turn it
over. Mr. Bowers talked about the need for bringing services
out to the rural areas. It is a different kind of war. As you
mentioned, it is not a draft. So most of the recruits are
coming from rural areas and this is where the need is going to
be.
So instead of maybe in past wars where you can locate in
large urban areas, the recruits, the needs are coming from
different areas. And I think that is something that the VA
needs to recognize.
Mr. Bowers. It is. And I would also add to that that it is
very important to know that rural veterans do not necessarily
have access to the Internet. So as we often hear that, well, we
can put together a Web site and an outreach element, that is
very effective for most, but only 8 percent of this country's
rural areas have access to broadband.
You also have issues with individuals who have traumatic
brain injury or post traumatic stress disorder. It is going to
be extremely difficult for them to try and rely on a Web site
to find answers. You know, that is something that we have
always said there needs to be that direct contact.
And specifically at my Reserve center last weekend, we
actually had the VA there. They were there to register every
single Marine there. We also met with folks from the Vet
Centers. There were six individuals there and we also completed
an electronic version of our post-deployment health
reassessment form. It was textbook. It was exactly what we
needed to start doing the second these conflicts began and when
troops started returning home.
But there has been a long period of time since then and a
lot of people have fallen through that gap. And the biggest
takeaway was that it was not mandated. It was just my unit
being proactive and saying we need to make sure our Marines get
this. It is not a mandate by any way, shape, or form.
Ms. Beck. Sir, Sarah will come after me if I do not point
out that, yes, the rural veterans are certainly in need of the
aspects. But what Sarah would point out and I will speak for
her is that they were from Chapel Hill, North Carolina. They
were in the heart of the research triangle and because of the
way benefits were configured, they did not have access to the
places they need to be. So that is also a concern.
Mr. Mitchell. Thank you.
Ms. Brown-Waite.
Ms. Brown-Waite. Thank you. Thank you, Mr. Chairman.
Mr. Bowers, when I read your biography, it was one of those
moments when you say ``wow.'' Thank you so much for your
service as a Marine and for your two voluntary tours in Iraq.
Mr. Bowers. Another one coming up in January, too, so I
will miss you guys.
Ms. Brown-Waite. Please stay in touch by the Internet. You
heard me before say about the importance of staying in touch
with your Member of Congress.
I congratulate you on your award for the Purple Heart. You
know, it is amazing that the sniper round hit your rifle scope.
You know, we can only hope that you, too, had him in the scope
of your rifle.
You had indicated that your organization has about 80,000
active members.
Mr. Bowers. Yes, ma'am.
Ms. Brown-Waite. Could you tell us how many of the
approximately 80,000 active members would fall in the category
of today's hearing, just a percentage, and can you give us any
specific complaints, shortfalls, or perhaps unaddressed issues
that we have not touched on today? In other words, people and
issues that kind of fall through the cracks.
Mr. Bowers. I would say that of our membership, we have
relatively low numbers of individuals who deal with polytrauma
centers and who have been injured. With that said, I spend a
lot of time up at Walter Reed and Bethesda just hearing from
the servicemembers and finding out what their difficulties are.
The biggest thing that I have come across is the lack of
support for families. I would say that is the number one thing
that we have heard from folks at a lot of different levels.
Many times with families, and Ms. Wade was right on with this,
you know, she is, you know, bearing the brunt of a lot of the
lack of support networks and things for these wounded
servicemembers. And that is probably the biggest thing I have
heard across the board there.
Ms. Brown-Waite. Have you heard of any of the other
polytrauma units actually hiring the spouse to work in the VA
hospital? I know that down in Tampa in Haley Hospital, they
actually do that. Is that happening around the country in the
other polytrauma units?
Mr. Bowers. I have not heard of any cases. I have heard of
one case where someone was offered a job, but the polytrauma
center was 4 hours away, so they could not facilitate the move.
Ms. Brown-Waite. This actually was a family that moved to
Tampa to be close to the servicemember while he was being
treated there. And I thought that is wonderful. We should
encourage that. You know, if they want to work or if they need
to work, that is a great way to provide families support and
have that person right there in the hospital.
Ms. Beck. Ma'am, if I could, one of the primary objectives
of the Wounded Warrior Project, we do not have members, but
that is our sole base is attempting to have caregivers
compensated for the work that they are doing.
The VA actually already has this program for spinal cord
injury patients. And they train, certify, and make eligible for
compensation those family caregivers.
In many cases, I know that it may not be the most ideal
situation for the family member to be providing that care, but
they are doing it anyway.
So what we would ask is that through those programs,
looking at that San Diego VA where they provide that service,
looking at replicating that especially for the most severely
injured, brain injured servicemembers where their families are
often leaving their jobs and providing that care really and
suffering from extreme financial distress from doing so.
Ms. Brown-Waite. Do you have an estimate of how much the
proposed respite care pilot program would cost the VA?
Ms. Beck. I do not have an overall estimate. I would say
that since it would be done with the universities and the
students would be not paid, they would be getting course credit
for doing that, it would really be a cost of organizing and
coordinating, not necessarily the payment process for providing
that service.
Ms. Brown-Waite. We are having the Blackberries going off
and it is not to be rude, but we have to have them on so we
know when once again we will be called to the floor.
Do you have any additional suggestions that you did not
include in your testimony?
Ms. Beck. Gosh, I could go on forever, but I will not.
Really I think Todd hit the nail on the head with the
family aspect of this, including the families in the care
aspect of it, and also understanding that without the families,
the VA would be in a lot of trouble, and that we rely on them
tremendously. And for that aspect, the issue of coordination
among the agencies which I know is something that we have
talked about before, but it is of utmost importance.
I had someone from the Department of Defense, from TRICARE
tell me, we were trying to resolve a very complex issue that
faces these servicemembers about their eligibility for Medicare
and TRICARE, and her response was what do you want me to do,
hand walk these guys through the process. That was my answer.
So, yes, yes, actually. Then we solved the problem.
Ms. Brown-Waite. That is that person's job?
Ms. Beck. The awareness factor here is tremendous and
promoting that awareness of what these servicemembers do and
how the families are suffering should not be borne by only
those people who happen to be either interested in or happen to
be suffering from it. So the increased awareness from Members
of Congress, their staff, down to every citizen in the United
States is absolutely imperative.
Mr. Bowers. One portion that I did not include in my
testimony, but I would point the Subcommittee toward, the
Independent Budget makes a lot of comments in regards to
nursing home care. A tremendous amount of veterans are coming
home and having to rely on nursing home care because of the
increased amount of traumatic brain injuries that we have seen
in the wars in Iraq and Afghanistan.
What we have heard from our membership and from personal
stories from individuals is that it is hard to be a 22- and 25-
year-old in a nursing home, in a VA nursing home. There is not
a lot going on for these younger veterans and they are still
young, vibrant individuals who still have their entire lives to
look forward to. And the resources are not necessarily made
available to them to be able to continue to better themselves.
And whether it be educational resources, social activities,
things along those lines, there is a gap for a lot of those
folks that are at the nursing homes. And there has also been
some discrepancies that the Independent Budget also identifies
that there has been a shortage of beds within these nursing
homes also.
Ms. Brown-Waite. I know that there is a program of assisted
living where the person truly just needs some assistance. Do we
need to focus more resources on that? And I happen to
personally agree with you. I come from Florida. I know that the
majority of people in nursing homes in Florida are elderly. And
there is a great divide there and a lack of common interest
even. And so is the answer more assisted living facilities and
specific nursing homes for OIF/OEF returning warriors?
Ms. Beck. I think we need to be careful, however, because
we do have an opportunity here because this is a smaller
population. But if we build these large facilities just for
OEF/OIF servicemembers, then their families will have to travel
to those facilities because there just are not enough of them,
of a need there.
So building a facility is maybe one option, but I think
that looking at the options of, you know, thinking outside the
box here. We have individuals with individual needs. We should
take this as an opportunity that we have of such a small
population and perhaps leverage community resources and
leverage those things that are already there to be able to
provide the best care and nursing home care near these people's
homes.
Ms. Brown-Waite. Do you think that the veteran population
would resist perhaps, especially in rural areas, a contract
with a service provider of respite care, of physical therapy? I
mean, we want to make sure the services come to the veteran who
needs them.
Mr. Bowers. I would definitely stand by that individuals
when given the choice whether they need to stay at a nursing
home or be at home with assisted living will much rather be at
home with assisted living. It allows them to be out involved
more with the community. So I would say yes to that.
If they do require a nursing home, if they do not have the
family support and, therefore, they do have to live in a
nursing home, those steps to make it easier for these
individuals would be much more effective.
But I would agree with Meredith that by going out and
developing centers specifically for OIF/OEF veterans may be a
bit much. We need to think long term.
And, you know, just speaking with my Marines, we know the
Global War on Terrorism is never going to end. So we have got a
lot of work to do.
Ms. Brown-Waite. Please thank your Marines for us and thank
you for again going back and thank you for your service.
And, Ms. Beck, thank you for all that you do.
I yield back.
Mr. Mitchell. Thank you.
And thank you very much.
I would like at this time to welcome panel three and I am
probably going to mess your name up. I am sorry. Dr. Madhulika.
Dr. Agarwal. Madhulika Agarwal.
Mr. Mitchell. Agarwal. Thank you. Is the Chief Patient Care
Services Officer for the Veterans Health Administration (VHA).
We look forward to hearing from her and her team.
Let me just say before you start, and I appreciate you
being here and I know that you are also a messenger, and
hopefully what you heard today, what we all heard today brings
some results and some fruits because it is just frustrating
when we hear these things and we write it down and it is just
another report somewhere.
You have heard today real needs and real concerns. And I
suspect that you are in a position to do something about it, at
least we hope so. Thank you.
STATEMENT OF MAHDULIKA AGARWAL, M.D., MPH, CHIEF OFFICER,
PATIENT CARE SERVICES, VETERANS HEALTH ADMINISTRATION, U.S.
DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY KRISTIN DAY,
LCSW, CHIEF CONSULTANT, CARE MANAGEMENT AND SOCIAL WORK
SERVICE, OFFICE OF PATIENT CARE SERVICES, VETERANS HEALTH
ADMINISTRATION; AND LUCILLE BECK, PH.D., CHIEF CONSULTANT,
REHABILITATION SERVICES AND, PROGRAM DIRECTOR FOR AUDIOLOGY AND
SPEECH PATHOLOGY PROGRAM, OFFICE OF PATIENT CARE SERVICES,
VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF VETERANS
AFFAIRS
Dr. Agarwal. Thank you.
Good afternoon, Mr. Chairman and distinguished Members of
the Subcommittee. Thank you for the opportunity to testify
before you on the Department of Veterans Affairs care for
seriously wounded veterans after they complete their inpatient
care.
I am accompanied by Dr. Lucille Beck on my right, who is
the Chief Consultant for Rehabilitation Services, and Ms.
Kristen Day on my left, who is the Chief Consultant, Care
Management and Social Work Services.
I would like to request that my written statement be
submitted for the record.
Mr. Mitchell. Yes, it will.
Dr. Agarwal. Thank you.
With your permission, sir, before I begin my oral
testimony, I would like to thank Corporal Owens, Sergeant Wade,
and Ms. Wade. As you said earlier, they have tremendous courage
and enormous resilience. I want to thank them for their
sacrifice and for their service to our country.
We have heard your story and with your input and your
support, we will continue to work every day to enhance and
improve our healthcare system.
VA is committed to providing the scope of services that
ensure a continuum of world-class care, which extends from
acute rehabilitation to vocational and community reentry
programs for all veterans at locations closer to their home and
communities.
In May 2007, VA expanded the case management program for
OEF/OIF veterans in response to the President's Commission on
Care for America's Returning Wounded Warriors.
VHA and the Veterans Benefits Administration (VBA)
established new procedures for the transition of care,
coordination of services, and case management of the OEF/OIF
veterans.
This program represents an integrated team approach located
in VA medical centers. Now the OEF/OIF veterans are screened
for case management needs and those with severe injuries are
automatically provided a case manager. Additionally, any
veteran who requests a case manager is also provided one.
VA provides clinical rehabilitative services in several
specialized areas that employ the latest technology and
procedures to provide our veterans with the best available care
and access to rehabilitation for polytrauma and traumatic brain
injury, spinal cord injury, visual impairment, mental health,
and other areas.
In October 2007, as recommended by the Dole-Shalala
Commission, we have partnered with DoD to establish the Joint
VA/DoD Federal Recovery Coordination Program. The Federal
Recovery Coordinator, or the FRC, is intended to serve all
seriously injured servicemembers and veterans regardless of
where they receive their care and has the unique authority to
navigate within and between the VA, DoD, and the private
sector.
These newly established FRCs will collaborate with VA
medical centers, military treatment facilities, and private-
sector treatment teams during recovery and rehabilitation phase
to ensure that veterans receive the right services at the right
time.
VA is committed to providing key services to assist
caregivers with case management service coordination and
support for the veteran, as well as education on how to obtain
community resources such as legal assistance, financial
support, and housing assistance.
Eight caregiver assistance pilot programs were awarded
grants in October 2007 to explore options, providing support
services for caregivers in areas across the country, especially
in areas where few such options are available.
In February 2008, VA's Under Secretary for Health approved
funding to enhance programs that provide specialized support
and care in home and communities that facilitate the transition
and support of seriously injured veterans.
These programs include the Volunteer Respite Program which
will create access to the needed home respite services for
family caregivers, and the Medical Foster Home Program which
provides an in-home alternative to nursing home care, merging
personal care in a private home with medical and rehabilitation
support from specialized VA home care programs.
These programs will aid seriously injured veterans living
in their own homes and those who are no longer able to live
independently, but prefer an in home alternative within their
community.
Moreover, in compliance with the 2008 ``National Defense
Authorization Act,'' VA is collaborating with the Defense and
Veterans Brain Injury Center to design and execute a 5-year
pilot program to assess the effectiveness of providing assisted
living services to eligible veterans to enhance their
rehabilitation, quality of life, and community reintegration.
VA is providing outreach both locally and nationally to
veterans and servicemembers. This begins with a letter from the
Secretary of Veterans Affairs providing information about
healthcare and other benefits while thanking them for their
services and welcoming them home.
VA works with the DoD in implementing the post-deployment
health reassessment and among National Guard and Reserve
component.
Additionally, VA established a national polytrauma Web site
and a polytrauma call center. The call center is available 24
hours a day, 7 days a week for families and patients for
questions about care as well a polytrauma system of care. This
center is staffed by healthcare professionals.
We are honored to provide care and service to America's
veterans. VA has the unique privilege of having a lifelong
commitment to those who have borne the battle in service to our
country.
For those who return from combat with serious injuries or
illness, we work closely with DoD to ensure a continuum of
care, but we also work with those who do not need immediate
care to make it as accessible as possible.
Thank you again for the opportunity to testify before you
and for your input. I will be happy to address your questions
at this time.
[The prepared statement of Dr. Agarwal appears on p. 57.]
Mr. Mitchell. Thank you very much.
There is a couple of things that I heard about the programs
you had and I think you heard some response by the first panel
about some of the programs.
And Web sites may be good, but what are we doing about
individualizing, people who do not access the Web sites, people
who cannot access the Web sites, people who cannot because they
do not know how, or they are not connected with the internet?
You know, one of the things that I think, and I want to say
this in general, because as we listen to these individuals, and
this is a different war with different injuries, you are going
to have a much different clientele than the VA is used to
having.
We heard even from the last panel about young veterans
being in care centers, 24-year-olds, 25-year-olds. There is a
difference. And I think that someone needs to recognize the
difference and also the fact that it is great for the long term
that we are changing the VA.
But, again, these people are living right now and these
people need services now. They need respite care now. They need
people to guide them through now. And it is great to have long-
term vision and do this, but I am concerned about what is
happening right now.
One of the things that I have been concerned about since
the very beginning is the records and tracking the records. And
I hope that you will be able to get the records that were asked
for in the very first panel.
And I am going to ask you again to get those records and we
are going to check back that all the complete records that
these people deserve and should have, are received. And if you
would afterward find out how to contact them so they can get
their records.
Dr. Agarwal. Yes, sir.
Mr. Mitchell. The other thing that is important, and I
think you recognize this by listening to these people, that
total care is a family thing and that if families do not get
the help, and we heard earlier and in the very first panel
where a 19-year-old mother finally just gave up and left. This
is what we are dealing with. It is not just the soldiers.
In fact, when I went to Iraq, we heard from the military
people at that time that because this is an all-volunteer Army
and all-volunteer service now, they are recruiting families. It
is not just the soldier. So the families are a very important
part of the total service and, therefore, the families should
be treated in the same way that the individual servicemember is
treated.
One of the things that is important, and I knew this from
being a government teacher and involved with all levels of
government, you know, it is important to have a trust in
government. And sometimes the only government agency, wherever
it is, whatever level, that a person goes to gives them an
attitude about the whole government in general. And I am not
talking local or State. All of them.
And it sounds to me from the very first panel that Corporal
Owens just gave up. He did not trust the VA anymore. He went to
private providers. This is horrible. And how do we get people
to continue to volunteer not only for the military, but in
government service in general if they lose trust because it is
too much trouble, it is too big, they do not take care of their
needs?
And you are an important part of helping build trust in
government because I do not know of anyone, and you have heard
this up here, who does not believe that these soldiers, deserve
the very best. They are giving up more than the general public
because this is a volunteer Army.
The other thing I want to mention that there was an office,
the Office of Seamless Transition that was created and it was
supposed to be a point of contact between the veterans and the
DoD. And this office was disbanded almost immediately after it
was implemented.
And we continually talk about a seamless transition from
the DoD to VA. I want to ask if you know why this office was
disbanded and why we have not been working toward a seamless
transition?
Dr. Agarwal. I am sorry if I may answer the last question.
We do have seamless transition processes currently in the
Central Office. And, in fact, Kristen Day's office in the
Office of Patient Care Services has assumed a large part of
that responsibility of working with the DoD as well as working
within our own system in the VA.
Mr. Mitchell. So you are saying that the Office of Seamless
Transition is in effect, it is there, or is it just individual
departments within the VA that are trying to bring about a
seamless transition?
Dr. Agarwal. I----
Mr. Mitchell. If you do not know, that is okay. But I would
like if you would check into it and get back to us.
Dr. Agarwal. I will check into it and get back to you.
Mr. Mitchell. What happened to this office? What has
happened to making sure----
Dr. Agarwal. Sure. I will do that.
Mr. Mitchell [continuing]. That there is a seamless
transition?
Dr. Agarwal. Yes.
[The following information from VA was subsequently
received:]
Question: Why was the Office of Seamless Transition
dissolved? Who has taken on their responsibilities?
Answer: The Office of Seamless Transition is not dissolved;
rather, it is reorganized to best allow for the operation and
management of the component parts. The component parts evolved
as the mission expanded, and the logical placement of the work
became evident. The Office of Seamless Transition has
transitioned into the following three categories: clinical,
outreach and policy.
Care Management and Social Work Services (Care Management) is
responsible for the clinical component. Care Management works
closely with Polytrauma, Rehabilitation, Social Work, and
Mental Health Services. These program offices are all under the
single VHA organizational structure of Patient Care Services.
Military liaisons, VBA and our internal social work and nursing
staff members are responsible for patient issues.
This new office's missions are to coordinate patients' health
care and to partner with VBA in meeting their benefits needs.
OEF/OIF coordinators at each VA medical center and benefits
office coordinate with DoD discharge staff to facilitate a
continuum of care and services at locations nearest the
veteran's residence after their military discharge. This
coordination allows enhanced identification of these veterans
at their local VA facilities for processing of benefits claims
and continuity of medical care.
VA/DoD Coordination is responsible for the VHA OEF/OIF
outreach component. This component works with the Reserve and
National Guard and closely with DoD. For example, starting in
May 2008, VA/DoD Coordination began making phone calls to
17,000 veterans who may have a need for care management, and to
550,000 separating Guard/Reserve veterans who may not be aware
of the VA health care system. VA/DoD Coordination also
coordinates efforts with Reserve and National Guard Units on
DoD's Post-Deployment Health Reassessment (PDHRA) Initiative.
During the period November 2005 thru May 2008, Vet Centers
staff have supported over 1,400 PDHRA On-Site and Call Center
Unit level events along with DoD's 24/7 PDHRA Call Center.
These Reserve and National Guard PDHRA activities have
generated over 60,000 referrals to VA Medical Centers and Vet
Centers.
The OEF/OIF Policy Coordination Office is responsible for the
policy component. The Executive Director and staff serve the
Under Secretary for Health in a special assistant role created
to address the numerous Commission, Task Force and report
recommendations that have come out in the past year. The Policy
Coordination Office works with several offices, departments and
agencies within and outside of VHA to facilitate changes. The
office also serves as the Under Secretary for Health's daily
contact point for Senior Oversight Committee (SOC) activities.
Mr. Mitchell. And one last question before I turn it over.
The Federal Recovery Coordinators, what kind of benefits will
they provide? Are they going to be able to provide not only
medical benefits and information but also the general benefits
that every veteran is entitled to?
Dr. Agarwal. Sir, they are the overarching coordinators and
so, therefore, they will have the ability and the authority to
oversee all benefits.
Mr. Mitchell. Not only medical----
Dr. Agarwal. Not just healthcare----
Mr. Mitchell [continuing]. But all the benefits.
Dr. Agarwal [continuing]. But all, yes, sir.
Mr. Mitchell. We are talking about GI Bill, everything.
Dr. Agarwal. Yes, sir.
Mr. Mitchell. Thank you.
Ms. Brown-Waite.
Ms. Brown-Waite. Thank you.
And as you can tell, we have votes that have started.
Doctor, why are the VHA and VBA just now jointly developing
a comprehensive list of severely injured OEF/OIF veterans? Is
this not something that should have been done all along, that
the Department should have been tracking?
Dr. Agarwal. Thank you for that question, ma'am.
Yes, they have been tracking. But I think they are working
on the proper requirements and the definitions in that list.
There is such a list that exists at this point in time between
the two departments and we are further refining it.
Ms. Brown-Waite. When did the list start to be created?
Dr. Agarwal. In fact, very soon, we have an initiative in
place which is going to work toward outreaching for all those
that were mentioned earlier who may not have come into our
system, to have the telephone contact so that we can then
connect them to our OEF/OIF case management programs as well as
to the right kinds of individuals in our own healthcare system.
Ms. Brown-Waite. Let me make sure I understand what you
said because I do not think you answered my question. How long
ago did you start this list?
Dr. Agarwal. Ma'am, I will have to take that for the record
and get back to you. I do not know when we started this list.
[The following information from VA was subsequently
received:]
Question: Why are VHA and VBA only now tracking seriously
injured (SI) veterans? When did this process start?
Answer: The Department of Veterans Affairs (VA) began
tracking seriously injured veterans in 2003 by placing VA
Liaisons for Health Care and benefits counselors at those
military treatment facilities serving as key medical centers
for seriously wounded returning troops. VA experimented with
organizing this data several different ways, but found earlier
versions were not sufficiently responsive to clinical and care
management needs. VA is now working with the Department of
Defense to consolidate data into a single, comprehensive list.
VHA's Care Management and Social Work Service, in
collaboration with VBA, is overseeing the development of a VA
national list of severely injured patients from Operation
Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF)
treated in VA's health care system. This national VA list
integrates information across programs and includes patients
receiving VA care management within the following programs: (1)
Spinal Cord Injury, (2) Polytrauma, (3) Visual Impairment, and
(4) Amputation. Each list also identifies Care Managers in
these program areas, the VBA regional office of jurisdiction,
and the OEF/OIF Coordinator responsible for case managing the
servicemember or veteran's claims.
VA also developed a Web-based system that will identify care
managers, by name, across the VA system for patients whose care
falls into the four categories mentioned above. Additional
features were built into this online system to identify care
management follow-up timeframes and issues identified in the
care management process. VA implemented the application on
April 29, 2008.
VA staff gathers critical information about servicemembers
medically evacuated from the war zones in and around Iraq and
Afghanistan shortly after their arrival at military treatment
facilities in the United States. Additionally, VA medical
centers and Regional Offices established local teams to provide
benefits, services, and track care management locally
throughout their program areas. In April 2007, VA implemented
the Veterans Tracking Application (VTA), a modified version of
the DoD Joint Patient Tracking Application (JPTA) that tracks
the movement of medically evacuated servicemembers, and their
medical information, from the theater of operations to MTFs.
VTA merged information from existing spreadsheets and other
programs to form one Web-based system that allows users from
different locations to access real-time information about the
servicemembers and veterans we serve.
Not all servicemembers or veterans transition from an MTF to
a VA medical center. The newly created Federal Recovery
Coordination Program identifies these individuals and assists
in coordinating their care as required.
Ms. Brown-Waite. A ballpark. Last year, last 2 years,
last----
Dr. Agarwal. I am going to ask Kristen Day.
Ms. Day. The original Office of Seamless Transition began
consolidating information and the list, I believe, in
approximately 2005. The clinical care of those individuals are
consolidated in the new Office of Care Management and Social
Work.
And the coordination, we have VBA representatives in our
office. We have DoD representatives in our office. And we are
refining and building a list that is more comprehensive and has
more data elements attached to it. So the list has been in
existence for several years, but we are implementing a strategy
that will go beyond a list and identify the single point of
contact case manager, the current needs, and the current
status.
Ms. Brown-Waite. Okay. So it is a refined list is what I
think I am hearing you say?
Ms. Day. Yes, ma'am.
Ms. Brown-Waite. Okay. Doctor, in your testimony, you
mentioned medical foster homes and volunteer respite services.
We unfortunately have found that many times when you have
volunteers that their intentions are not always what we would
hope that they would be.
What kind of screening procedure do you have or plan on
having? What kind of background checks are you going to be
doing for these volunteers to protect the obvious wounded
military person?
Dr. Agarwal. Yes, ma'am. Thank you for that question.
May I just address the issue of the medical foster homes?
This program has been in effect for several years at this point
in time. It actually started in Arkansas and has been scaled to
some other areas and has also been used in a pilot program
setting with the spinal cord injury and disease programs. It
has proven to be remarkably successful with seemingly high
satisfaction rates much to the surprise of our own staff as
well as, of course, the families and the veterans.
So there is fairly intense screening that goes on before
the veterans are placed in these settings, which includes home
inspections, which includes regular visits, which includes all
kinds of background checks, as well as constant vigilance. This
is a medical foster home, so the individuals who are placed in
these settings are also followed by our home-based primary care
teams or the spinal cord injury and home care teams.
And that is what is envisioned for the traumatic brain
injury program at this moment.
Ms. Brown-Waite. So I want to make sure that I fully
understand what your plans are. You are going to have extensive
background checks done on the volunteer respite program?
Dr. Agarwal. Ma'am, let me confirm the extensive piece of
it, but I know that for----
Ms. Brown-Waite. Doctor, I am sorry. I did not mean to be
disrespectful. If you do not do criminal checks, that is
criminal.
Dr. Agarwal. I agree with you.
[The following information from VA was subsequently
received:]
Question: Please describe the background checks VA performs
on volunteers in the Medical Foster Home and Volunteer Respite
programs, as well as any other programs where volunteers
provide in-home assistance to veterans.
Answer: Volunteers who have home respite assignments require
a Special Agreement Check (SAC) for fingerprints, which serves
as a criminal background check. Volunteers are also checked
against the List of Excluded Individuals & Entities (LEIE)
database and the Healthcare Integrity and Protection Data Bank
(HIPDB), both of which are administered by the Department of
Health and Human Services (HHS).
VA's Medical Foster Home Program follows Federal Regulations
for Community Residential Care (38 CFR 17.61 to 17.72). The
home caregivers or sponsors are not volunteers, as they are
paid by the veteran. VA is revising Community Residential Care
regulations to clarify that Federal or State criminal
background checks are required to participate in VA's Community
Residential Care programs. Currently, VA follows State
regulations regarding mandated background checks.
All VISNs and VA facilities accept and process volunteers
according to the same standardized procedures outlined in the
VHA Handbook 1620.01, ``Voluntary Service Procedures,'' and the
memorandum titled ``Acceptance Requirements for VA Volunteers''
from the Deputy Under Secretary for Operations and Management
(10N), dated February 22, 2007. This handbook and the
memorandum are attached.
[The VHA Handbook 1620.01, ``Voluntary Service Procedures''
will be retained in the Committee files.]
[The Memorandum entitled, ``Acceptance Requirements for VA
Volunteers'' from the Deputy Under Secretary for Operations and
Management (10N), dated February 22, 2007, appears on p. 63.]
Ms. Brown-Waite. Mr. Chairman, I yield back.
Mr. Mitchell. Thank you.
Again, we are going to wrap up because we have had all the
panels, but I just want to emphasize that I hope that you get
the records for Corporal Owens and for Sergeant Wade, the
medical records that they have been asking for since their
injuries and get them to them.
[The following information from VA was subsequently
received:]
The FRC provided hard copies of the results to Mr. and Mrs.
Wade during their face-to-face meeting on March 6, 2008.
Corporal Owens confirmed the receipt of his records on April
25. Additional information was provided to the Subcommittee,
which will be retained in the Committee files.
Mr. Mitchell. Thank you very much----
Dr. Agarwal. Thank you.
Mr. Mitchell [continuing]. For being here. And I want to
thank all our witnesses and thank you all again for something
that is very important to all of us.
Thank you. This Committee is adjourned.
[Whereupon, at 1:00 p.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
We are here today to hear from veterans, their families, and the
Department of Veterans Affairs about the long-term care of our most
severely wounded Afghanistan and Iraq veterans. We know that DoD and VA
provide the excellent inpatient healthcare for these warriors. But many
of the most seriously injured require extensive outpatient care, some
of them for life. Their families need care and assistance as well.
Unfortunately, once these veterans leave the hospital, the care they
receive does not seem to be on par with what they received directly
following their injury. I think we can do better.
Planning for veterans' healthcare was not planned very well at the
outset of this war. The need to provide care and assistance to wounded
servicemembers, and their families, in significant number and for the
long term has been largely ignored. We will hear today what it has been
like for some of them. Their stories are inspiring but also
discouraging. They are inspiring because--even after they have suffered
terrible injuries--they carry no bitterness, only pride from their
service. Discouraging because they have been left to fend for
themselves for too long.
The Department of Defense and the VA are large organizations with
an overwhelming bureaucracy. Their care and services often overlap in
messy and unpredictable ways. At a time of enormous stress, this
bureaucracy only hurts the injured warrior and his family
When our troops return from theater with serious injuries, they are
met with a dozen seemingly unrelated people with different services. We
addressed much of these problems last year with the passage of the
Dignity for Wounded Warriors bill. But there is obviously still more to
be done.
We need to realize that families are an integral part of treatment
and recovery, and have their own needs. Unfortunately, the VA is
restricted from providing the many services families need and deserve
when their sons, daughters, siblings, and parents return with service-
connected injuries.
We have been playing catch-up since the beginning of this war. It
is irresponsible that the only support structure available to the 19
year old wife of an injured soldier is the wife of a similarly injured
soldier.
We are going to hear from people that have been dealing with the
difficulties of the system for a long time. On February 14, 2004 Army
Sergeant Ted Wade lost his right arm and suffered severed traumatic
brain injury, along with many other injuries, in an IED explosion in
Iraq. Sgt. Wade is here today with his wife, Sarah.
Marine Corporal Casey Owens of Houston, Texas lost both his legs
when his unarmored Humveee struck a landmine in Iraq on September 20,
2004. Corporal Owens and Mrs. Wade will tell us about the frustrations
and difficulties they have faced, and we look forward to their
testimony.
Sarah and Ted Wade have devoted themselves to helping hundreds of
other injured servicemembers and their families. And just 2 weeks after
he was injured, Casey Owens told his family that he wanted a camcorder
so he could document his progress from start to finish. He could only
communicate by writing at the time of his request. He wanted to show
his future children how far he had come and how good he'd had it.
Today, you can find Casey gliding down the slopes at Aspen. We owe
Corporal Owens and Sergeant Wade a great debt. We cannot repay that
debt, but we can make sure that Corporal Owens and Sergeant Wade, their
families, and everyone like them, get long-term care and services that
are also world class.
Prepared Statement of Hon. Nick Lampson
a Representative in Congress from the State of Texas
Thank you, Chairman Mitchell and Ranking Member Brown-Waite for
inviting me to today's hearing. I am honored to join you on this
distinguished Subcommittee and am proud to introduce Corporal Casey
Owens of Missouri City, Texas. Casey is an exemplary young man, and I
commend him for his willingness to continue to serve his country and
his fellow veterans.
I was impressed when we met yesterday for the first time by all of
his accomplishments. A graduate of Mayde Creek High School, he went on
to the University of Texas. But following the attacks on September 11,
he decided to join the Marines. He was deployed twice--the first time
from February 2003 to October 2003 and the second time from August 2004
until September 20, 2004 when he sustained his injuries. During his
time in the Marine Corps he received several medals in recognition of
his distinguished service.
Less than a year after sustaining his injuries, Casey successfully
completed the Marine Corps Marathon in 2005 using a hand-cranked wheel
chair with a time of approximately 2\1/2\ hours--probably better than
any of us here. He is currently training as a member of a competitive
ski team in Colorado that has been recognized by the Paralympics and
the VA as an official training center.
Even more impressive than these accomplishments, in my opinion, is
Casey's advocacy for veterans' care. He has worked with Mayor Bill
White's Veterans Task Force, which was established last year to address
the needs of Houston's veterans, both young and old, when it comes to
housing, health and mental care, job training, and other issues. And he
has come here today, to testify before Congress about the challenges
new veterans in this country continue to face as they transition from
DoD to the VA system and try to navigate it.
Most impressive, though is the concern for his fellow veterans and
those that will come after him. He is here today to ensure that our
Nation's future wounded warriors will not go through the same
frustrations and feelings of neglect that he and his friends have
experienced as the DoD and VA have struggled to adapt to a new breed of
patients. They deserve much more in return for their service, and I
commend Casey for his advocacy on their behalf.
__________
Thank you again, Chairman Mitchell and Ranking Member Brown-Waite
for allowing me to join the Subcommittee today for this hearing. As a
Representative from a State with of one of the Nation's largest
veterans' populations, I sincerely appreciate your invitation, and
would like to commend your leadership and the entire Committee for your
commitment to all of our Nation's veterans. I am especially pleased to
be here to listen to the testimony of my constituent, Casey Owens, as
well as the other witnesses.
Care for veterans such as Edward Wade and Casey Owens was by trial
and error, as there was no system of care in place for these new types
of injuries--both external and internal. Casey expressed to me his
worry that there are still issues with care for polytrauma patients
today. And I was most impressed with his concern for those who will
come after them and his hope that they will not come to Congress with
the same exact issues, complications, and frustrations as we are
hearing today. I am proud that this Congress has taken steps to address
the issues--through record funding levels and new initiatives to
address the injuries of these conflicts--multiple amputations, TBI,
PTSD. The DoD and VA have initiated new, and innovative ways to help
OEF and OIF veterans, but the system is still daunting and adapting to
a new model for care has proven difficult. Casey pointed out however,
that as he has traveled across the country, meeting and competing with
fellow veterans, he has realized and encountered the disparity in care
at VA centers across the country. He also brought up an important point
to me--what are the new caseworkers and nurses doing? How is the new
funding being put to use exactly? What are the results? As we are knee-
deep in the budget season and approach the appropriations process, I
believe these are critical questions that MUST be answered--so that
veterans 2 to 3 years down the line do not come to us with the same
problems. These wounded warriors deserve no less--they truly have made
the ultimate sacrifice for our country and they do not deserve to be
feel that they must jump through hoops--or worse, that they have been
neglected, when they need our help the most.
Over the past couple of years I have heard about the same issues
from veterans across my district--as well as from the testimony we will
hear today: increase options for care, increase coordination between
DoD and VA regarding records and evaluations, increase coordination
between departments of the VA, and the need for more help for families
and caregivers. Last year this Congress approved record funding levels
and other legislation to address these issues--and I am eager to hear
about the progress. As we are continuing to hear about these issues, I
fear we still have a long way to go. The hurdles our soldiers and their
families face should not be so difficult.
Prepared Statement of Corporal Casey A. Owens, USMC (Ret.), Houston, TX
(U.S. Marine Corps Combat Veteran)
I was seriously injured on September 20, 2004 while serving under
1st Battalion 7th Regiment. I was assisting in a
medivac (medical evacuation) to rescue Sgt. Foster Harrington when I
ran over two anti-tank mines, which resulted in the loss of both legs.
Consequently, I also suffered two collapsed lungs, numerous shrapnel
wounds, pulmonary embolism, broken clavicle and jaw, perforated
eardrums, trauma to my head. I was flown to Landstuhl, Germany from a
field hospital in Iraq, and awoke from a coma 3 weeks later in Bethesda
Maryland Naval Hospital. After numerous surgeries to stabilize me, I
was transferred to Walter Reed Army Medical Center and Brooke Medical
Center for my recovery phase. Over the next year and a half, I received
more than sufficient care from these centers.
I was retired February 26, 2006. Shortly thereafter, I had to
return to Brooke Army Medical Center to have my right myodesis repaired
for a second time. I enrolled into the VA on April 1, 2006. I had
transitioned to care under the VA system and was no longer in the
Department of Defense's system. By this time, my right myodesis failed
for a third time. After bringing it to the attention of the VA doctors,
I was instructed to return to Brooke Army Medical Center for treatment.
The doctor had suggested that I undergo the same procedure that I had
the first two times again. I did not approve of their recommendation,
and my objections had fallen on his deaf ear. I returned to the Houston
VA letting them know I was not satisfied.
It was not until 6 months later that the procedure I had requested
and wanted was performed. The two previous surgeries took less than 72
hours to be approved. I decided to call on non-profit organizations for
assistance. Organizations such as Semper Fi Fund, Marine for Life,
Wounded Warriors and other non-government personnel helped me and their
help was colossal. In my opinion, this reflects poorly upon the culture
and decisions of the VA system currently in place. While some of the
problems I have encountered have been resolved, many have not. The
learning curve of VA's system is steep and its bureaucratic maze is
hard to understand. It has been 30 years since the last major war and
what lessons has the VA learned since then? Did no one expect another
war or learn anything from Viet Nam? What have the educated and highly
paid personnel who have been appointed to correct the system been
focusing their attention on? While the system continues to be broken,
where is all the government funding going that is supposed to be fixing
the system and what are they doing with it?
A tremendous problem that I have encountered is the double standard
of the VA and the Department of Defense's claims and rating for
veterans. It took me 3 to 5 months of agonizing appointments and
addendums to finalize my medical board, which were performed by
competent and qualified military and civilian personnel. After I had
completed my medical boards, I thought I was finished with that
process, only to find out I was not. When I enrolled in the VA, it took
almost another year and a half to finalize those claims. It is actions
like this that make veterans avoid the VA. My qualms are not that the
VA does not have enough programs in place to benefit veterans or the
adequacy of it rather, it is the bureaucracy and red tape that are the
problems. While many problems have been addressed, it is time for
SOLUTIONS.
A key solution to solving many problems is establishing an OIF/OEF
Center. Though this idea has been explored by setting up OIF/OEF
coordinators at every VA, it is not enough. There needs to be a
centralized building or group of personnel specifically for them. A
great example for the VA to emulate is something I experienced at
Walter Reed and Brooke Army Medical Centers. There, key staff met
weekly to discuss all aspects of patient care and kept an open line of
communication between departments. For example, Joe Marine does not
show up for physical therapy or his prosthetic appointments. With all
of the departments communicating with one another, a psychologist may
intervene and have some insight as to why he may be avoiding these
appointments. It may be because he is suffering from severe PTSD and
does not want to leave his room. From there, the department heads can
agree on the best course of treatment and can initiate it in a holistic
approach. Another matter I take great issue with, and have experienced
it and continue to do so, is the sharing of medial records between the
Department of Defense and the VA. One solution may be the
implementation of an ID card, similar to that which is in place for
Active duty personnel. Each ID card has a microchip, which could
contain all of their military and medical records accessible by a
computer.
The impression that I get from the VA is that some within the
organization think it is the duty of the veteran to endure and resolve
these problems on their own. Those, like me, who were paid as a Marine
Corp Grunt to do their job to the best of their ability never
questioned whether if we got injured my government would be there for
me. We all knew it would. It is now time for those who are responsible
for the VA to care for those who did their duty.
This is my sworn testimony and I stand by it just as I stand by my
Marine Corp and the job we did in Iraq.
Semper Fi
Cpl. Casey Owens, 1-7 US
Prepared Statement of Sarah Wade, Chapel Hill, NC
on behalf of Sergeant Edward Wade, USA (Ret.)
(U.S. Army Combat Veteran)
Chairman Mitchell, Members of the Subcommittee, thank you for the
opportunity to speak to you today regarding our experiences following
my husband's injuries in Iraq. My name is Sarah Wade. I am the wife of
SGT Edward Wade, or Ted as he prefers to be called.
My husband joined the Army's 82nd Airborne Division
during the summer of 2000, and following the attacks of September 11,
he was called on to serve first in Afghanistan and later Iraq. On
February 14, 2004, his humvee was hit by an Improvised Explosive Device
on a mission in Mahmudiyah. He sustained a very severe traumatic brain
injury, or TBI, his right arm was completely severed above the elbow,
suffered a fractured leg, broken right foot, shrapnel injuries, visual
impairment, complications due to acute anemia, hyperglycemia,
infections, and would later be diagnosed with Post Traumatic Stress
Disorder. He remained in a coma for over 2\1/2\ months, and withdrawal
of life support was considered, but thankfully he pulled through.
As an above elbow amputee with a severe TBI, Ted was one of the
first major explosive blast ``polytrauma'' cases from Operation Iraqi
Freedom, Walter Reed Army Medical Center or the Department of Veterans
Affairs (VA) had to rehabilitate. Much of his treatment was by trial
and error, as there was no model system of care for a patient like Ted,
and there still is no long-term model today. His situation was an
enormous challenge, as Walter Reed was only able to rehabilitate an
amputee, not a TBI, the VA was able to nominally treat a TBI, but not
an above elbow amputee, and neither were staffed to provide appropriate
behavioral health care for a patient with a severe TBI. Because Ted
could not access the necessary services, where and when he needed them,
he suffered a significant setback in 2005, that put him in the hospital
for 2 weeks, and would take a year to rebound from.
Ted has made a remarkable recovery by any standard, because we have
strayed from standardized treatment, and developed a patient-centered
path. I had to educate myself about, and coordinate, additional outside
care. Often, access to the necessary services required intervention
from the highest levels of government, or for us to personally finance
them ourselves. But despite our best efforts, Ted is still unable to
easily receive comprehensive care for all of his major health issues,
due to shortcomings in the current system, and because of the time his
needs demand of me, I have been unable to return to regular work or
school. We have been blessed to have family, with the means to see us
through these difficult times, and help with the expenses. I was
fortunate to have the education, of growing up in Washington, D.C. and
learning about the workings of the various Federal agencies. Our
situation is not typical though.
We have a few ideas, to provide better long-term care, we
respectfully wish to share:
Special Monthly Compensation for Integration, Quality of Life,
Dependents' Educational Assistance, and Respite Care
Individuals like SGT Wade, who require someone to be available for
assistance at all times, are not compensated appropriately. These
Veterans would require residential care otherwise, but are not granted
the higher level of Aid and Attendance, because they do not require
daily healthcare services provided in the home by a person licensed to
perform these services, or someone under regular supervision of a
licensed healthcare professional. We feel the criteria should be
clearly outlined, so appropriate compensation may be granted in the
case of an individual who needs assistance managing care, personal
affairs, or requires support outside of the home, to rehabilitate and
integrate into their community, or to achieve a better quality of life.
Both in the past and at present, we have paid someone to assist Ted
outside of the home. This allows him the flexibility to hire a peer of
his choice, to provide community support, and accompany him on
sightseeing outings he has researched and planned with his therapist as
part of his community integration, to provide transportation to the
store to purchase books for homework assignments, go to the community
center to swim laps, or help him balance his checkbook at the end of
the day. Not only has this enabled Ted to come closer to achieving
independence, but it has greatly improved symptoms of depression by
restoring hope and self confidence, allowed him to attain fitness goals
and control his blood sugar without insulin injections, all while
providing much needed respite care for me. Unfortunately, the current
VA respite programs are not appropriate for a veteran like Ted. With
better resources, I might be able to access the Dependents' Educational
Assistance for which I qualify, but our circumstances do not allow me
to take advantage of, before the benefits expire. This would not only
help me get back to having a life of my own, but raise Ted's standard
of living as well, by increasing my earning capacity.
Compensated Work Therapy (CWT) for TBI
Largely due to the success of the program we have created for Ted,
the next phase of his recovery will probably include some sort of
vocational rehabilitation. He has already had the opportunity to
participate in volunteer work, through counseling and job coaching
provided by a private practice near our home, where he attends a day
treatment program for behavioral health and TBI. Now he is ready for
the next stepping stone to employment. The current Department of
Veterans Affairs Vocational Rehabilitation and Employment Service is
more of a challenge than is healthy for someone with the significant
cognitive deficits and the emotional needs Ted has. VA work therapy
programs, while developing work tolerances and promoting effective
social skills for the more seriously impaired, are set in an insulated
environment. A work therapy program, expanded to other community
settings, to accommodate patients like Ted, who are better served
outside of a sheltered atmosphere, would be more effective. Volunteer
or internship positions, or later, a part-time job that sparks his
interest, would be more therapeutic. Not only would this help him
acquire the confidence and independence he needs to someday become
gainfully employed, but aid in his integration, by providing
constructive, meaningful activities for him to participate in outside
of the home.
Counseling, Life Skills and Patient-Specific Case Management
Although many basic therapies are offered, rarely do they include
teaching socially appropriate behaviors, which are commonly an issue
after a TBI. This task often falls on the veteran's family member or
spouse, increasing the responsibility of the caregiver, and causing
conflict with the veteran, who feels he is being treated like a child.
Ted has had the advantage of community peer support, but also a
counselor at the private practice I have previously mentioned, to help
him redevelop age appropriate social skills, allow me to be his spouse,
and him to maintain his dignity. She has also worked with Ted to
develop healthy coping skills, to manage cognitive deficits, improve
mental health, and develop patient-centered treatment plans, which
focus specifically on his unique challenges. Again, our situation is
not typical though. This is something difficult to provide in an
institutional care environment, like the Veterans Health
Administration, without greater flexibility, and more resources to
provide increased face time with the patient, and better injury-
specific expertise.
Conclusion
The challenges we have faced are the same as countless other
veterans, many of whom have not had the resources Ted has had available
to him, or an advocate capable of negotiating the system. A veteran I
often think about, who had a young wife with a newborn baby, and
nothing more than a high school education, should have received the
same world-class care as my husband, but sadly will not. Despite my
best efforts to be a support to his spouse, who was overwhelmed by
motherhood, while trying to negotiate a seemingly impossible system,
she eventually left him, because it was more than she could handle. A
veteran's care should not depend on what family they were born into,
who they married, or whether or not family obligations allow for their
loved one to advocate for them, but sadly it does. Though we will never
be able to fully compensate seriously wounded veterans for the
sacrifice they have made on our behalf, we can certainly do a better
job of managing their care, rehabilitating them to their fullest
potential in a timely manner, and providing the necessary resources to
maximize their quality of life. I am pleased to see the Subcommittee is
taking a look back to explore ways to learn from the past, and address
the needs of the veteran injured yesterday. This will ultimately
improve the care of the servicemember injured today, as well. Mr.
Chairman, thank you again for the opportunity to share our story with
you today. I look forward to answering any questions you may have for
us.
Prepared Statement of Meredith Beck
National Policy Director, Wounded Warrior Project
Mr. Chairman, Ranking Member Brown-Waite, distinguished Members of
the Subcommittee, thank you for the opportunity to testify before you
regarding post-acute care for the seriously injured. My name is
Meredith Beck, and I am the National Policy Director for the Wounded
Warrior Project (WWP), a non-profit, non-partisan organization
dedicated to assisting the men and women of the United States Armed
Forces who have been injured during the current conflicts around the
world.
During the recent conflicts in Iraq and Afghanistan, there have
been approximately 30,000 soldiers, sailors, airmen, and Marines
wounded in action. Fortunately, due to advances in medical technology,
the number of those killed in action is far lower. However, in many
cases, as the wounded have suffered devastating injuries and require
long-term outpatient care and rehabilitation, WWP is pleased that the
Subcommittee has chosen to focus on this aspect.
As a result of our direct, daily contact with these wounded
warriors, we have a unique perspective on their needs and the obstacles
they face as they attempt to transition, reintegrate, and live in their
communities. As such, WWP has identified the following areas of
concern:
Options for Care: Specifically with respect to Traumatic Brain
Injury, those suffering from TBI require individualized, comprehensive
care, and while the VA has made progress in this area, the agency is
still in the process of establishing an extensive, consistent, long-
term continuum of care available throughout the Nation. As such, and
due to the need for ongoing therapy and rehabilitation, many seriously
injured veterans and families have indicated that their number one
request is increased access to options for care, including access to
private facilities previously available to them while on active duty.
Discrepancies in Benefits: On a related topic, many veterans and
families of the seriously injured have indicated confusion,
frustration, and disappointment upon learning that they are not
eligible for the same benefits and care as veterans as they were on
active duty and vice versa. For example, consider that an active duty
patient can be seen at a VA Polytrauma Center to treat his Traumatic
Brain Injury. However, while at the VA facility, the servicemember, due
to his duty status, cannot enjoy VA benefits such as Vocational
Rehabilitation or Independent Living Services that can be helpful in
his recovery. Alternately, as mentioned previously and unbeknownst to
most families, a medically retired servicemember cannot use his/her
TRICARE benefits to access private care as TRICARE does not cover
cognitive therapy once retired. While there is an obvious need for an
advantage to active duty service, those who are severely injured as a
result of their service in an all-volunteer force deserve special
consideration.
The recently passed National Defense Authorization Act for FY2008
contained a provision intended to address these discrepancies.
Specifically, section 1631 authorizes for a limited period of time the
Secretary of Defense to provide any veteran with a serious injury or
illness the same medical care and benefits as a member on active duty
and entitles the severely injured still on active duty to receive
veterans' benefits, excluding compensation, to facilitate their long-
term recovery and rehabilitation. While this provision recognizes the
strengths of each agency and the necessity of basing an individual's
care and benefits on his/her medical condition rather than on military
status, it is subject to regulation and will require significant
oversight to ensure its success.
Respite Care: For those who are seriously injured, one cannot
discuss their care without discussing their caregiver. While the VA
currently offers some respite care, the available options are often not
entirely appropriate given the average age and types of injuries of
those serving in Iraq and Afghanistan. For example, retired Army
Sergeant Eric Edmundson suffered a severe brain injury in Iraq several
years ago, but he is aware and responsive. In fact, he enjoys spending
time with his family and recently went fishing with his 3-year-old
daughter Gracie. Eric's family is unwilling to place him in a respite
facility for fear that it could cause a regression in his
rehabilitation and cause Eric distress.
However, WWP has noted that similar to others, Eric's family has
used their personal funds to pay for an innovative type of
individualized therapy that also provides a unique form of respite for
the caregiver. In Eric's case, rather than staying indoors all day, his
family pays an individual to take him to the park to watch his daughter
play. Eric thrives each time, and his progress and enjoyment are
noticeable.
As a result of Eric's success as well as others in similar
situations, WWP proposes that the Department of Veterans Affairs (VA)
initiate a pilot program partnering with local universities to provide
such a care/respite initiative for those with brain injury. As part of
the veteran's ongoing therapy, the program would draw graduate students
from appropriate fields (i.e. social work, nursing, psychology, etc.),
train them to interact with the veterans, and match them with eligible
veterans in their local area so that an individualized program can be
developed. In return for making the requisite reports to the veteran's
physician on his/her status, the graduate student would receive course
credit.
The creation of such a program would have several positive effects
including:
1. In recognition of the individual nature of Traumatic Brain
Injury (TBI), the program would encourage an innovative means of
providing age-appropriate maintenance therapy to those suffering from
TBI.
2. While the veteran is benefiting from the therapy aspects of the
program, the family caregiver would be offered much needed respite.
3. Interaction with the graduate students would increase general
community awareness of the sacrifices of our Nation's veterans and the
needs of those suffering from TBI.
Caregiver Compensation: Traumatic Brain Injury (TBI) has been
widely identified as the ``signature wound'' of the Global War on
Terror. While many organizations appropriately focus on the needs of
the affected servicemember, the Wounded Warrior Project (WWP) has also
identified the family caregiver as an individual in need of assistance.
For example, in many circumstances, the spouse or parent is forced to
leave his/her job to provide the necessary care for their loved one,
leaving the entire family to suffer from an adverse economic situation.
In these cases, the VA relies on the family member to assist in the
servicemember's care, but has been denied financial compensation for
such labor.
In recognition of this reality, WWP developed and endorsed
legislation introduced by Representatives Salazar and Pascrell
requiring the VA to train, certify, and make eligible for compensation
the personal care attendants of severely injured TBI patients. This
program would expand on one already in existence at the San Diego VA
Medical Center for Spinal Cord Injury patients and would help alleviate
some of the financial burden incurred by these families. WWP encourages
the Subcommittee to review the program and help to ensure its
implementation.
Oversight: Finally, consistent with the recommendation of the
Veterans Disability Benefits Commission and to ensure the best care and
benefits for those who have sacrificed so much for our Nation, it is
imperative that a joint, permanent structure be in place to evaluate
changes, monitor systems, and make further recommendations for process
improvement. This office must be structured to minimize bureaucracy and
must have a clearly defined mission with the appropriate authority to
make necessary changes or recommendations as warranted. With the
passage of time, as veterans issues fade from the national spotlight,
it will be necessary to have such a joint structure in place to ensure
future inter- and intra-agency coordination.
Mr. Chairman, thank you again for the opportunity to testify today,
and I look forward to answering any questions you may have.
Prepared Statement of Todd Bowers
Director of Government Affairs, Iraq and Afghanistan Veterans of
America
Mr. Chairman, Ranking Member and distinguished Members of the
Committee, on behalf of Iraq and Afghanistan Veterans of America, and
our tens of thousands of members nationwide, I thank you for the
opportunity to testify today regarding this important subject. I would
also like to point out that my testimony today is as the Director of
Government Affairs for the Iraq and Afghanistan Veterans of America and
does not reflect the views and opinions of the United States Marine
Corps.
The tremendous advancements in frontline medical care have made
many combat injuries more survivable. In Vietnam, the mortality rate
for combat injuries was 1 in 4, while the mortality rate in Iraq is 1
in 10. That means today's battlefield medicine has saved approximately
6,000 American lives that would have been lost if we were still using
Vietnam-era medical techniques. This is a tremendous success story for
the DoD medical system.
But the corollary of the improved survival rate is an increase in
the number of severely wounded troops returning home. As the
Independent Budget states, ``We are seeing extraordinarily disabled
veterans coming home from Iraq and Afghanistan with levels of
disability unheard of in past wars.'' Many of these young, wounded
veterans will require long-term care, not just at Walter Reed and
Bethesda, but in their communities across this country. At the VA,
these veterans with Traumatic Brain Injury and blast injuries are
confronting a system designed to treat diabetes and Alzheimer's.
The DoD and the VA have already taken some crucial steps to improve
inpatient care for these young, severely wounded patients. There are
four major Polytrauma Rehabilitation Centers, in Tampa, FL, Richmond,
VA, Minneapolis, MN, and Palo Alto, CA, which use teams of physicians
and specialists that administer individually tailored rehabilitation
plans, including full-spectrum care for Traumatic Brain Injuries. These
centers are also part of the Defense and Veterans Brain Injury Center
network.
[GRAPHIC] [TIFF OMITTED] 41376A.001
These key centers offer cutting-edge treatment for the severely
wounded troops who are receiving inpatient care. But what is available
to troops near their homes? As of 2003, according to the GAO, ``more
than 25 percent of veterans enrolled in VA health care--over 1.7
million--live over 60 minutes driving time from a VA hospital.'' This
number is likely higher today, because the mission in Iraq has relied
heavily on recruits from rural areas often underserved by VA hospitals
and clinics. This places a tremendous burden on the families and also
the veteran. With the current gasoline prices and many treatment
centers hours away, treatment is often impossible to facilitate.
Imagine if you will that your loved one has returned from combat
wounded and it is your responsibility to make sure they are receiving
the proper treatment. This is too much to ask of our servicemembers and
veterans' families.
In response, the VA has created regional network sites that work
with the major polytrauma centers to cater to patients closer to their
homes. The VA is also planning to add new Polytrauma Support Clinics to
provide followup services for those who no longer require inpatient
care but still need rehabilitation. The 75 Polytrauma Support Clinic
Teams help veterans get access to specialized rehabilitation services
closer to their home communities, and also are responsible for ensuring
that these patients don't ``fall through the cracks'' after leaving
full-time care. For hospitals without a Polytrauma Support Clinic, a
single person has been designated as the ``point of contact'' to
coordinate care for local veterans with polytraumas.
These are good first steps, but much more must be done to get these
wounded veterans the care they need. A ``point of contact'' that can
offer referrals to distant hospitals and clinics is simply not an
adequate response to a wounded veteran's health care needs. IAVA joins
the other IB-VSOs in calling for increased funding for home and
community-based care, and a detailed plan from the VA regarding their
long-term response to the needs of today's veterans.
Respectfully submitted.
Prepared Statement of Mahdulika Agarwal, M.D., MPH
Chief Officer, Patient Care Services, Veterans Health Administration
U.S. Department of Veterans Affairs
Good morning, Mr. Chairman and Members of the Subcommittee. Thank
you for the opportunity to discuss the Department of Veterans Affairs'
(VA's) care for seriously wounded veterans after they complete their
inpatient care. I am accompanied by Dr. Lucille Beck, Chief Consultant
for Rehabilitation Services and Ms. Kristin Day, Chief Consultant Care
Management & Social Work Service, Veterans Health Administration (VHA).
VHA has long emphasized the importance of a personalized continuum
of care for servicemembers. Our commitment extends beyond the initial
transition across systems of care to ensure services continue to be
provided to these individuals as veterans, and to their family members,
who are essential to the recovery and rehabilitation of these injured
warriors.
It is important to emphasize, however, that neither the transfer
between health care systems, nor the transfer to veterans' status is a
linear path. To ensure every veteran or servicemember receives the care
and benefits they deserve, VA has created a Case Management Program for
Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) veterans.
The VA/DoD Federal Recovery Coordination Program (FRCP) further
provides needed assistance and support for veterans and servicemembers
with serious injuries or illnesses. VA's provision of both inpatient
and outpatient rehabilitation services in locations across the country
is designed to meet the short- and long-term needs of veterans with
serious injuries, including Polytrauma, Traumatic Brain Injury (TBI),
Spinal Cord Injury (SCI), and mental health needs. These overlapping
strategies of case management and coordination of rehabilitative care
allow me to state with confidence that VA is adapting to the needs of
our returning veterans and operating a system capable of providing
lifelong care to them. These programs provide little net value if
veterans are unaware of the services available to them; consequently,
VA has pursued outreach on multiple levels to see that our veterans,
particularly those with severe injuries or illnesses, can access our
system and receive the care they have so bravely earned.
OEF/OIF Case Management Program and Federal Recovery Coordination
Program
We deeply appreciate the recommendations of The President's
Commission on Care for America's Returning Wounded Warriors, chaired by
Senator Dole and Former Secretary Shalala. Specifically, we echo their
description of the importance of integrated care management, which they
describe as providing, ``. . . patients with the right care and
benefits at the right time in the right place by leveraging all
resources appropriate to their needs. For injured servicemembers--
particularly the severely injured--integrated care management would
build bridges across health care services in a single facility and
across health care services and benefits provided by DoD and VA.'' \1\
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\1\ President's Commission on Care for America's Returning Wounded
Warriors. ``Serve, Support, and Simplify: Subcommittee Reports and
Findings.'' p. 20-21. Available online: http://www.pccww.gov/docs/
TOC%20Subcommittee%20Reports.pdf.
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VHA and VBA published a joint handbook (VHA Handbook 1010.01) in
May 2007 establishing procedures for the transition of care,
coordination of services and case management of OEF/OIF veterans. This
joint Case Management Program represents a fully integrated team
approach, and includes a Program Manager, Clinical Case Managers, a VBA
Veterans Service Representative, and a Transition Patient Advocate.
These teams are active at every VA Medical Center (VAMC). The Program
Manager, who is either a nurse or social worker, has overall
administrative and clinical responsibility for the team, and must
ensure all OEF/OIF veterans are screened for case management needs.
OEF/OIF veterans with severe injuries are automatically provided a case
manager; all other OEF/OIF veterans are assigned a case manager upon
request. Clinical Case managers, who are either nurses or social
workers, coordinate patient care activities and ensure all VHA
clinicians are providing care to the patient in a cohesive, integrated
manner. VBA team members assist veterans by educating them on VA
benefits and assisting them with the benefit application process.
The Transition Patient Advocates (TPAs) serve as liaisons between
the VAMC, the Veterans Integrated Service Network (VISN), VBA, and the
patient. The TPA acts as a communicator, facilitator and problem
solver. The team documents their activities in the Veterans Tracking
Application (VTA), a Web-based tool designed to track injured and ill
servicemembers and veterans as they transition to VA. VHA is also using
the Primary Care Management Module (PCMM), an application within VHA's
VistA Health Information system, to track patients assigned to an OEF/
OIF Case Management team.
VA has developed a rigorous training schedule for this new program
to ensure it is operating fully and effectively for all veterans
requesting assistance. TPAs and VISN Points of Contact attended a
training conference in Washington, D.C. in June 2007, and Program
Managers received training in September 2007. VA held a week-long
training conference in San Diego in January 2008 for Case Managers, and
two regional training conferences for the entire OEF/OIF Case
Management Team are planned for May and June 2008.
As a part of this effort, VHA and VBA are jointly developing a
comprehensive list of severely injured OEF/OIF veterans. The two
administrations are defining the requirements and definitions for this
list, and will establish a single record to track VHA or VBA contact
each month with severely injured veterans and servicemembers.
VA and DoD are working on jointly developing and implementing a
comprehensive policy on improvements to the care, management, and
transition of recovering servicemembers, pursuant to the National
Defense Authorization Act of 2008.
In October 2007, VA partnered with DoD to establish the Joint VA/
DoD Federal Recovery Coordination Program (FRCP). The FRCP will
identify and integrate care and services for the seriously wounded,
ill, and injured servicemember, veteran, and their families through
recovery, rehabilitation, and community reintegration. VA hired an FRCP
Director, an FRCP Supervisor, and eight Federal Recovery Coordinators
(FRCs) in December 2007. The FRCs are currently deployed to Walter Reed
and Brooke Army Medical Centers, as well as National Naval Medical
Center at Bethesda. Two additional FRCs are currently being recruited
and will be stationed at Brooke Army Medical Center and Balboa Naval
Medical Center in San Diego. The FRCP is intended to serve all
seriously injured servicemembers and veterans, regardless of where they
receive their care. The central tenet of this program is close
coordination of clinical and non-clinical care management for severely
injured servicemembers, veterans, and their families across the
lifetime continuum of care.
Caregiver Assistance
The Caregiver Pilot Task Force was formed in response to a
provision of the ``Veterans Benefits, Health Care, and Information
Technology Act of 2006''. Eight Caregiver Assistance Pilot Programs
were awarded grants beginning in October 2007, at a total cost of
approximately $5 million. The goal is to explore options for providing
support services for caregivers in areas across the country where such
services are needed for families of disabled or aging veterans, and
where there are few other options available. These programs will also
increase the caregiver support services available to OEF/OIF veterans
in the immediate future and the long term. Examples of these pilots
include:
Home Based Primary Care programs, in Memphis and Palo
Alto, are implementing interventions from the evidence-based REACH II
National Institutes of Health Initiative to train and support
caregivers in managing patient behaviors and their own stress.
Caregivers in Gainesville, Florida will participate in a
Transition Assistance Program using videophone technology to provide
skills training, education and supportive problem solving.
In Ohio, Caregiver Advocates will be available via
telephone 24 hours a day to coordinate between VA and community
services.
VA will work with a community coalition to provide
education, skills, training, and support for caregivers of veterans
with TBI in California, using telehealth technology.
The VA Pacific Islands Healthcare System will develop a
Medical Foster Home program to provide overnight respite care for
veterans.
In Miami and Tampa, funding will be used to expand
respite care, train home companions, and develop an emergency response
system.
Atlanta will use a model telehealth program to provide
instrumental help and emotions support to caregivers who live in remote
areas.
VA is committed to providing key services to assist caregivers with
case management, service coordination, and support for the veteran, as
well as education on how to obtain community resources such as legal
assistance, financial support, housing assistance, and spiritual
support.
Medical Foster Homes and Volunteer Respite Services
In February 2008, VA's Under Secretary for Health approved funding
for programs to facilitate the transition and support of seriously
injured veterans with Polytrauma, TBI, and/or SCI by providing
specialized support and care in their homes and communities. This
program will aid both veterans living in their homes and those who are
no longer able to live independently but prefer an in-home alternative
within their community. The Volunteer Respite program will create
access to needed home respite services for family caregivers, while
giving members of the community an opportunity to volunteer with VA
closer to home, regardless of distance from a VA facility. VA Voluntary
Service would recruit, train, and coordinate community volunteers to
provide respite care in the homes of OEF/OIF veterans. The Medical
Foster Home component provides an in-home alternative to nursing home
care, merging personal care in a private home with medical and
rehabilitation support from specialized VA home care programs.
Through these programs and others, VA will expand the availability
of Medical Foster Homes (MFH) to seriously injured OEF/OIF veterans
near specialized facilities within the communities in which they live.
We will also expand the number of MFH sites and modify them to meet the
needs of younger, seriously injured veterans with Polytrauma, TBI, and/
or SCI, and strengthen the rehabilitation expertise of the VA home care
teams who will serve them. Veterans with disabling injuries or
conditions may need the support of a non-familial caregiver as they
work toward independent living in the community, or may have long term
care needs that initially, or eventually, exceed the capabilities their
family can sustain. MFH may be a favorable alternative to nursing homes
for these veterans as we facilitate their return to homes and
communities.
Rehabilitative Services
VA provides clinical rehabilitative services in several specialized
areas that employ the latest technology and procedures to provide our
veterans with the best available care and access to rehabilitation for
polytrauma and traumatic brain injury, spinal cord injury, visual
impairment, and other areas. VA's Under Secretary for Health directed
our facilities to seek a second opinion from civilian physicians upon
request. Whenever an OEF/OIF veteran requires specialized
rehabilitative services, the assigned OEF/OIF case manager engages with
the clinical case manager that is appropriate for that area of
rehabilitation; e.g., polytrauma, spinal cord injury, blindness.
Throughout the rehabilitative process, the OEF/OIF case manager
coordinates with the appropriate clinical case manager regarding the
veteran's progress and rehabilitation.
Polytrauma System of Care
Over the past 2 years, VA has implemented an integrated system of
specialized care for veterans sustaining traumatic brain injury (TBI)
and other polytraumatic injuries. The Polytrauma System of Care
consists of four regional TBI/Polytrauma Rehabilitation Centers (PRC)
located in Richmond, VA; Tampa, FL; Minneapolis, MN; and Palo Alto, CA.
A fifth PRC is currently under design for construction in San Antonio,
TX, and is expected to open in 2011. The four regional PRCs provide the
most intensive specialized care and comprehensive rehabilitation for
combat injured patients transferred from military treatment facilities.
As veterans recover and transition closer to their homes, the
Polytrauma System of Care provides a continuum of integrated care
through 21 Polytrauma Network Sites, 76 Polytrauma Support Clinic Teams
and 54 Polytrauma Points of Contact, located at VAMCs across the
country. Throughout the Polytrauma System of Care, we have established
a comprehensive process for coordinating support efforts and providing
information for each patient and family member. On February 27, 2006,
VA established a national Polytrauma Call Center available 24 hours a
day, 7 days a week, for families and patients with questions. This
Center is staffed by health care professionals trained specifically in
Polytrauma care and case management issues and can be reached by
calling 1-888-827-4824.
The care coordination process between the referring DoD military
treatment facility and the PRC begins weeks before the active duty
servicemember is transferred to VA for health care. The PRC physician
monitors the medical course of recovery and is in contact with the MTF
treating physician to ensure a smooth transition of clinical care. The
admissions nurse case manager maintains close communication with the
referring facility, obtaining current and updated medical records. A
social work case manager is in contact with the family to address their
needs for psychosocial and logistical support. Prior to transfer, the
PRC interdisciplinary team meets with the DoD treatment team and family
by teleconference as another measure to ensure a smooth transition. The
PRCs provide a continuum of rehabilitative care including a program for
emerging consciousness, comprehensive acute rehabilitation, and
transitional rehabilitation. Each of the PRCs is accredited by the
Commission on Accreditation of Rehabilitation Facilities (CARF).
Intensive case management is provided by the PRCs at a ratio of 1 case
manager per 6 patients, and families have access to assistance 24 hours
a day, 7 days a week. The interdisciplinary rehabilitation treatment
plan of care reflects the goals and objectives of the patient and/or
family.
From March 2003 through December 2007, the PRCs provided inpatient
rehabilitation to 507 military servicemembers injured in combat
theaters. The transition plan from the PRCs to the next care setting
evolves as the active duty servicemember progresses in the
rehabilitation program. Families are integral to the team and are
active participants in therapies, learning about any residual
impairments and ongoing care needs. The team collaborates with the
family to identify the next care setting, and determine what will be
needed to accommodate the transition of rehabilitative care. The
consultation process includes a teleconference between the PRC team,
the consulting team, the family, and the patient. These conferences
allow for a coordinated transfer of the plan of care, and an
opportunity to address specific questions.
Prior to discharge, each family and patient is trained in medical
and nursing care appropriate for the patient. Once a discharge plan is
coordinated with the family, VA initiates contact with necessary
resources near the veteran's home community. Based upon location, an
agreement is reached with one of the 21 VA Polytrauma Network Sites or
an appropriate local provider within the patient's community. As
veterans and servicemembers transition to their home communities,
ongoing clinical and psychosocial case management is provided by a
rehabilitation nurse and social worker from one of 76 Polytrauma
Support Clinic Teams. VA social work case managers follow each patient
within the Polytrauma System of Care at prescribed intervals contingent
upon need. For example, there are four levels of case management:
intensive case management, where contact is made daily or weekly;
progressive case management, where VA contacts the patient monthly;
supportive case management, quarterly; and lifetime case management,
annually. For the many patients who are still active duty
servicemembers, the military case managers are responsible for
obtaining authorizations from DoD regarding orders and followup care
based upon VA medical team recommendations.
VA is committed to ongoing review and improvement of our provision
of care for these wounded or injured warriors. In this spirit, VA
assembled a national research task force last summer to review and
evaluate the long term care needs of our most seriously wounded or
injured returning OEF/OIF veterans. This taskforce recently completed
its work and identified several recommendations, which are being
submitted to the Secretary for his review. Moreover, in compliance with
the 2008 National Defense Authorization Act, VA is collaborating with
the Defense and Veterans Brain Injury Center to design and execute a 5-
year pilot program to assess the effectiveness of providing assisted
living services to eligible veterans to enhance their rehabilitation,
quality of life, and community integration.
Spinal Cord Injury and Disorders
For Spinal Cord Injury and Disorders (SCI/D), VA has the largest
single network of care in the Nation. VA facilities nationwide provided
a full range of services to 26,191 veterans with SCI/D in 2007; 12,789
of these veterans received specialized care within the Spinal Cord
Injury Centers and Spinal Cord Injury Support Clinics. For veterans
with SCI/D, VA provides health care, maintains their medical equipment,
and provides supplies, education and preventive health services. Since
2003, 364 active duty servicemembers have been treated in VA SCI units;
of these, 116 acquired spinal cord injury in an OEF/OIF theater of
operations. Each of these patients received care from a VA facility
accredited by CARF. A national, multi-site vocational improvement
research project identifies evidence-based vocational rehabilitation
programs for veterans with SCI/D.
VA is improving and expanding our SCI/D nationally, with plans for
a ribbon-cutting ceremony for a new facility in Minneapolis in February
2009. Our Denver, CO facility's design was funded in 2004 and land was
acquired in 2006, while our Jackson, MS facility's funding is still
being determined. Tampa's LTC facility (30 beds) is under construction
and planning is underway for the VISN 3 SCI LTC facility. Each VA
Spinal Cord Injury Center will be provided with state-of-the-art
technology and equipment to better support home-based therapies,
provide closer management and monitoring of function and complications
in the home, and offer closer attention to health promotion and
prevention.
Blind Rehabilitation
For veterans and active duty personnel with visual impairment, VA
provides comprehensive Blind Rehabilitation services that have
demonstrated significantly greater success in increasing independent
functioning than any other blind rehabilitation program. Currently, 164
Visual Impairment Service Team (VIST) Coordinators provide lifetime
case management for all legally blind veterans, and all OEF/OIF
patients with visual impairments. Additionally, 38 Blind Rehabilitation
Outpatient Specialists (BROS) provide blind rehabilitation training to
patients who are unable to travel to a blind center.
The VA Blind Rehabilitation Continuum of Care, announced January
2007, further extends a comprehensive, national rehabilitation system
for all veterans and active duty personnel with visual impairments.
Program expansion during 2008 will add 55 outpatient vision
rehabilitation clinics, 35 additional BROS at VAMCs currently lacking
those services, and 11 new VIST positions. The continuum of care will
provide the full scope of vision services--from basic, low vision
services to blind rehabilitation training--across all Veteran
Integrated Service Networks (VISNs).
Outreach
VA has always been committed to outreach, and all the more so
during periods of armed conflict. Given the importance of outreach to
servicemembers and veterans of OEF/OIF, VA promotes and conducts
activities at both national and local levels. VA has developed an array
of training materials, directives, publications, and established points
of contact at each VA facility. VA also partners with Federal agencies,
Veterans Service Organization (VSOs), and State, county, and local
agencies and governments. Our outreach to OEF/OIF participants begins
when the servicemember returns home and continues through the
transition period from servicemember to veteran and beyond.
Outreach to active duty personnel is a major part of VA's Outreach
program and is generally accomplished through the Transition Assistance
Program (TAP) sponsored in cooperation with the Departments of Defense
and Labor. All VA benefits and services are included in TAP briefings.
All returning OEF/OIF servicemembers are given a copy of VA Pamphlet
80-06-01, Federal Benefits for Veterans and Dependents.
Special outreach to Reserve/Guard members is an integral part of
VA's outreach efforts. VA provides briefings on benefits and health
care services at townhall meetings, family readiness groups, and during
unit drills near the homes of returning Reserve/Guard members.
Since 2003, VA's outreach to those severely injured in OEF/OIF
includes placing VA/DoD Social Work and Registered Nurse Liaisons and
Benefits Counselors at Walter Reed Army Medical Center, the National
Naval Medical Center and nine other military treatment facilities
across the country.
In November 2005, VA began partnering with DoD in implementing the
Post-Deployment Health Reassessment (PDHRA) among National Guard and
Reserve Component (RC). The PDHRA is a DoD global health-screening tool
that includes specific questions covering PTSD, alcohol misuse and
Traumatic Brain Injury (TBI). VA's role in this partnership is
fourfold: provide information on VA benefits among Reserve and Guard
personnel; enroll eligible veteran in VA health care; provide
assistance in scheduling followup appointments at VAMCs and Vet
Centers; and develop ongoing referral and training relationships with
Reserve and Guard Commanders. As of January 31, 2008, VA has supported
PDHRA referrals from DoD's 24/7 Call Center, 283 Unit Call Center PDHRA
events and 888 Unit On-Site PDHRA events. The RC PDHRA initiative has
generated over 75,000 referrals, including 36,199 referrals to VAMCs
and 17,214 referrals to Vet Centers representing 71% of total
referrals.
Vet Center staff regularly participates in DoD-sponsored PDHRA
events. Vet Centers provide information on VA benefits and care to
servicemembers as they transition from military to civilian life at
National Guard and Reserve demobilization sites, active duty transition
briefings, and community events involving returning combat veterans
such as homecoming events. Outreach is also performed with local VSOs
and community agencies. Vet Center outreach is designed to provide
information, minimize stigma, and help veterans obtain needed services
as early as possible. More than 200,000 servicemembers have been
provided outreach services, primarily at military demobilization sites,
including National Guard and Reserve units. Vet Centers initiate
outreach efforts to area military installations and closely coordinate
their efforts with military family support services at various military
bases.
In October 2005, DoD Health Affairs began providing VA with a list
of servicemembers entering the Physical Evaluation Board (PEB) process.
These servicemembers sustained an injury or developed an illness that
may preclude them from continuing on active duty and result in medical
separation or retirement. This list will enable VHA to send outreach
letters encouraging them to contact the nearest VA medical facility for
future assistance in enrolling in VA health care and addressing their
health care needs as they transition from active duty to veteran
status. As of January 31, 2008, the VA has mailed 16,905 PEB outreach
letters to servicemembers.
The Veterans Assistance at Discharge System process mails a
``Welcome Home Package,'' including a letter from the Secretary, ``A
Summary of VA Benefits'' (VA Pamphlet 21-00-1), and ``Veterans Benefits
Timetable'' (VA Form 21-0501), to veterans recently separated or
retired from active duty (including Guard/Reserve members). We re-send
this information 6 months later to these veterans.
The Secretary of Veterans Affairs sends a letter to newly separated
OEF/OIF veterans. The letters thank veterans for their service, welcome
them home, and provide basic information about health care and other
benefits provided by VA. To date, VA has mailed over 766,000 initial
letters and 150,000 followup letters to veterans.
VA Regional Offices assist and support seriously injured OEF/OlF
servicemembers and veterans by conducting case management activities,
including outreach, coordinating services, and streamlining claims
processing procedures.
In collaboration with DoD, VA published and distributed one million
copies of a new brochure called, ``A Summary of VA Benefits for
National Guard and Reservists Personnel.'' The new brochure summarizes
health care and other benefits available to this special population of
combat veterans upon their return to civilian life.
As part of VA's ``Coming Home to Work'' program, participants work
with a Vocational Rehabilitation and Employment Counselor (VRC) to
obtain unpaid work experiences at government facilities. This
represents an early outreach effort with special emphasis on OEF/OlF
servicemembers pending medical separation from active duty at military
treatment facilities.
VA also continues its Benefits Delivery at Discharge program, where
servicemembers can apply for service-connected compensation, vocational
rehabilitation, and employment services before discharge. Normally,
prior to discharge, required physical examinations are conducted,
service medical records are reviewed, and rating decisions are made.
Access to Care
VA has identified access to outpatient care as a priority in our
effort to provide care for seriously wounded veterans after inpatient
care is complete. VHA's strategic direction is to enhance non-
institutional care with less dependence on large institutions. Our
comprehensive care management plans offer guidance for providing care
to veterans in their homes and communities. For those veterans who
prefer to visit in person, VA issued a directive last June instructing
our medical centers to explore offering extended hours for veterans
unable to schedule appointments during the day. Similarly, our Vet
Centers are available to veterans on nights and weekends for
readjustment counseling needs.
Community Based Outpatient Clinics (CBOCs) have been the anchor for
VA's efforts to expand access for veterans. CBOCs are complemented
through partnerships, such as contracts in the community for physician
specialty services or referrals to local VA medical centers, depending
on the location of the CBOC and the availability of specialists in the
area. In addition, we provide rural outreach clinics that are operated
by a parent CBOC to meet the needs of rural veterans.
Telehealth provides veterans with access to care in their homes and
local communities where possible and appropriate. It is a new modality
of care requiring robust clinical practices, technology infrastructure
and business processes to maintain and sustain the modality. Telehealth
capabilities in VA have expanded in all clinical areas since FY 2004.
There are telehealth programs within all VISNs and many programs have
grown from point-to-point connections to inter-hospital and VISN-based
networks. VA continues to evaluate the effectiveness of telehealth and
to work with clinical leadership in the VISNs and VA facilities to
introduce new clinical processes based on information technologies to
assist clinicians in meeting the health care needs of older veterans.
This reduces the barriers of distance and time that may restrict the
availability of care. Currently, VA is piloting applications to create
national tele-consultation networks to expand the provision of
specialty care to rural and remote areas.
Conclusion
We are honored to provide care and service to America's veterans.
For those who return from combat with serious injuries or illness, we
work closely with DoD to ensure a swift and seamless transition to VA,
but we also work with those who do not need immediate care to make it
as accessible as possible. Thank you again for you the opportunity to
meet with you today. I would be happy to address any questions that you
have at this time.
__________
Memorandum
Department of Veterans Affairs
Date:
February 22, 2007
From:
Deputy USH for Operations and Management (10N)
Subj:
Acceptance Requirements for VA Volunteers
To:
All VISN Directors (10N1-23)
All Medical Center Directors (00)
1. Effective immediately, all VISNs and VA facilities will accept
and process volunteers according to the standardized process outlined
in this memorandum and attachment.
2. This process is necessary to reduce barriers to volunteering at
VA facilities, while complying with current laws and VA regulations. It
enables VA to establish reasonable expectations for managing our
ability to accept new volunteers while enhancing our volunteer
recruitment activities.
3. For the purpose of accepting new volunteers, and determining
the level of cyber security and privacy training they will require,
four specific groups of volunteers have been established. Each group
has specific requirements that correlate with the level of cyber
security risk involved in their volunteer assignment. Every volunteer
assignment will be categorized in one or more of the groups listed
below.
Group A
VA employees who have volunteer assignments will require:
A completed and signed application
A general orientation
An assignment-specific orientation
A physical examination if driving is their volunteer
assignment
Type of 10 Badge Required: Standard employee 10 badge
Group B
Volunteers with recreation, cemetery, book cart, or similar
assignments will require:
A completed and signed application
A general orientation
An assignment-specific orientation
Privacy Policy Training
A PPD Inoculation
A photo 10 badge
A physical examination if driving is their volunteer
assignment
A List of Excluded Individuals & Entities (LEIE)
Health and Human Services (HHS) database check. The LEIE
database check is performed automatically between databases.
A Healthcare Integrity and Protection Data Bank
(HIPDB) HHS database check. The HIPDB database check is
completed by facility personnel.
Type of 10 Badge Required: FLASH
Group C
Volunteers who have assignments in any of the seven categories
outlined in VHA Directives 0710 and VHA Handbook 1620.1 will require:
All Group B requirements plus:
A Special Agreement Check (SAC) for Fingerprint Only
Type of 10 Badge Required: NON-PIV
The seven categories for Group C are volunteers who have:
Assignments associated with home health care;
Assignments involving the provision of patient care
or working alone with patients;
Assignments involving contact with pharmaceuticals
or other biological agents;
Assignments that provide access to patient records;
Assignments involving clinical research;
Assignments that provide access to any VA computer
system; or
Access to any sensitive information not identified
above (e.g., Privacy Act Protected Information)
Group D
Volunteers who have computer access or access to the LAN will
require:
All Group B & C requirements plus:
A National Agreement Check Inquiry (NACl)
Investigation
Cyber Security Training
A signature that the volunteer has read the VA's
Rules of Behavior
Type of 10 Badge Required: PIV
4. These volunteer categories will standardize the acceptance
process for all VA volunteers, regardless of the facility where they
volunteer their time. This process will enable members of the community
to serve those who have served, while safeguarding veteran private
information.
5. The process outlined in this memorandum will be included as
policy in VHA Handbook 1620.1, 'Voluntary Service Procedures''. All
VISN Directors and Medical Center Directors will ensure the
implementation of this standardized process for acceptance of
volunteers.
William F. Feeley, MSW, FACHE
----------
Attachment: Volunteer Acceptance Requirements
----------------------------------------------------------------------------------------------------------------
Volunteers with No Access Volunteers with Volunteers with
VA Employees as Volunteers (already have to Veterans Records or VA Access to Access to VA IT
necessary training and checks) IT Systems Veterans Systems
----------------------------------------------------------------------------------------------------------------
Completed Completed and All Group B All Group B & C
signed
and signed application requirements requirements plus:
application General plus:
orientation
General Assignment-specif NACI
ic
Orientation orientation Specia Investigation
l
Assignment- Privacy Policy Agreement Complete
Training d
specific PPD Inoculation Checks Returned
orientation Photo ID (SAC) for Cyber
Security
Physical Physical Fingerprint Training
exmination
exmination (for volunteer drivers) Only Sign VA's
Rules
(if driving LEIE database of Behavior
check
is their (List of Excluded
volunteer Individual/Entities,
assignment) Health and Human
Services database, not
completed by the
volunteer)
Health Integrity
and Protection Data Bank
Check
----------------------------------------------------------------------------------------------------------------
Ongoing Requirement--Annual Supervisor Evaluation.
Committee on Veterans' Affairs
Subcommittee on Oversight and Investigations
Washington, DC.
April 17, 2008
Hon. James B. Peake
Secretary
U.S. Department of Veterans Affairs
810 Vermont Avenue, NW
Washington, DC 20420
Dear Secretary Peake:
On Thursday, March 13, 2008, the Subcommittee on Oversight and
Investigations of the House Committee on Veterans' Affairs held a
hearing on Care of Seriously Wounded After Inpatient Care.
During the hearing, the Subcommittee heard testimony from Dr.
Madhulika Agarwal, Chief Patient Care Services Officer for the Veterans
Health Administration. Dr. Agarwal was accompanied by Dr. Lucille Beck,
Chief Consultant for Rehabilitation Services in the Veterans Health
Administration; and Kristin Day, Chief Consultant for Care Management
and Social Work. As a followup to that hearing, the Subcommittee is
requesting that the following questions be answered for the record:
1. Please provide the Committee with a timeline for full
implementation of the Federal Individual Recovery Plan (FIRP), and
include in the timeline dates for each stage of implementation.
2. When will VA go back through the medical records and other
sources of information for those seriously wounded veterans who have
already been discharged into the civilian community (like Corporal
Owens and Sergeant Wade) and bring these veterans into the FIRP with
their own assigned Federal Recovery Coordinator (FRC), or otherwise
provide those veterans with effective case management services?
3. Does the VA currently have sufficient staffing to handle the
number of servicemembers and veterans who will need to rely on a
Federal Recovery Coordinator (FRC) to assist them with their FIRP?
4. Are the FRCs in the current pilot assigned to newly injured
servicemembers, to previously injured servicemembers (i.e.,
servicemembers who were injured prior to the creation of the FRC
pilot), or a combination thereof? If a combination, please provide the
relative percentages of the two groups. If the pilot FRCs are being
assigned primarily to newly injured servicemembers, please explain why
this scare resource--FRCs--is being assigned to newly injured
inpatients who have multiple case managers instead of previously
injured servicemembers who may not have adequate case management?
5. Many of the most seriously injured OEF and OIF vets are
treated in the VA's four Polytrauma Rehabilitation Centers (PRC). Has
the VA tracked PRC patients after they leave the PRCs? If not, why not?
How is VA ensuring that they receive everything they need?
6. Apart from PRC patients, what steps has VA taken to identify
severely injured separated servicemembers who need ongoing care
coordination?
7. What are VA's criteria to decide when a servicemember who has
been treated at a PRC is no longer the responsibility of PRC case
managers? In other words, what are the criteria for deciding to
transition a servicemember from PRC case management to OIF/OEF care
coordinator case management or something else?
8. What is the average caseload of a OIF/OEF care coordinator? Is
this considered manageable? Is there a health care standard for this
issue?
9. Have the special needs of severely injured rural vets been
identified?
10. Please explain how VETSNET is being used to support the FRC
pilot and the OIF/OEF care coordination program.
11. The testimony of Dr. Agarwal on page 3 states:
As a part of this effort, VHA and VBA are jointly
developing a comprehensive list of severely injured OEF/OIF veterans.
The two administrations are defining the requirements and definitions
for this list, and will establish a single record to track VHA or VBA
contact each month with severely injured veterans and servicemembers.
Describe in detail how this list is being constructed and what
the timeline is for completion of a comprehensive list.
We request you provide responses to the Subcommittee no later than
close of business on June 11, 2008. 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
The Honorable Harry E. Mitchell, Chairman
The Honorable Ginny Brown-Waite, Ranking Republican Member
Oversight and Investigations Subcommittee
House Veterans' Affairs Committee
March 13, 2008
Care of Seriously Wounded After Inpatient Care
Question 1: Please provide the Committee with a timeline for full
implementation of the Federal Individual Recovery Plan (FIRP), and
include in the timeline dates for each stage of implementation.
Response: A memorandum of understanding (MOU) between the
Department of Veterans Affairs (VA) and the Department of Defense (DoD)
was signed on October 30, 2007, for the joint oversight of the Federal
recovery coordination program (FRCP). In December 2007, VA hired the
program's director and supervisor. In January 2008, VA hired Federal
recovery coordinators (FRCs) who were placed at the following military
treatment facilities (MTF):
----------------------------------------------------------------------------------------------------------------
Number of FRCs
----------------------------------------------------------------------------------------------------------------
3 Walter Reed Army Medical Center, All on site and serving
Washington DC patients
----------------------------------------------------------------------------------------------------------------
2 National Naval Medical Center, (1) On site and serving patients
Bethesda, MD (1) Starts 5/19/08
----------------------------------------------------------------------------------------------------------------
3 Brooke Army Medical Center, San (2) On site and serving patients
Antonio, TX (1) In boarding process
----------------------------------------------------------------------------------------------------------------
2 Naval Medical Center, San Diego, (1) In final selection stage
CA (1) In boarding process
----------------------------------------------------------------------------------------------------------------
The FRCs started working with patients January 28, 2008. FRCs
developed Federal individualized recovery plans (FIRP) for severely
wounded, ill and injured servicemembers or veterans who meet the FRCP
criteria. Phase One of the FRC program targeted those catastrophically
wounded, ill or injured arriving from theatre to the MTF and is
scheduled to be completed in May 2008. Phase Two, which will begin
immediately after Phase One is complete, will expand the program's
scope to include those servicemembers and veterans who were discharged
from an MTF prior to January 2008.
Question 2: When will VA go back through the medical records and
other sources of information for those seriously wounded veterans who
have already been discharged into the civilian community (like Corporal
Owens and Sergeant Wade) and bring these veterans into the FRCP with
their own assigned Federal Recovery Coordinator (FRC), or otherwise
provide those veterans with effective case management services?
Response: At this time, FRCs are accepting servicemembers/veterans
injured prior to January 2008 into the FRCP on a referral basis. As
mentioned above, Phase Two will start in June 2008, and will expand the
program's scope to include those servicemembers and veterans who were
discharged from a MTF prior to January 2008. Identification of this
population will be conducted through a review of VA rehabilitation
databases, to include spinal cord and blind rehabilitation, along with
the polytrauma centers. In tandem, DoD will work through TRICARE in an
effort to identify the same population for potential inclusion into the
FRCP. Recruitment of staff to support this expansion effort has begun.
An additional registered nurse is being recruited to champion this
effort along with additional FRCs whose geographic placement will be
based on identified patient needs.
Question 3: Does the VA currently have sufficient staffing to
handle the number of servicemembers and veterans who will need to rely
on the Federal Recovery Coordination Program to assist them with their
FIRP?
Response: VA and DoD continue to closely monitor workload and
geographic distribution of cases as the program matures. As of now the
number of FRCs is adequate, but we expect that number to increase as we
continue to identify servicemembers in need of their services.
Question 4: Are the FRCs in the current pilot assigned to newly
injured servicemembers, to previously injured servicemembers, (i.e.
servicemembers who were injured prior to the creation of the FRCP), or
a combination thereof? If a combination, please provide the relative
percentages of the two groups. If the pilot FRCs are being assigned
primarily to newly injured servicemembers, please explain why this
scarce resource--FRCs--is being assigned to newly inured inpatients who
have multiple case managers instead of previously injured
servicemembers who may not have adequate case management?
Response: Almost 25 percent of the patients in the FRCP were
admitted to a MTF prior to the implementation of the program January
21, 2008. Phase One of the program is targeting catastrophically
wounded, ill or injured arriving from theatre to a MTF. Phase Two will
expand the program's scope to include those servicemembers and veterans
who were discharged from a MTF prior to January 2008. The rationale
behind this decision was that it allowed the FRCs to establish working
relationships with the multidisciplinary teams, the MTF leadership, and
those programs that support the severely ill/injured servicemembers.
Question 5: Many of the most seriously injured OEF and OIF vets are
treated in the VA's four Polytrauma Rehabilitation Centers (PRC). Has
the VA tracked PRC patients after they leave the PRCs? If not, why not?
How is VA ensuring that they receive everything they need?
Response: Follow-up case management is provided by the PRCs in
accordance with Veterans Health Administration (VHA) Handbook 1172.1.
The assigned case manager is involved in developing the discharge plan
of care with the treatment team, patient and family. This includes,
arranging and coordinating ongoing services, and communicating with DoD
and/or the local VA case manager.
While a patient is on active duty, DoD has authority over the
servicemember's medical care. The PRC case manager partners with the
military case manager, and documents post-discharge recommendations in
the medical record to provide to DoD for active duty patients.
For patients who are veterans when they leave the PRC, the PRC case
manager provides regular contact and followup with the patient, family,
VA and any other service providers. The PRC case manager also tracks
and monitors implementation of the care plan by the local VA by
reviewing the electronic medical record. Video teleconferencing is
often used to facilitate a smooth transition of care to the receiving
VA care team and the polytrauma network site (PNS) responsible for
monitoring the care plan and consulting with the local VA team.
Question 6: Apart from PRC patients, what steps has VA taken to
identify severely injured separated servicemembers who need ongoing
care coordination?
Response: VHA liaisons for health care and Veterans Benefit
Administration (VBA) benefits counselors are stationed at 11 of the
major MTFs receiving casualties from Afghanistan and Iraq. VHA
liaisons, are either social workers or nurses. They facilitate the
transfer of servicemembers and veterans from the MTF to a VA PRC or
medical center closest to their home or most appropriate for the
specialized services their medical condition requires. The benefits
counselors brief servicemembers about VA benefits and assist them in
applying for VA benefits and services.
These teams ensure that a VA facility has a process in place for
the care of all Operation Enduring Freedom/Operation Iraqi Freedom
(OEF/OIF) veterans and servicemembers. The care is coordinated. Each VA
medical center has an OEF/OIF team which includes a nurse or social
worker program manager, and nurse or social worker case manager.
Transition patient advocates also support severely injured or ill OEF/
OIF veterans by acting as an advocate for the patient and family as
they move through the VA system of care. Additionally, each VA medical
center has a process in place to ensure that the care of all OEF/OIF
veterans and servicemembers is well-coordinated and that those who are
severely ill or injured receive case management services from a nurse
or social worker case manager.
The polytrauma system of care integrates services at regional
centers, network sites, and at local VA medical centers to optimize
resources and create points of access along a continuum of care.
Specialized polytrauma care is provided at the VA facility closest to
the veteran's home with the expertise necessary to manage
rehabilitation, medical or mental health needs, and facilitate the
veteran's re-integration into the home community.
The polytrauma system of care is designed to provide smooth
transition from one level of care to the next. The PRC case manager
maintains contact and/or monitors the care of patients discharged from
the PRC for the patient's lifetime. The level of oversight, monitoring,
or direct involvement of the PRC depends on the patient's access to
care and services that are being provided at the local level.
Question 7: What are VA's criteria to decide when a servicemember
who has been treated at a PRC is no longer the responsibility of PRC
case managers? In other words, what are the criteria for deciding to
transition a servicemember from PRC case management to OIF/OEF care
coordinator case management or something else?
Response: The transition process may range from weekly or monthly
contact for some, while monitoring on a quarterly or annual basis for
others is appropriate. When direct PRC case management is no longer
required, the PRC case manager will monitor the patient through the
polytrauma case manager at a PNS, polytrauma support clinic team, or
the OEF/OIF case manager. The PRC case manager continues to have
ongoing responsibility to review the medical record and continue to
followup with the primary case manager. The local VA continually has
access to its PNS or PRC for consultation if new problems arise, or if
the patient needs to be referred to a higher level for evaluation and
treatment.
Question 8: What is the average caseload of an OEF/OIF care
coordinator? Is this considered manageable? Is there a health care
standard for this issue?
Response: Each OEF/OIF care manager follows approximately 24
patients as a national average. VHA Handbook 1010.01 states the
caseload for nurse and social worker case managers will typically be no
more than 25 to 30 patients per care manager. This ratio is consistent
with DoD caseload as published in its medical management guide, DoD/
TRICARE management activity, dated January 2006, which suggests a
caseload of 25-35 acute and chronic cases per care manager.
Recognizing the crucial role nurses and social workers provide in
case management and the need for a more consistent approach to
determining caseloads, two national organizations are currently
studying caseload calculations for nurses and social workers. The Case
Management Society of America and the National Association of Social
Workers are developing a caseload matrix.
Question 9: Have the special needs of severely injured rural vets
been identified?
Response: Severely injured veterans living in rural areas are
provided the case management services and oversight available to each
veteran seen throughout the VA polytrauma system of care as well as the
OEF/OIF care management program located at each VA medical facility
(e.g., a nurse or social worker clinical case manager, transition
patient advocates, OEF/OIF case manager, VBA counselors). An
interdisciplinary team of rehabilitation specialists assesses the needs
of seriously injured patients to match the treatment plan and
coordinate support services needed. If local VA care is not available
to a patient due to their geographic location, fee-based rehabilitation
services are provided through the local community. The Office of Rural
Health is working closely with the veterans integrated service networks
to address access for all rural veterans, and has recently implemented
initiatives to increase access to care to primary care.
Question 10: Please explain how VETSNET is being used to support
the FRC pilot and the OEF/OIF care coordination program.
Response: Veterans services network (VETSNET) provides benefits
counselors, OEF/OIF managers and coordinators with improved access to
veteran and claims data, on-time updates, and immediate status on pay.
VETSNET is not directly available to the FRCs or the OEF/OIF team at
the VA medical centers.
VETSNET is primarily used at this time by benefits counselors at
MTFs. The benefits counselors meet with servicemembers and their
families to provide benefits information and assistance to
servicemembers applying for VBA benefits and services. Counselors
assist servicemembers in completing claims and in gathering supporting
evidence. While servicemembers are hospitalized, they are routinely
informed of the status of their pending claims and given their
counselor's name and contact information should they have followon
questions or concerns.
The OEF/OIF team at the VA medical centers collaborates with the
benefits counselors at the closest VA regional office.
Question 11: Dr. Agarwal's testimony on page 3 states that VHA and
VBA are jointly developing a comprehensive list of severely injured
OEF/OIF veterans. Describe in detail how this list is being constructed
and what the timeline is for completion of a comprehensive list.
Response: VHA recently developed a new tool to track the care
management of severely ill and injured OEF/OIF veterans. The new
application is known as the care management tracking and reporting
application (CMTRA). This robust tracking system allows OEF/OIF care
managers to specify a care management schedule for each individual
veteran and to identify specialty care managers such as polytrauma case
managers and spinal cord injury case managers. The new application was
implemented at VA medical centers on April 29, 2008. VHA mandated that
all severely ill and injured OEF/OIF patients being case-managed need
to be added to CMTRA. VBA is identifying a similar list of severely
ill/injured patients. VA information technology staff will consolidate
VHA and VBA information into a single, comprehensive database.